HospitalInspections.org

Based on clinical record review, policy and procedure review and interview, it was determined four of four (#4-#7) patients were restrained without an order from a physician. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints. The failed practice affected Patient #4-#7 and had the potential to affect all patients requiring restraints. The findings follow:

A. Review of the policy "Use of Restraints in Non-Psychiatric Hospital or Unit" on 03/23/17 revealed the following:
1. "1. Determination if a device is a restraint... The following are NOT considered restraints: i. Side rails used to prevent the patient from falling out of bed. Examples include side rails used on stretchers, raising fewer than 4 rails when the bed has segmented side rails allowing the patient to freely exit the bed, use of all 4 side rails in a bed that is in constant motion, use of padded side rails in patients needing seizure precautions, and use of side rails in patients that are not physically able to get out of bed therefore the side rails are not causing a limitation of movement."
2. "2. Devices NOT approved for use. a. Restraint belts: non-removable fabric belt placed around the torso or waist with straps to restrain individuals in bed or chair. (Pelvic Restraints that are applied through the legs and around the pelvis are authorized for use only when the patient is up in a chair or wheelchair and are considered restraints)."
3. "Order/Renewal" for non-violent, non-self-destructive patients "Requires LIP (Licensed Independent Practitioner) reorder every 24 hours."

B. The findings of A were confirmed in an interview with the Director of Quality/Risk Management and the Nurse Manager of the South and East Units on 03/23/17 at 1015. They confirmed when four side rails were up to prevent the patient from exiting the bed the side rails would be considered a restraint. They confirmed an enclosed bed would be considered a restraint.

C. Review of Patient #4's clinical record on 03/23/17 revealed siderails times four was implemented from 02/11/17 at 1500 to 02/12/17 at 0659, from 02/12/17 at 1000 to 02/12/17 at 1159, from 02/12/17 at 1500 to 02/13/17 at 0559 and from 02/13/17 at 2000 to 02/14/17 at 1759. There was no evidence of a physician's order for the restraint.

D. The findings of C were confirmed in an interview with the Director of Quality/Risk Management and the Nurse Manager of the South and East Units on 03/23/17 at 0950.

E. Review of Patient #5's clinical record on 03/23/17 revealed the following:
1. Siderails times four was implemented, for example, from 03/02/17 at 1800 to 03/03/17 at 0359, from 03/06/17 at 0600 to 03/07/17 at 0559, from 03/08/17 at 2200 to 03/09/17 at 0959, from 03/10/17 at 1600 to 03/11/17 at 1959, from 03/14/17 at 2000 to 03/15/17 at 0759, from 03/21/17 at 1800 to 03/22/17 at 0559 and from 03/22/17 at 1800 to 03/23/17 at 0559.
2. A pelvic restraint was implemented, for example, from 03/02/17 at 0800 to 03/02/17 at 1759, from 03/04/17 at 0800 to 03/04/17 at 1359, from 03/15/17 at 1200 to 03/15/17 at 1559 and from 03/20/17 at 0600 to 03/23/17 at 1159.
3. There was no evidence of a physician's order for the restraints.

F. The findings of E were confirmed in an interview with the Director of Quality/Risk Management and the Nurse Manager of the South and East Units on 03/23/17 at 0945.

G. Review of Patient #6's clinical record on 03/23/17 revealed the following:
1. A bed enclosure was implemented, for example, from 02/12/17 at 2000 to 02/13/17 at 0759, from 02/13/17 at 1600 to 02/14/17 at 0359, from 02/15/17 at 2000 to 02/16/17 at 0559, from 02/16/17 at 1400 to 02/17/17 at 0759, from 02/18/17 at 0600 to 02/18/17 at 1759, from 02/20/17 at 2000 to 02/21/17 at 0759 and from 02/22/17 at 2000 to 02/23/17 at 0559.
2. A pelvic restraint was implemented from 02/23/17 at 1000 to 02/23/17 at 1159.
3. There was no evidence of a physician's order for the restraints.

H. The findings of G were confirmed in an interview with the Director of Quality/Risk Management and the Nurse Manager of the South and East Units on 03/23/17 at 1005.

I. Review of Patient #7's clinical record on 03/23/17 revealed the following:
1. A bed enclosure was implemented from 01/23/17 at 1900 to 01/24/17 at 0599 and from 01/25/17 at 1800 to 01/25/17 at 1959 and a lap buddy (pelvic restraint) was implemented from 01/25/17 at 1200 to 01/25/17 at 1659.
2. There was no evidence of a physician's order for the enclosed bed or the pelvic restraint.

J. The findings of I were confirmed in an interview with the Director of Quality/Risk Management and the Nurse Manager of the South and East Units on 03/23/17 at 1015.