HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that a comprehensive review of the patient's mental and health conditions were documented 1 hour after initiation of violent restraint intervention, in 1 of 7 behavioral health patients reviewed (Patient #1).

Findings include:

Record reviews were conducted on 10/2/2017 at 11 a.m.
1) Record review revealed that Patient #1 was placed in locked seclusion for increased agitation on 9/25/2017 at 10:14 a.m. The documentation of the 1 hour face to face evaluation conducted by Physician C on 9/25/2017 at 10:14 a.m. did not contain: 1) the patient's reaction to the restraint, or 2) a comprehensive review of the patient's medical condition.

2) Record review revealed that Patient #1 was placed in a physical hold for increased agitation and striking out at staff on 9/29/2017 at 7:56 p.m. The documentation of the 1 hour face to face evaluation conducted by Physician D on 9/29/2017 at 7:56 p.m. did not contain: 1) the patient's reaction to the restraint, or 2) a comprehensive review of the patient's medical condition.

Record review of facility policy "restraint and seclusion, last revised 5/2017" revealed under ".4.B. ...At the time of the face to face evaluation, the physician works with the patient and staff to: a. Identify ways to help the patient regain control, b. Make necessary revisions to the patient's treatment plan, and c. Provide a new written order if necessary... 4. C. 1. Physician completes the following: a. Face to face examination of the patient by a physician within 1 hour and initial assessment progress note section completed with the EHR (electronic health record) form "restraint/ Seclusion-Violent behavior Progress Note."

During interview with Staff A and B on 11/2/2017 at 11 a.m., Staff A and B stated there was "no additional information" regarding the physician's documentation of the one hour face to face evaluations.