HospitalInspections.org

Based on record review and interview the facility failed to ensure that a restraint assessment was completed every 2 hours for patients in restraints per facility policy in 3 of 10 patient medical records reviewed (Patients (Pt.) #2, 4, 5) out of a total universe of 10 medical records reviewed.

Findings include:

A review of facility policy, titled "Restraints and Seclusion, GL-6014", last approved 09/18/2023, revealed: "...Protective (Nonviolent) restraints prevent interference with medical treatment, promote medical healing, or prevent the patient from exiting the bed...Special considerations...Four side rails...RN is to document "not in use" every 2 hours when the patient is out of bed...PROTECTIVE RESTRAINT...B. Nursing...2. Ongoing Monitoring a. The following assessment areas are documented in the Restraint Flowsheet: i. Psychological status ii. Skin and circulation iii. Range of motion iv. Food and fluids v. Elimination vi. Physical comfort a. At these time frames: i. On initiation ii. Every 2 hours until discontinued i. a 30 minute extension window is acceptable if needed...Discontinuation...ii. When the RN determines restraints are no longer required, the restraints should be removed, and the order discontinued. iii. Document "discontinued" in the Protective Restraint Status row..."

Review of Pt. #2's medical record revealed an admission on 05/27/2024 for Pneumoperitneum (air or gas in abdmoninal cavity). Pt. #2 was a current inpatient. The record revealed bilateral wrist restraints were ordered and in use on 05/27/2024. Review of the restraint flowsheet revealed no assessments documented on 05/27/2024 from 3:30 PM until 8:00 PM - a period of 4 hours 30 minutes between restraint assessments.

Review of Pt. #4's medical record revealed an admission from 05/26/2024 - 05/30/2024 for C1 cervical fracture. The record revealed an order for the use of all 4 side rails up (as requested by patient/family) on 05/26/2024 & 05/27/2024 with no assessments documented from 6:00 PM on 05/26/2024 until 9:26 AM on 05/27/2024 - a period of 14 hours 26 minutes between restraint assessments.

Review of Pt. #5's medical record revealed an admission on 05/24/2024 for C6 cervical fracture. Pt. #5 was a current inpatient. The record revealed bilateral wrist restraints were ordered and in use on 05/27/2024. Review of the restraint flowsheet revealed no assessments documented on 05/27/2024 from 4:00 AM until 7:45 AM - a period of 3 hours 45 minutes between restraint assessments.

The above findings were confirmed on 05/30/2024 at 3:30 PM during medical record review with Quality & Patient Safety Nurse E who stated that there should have been documentation of either "not in use or discontinued" on the restraint flowsheet if the patients were out of bed or restraints were removed.