HospitalInspections.org

Based on interview and record review, the facility failed to ensure a physician performed a face to face assessment within one hour of the initiation of a physical restraint for 2 (Patients #5 and 7) of 3 patients reviewed for restraints out of a total sample of 10, resulting in the potential for poor outcomes.

Findings include:

Review of P-5's medical record on 9/13/2023 at 1230 revealed he was a 36-year-old male admitted to the hospital on 6/11/2023 with diagnoses to include tremors and alcohol intoxication. Review of restraint documentation revealed a physician order for violent restraints dated 06/14/2023 at 1530 with nursing documentation of application of restraints on 06/14/2023 at 1530. Review of entire record for P-5 with Staff A did not reveal a face-to-face assessment by a physician or medical provider after the application of restraints.

Review of P-7's medical record on 9/13/2023 at 1240 revealed he was a 82-year-old male admitted to the hospital on 08/25/2023 with diagnoses to include cholangitis. Review of restraint documentation revealed a physician order for violent restraints dated 08/28/2023 at 0158 with nursing documentation of application of restraints on 08/28/2023 at 0159. Review of entries record for P-7 with Staff A did not reveal a face-to-face assessment by a physician or medical provider after the application of restraints.

In an interview on 09/13/2023 at 1245, Staff A stated the facility policy for restraint use requires that a provider do a face-to-face assessment of the patient within one hour after the initiation of a violent restraint.

In an interview on 9/13/2023 at 1445, Staff M stated when a physician writes the order for a violent restraint that physician should do the assessment of the patient at that time.

Review of the facility policy, "Use of Physical Restraints: Ordering, Monitoring, and Documentation Requirements" dated 06/22/2022 revealed, Violent or Destructive Patient: C Restraints or seclusion used for the management of violent or self-destructive behavior that jeopardized the physical safety of the patient, staff, or theirs may be initiated by the RN. Immediate notification of the physician, NP or PA must occur an and order should be entered in the chart. A face-to-face assessment of the patient must occur within one (1) hour of the intervention.