HospitalInspections.org

Surveyor: Henderson, Patricia

Based on review of policies and procedures, hospital documents and medical records, and interviews with hospital staff, the hospital failed to ensure all physician's orders for restraints contained the type of restraint to be used and the reason for the restraint. This occurred in two of four records (Records #2 and 4) reviewed were restraints were used.

Findings:

1. The hospital's policy, PCM.02.10.00.00 with a revision date of 10/12, " RESTRAINTS " , documented, " ...The restraint order is to include the type of restraint device ... " and " ...all-necessary order components are present ... "

State Hospital Licensure Standards, Chapter 667, Subchapter 15-8, requires that a patient may be restrained only upon the order of a physician or licensed independent practitioner. "Orders for physical restraint shall include a statement of reason for the restraint and specify which approved facility methods and devices shall be used."

2. Records #2 and #4 contained restraint orders, yet the physician did not consistently specify the restraint type or reason for the restraint.

3. This was verified at the time of record review with staff B.

Based on review of medical records and hospital documents, and interviews with hospital staff, the hospital failed to ensure restraints were applied according to physician orders. This occurred in two of four records (Records#2 and 4) reviewed where restraints were used.

Findings:

State Hospital Licensure Standards, Chapter 667, Subchapter 15-8, requires that a patient may be restrained only upon the order of a physician or licensed independent practitioner. "Orders for physical restraint shall include a statement of reason for the restraint and specify which approved facility methods and devices shall be used."

1. Record #2 - the type of restraints ordered by the physician was not the type used by nursing staff.
a. When the physician specified the type of restraint on the order, with the exception of 06/04/13, he ordered side rails times 4 for a patient who, according to nursing staff, attempted to pull out devices/equipment.
b. Nursing staff documented changing the types of restraints throughout the record without getting physician orders for the changes.
c. Nursing staff documented restraint use of either soft wrist or vest restraints being used for the time period of 05/30/13 through 06/04/13.

2. Record #4 - the type of restraints ordered by the physician, when specified, was not the type used by nursing staff. Nursing staff documented changing the types of restraints throughout the record without getting physician orders for the changes.

3. These findings were verified at the time of record review on the afternoon of 07/31/13 with staff B.