HospitalInspections.org

Based on interview and record review, the facility failed to conduct a one hour face to face evaluation of a patient in restraints, according to facility policy for 1 of 12 patients (Patients #3) reviewed for restraints, from a total sample of 21 patients, resulting in the absence of a thorough assessment of patient #3 while in restraints, which has the potential for unnecessary restraints and the potential for unknown injuries. Findings include:

Review of Patient #3's medical record with Department Database Specialist (Staff C) on 4/28/16 at 1150, revealed a 26 year old female who was admitted to the Emergency Department (ED) on 2/29/16 with a chief complaint of telling her parents she had thoughts of harming herself. Review of nursing documentation for Patient #3 revealed she had restraints placed on 4 extremities on 2/29/16 at 0200 for violent behavior. A physician order for the restraints was documented on 2/29/16 at 0234. The first face-to-face assessment by a physician for Patient #3 after the initiation of the restraints was 2/29/16 at 0430.

Review of facility "Restraints: Care of the Patient in Restraints" policy (dated 10/08/2015) on 4/27/16 at 1030, revealed, "The patient must be seen face-to-face by the physician or PA (physician assistant), within 1 hour after the initiation of the restraint...".