HospitalInspections.org

Based on hospital policy review, medical record review, and staff interviews, the hospital failed to monitor a patient in non-violent restraints per hospital policy in 2 of 3 restraint records reviewed. (Patient #3, Patient #4)

Findings included:

Review of facility policy, "Restraints and Seclusion," effective 04/06/2020, revealed, "...Non-Violent Restraints... D. Monitoring... 4. The following will be monitored and documented every 2 hours (within 15 minutes before or after) or more often if indicated by patient condition: Circulation, Skin condition, Correct application of the restraint, Patient positioning/alignment and range of motion, Nutrition..., Hydration..., Elimination needs, Level of distress/agitation, mental status and cognitive functioning..."

Closed medical record review on 04/19/2022 of Patient #4, revealed a 73-year-old female, admitted on 01/26/2022 at 1641 to the emergency room with shortness of breath (SOB). Review of the History and Physical dated 01/26/2022 at 0904 revealed "...presents for evaluation of SOB and abdominal pain...and found to be positive for COVID-19...Active Problems:...Chronic atrial fibrillation (irregular heartbeat)..." Review revealed on 02/07/2022 at 1707 non-violent wrist restraints were ordered by Medical Doctor (MD) #5 citing "...removing essential medical equipment..." A renewal restraint order was placed on 02/08/2022 at 1109 by MD #6. Review of the Restraint Monitoring record revealed there was no restraint monitoring from 0500 through 1109 (6 hours, 9 minutes) on 02/08/2022 by Registered Nurse (RN) #9. Record review revealed on 02/09/2022 a new order for non-violent wrist restraints was placed at 1113 for Patient #4 by MD #6, citing "...removing essential medical equipment..." Record review of Restraint Monitoring revealed there was no restraint monitoring from 1350 through 1811(4 hours and 21 minutes) on 02/09/2022 by RN #9. Medical record review revealed Patient #4 was discharged to a skilled nursing facility for rehabilitation on 02/21/2022 at 1247.

Request on 04/19/2022 at time to interview travel nurse, RN #9 revealed she was no longer employed and unavailable for interview.

Interview on 04/21/2022 at 0945 with Medical Surgical Charge Nurse, (RN #10) revealed the hospital's policy was to monitor a patient in non-violent restraints every two hours. Interview after review of Patient #4's restraint monitor record revealed there were two intervals of missing restraint monitoring on 02/08/2022 from 0500 to 1109 (6 hours and 9 minutes) and 02/09/2022 from 1350 to 1811 (4 hours and 21 minutes). Interview revealed the hospital restraint policy was not followed.

Interview on 04/21/2022 at 1455 with Medical-Surgical Nursing Manager, (RN #8) revealed "...the expectation for monitoring non-violent restraints was every 2 hours..." Interview after review of Patient #4's restraint monitor record revealed Patient #4 had intervals of missing restraint monitoring confirmed by RN #8 on 02/08/22 from 0500 to 1109 (6 hours and 9 minutes) and 02/09/2022 from 1350 to 1811 (4 hours and 21 minutes). Interview revealed the hospital restraint policy was not followed.

Interview on 04/21/2022 at 1616 with Director of Nursing (DON) #3 revealed the expectation for nursing staff was to document non-violent restraints every two hours. Interview revealed the facility had implemented documentation exemptions due to the COVID-19 pandemic, but documentation of restraints was not included in the documentation exemption waiver in effect until 02/22/2022.


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Review of "Combined Non-Violent Restraint Evaluation and Monitoring Tool Report" revealed the following: "... Restraint monitoring every 2 hours during calendar day while restrained: ... Oct. 2021 - 88% (87/99), Nov. 2021 - 87% (81/93), Dec. - 87% (86/99), Jan. 2022 - 86% (85/99), Feb. 2022 - 90% (91/101), Mar. 2022 - (80/96) = Total Compliance Rate (April 2021 - March 2022) 87% (985/1130)..."

Closed medical record review on 04/20/2022 of Patient #3 revealed a 77-year-old female who presented to the Emergency Department on 02/11/2022 at 1843 with a chief complaint of blood infection. Medical record review revealed Patient #3 was subsequently admitted and transferred to the Intermediate Cardiac Care Unit facility with a diagnosis of Sepsis. Review of the History and Physical dated 02/11/2022 at 2126 revealed, "...Patient was found to be febrile, tachycardic, confused at skilled nursing for (sic) facility this morning. Presented to outside hospital, CT imaging concerning for possible right hip infection with stranding (sic) and gas in postoperative site as well as right ureteral stone and right hydronephrosis, concern for potential septic stone... SNF (skilled nursing facility) reported purulent drainage from R (right) hip surgical site... Subacute Metabolic Encephalopathy(condition where brain function is abnormal due to inflammation or another disease)... since her 2 admissions in January she has had significant cognitive impairment, delirium, confusion and overall metabolic encephalopathy..." Review of Physician Orders revealed Non-violent bilateral wrist restraints were ordered for 24 hour duration on 02/27/2022, 02/28/2022, and 03/01/2022. Review of Non-Violent Restraint Q2h (2 hour) monitoring revealed the following intervals of missing documentation: 02/27/2022 at 1427 until 02/27/2022 at 2000 ( 5 hours, 33 minutes), 02/28/2022 at 1405 until 02/28/2022 at 2000 (5 hours, 55 minutes), 03/01/2022 at 1445 until 03/01/2022 at 2000 (5 hours, 15 minutes). Review of the Discharge Summary dated 03/06/2022 at 1345 revealed, "...Unfortunately, the patient continued to deteriorate clinically. She had significant encephalopathy likely secondary to ongoing infection... Patient has therefore been transferred to the palliative care unit..." Medical record review revealed Patient #3 was transferred on 03/06/2022 at 2309 to an in-patient hospice care facility.

Interview on 04/20/2022 at 1340 with MD #1 revealed Patient #3 had restraints due to pulling at medical devices, likely due to her encephalopathy.

Interview on 04/20/2022 at 1325 with RN #2 revealed she provided nursing care for Patient #3 while in non-violent restraints on 02/28/2022 and 03/01/2022. Interview revealed that RN #2 was a travel nurse and did recall being oriented to restraints on hire. Interview revealed RN #2 did not recall anything happening that would have impacted her ability to document or monitor the restraints on Patient #3 according to facility policy.

Interview on 04/21/2022 at 1616 with DON #3 revealed the expectation for nursing staff to monitor and document non-violent restraints every two hours according to policy. Interview revealed Patient #3's restraint monitoring had intervals of missing documentation. Interview revealed the facility had implemented documentation exemptions due to the COVID-19 pandemic, but documentation of restraints was not included in the documentation exemptions waiver in place through 02/22/2022.

NC00187010 NC0000186768 NC00186415 NC00184680