HospitalInspections.org

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure patient monitoring according to facility policy for 1 (#7) of 10 sampled patients.

Findings include:


Review of the medical record of patient #7 revealed that restraints had been applied at 4:40 p.m. The reason for the restraint was documented as "emergent, violent, danger to others. There was no documentation of restraint monitoring or when the restraint was removed. There is a physician order written at 8:18 p.m. and there is documentation that restraints are in place at 7:19 p.m. No additional documentation regarding the restraint could be found. The facility's policy "Restraints; violent and non-violent ", #09-01-0011, revised 7/11, requires that an order for restraint be acquired prior to the application of restraints, or during the emergency application or within a few minutes after the application. Monitoring of the patient is to be documented every 15 minutes. The nursing director of the emergency department (ED) was interviewed on 11/10/11 at approximately 2:00 p.m., she confirmed there was no documented evidence that the staff complied with the facility's policy regarding timing of the physician order and monitoring of the patient.