HospitalInspections.org

Based on document review and interview, the facility failed to ensure that patients with restraints had their plan of care modified to reflect the need for restraint use for 2 of 10 patients (Pts. #7 and #10).

Findings:
1. Review of the policy and procedure "Use Of Restraints And Seclusion", policy number SF 1.01 AP, with a last approval date of June 2013, indicated:
a. Under section "V. Policy Statements", it reads in item P. "P. The patient's plan of care reflects the use of restraints or seclusion."

2. Review of medical records indicated:
a. Pt. #7 had:
A. Restraints, at a minimum, on 2/6/15 from 0000 hours to 0400 hours; 2/7/15 from 2000 hours to 2341 hours; and 2/8/15 from 0000 hours to 0600 hours, as per the "All Results Flowsheet" in the "Restraint Initiation/Restraint Monitoring" areas.
B. No documentation in their care plan that would indicate the use of restraints during their hospitalization.
b. Pt. #10 had restraints documented on 2/9/15 at 2200 hours on the "All Results Flowsheet" in the "Restraint Initiation/Restraint Monitoring" area, but lacked addition of restraint use to the care plan.

3. Interview with staff member #57, the RN CNS (certified nurse specialists) for NCC1 and NCC3 (neuro critical care units), and #58, the RN CNS for 4S and 5N, at 4:15 PM on 2/25/15 and 10:00 AM on 2/26/15 indicated:
a. It was agreed that neither patient record #7 nor #10 had restraint use noted in the nursing plan of care.

Based on document review and interview, the facility failed to ensure that physician orders for restraint included all types of restraints utilized for 6 of 10 patients (Pts. #1, 2, 3, 4, 6, and 7).

Findings:
1. Review of the policy and procedure "Use Of Restraints And Seclusion", policy number SF 1.01 AP, with a last approval date of June 2013, indicated:
a. Under section "VI. Procedures", it reads in item B. "Use of Physical Restraints for Non-violent Behavior", "...2. Obtain/Provide a Restraint Order...d. Order elements must include: date, time, type of restraint, rationale for restraint and duration of restraints...".

2. Review of patient medical records indicated:
a. Pt. #1 had:
A. An order on 1/16/15 at 10:46 AM for "Soft (Velcro) Bilateral Wrists" restraints.
B. No order documented for "elbow splints" to both arms and "Pelvic/Chest" restraint that were noted in the "Non-violent Restraint Monitoring" section of the EMR (electronic medical record) from 10:00 AM 1/6/15 to 10:00 PM on 1/17/15.
C. Orders written on 1/21/15 at 8:33 AM and 1/22/15 at 5:52 AM for "Soft (Velcro) Bilateral Wrists" restraints.
D. No order documented for "elbow splints" to both arms, "Pelvic/Chest" restraint, and "Side rails Up x 4 as a Restraint" that were noted in the "Non-violent Restraint Monitoring" section of the EMR from 8:00 AM 1/21/15 to 8:00 AM on 1/23/15.
E. Orders written on 2/1/15 at 5:38 PM for "Soft (Velcro) Bilateral Wrists" restraints.
F. No order documented for "Soft Ankle/Both Ankles", and "Vest/Chest" restraints that were noted in the "Non-violent Restraint Monitoring" section of the EMR from Midnight 2/1/15 to 10:00 PM on 2/1/15.

b. Pt. #2 had:
A. Orders written at 3:20 PM on 2/16/15 for "Soft (Velcro), Locking limb...Vest to Chest" restraints for "Bilateral Wrists, Right Leg, Torso/Waist".
B. No documented order for "Side Rails Up x 4 as a Restraint" that was noted every two hours from 2:00 AM on 2/17/15 through 3:00 AM on 2/18/15 in the "Non-violent Restraint Monitoring" section of the EMR.
C. Orders written at 4:18 PM on 2/17/15 for "Soft (Velcro), Locking limb...Vest to Chest" restraints for "Bilateral Wrists, Right Leg, Torso/Waist".
D. No documented order for "Side Rails Up x 4 as a Restraint" nor for "Elbow splints to both arms" that was noted every two hours from 12:00 PM on 2/18/15 through 10:00 AM on 2/19/15 as was documented in the "Non-violent Restraint Monitoring" section of the EMR.
E. Orders written on 2/23/15 at 1:02 PM for "Soft (Velcro), Locking limb...Vest to Chest" restraints for "Bilateral Wrists, Right Leg, Torso/Waist".
F. No documented order for "Mitt (tied down)" "Right hand" that was noted by nursing as being in place from 4:00 PM on 2/23/15 through 2:00 AM on 2/24/15 as was documented in the "Non-violent Restraint Monitoring" section of the EMR.

