HospitalInspections.org

Based on document review and interview, the hospital failed to ensure restraints were renewed and authorized in accordance with hospital policy in 4 instances where restraints were ordered for 2 patients in 1 facility.

Findings include:

1. Policy and Procedure review indicated the following:
Policy titled Authenticating Telephone Orders, Review/Revision Date 2/18: It is the policy of (The Hospital) to ensure a complete Medical Record, that all telephone orders shall be authenticated within 48 hours.
Policy titled Seclusion, Restraint, Physical Hold, Review/Revision Date 12/18: If a patient is released from seclusion or restraints prior to the expiration of the order, the RN (registered nurse) must obtain a new order to re-employ the seclusion or restraint.

2. Review of medical record (MR) restraint documentation for patients P3 and P4 indicated the following:
RE: Patient P3:
A telephone order to restrain patient P3 was received on 7/10/19 at 1522 hours with a maximum time of 2 hours. The order was signed by the physician on 7/26/19 (time not documented). The "Restraint/Seclusion Order/Record" indicated the patient was placed in a physical restraint at 1522 hours and released at 1527 hours. The same record indicated that P3 was placed in a physical restraint again on 7/10/19 at 1536 hours and released at 1540 hours. The same record also indicated that the patient was physically restrained on that date at 1745 hours and released at 1800 hours. The record lacked documentation of a new order having been obtained following release and prior to the 2 subsequent restraint actions.
A telephone order to restrain patient P3 was received on 7/14/19 at 1057 hours. The order was signed by the physician on 7/26/19 (time not documented).
A telephone order to restrain patient P3 was received on 7/15/19 at 1100 hours. The order was signed by the physician on 7/26/19 (time not documented).
RE: Patient P4:
A telephone order to restrain patient P4 was received on 7/5/19 at 1350 hours. The order was signed by the physician on 8/5/19 at 1720 hours.

3. In interview on 8/16/19, between approximately 4:30 p.m. and 5:30 p.m., A1, Director of Nursing, verified that the 3 restraint orders for patient P3 and the 1 for patient P4 had not been signed by the physician within 48 hours of receipt of the telephone order and that the 3 instances of physical restraint documented under one order on 7/10/19 should have each had a separate order prior to re-employing the restraint.

Based on document review and interview, the hospital failed to ensure patients were seen face-to-face within 1 hour after the initiation of restraint for 4 of 5 patients (P1, P2, P3, P5) who were restrained; the hospital failed to ensure face-to-face assessment was in accordance with their policy for 1 of the 4 patients (P3) and the hospital failed to ensure 6 nurses conducting face-to-face evaluations for 10 patients had had annual competency evaluations in accordance with their policy.

Findings include:

1. Review of the policy titled Seclusion, Restraint, Physical Hold, Review/Revision Date 12/18, indicated the following:
A physician, qualified RN (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person, face to face assessment of the patient in S/R (seclusion/restraint) within 1 hour of initiation and documents findings on the Face to Face Assessment form... The face to face evaluation is performed even in those situations where the person is release early (prior to one hour)... The evaluation incorporates the following:
*Reviews, with the staff, the physical and psychological status of the patient. *Evaluates the patient's immediate situation, the patient's reaction to the intervention, the patient's behavioral condition... *Evaluates the patient's medical condition, including a complete review of systems assessment...
Special training in addition to the S/R training completed by all clinical staff, is required for registered nurses prior to conducting the one hour face to face evaluation...
* Certification of competency is required to successfully complete training
* Competency reassessment is to be renewed annually
* The medical director/DON (Director of Nursing) or designee conducts the training sessions

2. Review of medical records (MR) indicated patients P1, P2, P3, P4 and P5 had each been restrained during their hospitalization. The MRs for patients P1, P2, P3 and P5 lacked documentation of the patients having been seen face-to-face within 1 hour of initiation of physical restraint as follows:
A. Patient P1 was restrained on 8/11/19 at 1320 hours. The MR indicated a face-to-face assessment was performed by RN (registered nurse) N2 on 8/11/19 at 1520 hours.
B. Patient P2 was restrained on 8/14/19 at 2015 hours. The MR indicated a face-to-face assessment was performed by RN N5 on 8/15/19 at 0150 hours.
C. The MR of patient P3 indicated the patient face-to-face assessments were not performed within 1 hour and were not in accordance with hospital policy as follows:
On 7/10/19 at 1522 hours, P3 was restrained. The MR indicated a face-to-face assessment was performed by a RN (not identified) on 7/10/19 at 1800 hours.
On 7/14/19 at 1100 hours, P3 was restrained. The MR indicated a face-to-face assessment was performed by a RN (not identified), date/time not documented. The "Face to Face" form indicated the patient was sleeping, but lacked documentation of the patient's "Current physical/medical status". Seven of nine (7/9) areas of the form were blank.
D. Patient P5 was restrained on 7/12/19 at 0915 hours. The MR indicated a face-to-face assessment was performed by RN N9 on 7/12/19 at 1100 hours.

3. The personnel files of N1, N2, N4, N5 and N6 were selected for review due to each having been identified as having performed face-to-face assessments within the past 3 months. The files lacked documentation of N1, N2, N4, N5 or N6 having been reassessed for "QRN" competency to perform face-to-face assessments within the past year.

4. The following was indicated in interview on 8/16/19:
Between approximately 2:30 p.m. and 4:30 p.m., A1, Director of Nursing, verified that RNs N1, N2, N4, N5 and N6 could and had performed face-to-face assessments as a QRN.
Between approximately 4:30 p.m. and 5:30 p.m., A1, Director of Nursing, verified that the MRs for patients P1, P2, P3 and P5 lacked documentation of a face-to-face having been conducted within 1 hour of initiation of restraint and verified that the face-to-face for P3 on 7/14/19 was incomplete as noted.
Between approximately 3:30 p.m. and 4:15 p.m., A5, Staff Development, verified that N1, N2, N4, N5 nor N6 had had annual competency for QRN assessment within the past year.