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Based on document review and interview, the hospital failed to ensure a physician's order for a restraint was renewed within the required timeframe for two (2) of five (5) restraint records (Patient #3R and Patient #4R).

Findings:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, stated, "...restraint orders would not exceed two (2) hours for adults ages eighteen (18) and older..."

1. On 3/22/2022, Patient #3R's medical record was reviewed with the Quality Improvement Specialist II. Documentation in the record indicated Patient #3R (an adolescent) was placed in restraints on 6/19/2021 at 7:30 PM per physician's order. There was no documented evidence from the last restraint check on 6/19/2021 at 8:21 PM to the time of discharge on 6/22/2021, that the restraint order was renewed within the two (2) hour timeframe or when the restraint was removed.

2. On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. Documentation in the medical record indicated Patient #4R (an adult) was placed in restraints on 12/8/2021 at 1:57 PM and discontinued on 12/10/2021 at 3:09 PM. During the patient's time in a restraint, there was no documented evidence that the restraint order was renewed within the four (4) hour timeframe.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure, after twenty-four (24) hours in restraints, that patients were seen and assessed by a physician or other Licensed Provider ("LP") before writing a new restraint order for two (2) of five (5) patients (Patient #3 Patient #4R).

Findings:

The hospital policy, "Restraint and Seclusion", last reviewed on 9/2021, stated, "...after twenty-four (24) hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a Provider or designee who is responsible for the care of the patient must see and assess the patient..."

1. On 3/22/2022 Patient #3R's record was reviewed with the Quality Improvement Specialist II. The medical record of this adolescent documented placement of restraints on 6/19/2021 at 6:50 PM per physician's order. Additionally, there was no time documented for discontinuation of the restraint. Therefore, it was unable to be determined if the restraint lasted twenty-four (24) hours and required further assessment.

2. On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. The medical record of this adult documented placement of a restraint on 12/8/2021 at 1:57 PM. The restraint was discontinued on 12/10/2021 at 3:09 PM. There is no documentation that after twenty-four (24) hours in restraints, the patient was seen and assessed.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure a restraint was discontinued at the earliest time possible for two (2) of five (5) patients (Patient #3R and Patient #4R).

Findings:

The MaineHealth policy, "Restraint and Seclusion", last reviewed on 9/2021 states, "...restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order..."

1. On 3/22/2022 Patient #3R's medical record was reviewed with the Quality Improvement Specialist II. The medical record documented this adolescent was placed in four (4) point restraints on 6/19/2021 at 6:50 PM per physician's order and a second order was placed on 6/19/2021 at 7:30 PM. There was no documentation that the restraint order was discontinued; therefore, it could not be determined if the restraint was discontinued at the earliest possible time.

2. On 3/22/2022 Patient #4R's medical record was reviewed with Quality Improvement Specialist II. The medical record documented this adult was placed in restraint on 12/8/2021 at 1:57 PM and discontinued on 12/10/2021 at 3:09 PM. There was no documentation that the restraint order was discontinued; therefore, it could not be determined if the restraint was discontinued at the earliest possible time.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, 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 one (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy, "Restraint and Seclusion", last reviewed on 9/2021, states, " ...the LIP or his/her designee must complete a face to face evaluation of the patient within 1 hour from the onset of restraint, even if the restraint has been discontinued ..."

On 3/22/2022 Patient #4R's medical record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure 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 of one (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy, "Restraint and Seclusion", last reviewed on 9/2021, states, "...a face to face evaluation of the patient within 1 hour of initiation ...to evaluate:
-the patient's immediate situation,
-the patient's reaction to the intervention,
-the patient's medical and behavioral condition, and
-the need to continue or terminate the restraint ..."

On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of the evaluation of the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint during the one (1) hour face-to-face assessment after restraint initiation.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure a registered nurse consulted a provider as soon as possible after the completion of the one (1) hour face-to-face evaluation for one (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, states, " ...restraint use may be initiated by a registered nurse ...the LIP is notified either during the application of restraint or as soon as possible but no later than 1 hour thereafter ..."

On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of a face-to-face by a registered nurse; therefore it could not be determined if a provider was consulted within the one (1) hour timeframe.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure a one (1) hour face-to-face evaluation was documented for using restraints to manage violent or self-destructive behavior for (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, states, " ...documentation should include ...the 1 hour face-to-face evaluation ..."

On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. This medical record contained documentation of a restraint for imminent harm to others, however it did not include documentation of the one (1) hour face-to-face evaluation.

The finding was confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure there was documentation describing the patient's behavior and interventions used for (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, states, "...documentation of ...behaviors that will be assessed ...the need for other interventions or treatments ..."

On 3/22/2022 Patient #4R's record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of the behaviors that required interventions.

The finding was confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure before restraint initiation that alternatives or other less restrictive interventions were attempted for (1) of five (5) patients (Patient #4R).

Finding:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, states, " ...the RN initiating the restraints must assess the patient and document in the EMR...The assessment must include the following: least restrictive measures considered, utilized, and outcome ..."

On 3/22/2022 Patient #4R's medical record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of alternative or least restrictive interventions attempted before the initiation of the restraint.

The finding was confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview the facility failed to ensure there was documentation in the medical record to indicate the patient's response to the restraint and the impact of the intervention on the patient's behavior for two (2) of five (5) restraint (Patient #3R and Patient #4R).

Findings:

The MaineHealth policy "Restraint and Seclusion", last reviewed on 9/2021, states, " ...restraint or seclusion must have ongoing assessment of the patient's progress towards meeting criteria for release that will occur every fifteen (15) minutes ..."

1. On March 22, 2022 Patient #3's record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of the impact the application of restraints had on the behavior that warranted the continued use of restraints.

2. On March 22, 2022 Patient #4's record was reviewed with the Quality Improvement Specialist II. The medical record did not include documentation of the impact the application of restraints had on the behavior that warranted the continued use of restraints.

These findings were confirmed by the Quality Improvement Specialist II at the time of the document review.

Based on document review and interview, the hospital failed to ensure policies and procedures addressed a process for tracking and documenting the Coronavirus 2019 ("COVID-19") vaccination status of any staff who had obtained any booster doses as recommended by the Federal Center for Disease Control and Prevention ("CDC").

Finding:

A review of MaineHealth policy "Healthcare Worker Immunization Requirements," dated 2/04/2022, the policy did not address a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

On 3/21/2022 at 3:21 PM, the Infection Prevention Manager was interviewed. She confirmed there is no policy for addressing the process for tracking and documenting staff that has received the COVID-19 vaccination booster doses as recommended by the CDC.