HospitalInspections.org

Based on record view and interview the hospital failed to ensure there was doumentation in the medical record that described the steps or interventions used before soft wrist restraints were applied for 1 of 5 patient's medical records reviewed for restraints. (#1). Findings:

Review of the medical record for Patient #1 revealed she was admitted to the hospital on 4/29/2010 with a small bowel obstruction where she was taken to the operating room for an exploratory laparotomy. Patient #1 was in the Intensive Care Unit after her surgery and on a ventilator 4/30/2010.Review of the nurse's notes on 4/30/2010 at 2:30 am revealed "... Pt awakens to verbal, follows commands with B weak handgrips..." Further review revealed at 5:35 am "...Pt bathed with linens changed. Pt more awake, reaching for ETT. B soft wrist restraints applied..." Further review revealed a signed physician order on 4/30/201at 9:05 am to "...Apply soft wrist restraints for prevention of self extubation. Soft wrist restraints not to exceed 24 hours- renew or discontinue prior to 5/1/2010 at 5:45 am..." The soft wrist restraints were applied on 4/30/2010 at 5:45 am.

An interview was held with S2, Director of Nurses on 3/9/2011 at 1:30 pm. After review of the entire medical record for Patient #1, she confirmed there was no documentation in the chart from 2:30 am on 4/30/2010 when the patient was following commands to 5:45 am on 4/30/2010 to support why the soft wrist restraints were applied. S2 Director of Nurses reported there was no documentation of the least restrictive measures or that the restraints had been explained to Patient #1 before the application of soft wrist restraints.

Review of the hospital policy and procedure titled "Restraint Usage in Behavioral and Acute Medical Surgical Care" revealed "...Before any physical restraint may be ordered or applied to a patient for medical or behavioral management there shall be supporting documentary evidence in medical record demonstrating the need for the use of emergency restraints to manage that behavior. A qualified registered nurse shall document patient behaviors that require the use of restraints to patient harm to self or others ..."