HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) clinical records reviewed for restraints, the Hospital failed to ensure that the patient was free from restraints of any form that are not medically necessary.

The findings include:

1. On 9/7/2021, the Hospital's policy titled, "Restraint and Seclusion" (reviewed by the Hospital on 1/18/2021), was reviewed and indicated, " ...Restraint must be discontinued at the earliest possible time, when the patient meets behavior criteria for their discontinuation ..."

2. On 9/7/2021, Pt#1's clinical record was reviewed and indicated that on 7/26/2021, Pt#1 presented to the Emergency Department (ED) with psychosis, homicidal ideation, and suicidal ideation.

-Pt#1's record indicated that on 7/26/2021 at 4:17 AM and again at 8:17 AM, violent 4 point hard restraints were ordered by the Physician for a duration of 4 hours (each episode).

-The restraint flowsheet, dated 7/26/2021, indicated that Pt. #1's restraints were applied on 7/26/2021 at 4:18 AM and were discontinued on 7/26/2021 at 8:30 AM.

-The restraint flowsheet indicated that Pt#1 was monitored continously as required, and observation was documented every 15 minutes. On 7/26/2021 from 7:00 AM until 8:30 AM, Pt#1 was documented as sleeping, yet remained in restraints.

-Pt#1's clinical record lacked documentation of the continued need for 4 point restraints after 7:00 AM, when Pt #1 was noted to be sleeping.

3. On 9/8/2021, at approximately 9:40 AM, an interview was conducted with the Director of Behavioral Health (E#9). E#9 stated that once a patient is no longer exhibiting the behaviors that required the restraint, her general rule was to remove the restraints within 30 minutes. E#9 stated that if a patient was sleeping with restraints on for 1.5 hours, she would definitely be asking why the restraints were left on.