HospitalInspections.org

Based on a review of facility policy, medical records (MR) and interview with facilty staff (EMP), it was determined that Conemaugh Nason failed to obtain a complete Physician Order for restraints for two of three medical records (MR8 and MR9).

Findings include:

Review of policy entitled "Patient Restraint Policy", dated August 2015, revealed, " ... Procedure for Ordering/Implementing Restraint: 1. Initiation and Renewal of Orders ... B. A valid restraint order must specify: 1. the restraint type, 2. the justification for the restraint, 3. date and time ordered ... ."

1. Review of MR8 revealed a Physician Order for restraint use dated January 20, 2018, at 2:11 AM. The Order failed to indicate the type of restraint or the reason for restraint.

2. Review of MR9 revealed a Physician Order for restraint use dated January 15, 2018, at 9:13 PM. The Order failed to indicate whether or not the restraint was to be applied bilaterally. Corresponding Nursing documentation indicated that the patient had both right and left wrist restraints applied.

3. Interview with EMP1 on March 2, 2018, confirmed the above findings.