HospitalInspections.org

Based on a review on 10/18/16, of three open and 12 closed medical records, inclusive of four restraint records from patients who had restraints applied for violent behavior in October, 2016, it was determined that the medical staff failed to document a face to face assessment for two of the four patients sampled (patient 2 and 3).

There was documentation regarding a face to face evaluation found in the medical records of patient 2 or 3. Other documentation from nursing and a physician's assistant (PA-C) indicated that the physicians were at the bedside either during or immediately after the restraints were applied but no face to face was documented in either case.

In addition, a review of the training given to physicians regarding their documentation requirements revealed that the face to face obligation was mentioned but no explanation of the required facets of the assessments were contained in the training.