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Tag No.: A0168
Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that Reading Hospital and Medical Center failed to obtain physician order for the use of restraints for four of seven restraint records reviewed (MR1, MR2 MR3 and MR6).
Findings include:
A review on October 4, 2011, of "The Reading Hospital and Medical Center Nursing Policy" last reviewed, Auust 2010 revealed " ...VI. Medical Surgical Restraint ...D. A physician order is required prior to the application of restraint. ... 4. Continued use of restraint beyond the first 24 hours requires a written order based on examination of the patient by the physician no less than once each calendar day. ... "
1) A review of MR1 on October 4, 2011, revealed the patient was in bilateral upper soft limb restraints on September 4-5, 2011. Further review revealed there was no physician order for the use of restraint.
An interview on October 4, 2011, at 2:00 PM with EMP1 confirmed there was no physician order for the use of restraints on September 4-5, 2011 for MR1.
2) A review of MR2 on October 4, 2011, revealed the patient was in bilateral upper soft limb restraints on September 29, 2011, and October 1, 2011. Further review revealed there was no physician order for the use of restraint.
An interview on October 4, 2011, at 10:45 PM with EMP2 confirmed there was no physician order for the use of restraints on September 4-5, 2011 for MR2.
3) A review of MR3 on October 4, 2011, revealed the patient was initially placed in bilateral upper soft restraint on September 28, 2011, at 11:00 PM. Further review revealed the physician order was not obtained until September 29, 2011, at 05:41 AM.
An interview on October 4, 2011, at 10:45 PM with EMP2 confirmed that the order for the use of restraint for MR3 had not been obtained timely.
4) A review of MR6 on October 4, 2011, revealed the patient was in bilateral upper soft restraint on September 20, 2011. Further review revealed there was no physician order for the use of restraint.
An interview on October 4, 2011, at 2:00 PM with EMP1 confirmed there was no physician order for the use of restraints on September 20, 2011 for MR6.