HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt #2) patients, reviewed for physical hold/seclusion, the Hospital failed to ensure debriefings were conducted, as determined by hospital policy in accordance with State law. This has the potential to affect all patients who require the use of physical hold/seclusion, approximately 31 physical hold events and approximately 3 seclusion events in the last 3 months.

Findings include:

1. Policy number POC-40, Behavioral Intervention: Physical Hold, Seclusion, and Less Restrictive Alternatives (Reviewed by the Hospital, XXX)was reviewed on 10/2/19 at approximately 1:05 PM. On page 11, the policy indicated, "Post Physical Hold Evaluation and Debriefing:... Complete Post Seclusion and Physical Hold Evaluation Form... Debriefing Evaluation Form: Within 24- hours, coordinates debriefing with the patient, the unit staff involved in the code, and if possible, the patient's family."

2. Pt #2 Admission Date: 7/17/19
Diagnosis: Major Depressive Disorder. Pt #2's medical record was reviewed on 10/2/19 at approximately 1:50 PM. On 9/21/19, the "Seclusion/Physical Hold Record Section" documentation indicated Pt #2 was placed in a physical hold from 8:00 PM to 8:05 PM. Pt #2's medical record lacked documentation of a debriefing.

3. An interview was conducted with the Director of Performance Improvement (E#1) on 10/3/19 at approximately 3:25 PM. E#1 reviewed the medical records of Pt #2 and verbally agreed the medical record lacked documentation that a debriefing was conducted for the 9/21/19 physical hold and there should have been.