HospitalInspections.org

Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the attending physician was consulted as soon as possible after a restraint for one of one medical record (MR1) reviewed.


Findings include:


On November 27, 2023, a review of the facility policy, "Restraints Seclusion in Behavioral Health Hospital," revision date of July 2023, revealed, "Notification: The patient's attending psychiatrist must be consulted as soon as possible if the on-call psychiatrist ordered the restraint/seclusion."


A medical record review was completed for MR1 on November 28, 2023, at 10:45AM along with EMP5 for confirmation of the content of the medical record.


MR1 had a telephone order taken by EMP5 on October 21, 2023, at 1815, from on-call physician for a physical hold up to 5 minutes in length. MR1 failed to include evidence that the attending psychiatrist was notified as soon as possible after the restraint.


During an interview on November 28, 2023 at 11:24 AM, EMP5 confirmed the on-call physician she took the verbal order from on October 21, 2023, was not MR1's attending psychiatrist. EMP5 further confirmed there was no evidence in the record that MR1's attending psychiatrist was notified after the restraint.

Based on a review of facility documentation and medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure a one hour face-to-face was conducted for one of one medical records reviewed (MR1) where a physical restraint was implemented.

Findings include:

On November 27, 2023, a review of the facility policy, "Restraints Seclusion in Behavioral Health Hospital," revision date of July 2023, revealed, "C. interventions/Procedures...g...RNs can initiate the use of manual physical restraints (Escort/Physical Hold) in emergency situations to prevent immediate harm to the individual...If the physical hold is released immediately following the administration of medication, a qualified RN, Physician's Assistant or MD may complete the face-to-face evaluation required to be done within one hour of restraint."


A medical record review was completed for MR1 on November 28, 2023, at 10:45AM along with EMP5 for confirmation of the content of the medical record.


MR1 included a telephone order taken by EMP5 on October 21, 2023, at 1815, from on-call physician for a physical hold up to 5 minutes in length.


MR1 revealed a "2 Hour Face-to-face" form that EMP5 signed to indicate an assessment was completed for MR1. This form was not dated or timed by EMP5 for the time/date of the face-to-face assessment.


During an interview with EMP5 at 10:45 AM, she confirmed she never dated or signed when she assessed MR1. Further interview confirmed she was unaware of the facility policy requiring the assessment to be within one hour of the initiation of a restraint, she thought she had 2 hours to assess.

Based on a review of facility documentation and medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure the registered nurse consulted the attending physician after completion of the post restraint face-to-face for one of one medical records reviewed (MR1) where a physical restraint was implemented.



Findings include:



A medical record review was completed for MR1 on November 28, 2023, at 10:45AM along with EMP5 for confirmation of the content of the medical record.



MR1 included a telephone order taken by EMP5 on October 21, 2023, at 1815, from the on-call physician for a physical hold up to 5 minutes in length.



MR1 revealed a "2 Hour Face-to-face" form that EMP5 signed to indicate an assessment was completed for MR1.



During an interview with EMP5 at 11:24 AM, she confirmed there was no evidence in the record that MR1's attending psychiatrist was notified after the face-to-face.