HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure restraint orders specified which limbs were to be restrained for one (1) out of six (6) restrained patient records reviewed (Patient #11).

This failure led to Patient #11 being restrained without specific orders in 4-point (bilateral wrists & bilateral ankles) restraints as well as a body net (a net restraint device used to secure a patient's body to the bed).

Northern Light Mayo Hospital's policy titled, "Restraints," last revised 09/20/2023 states in part, "...The order shall specify the method of restraint to be used..."

Patient #11's medical record revealed an order for violent restraints, which was electronically signed by Physician Assistant #1 on 11/12/2024 at 1:30 PM. Physician Assistant #1's order stated in part, "...Injury to self, Soft limb, Order valid for 4 hours. Evaluate patient and order Restraint Continue Violent if indicated..." Physician Assistant #1's order did not specify which limbs were to be restrained.

On 04/30/2025 at 12:50 PM, the Quality Program Coordinator reviewed Patient #11's medical record and confirmed that Physician Assistant #1 ordered, "soft limb" restraints for Patient #11, but did not specify which limbs were to be restrained in the order. The Quality Program Coordinator confirmed that per Patient #11's medical record, the patient was placed in a body net and 4-point [hook-and-loop fastener] ankle and wrist restraints on 11/12/2024 at 1:45 PM. The Quality Program Coordinator additionally confirmed the body net was never ordered.