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BON SECOURS ST FRANCIS MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on document review and interview, it was determined the facility failed to monitor the patient in non-violent restraints in accordance with the facility policy for two (2) of four (4) patients sampled.
The finding include:
On 09/30/2024 at 2:25 PM, the surveyor initiated the medical record review of four patients who had received non-violent restraints [Patient # (2-5)] with the assistance of Staff Member #3.
During review, the surveyor observed missing monitoring documentation for both Patient #2 and Patient #4 (see below).
Patient #2: Restrained with soft bilateral wrist restraints from [3:38 AM until 8:19 AM] on July 10, 2024. Throughout restraint use, there was no documentation of restraint justification, visual/safety checks, circulation, range of motion, fluid and food, or toileting.
Patient #4: Restrained with soft bilateral wrist restraints from [8:15 PM until 9:41 AM] on August 21, 2024, and August 22, 2024, respectively. There was no documentation of restraint justification, visual/safety checks, circulation, range of motion, fluid and food, or toileting after 6:00 AM until the restraint was discontinued at 9:41 AM.
In the afternoon of September 30, 2024, the surveyor received and reviewed the facility policy titled, "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints" (Approval Date: 11/02/2023).
Under "Monitoring/Documentation" section of page four, the policy stated, in part, that the following monitoring documentation of general care needs for patients in restraints should be performed every two hours:
"Continued Justification, Visual / Safety check, Circulation / Skin Integrity, Range of Motion, Fluids, Food and Meal, and Elimination" [sic].
On September 30, 2024, at approximately 4:30 PM, the surveyor met with Staff Member #2 regarding the missing restraint documentation. The surveyor discussed the concerns regarding the missing documentation for Patient #2 and Patient #4. The surveyor received verbal confirmation from the staff member that that restraint monitoring and assessment documentation should be documented at least every two hours, consistent with the aforementioned restraint policy.