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Based on interview and document review, the hospital failed to complete a face-to-face evaluation within one hour of restraint implementation to include a physical/behavioral assessment for 4 of 6 patients (P1, P2, P4, and P5) reviewed for restraint/seclusion use. This had the potential to affect all future patients who may need restraints to control behavior.

Findings include:

P1 was placed in seclusion for violent behaviors on 7/16/19. The medical record indicated the patient was placed in seclusion at 8:00 a.m. and discontinued at 8:25 a.m. There was no face-to-face evaluation documented in the medical record that included a physical/behavioral assessment had been done.

P2 was placed in 4 point wrist/ankle restraints for violent behaviors on 7/15/19. The medical record indicated the restraints were applied at 10:10 p.m. and discontinued at 10:49 p.m. There was no face-to-face evaluation documented in the medical record that included a physical /behavioral assessment had been done.

P4 was placed in 4 point wrist/ankle restraints for violent behaviors on 7/4/19. The medical record indicated the restraints were applied at 4:14 a.m. and discontinued at 9:35 a.m. There was no face-to-face evaluation documented in the medical record that included a physical /behavioral assessment had been done.

P5 was placed in bilateral wrist restraints for violent behaviors on 5/25/19. The medical record indicated the restraints were applied at 6:53 p.m. and discontinued at 10:57 p.m. There was no face-to-face evaluation documented in the medical record that included a physical /behavioral assessment

On 7/24/19, at 10:00 a.m. the behavioral health unit (BHU) manager was interviewed and confirmed a face-to-face evaluation that included a physical/behavioral assessment had not been completed per facility policy on the above identified patients.

Review of the facility's Patient Restraint or Seclusion Policy dated 11/8/17, listed procedures for when a patient is secluded or restrained that included: (1) an authorized provider responsible for the care of the patient must evaluate the patient in person within 1 hour of the initiation of seclusion or violent restraints; (2) the evaluation should include an initial comprehensive individualized assessment that includes a physical assessment to identify medical problems that may be causing the behavior.