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LEHIGH VALLEY HOSPITAL - MUHLENBERG
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0166
Based on review of facility policy and procedures, review of facility document, review of medical records and interview with staff (EMP), it was determined the facility failed to ensure documentation was accurate and completed for patient's plan of care while in restraints for one of four restraint medical records reviewed (MR1).
Findings include:
Review on November 3, 2017, of facility policy "Restraint and Seclusion for Violent/Self Destructive Behavior," approved February 1, 2017, revealed, " ... F. Documentation 3. Reassessments will be performed under the direction of a Registered Nurse every 15 minutes and monitoring documented on the Restraint/Seclusion for Violent/Self-destructive Behavior Observation Checklist ... f. patient behavior ... k. readiness for discontinuation of restraint or seclusion ... ".
Review on November 3, 2017, of facility document "Restraint/Seclusion for Violent/Self-destructive Behavior Observation Checklist," revealed, " ... Time Every 15 minutes ... Patient Behavior ... Guidelines for Use ... Effectiveness of Alternatives/Interventions ... N = Not Effective ... D/C = Restraints Discontinued Debriefing Completed ... ".
Review on November 3, 2017, of MR1 revealed the patient was placed in four point restraints on April 23, 2017. Review of the "Restraint/Seclusion for Violent/Self-destructive Behavior Observation Checklist" for MR1 revealed no documentation of the patient's behavior at 8:30 PM, 8:45 PM, 9:00 PM, 9:15 PM and 9:30 PM.
Continued review of the "Restraint/Seclusion for Violent/Self-destructive Behavior Observation Checklist" for MR1 dated April 23, 2017, revealed "Effectiveness" [of restraint] was documented "N" [not effective] at 8:15 PM, 8:30 PM, 8:45 PM, 9:00 PM, 9:15 PM and 9:30 PM. Further review of the "Restraint/Seclusion for Violent/Self-destructive Behavior Observation Checklist" for MR1 revealed no documentation the restraints were discontinued and debriefing was completed for the restraint episode.
Interview with EMP1 on November 3, 2017, at 12:30 PM confirmed the above documentation was not accurate or complete for MR1 for the restraint episode.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0184
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure documentation of the 1 hour face-to-face medical and behavioral evaluation when the restraint was used to manage violent or self-destructive behavior in two of four restraint medical records reviewed (MR1, MR2).
Findings include:
Review on November 3, 2017, of facility policy "Restraint and Seclusion for Violent/Self-Destructive Behavior" approved February 1, 2017, revealed " ... B. Emergent use of restraint/seclusion 1. initial order ... g. The patient must be examined by a LIP within one hour of initiation. The examination must be documented."
Review on November 3, 2017, of MR1 revealed documentation the patient had four point restraints applied on April 23, 2017, at 8:15 PM. Further review of MR1 revealed no documentation of an examination by an LIP within one hour of initiation of the restraints.
Review on November 3, 2017, of MR2 revealed documentation the patient had four point restraints applied on April 23, 2017, at 11:06 PM. Further review of MR2 revealed no documentation of an examination by an LIP within one hour of initiation of the restraints.
Interview with EMP1 on November 3, 2017, at approximately 12:15 PM confirmed there was no documentation of an examination by an LIP within one hour of initiation of restraints for MR1 and MR2.