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FRANKLIN MEMORIAL HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0176
Based on document review and interview, the hospital failed to ensure that physicians were trained according to hospital policy in the use of restraint or seclusion for 5 of 5 physicians reviewed, (Physician #5, Physician #6, Physician #7, Physician #8, and Physician #9).
Finding:
Document review of the "Restraint Use-Comprehensive Policy," revised 8/25/2020, stated All authorized ("LIPs") (licensed independent practitioners) ordering restraints must have a working knowledge of the FMH (Franklin Memorial Hospital) restraint policy. This restraint policy will be reviewed by authorized LIPs as part of orientation and annually through "NetLearning" (computerized training system).
Document review of the physician training records for Physician #5, Physician #6, Physician #7, Physician #8, and Physician #9 failed to include evidence of annual training in the restraint policy.
On 8/4/2021 at 12:15 PM, the Chief Operating Officer stated, the annual training required in the restraint policy for the five physicians identified is not documented in their NetLearning training records as completed or documented in the medical staffing meeting minutes as completed.