HospitalInspections.org

Based on interview and record review, it was determined facility staff failed to perform a face-to-face assessment of a patient within one (1) hour following the application of restraints for violent behavior for one (1) out of six (6) medical records reviewed.

The findings include:


A random sample of facility patients who had associated restraint use were reviewed. One of the medical records, Patient #6, was reviewed on 11/17/20 with Staff Member #2, Staff Member #5, and Staff Member #6.

The surveyor noted that Patient #6 was ordered by Staff Member #12 (Attending Physician) to have four-point restraints for violent behavior on 08/15/20 at 11:23 pm during Emergency Department stay. Upon further chart review, the surveyor determined a face-to-face was not conducted for Patient #6 within one (1) hour of application of the violent restraints.

The surveyor reviewed the facility policy titled, "Patient Restraint and Seclusion" (with last review date of 10/31/2019). Under section, "F. Monitoring and Assessment", the aforementioned policy reads, "When Restraint or Seclusion is used for the management of Violent or Self-Destructive Behavior the patient must be seen face-to-face within one (1) hour after the initiation of the intervention by a physician or RN, Physician Assistant ("PA"), or Nurse Practitioner ("NP") who has been trained ...".

The History and Physical (H&P) assessment by Staff Member #12 reads, "Face to Face Assessment, 08/16/20 3:11 [am]". According to documentation, required face-to-face assessment of Patient #6 occurred nearly four (4) hours following initiation of violent restraints.

The surveyor informed this to Staff Member #2, Staff Member #5, and Staff Member #6 on 11/18/20. Staff Member #6 inquired if Staff Member #13 (who has restraint-related education and competencies) performed a face-to-face assessment of Patient #6 within an appropriate period.

The surveyor reviewed the restraint documentation of Staff Member #13 who documented the following assessment data within one hour of restraint initiation: restraint position, circulation, mental status, alternative interventions, patient rights, stress/agitation, and plan.

Staff Member #13, however, did not show evidence of assessment of Patient #6 for the following required components of a face-to-face evaluation: behavioral criteria that must be met for release of restraints, explanation for the restraint use, as well as notifying the attending physician (Staff Member #12) of the face-to-face restraint assessment.

The surveyor informed the aforementioned information to Staff Member #2, Staff Member #5, and Staff Member #6 on 11/18/20, who verbalized understanding with the surveyor.