HospitalInspections.org

Based on a review of medical records, facility policy and staff interview, it was determined that the facility failed to ensure that patients ordered restraints did not receive the required every 2 hour monitoring and assessment for one of five medical records reviewed (MR5, MR6, MR7, MR8, and MR14).


Findings include:


Review of facility policy, Restraints Non-Violent, Non-Self-Destructive, reviewed, December 2018. ... D. Monitoring: 1. Patient will be monitored during the use of restraints to determine their physical and psychological well-being at a minimum of every two (2) hours. a. Monitoring will include, but not limited to, the assessment of peripheral circulation/sensation, range of motion, skin integrity/breakdown, integrity of lines/airway. b, Patients will be offered food/fluid, toileting and hygiene at least every two (2) hours. PROM exercises or position changes will be provided at least every two (2) hours. ...."


Review of MR5, January 22, 2019. December 11, 2018, Restraints ordered for bilateral wrists at 7:00 PM, documentation of monitoring and assessment from 7:00 PM to 1:00 AM. No further documentation noted.


Review of MR5, January 22, 2019. December 12, 2018, Restraints ordered for bilateral wrists at 7:00 AM, documentation of monitoring and assessment from 7:00 AM to December 13, 2018, at 1:00 AM. No further documentation noted.


Review of MR5, January 22, 2019. December 17, 2018, Restraints ordered for bilateral wrists at 7:00 PM, documentation of monitoring and assessment from 7:00 AM to 8:00 PM. After 8:00 PM monitoring and assessment documentation was noted every three (3) hours.


During interview with EMP1 January 23, 2019 at approximately 1:30 PM, EMP1 confirmed above findings.