The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on review of facility's policy and interview with staff the facility did not follow their hospital policy on Restraint and Seclusions.


A. Reviewed Hospital's "Restraint and Seclusion Policy". Last revised 2014:

1. Restraints were used on patient #1 and the type was a soft cuff. The restraint protocol for " Non-Violent, Non-Self-Destructive patient " protocol of the restraint policy was used "to limit mobility related to medical or surgical procedure to prevent interruption of care." The soft cuff were used for the patient's safety since he became aggressive and suffered anxieties when family was not around attempting to pull his medical tubing and lines out.

2. " Non-Violent or Non-Self-Destructive Restraint orders. According to hospital policy:

"Each order for restraint to ensure to physical safety of non-violent or non-self-destructive
patient must be renewed once every calendar day except for ventilated ICU patients.
Ventilated ICU patient need an order for each episode of care. "

The question is what is considered a " Calendar Day? " The Duhaim ' s Law dictionary defines a " Calendar Day " as ..... " a period of time from midnight to midnight. In others a full 24 hour period (e.g. 3am to 3am) "

In better understanding of the definition of "Calendar Day." Patient #1, an 84y/o male last physician order for non-violent, non-self-destructive restraint was issued on October 25, 2015 at 6:55am and should have been discontinued unless renewed by a physician by October 26, 2015 at 6:55am. But as per documentation in medical record the order was discontinued on October 26, 2015 at 8:00am. One hour and 5 minutes later than the time the restraint were supposed to be discontinued. When the patient ' s daughter came to visit patient on the morning of October 26, 2015 (exact time unknown in the morning) she noticed the patient had soft cuff ' s on and inquired to nursing staff why they were on.

3. " D. Notification of the Patient ' s Family "

"Efforts are made to discuss the issue of restraint, when practical, with the patient and
family around the time restraint or seclusion is applied. In cases in which the patient, or
surrogate decision maker, has consented to have the family kept informed regarding his or
her care and the family has agreed to be notified, staff attempts to contact the family
promptly to inform them of the restraint or seclusion episode and document the
notification in the medical record. "

Did not see in medical record where this step was taken on October 24 an October 26, 2015 when the patient physician gave orders for restraining the patient using the "non-violent, non-self-destructive protocol". Notification form for family was included in the record but was not filled out by staff with a signature from the patient/representative of the patient. There is no evidence that the patient's representative was informed.

4. On section " G. Documentation " it states " iv. Notification of the patient ' s family, when appropriate "
There was no evidence the patient family was notified.

5. In review of the "24-Hour Restraint Flowsheet" which is the every 2 hour restraint assessment sheets. It was observed that on these sheets from the period of October 24, 2015 to October 26, 2015 the assessment sheets were incomplete. They are checked off every 2 hours as required but there is no signature with initials, date and time of the staff that performed the assessments.

B. Interview with Staff:
1. Interviewed staff # 6, Nurse Director at 10:20 am on February 25, 2016,in the Health Information Management office. Staff #6 also reviewed medical record from period of October 14, 2015 to November 2, 2015. Staff #6 could not find evidence that the patient family was notified of patient needing to be restrained with soft cuffs. There was a form in the medical record titled "Laredo Medical Center - Restraint Education and Guidelines " that informs family members that a patient may be physically restrained to prevent harm to the patient while he/she is recovering from an illness or injury. The family signature and relationship to patient area is left blank but a date of 10/24/15 and time 0655 is written in the date and time space. Staff #5 when asked when the physician order for restraint on October 25, ,2015 should have ended she also explained anytime within and not to exceed 6:55am on October 26, 2016. No evidence could be provided that the hospital policy was followed with these two requirements.

2. Interviews with staff # 7, registered nurse and staff #8, registered nurse at 3:20pm and 3:35pm in the medical directors office on the telemetry unit also could not provide evidence that the policy was followed on these two situations.