HospitalInspections.org

The hospital reported a census of 22 patients. The patient sample included 19 active inpatients and one closed record. Based on document review and interview the hospital ' s administrative staff failed to develop policies and train their staff in restraint use that reflected federal requirements.

Findings include:

- The hospital ' s " Restraint " policy reviewed on 3/23/11 at 2:15pm directed the following:

" . . .It is the responsibility of the hospital CEO or designee to disseminate this policy and its content to all appropriate hospital employees and licensed independent practitioners and to ensure compliance " . . . " .

The hospital ' s " Restraint " policy directed licensed nursing staff " ... will only impose a restraint upon the receipt of appropriate physician orders, when needed to ensure the immediate physical safety of the patient ...will not accept restraint order as a PRN (as needed) or standing order ...may reapply the restraint without a new order if the patient again meets the indications that justified the original restraint order ... " .

- Review of the hospital ' s restraint training program titled " Restraint as a last Resort: Consider the Alternatives " on 3/23/11 at 2:30pm revealed the administrative staff provided the following education to their licensed nursing staff:

1. The restraint order was time limited for a maximum 24 hours. Staff must obtain a new order after the original order expired.

2. The RN (Registered Nurse), at their discretion, may discontinue the restraint prior to the expiration of the order. If the RN assessed the patient ' s behavior and the patient demonstrated a reduction in the behavior that warranted restraints, staff may discontinue the restraint on a " trial basis " .

3. If the patient ' s behavior escalated again, and the escalating behavior is part of the same episode that prompted the initial order, staff may use restraints without a new order. This applied as long as the original order had not expired.

Licensed nurse B interviewed on 3/22/11 at 9:35am explained the physician ' s restraint order was good for 24 hours therefore nursing could remove and reapply the restraint as many times as needed within that 24 hour time frame. Licensed nurse B stated a new physician ' s order was not necessary to put a patient back in restraints.

Licensed nurse C interviewed on 3/24/11 at 11:23am shared restraint orders were good for 24 hours and a patient can be out of restraints and then placed back in.

Licensed Independent Practitioner staff D interviewed on 3/24/11 at 11:40am explained they had training regarding restraints but not from this hospital. Staff D explained that nursing staff called them and requested a restraint order for the type of restraint nursing wanted to use.

Administrative staff A interviewed on 3/22/11 at 11:45am shared they felt the hospital struggled to get the restraint use right. Administrative staff A explained that a physician order for restraints was good for 24 hours, that a patient can be out of restraints for hours and that a new order was not necessary to reapply the restraint.

The hospital reported a census of 22 patients. The patient sample included 19 active inpatients and one closed record review. Based on interview and record review licensed nursing staff failed to update the plan of care for 5 of 5 patients they placed in restraints (#6, 10, 13, 14 and 20).

Findings include:

- The hospital ' s " Restraint " policy reviewed on 3/23/11 at 2:15pm directed nursing staff to modify the patient ' s care plan to reflect the need for restraint.

- Record review on 3/23/11 at 7:20am on Patient #6 revealed the hospital admitted patient #6 to the hospital on 2/24/11 with diagnoses of status post traumatic brain injury secondary to schizophrenia. Nursing staff initiated the use of restraints on 2/24/11. Review of patient #6 ' s nursing plan of care revealed nursing staff failed to modify/update the plan of care when they initiated the use of restraints.

- Record review on 3/22/11 at 2:18pm for Patient #10 revealed the hospital admitted patient #10 on 2/4/11 with diagnosis of respiratory failure. Nursing staff placed patient #10 in restraints on 2/5/11. Review of patient #10 ' s nursing plan of care revealed nursing staff failed to update/modify the plan of care when they initiated the use of restraints.

- Record review on 3/23/11 at 11:10am for patient #13 revealed the hospital admitted patient #13 to the hospital on 2/1/11 with the diagnosis massive head trauma secondary to contact with a moving vehicle mirror. The patient was status post decompression and hemi-craniotomy with repair of a brain lesion. The patient was nonverbal and nonresponsive. Nursing staff initiated the use of restraints on 3/2/11. Review of the patient #13's plan of care evidenced licensed nursing staff failed to modify/update the plan of care when they initiated the restraint on 3/2/11.

- Review of patient #14 record on 3/23/11 at 10:51am revealed the hospital admitted patient #14 to the hospital on 2/11/11 with diagnoses of respiratory failure, sepsis and coccyx decubitis. Review of the patient #14's plan of care dated 2/11/11 evidenced licensed nursing staff failed to update the plan of care when they initiated the restraint.

