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OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0187
Based on record review and interview, the hospital failed to ensure there was documentation in the medical record of the patient's condition that warranted the use of 4-point soft restraints for 1 (#1) of 3 patients medical records reviewed.
Findings:
Review of the hospital's policy titled "Restraint and/or Seclusion and Safe Patient Behavior Management" last reviewed 06/23/2025 revealed in part: "Philosophy: Whenever restraint must be used, the least restrictive device is utilized. Policy: The patient has the right to be free from restraint or seclusion that is not deemed clinically appropriate and justified. The decision to use restraint or seclusion is not driven by setting or diagnosis, but by a comprehensive individual assessment which concluded that for this patient, at this time, the use of less intrusive measures poses a great risk than the risk of using restraint or seclusion."
Review of Patient #1's medical record revealed Patient #1 was admitted on 11/01/2025 with an admit diagnosis of circulatory shock. Further review of the medical record revealed an order dated/timed on 11/05/2025 at 4:00 AM for bilateral 4-point soft wrist and ankle restraints. The 4-point soft restraints were discontinued on 11/05/2025 at 11:30 AM. Further review of Patient #1's medical record revealed Patient #1 was pronounced dead on 11/05/2025 at 1:23 PM.
Review of Patient #1's nursing notes dated 11/05/2025 at 4:12 AM by S3RN revealed a clinical justification for the use of 4-point soft restraints for pulling lines; pulling tubes; removal of equipment; and removal of dressing. Further review of Patient #1's nursing notes dated 11/05/2025 at 4:14 PM revealed another note documented by S3RN stating Patient #1 was restless with a Richmond Agitation Sedation Scale of +1, but responded and obeyed commands.
In an interview on 12/09/2025 at 2:30 PM with S3RN, he verified the only clinical justification documented for the 4-point soft restraints were the following: pulling lines; pulling tubes; removal of equipment; and removal of dressing. S3RN further verified no documentation for clinical justification for the bilateral soft ankle restraints.