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MARY WASHINGTON HOSPITAL, INC
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on medical record review, staff interview, and facility policy review, it was determined a physician failed to assess a patient within twenty-four (24) hours after initiation of a restraint for two (2) of three (3) records reviewed.
The findings included:
On 7/25/2022, the surveyor reviewed the medical record with Staff Member (SM) #5. The surveyor reviewed orders for application of non-violent restraints for Patient #2. Restraints were initially applied to Patient #2 on 7/21/2022 and renewed on 7/22/2022 and 7/23/2022. The surveyor requested SM #5 to navigate through the medical record to locate documentation of the examination conducted by a physician/credentialed AHP (Allied Health Professional) required after the application of the restraint. SM #5 navigated through the record but was unable to locate any documentation indicating an examination was performed.
The surveyor reviewed Patient #3's medical record with SM #5. Patient #3's initial application of non-violent restraints was on 7/19/2022. The restraints were ordered again on 7/21/2022, 7/22/2022, and 7/23/2022. The surveyor and SM #5 navigated through the medical record to locate documentation of the physician examination, but no documentation was found.
Review of a facility policy titled, Restraint Policy, read in part: "...Restraint Process for non-VSD (Violent Self-Destructive):... 5. The physician/credentialed AHP must see and examine the patient within 24 hours and sign, date and time the Restraint Order. The physician/credentialed AHP documentation shall include the observation and evaluation of the patient, the decision and rationale for restraint; and an evaluation for the continuation or discontinuation of the restraint. 6. Steps 1 through 5 are repeated daily until the restraint has been discontinued and a less restrictive measure has been found to be effective...".
The surveyor and SM #5 discussed the missing documentation during the medical record review and how it was not in compliance with the facility's policy. At the exit conference, the surveyor also discussed the findings with SM #1 and #2.