HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 4 clinical records (Pts. #9 and #10) reviewed for restraint use, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician/licensed practitioner.

Findings include:

1. The Hospital's policy titled "Restraints and Seclusion" (effective 4/7/2021), was reviewed on 7/20/2021 and required, "...Violent Restraints/Seclusion: An order from a physician and/or APP [Advanced Practice Provider] must be obtained immediately or as soon as clinically appropriate... The orders for restraints/seclusion may be renewed as follows: 4 hours for adults 18 years or older..."

2. The clinical record of Pt. #9 was reviewed on 7/20/2021 with the Education Coordinator (E#10). Pt. #9 was admitted on 5/27/2021, to the Cardio/Neuro Medical Unit, with diagnoses of aspiration and intoxication. The record included a physician's order, dated 5/30/2021 at 12:51 PM, for 4-way locking (violent) restraints, continous for up 4 hours, due to danger to self and others. The orders included a notation: "Orders must be renewed every 4 hours or when discontinued." Restraint flowsheets indicated that Pt. #9 was put in violent restraints starting on 5/30/2021 at 12:51 PM and included documentation that Pt. #9 remained in violent restraints until 5/31/2021 at 3:00 AM (nearly 14 hours). The record included two additional orders for violent restraints (up to 4 hours each) on 5/30/2021 at 4:51 PM (expired at 8:51 PM) and again on 5/31/2021 at 12:07 AM. The record lacked a renewal order for the violent restraints to remain on from 5/30/2021 at 8:51 PM to 5/31/2021 at 12:07 AM (3 hours and 16 minutes).

3. The clinical record of Pt. #10 was reviewed on 7/20/2021 with E#10. Pt. #10 was admitted on 6/27/2021, to the Medical/Surgical/Telemerty Unit, with a diagnosis of dementia with aggressive behavior. The record included a physician's order, dated 6/28/2021 at 1:39 PM, for 4-way locking (violent) restraints, continous for up 4 hours, due to danger to self and others. The orders included a notation: "Orders must be renewed every 4 hours or when discontinued." Restraint flowsheets indicated that Pt. #10 was put in violent restraints on 6/28/2021 from 1:30 PM to 10:30 PM (9 hours). The record included only one renewal order for the violent restraints on 6/28/2021 at 5:06 PM. The record lacked a new/renewal physician's order for restraints after the last restraint order expired on 6/28/2021 at 9:06 PM (1 hour and 24 minutes before the restraints were removed).

4. An interview was conducted with the Education Coordinator (E#10) on 7/20/2021, at approximately 11:20 AM. E#10 stated that violent restraint orders (for adults over 18 years of age) are good for up to 4 hours. E#10 stated that after 4 hours, the original orders must be renewed or a new order placed.

Based on document review and interview, it was determined that for 2 of 4 clinical records (Pts. #9 and #10) reviewed for restraint use, the Hospital failed to ensure that the patients were seen face-to-face within 1-hour after the initation of violent restraints by a physician or qualified registered nurse.

Findings include:

1. The Hospital's policy titled "Restraints and Seclusion" (effective 4/7/2021), was reviewed on 7/20/2021 and required, "...Violent Restraints/Seclusion: ...The physician / APP [Advanced Practice Provider] or qualified RN [Registered Nurse] must see the patient within ONE HOUR of initiation... The physician / APP or qualified RN conducts an in-person evaluation of the patient within ONE HOUR of the initiation of restraint... This evaluation should include: evaluation of immediate situation; reaction to intervention; medical and behavioral conditions that may place patient at greater risk during restraint including but not limited to history and physical or sexual abuse; need to continue or terminate the restraint/seclusion..."

2. The clinical record of Pt. #9 was reviewed on 7/20/2021 with the Education Coordinator (E#10). Pt. #9 was admitted on 5/27/2021, to the Cardio/Neuro Medical Unit, with diagnoses of aspiration and intoxication. The record included a physician's order, dated 5/30/2021 at 12:51 PM, for 4-way locking (violent) restraints, continous for up 4 hours, due to danger to self and others. The orders included a notation: "The physician and/or Advanced Practice Provider (APP) must conduct a face to face assessment within 1 hour of initation of restraint order..." Restraint flowsheets indicated that Pt. #9 was put in violent restraints starting on 5/30/2021 at 12:51 PM and included documentation that Pt. #9 remained in violent restraints until 5/31/2021 at 3:00 AM (nearly 14 hours). The record lacked documentation that a face-to-face evaluation was conducted within 1 hour of restraint initiation (on 5/30/2021 between 12:51 PM and 1:51 PM).

3. The clinical record of Pt. #10 was reviewed on 7/20/2021 with E#10. Pt. #10 was admitted on 6/27/2021, to the Medical/Surgical/Telemerty Unit, with a diagnosis of dementia with aggressive behavior. The record included a physician's order, dated 6/28/2021 at 1:39 PM, for 4-way locking (violent) restraints, continous for up 4 hours, due to danger to self and others. The orders included a notation: "The physician and/or Advanced Practice Provider (APP) must conduct a face to face assessment within 1 hour of initation of restraint order..." Restraint flowsheets indicated that Pt. #10 was put in violent restraints on 6/28/2021 from 1:30 PM to 10:30 PM (9 hours). The record lacked documentation that a face-to-face evaluation was conducted within 1 hour of restraint initiation (on 6/28/2021 between 1:30 PM and 2:30 PM).

4. An interview was conducted with the Education Coordinator (E#10) on 7/20/2021, at approximately 11:20 AM. E#10 stated that a face-to-face evaluation by a physician, APP, or Nursing Supervisor (the only RNs qualified to perform the evaluation) is required to be completed within 1 hour of restraint initiation. E#10 was unable to find documentation of the required 1-hour face-to-face evaluation in the electronic medical records of Pts. #9 and #10.