HospitalInspections.org

Based on staff interview, document review, and review of medical records (MR), it was determined the facility failed to monitor patients in restraints in accordance with facility policies in one (1) of six (6) MRs reviewed of patients in restraints. MR15.

Findings:

MR15 was reviewed and contained documentation that the patient was placed in non-violent bilateral soft wrist restraints for interfering with medical treatment. The restraints were ordered by the physician on May 16, 2025 at 00:24 AM. MR15 remained in restraints on May 17 and 18, 2025. There was no monitoring of the patient in restraints documented from 2:00 AM - 8:00 AM on May 18, 2025.

An interview was conducted with EMP11 on May 28, 2025 at 9:50 AM who indicated that a patient in restraints for non-violent reasons should be monitored at least every two (2) hours by a Registered Nurse and no such documentation was present in MR15.

The facility's policy, IHS Restraints and Restraint Alternatives Policy (last revised 6/25/24) was reviewed and reads in part, "...Patients are monitored, assessed, and reassessed at specific intervals during use...Addendum B Restraint and Restraint Alternative Algorithm...Non-violent/non-self-self-destructive restraint...Patient Care Monitoring Documentation...Q2 hour assessment and documentation of skin, respiratory, circulatory, neurovascular, behavior indicating the need or discontinuation of restraint. Q2 hour restraints released and documented as well as range of motion, repositioning..."