HospitalInspections.org

Based on facility policy and procedure review, medical record reviews and staff interviews the facility's staff failed to ensure the physician or licensed practitioner documented the one hour face-to-face evaluation within 1 hour after initiation of restraint in 2 of 2 patients (Patient #2 and #8) requiring intervention of violent or self-destructive behaviors.

The findings include:

Review of facility policy "Restraint and Seclusion" revised 11/04/2020 revealed "...When restraint or seclusion is used for the management of violent or self-destructive behavior the patient should , within 1 hour after initiation of the intervention, be seen face-to-face by a physician or other licensed practitioner..."

1. Closed medical record review of Patient #2 revealed a 27-year-old female who presented to the facility's emergency department on 03/24/2022 under involuntary commitment petition due to homicidal ideations. Review revealed Patient #2 was placed in a physical hold due do "pushing through the door" at 1202 on 03/25/2022 and released at 1208. Review revealed no documentation of the one-hour face-to-face evaluation completed within 1 hour after initiation of the restraint.

Interview on 04/05/2022 at 1155 with MD #1 revealed he received restraint training upon hire. Interview revealed he failed to document the one-hour face to face assessment on Patient #2.

2. Closed medical record review of Patient #8 revealed a 34-year-old male who presented to the facility's emergency department on 01/14/2022 under involuntary commitment petition due to hallucinations. Review revealed Patient #8 was placed in a Physical hold and administered medications due to "uncooperative and self-destructive behavior" at 2334 on 0/14/2022 and released at 2339. Review revealed no documentation of the one-hour face-to-face evaluation completed within 1 hour after initiation of the restraint.

Interview on 04/05/2022 at 1205 with MD #2 revealed she received restraint training upon hire. Interview revealed Patient #8 was her first restraint episode. Interview confirmed she did not perform or document the one-hour face-to-face evaluation within 1 hour after initiation of restraint.

NC00186610