HospitalInspections.org

Based on review of two (2) of three (3) medical records (#1 and #9) of patients in restraints, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure the notification of family or the significant other, of the need for patient restraints, in accordance with facility policy.

Findings include:

Reference: facility policy titled, "Restraint Policy-Non Violent (NUR 1.04)" states, "...II. Responsibilities. A. Registered Nurse...9. Notify patients family or significant other of need to place restraints..."

1. Review of Medical Record #9 on 1/19/2022 at 10:00 AM, revealed the following:

a. Review of the History and Physical Reports, dated 12/5/2021 at 6:27AM states, "...on arrival patient was lethargic but able to follow simple commands...a/o X 3..."

b. The "Assessment and Treatments" and "Restraints Information" documents, dated 12/6/2021 at 1:00 PM, states, "(Initial Behavior Requiring Restraint NV) Pulling at Lines, Tubes or Devices ... Restraint Explanation Given To - Patient."

c. There was no documented evidence of notification to the patient's family or significant other regarding the need for restraints.

2. Review of Medical Record #1 on 1/19/2022 at 1:15 PM, revealed the following:

a. Review of the History and Physical Reports, dated 10/9/2021 at 12:19AM, states the patient is "aao [alert, awake, oriented] X1 at times gets agitated..."

b. The "Assessment and Treatments" and "Restraints Information" documents, dated 12/23/2021 at 10:00 PM, states, "(Initial Behavior Requiring Restraint NV) Pulling at Lines, Tubes or Devices ... Restraint Explanation Given To - Patient."

c. There was no documented evidence regarding the notification of the patient's family or significant other regarding the need for restraints.

3. These findings were confirmed with Staff #2 and Staff #3.