DOCSLIB.ORG

Florida State Hospital State of Florida Operating Procedure Department of No

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Florida State Hospital State of Florida Operating Procedure Department of No FLORIDA STATE HOSPITAL STATE OF FLORIDA OPERATING PROCEDURE DEPARTMENT OF NO. 150-14 CHILDREN AND FAMILIES CHATTAHOOCHEE, April 26, 2017 Health MEDICAL RESTRAINTS & SAFETY DEVICES 1. Purpose: This operating procedure prescribes the use of medical restraints and safety devices at Florida State Hospital. It establishes guidelines and methods to be employed by Hospital staff in restraining residents when the need is of a medical nature. 2. Scope: This procedure applies to all units at Florida State Hospital which use medical restraints. 3. References: a. Florida Statutes, Chapter 394 b. Florida Administrative Code 59A-3, Hospital Licensure c. Restraint Proper Environment OBRA Restraint Guidelines d. State Operations Manual, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, e. Centers for Medicare & Medicaid Services, HHS. §482.13 Conditions of Participation: Patient’s Rights 4. Philosophy of Florida State Hospital: Medical restraints of residents are methods of last resort and shall not be used unless lesser restrictive methods of intervention have been attempted and determined to be ineffective. Residents will be fully evaluated for restraint elimination and/or reduction at the time of each recovery team review (monthly, bi-monthly, 6-months and annual) and at the time of the 180-day review. Medical restraints shall be applied/ utilized in a manner that is most comfortable to the resident while preserving his/her dignity. Medical Restraints and safety devices shall NOT: a. impair neurovascular integrity; b. impair respiration; c. be tied to bedrails or moving parts of a gerichair or wheelchair; d. prevent residents from eating comfortably; e. interfere with toilet needs; This Operating Procedure supersedes: Operating Procedure 150-14 dated April 21, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Medical Services DISTRIBUTION: See Training Requirements Matrix April26,2017 FSHOP150-14 f. interfere with bathing, dressing changes, or other hygiene needs; g. prevent immobile residents from being repositioned every two hours; h. impair skin integrity (i.e., cause bruises, etc.); i. be used for the convenience of staff; j. be used as punishment; or k. be used as aversive stimulus. 5. Staff Training: Staff shall be trained by Professional Development and Training as part of orientation and subsequently on an annual basis. Staff responsible for the following actions will demonstrate competency in the following skills before participating in a medical restraint, related assignment or in provision of care for a resident in medical restraint: a. Observing for and reporting signs of physical and psychological distress. b. Safe and appropriate use of medical restraint techniques and safe application of medical restraint devices. c. Monitoring the physical and psychological well-being of the person who is restrained, including but not limited to respiratory and circulatory status, skin integrity, vital signs and any other associated requirements. 6. Requirements: Prior to using medical restraint, less restrictive measures, that include, but not limited to pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented. a. Restrictions: Medical restraints shall be used only when clinically indicated to: (1) protect the resident from self-injury; (2) facilitate the rendering of necessary medical treatment such as, nasogastric feeding or the elevation of an extremity; (3) act as an enabler to increase the resident's level of independence; for example the use of soft helmet for a resident with a seizure disorder if its purpose is to allow the resident some freedom of movement; (4) prevent the exacerbation of an existing medical condition; and (5) serve as a preventive measure in the spread of a communicable disease. b. Residents’ Rights: The resident's safety, dignity, and civil liberties must be top priorities each time medical restraints are utilized. Use of the restraining device must first be explained to the resident, and documented in the progress notes. Staff shall communicate with resident before and during application of medical restraints, in order to reduce resident's distress or anxiety. c. Physician’s Orders: As part of the Recovery Plan, the attending physician shall write the order for medical restraint after a clinical assessment of the situation. The assessment and the rationale for 2 April26,2017 FSHOP150-14 the use of medical restraint shall be included in the progress notes. The resident’s treatment order shall specify: (1) the conditions/medical rationale under which the resident is to be restrained; (2) the type of restraint