HospitalInspections.org

Based on review of one (1) of two (2) Medical Records (#8) of patients who were restrained, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure restraint renewal orders are obtained every twenty-four hours.

Findings include:

Reference: Facility policy titled, "Restraints and Seclusion" states, "... Use of Restraints for Non-Violent or Non-Self Destructive Patients ... Continuing use of restraint requires a renewal order which must be obtained at least once every twenty-four (24) hours ..."

Review of Medical Record #8, on 5/31/2022, revealed the following:

On 5/26/22 at 11:01 AM, "Restraints: Non-Violent or Non-Self Destructive Continuous X (times) 24 hours" were ordered. On 5/27/22 at 11:43 AM, the restraint order was renewed. The restraint renewal order was not obtained within twenty-four hours.

On 5/28/22 at 11:18 AM, "Restraints: Non-Violent or Non-Self Destructive Continuous X (times) 24 hours" were ordered. On 5/29/22 at 11:22 AM, the restraint order was renewed. The restraint renewal order was not obtained within twenty-four hours.

On 5/30/22 at 10:42 AM, "Restraints: Non-Violent or Non-Self Destructive Continuous X (times) 24 hours" were ordered. On 5/31/22 at 12:42 PM, the restraint order was renewed. The restraint renewal order was not obtained within twenty-four hours.

The above findings were confirmed with Staff #3 on 5/31/22 at 1:30 PM.