Temperance
ongoing patient assessment and monitoring for restraints' are documented here
What is Restraint Episode/Evaluation in cerner
Description of patient’s condition or symptoms/behavior warranting the use of restraint or seclusion
What must be documented and updated in the patient's medical record.
Thoughts of harming or killing oneself, in addition to the presence of a plan.
What is suicidal ideation
Every 15 minutes
Document restraint or suicide observation
Restraint Removed
What is discontinuation of restraint required documentation
Any manual method, physical, mechanical or chemical that limits movement.
What is a Restraint
A death that occurs while a patient is in restraint or seclusion; A death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
What Must be reported to CMS
Holding to give medications or treatments
What is a restraint
implement every 15 minutes violent, every 2 hours non-violent)
What is documentation time frames according to type.
Required evaluation and documentation, intervention , medical and behavioral conditions , every hour.
What is the required assessment and evaluation documentation for a violent patent.
harmful to self or others
What is a clinical situation where a restraint or seclusion are indicated.
At least every 2 hours
vital signs, circulation, hydration needs, elimination . Assess if the use of restraint or seclusion can be discontinued at the earliest possible time.
All patients are screened for suicide ideation and behavior. using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale
What is the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale
REASON FOR RESTRAINT
What are lesser restrictive intervention that have failed.
Chemical , Physical and Environmental
What Are Three Types of Restraints
Moving patient closer to nursing station, Increase observation of patient/increase frequency of nursing rounds , Reduce the stimulation and noise
What are attempts to provide the least restrictive environments.
Where do you document restraints?
What is an IPOC Restraint’ assessment
A cord, rope, or other material for the purpose of hanging or strangulation.
What is a ligature risk?
Have you been THINKING about
how you might kill yourself?
What is MODERATE measures/interventions based on C-SSRS Screening tool.
Complete Safe Room Checklist
Notify MD and MD to order Mental Health referral
Observation (every 15 min. checks)
Family Notified
What is partnering with family for an improved outcome.
Renew orders in accordance with the following time limits for up to a total of 24 hours.
What must an RN do to manage restraint application.
4 Bedrails Up
What is an incorrect restraint
Initiate 1:1 observation Room safety check, Mental Health Consult ,re-assess suicide risk and need for suicide precautions at least once a shift
What are high risk suicide interventions ?
Documenting explanation to patient to avoid restraints
What is restraint debriefing
Notify within 12 hours
What is Physician notified of application of non-violent restraints