HospitalInspections.org
Bringing transparency to federal inspections
RIVERSIDE WALTER REED HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0185
Based on document review and interview, it was determined that the facility failed to ensure Staff (Physician and/or Registered Nurse) documented the Patient's physical and mental status at the time of restraint for one (1) of one (1) Patients (P), P # 5.
The findings include:
On September 26, 2023, clinical record review for P # 5 revealed the following:
P # 5 had an order for bilateral wrist restraints on September 20, 2023 at 6:58 p.m.
There was no documentation at the time the restraints were applied to include P # 5's physical and mental status, and any environmental factors that may have contributed to the application of restraints.
On September 26, 2023 at 2:00pm an interview with Staff Member # 4 revealed "there was no documentation at the time restraints were applied. The first documentation was at 8:58 p.m."
On September 26, 2023, a review of the facility policy titled " Restraints" reads in part "Prior to application of any restraint, the licensed practitioner and/or Registered Nurse (RN) will perform an assessment. The assessment is based on the individual's needs in the immediate care environment and interaction of the individual with staff/others in the environment."
On September 26, 2023, the findings were discussed with Staff Members # 1, # 2, # 3, # 4, # 5, # 6, # 7 and # 8 during the exit interview.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0186
Based on document review and interview, it was determined that the facility failed to ensure Staff documented any alternatives attempted before restraints were applied for one (1) of one (1) Patients (P), P # 5.
The findings include:
On September 26, 2023, clinical record review revealed the following:
P # 5 had an order for bilateral wrist restraints on September 20, 2023 at 6:58 p.m.
There was no documentation at the time the restraints were applied to include alternative attempts for less restrictive methods.
On September 26, 2023 at 2:00pm an interview with Staff Member # 4 revealed "there was no documentation at the time restraints were applied. The first documentation was at 8:58 p.m."
On September 26, 2023, a review of the facility policy titled " Restraints" reads in part "Non-physical interventions are the first choice as an intervention, unless safety issues demand an immediate physical response."
On September 26, 2023, the findings were discussed with Staff Members # 1, # 2, # 3, # 4, # 5, # 6, # 7 and # 8 during the exit interview.