HospitalInspections.org

Based on medical record review, staff interview, and review of the facility's intervention time summary, the facility failed to ensure the documentation was accurate for 1 of 6 patients (#8) who received restraint/seclusion intervention. The findings were:

Review of page one of the 12/5/11 restraint/seclusion order/record for patient #8 showed the start time for mechanical restraints was 1800 [6 PM]. However, the 1800 time was written over another entry, and the original entry could not be discerned. Review of page four of the document showed 1810 [6:10 PM] as the start time for initiation of the physical restraints. Further review revealed, in the boxed in area titled "circulation checks", that initiation of the patient's physical restraints was documented at 1830 [6:30 PM]. The following concerns were noted:
a. The facility failed to document the accurate time for the start of physical restraints for patient #8. Instead, there were three contradictory documented start times (6 PM, 6:10 PM, and 6:30 PM).
b. The start time for the restraint on page one was written over another entry. The facility failed to properly document the new entry and provide a written explanation for the change.
During a telephone interview with the chief nursing officer (CNO) on 3/28/12 at 9:50 AM, she confirmed the restraint/seclusion order/record of 12/5/11 "was confusing" and should have only one physical restraint start time. She further stated that it was not standard practice at the facility to "write over" another entry without providing an explanation. In addition, review of the facility's intervention time summary for patient #8, received from the CNO on 3/29/12 at 10:37 AM, revealed the CNO and director of nursing verified the start time in the patient's restraint/seclusion record for the 12/5/11 incident was not documented accurately and was confusing and contradictory.