HospitalInspections.org

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Based on interview, document review, and review of hospital policy and procedure, the hospital failed to evaluate and document the type of restraint utilized for patients on the medical unit in 1 of 5 medical records reviewed (Patient #1).

Failure to evaluate and document the types of restraints utilized for patients risks physical and psychological harm, loss of dignity, and a violation of patients' rights to be removed from restraints as soon as indicated.

Findings included:

1. Documentation review of the hospital's policy titled, "Restraint and Seclusion for Patient Safety," policy number 900.5274, last reviewed 07/22, showed that the type of restraint used on patients will be documented once a shift by the assigned registered nurse (RN).

2. On 7/26/23 at 10:00 AM Investigator #1, Investigator #2, Special Program Manager (Staff #1), Patient Safety Consultant (Staff #2), and the Inpatient Director (Staff #3) reviewed the medical records of Patient #1. The medical record showed that from 05/15/23 to 05/21/23, a RN from the 7:00 AM to 7:30 PM shift failed to define the type of restraints in use as part of Patient #1's care.

3. On 07/26/23 at 10:30 AM, Staff #2 confirmed to Investigator #2 that documentation of the type of restraint used could not be found in the medical record.
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Based on interview and document review, the hospital failed to document that the providers ordering restraints were given a working knowledge of hospital policy regarding the use of restraints in 2 of 2 provider files reviewed (Staff #5, Staff #6).

Failure to ensure that providers have a working knowledge of restraint policy puts patients at risk for restraint-related harm.

Findings included:

1. Documentation review of the hospital's policy titled, "Restraint and Seclusion for Patient Safety," policy number 900.5274, last reviewed 07/22, showed that providers who order restraint or seclusion shall be educated in the requirements of the restraint and seclusion policy.

2. On 07/26/23 at 1:30 PM, Investigator #1 and Investigator #2 reviewed medical staff documentation with the Medical Staff Specialist (Staff #7) and the Accreditation & Clinical Compliance Consultant (Staff #1). The review showed that documentation of restraint and seclusion education could not be found for Staff #5 or Staff #6.

3. On 07/28/23 at 9:00 AM, Staff #1 verified that documentation of restraint and seclusion education could not be found for Staff #5 or Staff #6.
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