HospitalInspections.org

Based on review of hospital policy, medical records and staff interviews, the nursing staff failed to ensure a physician's order for restraints for 1 of 3 non-violent restrained patients reviewed (Patient #1).

The findings include:

Review of the hospital's policy, "Restraint and Seclusion", revised 05/2012, revealed, "...RESTRAINT ORDERS: ...4. All restraint orders will be time limited, not to exceed a maximum of 24 hours. A new order will be obtained for each 24 hour period that restraint use is indicated based on the physician's examination of the patient...".

Closed medical record review of Patient #1 revealed a 66 year-old male admitted on 04/20/2014 with an acute cerebrovascular accident (stroke). Record review revealed Patient #1 was restrained on 04/20/2014 at 1700 with bilateral soft wrist restraints to prevent the patient from removing lines and equipment. Record review revealed the patient remained in restraints until 04/29/2014 at 1000. Record review revealed no physician order for restraints on 04/22/2014 and 04/23/2014.

Interview on 05/28/2014 at 1330 with administrative nursing staff revealed all restraints require a physician's order every 24 hours. Interview confirmed Patient #1 was restrained on 04/20/2014 at 1700 with bilateral soft wrist restraints to prevent the patient from removing lines and equipment and the patient remained in restraints until 04/29/2014 at 1000. Interview confirmed there was no documentation of a physician's order for restraints on 04/22/2014 and 04/23/2014. Interview confirmed the nursing staff failed to follow the hospital's restraint policy.

NC00096934