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Based on record review, policy and procedure review, and interviews, the Hospital failed to ensure that for one patient, (Patient #5), out of a total sample of 10 patients, the Plan of Care with regard to restraint use, was updated and evaluated in accordance with Hospital Policy.

Findings include:

The Hospital Policy titled Restraint Use, effective date November of 2012, indicated that a care plan to reduce restraint use will be implemented on all patients in restraints to ensure that the physical safety of the non-violent or non-self-destructive patient will be reviewed and renewed daily.

The Medical Restraint Order and Flow Record indicated that every 24 hours: a) an evaluation of the least restrictive intervention used/considered that are ineffective will be documented, b) a reason for restraint use is documented and c) the nurse will assess the restrained patient every 2 hours while in restraints for patient safety and physical needs and document.

The Medical Restraint Order and Flow Record indicated that every 12 hours (once on the 7:00 A.M. to 7:00 P.M. shift and once on the 7:00 P.M. to 7:00 A.M. shift): a) a precipitating/continued reason for restraints will be documented, b) patient specific interventions will be documented and c) the Plan of Care with regard to continued or discontinued restraint use will be assessed and documented.

Review of Patient #5's Hospital Record indicated that Patient #5 was admitted to the Hospital on 2/10/14 with a diagnosis of respiratory failure and alcoholic encephalopathy (altered mental status resulting from alcoholism). Record review indicated Patient #5 had a tracheotomy (a surgical opening into the neck which allows a person to breath without the use of the nose or mouth), feeding tube (a tube surgically inserted though the abdomen into the stomach to provide nutrition to patients that cannot obtain nutrition by mouth) and a peripherally inserted central catheter (PICC line-allows medication to be infused into a vein for a prolonged period of time). The Hospital Record indicated that Patient #5 was agitated and confused, was pulling at tubes and was unable to follow safety instructions.

Review of the Medical Restraint Order and Flow Records for Patient #5, dated 2/11/14 through 3/26/14, indicated that Patient #5 had soft mitts on both hands to prevent him/her from pulling out his/her lines and tubes which were vital to his/her care.

Review of the Medical Restraint Order and Flow Records, from 2/11/14 to 3/26/14 (39 days reviewed), for Patient #5 indicated that:

1) For 8 out of the 39 Medical Restraint Order and Flow Records reviewed, less restrictive interventions used/considered that were ineffective were not documented as required.

2) For 15 out of the 39 Medical Restraint Order and Flow Records reviewed, the reason for restraint use was not documented as required.

3) For 13 out of the 39 Medical Restraint Order and Flow Records reviewed, the every 2 hour Registered Nurse (RN) check for patient safety and need was not consistently documented as required.

4) For 11 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M shift, the precipitating or continued reason for restraint use was not documented as required.

5) For 21 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M shift, the precipitating or continued reason for restraint use was not documented as required.

6) For 5 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M. shift, patient specific interventions attempted to avoid the use of restraints were not documented as required.

7) For 11 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M. shift, patient specific interventions attempted to avoid the use of restraints were not documented as required.

8) For 34 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.


9) For 25 out of the 39 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.