HospitalInspections.org

Based on interview and document review, the hospital failed to ensure staff removed restraints at the earliest possible time for 3 of 11 patient records reviewed (#1, #3, & #10).

Failure to ensure that staff limit the use of restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital policy and procedure titled, "Restraint and Seclusion Policy, 964," revised 07/08/24, showed that
staff must assess and monitor the patient's condition on an ongoing basis so the patient is released from the restraints at the earliest possible time regardless of the scheduled expiration of the order.

2. On 04/10/25 between 9:00 AM and 12:00 PM, the investigator and the Health Educator (Staff #1) reviewed medical records of patients who had been placed in restraints for violent or self -destructive behavior. The review showed the following:

a) On 03/01/25 at 12:00 AM, a provider ordered non-violent restraints to prevent Patient #1 from removing medical devices. During the every 2 hour required rounding for patients in non-violent restraints, at 2:00 AM and 4:00 AM, the patient was documented as sleeping and the restraints were left in place. At 6:00 AM the patient continued to sleep and the restraints were removed.

b) On 03/01/25 at 5:30 PM, a provider ordered non-violent restraints to prevent Patient #3 from removing medical devices. During the 2-hour restraint assessments on 03/02/25 at 12:00 AM, 2:00 AM, and 4:00 AM, staff failed to remove the restraints despite documenting that the patient was sleeping. Staff documented removal of the restraints at 6:00 AM.

c) On 08/29/24 at 10:15 PM, a provider ordered non-violent restraints to prevent Patient #10 from removing a medical device. On 08/30/24 at 2:00 AM, staff documented the patient was sleeping, but the restraints were not removed until 4:00 AM.

3. At the time of the review, Staff #1 confirmed the findings above.