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WELLSTONE REGIONAL HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on document review and interview, the facility failed to ensure a physicians order was obtained for use of physical restraint on 1 of 10 patients.
Findings include:
1. Review of Policy/Procedure, PolicyStat ID: 9808595, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion, reviewed/revised 5/2021, states Restraint or seclusion shall be used in emergency situations only and requires an order from a physician.
2. Review of Patient 2's medical record (MR) lacked completed Restraint/Seclusion Form, physician order and documentation of physical restraint/arm hold used on patient to administer Risperidone injection on 9/07/2021 at 1330 hours.
3. Interview with Staff N4, Registered Nurse (RN) on 9/14/2021, at approximately 1515 hours indicated physical restraint/arm hold was used on patient to administer Risperidone injection on 9/07/2021.
4. Interview with Personnel A4, Chief Nursing Officer (CNO), on 9/14/2021, at 2000 hours indicated Restraint/Seclusion Form which includes the order for physical or chemical restraint use is to be completed on all patients receiving any physical or chemical restraint at any time.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0185
Based on document review and interview, the facility failed to ensure patient's medical record provided documentation of physical restraint use on 1 of 10 patients.
Findings include:
1. Review of Policy/Procedure, PolicyStat ID: 9808595, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion, reviewed/revised 5/2021, states Restraint or seclusion shall be used in emergency situations only and the use of restraint/seclusion will be thoroughly documented in the patient's medical record (MR).
2. Review of Patient 2's MR lacked completed Restraint/Seclusion Form and documentation of physical restraint/arm hold used on patient to administer Risperidone injection on 9/07/2021 at 1330 hours.
3. Interview with Staff N4 on 9/14/2021 at approximately 1515 hours indicated physical restraint/arm hold was used on patient to administer Risperidone injection on 9/07/2021 at 1330 hours.
4. Interview with Personnel A4 on 9/14/2021 at 2000 hours indicated Restraint/Seclusion Form is to be completed on all patients receiving any physical or chemical restraint at any time.