HospitalInspections.org

Based on document review and interview it was determined that for 1 (Pt #4) of 2 clinical records reviewed for restraints, the Hospital failed to ensure the patient was evaluated within one hour after the application of restraint in accordance with policy.

Findings include:

1. Policy entitled "Use of Restraint and Seclusion (Revised 9/2013) indicated "For the Behavioral Health Units Only 4. Initial Evaluation A Physician LIP (Licensed Independent Practitioner), trained registered nurse or physician assistant, must see the patient face to face within one (1) hour after the initiation of Restraints or Seclusion to evaluate the patient."

2. On 1/6/16 the clinical record of Pt #4 was reviewed. Pt #4 was a 26 year old male admitted on 12/9/15 to the Behavioral Health Unit (3 West) with diagnoses of schizophrenia, suicidal and homicidal ideation. Pt #4's clinical record contained a physician's order dated 12/15/15 at 12:00 PM for seclusion and 4 point locked restraints. Pt #4's clinical record also contained a preprinted form titled "Assessment by LIP within One hour of Occurrence" dated 12/15/15 and signed by a LIP but lacked the time Pt #4 was assessed after the application of restraints.

3. On 1/6/16 at approximately 1:00 PM the findings were discussed with the Nurse Manager of the Behavioral Health Unit (E#1). E#1 stated patients are to be evaluated within an hour after the application of restraints. E #1 stated the document in Pt #4's clinical record failed to include the time the assessment occurred.