HospitalInspections.org

Based on document review and interview, the facility failed to follow policy and procedure for use of restraint for 1 of 10 medical records reviewed (PT1).

Findings include:

1. Review of policy/procedure Use of Restraints and Seclusion, QSM-SYS-PS-2-P, indicated the following on page 10; #4a, a restraint order must be obtained from a LIP (Licensed Independent Practitioner) immediately prior to or within 30 minutes of initiating restraints. This policy/procedure was last reviewed 06/30/16.

2. Review of PT1's MR indicated that on 08/13/16 at 9:56, the patient was placed in 4-way restraints. The MR lacked documentation of an order for 4-way restraints, including kind of restraint and duration of restraint.

3. Interview on 01/16/18 at 11:35 with P54, Manager of the Emergency Department and P61, Director of Operations, Emergency Department and Trauma, confirmed lack of documentation of order from physician to place restraints.

Based on document review and interview, the facility failed to ensure that nursing follow facility policy and procedure for monitoring patients in restraints for 1 of 10 medical record (MR) reviewed (PT1).

Findings include:

1. Review of policy and procedure Use of Restraints and Seclusion, QSM-SYS-PS-2-P, indicated on page 12 the following: #9d.i. that staff document every 15 minutes on patient safety and comfort. This policy and procedure was last reviewed 06/30/16.

2. Review of PT1's MR, indicated the patient was in restraints on 08/13/16 from 9:56 am to 10:11 pm. The MR lacked documentation of 15 minute checks for patient safety and comfort on 08/13/16 from 1:30 pm to 3:00 pm, 3:15 pm to 4:45 pm and 5:15 pm to 10:00 pm. Documentation indicates patient in restraints from 9:56 am until time of departure at 10:11 pm.

3. Interview on 01/16/18 at 12 noon with P54, Manager of the Emergency Department and P61, Director of Operations, Emergency Department and Trauma, confirm inconsistency of documented 15 minute checks by a registered nurse.