HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt. #2) clinical records reviewed for patients in restraints, the Hospital failed to ensure the use of restarints was in accordance with the order of a physician.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion (6/2021)" was reviewed on 4/12/2021 and required, "Initial restraint order from the attending physician ... is required immediately or within a few minutes from initiating restraints."

2. The clinical record of Pt. #2 was reviewed on 4/12/2021. Pt. #2 was admitted on 3/13/2021 with the diagnosis of encephalopathy (altered brain function). The Restraint Care Plan indicated that bilateral hand mitten restraints were applied on 4/5/2021 at 12:00 PM, due to pulling at lines and risk of injury. The telephone order for hand mitten restraints did not include the name of the physician who approved the order.

3. During an interview on 4/12/2021 at approximately 11:30 AM, the Assistant Chief Clinical Officer (E#5) stated, "The telephone order line on the restraint order form should have included the physician's name, who authorized the use of restraints."

Based on document review and interview, it was determined that for 1 of 3 (Pt. #2) clinical records reviewed for patients in restraints, the Hospital failed to monitor the patient every 2 hours, as required by hospital policy.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion (6/2021)" was reviewed on 4/12/2021 and required, "Ongoing Safety Checks & Monitoring (at least every two hours) by the patient's clinical team of the patient's response to the restraint, including any condition changes. ... All documentation of patient status should be in real time."

2. The clinical record of Pt. #2 was reviewed on 4/12/2021. Pt. #2 was admitted on 3/13/2021 with the diagnosis of encephalopathy (altered brain function). A physician's order, dated 4/5/2021, included orders for bilateral wrist restraints. The Restraints Monitoring tool, dated 4/10/2021 lacked documentation of every 2 hour safety checks from 6:00 AM through 8:00 PM (14 hours).

3. During an interview on 4/12/2021 at approximately 11:30 AM, the Assistant Chief Clinical Officer (E#5) stated, "Documentation for those 14 hours is definitely missing and should be there. Restraint documentation is required every 2 hours."