HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt #13), clinical record reviewed for violent restraints, the Hospital failed to ensure that the restraint order for a minor was renewed every hour, in accordance with policy.


Findings include:


1. The Hospital's policy titled, "Restraint Use" (dated 9/16/2024), was reviewed and required, "...Obtaining a Restraint Order...Violent and Self-Destructive Behavior. a. Time limited order applies and may not exceed: 1 Hour-for under age 9...Continuation of a Restraint Order. Violent and Self-Destructive Behavior. When the order is about to expire, a nurse must contact the LIP [licensed independent practitioner], report the results of the most recent assessment and request that the order be renewed if appropriate..."

2. The clinical record for Pt #13 was reviewed on 3/25/2025. Pt #13 was admitted to the Pediatric Unit on 3/3/2025. Pt #13 was under the age 9. Pt #13's physician orders were reviewed. The orders included a restraint order for violent behavior (initiated on 3/6/2025 at 9:37 AM). Subsequent orders for Pt #13's violent restraints, included orders on 3/6/2025 at 10:45 AM, and 11:43 AM.

-Pt #13's restraint flowsheets included documentation indicating that Pt #13 was in violent restraints beginning on 3/6/2025 at 9:45 AM through 3/6/2025 at 2:30 PM.

Pt #13's last restraint order was on 3/6/2025 at 11:43 AM. There were 2 hourly restraint orders lacking for 12:43 PM and 1:43 PM.

3. On 3/25/2025 at approximately 1:00 PM, an interview was conducted with a Pediatric Intensive Care Unit Registered Nurse (E #13). E #13 stated that for a child under the age of 9, the order for violent restraint needs to be renewed every hour.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #2) requiring removal of an indwelling catheter, the hospital failed to ensure the nursing decatheterization (removal) protocol was followed.

Findings included:

1. The hospital's nurse driven protocol approved by the medical executive committee - "Discontinuation of indwelling Urinary Catheter per Decatheterization Protocol" was reviewed on 3/24/2025 and required, "Voids [urinate] greater then 200 ml within 6 hours or less. After each void, obtain PVR [post void residual] two times via bladder scan. If bladder scan is greater than 300 ml, proceed with straight catheterization. Repeat as needed."

2. The daily flow sheets included that the indwelling urinary catheter was removed on 7/27/2024 at 12:00 PM. The urinary totals were as follows:
- 7/27/2024 at 5:18 PM - voided 75 ml, bladder scan 290 ml
- 7/27/2024 at 11:49 PM - voided 200 ml, bladder scan 285 ml
- 7/28/2024 at 4:19 AM - voided 225 ml, bladder scan 186 ml
- 7/28/2024 at 10:55 AM - voided 225 ml, bladder scan 550 ml
- 7/28/2024 at 1:22 PM - voided 200 ml, bladder scan 433 ml
- 7/28/2024 at 3:45 PM - voided 100 ml, bladder scan 630 ml
- 7/28/2025 at 5:27 PM - voided 110 ml, bladder scan 572 ml
- 7/28/2024 at 8:00 PM - voided 100 ml, bladder scan 643 ml
- 7/28/2024 at 10:00 PM - voided 125 ml, bladder scan 686 ml
- 7/29/2024 at 12:00 AM - unable to void, discomfort, straight cath 680 ml
- 7/29/2024 at 8:00 AM - voided 10 ml, bladder scan 357 ml
- 7/29/2024 at 3:00 PM - indwelling catheter inserted per order

3. The registered nurse (E#8), who cared for Pt. #2 during the decatheterization process, was interviewed via telephone on 3/25/2025 at 10:30 AM. E#8 did not recall Pt. #2, but stated that based on the above data Pt. #2 should have been straight cathed (temporary placement) earlier. E#8 stated, "Once the catheter is removed, we wait 6 hours and allow the patient to void. Then we perform a bladder scan. If the amount of urine scanned is greater than 300 ml we will notify the attending service. Then a straight Cath will be done and the process is started over again."