HospitalInspections.org

Based on medical record review, facility policy review and interview it was determined the Registered Nurse failed to supervise and evaluate nursing care related to following policy and procedure on restraint use for one (#5) of ten sampled patients.

Findings included:

Review of Patient #5's medical record revealed the patient was placed in soft wrist restraints at 2:55 a.m. on 09/20/2015 with order from the physician for patient safety due to patient not following directions and pulling at tubes and intravenous lines. It was discontinued at 8:21 a.m. on 09/20/2015.

Continued review revealed the patient was placed back in soft wrist restraints at 6:44 p.m. and discontinued at 8:17 p.m. A thorough review did not reveal any order from the physician for the restraint.

Review of the facility policy titled "Restraint Usage, Implementation, and Monitoring" #2.00.012.6 last reviewed 06/2015, states "order must be obtained from MD immediately after applying the restraint/seclusion if not obtained prior to application of the restraint/seclusion".

An interview on 11/02/2015 at 2:00 p.m. with the Manager Strategic Performance and Quality, Patient Safety Officer confirmed the above findings