HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure staff followed hospital policy relative to conducting a face-to-face evaluation of a patient in restraint/seclusion within one (1) hour after the initiation of the intervention. This deficient practice was found in two (2) of six (6) patients reviewed who were placed in restraint/seclusion (patients #4 and #6). This failure has the potential to negatively impact the safety and quality of care received by all patients served by the hospital who are placed in restraint/seclusion.

Findings include:

1. Review of the hospital policy entitled, "Seclusion and Restraint", last revised 3/15, states in part: "...the physician or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation."

2. Review of the medical record for patient #4 revealed no evidence of a face-to-face evaluation by the physician or Registered Nurse (RN) within one (1) hour of order initiation for the following dates: 9/24, 9/25, 9/30, 10/2, 10/8, 10/13, 10/14, 10/19, 10/20, 10/21, 10/23, 10/27, 10/28 and 11/3/15.

3. Review of the medical record for patient #6 revealed no evidence of a face-to-face evaluation by the physician or RN within one (1) hour of order initiation for the following dates: 9/22, 9/25, 10/2, 10/8, 10/19, 10/20 and 10/21/15.

4. The above records were reviewed with the Program Manager of the Tween Unit on 12/3/15 at 10:15 a.m. and she agreed with the findings.