HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to develop a plan of care in accordance with their hospital policy and Federal regulations for the use of restraints for 3 of 6 patients reviewed, Patient ID#'s 1, 2 and 3.

Findings are as follows:

Review of the hospital's policy titled "Lifespan Patients Restraint and Seclusion" last reviewed 11/2023, states in part:

"...III. Procedure ...Initiation of Restraint or Seclusion

Action 6. Modify the Plan of Care
Update the plan of care based on initial and ongoing assessment..."

Record review for Patient ID #1 revealed the patient was admitted to the Medical Intensive Care on 9/29/2024 with Respiratory Failure. On 9/30/2024 a physician order was placed for nonviolent restraints to maintain the integrity of their lines and tubes. The medical record lacked evidence that the Plan of Care was modified following the initiation of the restraints.

Record review for Patient ID #2 revealed the patient was admitted to the Neuro Critical Care Unit on 9/25/2024 with a Left Internal Carotid Artery Occlusion. On 10/10/2024, a physician order was placed for nonviolent restraints to maintain the integrity of their tubes and invasive lines. The medical record lacked evidence that the Plan of Care was modified following the initiation of the restraints.

Record review for Patient ID #3 revealed the patient was admitted to the Trauma Intensive Care on 10/10/2024 with Multiple Trauma Injuries. Upon admission to the unit a physician order was placed for nonviolent restraints to maintain integrity of their tubes and invasive lines. The medical record lacked evidence that the Plan of Care was modified following the initiation of restraints.

During an interview with the Risk Manager on 10/15/2024 at approximately 11:30 AM, she was unable to produce evidence that the patient's Plan of Care was updated to include the use of restraints.