to be used; and (3) parameters that determine the duration of restraints use. In the event the condition of the resident is such that he/she should be observed more frequently than every two (2) hours, the physician shall order the frequency of observation. Medical restraint orders are valid for up to seven (7) days, at which time they must be rewritten if continued use is necessary and clinically indicated. If the condition of the resident is chronic but relatively stable, then the requirement for frequency of renewal of Physician’s Order may be reduced. For example, the duration of the order may last for up to one (1) month, at which time the order must be rewritten. These restraints will be considered extended medical restraints. d. Emergency Medical Restraints: The physician and/or the nurse have the authority to utilize emergency medical restraints. e. Observations: Generally, an observation of the restrained resident is to be made and documented every two (2) hours; but more frequently as ordered by the physician. A registered nurse shall evaluate the resident shortly after the shift and approximately four (4) hours later. This evaluation shall be documented in the progress notes. The LPN can observe, gather data, and report. f. Care of the Resident: All efforts will be made to ensure the physical comfort, dignity and safety of the resident while he/she remains in restraints. Efforts shall be documented on the flow sheet and include: (1) Exercise and Repositioning: During each two-hour period, active or passive exercises and repositioning will be provided unless contraindicated. (2) Meals: Residents will receive all meals at regular times. Residents will be positioned and restraints will be adjusted as necessary in order for meals to be eaten both safely and comfortably. (3) Toileting: Residents will be allowed to toilet themselves in the most normal and dignified manner possible. Toileting will be allowed upon request, but will be offered during each one- hour period. If the resident is incontinent, care will be provided at each time of need. (4) Bathing: Baths will be provided based on the resident's condition. g. Flow Sheets: A Medical Restraint Flow Sheet will be maintained by the direct care staff during the entire period that the resident is in medical restraints. It is the immediate supervisor’s responsibility to check the flow sheet to ensure it is being completed correctly. h. Recovery Team Responsibility: The recovery team shall review the need for medical restraints as part of their total management of the resident. This is done during scheduled team meetings (monthly, bi-monthly, 6-months and annual cycle). The team will assure that adequate positioning interventions and other specific individual interventions are included in the Recovery Plan. Reduction plans as well as regular attempts/evaluations without restraint will be incorporated into the plan. Plans to reduce restraints shall include specific instruction and time frames for reduction. 3 April26,2017 FSHOP150-14 i. Physician Documentation: The physician will document the rationale for the medical restraint order on the Physician's Order form. (1) The physician will document in the Progress Note the following: (a) a description of the behavioral and clinical assessment of the resident which prompted the decision to utilize medical restraint; (b) the precise goals of medical restraint; and (c) the condition for discontinuing the medical restraint. (2) Monthly Progress Note: The physician will write monthly progress notes for all residents with orders for medical restraints. The note will describe, assess and justify the requirement for, and the effects of the medical restraint used. (3) The physician will review, initial and date all consultations (Form 29) related to restraint usage. j. Licensed Nurse/Shift Supervisor Documentation: (1) Emergency Restraints: The Registered Nurse will assess the resident within thirty (30) minutes after the restraint is applied; and document his/her findings on the Medical Restraint Nursing Assessment/Progress Note (Form 617). The assessment shall be done at the beginning of each shift and approximately four (4) hours later for the duration of the order. All assessments shall be documented on the Medical Restraint Nursing Assessment/ Progress Note, Form 617. This form should be filed in chronological order in the Progress Note section of the chart. (2) All residents in medical restraints must have documentation which indicates that they were observed by an RN/LPN shortly after the beginning of the shift and approximately four (4) hours later. The LPN can observe, gather data, and report. (3) The RN’s assessment form will be required for all residents in medical restraint, regardless of the duration of the restraint. (4) Monthly Progress Note: Prior to a Physician’s Order being rewritten, the registered nurse will assess
