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CROZER CHESTER MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to obtain a complete restraint order in one of eleven medical records reviewed (MR1).
Findings include:
A review on December 28, 2010, of facility Restraint/Seclusion policy effective date 05/01/2010, revealed, "Restraint orders must include the following: a. date and time of order, b. type of restraint to be applied and/or drug given, c. rational for use of physical/chemical restraint, and d. specific time period during which the order is valid ... ."
A review on December 28, 2010, of MR1 revealed documentation that the patient was placed in four point Velcro restraints on December 10, 2010. Further review of MR1 revealed a restraint order on December 10, 2010, for tuff cuffs with no documentation of the limbs to be restrained.
Interviews conducted on December 28, 2010, at 11:10 AM with EMP4 and EMP6 confirmed that MR1 contained a physician order dated December 10, 2010, for restraint usage that did not include the limbs to be restrained.