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PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0176

Based on document reviews and interviews, the hospital failed to ensure a provider completed mandatory restraint training prior to ordering patients be placed in restraints for one (1) out of six (6) provider training records reviewed (Physician Assistant #1).

Northern Light Eastern Maine Medical Center's Policy titled, "Restraint and Seclusion," last revised 09/19/2023 states in part:
"...All staff having direct patient contact with a patient in restraint will receive education and training upon hire and annually... Physicians and other AHPs will be provided education in order to maintain a working knowledge of this policy and appropriate order sets..."

Patient #14's medical record revealed that Physician Assistant #1 ordered Bilateral Mitts, a Non-Behavioral Restraint, on 03/26/2025 at 9:41 AM.

On 04/23/2025 at 8:59 AM, the surveyor requested evidence that Physician Assistant #1 had completed their mandatory restraint training.

On 04/23/2025 at 1:32 PM, the Regulatory and Licensing Compliance Officer confirmed that Physician Assistant #1 had not completed their mandatory restraint training until 04/23/2025, one (1) day after the date of the initiation of the survey.

The Regulatory and Compliance Officer confirmed on 04/23/2025 at 1:32 PM that the mandatory restraint training course Physician Assistant #1 had not completed was titled, "SQ Acute: Restraint and Seclusion (PA)." The Regulatory and Compliance Officer confirmed that when Physician Assistant #1 ordered restraints for Patient #12 on 03/26/2025 they did not have their mandatory restraint training completed.