Load more

Recommended publications
  • Nursing Service Guidelines FALL PREVENTION MULTIDISCIPLINARY FALL PREVENTION
    Nursing Service Guidelines FALL PREVENTION Title: MULTIDISCIPLINARY FALL PREVENTION Responsibility: Multidisciplinary staff need to take an active role in fall prevention. Equipment: Fall identification wrist bands, fall identification materials, and fall prevention equipment. Purpose: Since research has identified that numerous intrinsic and extrinsic variables can contribute to a patient’s risk of falling during a hospitalization, it is essential to determine the risk factors that place the patient at the greatest (highest) risk. By utilizing strategies that take into consideration the fall risk assessment score, clinical judgement, medication management, the patients mental status, and the patients ability to ambulate, it is intended that this approach will help prevent patient falls. The purpose of this guideline is to provide multidisciplinary staff with fall risk assessment tools that can be used to assist them in properly identifying those patients at risk for falling and determining interventions. General Information: A fall is defined as any unplanned descent to the floor, with or without injury (National Database of Nursing Quality Indicators [NDNQI], 2015). A fall may be either unassisted or assisted (where someone helps to ‘break’ the fall by helping the patient to the floor) and the NDNQI definition also includes falls where a patient lands on a surface where you would not expect to find the patient. University of Toledo Medical Center’s (UTMCs) fall injury level categories: • None • Minor (dressing, ice, cleaning, or elevation) • Moderate (suturing, splinting, or steri-strips/skin glue) • Major* (surgery, casting, traction, or neuro consult) • Death* (died as a result of injuries sustained from the fall) *if a patient’s fall has a major injury level or results in a death, the department manager or house supervisor and Quality Management need to be notified immediately.
    [Show full text]
  • Advanced Journal of Emergency Medicine. 2018; 3(1)
    ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2019; 3(1): e7 Ziaei et al Review Article DOI: 10.22114/ajem.v0i0.117 Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles Maryam Ziaei1, Ali Massoudifar2, Ali Rajabpour-Sanati3, Ali-Mohammad Pourbagher-Shahri3, Ali Abdolrazaghnejad1* 1. Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran. 2. Department of Psychiatry, School of Medicine, Hormozgan University of Medical Sciences, Bandarabbas, Iran. 3. Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran. *Corresponding author: Ali Abdolrazaghnejad; Email: [email protected] Published online: 2018-11-29 Abstract Context: The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods. Evidence acquisition: This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review. Results: Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint. Conclusion: In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.
    [Show full text]
  • State of Florida Division of Administrative Hearings
    STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ) ADMINISTRATION, ) ) Petitioner, ) ) vs. ) Case Nos. 09-5360 ) 09-5363 GULF COAST MEDICAL CENTER, ) 09-5364 LEE MEMORIAL HEALTH SYSTEM, ) 09-5365 ) Respondent. ) ) RECOMMENDED ORDER Pursuant to notice to all parties, a final hearing was conducted in this case on January 25 through 29, 2010, in Fort Myers, Florida, before Administrative Law Judge R. Bruce McKibben of the Division of Administrative Hearings. The parties were represented as set forth below. APPEARANCES For Petitioner: Andrea M. Lang, Esquire Agency for Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 For Respondent: W. David Watkins, Esquire Watkins & Associates, P.A. Post Office Box 15828 Tallahassee, Florida 32317-5828 STATEMENT OF THE ISSUES The issues in this case are set forth in 11 separate counts within the four consolidated cases: Case No. 09-5360 Count I--Whether Respondent failed to properly monitor and care for a patient in restraints. Count II--Whether Respondent failed to ensure the physician's plan of care for patient was implemented. Case No. 09-5363 Count I--Whether Respondent failed to properly implement the physician's plan of care for patient. Case No. 09-5364 Count I--Whether Respondent failed to ensure a patients' right to privacy. Count II--Whether Respondent failed to ensure that food was served in the prescribed safe temperature zone. Count III--Whether Respondent failed to ensure that only authorized personnel had access to locked areas where medications were stored. Count IV--Whether Respondent failed to perform proper nursing assessments of a patient.
