HospitalInspections.org

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician or other licensed independent practioner who is responsible for the care of the patient for two of five medical records reviewed (MR8 and MR9).

Findings include:

Review of facility policy, "Patient Restraint and Seclusion," last revised April 2017, revealed, "... IV. Guidelines for restraint and seclusion use: ... B. Non-violent, non-self-destructive patient's restraint use: 1. The registered nurse my initiate restraints/seclusion. A telephone or verbal order must be obtained from a licensed independent practioner as soon as possible. ... 2. Orders cannot be written as standing or PRN. A restraint order, either to continue or discontinue the restraint, is required each calendar day that a restraint is in use. ..."

1. Review of MR8 revealed documentation restraints were initiated on March 20, 2019, at 04:42. An order was not obtained until March 20, 2019 at 09:11.

2. Review of MR9 revealed documentation the patient was restrained on March 4, 2019 and March 7, 2019 without a physician order.

3. Interview with EMP1 on April 2, 2019, at 1:00 PM, confirmed the above findings.