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LAUREL RIDGE TREATMENT CENTER 17720 CORPORATE WOODS DRIVE SAN ANTONIO, TX 78259 April 4, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record reviews and interviews, nursing staff failed to ensure that for one of one patients (patient #1), a telephone order from Physician #1 for a restraint and seclusion was documented.

Findings included:

Record review of facility form called Special Treatment Procedures Observations, dated 02/06/13, revealed that patient #1 was restrained on 02/06/13 from 1850 PM to 1854 PM and placed in locked seclusion on 02/06/13 from 1854 PM to 1915 PM due to self-harming behaviors and physical aggression towards staff. The restraint/seclusion was initiated by Nurse #1.

Record review of Physician's Orders from 02/06/13 to 02/09/13 during patient's dates of admission/discharge did not reveal a verbal/telephone order from Physician #1 for a restraint and/or seclusion during this time period.

Record review of Read Back of Telephone Orders Policy and Procedure, last reveiwed in January 2012, revealed that for telephone orders, the individual giving the order or test result verifies the complete order by having the person receiving the information record and "read-back" the complete order. The individual receiving the information writes down the complete order.

Interview on 04/04/13 at 11:20 AM with the facility's Chief Nursing Officer confirmed that Nurse #1 should have documented a telephone order from Physician #1 when she initiated the restraint and subsequent seclusion.