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ST MARY MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to obtain an order for the use of restraint within the time frame as specified in hospital policy for two of five medical records reviewed (MR16 and MR18).
Findings include:
Review on October 10, 2019, of facility, " Restraints Use Policy and Procedure," dated July 5, 2019, revealed, " ... Procedure A. ... 3. Physician Order ... The physician's order for Non Violent/Non Self Destructive Restraint must be obtained within one hour of initiation of restraint ... ."
Review on October 10, 2019, of MR16 Restraint Documentation, revealed restraints for non violent behavior were applied on October 3, 2019 at 10:00 PM. Further revealed order for the use of restraint was documented as obtained on October 4, 2019 at 12:21 AM.
Review on October 10, 2019, of MR18 Restraint Documentation, revealed restraints for non violent behavior were applied on September 13, 2019 at 12:00 AM. Further revealed order for the use of restraint was documented as obtained on September 13, 2019 at 2:04 AM.
Interview with EMP16 on October 10, 2019 between 9:30 AM and 10:30 AM confirmed for 2 of 5 restraint records reviewed (MR16 and MR18) the MD orders were not obtained within the time frame specified in hospital policy.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0188
Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to document patient's response to restraint as per hospital policy for two of five medical records reviewed (MR14 and MR17).
Findings include:
Review on October 10, 2019, of facility, " Restraints Use Policy and Procedure," dated July 5, 2019, revealed, " ... Procedure A. Restraint Use ... NonViolent/NonSelf Destructive Restraint ... 4. Continued Assessment, Monitoring & Care: a. Assessment requirements by a Registered Nurse are every two (2) hrs [hours] to determine the physical and emotional well-being of the patient ... B. Restraint Use for Management of Violent/Self Destructive Behavior ... 8. Documentation of Care: a. The nurse is responsible for completing in PCS the Restraint Assessment Screen every hour ... ."
Review on October 10, 2019, of MR14 Restraint Documentation, revealed restraints for non violent behavior were applied on September 27, 2019 at 6:09 AM. Further revealed order for the use of restraint was documented as obtained on September 27, 2019 at 2:17 AM. Further revealed RN Assessment completed once on September 27, 2019 at 6:09 AM. Further revealed, death pronounced at 3:38 PM on September 27, 2019.
Review on October 10, 2019, of MR17 Restraint Documentation, revealed restraints for violent behavior were applied on September 23, 2019 at 6:35 AM. Further revealed physican order for the use of restraint was documented as obtained on September 23, 2019 at 6:21 AM. Further revealed RN Assessment completed September 23, 2019 at 6:35AM 6:45 AM, 8:00 AM, 10:00 AM, and 12:00 PM .
Interview with EMP16 on October 10, 2019 between 9:30 AM and 10:30 AM confirmed for 2 of 5 restraint records reviewed (MR14 and MR17) the RN assessment while patient was in restraint was not completed per hospital policy.