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UCHICAGO MEDICINE ADVENTHEALTH LA GRANGE
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0174
Based on document review and interview, it was determined that for 2 of 2 clinical records (Pt. #5 and Pt. #6) reviewed for restraints, the Hospital failed to ensure restraints were discontinued at the earliest possible time.
Findings include:
1. On 4/2/2025, the Hospital's policy titled, "Restraint Management" (dated 11/28/2023) was reviewed and required, "It is the objective of our Hospital to limit and/or eliminate the use of restraint...When the restraint is no longer needed, it may be discontinued at the direction of a physician, authorized licensed practitioner or trained RN or physician assistant..."
2. On 4/2/2025, Pt. #5's clinical record (dated 3/30/2025) was reviewed and indicated:
-Pt. #5 was admitted to the Hospital on 3/29/2025 with diagnosis of altered mental status.
-Pt. #5's physician order dated 3/30/2025 noted "nonviolent restraints - bilateral wrist restraints -reason for restraint -interference with medical treatment"
-Pt. #5's restraint monitoring flowsheet (every 2 hour monitoring) dated 3/30/3035 noted Pt. #5 was asleep from 3:37 AM to 8:00 AM. During this time, the flowsheet indicated that Pt. #5 was sleeping, but the restraints were kept on.
3. On 4/2/2025, Pt. #6's clinical record (dated 11/12/2024) was reviewed and indicated:
-Pt. #6 was in the ED (Emergency Department) on 11/12/2024 with the diagnosis of agitation, bipolar disorder (a mental health disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Pt. #6's physician order dated 11/12/2024 noted, "violent restraints - reason for restraints - danger to self/others - key lock bilateral wrists and ankles."
-Pt. #6's restraint monitoring flowsheet (every 15 minute documentation of monitoring) dated 11/12/2024 noted Pt. #6 was asleep from 3:45 PM to 4:30 PM. During the time Pt. #6 was documented as sleeping, the key lock bilateral wrist and ankle restraints were kept on.
4. On 4/2/2025 at 11:40 AM, an interview was conducted with the Clinical Educator (E #6). E #6 stated that restraints should be discontinued when the patient no longer has behaviors.