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Based on interview, and record review, the facility failed to include restraint use in one of two sampled patient's nursing plan of care (Patient 1).

This failure had the potential for missed interventions, and assessments that could have resulted in negative health outcomes for Patient 1.


Findings:


The facility's policy titled, "Use of Restraint or Seclusion (Nursing)," effective date 4/15/22, was reviewed, and indicated that the use of restraints must be documented in the patient's plan of care, or treatment plan.

Patient 1's medical record was reviewed. Patient 1 was admitted with diagnoses including chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow) and COVID-19 (a contagious respiratory virus).

A review, of Patient 1's physician's orders indicated that on 11/3/23 at 10:45 am, that he had been ordered soft wrist restraints for to both wrists for pulling on lines, tubing or dressings. On 11/4/23 at 5:38 am, this order had been discontinued.

A review, of Patient 1's nursing assessments indicated that on 11/3/23, the 7 am - 7 pm assessment was completed by Registered Nurse (RN) 1. On 11/3/23, the 7 pm - 7 am assessment was completed by RN 2. On 11/4/23, the 7am - 7 pm assessment was completed by RN 3.

In a concurrent interview, and record review, with the Patient Safety Manager (PSM) on 11/15/23 at 11:30 am, a review of Patient 1's plans of care indicated that there was no plan for restraint use, which the PSM confirmed.

In an interview, on 11/17/23 at 12:20 pm, the Senior Director of Nursing (SDN) stated, that she would think there should be a nursing plan of care for restraints.