HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 4 clinical records (Pts. #2 and #10) reviewed for restraint use, the hospital failed to ensure that least restrictive measures/alternatives were attempted prior to placing the patient in restraints.

Findings include:

1. The hospital's policy titled, "Restraint and/or Seclusion Use and Indications in the Acute Care Setting" (revised 04/20/2023), was reviewed and required, "...Restraints are used only after alternative strategies have been attempted or considered and are unsuccessful..."

2. The clinical record of Pt. #2 was reviewed on 03/17/2025 at 10:35 AM. Pt. #2 was admitted on 03/12/2025 with a diagnosis of closed right hip fracture. A physician's order was placed on 03/13/2025 for non-violent (bilateral soft wrist and mitten) restraints due to altered mental status. Restraint flowsheets indicated that Pt. #2 was placed in non-violent restraints on 03/13/2025 at 8:38 AM. The record lacked documentation of least restrictive alternatives attempted or considered prior to using restraints.

3. The clinical record of Pt. #10 was reviewed on 03/18/2025. Pt. #10 was admitted on 01/22/2025 with a diagnosis of rhabdomyolysis (serious condition where damaged muscle tissue releases contents into the bloodstream, potentially leading to kidney damage and other complications). A physician's order was placed on 01/22/2025 for non-violent (bilateral soft wrist) restraints due to altered mental status and disrupting treatment (removing oxygen, cardiac monitor). Restraint flowsheets indicated that Pt. #10 was placed in non-violent restraints on 01/22/2025 at 1:45 PM. The record lacked documentation of least restrictive alternatives attempted or considered prior to using restraints.

4. An interview was conducted with the Manager of the 8 South Ortho Unit (E#3) on 03/17/2025, at approximately 10:45 AM. E#3 stated that the nurse should document least restrictive alternatives attempted prior to putting the patient in restraints. E#3 stated that there is a space on the restraint flowsheets for the nurse to document the alternatives; however, E#3 confirmed that it was left blank. E#3 stated that sometimes the nurse may write it in a narrative note; however, E#3 also confirmed that the notes did not include what alternatives were attempted.

A. Based on document review, observation, and interview, it was determined that for 1 of 2 patient (Pt. #2) observed, the hospital failed to ensure that the registered nurse responsible for supervision of the patient's care ensured that the call light was within reach of the patient, so that the patient could ask for assistance when needed.

Findings include:

1. On 03/18/2025, the hospital's policy titled, "Restraint and/or Seclusion Use and Indication in the Acute Care Setting" (effective 4/20/2023) was reviewed and included,"...Call light is placed within reach..."

2. On 3/17/2025 at approximately 10:05 AM, an observational tour of the 8 South Unit (Orthopedic Unit) was conducted. At approximately 10:08 AM, a patient (Pt. #2) in room 820 was observed to have bilateral soft wrist restraints on and tied to the bed. Pt. #2's call light was observed to be hanging down off the side of the bed, and Pt. #2 could not reach the call light. At approximately 10:10 AM, a registered nurse (E#4) entered the room and provided care to Pt. #2 and provided carefor Pt. #2; however, when E #4 exit Pt. #2's room the call light remained hanging from the bed and was not within the reach of the patient.

3. On 03/17/2025 at approximately 10:15 AM, E#4 was interviewed regarding access to the patient's access to call lights. E#4 stated that the call light should be close, and the patient should be able to reach it.


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B. Based on document review and interview, it was determined that for 2 of 2 post-surgical patient (Pts. #2 and #3) records reviewed, the hospital failed to ensure that assessments of vital signs were completed as required.

Findings include:

1. The hospital's policy titled, "Post-Surgical Patient Management Protocol" (revised 12/23/2022), was reviewed and required, "...Assess for: ...b. hypotension [low blood pressure]; c. fever... g. routine Post-Operative Vital Signs: q 15 min [every 15 minutes] x 3 then q4H [every 4 hours] x 48 H [hours], or as ordered..."

2. The clinical record of Pt. #2 was reviewed on 03/17/2025 at 10:35 AM. Pt. #2 was admitted on 03/12/2025 with a diagnosis of closed right hip fracture. The record indicated that Pt. #2 had a surgical procedure on 03/14/2025 at 11:25 AM, and returned to the 8 South Ortho Unit following the procedure on 03/14/2024 at 4:24 PM. A complete set of vital signs (temperature, heart rate, respirations, blood pressure, and oxygen saturation) was taken on 03/14/2025 at 4:26 PM. The next sets of vitals at 4:30 PM, 4:45 PM, and then 5:00 PM lacked the patient's temperature and respirations. Thereafter, the next set of complete vital signs was completed at 11:58 PM (nearly 7 hours later). The record also lacked vitals every 4 hours on 03/15/2025 from 12:36 PM and 10:32 PM (nearly 10 hours later); from 03/15/2025 at 10:32 PM to 03/16/2025 at 7:30 AM (nearly 9 hours later); and on 03/16/2025 from 7:30 AM to 3:47 PM (greater than 8 hours later).

3. The clinical record of Pt. #3 was reviewed on 03/17/2025 at approximately 10:50 AM. Pt. #3 was admitted on 03/08/2025 with a diagnosis of closed right hip fracture. The record indicated that Pt. #3 had a surgical procedure on 03/09/2025 at 12:59 PM, and returned to the 8 South Ortho Unit following the procedure on 03/09/2025 at 5:56 PM. A complete set of vitals signs were taken on 03/09/2025 at 6:05 PM. The record lacked documentation of the next set of vitals every 15 minutes x 3 as required. The record also lacked vital signs every 4 hours between 03/09/2025 at 10:19 PM to 03/10/2025 at 8:05 AM (nearly 10 hours later) and on 03/11/2025 from 1:32 AM to 8:20 AM (nearly 7 hours later). Other than the gaps mentioned, vitals were taken every 4 hours for a 48-hour period post-operatively; however, some assessments did not include a full set of vitals (either temperature, heart rate, respirations, blood pressure, and/or oxygen saturation were missing).

4. An interview was conducted with the Manager of the 8 South Ortho Unit (E#3) on 03/17/2025, at approximately 10:55 AM. E#3 stated that post-operatively, staff should follow the policy in regard to the frequency of vital signs. E#3 stated that for each assessment, the expectation is to obtain a complete set of vitals which includes temperature, heart rate, respirations, blood pressure, and oxygen saturation.