Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
Compliance tips for:
When restraint (physical or chemical) or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within one hour after the initiation of the intervention by a qualified practitioner within their scope of practice. That face-to-face assessment must address: the patient’s immediate situation, their reaction to the intervention, their medical and behavioral condition, and the need to continue or terminate the intervention. ■ Audit violent restraint records for one-hour, in-person assessments. ■ Ensure the records address the four required elements.
Hospital policies are expected to guide staff in determining the type of restraint or seclusion used and appropriate intervals for assessment and monitoring based on the individual needs of the patient. Surveyors look for evidence that the policies are put into practice for all restrained or secluded patients. ■ Audit medical records for entries related to monitoring schedules.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Train staff qualified to provide monitoring on the required time frames. The ACHC Standard provides suggested parameters but hospitals should not blindly write these into policy without committing to enacting procedures to ensure compliance.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
■ Confirm that practitioners performing face-to-face assessments for violent restraints or seclusion have been appropriately privileged.
Nerd Trailblazers (prepare the path for others)
15.03.01 Identifying patients at risk 15.03.02 Environmental safety risks
15.02.17 Monitoring of the patient Frequency of the citation: 42%
Frequency of the citation: 15.03.01 32%, 15.03.02 35%
Overview of the requirement: A patient who is restrained or secluded is monitored by a trained professional to prevent injury or death, and to ensure that the intervention is ended at the earliest possible time. Comment on deficiencies: The standard is evaluated through document review. Most deficiencies noted variance between policy and actual practice related to the frequency of monitoring. Examples of ACHC Surveyor findings: ■ The facility restraint policy does not address the frequency of monitoring or assessments of patients for either violent or non-violent restraints. ■ Non-violent restraint records lacked evidence of assessment every two hours. ■ Based on medical record review, records lacked evidence of monitoring documentation for a patient in violent restraints every 15 minutes as required by hospital policy. ■ For four-point violent restraint episodes, documentation is required every 15 minutes with specific assessments. ‘Physical discomfort' was absent for entire episode of restraints, and two checks lacked 'psychological status' as required by hospital policy. ■ Based on interview with the day shift ED manager, patients who are in seclusion are periodically monitored by staff. Hospital policy is silent on the frequency of monitoring and assessment for seclusion.
Overview of the requirement: These closely related standards require that all inpatients and Emergency Department patients are screened for risk of harm to self or others and that patient care areas undergo at least annual environmental risk assessments for ligature points, and access to sharps, harmful substances, cords or tubing, breakable glass, etc. Comment on deficiencies: Compliance is assessed through direct observation, and review of documentation. Surveyors noted patient screening policies that omitted required elements or were not followed in actual practice. Many citations noted missing environmental risk assessments or failure to take mitigating action identified by existing risk assessments. Examples of ACHC Surveyor findings: ■ Hospital policy allows family members to provide 1:1 observation. During interview, staff noted that a family member could be responsible for performing 1:1 monitoring for a suicidal patient. This is in violation of policy and regulatory requirements. ■ The adult and adolescent BH unit had adopted screening, identification, and assessment processes. The methods outlined in the policy were not congruent with current nationally recognized tools. The policy did not clearly identify risk levels or interventions to be implemented based on risk. ■ No evidence of staff training on hospital policy regarding patient-at-risk screening, removal of at- risk items from patient room, and implementation of a 1:1 sitter.
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