HospitalInspections.org

Based on document review and interview, it was determined that for 1 (Pt. #3) of 3 records reviewed of patients on restraint/seclusion, the Hospital failed to ensure that a notice of restriction of rights was completed as required by policy.

Findings include:

1. The Restraint log for the Adult unit from 1/1/15 to 8/20/15 was reviewed on 8/25/15. The log included Pt. #3 being placed on a therapeutic hold on 7/27/15, for a duration of 7 minutes.

2. The clinical record for Pt. #3 was reviewed on 8/25/15. Pt. #3 was an 18 year old male admitted on 7/27/15 with a diagnosis of depression. The clinical record included an order for the Therapeutic hold, however a Restriction of Rights form was not completed as required.

3. The Hospital policy titled, "Restraint and Seclusion" (rev 5/12/15) required, "Definition-Restraint-Any method, physical or mechanical...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...." Documentation...A restriction of Rights form is completed...The patient is advised of the rights to have a person of their choosing notified of the restraint/seclusion."

4. The above finding was discussed with the Adult unit Nurse Manager on 8/25/15 at approximately 2:30 PM, who stated that a restriction of rights notice form should have been completed.

Based on document reviews, and interview it was determined that for 1(Pt. #2) of 3 records reviewed for restraints and seclusions, the Hospital failed to ensure orders were obtained for initiating and renewing patient seclusion.

1. The clinical record for Pt. #2 was reviewed on 8/25/15. Pt. #2 was a 22 year old male admitted on 8/17/15 with a diagnoses of bipolar affective disorder, anxiety and mood disorder. The clinical record contained a "Notice Regarding Restricted Rights of Individuals" indicating that Pt. #2 was placed in seclusion on 8/17/15, at 12:15 PM and continued till 7:00 PM. However, the record lacked a physician's order for initiating the seclusion on 8/17/15 at 12:15 PM and a renewal order, to continue with the seclusion until 7:00 PM.

2. The Hospital policy titled, " Restraint and Seclusion" (rev 5/12/15) required, "When restraint/seclusion is required...an order is obtained from the attending psychiatrist within 1 hour of the initiation. The order must be signed within the EMR within 24 hours... Orders are renewed by the psychiatrist as follows: ...4 hours for adult 18 years and older...."

3. The above findings were discussed with the Manager of the Adult unit during an interview on 8/25/15 at approximately 2:45 PM, who stated that an order and renewal order should have been obtained and written for Pt. #2's seclusion from 12:15 PM to 7:00 PM on 8/17/15.

Based on document reviews, and interview it was determined that for 1 of 3 (Pt #2) records reviewed for restraints or seclusions, the Hospital failed to ensure a 1 hour face to face evaluation was conducted.

1. The clinical record for Pt. #2 was reviewed on 8/25/15. Pt. #2 was a 22 year old male admitted on 8/17/15 with diagnoses of bipolar affective disorder, anxiety and mood disorder. The clinical record contained a "Notice Regarding Restricted Rights of Individuals" indicating that Pt. #2 was placed in seclusion on 8/17/15, at 12:15 PM until 7:00 PM. However, the record lacked a face to face evaluation within 1 hour of the implementation.

2. The Hospital policy titled, " Restraint and Seclusion" (rev 5/12/15) required, "A physician or RN in a supervisory position examines the patient within 1 hour of implementation...this evaluation includes: 1. Evaluation of patients' immediate situation, 2. The patient's reaction to the intervention, 3. The patients medical and behavioral condition, 4. The need to continue or terminate the restraint/seclusion.

3. The above finding was discussed with the Manager of the Adult unit during an interview on 8/25/15 at approximately 2:45 PM, who stated that a face to face evaluation is conducted within 1 hour of restraint/seclusion.