    [Show full text]
  • Restraint Module for Travel Nurses
    Restraints Objectives Recognize federal regulations related to use of restraint. Distinguish between behavioral and non-behavioral restraint application requirements. Competent to apply restraints Understand proper documentation of restraint use Knowledge of restraint monitoring Knowledge of alternatives to restraint Knowledge of restraint discontinuation 1 Joint Commission and CMS Requirements The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) standards related to restraint use focus on limiting the use of restraints and seclusion to: . Emergency situations when a person is at imminent risk of harming himself or herself or others . When nonphysical safety measures have been ineffective . When safety requires an immediate physical response . Restraint use MUST be Ordered by the Physician AND MUST BE APPROPRIATELY DOCUMENTED Hospital policy on Restraints . The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others . Restraints should be considered once less restrictive interventions have been considered/tried and are determined to be inadequate for the clinical purpose. Any use of restraint will be discontinued at the earliest possible time, based on reassessment of the patient’s continuing need for the restraint . Restraint is never used as a means of coercion, convenience, or retaliation by staff. 2 Definitions RESTRAINTS . A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A restraint is a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.
    [Show full text]
  • Slides and Handouts
    Organizing Clinical Information Systems to Manage and Improve Care Jennifer Allan, BSN, RN Methodist Healthcare System Jane Englebright, PhD, RN Columbia/HCA Healthcare Corporation Our Documentation System 1994 to 1996 • Four sites using a computerized clinical documentation system – Two using NANDA format – Two using NIC format • One site on paper Unresolved Problems Included: • Increased charting time, increased cost • Ambiguous, complex care plans • Hundreds of documentation screens • Physician dissatisfaction with nursing • Physician dissatisfaction with medical record • Fragmented, duplicative and conflicting information in the medical record “Fix” the System or De-install! • Meet legal, regulatory & clinical requirements • Decrease documentation time • Reduce costs • Eliminate repetition • Streamline record • Automate reports • Introduce interdisciplinary documentation • Lay foundation for quality monitoring • IMPROVE PATIENT CARE Two Early Rewrites Used Established Nursing Taxonomies Advantages Disadvantages NANDA Well known to Foreign to non- nurses nurses Non-exclusive diagnoses NIC Facilitates Long look-up for charging and interventions acuity Does not tie to care plan Review of Literature • NIC (Nursing Intervention Classification) • NANDA (North American Nursing Diagnosis Association) • Charting by Exception • Focus Charting • Problem Oriented (SOAP) • Practice Guidelines No current methodologies supported our vision: Concepts from NANDA, Our NIC, Charting by Goals Exception, Systems Theory Patient Centered Documentation ©
    [Show full text]
  • Agency Nurse Orientation 2020
    CHI Saint Joseph Health: Agency Nurse Orientation 2020 Table of Contents Welcome and Introduction.............................................................................................................................. 4 Mission, Vision and Values .............................................................................................................................. 4 Standards of Conduct ...................................................................................................................................... 5 Orientation Information .................................................................................................................................. 5 CHI Saint Joseph Health Nursing Vision ................................................................................................... 6 Confidentiality .......................................................................................................................................... 6 Disaster Codes .......................................................................................................................................... 6 Dress Code ................................................................................................................................................ 6 Environment of Care ................................................................................................................................ 9 Incident Reporting .................................................................................................................................
