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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on a review of facility documents, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to follow established policies for completion of restraint orders in one of six medical records reviewed (MR1).

Findings include:

A review of Facility Policy "Use of Restraints/Seclusion on Inpatient Units," dated February 1, 2010, revealed "1....Policy...A. Each of our patients has the right to be free from physical or mental abuse and corporal punishment...A. Restraint: physical restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely...VI. Procedure See attached Procedure for detailed steps...Procedure for Use of Restraint and/or Seclusion...It is the policy....that these procedures are followed completely and comprehensively by clinical staff when utilizing restraint/seclusion in the inpatient settings...II. Physician Orders...D. Each physician's order for restraint includes: 1. Time and date...2. Type of Restraint...3. Duration...4. Reason for restraint..."

1) A review of MR1 revealed documentation that the patient had four episodes, where the patient was placed in restraints. Further review of MR1 revealed a restraint order for September 10, 2010, with no documentation of the type of restraint, duration, and reason for restraint as required by facility policy.

An interview with EMP1 on September 17, 2010, at approximately 11:00 AM confirmed that MR1 contained a physician order dated September 10, 2010, for restraint usage that did not contain the type of restraint, the duration, and the reason for the restraint.