HospitalInspections.org

Based on record review and interview, the facility failed to ensure that attending physicians were consulted after another practitioner ordered restraints for 3 of 3 patients (Patient #1, #2, and #3) who were in restraints from June 2014 to August 2014.


Findings included:

-Patient #1 was admitted on 6/27/14 for "ventilator weaning following tracheostomy placement for respiratory failure." The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

Review of Patient #1's medical record did not contain notifications to the attending physician about restraint orders on the following dates: 6/28/14, 6/29/14, 6/30/14, 7/1/14, 7/2/14, 7/3/14, 7/14/14, and 7/15/14.

-Patient #2 was admitted on 6/12/14 for antibiotic therapy for right posterior thigh ulceration. The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

Review of Patient #2's medical record did not contain notifications to the attending physician about restraint orders on the following dates: 6/23/14, 6/25/14, 6/28/14, 6/30/14, 7/2/14, 7/4/14, 7/5/14, 7/6/14, 7/9/14, and 7/10/14.

-Patient #3 was admitted on 8/12/14 for "pulmonary and psychological treatment" and "continue to treat with other medical issues." The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

Review of Patient #3's medical record did not contain notifications to the attending physician about restraint orders on the following dates: 8/16/14, 8/17/14, 8/23/14, 8/25/14, 8/28/14, 8/29/14, and 8/30/14.

In an interview on 9/17/14 at approximately 1:30 PM, Personnel #1 and #2 was informed of the above findings. Personnel #1 and #2 confirmed the findings.

Policy # 201-21-036.11 "Restraints" revised 3/2013 page 6 required "i. The treating physician must be consulted as soon as possible if the restraint is not ordered by the patient's treating physician."

Based on record review and interview, the facility failed to ensure restraint orders were renewed within the required time limit for up to a total of 24 hours. Physicians' restraint orders were renewed after 24 hours, citing 3 of 3 patients (Patient #1, #2, and #3) who were in restraints from June 2014 to August 2014.

Findings included:

-Patient #1 was admitted on 6/27/14 for "ventilator weaning following tracheostomy placement for respiratory failure."

Review of Patient #1's medical record reflected a physician restraint order written on 6/29/14 at 7:00 AM. The order was renewed on 6/30/14 at 8:00 AM, 25 hours later.

-Patient #2 was admitted on 6/12/14 for antibiotic therapy for right posterior thigh ulceration.

Review of Patient #2's medical record reflected a physician restraint order written on 6/30/14 at 8:00 AM. The order was renewed on 7/1/14 at 6:00 PM, 34 hours later. Another order for restraints was written on 7/6/14 at 7:00 AM. The order was renewed on 7/7/14 at 5:00 PM, 34 hours later.

-Patient #3 was admitted on 8/12/14 for "pulmonary and psychological treatment" and "continue to treat with other medical issues."

Review of Patient #3's medical record reflected a physician restraint order written on 8/18/14 at 6:00 AM. The order was renewed on 8/19/14 at 7:30 AM, 25.5 hours later.

In an interview on 9/17/14 at approximately 1:30 PM, Personnel #1 and #2 were informed of the above findings. Personnel #1 and #2 confirmed the findings.

Policy # 201-21-036.11 "Restraints" revised 3/2013 page 5 required "8. The physician order should not exceed a period of 24 hours."

Based on record review and interview, the facility failed to ensure alternatives or less restrictive interventions were attempted prior to the use of restraints, citing 3 of 3 patients (Patient #1, #2, and #3) who were in restraints from June 2014 to August 2014.

Findings included:

Medical record review of the following patients did not indicate alternatives or less restrictive interventions were attempted prior to use of restraints:

-Patient #1 was admitted on 6/27/14 for "ventilator weaning following tracheostomy placement for respiratory failure." The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

-Patient #2 was admitted on 6/12/14 for antibiotic therapy for right posterior thigh ulceration. The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

-Patient #3 was admitted on 8/12/14 for "pulmonary and psychological treatment" and "continue to treat with other medical issues." The patient was on bilateral wrist restraints to prevent "traumatic removal of a medical device" and "unintentional harm to self" due to "cognitive impairment."

In an interview on 9/17/14 at approximately 1:30 PM, Personnel #1 and #2 were informed of the above findings. Personnel #1 and #2 confirmed the findings.

Policy # 201-21-036.11 "Restraints" revised 3/2013 page 2 required "Hospital leadership ensures...Use of least restrictive interventions to protect patient's safety. Alternatives to restraints or seclusion have failed."