HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt #10) clinical records reviewed for restrained patients, the Hospital failed to ensure the use of restraints was in accordance with the order of a physician or other licensed practitioner.

Findings include:

1. On 6/22/2021, the Hospital's policy titled, "Utilization of Restraints and Seclusion [Hospital's Name]" (revised 5/21/2021) was reviewed. The policy required, "V. Required Procedures: A. The following apply to the use of all restraints... 4. The use of restraints or seclusion must be... c. Based on the order of the Attending Physician or Licensed Independent Practitioner..."

2. On 6/22/2021, Pt. #10's clinical record was reviewed. Pt. #10 was treated in the Hospital's Emergency Department (ED) on 3/2/2021, for aggression and homicidal ideation. The ED notes, dated 3/2/2021 at 12:15 PM, included that Pt. #10 was placed in 5 point (bilateral wrists, ankles, and torso) restraints "to prevent injury to self," and "physically abused [to] others." The ED notes included that Pt #10 was restrained from 12:15 PM until 5:00 PM, when Pt. #10 was removed from restraints. Pt #10 clinical record lacked a physician's or licensed practitioner's order for the use of restraints.

3. On 6/22/2021 at 11:40 AM, an interview was conducted with the ED Manager (E #2). E #2 stated that there should be a physician's order for the use of restraints.