HospitalInspections.org

Based on record review and interview the facility failed to ensure that there was a physicians order for restraint every 24 hours in 1 of 1 restraint medical records reviewed (Patient #5) out of a total universe of 11 medical records.

Findings include:

The facility policy titled "Medical Restraint-Hospital" #14.260 last revised 01/21 was reviewed on 6/9/2021 at 10:30 AM. This document revealed "RESTRAINT PROCEDURES:-If use of restraint is necessary, a physician will order restraint prior to its application. Orders obtained in accordance with this policy to address a patient's medical care-related needs (safety) that are evidenced by non-violent or non-destructive behavior (non-behavioral restrain) are considered in full force and effect for up to one calendar day-which includes the day the order was obtained. For example, if a restraint is ordered on Monday the restraint ordered is current to the next calendar day (Tuesday)...-The Physcian's order will reflect the specific intent for the restraint, the type of restraint, and the duration for its use, which will not exceed one calendar day...Ongoing assessment of the patient's well-being while in restraints is made hourly by the nurse. The nurse will document in the EMR (Electronic Medical Record) every two hours."

Patient #5's medical record was reviewed on 6/9/2021 at 8:45 AM. Patient #5 was admitted to the facility on 4/28/2021 and discharged on 6/3/2021 after a prolonged hospitalization from a Cerebral Vascular Accident (CVA) with hemorrhage and resulting decompressive craniectomy. Patient #5 had a tracheostomy (trach) placed to maintain an airway and a percutaneous (PEG) gastric tube for feeding. Patient #5 had previously, successfully removed his trach with left hand (right hand affected from stroke and unable to move) and was admitted with a physician order for a mitt to be placed on left hand to prevent airway removal.

On 15 out of 36 days (5/5, 5/7, 5/8, 5/12, 5/14, 5/15, 5/16, 5/17, 5/20, 5/22, 5/23, 5/25, 5/27, 5/28 & 6/1/2021) there was no physician order for restraint documented and there was nursing documentation of the restraint being in place and being checked every 2 hours.

An interview was conducted with Chief Nursing Officer D at the time of Patient #5's record review who, when asked the expecatation for physician orders for restraints stated "There should be a MD (doctor) order for every one of those days. The nurses are documenting that it (left mitt) is on there should be an order and there isn't."