- Review of patient 20 ' s record on 3/23/11 at 12:26pm revealed the hospital admitted patient #20 on 1/25/11 with diagnoses of acute fracture right pubic ramus, hypertension and peripheral vascular disease. Nursing staff initiated restraints on 1/27/11. Review of patient #20 ' s plan of care revealed nursing staff documented the word " restraints " on the care plan of 1/27/11 but failed to develop an individualized plan regarding the restraint use.

Administrative staff A interviewed on 3/22/11 at 11:45am shared they expected nursing staff to update each patient ' s plan of care when nursing staff initiated the use of restraints.

The hospital reported a census of 22 patients. The patient sample included 19 active inpatients and one closed record review. Based on record review, interview and document review licensed nursing staff failed to obtain a physician ' s orders for each time they used restraints for 4 of 5 patients (#6, 10, 13 and 20).

Findings include:

- The hospital ' s " Restraint " policy reviewed 3/23/11 at 2:15pn directed the following:

1. Licensed nursing staff will only impose a restraint upon the receipt of appropriate physician orders, when needed to ensure the immediate physical safety of the patient.

- Record review on 3/23/11 at 7:20am on Patient #6 revealed the hospital admitted patient #6 to the hospital on 2/24/11 with diagnoses of status post traumatic brain injury secondary to schizophrenia.

Review of Physician ' s restraint orders and nursing staff documentation on the restraint flow sheet evidenced the lack of a physician ' s orders each time they restrained the patient. For example:

The restraint flow sheet dated 2/24/11 revealed nursing staff documented the patient had soft wrist restraints on his left wrist. Review of the physician ' s order section of the medical record revealed no restraint order on 2/24/11.

The restraint flow sheet dated 3/7/11 revealed nursing staff documented the patient was in soft wrist restraint to the left wrist and a tied mitten to the right hand. Review of the physician ' s order section of the medical record revealed no restraint order on 3/7/11.

The restraint flow sheet dated 3/9/11 revealed nursing staff documented the patient was in soft wrist restraint on the left and tied mitten restraint. Review of the physician ' s order section of the medical record revealed no restraint order on 3/9/11.

- Record review on 3/22/11 at 2:18pm for Patient #10 revealed the hospital admitted patient #10 on 2/4/11 with diagnosis of respiratory failure. Patient #10 on was a ventilator and required assistance with transfers and eating. The hospital staff documented the patient was confused at times.

Review of Physician ' s restraint orders and nursing staff documentation on the restraint flow sheet evidenced the lack of a physician ' s orders each time they restrained the patient. For example:

Licensed nursing staff documented on the restraint flow sheets they placed the patient in soft wrist restraints on 2/7, 2/16, 2/19, 2/23, 2/26, 3/5, 3/6, 3/7, 3/9 and 3/13. Review of the physician ' s order section revealed licensed nursing staff failed to obtain restraint orders for the above dates.

Licensed nursing staff documented on the restraint flow sheet they placed the patient in soft wrist restraints on 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, 3/21, 3/22 and 3/23. Review of the physician ' s order section evidenced nursing staff placed the restraint order sticker on the physician ' s order sheet however the physician failed to sign the order.

- Record review on 3/23/11 at 11:10am for patient #13 revealed the hospital admitted patient #13 to the hospital on 2/1/11 with the diagnosis massive head trauma secondary to contact with a moving vehicle mirror. The patient was status post decompression and hemi-craniotomy with repair of a brain lesion.

Review of Physician ' s restraint orders and nursing staff documentation on the restraint flow sheet evidenced the lack of a physician ' s orders each time they restrained the patient. For example:

Licensed nursing staff documented they placed the patient in restraints on 3/6/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 3/6/11 for the restraint use.

Licensed nursing staff documented they placed the patient in restraints on 3/7/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 3/7/11 for the restraint use.

Licensed nursing staff documented they placed the patient in restraints on 3/9/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 3/9/11 for the restraint use.

Licensed nursing staff documented they placed the patient in restraints on 3/12/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 3/12/11 for the restraint use.
Licensed nursing staff documented they placed the patient in restraints on 3/13/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 3/13/11 for the restraint use.

- Review of patient # 20 ' s record on 3/23/11 at 12:26pm revealed the hospital admitted patient #20 on 1/25/11 with diagnoses of acute fracture right pubic ramus, hypertension and peripheral vascular disease. Review of Physician ' s restraint orders and nursing staff documentation on the restraint flow sheet evidenced the lack of a physician ' s orders each time they restrained the patient. For example:

A physician order dated 1/27/11 at 2:00pm for soft wrist restraints, for 24 hours and for safety of indwelling lines lacked the physician's signature.

Licensed nursing staff documented they placed the patient in restraints on 1/28/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 2/28/11 for the restraint use.

