HospitalInspections.org

Based on a review of facility policy and medical records (MR), and staff (EMP) interview, it was determined the facility failed to assess the condition of restrained patients for three of five medical records (MR15, MR16, & MR17) reviewed.
Findings include:
1) A review of facility policy "Restraint and Seclusion," revised date, "September 2019", was reviewed on October 6, 2020. The "Restraint standards for the management of non-violent/non-self-destructive behavior ...Monitoring and documentation ...Patients are monitored and reassessed a minimum of every 2 hours during restraint use or more frequently if indicated. Documentation of ongoing assessment, monitoring, and interventions should occur at a minimum of every 2 hours."
2) A review of MR15 was completed on October 7, 2020, and revealed an admission date of September 12, 2020. An order dated September 30, 2020, for an enclosed bed was initiated at 1600. There were no assessments documented for the following dates and times:
October 1, 2020, at 0200, 1800, and 2000
October 2, 2020, at 0200, 00400, 2000
October 3, 2020 from 0600 through October 5, 2020 at 0700 missing
October 5, 2020 at 1900 through 0500 on October 6, 2020.

3) A review of MR16 was completed on October 7, 2020, and revealed an admission date of September 18, 2020. An order dated September 19, 2020, for bilateral soft wrist restraints was initiated at 1600. There were no assessments documented for the following dates and times:
September 20, 2020, at 1600, and 1800
September 27, 2020, at 1600, and 1800
September 29, 2020, at 1800 through September 30, 2020, at 0600 missing

4) A review of MR17 was completed on October 7, 2020, and revealed an admission date of October 3, 2020. An order dated October 4, 2020, for bilateral soft wrist restraints was initiated at 0200. There was no assessment documented for October 4, 2020, at 1800.

5) During an interview on October 7, 2020, at 9:55 AM, EMP1 confirmed the above findings and stated the every two hour nursing assessments should be documented on the restraint flow sheets in the electronic medical record.