HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined the hospital failed to ensure the Registered Nurse (RN) obtained an order for restraints, failed to document restraint observation and failed to document the discontinuation of restraints in one (1) of two (2) Emergency Department (ED) medical records reviewed for restraints (Patient #1). This has the potential to negatively affect all patient ' s by restraints being placed inappropriately.

1. Review of the medical record for patient #1 revealed the patient was placed in restraints on 1/14/13 at 0237. There was no documentation found to indicate the type of restraint used or when the restraint was removed. No physician order for restraint was found.

2. Review of hospital policy titled Restraints and Seclusion, last reviewed 12/12, revealed in part:

1. Documentation must occur in the medical record.

2. Orders for the use of restraints must be in the patient ' s record.

3. Behavior criteria for discontinuation of restraint or seclusion.

4. Fifteen minute assessments of the patient status.

5. Continuous monitoring.

3. During an interview conducted with the ED Nurse Manager on 9/8/14 at 1420, he agreed with these findings. He also revealed the restraint documentation process has been changed recently and the documentation of restraints has improved.