Licensed nursing staff documented they placed the patient in restraints on 2/4/11. Review of the physician ' s order section revealed nursing staff failed to obtain a physician ' s order on 2/4/11 for the restraint use.

- Licensed nurse E interviewed on 3/24/11 at 11:30am shared nursing staff should get a physician ' s order for restraints every 24 hours.

Administrative staff A interviewed on 3/24/11 at 11:45am acknowledged the hospital requires licensed nursing staff to obtain a physician ' s order for restraints every 24 hours.

The hospital reported a census of 22 patients. The patient sample included 19 active inpatients and one closed record review. Based on observation, record review, interview and document review licensed nursing staff failed to obtain physician orders for each episode of restraint use for 4 of 5 patients that staff placed in restraints (#10, 13, 14 and 20).

Findings include:

- The hospital ' s " Restraint " policy reviewed on 3/23/11 at 2:15pm directed the following:

1. Licensed nursing staff will only impose a restraint upon the receipt of appropriate physician orders, when needed to ensure the immediate physical safety of the patient.

2. Licensed nursing staff will not accept restraint order ' s as a PRN (as needed) or standing order

3. Licensed nursing staff may reapply the restraint without a new order if the patient again meets the indications that justified the original restraint order.

Record review evidenced licensed nursing staff failed to obtain physician order each time they placed patients ' in restraints. For example:

- Record review on 3/22/11 at 2:18pm for Patient #10 revealed the hospital admitted patient #10 on 2/4/11 with diagnosis of respiratory failure. Patient #10 on was a ventilator. The hospital staff documented the patient was confused at times.

The restraint flow sheet dated 3/15/11 revealed licensed nursing staff documented "No restraints, family at bedside" from 6:00am to 5:00pm. At 6:00pm, nursing staff documented they placed the patient in soft wrist restraint. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in the restraint at 6:00pm.

The restraint flow sheet dated 3/16/11 revealed licensed nursing staff documented "No restraints, son at bedside" from 6:00am to 5:00pm. At 6:00pm, licensed nursing staff documented they placed the patient in bilaterally soft wrist restraint. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in the restraints at 6:00pm.

A physician ' s restraint order dated 3/21/11 to place the patient in soft wrist restraint for the safety of indwelling lines and to manage the patient ' s agitation or combativeness.

Observations on 3/21/11 at 2:40pm showed patient #10 lying in their bed with side rails up times four. The patient had flung their legs over the side rails and attempted to get up. Staff intervened before the patient succeeded in getting out of the bed. Patient #10 was not in restraints at this time. Observation on 3/21/11 at 4:34pm revealed nursing staff placed the patient in a Geri-chair with a tray across his lap in their room (502-1).

Review of the restraint flow sheet dated 3/21/11 revealed licensed nursing staff documented they placed the patient in soft wrist restraints at 6:00pm. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in restraints at 6:00pm.

A physician ' s telephone order dated 3/22/11 at 12:00am to place the patient in soft wrist restraints, for 24 hours and for safety of indwelling lines.

Observations on 3/22/11 at 6:57am and at 8:25am the patient was lying quietly in bed with bilateral restraints to their wrists. At 12:40pm, the patient ' s family was in the room and staff had removed the wrist restraints. At 2:11pm, the patient remained restraint free. At 3:25pm, the patient rested in bed with the restraints off. At 3:30pm, patient's family left room 502-1, the nurse monitored the patient and the patient remained restraint free. At 4:10pm, the patient remained unrestrained. The patient rested quietly, no attempts to pull on tubes or get out of their bed.

Review of the restraint flow sheet dated 3/22/11 revealed licensed nursing staff documented they placed the patient in soft wrist restraints at 4:00pm. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in restraints at 4:00pm.

A physician ' s restraint order dated 3/23/11 for soft wrist restraints, for 24 hours and for safety of indwelling lines.

Observations on 3/23/11 at 7:00am two nursing staff provided care to patient #10 after an incontinent episode. The patient was alert and responded to verbal cues from staff. Nursing staff released the bilateral wrist restraints during the care. At 9:41am, the patient was alert, responsive and sat up in bed. The restraints remained off. At 11:44am, nursing staff placed patient #10 in a Geri-chair. At 2:31pm, staff placed patient #10 back in bed and the patient remained restraint free. At 4:02pm, patient remained in bed without restraints.

Review of the restraint flow sheet dated 3/23/11 revealed licensed nursing staff documented they placed the patient in soft wrist restraints at 6:00pm. Record review revealed licensed nursing staff failed to obtain a physician ' s order when then placed the patient back in restraints at 6:00pm.

