HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure restraints were removed or that the restraint order was renewed upon its expiration for (1) out of five (5) restrained patient records reviewed (Patient #12) This failure led to Patient #12 spending over twenty-four (24) hours in restraints without a provider's order.

Findings:

MaineHealth's Southern Region Policy titled, "Use of Restraints," (no date) states in part, "...The order for nonviolent non self-destructive restraint must be renewed daily if criteria for release of non-violent, non-self-destructive are not met..."

On 11/25/2024 at 1:15 PM, Patient #12's medical record was reviewed with the assistance of the Clinical Informatics Specialist. Patient #12's medical record revealed the following:

-An order for left and right wrist soft limb restraints ordered by Provider #1 and dated 11/22/2024 at 12:48 AM.

-Restraint flowsheet documentation indicating that Patient #12 was in left and right wrist soft limb restraints for the entirety of 11/22/2024, 11/23/2024, and 11/24/2024.

-An order for left and right wrist soft limb restraints ordered by Provider #2 dated 11/24/2024 at 2:47 PM.

Patient #12's medical record did not reveal an order for left and right wrist soft limb restraints for the time between the expiration of Provider #1's 11/22/2024 restraint order, and the initiation of Provider #2's 11/24/2024 restraint order.

The Clinical Informatics Specialist confirmed that, according to the medical record, Patient #12 was in restraints without an order from 11/23/2024 at approximately 12 AM until 11/24/2024 at 2:27 PM.