HospitalInspections.org

Based on review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with a written modification to the patient's plan of care in two of five restraint medical records reviewed (MR9 and MR10).

Findings include:

Review on October 25, 2016, of facility policy "Restraint: Alternatives and Utilization", dated March 2016, revealed "C. Documentation ... 2. Prior and during each episode of restraint the following information is documented ... m. Revision to the plan of care."

1) Review on October 25, 2016, of MR9's Nursing progress notes revealed the patient was in bilateral upper extremity soft limb restraints on October 11, 2016, at 12:00 PM. Further review of MR9 revealed no documented evidence the patient's plan of care was updated to include the use of restraints.

Interview with EMP9 on October 25, 2016, at 1:40 PM, confirmed there was documented evidence in MR9 the patient was placed in restraints on October 11, 2016. EMP9 further confirmed there was no written modification to the patient's plan of care in MR9.

2) Review on October 25, 2016, of MR10's Nursing progress notes revealed the patient was in bilateral upper extremity soft limb restraints on October 12, 2016, at 4:00 AM. Further review of MR10 revealed no documented evidence the patient's plan of care was updated to include the use of restraints.

Interview with EMP9 on October 25, 2016, at 1:50 PM, confirmed there was documented evidence in MR10 the patient was placed in restraints on October 12, 2016. EMP9 further confirmed there was no written modification to the patient's plan of care in MR10.