    [Show full text]
  • CMS Restraint Training Requirements H a N D B O O K the CMS Restraint Training Requirements Handbook Is Published by Hcpro, Inc
    THE CM Restraint Training Requirements As of January 2007, the Centers for HANDBOOK Medicare & Medicaid Services (CMS) requires that your hospital comply with new Conditions of Participation for patient restraint and seclusion. The new requirements focus on patient rights and include additional staff training requirements regarding restraint and seclusion. This portable handbook from HCPro is the perfect training tool to help staff members comply with the new CMS restraint and seclu- sion rules. Concise and easy to use, this handbook explains the specifics of the new training requirements, including the following prescriptive requirements: • Application of restraints • Implementation of seclusion • Monitoring of patients in restraint/seclusion • Assessment of patients in restraint/seclusion • Providing care for a patient in restraint/seclusion It also includes sample competency assessment “skill sheets” for staff who are involved in restraint and seclusion. For additional products about CMS compliance, visit HCPro’s online CMSRT | 200 Hoods Lane | Marblehead, MA | 01945 The CMS Restraint Training Requirements H a n d b o o k The CMS Restraint Training Requirements Handbook is published by HCPro, Inc. Copyright © 2007 HCPro, Inc. All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN 978-1-60146-068-4 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.
    [Show full text]
  • The Lethal Consequences of Restraint
    EQUIP FOR EQUALITY A SPECIAL REPORT from the Abuse Investigation Unit NATIONAL REVIEW OF RESTRAINT RELATED DEATHS OF CHILDREN AND ADULTS WITH DISABILITIES: The Lethal Consequences of Restraint UIP FO Q R E E TM Q Y U A L I T UIP FO Q R E E TM Q Y U A L I T Mission Established in 1985, the mission of Equip for Equality is to advance the human and civil rights of people with disabilities in Illinois. Equip for Equality is a private not- for-profit legal advocacy organization designated by the governor to operate the federally mandated Protection and Advocacy System (P&A) to safeguard the rights of people with physical and mental disabilities, including developmental disabilities and mental illness. Equip for Equality is the only comprehensive statewide advocacy organization for people with disabilities and their families. All individuals with a disability in Illinois (as defined by the ADA) are eligible for services, including children, senior citizens, and individuals in state-operated facilities, nursing homes, and community-based programs. Services, Programs, and Projects Abuse Investigation Unit works to prevent abuse, neglect, and deaths of children and adults with disabilities in community-based programs, nursing homes, and state institutions. The Unit works with public investigatory agencies to improve their performance and coordination with each other; conducts investigations of abuse and neglect cases; alerts service providers to dangerous conditions and practices. Public Policy Advocacy achieves changes in state legislation, public policies and programs to safeguard individual rights and personal safety, enhance choice and self- determination, and promote independence, productivity, and community integration.
    [Show full text]
  • Hospital Reporting of Deaths Related to Restraint and Seclusion
    Report Template Version = 06-15-05_rev.08 Department of Health and Human Services OFFICE OF INSPECTOR GENERAL HOSPITAL REPORTING OF DEATHS RELATED TO RESTRAINT AND SECLUSION Daniel R. Levinson Inspector General September 2006 OEI-09-04-00350 Report Template Version = 06-15-05_rev.08 Office of Inspector General http://oig.hhs.gov The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit Services The Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation and Inspections The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. Specifically, these evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness in departmental programs. To promote impact, the reports also present practical recommendations for improving program operations.
