HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt #11) clinical records reviewed for restraints, the Hospital failed to ensure that trained staff monitored a restrained patient, as required.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion" (dated 1/18/2021), was reviewed on 4/8/2021, and required, "Non-violent restraints: Nursing assessment and documentation must occur at least every 2 hours or sooner according to the patient's condition in the patient's medical record under the medical surgical restraint flowsheet..."

2. The clinical record for Pt #11 was reviewed on 4/8/2021. Pt #11 was admitted on 4/5/2021, with a diagnosis of AMS (altered mental status). Pt #11's physician's order dated 04/06/2021 at 10:00 PM, included, "Assess restraint medical surgical soft extremity: Upper right (3 limbs only). Soft extremity: Upper left [non-violent restraints]. Every 2 hours for 1 day."

- Pt #11's restraint assessments from 4/6/2021-4/8/2021, were reviewed. The restraint documentation on 4/7/2021 included restraint assessments on 4/7/2021 at 6:00 AM and then subsequent documentation on 4/7/2021 at 8:00 PM (14 hours time lapse). The clinical record lacked the required every 2 hour restraint assessments.

3. On 4/8/2021 at 3:30 PM, an interview was conducted with the East 4 Assistant Unit Director (E #2). E #2 stated that when a patient is in non-violent restraints, restraint documentation is required every 2 hours. E #2 stated that if there was a time when the restraint was taken off or discontinued, the nurse should document that it was.