HospitalInspections.org

Based on hospital policy review, medical record review, and staff interview, the facility failed to discontinue a restraint at the earliest possible time in 1 of 3 (Patient #2) restrained patients.

Findings include:

Review of hospital policy number: 365, titled "Use of Restraints" revised 12/14, revealed, "OBJECTIVE: It is the goal of XXX Hospital to be a restraint free organization with the understanding that during clinically justifiable situations, restraint usage may be necessary. POLICY: It is the policy of (named facility) to attempt the least restrictive measures prior to the initiation of restraints... While in restraints, the patient will be monitored and assessed throughout restraint usage for ongoing needs, the need for controlled restraint, and for a change in the patient condition that will allow for the discontinuation of restraints... Restraints will be removed when the patient is assessed to be alert and oriented to the environment, previously exhibited inappropriate behavior has ceased, and the patient exhibits an ability to contract for safety... DEFINITIONS: A. Physical restraint is 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... EXCEPTIONS: Excluded from the requirements of this policy are any devices used for reasons as described below: 1. Medical Immobilization: Devices customarily employed during medical, diagnostic, dental, or surgical procedures that are considered a regular part of such procedures or tests. Possible examples: Surgical procedures that are considered a regular part of such procedures or tests. Possible examples: ...arm boards during IV administration... PATIENT CARE PRINCIPLES: ...10. Discontinuation: Restraint shall be discontinued by a registered nurse once the behaviors or situations that prompted restraints are assessed to no longer be harmful to the safety of the patient, staff members, or others and treatment may be accomplished through less restrictive means... RESTRAINT STANDARDS: 1. NON-VIOLENT BEHAVIOR ...4. If a provider is not available to issue an order, the Registered Nurse initiates restraint use based on an appropriate assessment of the patient. The provider is notified as soon as possible of the initiation of restraint and a verbal or written order is obtained..."

Review of the closed medical record of Patient #2 revealed a 92 year old female patient, who presented to the hospital's Emergency Department (ED) on 07/26/2015 at 1620, with a complaint of Altered Mental Status. Review revealed a Nursing Note, written by Registered Nurse (RN) #1 on 07/26/2015 at 0124, "Pt (patient) very confused with altered mental status. Pulling at monitor cords and pulse ox (oximeter) sensors. Sitter placed at bedside to watch pt." Review revealed a Nursing Note, written by RN #1 on 07/27/2015 at 0140, "Pt placed in soft restraints at this time. Continues to attempt to get out of bed and continues to pull at everything. Sitter at bedside." Review revealed a Telephone Order, obtained from Medical Doctor (MD) #1 on 07/27/2015 at 0200, which read, "Soft restraints and soft lap belt restraint as needed for patient safety. TO (Telephone Order) (MD#1) / (RN #1) RB (Read Back)." Review revealed a Nursing Note, written by RN #1 on 07/27/2015 at 0345, "Pt in soft restraints for safety. Sitter at bedside. Continues to grasp at things, move legs all around. Siderails padded for safety." Review revealed a Restraint: Non-Violent Behavior Assessment, written by RN #1 on 07/27/2015 at 0347, "Non-Violent Behavior Restraint Status: Continued, Nursing Unit Patient is Located On: ED, Indications for Initiating Restraints: Attempting to remove: Other, Other: Getting out of bed, Type/Location of Restraints: Restraint Location: total Body, Restraint Type: Soft Limb / Belt, Least Restrictive Measures Attempted: Unsuccessful measures attempted: ...Release / ROM (Range of Motion) Q 2 Hours - Yes..." Review revealed a Status Rounds Assessment, written by RN #2 on 07/27/2015 at 0436, "... 4 point restraints, sitter at bedside. Condition: Stable. Comment: received report from (RN #1). Patient is in 4 point restraints and sitter is at bedside. Patient is aggetated (sic) and being comabative (sic)..." Review revealed a Restraint: Non-Violent Behavior Assessment, written by RN #2 on 07/27/2015 at 0436, which read, "Non-Violent Behavior Restraint Status: Continued, Nursing Unit Patient is Located On: ED, Indications for Initiating Restraints: Attempting to remove: Other, Type/Location of Restraints: Restraint Location: Right UE (Upper Extremity), Left UE, Right LE (Lower Extremity), Left LE..." Review revealed a Status Rounds Assessment, written by RN #2 on 07/27/2015 at 0440, "...Comment: patient removed from lle (Left Lower Extremity) and rle (Right Lower Extremity) soft restraints upper restraints readjusted on the stretcher frame properly, patient cleaned and brief placed, linens changed and patient repositioned in bed. IVF (Intravenous fluids) running." Review revealed a Status Rounds Assessment, written by RN #2 on 07/27/2015 at 0550, "...patient family remains at bedside patient remains calm and is more coherent and states, 'I feel fresh.' NAD (No Acute Distress)." Review revealed an Admission Nursing Assessment, written by RN #2 on 07/27/2015, which read, "...Neurological Assessment Orientation: Oriented to Person, Oriented to Place, Oriented to Time, Level of Consciousness: Alert / Confused, Patient has a Sitter: No: not at this time..." Review revealed a Restraint: Non-Violent Behavior Assessment, written by RN #2 on 07/27/2015 at 0625, "...Restraint Status: Continued... Indications for Initiating Restraints: Attempting to remove: IV, Type / Location of Restraints: Right UE..."

Staff interview was conducted on 08/12/2015 at 1309, with RN #3, a charge nurse in the ED, who came on duty on 07/27/2015 at 0700. Interview revealed RN #3 went in to Patient #2's room for rounding, and observed Patient #2 to be on a hospital bed, with a wrist restraint on her right upper extremity. Interview revealed facility staff have arm boards available to maintain proper extremity positioning for IV patency that could have been utilized in lieu of a wrist restraint. Interview revealed the wrist restraint could have been removed with the other three restraints, and an arm board could have been attempted to maintain IV patency.

NC00108862