HospitalInspections.org

Based on clinical record review, review of hospital documentation, review of hospital policy and interviews for 1 of 3 sampled patients (Patient #6) who was reviewed for restraints, the Hospital failed to ensure a physician order was written for the use a chair restraint. The findings include:

Patient #6 diagnoses included self-destructive behaviors.

Review of the nurse's note dated 2/27/24 with APRN #1 on 3/15/24 at 12:00 PM identified Patient #6 was picking at his/her fingers and when prompted to stop refused. Patient #6 was offered as needed (PRN) medication and/or to go to the blue room but refused. The nurse's note further identified that Patient #6 went to the dorm and banged his/her head on the wall and a physical hold was implemented for patient safety which transitioned into the restraint chair.

Review of the restraint documentation dated 2/27/24 identified that Patient #6 was placed in a physical hold (physical restraint) on 2/27/24 starting at 8:00 PM and ending at 8:05 PM (5 minutes) and Patient #6 was then placed in a restraint chair (mechanical restraint) on 2/27/24 starting at 8:05 PM and ending at 8:30 PM (25 minutes).

Review of physician's order dated 2/27/24 identified an order was obtained to place Patient #6 in a physical restraint not to exceed 20 minutes. Further review of clinical record failed to identify that an order was obtained for the chair restraint (mechanical).

Interview with APRN #1 on 3/15/24 at 12:00 PM identified that the physician's order should reflect the type of restraints the patient was placed in and an order for the restraint chair should be documented in patient #6's clinical record.

Review of facility policy on restraint use for the management of violent or self-destructive behavior identified that a restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Additionally, orders written for the application of restraints must include the date and time of the order, must be time limited, and specify the type of restraints utilized.