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Based on review of Patient #2's medical record, the Hospital 's Policy titled Behavioral Health Care Restraint and interview with the ED Director, the Hospital failed to ensure that an order was written for the initiation of behavioral restraints for Patient #2.

Findings include:

The ED Face Sheet indicated that Patient #2 came to the Hospital ED on 9/27/12 at 3:24 A.M. for depression and ingestion of rubbing alcohol.

ED Triage Notes, dated 9/27/12 at 3:47 A.M., indicated that Patient #2 had a history of depression with previous suicide attempts. Patient #2 's level of consciousness was documented as stuporous, but oriented X 3.

Patient Care Assessment Notes, dated 9/27/12 at 5:20 A.M., indicated that Patient #2 was becoming verbally aggressive to staff, was displaying self injurious behavior and attempting to strike and kick staff. Documentation indicated that Patient #2 was placed in 4 point keyed restraints.

The Security Safety Report, dated 9/27/12, indicated that Patient #2 was initially placed in 2-point soft wrist restraints but tried to kick staff and was subsequently placed in 4-point restraint.

The Hospital Policy, dated 7/20/12 titled: Behavioral Health Care Restraint, indicated that a physician or other licensed independent practitioner (LIP) must order a restraint prior to the application of the restraint. For emergency situations requiring the application of a restraint, the order must be obtained either during the emergency application or obtained within 1 hour after application.

The ED Physician Progress Notes and ED Physician Orders, dated 9/27/12, did not include an order for restraint application on Patient #2

Surveyor #1 and Surveyor #1 interviewed the ED Director on 10/9/12. The ED Director confirmed there was no order for restraint application on Patient #2.

Based on review of Patient #2 's medical record, review of the Behavioral Health Care Restraint Policy and interview with the ED Director, the Physician failed to perform a face to face evaluation within one hour for one of two sampled patients (Patient #2).

Please refer to A-0168 for Patient #2 's background information.

The Policy, dated 7/20/12 titled: Behavioral Health Care Restraint, indicated that a physician or other licensed independent practitioner (LIP) must see the patient face to face and evaluate the need for restraint within one (1) hour after the initiation of the intervention.

The ED Physician Progress Notes, dated 9/27/12, did not indicate that a face to face evaluation was performed on Patient #2.

The ED Director confirmed the face to face evaluation was not documented in Patient
#2 's clinical record.