HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 clinical record (Pt #1) reviewed for violent restraints, the Hospital failed to ensure a face-to-face assessment was completed within 1-hour after the initiation of applying violent restraints.

Findings include:

1. On 11/30/2022, the Hospital's policy titled, "Restraints (Violent/Self-Destructive Behaviors and Non-Violent/Non-Self-Destructive Behaviors) was reviewed and indicated, "...a physician/ALP (advanced licensed practitioner) must evaluate the patient in person within 1 hour of the order and document: a) evaluation of the patient's immediate situation including the medical and behavioral condition; b) the patient's reaction to the intervention..."

2. On 11/30/2022, Pt #1's clinical record was reviewed. Pt #1 was admitted to a Medical/Surgical unit on 7/12/2022 with the diagnosis of altered mental status change. Pt #1 was placed on violent locked 4 limb restraints on 7/14/2022 after attacking staff members. Pt #1's restraint order for locked 4 limb restraints was dated 7/14/2022 at 8:00 PM. There was no documentation in Pt #1's clinical record that indicated a face-to-face assessment was completed within 1-hour after the initiation of the restraint application.

3. On 11/30/2022 at 11:45 AM, an interview was conducted with the Assistant Vice President (E #5). E #5 stated that Pt #1's clinical record did not have the face-to-face assessment completed within 1 hour after the violent restraints were applied.