Q&A: Clarifying PC.03.05.05, EP 4 (Orders for restraint)

Q: The surveyor found that on the behavioral health unit in the electronic medical records (EMR), the order for seclusion was not timed; therefore, it could not be determined when a four-hour renewal order for seclusion was needed, and it was written as “continuous” for a second period of seclusion. Can I clarify this finding?

A: What you would consider in this case for a clarification is:

• Determine if there is a way to identify that timing of the order in the EMR.
• Does the EMR have a built-in timeout after four hours?
• What does your policy state regarding orders for seclusion and renewals?
• Were any restraints used for longer than four hours based on the flow sheets?
• Is there evidence of staff education and competency that addresses the time requirements?

If you can determine that the orders did exist in the record but the surveyors were unable to view them during the survey for some reason, can you demonstrate that you can meet 90% compliance by performing an audit of restraint and seclusion orders for 30 days prior to the visit? Your PI data may be routinely monitored and collected for this information, and you can then show 90% compliance without an additional audit. Otherwise, you will not be able to clarify this finding.

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