HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored every two (2) hours in accordance with hospital policy for one (1) of five (5) patients reviewed (Patient #4R).

Findings:

The hospital's "Use of Restraints Policy Summary", last reviewed 8/23/2024, states, in part, "...Approximately every two hours, the RN will assess and document the following within the EHR:
- Assess vital signs as ordered approximately every two hours. At a minimum respiratory rate should be assessed if vital signs cannot be obtained.
- A patient's need for toileting, fluid/food, and neurovascular checks to limbs, skin integrity and range of motion must be attended to approximately every two hours while awake, and the documentation should be completed appropriately.
- Criteria to determine if a restraint meets the requirements for using non-violent, non-self-destructive restraint.
- Behavioral observations of the patient in restraints.
- Patient care needs.
If the patient appears to be sleeping; the period between addressing patient's need for toileting, fluids/foods, neurovascular checks, skin integrity and range of motion cannot exceed 4 hours; and must be documented."

On 4/07/2025 at approximately 1:00 PM, Patient 4R's medical record was reviewed with the Clinical Informatics Specialist. This review indicated the following:
- On 2/12/2025 at 11:00 PM, Patient #4 had soft bilateral wrist restraints applied;
- On 2/16/2025 from 2:37 PM until 8:57 PM (a duration of five (5) hours and twenty (20) minutes), there was no documentated evidence of the required monitoring; and
- On 2/17/2025 at 6:49 PM, the restraints were discontinued.

On 4/07/2025 at approximately 1:00 PM, this finding was confirmed by the Clinical Informatics Specialist at the time of the review.