HospitalInspections.org

Based on clinical record review and policy and procedure review, it was determined the Facility failed to monitor restrained patients as required by the Facility policy and procedure numbered R02-N and titled "Restraints and Seclusion" for one (#10) of six (#1, #4, #10, #12, #13 and #15) patients. Failure to monitor and assess Patient #10 every two hours per Facility policy and procedure had the potential to allow patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible. Findings follow:

A. Review of Patient #10's clinical record revealed restraint orders (four side rails up) dated 03/17/14 and timed for midnight. Review of the restraint documentation revealed the patient was not checked every two hours from midnight to 1900. Review of the clinical record revealed restraint orders (four side rails up) dated 03/19/14 and timed 0001. Review of the restraint documentation revealed the patient was not checked every two hours from 0700 until 0600 on 03/20/14.

B. Review of the Facility policy and procedure numbered R02-N and titled "Restraints and Seclusion" under Medical Record Documentation and Plan of Care, page 8, fourth bullet: State observations/intervention/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every 2 hours or more often (observation every two hours for medical restraints and every 15 minutes for behavioral restraints.

C. The above findings were confirmed by the CNO at 1245 on 03/27/14.