HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient was free from the use of restraints for 1 of 10 patients (patient #1), failed to ensure a physician order was obtained for the use of a restraint for 1 of 10 patients (patient #1), and failed to ensure the patient right to safe implementation of restraint by trained staff for 1 of 10 patients (patient #1).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, nursing failed to obtain an order for non-violent restraints in 1 of 10 (Patient 1) medical records reviewed.

1. Review of policy titled: Restraint or Seclusion (PolicyStat ID: 7477109), last approved 03/2020, indicated when using non-violent restraints a Registered Nurse will obtain order from provider for restraint ASAP.

2. Review of policy titled: Fall Prevention (PolicyStat ID: 9099224), last approved 01/2021, indicated that a Patient Safety Device (PSD - self releasing safety device) can be used as a PSD if the patient can demonstrate the ability to remove the device in the manner it was designed to be removed; if the patient cannot remove the device, it will be considered a restraint.

3. Review of Patient 1's medical record indicated a roll belt was utilized on 06/24/22. The MR lacked documentation of provider order for non-violent restraints. The patient was unable to remove the belt, making it a restraint.

4. Interview on 07/05/22 at 11:43 am with P52 (Quality/Patient Safety Coordinator) confirmed that if patient cannot remove the roll belt, it would be considered a restraint and confirmed there was no order for non-violent restraints on Patient 1's medical record.

Based on document review and interview, nursing failed to follow policy in providing hourly assessments for 1 of 10 (Patient 1) medical records reviewed.

1. Review of policy titled: Restraint or Seclusion (PolicyStat ID: 7477109), last approved 03/2020, indicated when using non-violent restraints the Registered Nurse will assess patient at least hourly.

2. Review of Patient 1's medical record lacked documentation of hourly assessments by a Registered Nurse while patient was in non-violent restraints starting on 06/24/22.

3. Interview on 07/05/22 at 11:43 am with P52 confirmed lack of documentation of hourly RN assessments on Patient 1's medical record.

Based on document review and interview, nursing failed to follow policy regarding non-violent restraints in 1 of 10 (Patient 1) medical records reviewed.

1. Review of policy titled: Fall Prevention (PolicyStat ID: 9099224), last approved 01/2021, indicated that a Patient Safety Device (PSD - self releasing safety device) can be used as a PSD if the patient can demonstrate the ability to remove the device in the manner it was designed to be removed; if the patient cannot remove the device, it will be considered a restraint.

2. Review of policy titled: Restraint or Seclusion (PolicyStat ID: 7477109), last approved 03/2020, indicated when using non-violent restraints:
RN initiates restraint to ensure patient safety
RN obtains order for restraint ASAP from provider
Provider will see patient wiithin 24 hours
Caregiver meet patient's needs hourly and documents
RN assesses patient at least hourly
RN discontinues restraint at earliest possible time and documents.

3. Review of Patient 1's medical record indicated history of dementia/enchepalopathy with poor response to questions, was put in a roll belt and lacked documentation of hourly assessments and order for placement.

4. Interview on 07/05/22 at 11:43 am with P52 (Quality/Patient Safety Coordinator) confirmed that patient could not remove the roll belt per self; should be considered a restraint.