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Based on document reviews and interviews, the hospital failed to ensure the type of restraint that was ordered was the type of restraint used for 2 (two) of 5 (five) patients reviewed (Patient 1R and Patient 4R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "Restraints will be safely applied and removed, and patients will be monitored and reassessed by qualified staff as outlined within this policy ... Initiation: Each episode of restraint or seclusion shall be initiated: a. Upon the order of a provider who is responsible for the patient. At CMH [Central Maine Healthcare] Providers who may write orders for a restraint include Physician, Nurse Practitioner, Physician Assistants and Midwife. b. By a trained RN when he or she determines it is necessary to protect the patient, staff member or others. An order from a provider who is responsible for the patient shall be obtained as soon as possible after such initiation ...".

On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following:

1. Documentation in Patient 1R's record indicated the following:
- On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints;
- On 07/23/2023 at 4:20 PM, nursing documentation indicated that four (4) point hard restraints were applied; and
- On 07/23/2023 at 5:07 PM, Patient 1R's Provider ordered a four (4) point soft restraint.

2. Documentation in Patient 4R's record indicated the following:
- On 09/05/2023 at 4:21 PM, Patient 6R required four (4) point restraints;
- On 09/05/2023 at 4:21 PM, nursing documentation indicated that four (4) point hard restraints were applied; and
- On 07/23/2023 at 7:18 PM, Patient 4R's Provider ordered a four (4) point soft restraint.

Based on the above, the patients were not restrained with the type of restraint that was ordered by the physician as four (4) point soft restraints were ordered and four (4) point hard restraints were used.

On 01/23/2024, the above findings were confirmed with the Patient Safety Program Manager at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for two (2) of five (5) patients that were restrained (Patient 1R and 4R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint....".

On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following:

1. Documentation in Patient 1R's record indicated the following:
- On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

2. Documentation in Patient 4R's record indicated the following:
- On 09/05/2023 at 5:30 PM, Patient 4R required a physical hold for a chemical restraint;
- On 09/05/2023 at 4:21 PM, Patient 4R required four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

On 1/23/2024, the Patient Safety Program Manager confirmed the above findings at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for two (2) of five (5) patients that were restrained (Patient 1R and 4R).

Findings:
Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 5/26/2023 states, in part, Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... ".

On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following:

1. Documentation in Patient 1R's record indicated the following:
- On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

2. Documentation in Patient 4R's record indicated the following:
- On 09/05/2023 at 5:30 PM, Patient 4R required a physical hold for a chemical restraint;
- On 09/05/2023 at 4:21 PM, Patient 4R required four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

On 1/23/2024, the Patient Safety Program Manager confirmed the above findings at the time of the review.