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Based on record review and interview the facility failed to ensure a face to face assessment following behavioral restraint episodes was completed by staff trained in evaluating the patient's immediate situation, the patient's reaction to the restraint, the patient's medical and behavioral condition and the need to continue or terminate the restraint in three (Staff A, Staff U and Staff V) of five staff training records reviewed who completed face to face assessments of patients in restraint/seclusion. The facility census was 91.

Findings included:

1. Review of the facility's policy titled, "Seclusion and Restraint" dated 04/11 showed the attending psychiatrist or delegate of another psychiatrist, nurse practitioner, medical physician, or specifically designated and trained registered nurse (RN), must see and assess the patient within one hour of issuing a seclusion and restraint order."

2. Record review of discharged Patient #22's restraint documentation showed the physician ordered five point leather restraints, a physical escort and physical holding for medication on 07/28/11 at 10:44 AM. Review of the face to face evaluation dated 07/28/11 at 12:00 PM showed Staff A, RN and Director of the Senior Adult unit completed the face to face evaluation.

Review of the personnel record for Staff A showed no training documented for assessing a patient following a restraint/seclusion episode.

During an interview on 10/20/11 at 10:20 AM, Staff A, Director of the Senior Adult unit, stated, "I didn't have training on doing a face to face evaluation." Staff A acknowledged he/she had completed a face to face evaluation following a restraint episode for Patient #22. Staff A stated that he/she had completed a face to face evaluation on a second patient sometime in the past year, but could not recall the name of the patient.

3. Record review of discharged Patient #24's restraint documentation showed the physician ordered five point leather restraints, a physical escort and physical holding on 08/03/11 at 4:18 PM. Review of the face to face evaluation dated 08/03/11 at 4:30 PM showed Staff U, Family Nurse Practitioner completed the face to face evaluation.

Review of the credentialing file for Staff U showed Staff U is a family practice nurse practitioner. No specific training was documented for assessing a patient following a restraint/seclusion episode.

During an interview on 10/20/11 at 11:10 AM, Staff S, Chief Nursing Officer, stated that Staff U is a family nurse practitioner and is not a psychiatric nurse practitioner. Staff S stated that the facility has no record Staff U had specific training to complete the face to face evaluation on patients following a restraint/seclusion episode.


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4. Review of discharged Patient #26's physician's orders showed seclusion orders dated 09/06/11, 09/08/11, 09/12/11 and again on 09/13/11.

Record review of Patient #26's Seclusion/Restraint Justification Record forms showed on 09/06/11, 09/08/11, 09/12/11 and 09/13/11 the patient was released from seclusion and a face to face assessment was completed by Staff V, Supervisory RN.

During an interview on 10/20/11 at 11:25 AM Staff T, Human Resources Generalist stated Staff V had not been trained on how to perform a face to face assessment of a patient in seclusion or restraint.