HospitalInspections.org

Based on medical record review and facility policy review, it was determined the facility failed to ensure a physician's order for restraints was obtained when restraints were utilized for 2 of 5 (Patients #6 and 26) sampled patients with restraints.

The findings included:

1. Review of the facility's "Restraints--Clinical Restraint-Medical Interference Protocol" policy revealed the following : "...The use of restraint must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint by hospital policy. If restraints have been initiated by nursing staff, a physician order must be obtained as soon as possible..."

2. Closed medical record review for Patient #6 revealed verbal physician's orders dated 10/15/10 at 8:50 AM, included "Restraints per medical protocol" and ventilator settings.
An "Order for Clinical Restraint/Medical Interference Protocol" dated 10/15/10 at 11:15 AM documented, "Protocol criteria for application of restraints: Patient is intubated and may extubate if sedation level decreases or level of cognizance changes." The type of restraint was documented as soft, and location of restraint was documented as LUE and RUE. Documentation for "Alternatives tried: Change in environment, assess level of consciousness and presence of pain evaluated and relief measures instituted."
This form documented the patient's family was notified of the application of restraints and the patient and family were educated.

Telephone physician's orders, dated 10/19/10 at 10:12 PM included, "Haldol 2 mg IV Q 4 PRN agitation. OK to leave on soft restraints."

An "Order for Clinical Restraint/Medical Interference Protocol" dated 10/24/10 at 4:00 PM documented, "Protocol criteria for application of restraints: Patient is confused and is high risk for falling, wandering or interference with medical treatment." Type of restraint applied was marked as soft; location of restraint was marked as LUE and RUE. Alternatives tried were documented as "Invasive site covered, Change in environment, Asses Level of Consciousness, Presence of pain evaluated and relief measures instituted, and Utilize bed alarm monitors." There was no physician's signature on this order.

A Physical Therapy Evaluation dated 10/22/10 at 11:44 AM documented, "Pt with vest restraint on 2nd to fall in past several days... Comment: x 2. secured vest restraint B to bed... pt having previous fall per RN and now in vest restraint so pt not left up in bedside chair..."

Nurse's Notes dated 10/22/10 at 8:00 AM documented, "Torso Restraint Activity: initiated vest restraint".
Nurse's notes documented torso vest restraint was released and reapplied every 2 hours 10/22/10 at 8:00 AM through 10/24/10 at 2:00 AM.
Nurse's notes dated 10/24/10 at 2:00 AM documented, "Behavior Requiring Medical Restraint Pt confused/high risk interfering with medical tx, Pt has arterial/venous lines and may pull out, Behavior interfering with medical care, devices, tubes/drain."
There was no further documentation of restraints until 10/24/10 at 4:00 PM; nurse's notes at that time documented soft restraints LUE and RUE, and "No evidence of injury related to restraint, Restraints properly applied."
The Behavior Requiring Medical Restraint was documented as "Pt confused/high risk for falling/wandering, Pt confused/high risk interfering with medical tx."

3. Medical record review for Patient #26 revealed a verbal order dated 1/18/11 at 5:20 AM that documented "4 Point soft restraints PRN [when needed], Per Protocol."
An "ORDER FOR CLINICAL RESTRAINT/MEDICAL INTERFERENCE PROTOCOL" dated 1/18/11 at 7:00 AM documented, "...Type of restraint applied: ... Soft... Location of restraint: was marked LUE, RUE, LLE, and RLE..." There was no physician's signature on the verbal order written by the nurse.
Review of the Nurses Notes dated 1/18/11 from 12:00 PM until 1/19/11 at 2:00 AM documented "Torso Restraint Type Vest." There was no physician order for Vest restraint.