HospitalInspections.org

42587


Based on interview and document review, the hospital failed to obtain a physician order for the use of restraints for 2 of 3 patients (P23 and P29) whose non-violent restraint use was reviewed.

Findings include:

P23's electronic health record (EHR) indicated P23 was admitted to the facility on 12/19/23, with diagnoses including autistic disorder and aggressive behaviors.

P23's EHR indicated P23 was placed into right and left wrist and right and left ankle soft restraints on 12/26/23 at 12:30 p.m. A provider order was obtained on 12/26/23 at 12:41 p.m. The restraints were discontinued on 12/26/23 at 1:30 p.m.. On 12/26/23 at 3:55 p.m. P23 was again placed into right and left wrist soft restraints. The medical record lacked a new physician order.

On 11/12/24 at 2:06 p.m., registered nurse (RN)-D verified P23's medical record identified P23 was in restraints on 12/26/23 at 3:55 p.m. through 10:00 p.m.. Staff did not receive a new physician order for that time when P23's restraints had been re-applied after having been discontinued.

On 11/13/24 at 2:13 p.m., RN-E stated restraints should be discontinued as soon as possible. If a patient needs restraints applied again, even in the same day, a new physician order is necessary.

P29 was admitted to the intensive care unit (ICU) from the operating room on 11/8/24. P29 arrived at the ICU on a ventilator after completion of a surgical procedure at 5:51 a.m. that morning. P29's record identified he was in right and left soft wrist restraints with restraint documentation beginning on 11/8/24 at 8:00 a.m..

P29 had orders for non-violent restraints on 11/8/24 at 5:53 a.m., and again on 11/9/24, at 10:59 p.m.. Each restraint order identified the order was valid for a limited time of 24 hours.

On 11/13/24 at 2:33 p.m., registered nurse (RN)-A verified P29's medical record identified P29 was in restraints from 11/8/24 at 8:00 a.m., through 11/11/24 at 6:00 a.m.. There was no new restraint order obtained to identify restraints were appropriate past 11/10/24 at 10:59 p.m., when the order expired.

On 11/14/24 at 8:30 a.m., RN-B verified most patients were restrained when they were on ventilators for safety, to ensure they did not extubate (remove breathing tube) themselves. RN-B verified non-violent restraints were valid only for a maximum of 24 hours.

On 11/14/24 at 8:57 a.m., RN-C verified most patients on ventilators required restraints. RN-C reviewed P29's record and verified he was in restraints from 11/8/24 at 8:00 a.m., until 11/11/24 at 6:00 a.m.. RN-C agreed no new restraint order was obtained when the 11/9/24 order expired on 11/10/24 at 10:59 p.m.. P29 was restrained without a physician's order for an additional 7 hours.

Review of the Restraint and Seclusion policy dated 5/17/24, identified non-violent restraints must be renewed every calendar day based on assessment of continuing need. Restraints will be discontinued as quickly as possible and at the earliest possible time. When the restraint is discontinued, the order is discontinued as well. A new order is required to resume the use of a restraint once it has been discontinued.