HospitalInspections.org

Based on review of hospital policy, review of medical records, and interviews with staff, the hospital staff failed to ensure a physician's order for restraints in 1 of 3 non-violent restrained patients (#6).

The findings include:

Review on 09/13/2017 of hospital policy titled, "Restraints and Seclusion" with revision date of 06/2012, revealed "...A written order, based on an examination of the patient by the MD/DO or LIP (Licensed Independent Practitioner) is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate...."

Review on 09/12-14/17 of closed medical record (Patient #6) revealed a 76 year old female admitted on 04/13/2017 for vent weaning and rehabilitation. Further review revealed nursing documentation of "Interventions for Restrained Patients--Removed Restraints (10 minutes q (every) 2 hr on 04/16/2017 at 0700, 0900, 1100, 1400, 1600, 1800, and 2000. Further review of nursing documentation on 04/17/2017 revealed "Removed retraints" at 0700, 0900, 1100, 1300, 1500, 1700, 2200, 2400, 0100, 0300, 0400, and 0600. Further review of nursing documentation of restraints on 04/18/2017 revealed "Removed Restraints" at 0700, 0900, 1100, 1300, and every hour from 1900 to 0600. Further review of nursing documentation of restraints on 04/25/2017 revealed "Removed Restraints" at 0800, 1000, 1200, 1400, 1600 and 1800. Review of nursing documentation of restraints on 05/01/2017 revealed "Removed Restraints" on every hour from 0700 to 1800 and every 2 hours from 2000 to 0600. Patient was transferred to an acute facility on May 9, 2017.

Review of orders for restraints revealed no physician orders for April 16, April 17, April 18, April 25 or May 1, 2017.

Interview at 1000 on 09/12/2017 with RN #1 revealed nurses should follow restraint orders. Further interview revealed nurses should notifiy physician for restraint questions. Further interview revealed restraint documentation was not correct.
Interview revealed bedside nurses who documented restraints were not available for interview.

NC00130666, NC00130785