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Based on review of facility policy, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure restraints were ordered in accordance with established policy for two of 14 medical records reviewed where restraints were utilized (MR4 and MR13).

Findings include:

Review on December 28, 2015, of the facility policy "Restraint/Seclusion," dated last reviewed October 27, 2015, revealed "Purpose: Geisinger Health System is committed to; 1. Reducing the frequency of restraint use, striving to eliminate the use of restraints. 2. Limiting restraint use by defining the terms restraint, seclusion, and pharmacologic restraint. 3. Using these protective measures in accordance with regulatory standards. ... Non-Violent Patient/Non-Self Destructive Patient 1. Restraints ordered on: Non-Violent or Non-Self Destructive Restraint order set Pharmacological Restraint order set 2. Staff are responsible to use the least restrictive form of restraint. 3. Restraint(s) ordered promptly/immediately 4. Restraint orders are time-limited - for the Non-Violent or Non-Self Destructive Patient order once each calendar day. Note: Orders electronically submitted for restraint purposes if used continuously with the exception of the nursing staff bathing, toileting, turning and repositioning, performing range of motion(ROM), feeding the patient, etc. are valid until they are reordered if needed the next calendar day. If the restraint episode is discontinued any time during that calendar day because the patient no longer demonstrates the behavior that required the restraint or the patient is responding appropriately to alternatives tried by the staff, a new order must be obtained if the patient again requires the use of restraints. The current order is no longer valid. ..."

Review on December 28, 2015, of MR4 revealed an admission date of August 23, 2015. Restraints were required to prevent the patient from pulling out tubes, tracheostomy, peg tube and intravenous lines. A physician's order was written on August 23, 2015, for bilateral wrist restraints at 0224. Restraints were not applied at that time. Restraints were applied at 0900 and remained on the patient. The physician ordered a right wrist restraint at 1814. Bilateral wrist restraints remained on the patient for nine hours without a physician order.

Review on December 28, 2015, of MR13 revealed an admission date of August 28, 2015. Restraints were required, as the patient was restless, combative, and pulling on lines. Bilateral wrist restraints were applied at 0700. The physician order for restraints was documented at 1127.

Interview on December 28, 2015, with EMP1 confirmed there were no physician orders for the restraints utilized on MR4 and MR13. EMP1 confirmed the policy for restraint/seclusion was not followed.