HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to ensure that the practitioner responsible for the care of the patient authenticated, dated, timed and signed the restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for six out of 14 restraint orders reviewed for three current patients (#19, #22, and #23). This failure had the potential to cause poor nursing care outcomes for all patients placed in restraints. The census at the Central West End campus was 20, and at the South campus was 26, the hospital had a combined census of 46 patients.

Findings included:

Review of the hospital's policy titled, "Physical Restraints and Seclusion," dated 06/2022, showed:
- Staff should obtain an order for non-violent restraint (a device used to prevent the disturbance of an essential medical device or equipment; or to prevent the interference with necessary care or treatment) use immediately upon application or within a few minutes of initiating the restraints.
- A non-violent restraint order had a maximum duration of seven calendar days following the calendar day the order was obtained.
- The provider must complete an initial face-to-face with the patient within one calendar day after the restraint was applied.
- The ordering provider must complete an assessment related to the type of restraint used and criteria for release from the restraint.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 2019, showed practitioners are responsible for the prompt completeness and accuracy of the medical record and should ensure that all entries into the medical record and all verbal orders are to be authenticated, dated, timed and countersigned within 48 hours.
Review of the hospital's policy titled, "Authenticating Verbal/Telephone Orders and Transcribed Documents in the Electronic Medical Record," dated 06/2022, provided no direction to the provider or nursing staff regarding the required time frame for authenticating and signing telephone or verbal orders.

Review of the hospital's policy titled, "Order Entry in the Electronic Medical Record," dated 06/2022, provided no direction to the provider or nursing staff regarding the required time frame for authenticating and signing telephone or verbal orders.

Although requested, the hospital failed to provide a policy that specifically addressed the allowed time frame for the provider to authenticate, sign, date, and time any telephone or verbal orders.

Review of the restraint documentation for Patient #19 showed:
- He had non-violent mitten restraints applied to both hands on 03/23/23 at 4:45 PM and they remained in place until 10:10 PM, a total of five hours and 25 minutes. The provider signed the order for the restraints on 03/23/23 at 11:30 AM, five hours and 15 minutes before the restraints were applied.
- He had non-violent mitten restraints applied to both hands on 03/24/23 at 9:00 AM and they remained in place until 4:10 PM, a total of seven hours and 10 minutes. The provider assessment was not completed within one calendar day. The provider had not signed, dated, or timed the restraint order.
- He had non-violent wrist restraints applied to both wrists on 03/24/23 at 4:55 PM and they remained in place until 03/26/23 at 4:00 PM, a total of 35 hours and five minutes. The provider assessment was not completed within one calendar day. The physician had not signed, dated or timed the restraint order.
- He had non-violent wrist restraints applied to both wrists on 04/13/23 at 7:00 PM and they remained in place until 04/15/23 at 6:02 AM, a total of 35 hours and two minutes. The telephone order documentation was not completed, there was no ordering provider identified, and the provider assessment had not been completed within one calendar day. The provider had not signed, dated or timed the restraint order.

Review of the restraint documentation for Patient #22 showed she had non-violent, mitten restraints applied to both hands on 02/22/23 at 5:43 PM and they remained in place until 02/24/23 at 6:00 PM, a total of 48 hours and 17 minutes. The telephone order documentation was completed. The provider signed, dated and timed the restraint order, 48 hours and 17 minutes after the restraints were applied.

Review of the restraint documentation for Patient #23 showed she had non-violent, mitten restraints applied to both hands on 03/10/23 at 12:05 AM and they remained in place until 03/12/23 at 6:41 PM, a total of 42 hours and 36 minutes. The telephone order documentation was not completed, there was no ordering provider identified, and the provider assessment had not been completed within one calendar day. The provider had not signed, dated or timed the restraint order.

During an interview on 05/23/23 at 10:50 AM, Staff H, Registered Nurse (RN), stated that restraint orders and documentation were on paper, the orders were good for seven days and that the provider had 24 hours to sign any verbal or telephone order.

During an interview on 05/23/23 at 11:00 AM, Staff G, RN, stated that restraint orders and documentation were on paper, the orders were good for seven days and the provider had 48 hours to sign any verbal or telephone orders.

During an interview on 05/23/23 at 11:36 AM, Staff E, Wound Care Coordinator, stated that the physician had 24 hours to sign restraint orders and the orders were valid for seven days.

During a joint interview on 05/24/23 at 2:15 PM, Staff A, Director Quality Management and Staff M, Chief Executive Officer, stated that physicians were required to sign all verbal or telephone orders within 48 hours.