HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to ensure the promotion of a patient's right relative to the application of restraints and required documentation for each restraint episode.

Findings are as follows:

1. The hospital failed to follow its own policy titled, "Restraint Policy and Procedure," relative to the completion of the "Restraint Order Form" which includes a section to document less restrictive interventions, as well as the patient's response to the interventions and the clinical scenario leading to the application of the restraint for Patient ID #1, (Refer to A-0167).

2. The hospital failed to follow federal regulations and its own policy titled, "Restraint Policy and Procedure," relative to ensuring that a physician, other licensed practitioner, or a trained Registered Nurse completes a face-to-face assessment within an hour after the application of a restraint for Patient ID #1 who had multiple restraints ordered, (Refer to A-0178).

Based on record review and staff interview it has been determined that the hospital failed to ensure each episode of restraint is documented according to hospital policies and procedures for 1 of 4 patients reviewed for restraints, Patient ID #1.

Findings are as follows:

The hospital's policy titled, "Restraint Policy and Procedure" last approved in March of 2022 states in part,

" ...C. Restraint Documentation

1. Each episode of restraint is documented in the patient's record utilizing hospital approved documentation ..."

The hospital's "Restraint Order Form" last revised in April of 2020 outlines a section to be dated and timed by the Registered Nurse. This section includes a check list of less restrictive interventions, safe wards and de-escalation techniques implemented as well as the patient's response to the interventions and the clinical scenario leading to the application of the restraint.

Record review for Patient ID #1 revealed that on 3/14/2023 Velcro limb restraints were applied to his/her arms for self-injurious behavior and safety. The Velcro limb restraints were initially applied to the patient at 1:25 PM on this day and subsequently continued thereafter until 3/15/2023 at 11:00 AM.

Review of the "Physician's Order Form" revealed that the Velcro limb restraints were continuously ordered for this patient on the following dates and times for safety and self-injurious behavior:

3/14/2023 at:

- 1:50 PM
- 3:20 PM
- 5:02 PM
- 7:05 PM
- 9:00 PM
- 11:00 PM

3/15/2023 at:

- 1:00 AM
- 3:00 AM
- 5:00 AM
- 7:00 AM
- 9:00 AM

Further review of the above-mentioned physician orders failed to reveal evidence that a "Restraint Order Form" was completed per hospital policy for the following physician ordered Velcro limb restraints:

3/14/2023 at:

- 3:20 PM
- 7:05 PM
- 9:00 PM
- 11:00 PM

3/15/2023 at:

- 1:00 AM
- 3:00 AM
- 5:00 AM
- 7:00 AM
- 9:00 AM

During a surveyor interview on 4/12/2023 at 2:20 PM with the Chief Nursing Officer and the Administrator of Risk Management, they were unable to provide evidence that a "Restraint Order Form" was completed for the above-mentioned limb restraints applied to Patient ID #1.

Based on record review and staff interview it has been determined that the hospital failed to ensure that a patient was seen face-to-face within 1 hour by a physician, licensed practitioner, or a Registered Nurse per hospital policy after a restraint was initiated for multiple restraint episodes reviewed for Patient ID #1.

Findings are as follows:

The Hospital's policy titled, "Restraint Policy and Procedure" last approved in March of 2022 states in part,

" ...Assessment & Monitoring of a Patient in Restraint

...A face-to-face patient assessment/evaluation by a Supervising Registered Nurse (SRN) of LIP shall be done within the first hour of the restraint ..."

Review of the hospital's "One-Hour Face to Face Assessment" last revised in February of 2022 states in part,

"Instructions: For each episode of restraint, a LIP or SRN must conduct a face to face assessment using this form ..."

Additional review of the "One-Hour Face to Face Assessment" reveals the information to be gathered during this assessment includes a review of vital signs, medications, and labs, a neurological assessment, a behavioral assessment, a reason to continue the restraint, medications required, and an assessment to determine the patient's readiness for discontinuation of restraints.

Record review for Patient ID #1 revealed that on 3/14/2023 Velcro limb restraints were applied to his/her arms for self-injurious behavior and safety. The Velcro limb restraints were initially applied to the patient at 1:25 PM on this day and subsequently continued thereafter until they were discontinued on 3/15/2023 at 11:00 AM.

Review of the "Physician's Order Form" records revealed that the Velcro limb restraints were continuously ordered for this patient on the following dates and times for safety and self-injurious behavior:

On 3/14/2023 at:

- 1:50 PM ordered by Employee A
- 3:20 PM ordered by Employee B
- 5:02 PM ordered by Employee B
- 7:05 PM ordered by Employee A via telephone
- 9:00 PM ordered by Employee A
- 11:00 PM ordered by Employee A via telephone

On 3/15/2023 at:

- 1:00 AM ordered by Employee A via telephone
- 3:00 AM ordered by Employee A via telephone
- 5:00 AM ordered by Employee A via telephone
- 7:00 AM ordered by Employee A via telephone
- 9:00 AM ordered by Employee B

The patient's record failed to reveal evidence that the patient was seen face-to-face within one hour after the initiation of each restraint episode per hospital policy and federal regulations for the following Velcro limb restraints ordered by Employee A via telephone:

On 3/14/2023 at:

- 11:00 PM

On 3/15/2023 at:

- 1:00 AM
- 3:00 AM
- 5:00 AM

During a surveyor interview on 4/12/2023 at 2:05 PM with Employee B, Physician, in the presence of the Chief Nursing Officer, the Administrator of Risk Management, the Associate Administrator of Risk Management at Zambarano, and the Zambarano Nurse Manager, Employee B was provided with the hospital's "One-Hour Face to Face Assessment" form required to be completed per hospital policy for each restraint episode. When asked about the hospital's policy for completion requirements of this form, Employee B stated, "I don't think I have ever filled this out." Additionally, the Nurse Manager at Zambarano was unaware that this assessment and form was to be completed for each restraint episode.

Subsequently following the above-mentioned interview with Employee B, the Chief Nursing officer informed Employee B that the "One Hour Face to Face Assessment" form should be completed.

During a surveyor interview on 4/12/2023 at 2:20 PM with the Chief Nursing Officer, and the Administrator of Risk Management, they were unable to provide evidence that Patient ID #1 was seen face to face within an hour after the initiation of each restraint episode for which a "One Hour Face to Face Assessment" form was missing from the medical record.