HospitalInspections.org

Based on hospital policy and procedure review, medical record review and staff interviews, hospital staff failed to ensure application of soft wrist restraints were accompanied by a physician order for 2 of 2 medical records reviewed (Patients #7 and 8).
The findings include:
Review of hospital policy on 07/1/2015 entitled "Restraints and Seclusion (NC and SC) last revised on March 12+ revealed "Application of Restraint ...4. Order Required-a. Individual order required- The use of restraint or seclusion must be in accordance with the individual order of a practitioner who is responsible for the care of the patient. Orders must never be written as a standing order or on an as needed basis (PRN). C. Time limits- The continued justified use of restraint beyond the first 24 hours must be authorized by a new order. Subsequent restraint orders must be written no less often once each calendar day and are based on the practitioner 's examination of the patient and consideration of their needs and clinical condition." "An RN may discontinue the restraint/seclusion if the specific signs/symptoms requiring restraint no longer present ...A new order must be obtained before reapplying a restraint".
1. Medical record review of Patient #7 on 07/1/2015 revealed an 83 year old male admitted on 06/22/2015 for a total laryngectomy (removal of larynx) performed on 06/22/2015. Patient #7 had a history of malignant neoplasm of neck lymph nodes (cancer). On 07/1/2015 a sputum sampled tested positive for (MRSA) methicillin-resistant staphylococcus aureus, a contagious bacteria, and the patient was placed on contact precautions (to prevent the spread of the bacteria). On 06/25/2015, Patient #7 had an endogastroduodenoscopy ) (EGD- a procedure to look at his throat, stomach and upper bowel) and a feeding tube inserted (Dobhoff). Medical record revealed Patient #7 had confusion and was pulling at this tube after the procedure. Review of physician orders dated 06/25/2015 at 1639 revealed that an order for "continuous x 24 hours for bilateral soft wrist restraints due to "self-harm" were to be applied. Medical record review further revealed that bilateral wrist restraints were applied on 06/25/2015 at 1639 and remained on through 06/27/2015 at 1035. Reivew revealed the patient was monitored every two hours through 06/27/2015 at 1035. Record review showed no physician order for restraints on 6/26/2015 or 6/27/2015.
Staff Interview with RN (#7) on 07/1/2015 at 1400 confirmed that no additional physician orders were present for restraints in use between 06/26/2015 at 1649 through 06/27/2015 at 1035.
2. Medical record review of Patient #8 on 07/1/2015 on unit 6C (an intermediate ICU) revealed a 53 year old male admitted on 06/15/2015 with intracranial hemorrhage and a surgical procedure to remove the hematoma (blood causing pressure on the brain). Due to confusion and Patient #8 attempting to pull out his trache (airway) tube and intravenous lines, an order for bilateral soft wrist restraints was written on 06/16/2015 at 1001 to prevent self-decannulation (pulling trache tube out). Medical record further revealed that bilateral restraints were applied on 06/16/2015 at 1001 and remained on through 06/18/2015 at 1509 when they were removed. Bilateral wrist restraints were reapplied on 06/20/2015 at 0700 and remained on through 07/2/2015 at 0206. Review of physician orders revealed no order for restraint was obtained for 06/24/2015.
Staff Interview with RN (#7) on 07/1/2015 at 1500 confirmed that no physician order was present during the restraint use for 06/24/2015 from 0000 through 06/24/2015 at 2145.
Staff Interview with Clinical Practice Specialist (#8) and Accreditation Director (#9) on 07/1/2015 at 1515 revealed that a physician order is required for restraint use according to their hospital policy. It was confirmed physician orders for restraints were not available for each of the days above for 2 of 2 sampled patients were restrained (Patients #7 and #8).