HospitalInspections.org

Based on medical record and facility document review, facility staff failed to follow facility policy when using restraints in two (2) of four (4) patients whose medical records were included in the survey sample.

The findings include:

On 6/11/24 at 1:10 p.m., a review of four (4) patient medical records was conducted.

Patient #3 was placed in restraints on 5/15/24. There was no documentation in Patient's #3 medical record that the Registered Nurse notified or educated the patient, the patient's care partner and/or family on the reason Patient #3 was placed in restraints.

Patient #4 was placed in restraints on 5/25/24. There was no documentation in Patient's #4 medical record that the Registered Nurse notified or educated the patient, the patient's care partner and/or family on the reason Patient #4 was placed in restraints.

A review of the facility's policy "Restraint and Seclusion of Patients", revised 11/1/22 stated in part: "...e. The registered nurse shall made reasonable efforts to educate the patient or surrogate decision maker, care partner, and/or family on the reason for restraint, anticipated length of time the restraint will be used, alternatives attempted prior to applying the restraint, and conditions necessary for the restraints to be removed...7. Documentation...b. A registered nurse shall document the following using the Restraint Flowsheet...c) Education of the patient and/or care partner, family or surrogate decision maker concerning the use of restraints/seclusion...".

The findings were discussed with Staff Members #1, #2 and #5 at the exit conference at 5:00 p.m. on 6/11/24.