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Based on observation, interview and record review, the hospital failed to ensure staff completed assessments of patients with restraints (any manual method, physical, or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) at a minimum of every two hours per the hospital's policy and procedure for one of 32 sampled patients (Pt) 14.

This failure had the potential to place patients with restraints at risk of injury.

Findings:

During a concurrent interview and record review of Pt 14's clinical records, on 8/27/19 at 1:36 p.m., Informatics Registered Nurse (IRN) validated Pt 14's last restraint monitoring assessment was completed at 10 a.m. (a time lapse of 3 hours, 36 minutes).

During a concurrent observation and interview, on 8/27/19 at 1:49 p.m., Pt 14 was observed with soft restraints on both his wrists and ankles. Registered Nurse (RN) 2 stated Pt 14 required the use of restraints because he had involuntary movements and removed his medical equipment. RN 2 stated RNs were supposed to assess patients with restraints every two hours for signs of injury, skin breakdown, skin discoloration, and assess the need to continue or discontinue the use of restraints.

During an interview with Clinical Manager (CM) 1, on 8/28/19 at 3:40 p.m., she stated patients with restraints were to be assessed every two hours. CM 1 stated upon patient assessments, RNs were to perform range of motion, assess the skin, reposition the patient, and assess the patient's comfort level. CM 1 stated several reasons why it is important to assess restrained patients every two hours including, the patients were "...Tied up ...", to ensure patient safety, and because it was the hospital's policy. The CM validated Pt 14 had a missing restraint assessment.

A review of hospital policy and procedure titled, "Restraint and Seclusion" dated 2/5/18, indicated, "I. Purpose: A. To provide a consistent standardized, corporate-wide policy and procedure for the assessment, application and evaluation of the use of restraint and seclusion ...IV. Procedure ...E Ongoing Monitoring and Assessment of a Patient in Restraint or Seclusion ...2. Monitoring a patient in restraint or seclusion ...b. Minimum monitoring frequency ...i. Safety, non-violent; and non-destructive restraint - monitor at least every two (2) hours ...C. Ongoing assessment of patient in restraint or seclusion ...ii. Minimum assessment frequency...I. Safety, non-violent, and non-destructive behavior should be assessed at least every two (2) hours ..."

Based on interview and record review, the hospital failed to have a Registered Nurse (RN) evaluate the care of each patient on an ongoing basis in accordance with the hospital policy when one of 32 sampled patients (Pt) 18 did not receive a comprehensive assessment (an exam that reviews the health of all major body systems) every 12 hours.

This failure placed Pt 18 at risk of not having their medical needs met.

Findings:

During a concurrent interview and record review of Pt 18's clinical records, on 8/29/19 at 9:25 a.m., the Informatics Registered Nurse (IRN) stated Pt 18's most recent comprehensive assessment was completed by a RN on 8/26/19 at 8:15 p.m. The IRN validated Pt 18 did not receive a comprehensive assessment completed prior to discharge on 8/27/19 at 7:19 p.m. (a time lapse of 23 hours and four minutes without an RN assessment).

During a concurrent interview with Clinical Manager (CM) 2 and review of Pt 18's clinical records , on 8/29/19 at 2:25 p.m., CM 2 stated patients were to be assessed by an RN once every 12 hours at minimum. CM 2 stated it was the hospital's policy and it allowed RNs to gather data of patients' baseline status. CM 2 stated if a full assessment was not completed, the RN cannot determine if there had been a change of condition. CM 2 reviewed Pt 18's most recent comprehensive assessment and validated Pt 18's last comprehensive assessment was completed on 8/26/19 at 8:15 p.m. and Pt 18 was discharged on 8/27/19 at 7:19 p.m. CM 2 stated Pt 18 should have had another comprehensive assessment completed on the morning of 8/27/19. CM 2 stated because Pt 18 was discharged on 8/27/19, he should have had another comprehensive assessment completed prior to discharge to determine if Pt 18 was safe for discharge.

A review of the hospital policy and procedure titled, "Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units" dated 2/10/17, indicated, "I. Purpose: These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient ...Full Assessment ... Within 2 hours of admission and at the beginning of every shift ...Document within 12 hours ..."