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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure there was a physician's order for the use of restraint two of five restrained patients' medical records (MR24 and MR26).

Findings include:

A review of Albert Einstein Medical Center policy and Procedure entitled "Use of Restraints All Patient Care Areas (Acute Care and Rehab)" revealed, "... 5. The physician has the authority to order restraints. ... Order Time Limits ... 3. For non-violent or non-self destructive behavior each order may be renewed for maximum of 1 calendar day. ... "

1) A review on September 20, 2016, of MR24 revealed the patient was in bilateral soft limb restraints. There was a physician order on August 30, 2016, at 2027 PM and a renewal order on September 1, 2016, at 0026 AM. Review of nursing documentation revealed the patient remained in soft limb restraint on August 31, 2016.

2) A review on September 20, 2016, of MR26 revealed the patient had an order for bilateral soft wrist restraints. There was a physician order on September 4, 2016, at 1954 AM and a renewal order on September 6, 2016, at 0240 AM. Review of the nursing documentation revealed the patient remained in restraint on September 5, 2016.

An interview conducted on September 20, 2016, with EMP4 confirmed that MR24 and MR26 did not have a physician order for the use of restraint on August 31, 2016, and September 5, 2016, respectively.