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SOUTHERN MAINE HEALTH CARE
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0167
Based on document review and interviews, the hospital failed to ensure the hospital's policy for restraints, related to the content of the physician's order, was implemented for one (1) of three (3) restraint records reviewed (Record A).
Finding includes:
The hospital's Restraint and Seclusion for Behavioral Management policy stated, "Each order for restraints shall include ...A description of the type of restraint, including the points of restraint [location where restraint is placed on body] ..."
On May 3, 2017 at approximately 11:30 AM, a review of Record A was conducted. The patient was restrained utilizing four point restraints, on April 29, 2017 from 3:28 PM until 3:55 PM.
The Physician's order for the above restraint failed to include a description of the type of restraint including the points of restraint.
This finding was confirmed with the Director of Clinical Informatics and the Nursing Director at 11:30 AM, during the record review.