HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #6 and Pt. #7) clinical records reviewed regarding use of restraints for violent or self-destructive behavior, the hospital failed to ensure that the care plan was modified to reflect use of restraint as an intervention.

Findings include:

1. On 7/24/2024, the hospital's policy titled, "Restraints" (effective 3/2023) was reviewed and included, "... II.A... 1. Restraint for violent or self-destructive behavior: Initiated in emergency or crisis situation if a patient's behavior becomes aggressive or violent..." The policy did not include modification of care plan regarding use of restraints.

2. On 7/24/2024, the clinical record for Pt. #6 was reviewed. On 4/23/2024, Pt. #6 was admitted with a diagnosis of recurrent major depression. On 5/1/2024, Pt. #6 was placed on physical hold due to aggressive/violent behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention.

3. On 7/24/2024, the clinical record for Pt. #7 was reviewed. On 3/19/2024, Pt. #7 was admitted with dementia with behavioral disturbance. On 4/17/2023, Pt. #7 was placed in 4-point restraints due to aggressive/violent behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention.

4. On 7/24/2024 at approximately 1:30 PM, findings were discussed with E #8 (Education Coordinator). E #8 confirmed that Pt. #6 and Pt. #7's care plan was not modified reflecting the use of restraints for violent behavior. E #8 did not provide explanation whether use of restraint should be documented in the plan of care.