HospitalInspections.org

Based on record review and staff interview, it has been determined that the facility failed to ensure restraints were applied in accordance with the order of a physician or other licensed practitioner for 2 of 5 patients who were restrained, Patient ID#'s 2 and 6.

Findings are as follows:

The hospital's policy titled, "Patient Restraint and Seclusion" last revised in 2/2020 states in part,

"...III. Procedure

Initiation of Restraint or Seclusion...

Action...

...Order Restraint or Seclusion...

...Non-Violent Restraint...

...The ordering provider either enters the order into the medical record or issues a telephone order to the RN, following hospital telephone order policy..."

1. Surveyor review of the medical record revealed that Patient ID #2 was admitted to the hospital in April of 2022 after presenting with a viral upper respiratory infection and pneumonia. His/her medical history includes Autism.

Record review revealed that an order for a non-violent restraint was initiated on 4/28/2022 at 3:45 PM which stated in part, "Continuous x 24 hours...physical hold of patient..."

Further review revealed another order for a non-violent restraint initiated on 4/29/2022 at 6:02 PM which stated in part, "Continuous x 24 hours...physical hold of patient..."

Review of documents titled, "Restraint Monitoring and Response Every 2 Hours" revealed that on 4/28/2022, right and left arm restraints were initiated at 3:00 PM and continued through 4/29/2022 until a new order for this type of restraint was initiated on 4/30/2022.

The record revealed that the continuous physical hold orders from 4/28/2022 and 4/29/2022 did not correlate with the right and left arm restraints placed on Patient ID #2 on those dates. Additionally, the record failed to reveal evidence of physician orders for the right and left arm restraints applied on 4/28/2022 and 4/29/2022.

During a surveyor interview on 5/6/2022 at 9:05 AM with the Nurse Practitioner, Employee A, she revealed that right and left arm restraints were applied to Patient ID #2 on 4/28/2022 after a chest tube was placed. She acknowledged that the order placed on 4/28/2022 for a continuous physical hold was inaccurate as the patient had right and left arm restraints applied.

During a surveyor interview on 5/6/2022 at 9:39 AM with the Site Risk Manager, she was unable to provide evidence of a physician's order for right and left arm restraints applied to Patient ID #2 on 4/29/2022.

2. Surveyor review of the medical record revealed that Patient ID #6 was admitted to the hospital in January of 2022 after presenting with seizure activity, lethargy, poor feeding, and poor muscle tone. His/her medical history includes, but is not limited to, neoplasm (tumor) of the cerebellum, acquired obstructive hydrocephalus (excess build-up of cerebrospinal fluid in the brain), and acquired torticollis (asymmetrical head or neck position).

Review of documents titled, "Restraint Monitoring and Response Every 2 Hours" revealed that a right wrist restraint was documented as "Continued" for Patient ID #6 on 2/17/2022 from 8:00 PM through 10:00 PM and on 2/18/2022 from 12:00 AM through 6:00 AM.

The record failed to reveal evidence of physician orders for the application of a right wrist restraint on 2/17/2022 and on 2/18/2022.

During a surveyor interview with the Site Risk Manager on 5/6/2022 at 12:57 PM, she acknowledged that Patient ID #6 did not have physician orders in place for the right wrist restraint applied on the above-mentioned dates and times.