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Based on review of documentation and interview with staff, the facility failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner (LIP) who was responsible for the care of 1 of 1 applicable patient whose record was reviewed. Patient #1 was restrained on one occasion without an order.

Findings were:

Facility policy entitled RESTRAINTS: USE OF RESTRAINTS FOR MEDICAL/SURGICAL PURPOSES (NON-BEHAVIORAL), last reviewed in February of 2012, states in section 4.3.3 and 4.3.4 that an example of a restraint is a bed with all side rails in up position unless used as an assistive device which doesn't restrict the patient's freedom, such as in recovery from anesthesia or sedation following surgery. Section 4.5 outlines all requirements for physician orders if a patient needs to be restrained. Section 4.5.1 specifies that a physician order is required if a patient needs restraints. The policy's Attachment B is the blank physician order. Included in the order sheet are the types of restraint, which include "Bed Rails x 4."

Review of the medical record for Patient #1 revealed that the patient was on a medical unit, not in recovery from anesthesia or sedation after a surgical procedure. On 11/29/12, RN nursing notes state that the patient's family requested that all 4 side rails be kept up on the bed. The nurse explained that would be considered a restraint unless the family wanted the rails up. They expressed that they did want the 4 rails up. Review of the physician orders for Patient #1 revealed that there was no order written for the restraint. This is the only documented episode of restraint found in the record.

An in-person interview was conducted with the facility Chief Nursing Officer (CNO) the morning of 2/27/13. The CNO acknowledged the finding of a restraint of Patient #1 without a physician or LIP order which occurred on 11/29/12.