HospitalInspections.org
Bringing transparency to federal inspections
MAINEHEALTH MAINE MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on record review and interview, it was determined that the facility failed to obtain a physician order for restraints for 1 of 5 patients (Patient #4).
The findings follow:
Maine Medical Center Policy: Non-Violent, Non-Self -Destructive Restraints (NV-NSD) states, in part; " 10. The use of non-violent, non-self-destructive restraints must be in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient ... "
On July 6, 2016, during a patient record review, documentation was found that patient #4 was restrained on June 10, 2016 at 2:00 AM. A further review of this record found that the physician failed to order restraints until June 10, 2016 at 4:48 AM.
This finding was confirmed by the Interim Nurse Manager of the Inpatient Geri/Psych unit on July 6, 2016 at approximately 11:45 AM.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on record review and interview, it was determined that the facility failed to assess the restrained patient for 3 of 5 patients (Patient #3, #4, #5).
The findings follow:
Maine Medical Center Policy: Non-Violent, Non-Self -Destructive Restraints (NV-NSD) (Attachment E) states, in part; " ...V. Assessment for Continued Restraint Use 1. The registered nurse must reassess the need for the patient to continue in restraints every two hours. " " VI. Care and Monitoring Expectations during Restraint 1. A patient in Non-violent, non-self-destructive restraints will be observed no less than every two hours. " The Policy further requires, " VII. Documentation 9. Documentation of termination of restraint includes: A. Date, time, and reason for termination. B. A description of any impairment to the patient or others resulting from the placement in restraints. "
1. On July 6, 2016, during the record review of Patient #3, documentation was found that the patient was placed in restraints on June 15, 2016 at 9:00 AM and the restraints were discontinued on June 17, 2016 at 7:13 AM. The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time periods between June 15, 2016 @ 6:00 PM to June 16, 2016 @ 7:00 AM, and 6/16/2016 @ 6:00 PM to June 17, 2016 @ 7:13 AM.
2. On July 6, 2016, during record review of Patient #4, documentation was found that the patient was placed in restraints on June 10, 2016 at 2:00 AM and the restraints were last documented as " continued " on June 11, 2016 at 10:00 AM. " The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time period between June 10, 2016 @ 4:00 AM to June 10, 2016 @ 8:00 AM. The record further failed to contain " documentation of termination of restraint " as required by facility policy.
3. On July 6, 2016, during record review of Patient #5, documentation was found that the patient was " Continued " in restraints on June 3, 2016 at 10:00 AM and the restraints were last documented as " Continued " on June 6, 2016 at 3:33 AM. The Physician order for restraints was documented on June 3, 2016 at 8:11 AM. There is no documentation fo the patient restraint assessments between the time of the physician order 8:11 AM and 10:00 AM. The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time periods between June 3, 2016 @ 8:11 PM to June 4, 2016 @ 5:16 AM; June 4, 2016 1:40 PM to June 4, 2016 at 4:45 PM; and June 5, 2016 at 6:32 PM to June 5, 2016 at 10:04 PM. The record further failed to contain " documentation of termination of restraint " as required by facility policy.
On July 6, 2016
These findings were immediately confirmed by the Interim Nurse Manager of the Inpatient Geri/Psych unit who assisted this surveyor during the record reviews on July 6, 2016 at approximately 1:20 PM.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on record review and interview, it was determined that the facility failed to obtain a physician order for restraints for 1 of 5 patients (Patient #4).
The findings follow:
Maine Medical Center Policy: Non-Violent, Non-Self -Destructive Restraints (NV-NSD) states, in part; " 10. The use of non-violent, non-self-destructive restraints must be in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient ... "
On July 6, 2016, during a patient record review, documentation was found that patient #4 was restrained on June 10, 2016 at 2:00 AM. A further review of this record found that the physician failed to order restraints until June 10, 2016 at 4:48 AM.
This finding was confirmed by the Interim Nurse Manager of the Inpatient Geri/Psych unit on July 6, 2016 at approximately 11:45 AM.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on record review and interview, it was determined that the facility failed to assess the restrained patient for 3 of 5 patients (Patient #3, #4, #5).
The findings follow:
Maine Medical Center Policy: Non-Violent, Non-Self -Destructive Restraints (NV-NSD) (Attachment E) states, in part; " ...V. Assessment for Continued Restraint Use 1. The registered nurse must reassess the need for the patient to continue in restraints every two hours. " " VI. Care and Monitoring Expectations during Restraint 1. A patient in Non-violent, non-self-destructive restraints will be observed no less than every two hours. " The Policy further requires, " VII. Documentation 9. Documentation of termination of restraint includes: A. Date, time, and reason for termination. B. A description of any impairment to the patient or others resulting from the placement in restraints. "
1. On July 6, 2016, during the record review of Patient #3, documentation was found that the patient was placed in restraints on June 15, 2016 at 9:00 AM and the restraints were discontinued on June 17, 2016 at 7:13 AM. The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time periods between June 15, 2016 @ 6:00 PM to June 16, 2016 @ 7:00 AM, and 6/16/2016 @ 6:00 PM to June 17, 2016 @ 7:13 AM.
2. On July 6, 2016, during record review of Patient #4, documentation was found that the patient was placed in restraints on June 10, 2016 at 2:00 AM and the restraints were last documented as " continued " on June 11, 2016 at 10:00 AM. " The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time period between June 10, 2016 @ 4:00 AM to June 10, 2016 @ 8:00 AM. The record further failed to contain " documentation of termination of restraint " as required by facility policy.
3. On July 6, 2016, during record review of Patient #5, documentation was found that the patient was " Continued " in restraints on June 3, 2016 at 10:00 AM and the restraints were last documented as " Continued " on June 6, 2016 at 3:33 AM. The Physician order for restraints was documented on June 3, 2016 at 8:11 AM. There is no documentation fo the patient restraint assessments between the time of the physician order 8:11 AM and 10:00 AM. The record failed to contain documentation of the two hours assessments, required by Facility Policy, for the time periods between June 3, 2016 @ 8:11 PM to June 4, 2016 @ 5:16 AM; June 4, 2016 1:40 PM to June 4, 2016 at 4:45 PM; and June 5, 2016 at 6:32 PM to June 5, 2016 at 10:04 PM. The record further failed to contain " documentation of termination of restraint " as required by facility policy.
On July 6, 2016
These findings were immediately confirmed by the Interim Nurse Manager of the Inpatient Geri/Psych unit who assisted this surveyor during the record reviews on July 6, 2016 at approximately 1:20 PM.