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SELECT SPECIALTY HOSPITAL-KNOXVILLE
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on facility policy review, medical record review, and interview, the facility failed to re-assess restraints in 1 (#7) of 3 patients reviewed for restraints.
The findings included:
Review of facility policy Restraints and Seclusion last revised on 6/2012 revealed "...state observations...include safety, comfort, mobility, skin integrity...from periodic observations to include removal of restraints at least 10 minutes every 2 hours..."
Medical record review revealed Patient #7 was admitted to the facility on 5/24/16 for a diagnosis of Toxic Encephalopathy.
Medical record review of a nurse's note dated 5/26/16 at 12:00 AM revealed "...pt [patient] pulling at tubes...attempts at redirection failed...pt restrained for safety..."
Medical record review of a nurse's shift assessment dated 5/26/16 from 12:00 AM to 5/27/16 at 6:00 AM revealed "...interventions for restrained patients...re-assess need q2h [every 2 hours]...assess skin integrity...q2h...NA [not applicable]..." Continued review revealed the patient's restraints were first re-assessed on 5/27/16 at 7:00 AM (7 hours after application).
Interview with the Nurse Manager on 5/31/16 at 2:05 PM, at the nurses' station, confirmed the patient's restraints were not re-assessed every 2 hours and the facility failed to follow facility policy.