HospitalInspections.org

Based on record review, staff interviews and review of facility policy and procedure the Acute Care Hospital (ACF) failed to ensure that 4 of 7 restrained patients (Patient's 3,4,6 and 14) reviewed had appropriate orders and documentation of restraint use. This failed practice has the potential to cause harm or even death to all patients in the facility. On day of admission the facility census was 319 patients including the offsite facility.

Findings include:

A. Review of Patient (P) 3's medical record revealed that P3 was admitted on 5/7/24 at 5:39 PM with a diagnosis of altered mental status. On 5/7/24 at 6:14PM bilateral mitts to hands were ordered due to P3 pulling at lines and other interventions not effective. Bilateral mitts were placed. In restraint documentation it is documented that the mitts were removed on 5/8/24 at 8:00AM. The order for the restraints was not discontinued for this restraint episode. The order was automatically discontinued on patient discharge on 5/20/24 at 4:26PM.

B. Review of P4's medical record revealed, P4 was admitted on 6/21/24 for encephalopathy. On 6/24/24 at 1:20AM an order for nonviolent restraints was placed for bilateral mitts to hands. The medical record lacks documentation of mitt restraints being used. The order for bilateral mitts was discontinued on 6/29/24 at 3:01AM.
On 6/27/24 at 10:13AM an order was placed for violent or self-destructive restraints; restraint type is entered as personal/physical hold. The medical record lacks documentation of a physical hold being done.
On 6/27/24 at 9:06PM an order for non-violent restraints was placed. Restraints ordered were 4-point soft restraints. The medical record lacks documentation of restraint use on 6/27/24 at 9:06PM.
Order for restraints to be discontinued was entered on 6/29/24 at 10:53AM.

C. On 6/21/24 at 3:05PM P6 was admitted for a heart attack and cardiac arrest. The medical record revealed documentation of bilateral soft wrist restraints being initiated on 6/21/24 at 4:00PM and continuing through 7/2/24. The medical record lacks an order for the nonviolent restraints until 6/27/24 at 8:17AM being placed as a late order.

D. On 5/31/24 at 10:57AM P14 was admitted for septic shock (a serious condition that occurs when a body-wide infection leads to dangerously low blood pressures). On 6/1/24 at 11:49AM an order for nonviolent restraint was placed for 4-point soft restraints. P14 had an amputation above the left knee and only has 3 limbs. The medical record has documentation from 6/1/24 at 12:00PM for bilateral soft wrist restraints being used. Documentation in the medical record continues until 6/10/24 at 2:30PM when bilateral soft restraints were stopped. A discontinue order for the restraints was entered into the system on 6/14/24 at 7:16AM.

E. Review of facility policy Restraint management in Acute Care (Approved 3/2024) revealed for nonviolent, non-self-destructive restraint order:
- must be ordered with each episode of restraint initiation.
- The registered nurse (RN) will terminate the restraints when the clinical justification is no longer present.

F. Interview with the Director of Quality and Patient Safety (7/2/24 at 10:15AM) confirmed that the order for restraints should be discontinued in the system by nursing when restraints are discontinued.