HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (MD#1 and #2) Physician files reviewed, the hospital failed to ensure the Physician's ordering non-violent and violent restraints had a working knowledge of the hospital's policy. This has the potential to affect all patients who may require the use of violent and/or non-violent restraints.

Findings include:

1. The policy titled "Restraint and Seclusion Management" was reviewed on 6/6/23. The policy noted "9. Training: a. Physicians... that order and or evaluate for restraints, have working knowledge about the hospital policy for restraint use. Training occurs during orientation, every 2 years and if significant policy revisions occur..."

2. The Physician files were reviewed on 6/7/23 at approximately 10:30 AM. The following files lacked documentation the Physician's had working knowledge of the hospital's restraint/seclusion policy and competence in ordering restraints every 2 years:

MD#1 last restraint training was upon hire of 6/22/20
MD#2 last restraint training was upon hire of 6/22/20

3. During an interview on 6/7/23 at approximately 10:40 AM, the Quality and Safety Regulatory Coordinator (E#1) verbally agreed MD#1 and #2's personnel files lacked documentation of violent and/or non violent restraint training and competence.