HospitalInspections.org

Based on policy review, medical record review, and staff interview; the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure for one of one medical record reviewed with restraints (Patient #6). A total of ten medical records were reviewed. The current census was 56.

Findings include:

Review of the "Restraints" policy, revised 01/01/20, revealed a physician order was to be obtained prior to application of restraints or immediately afterwards during an emergency situation. Non-violent restraint orders were in effect for up to 24 hours and a new order was required each calendar day thereafter as appropriate.

Review of the medical record for Patient #6 revealed an admission date of 10/29/21 at 8:32 PM. A nursing note dated 10/29/21 at 10:00 PM documented the patient was disoriented, very impulsive and required a net bed and grey belt to prevent further falls. The nursing note also documented the patient was in the net bed at that time. The first order for restraints was documented on 10/30/21 at 11:27 AM for an enclosure bed and a rear locking seat belt. The medical record lacked documentation of a restraint order dated 10/31/21. The medical record contained restraint orders dated 11/01/21 at 9:10 AM and 1:31 PM for an enclosure bed and a rear locking seat belt. The medical record contained an order dated 11/02/21 at 10:43 AM for an enclosure bed and a rear locking seat belt. The medical record lacked documentation of a restraint order dated 11/03/21. The medical record contained a restraint order dated 11/04/21 at 4:14 AM for an enclosure bed and a rear locking seat belt. The medical record lacked documentation of a restraint order dated 11/05/21. The medical record contained orders dated 11/06/21 at 2:22 AM, 2:25 AM, and 2:23 PM for an enclosure bed and a rear locking seat belt. The medical record contained an order dated 11/07/21 at 1:26 PM for an enclosure bed and a rear locking seat belt. The medical record lacked documentation of a restraint order dated 11/08/21. The medical record contained an order dated 11/09/21 at 1:31 AM for an enclosure bed and a rear locking seat belt. The order dated 11/10/21 at 2:16 PM for an enclosure bed and a rear locking seat belt, was more than 24 hours after the previous order. Review of the restraint monitoring flowsheet documented the patient was restrained on 10/31/21, 11/03/21, 11/05/21, and 11/08/21. The medical record lacked documentation of any discontinuation of these restraints.

The findings were verified in an interview with Staff E on 11/10/21 at 2:00 PM.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored per policy for one of one medical record reviewed with restraints (Patient #6). A total of ten medical records were reviewed. The current census was 56.

Findings include:

Review of the "Restraints" policy, revised 01/01/20, revealed Non-violent restraint monitoring was to be completed every two hours and included hygiene/toileting, circulation and skin, hydration/feeding, range of motion, and level of consciousness/mental status.

Review of the medical record for Patient #6 revealed an admission date of 10/29/21 at 8:32 PM. A nursing note dated 10/29/21 at 10:00 PM documented the patient was disoriented, very impulsive and required a net bed and grey belt to prevent further falls. The nursing note also documented the patient was in the net bed at that time. The medical record contained orders for an enclosure bed and rear locking seat belt. The restraint monitoring flowsheet lacked documentation of two hour restraint monitoring checks on 10/31/21 from 6:00 AM to 8:00 PM, on 11/01/21 from 6:00 AM to 9:11 AM, on 11/01/21 from 10:00 AM to 1:32 PM, on 11/05/21 from 4:00 PM to 11/06/21 at 2:26 AM, on 11/06/21 from 4:00 PM to 7:54 PM, and on 11/09/21 from 3:34 AM to 8:00 AM. The medical record lacked documentation of any discontinuation of these restraints.

The findings were verified in an interview with Staff E on 11/10/21 at 2:00 PM.