HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure the orders for the use of restraint were never used as a standing order or on an as needed basis.

Findings included:

Facility policy titled "Restraints" stated in part, "Purpose: To establish guidelines for the utilization of those devices that maximizes patient safety ... To provide guidelines for the safe use of restraints.
Policy:
...D. Guidelines
...2. Restraint for Acute Medical and Surgical Care
...b. Documentation includes:
*Patient's behavior
*Interventions used
*Rationale for the use of restraints
*The patient's response to the use of the restraint
...c. Orders for Restraints
...9. 'PRN' [as needed] or standing Restraint orders are not acceptable and will not be initiated. 'Trial releases' of restraints constitute a 'PRN' order.
...12. A new order must be obtained if the patient was recently released from the restraints and the patient suddenly exhibits behavior that can only be handled by reapplication of the restraint.
13. If a patient is in restraints and the visiting family requests that the restraints be taken off during the visit, a new order for restraints must be obtained if reapplication of the restraints is necessary."

Review of the medical record for patient #2 revealed a physician order dated 9/25/17 at 12:00 pm that stated in part, "Restraint orders.
The need for restraints must be evaluated daily before restraints are re-ordered. Restraints may not be ordered PRN.
1. Type of Restraint: Rt. [right] Wrist; Lt. [left] Wrist
2. Purpose for Restraints: Prevention of Traumatic Removal of Medical devices; i.e. catheters, IV lines, extubation."

Restraint documentation for 9/25/17 revealed patient #2 was restrained from 12:00 pm through 2:00 pm and from 12:00 am through 6:00 am. There was no documentation to indicate the patient was in restraints from 3:00 pm through 11:59 pm. There was no new order but the patient was placed in restraints on 9/26/17 at 12:00 am.
Nursing note dated 9/26/17 at 12:45 pm stated in part, "Family here (sister) at bedside. Family released soft restraint pt [patient] calm, not pulling at anything." Although restraint documentation was not found for 1:00 pm and 5-6:00 pm, restraints were documented throughout 9/26/17 without new orders after the family released the restraints.

Physician orders dated 9/27/17 at 7:00 am stated in part, "1. Type of Restraint: Rt. Wrist; Lt. Wrist
2. Purpose for Restraints: Preventions of Traumatic Removal of Medical devices; i.e. catheters, IV lines, extubation ..." Restraints were not used from 7a-7p. Restraints were placed at approximately 7:00 pm with no new order documented.

Nurse's note dated 9/27/17 stated in part, "6:50p Soft wrist restraints put on d/t [due to] patient pulling of heart monitor and attempting to pull at dressing to Left arm and other lines.
7:30 pm Wife came by briefly and is leaving. Wrist restraints off and patient removed heart monitor. Soft wrist restraints reapplied at house supervisor notified. Heart monitor reapplied."

The above was confirmed in an interview with the chief nursing officer and director of quality on the morning of 4/26/18.