HospitalInspections.org

Based on document review and interview, the facility failed to ensure that a physician performed a face to face assessment within one hour of the initiation of a physical restraint for 2 (P-10, P-11) of 2 patients reviewed for behavioral (violent) restraints resulting in the potential for violation of patient rights and the potential for adverse patient outcomes. Findings include:

On 4/17/2024 at 1253, P-10's medical record was reviewed, and the patient was found to have been placed in behavior restraints on 1/2/2024 at 1648. The one-hour face to face assessment was not found to have been completed.

On 4/17/2024 at 1545, P-11's medical record was reviewed, and the patient was found to have been placed in behavioral restraints and a one hour face-to-face assessment was not found to have been completed

Staff Q was queried on 4/17/2024 at 1555 whether a face-to face was documented for P-10 or P-11 and he responded that "after reviewing the medical record" the face-to-face was not documented. Staff Q was further queried as to when the physician assessment was to be performed with behavioral restraints to which he replied, "The assessment should be done within an hour."

Facility policy titled "Restraints Use (Violent and Non-Violent) and Seclusion", Version 2, effective 3/5/2024 was reviewed on 4/17/20 at 1600. Physicial Face-to-Face Assessment, page 9 states, "Within 1 hour of initiation of violent restraint, or within 24 hours of initiation of non-violent restraint, the physician will perform a face-to-face clinical assessment of the patient." and "The clinical assessment will be documented in the medical record".