HospitalInspections.org

Based on policy review, medical record review, and staff interview the facility failed to ensure 1 (Patient 4) of 4 sampled patients placed in physical restraints to protect staff and the patients were ordered appropriately per the hospital policy. This failed practice has the potential to cause harm or negative outcomes to all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 661.

Findings are:

A. Review of the policy titled Restraint Use (last reviewed 6/2022) revealed:

1. Restraints used on patients because of violent or self-destructive behavior is limited to emergencies in which there is imminent risk of a patient physically harming himself, staff or others, and non-physical interventions would not be effective.

2. Only RNs (Registered Nurses) who prove competency in orientation, complete mandatory education, and competency......may make decisions about, implement, and discontinue restraint use. This staff training and education will focus on:
-Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraint.

3. Physical Restraints are defined by the facility as: any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

4.. The Restraint Procedure included:
-The use of restraints will be determined by the treating practitioner.

The facility policy defines a Medical Surgical Restraint (Protection of Tubes/Lines) (Non-Violent) vs. Restraint for Violent Behavior, and indications for use per type.

B. Review of the medical record (11/19/2024 at 10:45AM) revealed Patient 4 admitted to the hospital on 10/24/2024 for care and treatment of an odontoid fracture (broken neck) from a ground level fall with a past medical history of Alzheimer's (a disorder of the brain that affects memory, thinking and leads to the inability to carry out daily tasks independently). Patient 4's electronic medical record (EMR) psychosocial patient behavior documentation on 11/2/2024 included anxious, aggression, hitting and kicking staff [violent behavior] with a non-violent four-point restraint (restraints that are applied to both wrists and ankles at the same time that restricts/prevents a person from moving) order indicated for tube and line protection from 11/2/2024 at 1:00AM until discontinued at 9:25AM, confirmed by an Accreditation Coordinator. Patient 4's EMR documentation revealed a "saline lock" intravenous (IV) (a line in the arm not being used), and a C-Collar (neck device used to protect the spine), confirmed by an Accreditation Coordinator. Patient 4's EMR restraint documentation lacked evidence of the facility following policy regarding four-point restraint use on 11/2/2024, confirmed by an Accreditation Coordinator.

C. During an interview with an Accreditation Coordinator (11/19/2024 at 10:45AM) confirmed Patient 4's medical record lacked evidence of a violent four-point restraint order on 11/2/2024.