HospitalInspections.org

Based on review of policies and procedures, review of restraint education and staff interview, the hospital failed to ensure that 3 of 17 Physicians (Physicians Q, R and S) received education on the hospital's restraint policy and procedure. The hospital also failed to have a plan for the "periodic training" specified in their policy and procedure. The hospital identified 17 physician out of 134 who were "authorized to order restraints". The census on the first day of survey was 37 with none of those patients in medical restraints. During the 4 days of survey, 1 patient was in medical restraints. Findings are:

A. Review of the policy and procedure titled Restraint of Patients with a revised date of January 2010 revealed the following under Staff Education:
"Physicians authorized to order restraint shall have periodic training to gain and maintain a working knowledge of this restraint policy."

B. Review of a 3-ring binder that was titled Restraints revealed a page titled Restraint Education (with no date) that had signatures of 11 physicians (Physicians A, H, L, U, V, W, X, Y, Z, AA and BB) indicating they had received restraint education. The 3-ring binder also contained documents titled Restraints, effective October 4, 2009, showing restraint education for 3 additional physicians: Physician C's signature dated 10/9/09, Physician G's signature dated 10/14/09 and Physician T's signature dated 10/11/09. These forms indicated they had reviewed the restraint requirements included on the document.

C. Interview with the CNO (Chief Nursing Officer) on 3/24/11 from 8:40 AM to 8:45 AM, after going through the undated document titled Current Provider Credentialing Status Report, revealed 17 physicians were "authorized to order restraints" in the hospital. At this same time the CNO confirmed that Physicians Q, R and S were "authorized to order restraints" but had not received any training. Interview with the COO (Chief Operating Officer) and the CNO on 3/24/11 from 5:15 PM to 5:30 PM revealed no plan for the "periodic training" for physicians or how a newly credentialed physician "authorized to order restraints" would receive training.