HospitalInspections.org

Based on review of facility policy, medical records and interviews with facility staff, it was determined the facility failed to ensure nursing staff monitored 3 of 3 non-violent patients who were restrained. This affected Patient Identifier (PI) # 1, PI # 2, PI # 3 and has the potential to affect all patients admitted to this facility who require restraints.

Findings include:

Facility Policy:
Title: Restraints and Seclusion

1. Purpose: To establish guidelines for restraint use and seclusion and to distinguish between restraint for non-violent, non-self destructive behavior and restraint for violent, self-destructive behavior...

3.1 Definitions:

3.1.1. Restraint: 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; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...

4. Policy:

4.1 General

4.1.1. The restraint definition shall apply to all uses of restraint in all hospital care settings. Under this definition, commonly used hospital devices and other practices could meet the definition of a restraint, such as...

4.1.1.2. Use of net bed or an "enclosed bed" that prevents the patient from freely exiting the bed...

4.2. Initiation of Restraint of Seclusion...

4.2.6. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

4.2.6.1. Approved restraints from least to most are as follows:

4.2.6.1.1. side rails up times four with the intent to prevent patients from getting out of bed...

4.2.6.1.4. enclosure bed...

4.2.6.1.7. soft limb...

4.3. Monitoring and Assessment

4.3.1. Patients shall be reassessed by qualified RNs (Registered Nurses) and trained staff to determine changes in the patient's behavior or clinical condition that warrant the discontinuation of restraint or seclusion, or use of a less restrictive device, and determine the safety and well-being of the patient as indicated by the patient's condition.

4.3.2. Ongoing assessments must demonstrate that restraint or seclusion intervention is needed and remains the least restrictive way to protect the patient's safety.

4.3.3. Patient assessment and monitoring shall be individualized per patient and may include but not be limited to...
4.3.3.1. Physical assessment of skin integrity, circulation and respiration, vital signs as needed, hydration needs, elimination needs, level of distress or agitation, mental status and cognitive functioning...

4.3.4. Patients in restraints or seclusion will be offered the following as indicated by patient assessment or as requested but within the minimum time period specified in this policy.

... Fluids and nourishment... Toileting/elimination... Range of motion... Exercise of limbs... Systemic release of restrained limb...

4.3.5.1. Patients in restraints or seclusion for Non-violent, self-Destructive Behavior shall be assessed and monitored based on the patients condition, type of restraint utilized, response to restraint application, and need for interventions but at the least every 2 hours...

... Nurses Quick Guide to Restraints...

Monitoring of Restraint / Seclusion...

Document every two (2) hours using the Non-Violent, Non-Self Destructive Behavior monitoring form...

1. PI # 1 was admitted to the facility on 11/23/17 with diagnoses including Hypertensive urgency, Urinary Tract Infection (UTI), Hyperactive Delirium, Altered Mental Status related to hospitalization, UTI and Dementia.

Review of the Physician order dated 11/25/17 at 5:05 AM revealed orders for soft limb restraints and to monitor the patient every 2 hours. This order was discontinued on 11/25/17 at 10:41 AM. There was no documentation in the medical record the patient was ever restrained with soft limb restraints, nor was there documentation the patient was monitored every 2 hours according the physician orders related to these restraints.

Review of the Physician order dated 11/25/17 at 10:40 AM revealed orders for non-violent, non-self destructive restraint of an enclosure bed due to the patient was interfering with care and/or devices and an order to call materials management/central supply to order the bed.

Review of the Restraint Monitoring Form dated 11/25/17 at 7:00 PM, revealed the enclosure bed restraint was initiated.

Review of the Restraint Monitoring Form dated 11/26/17 revealed the patient and restraint was monitored at 5:19 AM.

Review of the Physician order dated 11/26/17 at 10:38 AM revealed orders for non-violent, non-self destructive restraint of an enclosure bed due to the patient was interfering with care and/or devices and to monitor the patient every 2 hours.

There was no documentation the patient and restraint were monitored until 11:23 AM, which was 6 hours and 23 minutes after the 5:19 AM monitoring.

Review of the Restraint Monitoring Forms dated 11/26/17 revealed the patient and restraint were monitored at 11:23 AM, the next documentation of assessment and restraint monitoring was at 1:53 PM, which was 2 hours and 30 minutes. The next documentation of an assessment of the patient and restraint was at 4:44 PM, which was 2 hours and 51 minutes.

Review of the Restraint Monitoring Form dated 11/26/17 revealed the patient and restraint were monitored at 5:26 PM. There was no documentation of an assessment of the patient and restraint completed until 7:00 AM, which was 13 hours and 34 minutes.

Review of the Restraint Monitoring Form dated 11/27/17 revealed the nurse documented having "Performed" discontinuation of the non-violent restraint at 7:00 AM. This documentation was not completed until 12:10 PM, which was 5 hours and 10 minutes later.

Review of the Acute PT (Physical Therapy) Daily Documentation dated 11/27/17 at 10:25 AM revealed, "... Additional Information... Pt (patient) supine in bed with needs in reach inside posey bed enclosure..."

The surveyor was unable to determine the exact time the patient's enclosure bed had been discontinued due to conflicting documentation by the nurse and PT.

An interview was conducted on 12/20/17 at 8:05 AM with Employee Identifier (EI) # 1, Director of Regulatory Services, who verified the above findings.

2. PI # 2 was admitted to the facility on 12/18/17 with diagnoses including Encephalopathy and Delirium, (unclear if the delirium was acute or a progressive decline).

