HospitalInspections.org

Based on document record review and staff interview, the Hospital's administrative staff failed to ensure Emergency Department (ED) staff followed hospital policy ordering restraints for 2 of 3 closed (Patient #1 and Patient #2) ED. Failure to obtain a restraint order appropriate for the patient's needs could result in the patient harming themselves, staff, or others as well as impacting the patient's dignity and well-being. Hospital administrative staff identified an average of 824 ED visits per month.

1. Review of the policy, "Restraint Management Protocol," dated 09/2018, revealed in part, "... Non-violent restraints ... Order must be obtained within 8 hours ... The order may be a verbal, telephone, for provider cosign or CPOE [Computer Physician Order Entry] order ..."

2. Review of Patient #1's medical record revealed:

-- on 10/11/2019 at 06:09 PM, Physician D ordered non-violent bilateral soft wrist restraints for Patient #1.

-- on 10/11/2019 at 06:14 PM, Nurse B documented, in part, "... Restraints applied at this time with physician at bedside for patient safety to bilat wrists and bilat ankles ...."

3. Review of Patient #2's medical record revealed:

--on 11/05/2019 at 02:25 AM, Nurse C documented the application of soft upper extremity wrist restraints.

4. Review of Patient #2's medical record lacked documentation a provider ordered Patient #2's restraints.

5. During an interview on 11/14/2019 at 08:25 AM, the ED Manager confirmed Patient #1 and Patient #2's medical record lacked a provider's order for soft wrist restraints.