HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt#8) patient records reviewed for restraint use, the Hospital failed to ensure that the patient was monitored every 2 hours while restraints were in use, as required by policy.

Findings include:

1. The Hospital's policy titled, "Restraints and Seclusion" (last reviewed by Hospital on 6/4/2021) was reviewed and required, " ...Applying restraints for non-violent or non-self-destructive behavior ... F. 2 Hour assessments and documentation are completed by the RN. Frequency may be changed based upon patient need, but occurs at a minimum of every two hours ..."

2. On 2/14/2022, the clinical record for Pt#8 was reviewed. Pt#8 was admitted to the Hospital on 1/11/2021, for a transient ischemic attack (symptoms similar to those of a stroke). Pt#8's record included an order, dated 1/13/2022 at 12:49 AM, for non-violent restraints using secured mitts on both left and right hands due to interference with medical treatment. The record included nursing assessments performed at 12:30 AM (restraint started), 2:30 AM, 4:30 AM, and 6:30 AM. The assessment at 6:30 AM indicated that the restraints were continued. The next restraint assessment documentation in Pt#8's chart was on 1/13/2022 at 5:00 PM and indicated that the restraints were discontinued. However, there was no restraint documentation from 6:30 AM until 5:00 PM.

3. On 2/15/2022, at approximately 9:00 AM, an interview was conducted with the Accreditation and Policy Manager (E#4). E#4 stated that patients in restraints should be assessed every 2 hours by nursing staff. E#4 stated that Pt#8 was monitored every 2 hours up until 6:30 AM, and after 6:30 AM, we don't know what happened but can see that they were discontinued at 5:00 PM.