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ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 Dec. 1, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on interview and a review of facility documentation, the facility failed to ensure the development of hospital policy to ensure that patients being considered for lap belt interventions for fall prevention were assessed for the ability to remove the belt to confirm that it did not serve as a restraint.

Findings:

A review of facility orientation materials revealed the following: "Fall Risk Prevention Strategies based on risk category: ... High Risk: ... Consider use of self-releasing belt in conjunction with bed alarms."

A review of a list of available safety device revealed the following among the options: "self-releasing safety belt."

A review of facility policies #100.500 Fall Prevention and "#010.147 - Restraints" did not reveal any content relative to safety belts and a requirement for patient assessments prior to their use in order to see if the patient was capable of releasing them without assistance. The facility was unable to produce any policies or protocols which mentioned a need for such assessments prior to use of a self-releasing safety belt. Thus, since there were no measures in place to determine through an assessment whether or not a self-releasing safety belt would act as a restraint on a patient due to their inability to perform a self-release, the facility's policies did not fully address restraint use.

During an interview of the Risk Manager on 12/01/17 at approximately 1:17 PM, she confirmed that the facility did not have a policy requiring the assessment of a patient for lap belt use, prior to its application, to confirm that the patient could release it and therefore ensure that it would not serve as a restraint.