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Based on interview and document review, the facility failed to ensure physician orders included type of restraint, reason for restraint, part of the body to be restrained, and duration of the restraint; and assessments for physical restraints were completed for 4 of 4 patients (P1, P2, P3, P4) reviewed for physical restraints.

Findings include:

P1's Face Sheet dated 6/13/16, identified the reason for the emergency room (ER) visit was difficulty breathing.
On 6/13/16, at 6:37 p.m. the physician ordered restraints to be placed on P1.
P1's Emergency Room Record dated 6/13/16, at 7:43 p.m. indicated P1 had become agitated, was verbal, but disoriented. The record further indicated P1 would require sedation and physical restraints.
The Registered Nurse (RN) Summary dated 6/13/16, at 6:30 p.m. indicated P1 had Velcro restraints to both arms. At 8:46 p.m. the RN Summary indicated behavior controlled with medication and restraints. P1's medical record lacked a Complete Restraint Flow Form and order form for management of Violent or Self-Destructive behavior or order form for Non-Violent Non-Self Destructive patient.

P2's Face Sheet 4/13/16, identified the reason for the ER visit was alcohol intoxication/agitation.

P2's ER Record dated 4/13/16, identified the reason for the ER visit was alcohol intoxication/agitation.

The Restraint Flow Assessment (RFA) dated 4/13/16, indicated at 1:30 a.m. P2 came to the ER in restraints. At 1:41 a.m. the physician gave the order for restraints. At 2:00 a.m. the RFA indicated P2's restraints were changed to leather restraints with help from law enforcement. At 3:20 a.m. the RFA indicated restraints discontinued after P2 was intubated and sedated to manage seizures. P2's medical record lacked documentation related to attempts to discontinue the restraints or why P2's restraints were changed to leather restraints.

P3's ER Record dated 9/17/15, identified the reason for ER visit was altered mental status.

On 9/17/16, at 6:45 a.m. the physician ordered restraints to be put on P3.

P3's RN Summary dated 9/17/15, at 7:49 a.m. indicated P3 was placed in four point restraints (arms and legs were restrained). P3's medical record lacked a Restraint Flow Form or form for management of Violent or Self-destructive behavior or order form for Non-Violent Non-Self Destructive patient.

P4's ER Record dated 2/14/16, identified the reason for ER visit was anemia.
P4's physician orders dated 2/14/16, at 6:15 a.m. indicated order for soft restraints for patient safety. A nurse's note dated 2/16/16, at 3:20 p.m. indicated P4 was placed in lower limb restraints at the start of the shift and were removed at 9:00 a.m. P4's medical record lacked a physician order for restraints on 2/16/16.
An interview on 8/11/16, at 9:45 a.m. with RN-A indicated there should be a written order for each day a restraint goes on a patient. At 10:05 a.m. RN-A stated staff should be filling out the restraint flow sheets when any patients are placed in restraints.
The facility policy Restraints dated 3/15/16, directed restraints will be used only where alternative methods are not sufficient to protect patients or others from injury, and are not a substitute for less restrictive forms of protective restraints. The policy also directed to notify physician if alternatives attempted have failed and patient continues to meet criteria for restraint application. The policy directed staff to complete the Restraint Flow Form and order form for management of Violent or Self-destructive behavior or order form for Non-Violent Non-Self Destructive patient. The policy also directed:
a. Initiation time of restraints (continue restraint requires a new order every calendar day) for Non-Violent Non Self Destructive patient.
c. Specific reason (clinical justification or indication that restraint use is being used to improve the patient's safety and well being).
e. The extremity or body part(s) to be restrained.
f. The duration (timeframe) for restraint application. (No PRN (as needed) or standing orders are allowed).
The policy further directed the condition of the restrained patient will be continually evaluated, monitored and reevaluated and observed at intervals not greater than 15 minutes. This will be documented on the restraint flow sheet.