Restraint: Violent/Medication/Seclusion

Please complete this compliance survey after a patient has had a violent or medication restraint or seclusion to capture compliant documentation.

Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?

Is there an order (for a violent restraint / medication restraint / seclusion?

Orders must be entered as soon as the situation is safe to do so.
Were the following documented:

Restraint device & location (if applicable); Reason, alternatives attempted; LAR notification; start time, end time, total time, education
Patient assessment was documented Q15 min (VR/Seclusion)
Were VS documented at the end of the episode?
Was the face-to-face assessment completed within 1 hour of application?

Provider = Face-to-face note

Trained RN with competency = A&I flowsheet (Bio/ED)

If the restraint episode exceeds the maximum time frame, a new order is required, the RN must contact the responsible practitioner, report the results of the recent assessment, and request the original order be renewed.

If a patient remains in a violent restraint 24 hours after the original order, the practitioner must see the patient and conduct a face-fo-face evaluation before writing a new order to continue the use of restraint.
If medications were given during the episode to manage behavior (medications that are not currently ordered as a standard daily treatment medication), were they ordered through the Medication Management for Acute Aggression/Agitation order set?

PRN medications are prohibited.

Medication (Chemical) restraint parameter must be completed in A&I flowsheet.

VS addressed/completed.
Is there an active "Violence" nursing plan of care?
What was the date of the event?
What was the start time of the event?