SRH Restraints Audit

• Audit Title:

• Department:

• Conducted on

  Date

• Participating Auditors

Auditor

• Name:

• Attendees:

Policy & Procedure Review

• Are there any regulatory standards for restraints?

  Yes

  No

  N/A

• What are some of those standards?

• Is there a clear definition of a restraint?<br>

  Yes

  No

  N/A

• Does this address patients with law enforcement restraints applied?

• Notes:

• Who is allowed to order/prescribe restraint use?

• Is there any requirement for notifying family of the patient when restraints are going to be used?

• Does current documentation specify the locations where restraints are to be applied? (2 point, 4 point vs. Right wrist, Left ankle)

  Yes

  No

  N/A

• Who is allowed to remove a restraint?

• Is there training documentation on team members who can apply and/or remove restraints?

  Yes

  No

  N/A

• What is the process for removing restraints for treatments, transport, feeding, etc.?

Chart Review

• Medical Chart of Patient in Restraints
  

Medical Record

• Do the orders specify which location(s) restraints are to be applied?

• Are the orders for non-violent patients renewed each calendar day?

  Yes

  No

  N/A

• Monitoring is completed every 2 hours for non-violent behavior

• Plan of Care is reviewed/updated daily.

  Yes

  No

  N/A

HR and Training File Review

• Personnel File Review
  

Team Member

• Team Member Initials:

• Team member has completed training on restraints

• Date of last training session:

  Date

Quality Monitoring

• Data Analysis is being conducted and reviewed for compliance with policy and for continuous improvement.

  Yes

  No

  N/A

• Restraint log includes date and time of order

  Yes

  No

  N/A

• Team Members who have not received training are not applying or removing restraints

  Yes

  No

  N/A

• Date and time of death associated with restraints is being recorded.

  Yes

  No

  N/A

• Comments:

Finding or Opportunity For Improvement

Finding

• Standard Not Being Met:

• Evidence:

• Recommended Corrective Action:

• Opportunity For Improvement

OFI

• Finding:

• Recommendation

Notable Effort

• Recognition for exemplary efforts

NE

• NE:

Additional Notes

• Auditor Signature

  Sign