- Record review on 3/23/11 at 11:10am for patient #13 revealed the hospital admitted patient #13 on 2/1/11 with the diagnosis of massive head trauma secondary to contact with a moving vehicle mirror. The patient was status post decompression and hemi-craniotomy with repair of a brain lesion. Nursing staff documented the patient was nonverbal, nonresponsive and the patient ' s left arm had contractures.

A physician ' s restraint order dated 3/23/11 for mitten restraint, for 24 hours and for safety of indwelling lines.

Observations on 3/23/11 at 7:05am revealed the patient continued with the mitten restraint to the right hand. At 9:41am, nursing staff re-positioned the patient and the patient was not in the mitten restraint. At 2:32pm, the patient rested quietly in bed with a mitten restraint to the right hand. At 4:01pm, the patient rested in bed with their eyes open, nonresponsive and nursing staff continued the mitten restraint to the right hand.

Review of the restraint flow sheet dated 3/23/11 revealed licensed nursing staff documented from 8:00am to 10:00am the patient was out of the of the mitten restraint. They documented they placed the patient back in restraints at 11:00am. Nursing staff removed the restraint again at 1:00pm, then documented they resumed the restraints at 3:00pm. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they documented they placed the patient back in restraints at 1:00pm and 3:00pm.

- Review of patient #14 record on 3/22/11 at 10:51am revealed the hospital admitted patient #14 to the hospital on 2/11/11 with diagnoses of respiratory failure, sepsis and coccyx decubitis.

A physician ' s restraint order dated 3/21/11 for soft wrist restraints, for 24 hours and for the safety of indwelling lines.

Observations on 3/21/11 at 2:58pm revealed patient #14 in bed with their family at the bedside. Nursing staff had released the patient's left wrist restraint. At 4:31pm, patient remained in bed and nursing staff had reapplied the left wrist restraint.

The restraint flow sheet dated 3/21/11 revealed nursing staff documented from 6:00am through 8:00am the patient was in soft wrist restraints to the left wrist. From 8:00am through 3:00pm nursing staff wrote across the time grid "Restraints off, family at bedside". At 4:00pm, nursing staff documented the patient back in wrist restraint to the left wrist. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they documented they placed the patient back in restraints at 4:00pm.

A physician ' s restraint order dated 3/22/11 for soft wrist restraints, for 24 hours and for the safety of indwelling lines.

Observations on 3/22/11 at 7:00am revealed patient #14 lying in bed with their left wrist restrained. At 9:24am, the patient was awake with their left wrist restrained. At 2:13pm, patient #14 remained in his bed with the left wrist restraint off at this time. At 3:29pm, the patient remained unrestrained at this time. At 4:13pm, the patient continued unrestrained.

The restraint flow sheet dated 3/22/11 revealed licensed nursing staff documented from 11:00am through 4:00am nursing staff that the " restraints off, restraints off ". At 5:00am, nursing staff documented they placed the patient back in the left wrist restraint. Record review revealed licensed nursing staff failed to obtain a physician ' s order at 5:00am when they placed the patient back in restraints.

- Review of patient # 20 ' s record on 3/23/11 at 12:26pm revealed the hospital admitted patient #20 on 1/25/11 with diagnoses of acute fracture right pubic ramus, hypertension and peripheral vascular disease.

A physician ' s restraint order dated 2/1/11 at 9:00am for soft wrist restraint.

The restraint flow sheet dated 2/1/11 revealed nursing staff documented from 6:00am to 6:00pm "No restraints". At 7:00pm licensed nursing staff documented they placed the patient in soft wrist restraints. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in restraints.

A physician ' s restraint order dated 2/2/11 for soft wrist restraint and for 24 hours. The physician failed to time the order and failed to indicate the reason for the restraint use.

The restraint flow sheet dated 2/2/11 revealed nursing staff documented from 6:00am to 6:00pm "No restraints". At 6:00pm licensed nursing staff documented they placed the patient in soft wrist restraints. Record review revealed licensed nursing staff failed to obtain a physician ' s order when they placed the patient back in restraints.

- Licensed nurse B interviewed on 3/22/11 at 9:35am explained the physician ' s restraint order was good for 24 hours therefore nursing could remove and reapply the restraint as many times as needed within that 24 hour time frame. Licensed nurse B stated a new physician order was not necessary to put a patient back in restraints.

Licensed nurse C interviewed on 3/24/11 at 11:23am shared restraint orders were good for 24 hours and a patient can be out of restraints and then placed back in.

Administrative staff A interviewed on 3/22/11 at 11:45am shared they felt the hospital struggled to get the restraint use right. Staff A explained the physician order for restraints was good for 24 hours, that a patient can be out of restraints for hours and that a new order was not necessary to reapply the restraint.