Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
15.03.02 Environmental safety risks Overview of the requirement:
Tips for compliance:
n Review policies to ensure restraints can only be ordered per hospital policy in compliance with state law and within scope of practice. n Ensure timely and complete order entries by training staff on restraint policies and procedures. n Conduct daily restraint chart audits.
Hospitals adopt an environment risk assessment tool with documented mitigation procedures when an at-risk patient is placed in an environment that includes potential ligature points. The required elements were revised in June 2023 to add clarity to the expectations. Whenever an errata is issued mid-year, it is safe to assume that those changes will receive special focus. Compliance is evaluated through observation and document review. Surveyors noted missing risk assessments, missing mitigation plans, or failure to implement mitigation as needed.
Comment on deficiencies:
15.02.17 Monitoring of the patient Overview of the requirement:
When restraint of seclusion are used during patient care, intervals for monitoring and reassessment must be defined and performed by qualified staff. Compliance is assessed through record review and interview. Surveyors noted incomplete policies, or monitoring documentation that deviated from the policy, usually for the type of monitoring required or the timing of reassessment.
Frequency of citation:
22%
Examples of surveyor findings:
n The hospital was unable to recall when the last environmental ligature risk assessment was conducted in patient care areas. n Neither of the most recent annual risk assessments identified locations of ligature points within the departments, nor did they include appropriate, effective mitigation strategies for patients at risk of harm. In the ED seclusion room, the hinges for the door present three potential ligature points. These ligature points are noted on the environmental risk assessment without a mitigation strategy. The ED nurse manager could verbalize that suicidal patients placed in that room have one staff member assigned to continuously monitor through the glass window, but the process for monitoring of patients in the room is not documented in written policy or procedure. n Risk assessment instructions state, “Areas are free of items that could be used to harm self or others. Areas that do not have sharps or potential contraband issues have been identified for risk of hanging and/or barricading.” The assessment makes no mention of the non-bolted, non-weighted chairs, overbed tables, or regular reclining chair that were in the patient rooms, does not identify the ligature points or potentials for barricading, and failed to note the loose air vent on the fan coil unit. n Risk assessment instructions state, “There is no use of wired bed/chair/ personal alarms – use cordless. If you must use bed cords, they are located close to an outlet and plugged directly into the outlet; cords are shortened to reduce looping around the neck and securing to an anchor point for hanging.” The mitigation states “Maintenance to position the cords closely to an outlet and they are plugged directly into the outlet. Cords are shortened to reduce looping potential and secured.” However, the cords have not been shortened and the zip ties used to reduce the length of the cords have left cords approximately three feet long. This does not appropriately mitigate risk for ligature use. n Environmental ligature risk assessments noted mitigation of ceiling vents as ligature points by covered them with plexiglass within the patient bathrooms. Three rooms lacked plexi covers.
Comment on deficiencies:
Frequency of citation:
22%
Examples of surveyor findings:
n Based on review of the “Restraint/Seclusion” policy, the policy does not address monitoring of a patient who is violent or in seclusion. n Records lacked documentation of patient monitoring every 15 minutes for the following assessment elements required hospital administration policy, “Restraints:” Vital signs, skin integrity, warmth and privacy, readiness for restraint release. n Four of six violent restraint episodes did not have every 15-minute monitoring of the patient as required by facility policy. n Seven of nine medical records reflecting use of restraints did not contain all elements for re-assessment and/or were missing re-assessments completed every 15-minute per policy. n Based on interview with emergency department leadership, patients are placed in the seclusion room with a staff member assigned to continuously monitor the patient through the large seclusion room window facing the nurse’s station in the ED. The organization’s restraint and seclusion policy is silent on the monitoring process for patients placed in the seclusion room.
Tips for compliance:
Restraints must be discontinued at the earliest possible time. This requires monitoring at consistent intervals.
n Review policies for required elements. n Define staff roles that may perform monitoring and/or assessment. n Ensure staff assigned to monitor/assess patients in restraint or seclusion are trained and have demonstrated competency to perform these tasks.
achc.org | (855) 937-2242 | 13
12
Made with FlippingBook - PDF hosting