HospitalInspections.org

Based on a review of two restraint/seclusion records of 10 patient records reviewed, patient #8, who was restrained/secluded multiple times, had no face to face assessment and documentation found in the record.

Patient #8 is a late-middle-aged male who admitted to the behavioral health unit. Patient #8 had 15 restraint and seclusion events ranging in time from 2 minutes to 4 hours, with 10 events of one hour or less. While the restraint/seclusion processes are found to be largely appropriate for patient #8, review of the record reveals no evidence of face to face assessment and related documentation. Based on this finding, the hospital fails to meet regulation for violent restraint and seclusion for a 1 hour face to face evaluation.

Based on a review of discharge summaries for the behavioral health unit, 1) the discharge summary for patient #8 fails to accurately describe patient #8 ' s treatment course; 2) the discharge summary was delegated to a Physician Assistant, but was never signed by the psychiatrist; 3) the discharge summary fails to accurately reflect the discharge disposition.

Patient #8 is a late-middle-aged male who admitted to the behavioral health unit. Patient #8 had 15 restraint and seclusion events during his admission of nearly one month.

A discharge summary written by a Physician Assistant (PA) states in part, " Patient responded to treatment with no unusual reactions, " and " Patient participated in the treatment plan as recommended. " These statements are an inaccurate description of patient #8 ' s treatment course which was fraught with at least 15 restraint/seclusion events.

A PA wrote the Discharge Summary on the day of discharge, which had not yet been signed by the psychiatrist at the time of survey 20 days later.

The discharge summary states the "Location to where patient will be discharged as: Home. However, patient #8 actually was discharged to a residential treatment placement.

Based on all Discharge Summary documentation, neither the account of patient #8 ' s treatment course, nor the description of his disposition are found to be accurate.