HospitalInspections.org

Based on document review and interview, it was determined for 1 of 4 (Pt #6) patients records reviewed, who required the use of restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LIP), authorized to order restraints.

Findings include:

1. The Policy titled "POC-46-a Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (revised 08/2024)" was reviewed on 04/14/2025. The policy noted, " ...3. The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated... 2. The physician's order for use of restraint or seclusion will be recorded in the medical record..."

2. The Restraint Log for January 1, 2025 to April 14, 2025 was reviewed on 4/14/2025. The log noted Pt #6 was placed in physical restraints on 2/1/2025, 2/14/2025, 2/15/2025, and 2/19//2025.

3. The clinical record of Pt #6 was reviewed on 04/15/2025. Pt #6's record lacked orders and/or Restraint Packets on the following dates: 2/1/2025, 2/14/2025, 2/15/2025, and 2/19/2025.

4. An interview was conducted on 04/15/2025 at approximately 11:30 AM with the Chief Nursing Officer (E #5). E #5 reviewed Pt #6's record and verbally agreed, there is no documentation of physical restraints in the record and no order for restraints. E #5 stated, "There should be documentation of the restraints and there should be restraint orders. The only way we knew (Pt#6) was in restraints was from the Restraint Log."