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RESTON HOSPITAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0166
Based on interview, medical record and facility document review, it was determined the facility failed to provide modifications to a patient's plan of care based on the use of restraints in two (2) of six (6) patient records sampled.
The findings include:
On June 2, 2025, the surveyor conducted a review of six (6) sampled patient records.
The medical records for Patient #4 and Patient #6's did not contain documentation of modification to the patient's plan of care for the use of restraints.
On June 2, 2025 at 1:30 PM, Staff Member #3 confirmed that the modifications to Patient #4 and #6's Plan of Care were not evidenced.
A review of the facility's policy "Patient Restraint/Seclusion, COG.COG.001 12/01/20", revised 6/2025, indicated in part: "...K. Care of the Patient/Plan of Care, 1. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications...M. Documentation Requirements...14. Modifications of the plan of care...".