HospitalInspections.org

Based on records reviewed and interviews the Psychiatric Hospital failed for one (Patient #1) of ten sampled patients to ensure: 1.) documentation of physician restraint and seclusion training and 2.) physicians working knowledge requirements for patient restraint evaluation and documentation consistent with Hospital policy potentially resulting in patient harm.

Findings included:

The document titled Admission History and Physical, dated 6/20/18, indicated the Hospital admitted Patient #1 to the Psychiatric Hospital for psychiatric evaluation and treatment.

1.) The Psychiatric Hospital policy titled Staff Development Policy Statement, dated 8/15/17, indicated the Hospital required new staff orientation and annual training on patient restraint training for all staff.

The Surveyor interviewed the Quality Management Director, at 3:55 P.M. on 7/18/18. The Quality Management Director said that all staff referenced in the Staff Development Policy included the Psychiatric Hospital physician staff.

The documents titled Restraint Training, dated 2017-2018, indicated no documentation of physician staff training on patient restraint and seclusion.

The Psychiatric Hospital provided no documentation to indicate the Hospital trained physician staff on patient restraint and seclusion was consistent with Hospital policy.

2.) The Psychiatric Hospital policy titled Mechanical Restraint, Seclusion, Physical Restraint, Medication (Chemical) Restraint of the Adult Inpatient Units, dated 6/5/18, indicated the physician would examine the patient and document pertinent findings and sign the Restraint Form for each renewal order for restraint.

Patient #1's medical record indicated doctor's orders for restraint at 10:45 P.M. on 6/26/18, at 12:45 A.M. on 6/27/18, at 2:45 A.M. on 6/27/18 and 4:45 A.M. on 6/27/18. The Restraint Form indicated no documentation of a physician signature or pertinent comments corresponding to the restraint orders at 10:45 P.M. on 6/26/18, at 12:45 A.M. on 6/27/18, at 2:45 A.M. on 6/27/18 and 4:45 A.M. on 6/27/18 consistent with Hospital policy.