HospitalInspections.org

Based on review of 10 patient records, the hospital failed to meet the standard of care when without an order, staff inserted an unnecessary indwelling catheter into patient #2 during a restraint event.

Patient #2 is a 17-year-old female who presented to the emergency department (ED) via ambulance on 8/11/2012 at 1:45 am. Patient #2 was noted to be drinking alcohol at a friend's home when her father discovered and attempted to bring her home. She resisted, fought him, and then became intermittently limp. Patient #2 has a history of bipolar disorder, Post Traumatic Stress Disorder (PTSD), and anxiety. On entry to care, her vitals were, blood pressure 130/75, pulse of 127, respirations of 23, and SpO2 of 96%. She was found positive for Cannabinoids, and had a serum alcohol of 183.
Documentation reveals that at 2:30 am, shortly after going into 4-point restraint, patient #2 received an indwelling Foley catheter. No physician order for the catheter appears in the record. Additionally, while staff needed urine for an ordered toxicology, there was no indication that an indwelling Foley catheter was necessary which presented an increased risk of infection for patient #2.

Based on a review of 10 patient records, and the hospital policy, the hospital failed to write a continuation order for the restraint of patient #2.

Patient #2 is a 17-year-old female who presented to the emergency department (ED) via ambulance on 8/11/2012 at 1:45 am. Patient #2 was noted to be drinking alcohol at a friend's home, when her father discovered and attempted to bring her home. She resisted, fought him, and then became intermittently limp. Patient #2 has a history of bipolar disorder, Post Traumatic Stress Disorder, and anxiety. On entry to care, her vitals were, blood pressure 130/75, pulse of 127, respirations of 23, and SpO2 of 96%. She was found positive for Cannabinoids, and had a serum alcohol of 183.
An order for restraint was written at 2:15 am for up to 2 hours. Patient #2 was placed in 4-point Velcro restraints which continued until 4:53 am. A new order for restraint, due at 4:15 am, is not found in the record.