HospitalInspections.org

Based on review of medical records and hospital documents, and interviews with hospital staff, the hospital failed to ensure restraints were:

a. Applied and continued only upon a physician order;
b. Contained the reason the patient was restrained, the type of restraint used, date, time and signature of the physician.

This occurred in seven of nine records (#1, 2, 3, 4, 7, 8, and 9) reviewed where restraints were used.

Findings:

The hospital's restraint policy stipulates that patients are restrained only upon a physician order.

The hospital's restraint policy also follows the Oklahoma State Hospital Licensure Standards, Chapter 667, Subchapter 15-8, which requires, "Orders for physical restraint shall include a statement of reason for the restraint and specify which approved facility methods and devices shall be used."

Record #1 contained a pre-printed restraint order form for the following dates 10/6/13 and 10/7/13. The orders were not complete. The order for 10/6/13 did not contain a physician signature. The order for 10/7/13 did not contain the time the order was written.

Record #2 documented restraints initiated on 10/23/13 at 0530, the preprinted restraint order form was dated, signed and timed several hours later at 1235.

Record #3 contained a pre-printed restraint order form that was not complete. The physician order did not contain the date, time, physician signature and type of restraint used.

Record #4, the medical record documented the patient was restrained everyday form 9/29/13 until 10/4/13. There was no order for 9/29/13 and 10/3/13. The restraint orders dated for 10/4/13 were not complete. There was no documented reason the patient was restrained.

Record #7 the medical record documented the patient was restrained 10/5/13 until 10/9/13 at 2000. There was no order for 10/7/13.

Record #8 the medical record documented the patient was restrained 10/25/13 until 10/28/13. The orders were not complete. The orders for 10/25/13 and 10/26/13 did not document the reason the patient was restrained. There was no order for 10/27/13.

Record #9 documented restraints were discontinued at 1000 on 10/19/13 and restarted on 10/19/13 at 1400. There was no order to reapply the restraint.