CMS SOM App. N, Tag N0149

That

documentation must be completed by the end of the shift in which the intervention

occurs. If the intervention does not end during the shift in which it began,

documentation must be completed during the shift in which it ends. Documentation

must include all of the following:

Interpretive Guidelines§ 483.358(h)

Relevant and appropriate staff must fully document the events leading up to, during and

after the implementation of restraint or seclusion as specified by §483.358(h)(1-5). This

includes documentation of the time in which the emergency safety situation/intervention

began, the request and receipt of any practitioner orders for intervention, a complete

description of the emergency safety situation, the results of the 1 hour face-to-face

assessment, and the names of all staff that were involved with the restraint and seclusion.

If the resident is still restrained or secluded at the end of a shift, the staff person who

witnessed the events that led up to the restraint or seclusion is accountable for providing

comprehensive documentation in the record of the events that led up to and the

implementation of the restraint or seclusion. After the resident has been removed from

restraint or seclusion, the staff that is present during the conclusion of the emergency

safety intervention is required to document their observations of the resident throughout

the duration of the seclusion or restraint and the discontinuation of the safety

intervention.