HospitalInspections.org

Based on policy review, clinical record review, and interview, it was determined the facility failed to ensure patients in restraints were monitored as required by facility policy for three (#7-#9) of five (#6-#10) restrained patients. Failure to monitor and assess restrained patients every two hours per facility policy created the likelihood for patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible. The failed practice could affect any patient in restraints. Findings follow.

A. Review of policy titled "Restraint Usage in Non-Behavioral Health Units" showed, "Documentation in the patient's medical record of this monitoring and assessment shall occur ...Every two (2) hours for Non Violent/Non-Self Destructive restraints."

B. Review of Patient #7's clinical record revealed orders for restraints on 12/25/17 and 12/26/17. Restraint monitoring was not documented on 12/25/17 from 7:30 AM through 9:00 PM and on 12/26/17 for 6:00 AM through 6:59 PM.

C. Review of Patient #8's clinical record revealed orders for restraints on 03/08/18, 03/09/18, and 03/11/18. Restraint monitoring was not documented on 03/08/18 from 1:00 PM through 8:19 PM, on 03/09/18 from 6:00 AM through 7:32 PM, and on 03/11/18 from 1:00 AM through 4:00 AM.

D. Review of Patient #9's clinical record revealed orders for restraints on 03/12/18. Restraint monitoring was not documented from 1:00 AM through 7:00 AM.

E. During clinical record review with the Clinical Informaticist on 03/14/18 from 2:10 PM through 4:07 PM, she confirmed the restraint monitoring was not documented.