HospitalInspections.org

Based on a review of medical records (MR), facility documents, and staff interview (EMP), it was determined that the facility failed to ensure that orders were written for the use of restraints for one of one medical records reviewed (MR2).

Findings include:

1) Review of "UPMC Standard Practice Subject: Restraint/Seclusion" policy and procedure dated July 1, 2013, revealed, "Subject: Restraint/Seclusion Policy...D. Restraint/Seclusion Orders 1. A time-limited physician's order is required as follows. ... 5. All orders (written, verbal or phone) for Restraint/Seclusion must be documented on the Restraint/Seclusion Physician Order Sheet ... ."

2) Review of MR2 dated July 30, 2013 revealed, " ... Mother reports she will not take patient home until he wakes up. Mother does not want restraints taken off or IV out until patient is awake ... ." Continued review of MR2 dated July 30, 2013, revealed no documented evidence of an order for restraints or restraint flow sheet.

Interview on September 6, 2013, at 11:30 AM with EMP2 confirmed that there was not a physician order for the restraint or flow sheet documented in MR2.