HospitalInspections.org

Based on interview and document review the hospital failed to implement the correct restraint procedure for a patient (Patient #1).

Failure to implement the correct restraint procedure puts patients at risk for being in restraints longer than medically necessary and puts patients at risk for psychological harm.

Findings include:

1. The hospital policy titled " Restraint Procedure", revised 01/11/2019 read in part " Restraint for violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, and order renewal is required: a. Every 4 hours for adults 18 years of age and older.

"Restraint for non-violent/non self destructive restraint used for patient medical or physical safety may be ordered for up to a total of 24 hours before a new order is needed.

The length-of-order requirement identifies critical points at which there is mandatory contact with the Healthcare Provider responsible for the care of the patient".

2. The hospital training module that staff completed to learn about the proper use of restraints read in part "The patient must be assessed by a LIP (licensed independent practitioner) responsible for the care of the patient and authorized to order restraint or seclusion 24 hours after initiation and before a new order is written for restraint or seclusion for the management of V/S (violent/suicidal) behavior.

3. Patient #1 came to the hospital on 12/12/2018 after being in a care facility for developmentally delayed individuals less than 48 hours after arriving from another area of the state. The patient had assaulted the caregivers in the community care facility. Upon arrival the patient was violent and hitting out at staff and trying to harm them self. The patient was placed in restraints for their safety and the safety of staff.

Restraints were used intermittently from 12/12/2018 through 12/17/2018. After 12/17/2018 until the patient was discharged on 01/03/2019 restraints were not needed for the patient.

On 12/13/2018 through 12/15/2018 the hospital used the incorrect restraint procedure. The hospital used the restraint procedure for non-violent patients ordered by the healthcare provider. The patient's behavior during that time was violent with "head butting, pushing, shoving, kicking and biting". The healthcare provider assessed the patient every 24 hours and not the every 4 hours as required for patients with violent behavior.

4. On 01/18/2019 at 11:00 AM, Staff #1 was interviewed. Staff A said the healthcare provider should have ordered the restraint protocol for violent patients not non-violent patients. Staff A further said the licensed nurses should have alerted the healthcare provider about the incorrect restraint orders.

5. On 01/18/2019 at 12:00 PM, Staff #2 was interviewed and verified the above. Staff #2 further said the staff training modules for restraints would need to be updated to reflect the hospital restraint policy.