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MAINEHEALTH MAINE MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0205
Based on document review and interviews, the hospital failed to ensure required assessment and documentation were completed related to violent restraint, for one (1) out of five (5) medical charts reviewed. (Patient 3R)
Findings:
MaineHealth Maine Medical Center Policy titled, "Southern Region Use of Restraints" (last revised 06/17/2025) states in part, "...The trained RN ongoing documentation will include the following at a minimum of approximately every 15 minutes on the Violent Self Destructive flow sheet in the EHR [electronic health record]."
The medical record indicated; on 06/22/2025 at [10:26 pm], Patient 3R was placed in 4-point violent restraints. initial assessment completed 06/22/2025 at [10:26 pm]. The hospital failed to document the following required assessments: Respirations, Psychological Status/Behaviors, Circulation/Skin Integrity, Continuous Observation with Close Proximity at all times, Patient's Dignity, Privacy, and Comfort Maintained, and Progress Towards Release, after the completion of the initial assessment.
On 07/08/2025 at 1:10 pm, the Clinical Informatics Specialist confirmed that according to the medical record, Patient 3R was in 4-point restraints, and the documentation/assessment was incomplete.