HospitalInspections.org

Based on record review, interview, and facility policy review, the facility failed to ensure a restraint was not utilized without an order from a physician or other licensed practitioner for 1 of 4 patients (P21) reviewed for restraints.

Findings included:

The facility's undated policy titled, "Restraint (Non-violent and Violent) and Seclusion Policy" indicated, "E. Practitioners order restraint or seclusion."

P21's "Admission Information" revealed the hospital admitted the patient on 04/25/2024.

A "Cardiology Consult Note" for a date of service of 04/26/2024 revealed that the patient presented with generalized weakness, falls, and shortness of breath. Per the note, the patient was admitted to the intensive care unit (ICU) for further evaluation and management, with plans to perform a right and left heat catheterization.

A "Non-Violent Restraints" flowsheet revealed soft wrist restraints to the patient's right and left wrists were started on 04/26/2024 at 12:48 PM, because the patient was pulling at lines and tubes and removing equipment.

P21's medical record did not reflect an order for the use of the restraints, and there was no further documentation regarding ongoing use or discontinuation of the wrist restraints.

During an interview on 05/30/2024 at 10:24 AM, Nurse Educator #4 said there was no order for P21's restraints.

During a follow-up interview on 05/30/2024 at 10:29 AM, Nurse Educator #4 said that P21 went for a procedure right after they were intubated, then moved to a different floor. Nurse Educator #4 said if the patient arrived at a different floor without restraints in place, the nurse would not have thought to document the removal of them.

During an interview on 05/30/2024 at 10:26 AM, the Clinical Nurse Practice Specialist of the Mental Health (MH) Department said that there was no documentation in P21's medical record regarding an order for restraints.