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Based on medical record reviews and interviews, the hospital failed to ensure that when restraint was used for 2 of 2 patients (#4, #5) for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, there was no face to face documentation of an evaluation. Findings include:

Review of the hospital policy on 1/18/2011 for Restraint/Seclusion for Behavioral Management of Patients Reference # R-009 noted "A licensed independent practitioner conducts an in-person evaluation of the patient who is in restraint or seclusion within one hour of restraint or seclusion initiation. This includes: an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue the restraint or seclusion."

Medical record review on 1/18/2011 at 2:03 p.m. noted Patient #4 was admitted to the hospital on 12/29/2010 with diagnoses including paranoid schizophrenia with self-destructive impulsivity and intent. On 1/2/11 at 9:00 p.m. a telephone call was placed to the physician due to Patient #4 requiring bilateral extremity restraints for self harm of banging her head on the window three times and a need for a face to face. Staff applied the restraints at 9:13 p.m. and removed them completely by 10:27 p.m. No documentation of a face-to-face from the physician was noted in the medical record for this restraint episode.

This was verified with nursing administration staff during the medical record review.

Medical record review on 1/18/2011 at 2:32 p.m. noted Patient #5 presented to the emergency department on 1/13/2011 from his clinic for evaluation of suicidal ideation. At 7:15 p.m. on 1/13/11, he became combative, increasingly agitated and attempted to push a nurse to leave the hospital. Bilateral extremity restraints were applied while in the emergency department. The restraints were completely removed at 8:30 p.m. The physician completed an emergency room note at 9:40 p.m. No documentation of a face to face was found in the medical record for this restraint episode.

This was verified with nursing administration staff during the medical record review.