HospitalInspections.org

Based on record review, interview, and policy review, the facility failed to document the type of restraint used for one patient (#3) of five patients reviewed.

The findings included:

Medical record review revealed Patient #3 was admitted to the facility on January 13, 2012, with diagnosis of Hematuria, Abdominal Pain, Chronic Kidney Disease, End Stage Renal Disease, and Urinary Tract Infection.

Review of Patient Notes dated January 21, 2012, at 6:59 a.m., revealed "...wore restraints temporarily: restraints d/'d (discontinued) at this time...". Review of the medical record revealed no documentation of the type of restraint used.

Review of the "Clinical Justification and Documentation for Medical/Surgical Restraints" form, dated January 20, 2012, at 2250 p.m., revealed an order for Patient #3 to be restrained, but no documentation of the type of restraint used.

Review of the facility's policy number PC.050, last revised November 2011, revealed, "...order must indicate...type of restraint to be used."

Interview with the Director of Nursing Quality Improvement, on February 1, 2012, at 1:00 p.m., in the Quality Improvement office, confirmed there was no documentation of the type of restraint applied to Patient #3 on January 20, 2012.



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