Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
15.02.14 Violent restraints and/or seclusion: One-hour face-to-face assessment 15.02.15 Violent restraints and/or seclusion:
15.02.07 Restraint or seclusion: Modification of the plan of care Frequency of the citation: 32% Overview of the requirement: An order for the use of restraint or seclusion requires a modification to the individualized plan of care. Comment on deficiencies: Compliance is evaluated by reviewing medical records of patients who required restraint or seclusion. Examples of ACHC Surveyor findings: ■ Based on review of closed records for the use of violent restraints, one of two care plans identified the use of non-violent restraints instead of violent restraints and did not note discontinuation of restraints until seven days after they were no longer in use. ■ In four of five records where restraint use was documented, the plan of care was not modified to reflect that restraints had been discontinued. ■ Hospital policy requires that initiation of restraint use and plan of care updates are completed by the end of the shift. One file reviewed was missing a timely entry.
One-hour face-to-face assessment components
Frequency of the citation: 15.02.14 26%, 15.02.15 29%
Overview of the requirement: These closely related standards identify who must perform a one-hour face-to-face assessment and what that assessment must include when restraint or seclusion is used to manage violent or self-destructive behavior. Comment on deficiencies: Compliance is based on interview and review of hospital policy and medical record documentation. Examples of ACHC Surveyor findings: ■ Violent restraint records did not have a dated or timed face-to-face evaluation completed within the one-hour time frame requirement. ■ Documentation was missing for a face-to-face assessment within one hour by the physician or a trained RN. In one case, an assessment was conducted two hours after the initiation of chemical restraint, in another, there was no assessment noted. Hospital policy requires a physician assessment/in-person evaluation completed within 30 minutes of notification of the event. ■ The facility's restraint/seclusion policy states that the face-to-face evaluation will "evaluate the patient's immediate situation, response to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints." The physician evaluation was missing:
Compliance tips for:
■ When restraint or seclusion is ordered, the plan of care must identify the rationale for their use, the intervention(s) selected, and the plan for patient monitoring including the frequency of reassessment of vital signs, safety, comfort, mental status, skin integrity/circulation checks, hydration, toileting, and readiness for release. ■ Audit records of patients for whom restraint or seclusion was ordered to ensure the plan of care includes all required information, including the discontinuation of the intervention. ■ Train staff on documentation to ensure that the plan of care modification reflects a process of assessment, intervention, and that ongoing evaluation data are included in progress notes.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
ٝ The patient's behavioral condition. ٝ The need to continue the restraint.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 19
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