HospitalInspections.org

Based on policy and procedure, medical records, and staff interviews. The facility failed to follow its policy and procedure by obtaining an order for restraints within minutes of initiation of restraints. In one of three patient record reviews. (Patient #1)

Findings included:

Review of the Policy and Procedure titled, " Patient Restraint/ Seclusion." Policy #CSG.CSG.001, Reviewed: 05/30/2020. Order for restraints must be obtained from a LIP/physician responsible for the care of the patient before the application ...
When a LIP/physician is not available to issue the restraints, an RN with demonstration competence may initiate restraint use based on face-to-face assessment. In an emergency situation, the order must be obtained during the emergency application or immediately (within minutes) after the restraint initiated ....

A review of the Medical record for Patient #1 revealed that on 06/24/2020 9:00 PM, Patient #1 was restrained for attempts to remove devices.
Further review of Patient #1 Medical records on 06/24/2020 at 11:56 PM, an order was obtained for the use of restraints to prevent pulling out treatment devices.

Medical record review shows no evidence that an order was obtained within minutes. The order for the restraint was two hours, and 56 minutes after Patient #1was already in restraints.

An interview was conducted with the VP of quality and the Director of Quality confirmed the above.