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TITUSVILLE AREA HOSPITAL
RESTRAINT AND SECLUSION
Tag No.: C2553
Based on review of facility documentation and medical record review (MR), as well as employee interview (EMP), it was determined that the facility failed to follow its policy to complete a face-to-face assessment within one hour after the application of a restraint for one of one violent restraint records reviewed (MR14).
Findings include:
On September 4, 2025, review of the policy provided for restraint applications, revised July 2020, revealed, "... C. Restraints ... F. Orders for Restraint of the Patient for a Behavioral Reason ... c. The physician must perform a face-to-face assessment of the patient within one (1) hour of application of restraints and an order obtained. ..."
1. On September 3, 2025, review of MR14 revealed no documentation of a completed face-to-face assessment by the physician within one (1) after the application of restraints.
This finding was confirmed by EMP1 at the time of the review.