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Review of a total sample of 10 medical records, including one closed restraint/seclusion patient record, revealed that the medical record did not contain evidence (justification) for continued seclusion. Therefore the seclusion was not discontinued at the earliest possible time.

Patient #2 was admitted to inpatient Behavioral Health Unit for altered mental status with auditory, visual and tactile hallucinations. On 7/23/15 the patient tried to barge into another patient's room. She then charged at nursing staff and attempted to place staff in a headlock. The staff attempted to intervene. A code green was called, and the patient placed in seclusion at 11:20 AM. The medical record review revealed that a face-to-face, inclusive of the elements, was performed at the time the patient was placed in seclusion. The patient was monitored every fifteen minutes, and hourly assessments were performed by the RN. The physician renewed the seclusion order at 3:06 PM. At 3:20 PM and at the previous 15 minute checks the patient was was noted to be still irritable and impulsive, refusing food. She did drink water with medications. There was nothing in the medical record describing specific behaviors that would indicate continued need for seclusion. The hourly entry at 3:20 PM by the RN noted that the physician assessed and reordered seclusion so the patient could be monitored closely and assessed immediately when she woke up. During the next 4 hours the patient was assessed hourly, and although there was no documentation of immediate threat to herself or others, she remained in seclusion.


The hourly entry at 4:20 PM by the RN noted that the patient remained asleep and shifting at times. As ordered by the physician the patient remained in seclusion until she was awake and stable or until her then current order expired.


At 5:00 PM the patient was awoken for medications. As noted she remained agitated and pulled her arm away from the nurse refusing her medications, food and water. She put her arm underneath her rear so she would not be scanned. She did not meet the criteria for termination of seclusion at this time.


At 6:10 PM it was noted that the patient was sleeping but remained irritable when attempts were made to awaken her. She was currently refusing food and water and the use of the restroom. Per physician order, seclusion was to continue until 7:05 PM.


At 7:00 PM the patient was sleeping in the seclusion room when the nurse performed her 1 hour assessment. The patient's vital signs were taken, and the physician was called and notified. The physician ordered discontinuation of seclusion and ordered a 1:1 sitter for the patient. The patient was resting in the quiet room with the door open and a sitter at her bedside.


Base on review of the medical record, patient #2 was kept in seclusion for an additional 4 hours without clear documentation of justification for the continued seclusion. The patient had a right to refuse care and treatment and may have been irritable but this did not justify continued seclusion. The option of providing a sitter could have been offered earlier in the process, and the seclusion discontinued. The medical record documentation did not support the continued use of seclusion for patient #2. Therefore the hospital did adhere to regulatory guidelines to discontinue seclusion at the earliest possible time.