Review of the Restraint Monitoring Form dated 12/18/17 revealed soft limb, 4 point restraints were initiated at 7:45 PM in the facility's emergency department.

Review of the Physician order dated 12/18/17 at 8:11 PM revealed orders for 4 point restraints for non-violent behavior as the patient was interfering with care/devices and to monitor the patient every 2 hours.

Review of the Restraint Monitoring Form dated 12/18/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 9:45 PM. This documentation was completed at 11:03 PM, which was 1 hour and 18 minutes later.

Review of the Restraint Monitoring Forms dated 12/19/17 revealed the nurse documented as having "Performed" assessments of the patient and restraints at 3:00 AM and 5:00 AM. Both assessments were documented at 7:21 AM.

Review of the Physician order dated 12/19/17 at 6:57 PM revealed orders for 4 point restraints for non-violent behavior as the patient was interfering with care/devices and to monitor the patient every 2 hours.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 7:00 AM. This documentation was completed at 8:58 AM, which was 1 hour and 58 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 9:00 AM. This documentation was completed at 10:46 AM, which was 1 hour and 46 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 11:00 AM. This documentation was completed at 12:24 AM, which was 1 hour and 24 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 1:00 PM. This documentation was completed at 2:32 AM, which was 1 hour and 32 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 3:00 PM. This documentation was completed at 3:51 AM, which was 51 minutes later.

Review of the Restraint Monitoring Forms dated 12/19/17 revealed the nurse documented having monitored the patient and restraints at 6:41 PM. The next documentation of monitoring the patient and restraints was on 12/19/17 at 10:20 PM, which was 3 hours and 39 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 7:00 PM. This documentation was completed at 10:25 PM, which was 3 hours and 25 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 9:00 PM. This documentation was completed at 10:20 PM, which was 1 hour and 20 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 11:00 PM. This documentation was completed at 11:45 PM, which was 45 minutes later.

Review of the Restraint Monitoring Form dated 12/20/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 1:00 AM. This documentation was completed on 12/19/17 at 11:37 PM, which was 1 hour and 23 minutes prior to 1:00 AM.

Review of the Restraint Monitoring Form dated 12/20/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints at 5:00 AM. This documentation was completed at 5:56 AM, which was 56 minutes later.

An interview was conducted on 12/20/17 at 8:05 AM with EI # 1, who verified the above findings.

3. PI # 3 was admitted to the facility on 12/17/17 diagnoses including Community-acquired Pneumonia, Non-ST-elevation Myocardial Infarction - type 2 and Hypertension. The patient required intubation and was admitted to the Intensive Care Unit.

Review of the Physician order dated 12/18/17 at 9:31 AM revealed orders for soft limb restraints for non-violent behavior as the patient was interfering with care/devices and to monitor the patient every 2 hours.

Review of the Restraint Monitoring Form dated 12/18/17 revealed the nurse documented having "Performed" initiation of restraints at 9:31 AM. This documentation was not completed until 11:51 AM, which was 2 hours and 20 minutes after the initiation of restraints.

Review of the Restraint Monitoring Form dated 12/18/17 revealed the nurse documented having "Performed" an assessment of the patient and restraints for 10:00 AM. This documentation was documented at 11:51 AM, which was 1 hour and 51 minutes after the assessment.

Review of the Restraint Monitoring Form dated 12/18/17 revealed the next documentation of an assessment of the patient and restraints was at 5:04 PM, which was 5 hours and 13 minutes later.

Review of the Restraint Monitoring Form dated 12/18/17 revealed an assessment of the patient and restraints was completed at 6:14 PM. The next assessment of the patient and restraints was documented at 10:42 PM, which was 4 hours and 28 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the next documentation of an assessment of the patient and restraints was at 1:51 AM, which was 3 hours and 8 minutes later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the next documentation of an assessment of the patient and restraints was at 4:52 AM, which was 3 hours and 1 minute later.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 4:00 AM and 6:00 AM. Both assessments were documented at 7:19 AM.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 8:00 AM. This documentation was completed at 10:22 AM, which was 2 hours and 22 minutes after the assessment was performed.

Review of the Physician order dated 12/19/17 at 9:49 AM revealed orders for soft limb restraints for non-violent behavior as the patient was interfering with care/devices and to monitor the patient every 2 hours.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 6:00 PM. This documentation was completed at 6:56 PM, which was 56 minutes after the assessment was performed.

Review of the Restraint Monitoring Form dated 12/19/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 10:00 PM. This documentation was completed on 12/20/17 at 1:19 AM, which was 3 hours and 19 minutes after the assessment was performed.

Review of the Restraint Monitoring Form dated 12/20/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 12:00 AM. This documentation was completed at 1:19 AM, which was 1 hour and 19 minutes after the assessment was performed.

Review of the Restraint Monitoring Form dated 12/20/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 2:00 AM. This documentation was completed at 3:42 AM, which was 1 hour and 42 minutes after the assessment was performed.

Review of the Restraint Monitoring Form dated 12/20/17 revealed the nurse documented having "Performed" assessments of the patient and restraints for 4:00 AM and 6:00 AM. Both assessments were documented at 7:21 AM.

An interview was conducted on 12/20/17 at 9:00 AM with EI # 1, who verified the above findings. EI # 1 stated it is the facility's expectation the staff documents within 30 minutes +/-(plus/minutes) of the actual time the assessment and/or initiation.