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Based on review of the hospital policy and procedures, medical records review, and staff interviews, hospital staff failed to obtain an order for non-violent restraint renewal prior to order expiration for 2 of 2 patients reviewed. (Patient #2 and Patient #3)

The findings include:

Review on 02/20/2020 of the hospital policy titled "Restrictive Intervention" with a revision date of 11/2019 revealed "... The use of restraint is in accordance with the order of a physician, physician assistant (PA) or nurse practitioner (NP) who is responsible for the care of the patient, has a working knowledge of hospital policy regarding the use of restraint and seclusion and is authorized to order restraint by hospital policy ... 3. Continued use of restrain beyond the first day is authorized by a new order prior to the end of the next calendar day ...

1. Review of the open medical record for Patient #2 revealed a 56-year-old female admitted to the hospital on 02/12/2020 at 2232 for "Acute and Chronic Respiratory Failure." Review revealed an order for non-violent restraints dated 02/13/2020 at 0315, 02/13/2020 at 2015 (17 hours from previous order), 02/14/2020 at 1843 (22 hours and 28 minutes from previous order), 02/16/2020 at 1458 (44 hours and 25 minutes from previous order), 02/17/2020 at 0723 (16 hours and 25 minutes from previous order), 02/18/2020 at 1414 (30 hours and 51 minutes from previous order), 02/19/2020 at 1357 (23 hours and 43 minutes from previous order), and 02/20/2020 at 0747 (17 hours and 50 minutes from previous order). Review revealed a verbal order for non-violent restraints dated 02/15/2020 and a start time of 1800 had been entered on 02/18/2020 at 1438 (67 hours and 55 minutes after the order was due). [and 4 hours and 38 minutes after onsite review began] Review of the medical record revealed no discontinuation of non-violent restraints between 02/12/2020 and 02/20/2020.

Telephone interview on 02/21/2020 at 1426 with RN (Registered Nurse) #8 revealed she did not take care of Patient #2 on 02/15/2020. Interview revealed RN #8 was looking through the orders and had seen the restraint order for 02/15/2020 was missing. Interview revealed RN #8 knew the restraint order had to be renewed every 24 hours and she could tell by the documentation that the patient was still in the restraints. Interview revealed RN #8 called the physician on 02/18/2020 and got a verbal order for the restraints for 02/15/2020 and entered it into the electronic medical record. Interview revealed "orders are put in usually the day they are ordered however if I see a missing restraint order we call and get a verbal order and enter it". Interview revealed this is the practice of the charge nurses when looking at restraints.

Interview on 02/21/2020 at 1106 with MD (Medical Doctor) #3 revealed it is the nurse's responsibility to put in the renewal order for the restraints and the physician will sign off on them. Interview revealed it doesn't happen that much but if it was missed the nurse should put it in.


2. Review of the closed medical record for Patient #3 revealed a 43-year-old female admitted to the hospital on 01/24/2020 for acute kidney injury. Patient #3's hospital stay was complicated by progression of her symptoms which were confirmed by her a worsening CIWA (Clinical Institute Withdrawal Assessment) score. Review revealed an order for bilateral soft wrist restraints for 01/27/2020 at 0856, 01/28/2020 at 0751, 01/29/2020 at 1245, 01/30/2020 at 1558 and 01/31/2020 at 0756. Review revealed the restraint order had been allowed to expire prior to the new order being written on 01/29/2020 (4 hours 55 minutes) and on 01/30/2020 (3 hours 14 minutes). Review of restraint documentation revealed Patient #3 had remained in restraints during the times when the restraint orders had expired.

Telephone interview on 02/21/2020 at 1123 with RN #6 revealed he remembered Patient #3 and he was the primary nurse on 01/29/2019. Interview revealed he spoke with the physicians that morning and they said they would reorder the restraints. Interview revealed RN #6 gave them time to put it in and when he saw that it had not been entered he entered the order. Interview revealed RN #6 waited about an hour before he entered the orders if the physician wanted to renew the restraints. Interview revealed RN #6 was unsure of what was going on that day that took so long for the physician to enter the order.

Telephone interview on 02/21/2020 at 1136 with RN #7 revealed she could not remember Patient #3 specifically. Interview revealed the physicians were responsible for entering orders and renewing orders for restraints. Interview with RN #7 revealed, generally nurses notify physicians a restraint order needs renewal, and if the physician gave a verbal order, the nurse would enter the order at the time it was given.

Telephone interview on 02/21/2020 at 1340 with MD (Medical Doctor) #2 revealed she remembered Patient #3. Interview revealed when she was given report she was told Patient #3 was in 4 point restraints (bilateral wrists and ankles). Interview revealed MD #2 did not recall if Patient #3 was in 2 or 4 point restraints. Interview revealed upon first seeing Patient #3 she needed to be intubated due to unresponsiveness. Interview revealed MD #2 remembered being asked to renew the restraint orders. Interview revealed it is the physicians responsibility to renew the restraint order prior to the order expiring or at the same time.

NC00161148