HospitalInspections.org

Based on record review, policy review and interview the facility failed to protect and promote patient rights in 1of 1 patients reviewed. Findings include:

The policy titled "Restraint Use: Adult (Non-Psychiatric Setting)" reads:

Provisions #9 A. "A face to face assessment by the physician/LIP is required each day for ongoing use of restraints."
Provision # 21states, "Medical; Minimally every 2 hours or more frequently if condition warrants, the patient's safety and other needs are assessed and documented on the restraint assessment form."
Provision # 22 states, "Behavioral; Observation of patient behavior is required continuously for the first 15 minutes and then every 15 minutes there after during restraint use. Nursing assessment of continued need is documented every 15 minutes during restraint use."

During tour of 5 Brush Center on 04/05/10 at 1140, when queried if there were any patients in restraints, staff # 10 confirmed that there was one patient in restraints on the unit at time of survey.

Review of the patient # 8's medical record revealed that on 04/03/10 at 1656 an order was entered for behavorial restraints-continuous, vest, soft limb x 2 and mitts x 2. Further review of the chart documentation reads behavorial reason for restraints-harmful to self.

There is no other assessment/documentation as to why the restraints were applied and the facility was unable to locate any documentation of monitoring of the patient during the use of the restraints. RN documentation on 04/04/10 under area titled Restraint Plan of care reveals the continued use of the restraints. A document provided, that was titled Single patient task and Scheduled patient care shows monitoring of restraints on 04/04/10 at 1029 and 1443 for Patient #8. The facility was unable to produce documentation of a physician order for restraints on 04/04/10.

Order for restraints on 04/05/10 written as medical restraints with monitoring/assessment documented as completed at 0001 and 0926. Per interview with staff #11 on 04/05/10 at 1145, it was confirmed that there was no documentation in the patient record of the attending physician being notified of the use of restraints on the patient.

During interview with staff # 3 on 04/05/10 at 1230, it was confirmed that the restraints were not ordered by an independent practitioner. They were ordered once by a Physician Assistant on 04/03/10 and once by a Nurse Practitioner on 04/05/10.