HospitalInspections.org

Based on record review and interview, facility staff failed to ensure a physician order was obtained for the use of restraints, per facility policy, for 2 of 4 patients (Patient #2, #3) with restraints out of a total universe of 10 medical records reviewed.

Findings include:

Review of facility policy #14.260 titled, "Medical Restraint - Hospital" last reviewed 07/2020 revealed, "Physical Restraint: Any manual physical or mechanical method or device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her legs, body or head freely. Side rails when used to prevent a patient from freely moving from the bed...If use of restraint is necessary, a physician will order restraint prior to its application. Orders obtained in accordance with this policy...are considered in full force and effect for up to one calendar day - which includes the day the order was obtained...Orders for medical restraints cannot be written for use on an as-needed basis...Each episode of restraint use must be initiated in accordance with the order of a physician...A physician no less than every calendar day evaluates the need for restraint...Any restraint not reordered within the next calendar day will constitute a discontinued order. Nursing is responsible to remove restraints if physician does not reorder within one calendar day..."

Review of Patient #2's electronic medical record was conducted on 01/19/2021 at 2:10 PM with Director C who confirmed the following per interview:

Patient #2 was admitted to the facility on 12/29/2020. Review of the medical record revealed bilateral soft wrist restraints, bilateral mittens, and 4 side rails up were initiated on 12/29/20. Patient #2 remained in these restraints through 01/04/2021. There were no physician orders for restraints on 12/30/2020, 12/31/2020, 01/01/2021, 01/02/2021, 01/03/2021, 01/04/2021. Restraints were again initiated on 01/06/2021. Patient #2 remained in restraints through 01/09/2021. There were no physician orders for restraints on 01/07/2021, 01/08/2021, and 01/09/2021. There were no physician orders for restraints for 9 of the 11 calendar days Patient #2 was in restraints.

Review of Patient #3's electronic medical record was conducted on 01/19/2021 at 2:38 PM with Director C who confirmed the following per interview:

Patient #3 was admitted to the facility on 12/22/2020. Review of the medical record revealed Patient #3 was restrained by the use of 4 side rails on 01/02/2021 and 01/15/2021 through 01/18/2021. There were no physician orders for restraints found.

During an interview with Chief Nursing Officer (CNO) B on 01/19/2021 at 2:41 PM, B confirmed a physician order is required for each calendar day a patient is in restraints and stated, "We struggle with getting physicians to enter the orders. We have identified it as an issue."