CMS SOM App. A, Tag A-0182

conducted by a trained registered nurse, the trained registered nurse must consult the attending

physician or other licensed practitioner who is responsible for the care of the patient soon as

possible after the completion of the 1 hour face-to-face evaluation.

Interpretive Guidelines §482.13(e)(14)

When a trained RN conducts the required face-to-face evaluation, he or she must consult the attending

physician or other LP responsible for the patient’s care as soon as possible after the completion of the

evaluation. Hospital policy should address the expected time frame for and the components of the

consultation with the attending physician or other LP consistent with “as soon as possible.” This

consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face

evaluation, the need for other interventions or treatments, and the need to continue or discontinue the use

of restraint or seclusion. A consultation that is not conducted prior to a renewal of the order would not

be consistent with the requirement, “as soon as possible.”

Survey Procedures §482.13(e)(14):

• Review the relevant hospital restraint and seclusion policy.

• Does the hospital policy clarify expectations regarding the requirement, “as soon as possible”?

• Does documentation in the patient’s medical record indicate consultation with the attending

physician or other LP when the 1-hour face-to-face evaluation was conducted by a trained RN?

• Is practice consistent with hospital policy?