HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure a physician's order was obtained for two (2) of six (6) patients that were restrained (Patient 2R and 6R).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last approved 12/22/2022 states, in part, "All use of restraint or seclusion will be implemented following an assessment by a trained RN and be ordered by a Licensed Provider (LP) in accordance with the Rights of Recipients of Mental Health Services of the Department of Health and Human Services of the State of Maine".

On 08/16/2023 at 8:30 AM, five (5) records were reviewed with Patient Safety Specialist III. This review revealed the following:

1. Documentation in Patient 2R's record indicated the following:
- On 11/27/2022 at 6:55 PM, Patient 2R required a physical hold;
- Staff maintained the physical hold until 6:58 PM; and
- There was no evidence in the medical record of a physician's order for the physical hold.

On 08/16/2023 at approximately 8:45 AM, Patient Safety Specialist III confirmed the finding at the time of the review.

On 08/16/2023 at 12:50 PM, one (1) additional record was reviewed. This review revealed the following:

2. Documentation in Patient 6R's record indicated the following:
- On 10/29/2022 at approximately 8:00 PM, per nursing documentation, Patient 6R required a physical hold to give intra-muscular medication;
- Nursing staff, Medical Doctor and security personnel maintained a physical hold for approximately ten (10) to fifteen (15) minutes; and
- There was no evidence in the medical record of a physician's order for the physical hold.

On 08/16/2023 at 12:58 PM, the Director of Quality confirmed the above finding.