HospitalInspections.org

27086

Based on staff interview and record review, it was determined the hospital failed to ensure restraint orders were complete for 4 of 4 restrained patients (#1, #2, #3, and #4) whose records were reviewed. This resulted in physician orders that were not clear. Findings include:

1. Patient #1 was a 77 year old female who was admitted to the hospital on 5/27/11. "RESTRAINT ORDERS," dated 6/09/11 at 11:00 AM, included an order for soft wrist restraints. The order did not state whether soft wrist restraints were for the right wrist, left wrist, or both wrists.

During an interview on 6/12/11 beginning at 2:50 PM, the Accreditation Manager reviewed Patient #1's record and confirmed the order did not identify which wrists were to be restrained.

A physician's restraint order did not include the location of the restraint. The order was incomplete.

2. Patient #2 was a 56 year old female who was admitted to the hospital on 6/06/11. "RESTRAINT ORDERS," dated 6/10/11 at 9:30 AM, included an order for soft wrist restraints. The order did not state whether the restraints were for the right wrist, left wrist, or both wrists.

During an interview on 6/12/11 beginning at 2:50 PM, the Accreditation Manager reviewed Patient #2's record and confirmed the order did not identify which wrists were to be restrained.

A physician's restraint order did not include the location of the restraint. The order was incomplete.

3. Patient #3 was a 67 year old female who was admitted to the hospital on 6/05/11. "RESTRAINT ORDERS," dated 6/10/11 at 9:30 AM, included an order for soft wrist restraints. The order did not state whether the restraints were for the right wrist, left wrist, or both wrists.

During an interview on 6/12/11 beginning at 2:50 PM, the Accreditation Manager reviewed Patient #3's record and confirmed the order did not identify which wrists were to be restrained.

A physician's restraint order did not include the location of the restraint. The order was incomplete.

4. Patient #4 was a 32 year old female who came to the Emergency Department on 6/11/11. "RESTRAINT ORDERS," dated 9/11/11 at 1:15 PM, included an order for Geodon for agitation and self-destructive behavior. The order did not state the dosage or route of the medication (chemical restraint).

During an interview on 6/13/11 at 4:00 PM, the Accreditation Manager reviewed Patient #4's record and stated an RN took a verbal order and entered the complete order in "IBEX" (a computer software program). She stated the hospital required physicians to complete a handwritten restraint order, in addition to the computer documentation. She acknowledged the order in the computer was not identified as a restraint and the handwritten order was incomplete.

A physician's chemical restraint order did not include the dosage or route of the restraint. The order was incomplete.




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