HospitalInspections.org

Based on staff interview, review of one (1) of four (4) medical records (#1) and review of facility policy and procedure, it was determined that the facility failed to ensure restraint monitoring is performed by nursing personnel in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Restraints and Seclusion" states, "... Monitoring ... Intervention while a patient is restrained are performed by nursing personnel: ... at least every 2 hours and/or more frequently for non-violent/non-Destructive patient. ... Administration and monitoring of adequate fluid intake at least every 4 hours. ..."

1. Review of Medical Record #1 on 4/12/22, revealed that on 1/23/22 and 1/24/22 an order for Non-Violent Bilateral Soft Wrist Restraints was in place.

a. Review of the Non-Violent Restraints Flow Sheet, in the section titled "Restraint Monitoring Every 2 Hours" revealed restraint monitoring was performed at 4:00 PM and 8:00 PM.

(i) Restraint monitoring was not performed on 1/23/22 and 1/24/22 at 6:00 PM.

2. Review of Medical Record #1 on 4/12/22, revealed that on 1/24/22 and 1/25/22 orders for Non-Violent Bilateral Soft Wrist Restraints was in place.

a. Review of the Non-Violent Restraints Flow Sheet, in the section titled "Restraint Monitoring Every 4 Hours" revealed restraint monitoring was performed on 1/24/22 at 4:00 PM and on 1/25/22 at 8:00 AM.

(i) Restraint monitoring was not performed on 1/24/22 at 8:00 PM or on 1/25/22 at 12:00 AM and 4:00 AM.

3. The above findings were confirmed with Staff #1 on 4/12/22 at 9:45 AM.