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MT SINAI HOSPITAL MEDICAL CENTER 15TH STREET AT CALIFORNIA CHICAGO, IL 60608 Feb. 6, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 3 (Pt. #3) patients in restraints, the Hospital failed to ensure a restraint renewal order was written daily.

Findings include:

1. The Hospital policy titled, "Restraint Policy (revised 6/24/15)" was reviewed on 2/8/17. The policy required, "After the initiation of restraint the order must be renewed each calendar day".

2. The clinical record of Pt. #3 was reviewed on 2/6/17. Pt. #3 was a [AGE] year old female who arrived to the emergency department (ED) on 6/30/15 and was admitted on to the intensive care unit on 7/1/15 with the diagnoses of chest pain and shortness of breath. Per the Restraint Documentation, Pt. #2 was in soft wrist restraints while in the ED and in SICU (surgical intensive care unit) from 7/1/15 at 2:30 PM until 7/5/15 at 10:00 PM. The clinical record included the following orders for non violent restraints: 6/30/15 at 10:22 PM, 7/2/15 at 8:04 AM, 7/4/15 at 8:31 AM and 7/5/15 at 6:51 PM. The clinical record lacked documentation of an order on 7/1/15 and 7/3/15.

3. During an interview on 2/8/17 at 12:40 PM, the Chief Nursing Officer (E#2) stated, "Yes, I reviewed the record and could not find restraint orders for those days. They should have been written".