HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 restrained patients (Patient #1) in the sample, the restraint order failed to specify the information required by hospital policy. Findings included:

The hospital policy entitled "Restraint Use" stated, "...applies to all patients requiring evaluation and need for restraints...Restraint Orders...The order will specify the reason, method/type of restraint and the time limit for the order..."

A. Review of Patient #1's Emergency Department medical record revealed the following entries on 10/15/17:

2:41 AM:
- placed in restraints to all extremities
- verbal physician's restraint order that failed to contain the reason, method/type of restraint and the time limit for the order, as required by hospital policy
3:30 AM:
- restraints were removed (49 minutes later)

Physician D confirmed these findings on 11/20/17 at 4:55 PM.