HospitalInspections.org

Based on a review of three restraint records, it is revealed that nursing failed to release patient #3 from seclusion at the earliest possible time.

Patient #3 was a young adult male who was admitted to the behavioral health unit in mid-March 2016. Patient #3 had mild mental retardation and autism. On 3/22, patient #3 became combative and was placed in seclusion at 2040.

Within 16 minutes of initial seclusion at 2056, nursing documented, "At this time pt is quiet in seclusion room. No acute distress noted. Will continue to monitor." Further documentation through 2140 reveals patient #3's behavior as "Unchanged" and from 2155 through 2210 as "Improved." This indicates that after 16 minutes of seclusion, patient #3 was had met criteria for release from seclusion, but was not released until more than one hour later.

Additionally, 15-minute monitoring for 2125 through the end of seclusion at 2215 was not documented until the following day between 1640 through 1655. Based on all documentation, the hospital failed to release patient #3 at the earliest possible time.

This regulation is not met as evidenced by:
Based on a review of a seclusion on the behavioral health unit, it is determined that no face-to=-face was conducted for patient #2 who was secluded.

Patient #2 was a young adult male who on 3/24/2016, was secluded from 2245 to 2345 due to increasingly agitated behaviors. Review of the record reveals no face to face by a physician, other licensed independent practitioner, or a trained RN. Based on this information, the hospital failed to meet regulatory requirements for conducting a face-to-face.