HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt #10) clinical records reviewed of a patient requiring the use of a restraint device, the Hospital failed to ensure that restraints were applied in accordance with a written physician's order.

Findings include:

1. The Hospital policy entitled, "Use of Restraint and Seclusion," (revision dated 5/31/16) was reviewed on 9/21/17 and required, "...V. Procedures...D. Non-Violent, Non-Self-Destructive Restraint. a. Use of a restraint or seclusion requires a physician's order..."

2. The clinical record of Pt #10 was reviewed on 9/21/17 at approximately 8:45 AM. Pt #10 was a 95 year old female admitted on 9/15/17 with a diagnosis of cellulitis lower extremity. Clinical documentation included that on 9/18/17 at 4:00 PM Pt #10 had a vest restraint applied. The clinical record did not include documentation of a physician's order for the application of the restraint device.

3. On 9/21/17, at approximately 10:10 AM, the Assistant Director (E#8) of the Telemetry Unit stated that a physician's order could not be located for the the patient's restraints.