HospitalInspections.org

Based on record review, document review and staff interview it was determined the hospital failed to ensure Face-to-Face evaluations were conducted within one (1) hour of initiation of restraints/seclusions on two (2) separate occasions (patient #6). This failure has the potential to negatively impact all patients receiving care at this hospital.

Findings include:

1. A review of the medical record for patient #6 revealed on 6/28/19 an order was received to restrain the patient at 2:15 p.m. until 3:14 p.m. The record indicates the patient was restrained from 1415 (2:15 p.m.) until 1500 (3:00 p.m.). A review of the document titled Face to Face Assessment within 1 hour of Initiation of Procedure reveals the patient's face to face was not completed until 1645 (4:45 p.m.).

2. A review of the medical record for patient #6 revealed on 6/29/19 an order was received from the physician to restrain the patient at 7:48 a.m. until 8:47 a.m. The record indicates the patient was restrained from 7:48 a.m. until 8:05 a.m. A review of the document titled Face to Face Assessment within 1 hour of Initiation of Procedure reveals the patient's face to face was not completed until 11:10 a.m.

3. A review of the hospital document titled Seclusion and Restraint, last revised 9/18, states under the heading: "Time Limited Order Children ages 9-17- "2" hours for each order ...Under the age of 9-"1" hour for each order." The document further states: "Face-to-Face Assessment completed by a physician, PA or RN within one hour of initiation of restraint/seclusion."

4. An interview was conducted with the Director of Nursing on 7/9/19 at approximately 1:05 p.m. She concurred the restraint documentation and orders were not completed according to hospital policy.