Healthcare Facility Compliance 14 items
Restraint & Seclusion Compliance Audit
Compliance audit of restraint and seclusion practices covering orders, assessment, monitoring, staff training, and death reporting under the CMS patient rights CoP.
CMS 42 CFR 482.13(e)-(f)CMS 42 CFR 483.12 / 483.10(e)TJC PC.03.05 / PC.03.03
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Least Restrictive & Alternatives
- Is restraint or seclusion used only when less restrictive interventions have been determined ineffective? *
- Is restraint/seclusion never used for coercion, discipline, convenience, or staff retaliation? *
- Is the restraint/seclusion discontinued at the earliest possible time? *
Orders & Assessment
- Is there an order by a physician or authorized LIP for each episode of restraint or seclusion? *
- Are PRN (standing/as-needed) orders for restraint or seclusion prohibited? *
- For violent/self-destructive behavior, do time-limited orders follow the age-based limits (4h/2h/1h)? *
- Is the patient seen face-to-face within 1 hour by a physician/LIP or trained RN for violent behavior use? *
Monitoring & Care
- Is the patient monitored/assessed at intervals consistent with policy and the patient's condition? *
- Are the patient's needs (hydration, toileting, circulation, range of motion, nutrition) addressed? *
- Is the condition that warranted restraint/seclusion documented and the plan of care updated? *
Staff Training
- Are staff trained and competency-assessed on safe application and alternatives before applying restraints? *
- Is training provided on recognizing signs of physical/psychological distress during restraint/seclusion? *
Death Reporting
- Are deaths associated with restraint or seclusion reported to CMS as required? *
- Is a log or documentation maintained of restraint/seclusion-associated deaths, including timeframes? *
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