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SPOTSYLVANIA REGIONAL MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0173
Based on the review of medical records and facility documentation, it was determined the facility staff failed to renew an order for a non-violent/non-destructive patient as authorized by the hospital's policy.
The finding included:
On 9/6/22 at 10:45 AM, a review of three (3) medical records of patient's who were in restraint's was conducted by the surveyor and navigated by staff #5. Patient #7 had been placed in restraints for non-violent behavior for attempting to remove devices. The order was placed by the physician on 9/5/22 at 7:58 AM and was indicated for 24 hours. On 9/6/22 at 8:11 AM another order was placed to continue the patient in restraints. There was no additional documentation on whether the restraints were discontinued prior to the new order on 9/6/22.
A review of the hospital's policy "Patient Restraint/Seclusion" under the title "5A. Order for Restraint with Non-Violent or Non-Destructive Behavior" stated "Renewal restraint order: If reassessment indicates an ongoing need for restraint, a renewal restraint order must be entered into the medical record within 24 hours of the initial restraint order".
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0174
Based on the review of medical records and facility documentation, it was determined the facility staff failed to provide evidence to support that a patient's restraints were discontinued for one (1) out of three (3) patients.
The findings included:
On 9/6/22 at 10:40 AM a review of three (3) medical records of patient's who were placed in restraints were reviewed by the surveyor and staff #5. The reviewed that patient #6 was placed in restraints, by order of the physician, for violent behavior in the Emergency Department on 8/30/22 at 10:01 AM. Documentation revealed that assessments were completed on the patient at 10:10 AM, 10:15 AM, 10:23 AM and 10:30 AM. There was no evidence of documentation on when the restraints were discontinued. The patient was discharged from the hospital on 9/1/22.
A review of the hospital's policy "Patient/Restraint/Seclusion" under the title "Documentation Requirements" stated "p. Restraint or seclusion removal/termination.