Is there an active non-violent restraint order in SCM?

• Renewal orders must be entered every calendar day.
• No PRN orders.

 

Verify that there is only one active non-violent restraint order per device.

• Discontinue duplicate/old/expired non-violent restraint orders.

Look at the Restraint Flowsheet in SCM. Ensure the following have been documented at least once a shift:

"Start date/time" should be documented only once at the time of the initial application of the restraint.

• If the application time is later than the order entry time, documentation should reflect what we are doing in the interim to keep the patient safe while we are waiting for the restraint to be applied.

Q2hr Documentation: Are all areas within the Patient Assessment section documented every 2 hours (or less)? "WDL Except" row should only be documented if applicable.

If the patient met the criteria for release, was the restraint removed, the "End time" documented, and the order discontinued?

• Removing a restraint while family visits and then reapplying when they leave constitutes a new episode and requires a new order.
• Temporary, directly supervised release of restraint for the purpose of caring for patient needs is not considered a discontinuation of restraint.

If the patient is on a neuromuscular blocking (NMB) medication drip, has the restraint been removed and discontinued?

Is there an active Restraint: Non-Violent Care Plan? And were plan of care interventions documented at least once this shift in the A&I flowsheet?