HospitalInspections.org

Based on review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility failed to ensure the physical safety of the non-self-destructive patient by renewing the restraint orders as authorized by hospital policy in one of three restraint medical records reviewed (MR3).

Findings include:

Review of "Restraint Policy," revision date March 4, 2022, revealed, "Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP) responsible for the patients' care and authorized to order restraint use ... The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once weekly ..."

1. Review of MR3, on June 20, 2024, revealed, no physician/licensed independent practitioner restraint order for the time period of February 28-March 11, 2024. Further review revealed that the patient was documented in restraints on those dates.

At approximately 2:27 PM on June 27, 2024, when asked if there were any orders for restraints for the missing time period, EMP1 stated, "I am unable to locate one (restraint order) at this time."

At approximately 11:49 AM on July 5, 2024, EMP1 confirmed that removal of lines and medical equipment is viewed as a non-self-destructive behavioral reason for restraint, per facility policy.