HospitalInspections.org

Bringing transparency to federal inspections

6847 N CHESTNUT

RAVENNA, OH 44266

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0179

Based on medical record review, policy review, and interview, the facility failed to ensure a physician's face-to-face evaluation was documented in the medical for one of one records reviewed of a patient in violent restraints (Patient #10). The total sample was 10 records. The facility's active census was 95.

Findings include:

Review of the policy titled, Use of Restraints and Seclusion (CP-2, Effective 07/2023) revealed application of restraint or seclusion for violent or self-destructive behavior involves a face-to-face assessment within one hour by the physician or APP (Advanced Practice Provider). The provider shall document the following: evaluation of the patient's immediate situation; reason for restraint (stated in behavioral terms, i.e., "the patient was attempting to hit, kick and bite staff"); patient's reaction to the intervention; type of restraint; patient's medical and behavioral condition; need to continue or terminate restraint or seclusion; specific time limits, depending on the reason for the restraint and/or seclusion and age; no contraindications exist for the use of restraint.

Review of Patient #10's record revealed the patient was placed in restraints for violent behavior on 01/22/24 at 8:15 PM. The medical record did not contain documentation of the details of a face-to-face evaluation.

The findings were shared in an interview with Staff C and Staff K on 01/24/24 at 12:10 PM and confirmed.