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Tag No.: A0168
Based on clinical record review, hospital policy and staff interviews for 3 of 6 sampled patients reviewed for restraints, (Patients # 3, #5, and #6), the hospital failed to ensure a physician order was obtained for the use of restraints. The findings include:
a. Patient # 3 was admitted on 12/21/19 with acute respiratory failure, shock liver and cardiogenic shock. Review of the non-violent restraint log identified Patient # 3 was placed in a bilateral soft holder restraint on 12/24/19 related to agitation and pulling at lines. Review of the clinical record with the Nurse Executive on 12/31/19 at 10:00 AM failed to identify a physician order was obtained for the use of the bilateral soft holder restraint on 12/24/19.
b. Patient # 5 was admitted on 12/2/19 following an MVA (motor vehicle accident) and found to have a pneumothorax, splenic lacerations and multiple rib fractures. Review of the patient flowsheets for 12/27/19 identified the resident was in bilateral soft holder restraint from 11AM to 6PM for agitation and restlessness. Review of the non-violent restraint log for December 2019 failed to identify Patient # 5 was placed in a bilateral soft holder restraint on 12/27/19 related to agitation and pulling at lines. Review of the clinical record on 12/31/19 at 10:00 AM with the Nurse Executive failed to identify a physician order was obtained for the use of the bilateral soft holder restraint on 12/27/19.
c. Patient # 6 was admitted on 11/26/19 with a right frontal intraparenchymal hemorrhage with subarachnoid extension. Review of the patients flow sheets dated 12/24/19 and 12/25/19 identified the patient had bilateral soft holder wrist restraints on until 1:48 PM on 12/25/19. Review of the clinical record with the Nurse Executive on 12/31/19 at 10:00 AM failed to identify a physician order was obtained for the use of bilateral soft holder wrist restraints on 12/25/19.
Interview with the Nurse Executive on 12/31/19 at 10:00 AM stated according to hospital policy when restraints are used on a patient a physician order must be obtained for the use of restraints.
Review of the hospital policy for restraints and seclusion identified for non-violent use of restraints, the provider must be notified as soon as possible and an order obtained. The order must include the start time, duration, type of restraint, restraint location, the reason for the restraint and discontinuation criteria.