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VERMILION BEHAVIORAL HEALTH SYSTEMS
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0182
Based on record review and interview, the hospital failed to ensure the RN who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician or other licensed practitioner as soon as possible after the evaluation for 1 (#3) of 2 (#1, #3) patient records reviewed for restraints or seclusion.
Findings:
Review of Patient #3's medical record revealed in part, she had been placed in a physical restraint on 10/31/2024 at 5:32 p.m. Patient #3 was released from the physical restraint and placed in seclusion at 5:34 p.m. Patient #3 was released from seclusion at 5:50 p.m. S3RN conducted the one hour face-to-face evaluation on 10/31/2024 at 6:25 p.m. S3RN consulted with the attending provider on 10/31/2024 at 5:30 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation.
Review of Patient #3's medical record revealed in part, she had been placed in a physical restraint on 11/04/2024 at 7:53 p.m. and released at 7:55 p.m. S4RN conducted the one hour face-to-face evaluation on 11/04/2024 at 8:11 p.m. S4RN consulted with the attending provider on 11/04/2024 at 7:55 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation.
Review of Patient #3's medical record revealed in part, she had been placed in a physical restraint on 11/05/2024 at 8:06 p.m. Patient #3 was released from the physical restraint and placed in seclusion at 8:07 p.m. Patient #3 was released from seclusion at 8:22 p.m. S4RN conducted the one hour face-to-face evaluation on 11/05/2024 at 8:30 p.m. S4RN consulted with the attending provider on 11/05/2024 at 8:09 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation.
In an interview on 11/06/2024 at 2:23 p.m. S1DON and S2DRM verified there was no documentation of the RN consulting with the provider as soon as possible after the one hour face-to-face evaluation for all 3 restraint/seclusion occurrences included in Patient #3's medical record.