HospitalInspections.org

Based on review of medical records and hospital documents, and interviews with hospital staff, the hospital failed to ensure restraints were applied according to physician orders. This occurred in three of three emergency department patient records (Record #s 1,2 and 3) reviewed where restraints were applied.

Findings:

1. Staff D from medical records confirmed on 08/15/13 in the afternoon that the medical records #1, 2, and 3 did not contain orders for restraints Staff D stated the computer program did not have a way to document a physician's order for restraints or for authentication of a restraint order.

2. According to nursing documentation:
a. Patients #1 had four-point leather restraints applied by the police officers;
b. Patient #2 had soft wrist and ankle restraints applied;
c. Patient #3 had leather restraints applied by the police officers and one nurse, but documentation did not specify the areas where the restraints were applied.