HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 6 restrained patients (Pt #5), the Hospital failed to ensure the condition of a restrained patient was monitored by trained staff in accordance with Hospital policy.

Findings include

1. On 4/5/2022, the Hospital policy titled, "Restraints and Seclusion," effective 2/29/2020, was reviewed and indicated, " ...Non-Violent Restraints ... At a minimum of every two hours: circulation, movement, and sensation, skin integrity, range of motion, hygiene and elimination, nutrition and hydration, general behavior, and criteria for discontinuation explained. Documentation of the above observation and monitoring will be reflected in the EMR [electronic medical record]..."

2. On 4/4/2022, the clinical record for Pt#5 was reviewed. Pt#5 was admitted to the Hospital on 2/12/2022, for treatment after falling at home. Pt#5's record included an order, on 2/14/2022 at 8:49 AM, for non-violent restraints, on both left and right wrists due to interference with medical treatment. The record indicated that the restraints were started on 2/14/2022 at 10:00 AM, and they were removed on 2/16/2022 at 9:11 AM. On 2/15/2022, Pt#5 was assessed at 6:00 PM and was not assessed again until 2/15/2022 at 9:10 PM (3 hours and 10 minutes between assessments).

3. On 4/4/2022, at approximately 12:30 PM, an interview was conducted with the Emergency Department Manager (E#2). E#2 stated that patients in non-violent restraints should be assessed every 2 hours by nursing staff.