HospitalInspections.org

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician for one of five medical records reviewed (MR4)

Findings include:

Review of facility policy, "Restraint and Seclusion, dated June 23, 2017, revealed, "... VIII. Use of Restraint for Non Violent/Non Self-Destructive Behavior. A. Order (Written/Computerized provider order entry or CPOE). A physician order, order of a CRNP or order of a PA is required for restraint use. ..."

1. Review of MR4 revealed documentation the left upper extremity restraint order was discontinued on May 25, 2018 at 10 am. Further review revealed restraint assessments on May 25, 2018 at 12 pm, 2 pm, 4 pm, 6 pm, 8 pm, and 10 pm documenting MR4 was in left upper extremity soft restraint. No physician order was observed for left upper extremity restraints until May 27, 2018 at 11:59 pm.
2. Interview with EMP3 on June 7, 2018 at 12:00 pm confirmed the above, and revealed, "Yes, there is a glitch in the system".

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the condition of a restrained patient by trained staff at an interval determined by the hospital policy for three of five medical records reviewed (MR2, MR3, and MR4)
Review of facility policy, Restraint and Seclusion dated June 23, 2017, revealed, " VIII. Use of Restraint for Non Violent/Non Self-Destructive Behavior ... D. Ongoing Patient Assessment and Care Interventions ... 4. The continued need for the use of restraint for Non Violent/Non Self-Destruction behavior will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. Non Violent/Non Self-Destructive Behavior - every 2 hours 5. The documented assessment may include but will not be limited to: a. Release of restraint, b. Color, sensation and movement of the involved extremity(ies), c. Skin integrity/signs of injury, d. Readiness for restraint discontinuation based on observed behaviors, 3. Alternatives provided to the patient. ... "
Review of MR2 revealed the patient was in restraints on May 29, 2018, at 4 pm and 6 pm and on May 30, 2018, at 12 am. Further review revealed no documentation of a 2 hour patient assessment and care interventions on May 29, 2018, at 4 pm and 6 pm or May 30, 2018, at 12 am.
Review of MR3 revealed the patient was in restraints on May 30, 2018, at 8 am. Further review revealed no documentation of a 2 hour patient assessment and care interventions on May 30, 2018, at 8 am.
Review of MR4 revealed the patient was in restraints on May 24, 2018, at 4 pm Further review revealed no documentation of a 2 hour patient assessment and care interventions on May 24, 2018, at 4 pm.
Interview with EMP3 on June 7, 2018 at approximately 12:30 pm, confirmed the above findings.