HospitalInspections.org

Based on review of documentation and interviews, the hospital failed to ensure that medical records were accurately written, promptly completed, properly filed and retained, and accessible.

Findings included:

1) Review of the policy titled: Restraint Reduced Environment, section on Procedure, Restraint for Acute Medical and Surgical Care, point 10 indicated that the patient will be observed at a minimum of every hour for physical and psychosocial well being and for correct application of the restraint. The licensed nurse will be responsible for physically assessing the patient every hour, removing/reapplying restraints as indicated at a minimum of every two hours for no less than 15 minutes and range of motion provided and documenting patient teaching and pertinent observations. Reassessment for the continued need for a restraint will be completed and documented at least every shift by the licensed nurse.

Point 11 indicated that documentation will be completed on the Restraint Flow Sheet by the licensed nurse. Documentation will reflect appropriate indication of restraint use with each new order including: a) the patient behavior and the intervention used b) the rationale for the use of the restraints c) the patient ' s response to the restraint d) alternatives or other less restrictive interventions attempted.

2) Ten medical records were selected and reviewed for patients who were restrained. Seven out of ten medical records reviewed were noted to have incomplete documentation on the Medical/Clinical Restraint Documentation Form:

Patient #1: Review of documentation on 3/7/11 indicated incorrectly that Patient #1 has " NO " restraint when soft wrist restraints were utilized from 10 pm - 11 pm. Documentation and interview with Nurse #3 on 3/14/11 at noon indicated the nurse incorrectly documented the restraint time in the AM column instead of the PM column.
Patient #2: Review of documentation indicated that nursing staff failed to document restraint application/removal and hourly checks on the following days and shifts: 11/1/10 - no documentation the entire day; 11/10, 13 &19/10 - no documentation for the 3pm to 11 pm shift; 11/20/10 - no documentation for the 11pm to 7 am shift; 11/30/10 - no documentation from 3 pm - 11pm; 12/3/10 - no documentation from 11pm to 7 am; 12/8/11 from 8 pm to 11pm; 12/11/10 - no documentation the entire day for hourly checks; 12/13/10 - no documentation from 3pm to 11pm.

Patient #4: Review of documentation indicated that nursing staff failed to document hourly checks on the following days and shifts: 11/30/11- no documentation the entire day; 12/9/10 - midnight through 6am; 12/11, 12, 13, 18, & 19/10 - missing from 3 pm to 11 pm; 12/23/10 - 9 pm to 11 pm; 12/29/10 - 11 pm to 2 am.

Patient #6: Review of documentation indicated that nursing staff failed to document hourly checks on the following days and shifts: 12/11/10 - no documentation the entire day; 12/19/10 - midnight to 6 am; 12/20/10 - 8 pm to 11 pm; 12/23/10 - 9 pm - 11 pm; 12/25/10 - 3pm to 11pm; 12/26/10 - from 9 pm to 11pm;12/27/10 - from 11pm to 7 am; 12/28/10 - from 8 am to 2 pm; 1/1/11 - from 8 am to 2 pm.

Patient #8: 12/31/10 - from 8 am to 2 pm; 1/2/11 - from 8 am to 10 am; 1/4/10 - from noon to 2 pm and 6 pm to 8 pm; 1/5/11 - from 8 am to 10am, 1 pm and 3 to 5 pm.

Patient #9: Review of documentation indicated that nursing staff failed to document hourly checks on the following days and shifts: 3/10/11 - from 8 pm to midnight; 3/12/11 - from 8 am to 11 pm; 3/13/11 - from 9 am to 6 pm.

Patient #10: Review of documentation indicated that nursing staff failed to document hourly checks on the following days and shifts: 10/29/10 - from 4 pm to 11pm; 11/1/10 - from 4pm to 11pm; 11/3/10 - from 8 pm to 11pm; 11/5/10 - from 8pm to 11pm; 11/7/11 - from 8 am to 11 pm; 11/9/10 - from midnight to 6 am; 11/10/10 - from 4 pm to 11 pm; 11/11/10 - from midnight to 6 am.