HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to modify its plans of care when restraint occurred.

Findings were:

Facility policy entitled " Restraints/Seclusion " stated in part: " Clinical justification: Potential situations requiring restraints for the medical-surgical patient ...Patient determined to be at risk for falling (based on recent and observable history) and who displays an inability to follow directions, has unsteady gait and/or inability to bear weight and attempts to get out of bed and or wheelchair without assistance. "
The same policy continued concerning the Plan of Care:
" Develop a Plan of Care to include:
? desired outcomes
? interventions including attempts at alternatives to restraints
? educate and collaborate with patient and family
? assessment of and need for restraint
? type of restraint
? reassurance that patient ' s needs will be met "

Review of the medical record of Patient # 1, who was restrained from 3/20/11 thru 3/23/11, revealed no updated Plan of Care concerning restraint.

In an interview with the Chief Clinical Officer on May 12, 2011, it was confirmed that in Patient # 1 ' s Plan of Care there was not modified after a restraint that lasted 3 days.