HospitalInspections.org

Based on record review, staff interview and review of hospital policies, it was determined that the hospital failed to implement the policy entitled "Restraint Use" for 2 of 9 sample patients relative to assessment (ID #'s 1 and 4) , and for 1 of 9 sample patients relative to physician's orders (ID # 8).

Findings are as follows:

A review of the hospital policy entitled "Restraint Use", under "Procedure, Guiding Principles" states:

"Restraints are initiated upon the order of of an LIP (Licensed Independent Practitioner) when the determination has been made for the specific patient at the time....."

Under "Restraint order/documentation requirements," item # 3 states:

"Assessments to be done minimally ever 4 hours to include patient's level of awareness, behavioral activity, and the need to continue or discontinue restraints...."

"..Restraints may be discontinued when patient has achieved desired behavior outcome...Document on Restraint Discontinuation Form."

Under "RN and other clinical staff", item #2 states:

"Document at least every 2 hours using the Restraint Monitoring Form."

1. A review of the clinical record for patient ID #1 revealed the patient presented to the ED (Emergency Department) via ambulance on 9/8/13, after becoming apneic and pulseless. The patient was intubated and placed on a ventilator. The patient was placed in two point soft wrist restraints on 9/9/13 at 4 AM secondary to a potential for self harm, as indicated on the Restraint Assessment Form. On 9/9/13 at 8:45 AM a note revealed restraints "not on". There was no evidence of a Restraint Monitoring form being completed 2 hours after the restraints were implemented. Additionally, there was no evidence of a Restraint Discontinuation Form being done when the restraints were removed, in accordance with hospital policy.

2. Review the clinical record for patient ID #4 revealed two point wrist restraints were used for the patient, as the patient had been pulling at oxygen and a feeding tube. A review of the patient's record revealed a Restraint Assessment was done on 9/16/13 at 11:23 AM . Although the Restraint Monitoring Form was done every 2 hours, there was no evidence of a Restraint Assessment being done within 4 hours in accordance with the hospital policy.

3. Review of the clinical record for patient ID #8 revealed a nursing note on 7/21/13 at midnight revealing that the patient was placed in 2 point limb restraints secondary to behavioral issues. The record revealed at 8 AM the patient's cognitive status improved and the restraints were discontinued. The record lacked evidence of a physician's order for the restraint.

During an interview and record review on 9/18/13 at 11:30 AM, the Risk Manager was unable to produce evidence that the hospital policy had been followed relative to restraints for the above noted patients.