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HEALTHSOUTH/MAINE MEDICAL CENTER, LLC

335 BRIGHTON AVENUE, UNIT 201

PORTLAND, ME null

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0208

Based on document reviews and interviews, the facility failed to ensure that Licensed Independent Providers ("LIP") completed annual restraint training for eight (8) of ten (10) LIPs reviewed (LIP #1 to #8).

Findings:

HealthSouth/Maine Medical Center, LLC's "Use of Restraints" policy, effective 11/18/2020 and last reviewed 8/24/2021, defines an LIP in part as, "...any individual who has a working knowledge of this policy and is permitted both by law and the hospital as having the authority under his/her license to independently order restraints..." and "All staff that has direct patient contact must have orientation as well as annual education, training, and competency assessment. LIP training should include a review of the hospital policy on use and the ordering of restraints and any other elements the physician may be involved in such as application of restraints as applicable".

On 10/25/2021, surveyors reviewed personnel files with the Director of Quality. This revealed the following information:

- LIP #1 and #4 had no documented evidence of receiving restraint training;
- LIP #2 had no documented evidence of receiving restraint training since 2/17/2016;
- LIP #3 had no documented evidence of receiving restraint training since 2/3/2016;
- LIP #5 had no documented evidence of receiving restraint training since 8/25/2019;
- LIP #6 had no documented evidence of receiving restraint training since 2/24/2020;
- LIP #7 had no documented evidence of receiving restraint training since 3/9/2018; and
- LIP #8 had no documented evidence of receiving restraint training since 8/28/2018.

On 10/26/2021 at 1:30 PM, the Director of Quality was asked if they applied restraints at this facility. She stated, "If we needed to restrain a patient in an emergency, we could do so until we were able to transfer them to an appropriate facility".

On 10/26/2021 at 1:37 PM, the Director of Quality stated, "I am confirming that the policy indicates there should be an annual review for LIPs on ordering of restraints, but they have not had yearly restraint training".