HospitalInspections.org

Based on a review of documentation and interview the facility failed to ensure that he use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy.

Findings included:

Facility based policy entitled, "Section 1-Client Focused Functions 1B - Provision of Care, Treatment & Services - Seclusion & Restraint" stated in part,
"B) Physician's order:
Only a physician member of the hospital's privileged medical staff may order restraint or seclusion. The physician's order for restraint or seclusion must : ...
5. describe the specific release behaviors that the patient must demonstrate before the restraint or seclusion will be discontinued; and ..."

Review of medical records revealed that 2 of 5 restraint or seclusion episode record did not describe the specific release behaviors that the patient must demonstrate before the restraint or seclusion will be discontinued on the order or on the restraint/seclusion forms
* Patients # 6 and 9 who both had behavioral interventions for aggression, on their restraint/seclusion forms the area for "Behavior which must be demonstrated before discontinuation of Seclusion or Mechanical restraint" was left blank. This information should be included for restraint and seclusion episodes per hospital policy.

The above findings were verified with staff members #1 and 2 on 09/01/21.