    [Show full text]
  • Respondent's Brief, Wanda Williams V. CMO Management, LLC, No. 15-0553
    No. 15-0553 IN THE SUPREME COURT OF APPEALS OF WEST V;.IR:..:::G~IN:...:..I:::....A:-__-::::::---:~ At Charleston ~OlS@ij WANDA WILLIAMS, INDIVIDUALLY AND ON BEHALF OF THE ESTATE AND WRONGFUL DEA H C~:~~r 2nZ~5,:~:J\ BENEFICIARIES OF ROBERT THOMPSON, Petitioner/Plaintiff Below, v. CMO MANAGEMENT, LLC (AS TO NICHOLAS COUNTY NURSING & REHABILITATION) Respondent/Defendant Below. Appeal from the Circuit Court of Nicholas County Honorable Gary L. Johnson, Judge Civil Action No. 13-C-92 BRIEF OF RESPONDENT/DEFENDANT BELOW CMO MANAGEMENT, LLC Jeffrey M. Wakefield, Esquire (W.va. Bar No. 3894) Mark A. Robinson, Esquire (W. Va. Bar No. 5954) Ryan A. Brown, Esquire (W. Va. Bar No.1 0025) FLAHERTY SENSABAUGH BONASSO PLLC P. O. Box 3843 Charleston, WV 25338-3843 Telephone: (304) 345-0200 Facsimile: (304) 345-0260 [email protected] [email protected] [email protected] Counsel for CMO Management, LLC TABLE OF CONTENTS TABLE OF AUTHORITIES ............................................................................................ii, iii STATEMENT OF THE CASE ...........................................................................................1 SUMMARY OF ARGUMENT ............................................................................................5 STATEMENT REGARDING ORAL ARGUMENT AND DECISION .................................8 ARGUMENT........................................................................................................................8 I. THE CIRCUIT COURT DID NOT ERR IN APPLYING THE MPLA'S
    [Show full text]
  • 6.003 Seclusion Or Restraint Process
    OREGON STATE HOSPITAL POLICIES AND PROCEDURES SECTION 6: Patient Care POLICY: 6.003 SUBJECT: Seclusion or Restraint Process POINT CHIEF MEDICAL OFFICER PERSON: APPROVED: JOHN SWANSON DATE: NOVEMBER 22, 2017 INTERIM ADMINISTRATOR I. POLICY A. Oregon State Hospital (OSH) provides humane care and treatment to each patient in the least restrictive manner consistent with safety for patients, health care personnel (HCP), and the public. OSH believes that a unit culture and milieu based on respectful, non-coercive interactions between HCP and patients is the safest environment. B. OSH strives to prevent, reduce, and eliminate the use of seclusion or restraint. Seclusion or restraint use is considered an indicator of treatment failure and a safety measure of last resort as expressed by the Substance Abuse and Mental Health Administration. C. Non-physical interventions should be used before physical interventions unless safety demands an immediate physical response. HCP must focus on using non- physical interventions early to prevent an emergency situation to decrease the need for using seclusion or restraint. D. The use of seclusion or restraint poses risks to the physical safety and the psychological well-being of the patient and HCP. Therefore, seclusion or restraint may be used only in an emergency when there is imminent danger of harm. 1. The use of restrictive measures must be the result of careful deliberation by HCP who: a. have sufficient clinical knowledge of the patient and the circumstances, and b. who are trained in the theory and practice of seclusion or restraint techniques as well as in the prevention of their use.
    [Show full text]
  • Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev
    State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 1, 05-21-04) Survey Protocol Introduction Task 1 - Off-Site Survey Preparation Task 2 - Entrance Activities Task 3 - Information Gathering/Investigation Task 4 - Preliminary Decision Making and Analysis of Findings Task 5 - Exit Conference Task 6 – Post-Survey Activities Psychiatric Hospital Survey Module Psychiatric Unit Survey Module Rehabilitation Hospital Survey Module Inpatient Rehabilitation Unit Survey Module Hospital Swing-Bed Survey Module Regulations and Interpretive Guidelines §482.2 Provision of Emergency Services by Nonparticipating Hospitals §482.11 Condition of Participation: Compliance With Federal, State and Local Laws §482.12 Condition of Participation: Governing Body §482.12(a) Standard: Medical Staff §482.12(b) Standard: Chief Executive Officer §482.12(c) Standard: Care of Patients §482.12(d) Standard: Institutional Plan and Budget §482.12(e) Standard: Contracted Services §482.12(f) Standard: Emergency Services §482.13 Condition of Participation: Patients’ Rights §482.13(a) Standard: Notice of Rights §482.13(b) Standard: Exercise of Rights §482.13(c) Standard: Privacy and Safety §482.13(d) Standard: Confidentiality of Patient Records §482.13(e) Standard: Restraint for Acute Medical and Surgical Care §482.13(f) Standard: Seclusion and Restraint for Behavior Management §482.21 Condition of Participation: Quality Assessment and Performance Improvement §482.21(a) Standard: Program Scope §482.21(b) Standard:
    [Show full text]