c. Pt. #3 had:
A. Orders written on 2/8/15 at 2:05 PM for "Soft (Velcro)" to "Bilateral Arms" and "Side Rails x 4".
B. No documentation of an order for "Elbow Splints" to "Both Arms" noted by nursing from 2:00 PM on 2/8/15 through 6:00 AM on 2/9/15 in the flowsheet area titled "Non-violent Restraint Monitoring".

d. Pt. #4 had:
A. Physician orders for "Soft (Velcro) Bilateral Arms" written at 6:18 PM on 2/9/15.
B. No order written for the "Elbow Splints" to "Both Arms" noted by nursing from 8:00 PM 2/9/15 through 8:00 PM on 2/10/15 as was documented in the "Non-violent Restraint Monitoring" section of the EMR.

e. Pt. #6 had:
A. Physician orders for "Soft (Velcro) Bilateral Wrists" restraints written at 9:17 PM on 2/18/15.
B. No order written for "Side Rails Up x 4 as a Restraint" that were documented from 10:00 PM on 2/17/15 through 8:00 AM on 2/18/15 and again on 2/18/15 from 2:00 PM through 8:00 PM as was documented in the "Non-violent Restraint Monitoring" section of the EMR.

f. Pt. #7 had:
A. Physician orders on 2/5/15, 2/6/15, and 2/8/15 for "Soft (Velcro) Bilateral Wrists" restraints.
B. No order written for side rails that were noted by nursing as "Side Rails Up x 4 as a Restraint" from 10:00 PM on 2/1/15 through 10:00 PM on 2/2/15 as was documented in the "Non-violent Restraint Monitoring" section of the EMR.

3. Interview with staff member #57, the RN CNS (certified nurse specialists) for NCC1 and NCC3 (neuro critical care units), and #58, the RN CNS for 4S and 5N, at 4:15 PM on 2/25/15 and 10:00 AM on 2/26/15 indicated:
a. Side rails up x 4 can be documented as a "safety" precaution, or as a "restraint".
b. It was thought that nursing erroneously documented side rails as a restraint, rather than as a safety measure.
c. No side rail restraint orders were noted for patients, as listed in 2. above.
d. It is confusing for nursing staff whether elbow splints are considered a restraint or not. When documenting elbow splints as a restraint, there should be an order for them as a restraint.
e. Per a one page "Quality & Safety Brief" document provided for nursing reference, mitts; 1 mitt tied or 2 mitts tied/untied are considered a restraint and splints, such as elbow splints, are considered restraints unless the patient can freely move the limb.

Based on policy and procedure review, medical record review, and interview, the facility failed to ensure the proof of consultation with the attending physician when a restraint was ordered by another practitioner for 6 of 10 patients (Patients #1, 2, 3, 4, 6 and 7).

Findings:
1. Review of the policy and procedure "Use Of Restraints And Seclusion", policy number SF 1.01 AP, with a last approval date of June 2013, indicated:
a. On page 3 under section "V. Policy Statements", it reads in section I., "I. When the practitioner giving an initial restraint order for Non-Violent behavior reasons is not the attending physician, the attending physician is notified by noon the following day."

2. Review of medical records #1 through #4, #6 and #7 indicated there was no documentation within the medical records that indicated notification of the patient's attending physician, by noon the following day, when restraint orders were given by another practitioner.

3. At 3:10 PM on 2/25/15, interview with staff members #53, and #54, RNs (registered nurses) and patient informatics specialists (computer specialists), indicated:
a. There was no documentation in the physician progress notes that would indicate notification of the patients having had restraints ordered by other practitioners.

