HospitalInspections.org

Based on the interview and record review, the hospital failed to ensure documentation of the description of the patient's behavior and intervention used in order to properly evaluate the appropriateness of the intervention used citing

Findings included:

Patient # 20 was admitted on 10/08/2021 at 22:35 and required application of restraints twice. The first application was on 10/09/2021 at 04:00 AM and the second restraint application on 10/10/21 at 20:00. The record review conducted on 07/07/2022 indicated no documentation that suggested a description of the patient's behavior on the second restraint application.

During an interview on 07/07/2022 at 1:00 PM, Personnel #1 and Personnel #2 was informed of the above findings and confirmed the above findings.

Policy and Procedure

According to the hospital policy CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion reflected 06/2022 "purpose ...This procedure establishes guidelines policy ... the policy of kindred hospital is to ensure the following Non-Violent, Non-self-destructive behavior guidelines are followed when, after a comprehensive, individualized assessment...6Clinicl/Nursing staff ..b.Clinical/Nursing staffing responsibilities-A registered nurse will perform assessment/reassessment at established intervals and as needed Patient plan of care: The RN will create and modify the patient's plan of care ..."