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Based on review of the medical record, the hospital failed to implement Patient #1's restraints in accordance with hospital policy by failing to implement 15-minute checks as evidenced by the following:

Patient #1 was a 90-year-old female admitted on the evening of 1/18/10 through the ED for suspected temporal arteritis. She was admitted to Unit 35 (Acute Care for the Elderly), awaiting biopsy to be performed on 1/19/10. A computerized nursing note recorded on 1/19/10 at 6:34 am documented that Patient #1 became increasingly agitated, verbally abusive, and combative, trying to kick, swat, spit, and scratch the nursing staff as well as try to remove her IV. An order was obtained to place Patient #1 in 2-point restraints (left and right wrists) for behavioral reasons from 4:45 am until 8:45 am; however, no documentation was found of the 15-minutes checks required by the hospital's "Management of Behavioral Restraints/Seclusion" policy.

Based on review of the medical record, the hospital failed to ensure that Patient #1 received a face-to-face assessment within one hour after the initiation of behavioral restraints as evidenced by the following:

Patient #1 was a 90-year-old female admitted on the evening of 1/18/10 through the ED for suspected temporal arteritis. She was admitted to Unit 35 (Acute Care for the Elderly), awaiting biopsy to be performed on 1/19/10. A computerized nursing note recorded on 1/19/10 at 6:34 am documented that Patient #1 became increasingly agitated, verbally abusive, and combative, trying to kick, swat, spit, and scratch the nursing staff as well as trying to remove her IV. Because of that behavior, an order was obtained to place Patient #1 in 2-point restraints (left and right wrists) for behavioral reasons from 4:45 am until 8:45 am; however, the record contains no documentation that the one-hour face-to-face evaluation required by this regulation and by the hospital's " Management of Behavioral Restraints, Seclusion " policy was ever made.

Based on review of the medical record, the hospital failed to correctly and descriptively document the patient's behavior that warranted the use of behavioral restraints as evidenced by the following:

Patient #1 was a 90-year-old female admitted on the evening of 1/18/10 through the ED for suspected temporal arteritis. She was admitted to Unit 35 (Acute Care for the Elderly), awaiting biopsy to be performed on 1/19/10. A computerized nursing note recorded on 1/19/10 at 6:34 am documented that Patient #1 became increasingly agitated, verbally abusive, and combative, trying to kick, swat, spit, and scratch the nursing staff as well as try to remove her IV. Consequently, an order was obtained to place Patient #1 in 2-point restraints (left and right wrists) for behavioral reasons from 4:45 am until 8:45 am.

On the Physician's Order Sheet, under Clinical Justification, the practitioner checked off the box with the generic phrase "Behavior that is dangerous to self" next to it and wrote on the line next to the checkbox "pulling IVs," which according to the hospital's "Management of Medical/Surgical Restraints" policy is a valid reason for ordering "Medical/Surgical" restraints but not "Behavioral" restraints.

In addition, no other documentation was made describing Patient #1's behavior which required the behavioral restraints which were placed around 4:30 am. The first nursing note with a description of that behavior was not entered into the computer until 6:34 am, almost two hours after the restraints were first placed. Additionally, the computer screen utilized for documenting patients' behavior requiring the application of behavioral restraints contains the generic phrases "Violent Behavior," "Harm to Others," Harm to Self," and "Aggression."

Based on a review of medical records, the facility failed to ensure that that all orders of Patients #2 and #3 were signed within forty-eight hours by the ordering practitioner as evidenced by the following:

A review of two randomly selected medical records from Unit 35 made on 4/5/10 revealed that both records contained multiple telephone orders left unsigned for greater than forty-eight hours:

Patient #2's record revealed the following telephone orders left unsigned by the practitioner who gave the order:
1) 4/1/10 at 2:20 am for chest x-ray and traveling off monitor
2) 4/1/10 at 11:50 am for chest CT with IV contrast
3) 4/2/10 at 11:00 am for head CT with contrast
4) 4/2/10 at 4:00 pm for Doppler ultrasound and abdominal x-ray
5) 4/2/10 at 4:20 pm for Gastrograffin enema
6) 4/2/10 at 4:20 pm for IV Dilaudid

Patient #3's medical record revealed the following telephone orders which were left unsigned by the practitioner who gave the order:
1) 3/28/10 at 9:00 pm to collect urine specimen and add labs
2) 3/28/10 at 12:45 pm to give oral contrast
3) 4/2/10 at 3:00 pm to discontinue IV fluid