4. At 4:30 PM on 2/25/15, interview with staff member #57, the RN CNS (certified nurse specialists) for NCC1 and NCC3 (neuro critical care units), and #58, the RN CNS for 4S and 5N, indicated:
a. Attending physicians are alerted during morning rounding of restraints that were ordered for their patients.
b. There is no protocol/process that would indicate that attending physicians are notified, prior to noon the following day, of restraint orders given by another practitioner, as required by facility policy.
c. Most, if not all, of the restraint orders were by other practitioners within a specialty group, and sometimes the attending practitioner will vary from one physician in a group and another in that same group, so it was thought that this would "override" the policy statement requiring notification of the attending physician. Or, that the policy requirement might be met because of this.

Based on document review and interview, the facility failed to ensure that every two hours monitoring was documented for patients in restraints, for 8 of 10 restrained patients (Pts. #1, 2, 3, 4, 5, 7, 8, and 9).

Findings:
1. Review of the policy and procedure "Use Of Restraints And Seclusion", policy number SF 1.01 AP, with a last approval date of June 2013, indicated:
a. Under section "VI. Procedures", it reads in item B. "Use of Physical Restraints for Non-violent Behavior...4. Monitoring": "Monitoring is used to provide for patient safety,...On-going monitoring is documented a minimum of every two (2) hours. a. Patient Safety...vital signs, circulation checks..., skin integrity...b. Patient Comfort...need for food, hydration, toileting...c. Circulation/Discontinuation...".

2. Review of medical records indicated:
a. Pt. #1 had no documentation of patient comfort or safety notation while in restraints from midnight 1/21/15 through to 8:00 AM documentation on 1/21/15 and on 2/5/15 for the 4 PM and 6:52 PM checks/notes by nursing, in the EMR (electronic medical record) portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
b. Pt. #2 had no documentation of patient comfort or safety notation while in restraints from 6 AM on 2/22/15 through to 8 AM on 2/23/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
c. Pt. #3 had no documentation of patient comfort or safety notation while in restraints for 2 AM, 4 AM, and 6 AM on 2/9/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
d. Pt. #4:
A. Lacked every two hour monitoring of patient restraints for the 6 PM (1800 hours) check on 2/9/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
B. Had no documentation of patient comfort or safety notation while in restraints on 2/11/15 from 8 PM to 6 AM on 2/12/15 and 8 AM and 10 AM on 2/23/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
e. Pt. #5 had no documentation of patient comfort or safety notation while in restraints for the 8 AM, 10 AM, 12 PM and 2 PM checks of restraints on 1/20/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
f. Pt. #7 had no documentation of patient comfort or safety notation while in restraints for the restraints documented from 3 PM on 2/6/15 through 6 AM on 2/8/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
g. Pt. #8 had no documentation of patient comfort or safety notation while in restraints for the restraints documented for the 8 AM, 10 AM, and 12 PM restraint checks of 2/9/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
h. Pt. #9:
A. Lacked every two hour monitoring of patient restraints between the checks of 9 PM on 2/22/15 to the midnight documentation on 2/23/15; between the 12:35 PM and 4 PM checks on 2/23/15; and between the 4 PM and 8 PM documentation on 2/23/15 in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.
B. Had no documentation of patient comfort or safety notation while in restraints on 2/22/15 from 3 PM to Midnight on 2/23/15 and again between 12:35 PM on 2/23/25 and the 8 PM documentation of comfort and safety in the EMR portion of the chart titled "All Restraints Flowsheet", specifically the "Restraint Monitoring" section.

3. Interview with staff member #57, the RN CNS (certified nurse specialists) for NCC1 and NCC3 (neuro critical care units), and #58, the RN CNS for 4S and 5N, at 4:15 PM on 2/25/15 and 10:00 AM on 2/26/15 indicated:
a. Every 2 hours monitoring of restraints was not documented for patients #4 and #9.
b. There was no every 2 hour documentation of safety and comfort checks for patients as listed in 2. above.