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MAINEGENERAL MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0164
Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints and seclusion, related to the documenting of less restrictive measures tried before applying restraints, was implemented for one (1) of five (5) restrained patients (Patient 1R).
Finding:
MaineGeneral Medical Center's "Restraint or Seclusion of Patients" policy last revised 07/2024 states in part, "While the patient is in restraint, the staff responsible for the patient will document the following: ... Alternative measures utilized prior to application of restraints and patient's response to the alternatives."
On 10/09/2024 at 12:33 PM, five (5) records were reviewed with the Emergency Department Nurse Director. This review revealed the following:
Documentation in Patient 1R's record indicated the following:
- Registered Nurse ("RN") #1 documented that Patient 1R had bilateral soft wrist restraints applied on 09/02/2024 at 1:47 PM;
- RN #1 documented that Patient 1R had the restraints discontinued on 09/02/2024 at 5:11 PM; and
- There was no documented evidence in the medical record that would show that less restrictive measures were attempted.
On 10/09/2024 at approximately 12:35 PM, the above findings were confirmed with the Emergency Department Nurse Director, at the time of the review.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on document reviews and interviews, the hospital failed to ensure a physician's order was obtained for one (1) of five (5) patients that were restrained (Patient 1R).
Finding:
MaineGeneral Medical Center's "Restraint or Seclusion of Patients" policy last revised 07/2024 states in part, "Restraint devices may be used only with the order of a physician or other licensed independent practitioner, under the standard conditions where the primary purpose is for non-violent or non-self-destructive behavior."
On 10/09/2024 at 12:33 PM, five (5) records were reviewed with the Emergency Department Nurse Director. This review revealed the following:
1. Documentation in Patient 1R's record indicated the following:
- On 09/02/2024 at 1:477 PM, Patient 1R required bilateral soft wrist restraints;
- The restraint was discontinued at 5:11 PM; and
- There was no evidence in the medical record of a Provider order for the bilateral soft wrist restraints.
On 10/09/2024 at approximately 12:40 PM, the above findings were confirmed with the Emergency Department Nurse Director, at the time of the review.