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Based on clinical record review, policy review and interview, it was determined the facility failed to ensure two (#4 and #6) of two (#4 and #6) restrained patients reviewed had orders for restraints the entire time they were in restraints. The failed practice had the potential to affect all restrained patients in the facility. Findings follow:

A. Review of the Restraint policy revised 02/07, revealed "The use of restraints must be re-assessed and re-signed by the physician every 24 hours on the physician order sheet." The policy failed to address the time frame for obtaining a physician's order for restraint upon emergency application of restraint by the Registered Nurse.

B. Review of the clinical record for Patient #4 revealed the following:
1) The Shift Activity Reports documented, "Wrist restraint on right arm."at 2300 on 01/14/15.
2) There was no Physician's Order for restraints until 0711 on 01/15/15.

C. Interview with the Clinical Med/Surge Coordinator at 0925 on 01/15/10 confirmed the patient was placed in restraints without a physician order.

D. Review of the clinical record for Patient #6 revealed the following:
1) The Restraint Flow Sheets documentation for Patient # 6 revealed the patient was in restraints all or part of each day from 01/06/10 through 01/12/10. Review of Physician 's Orders revealed an order at 1920 on 01/06/10 to "Place patient in bilateral soft wrist restraints up to 24 hours to protect integrity of ET tube and IV access."
2) Review of the Restraint Order Sheet revealed documentation by the RN renewing the restraints on 01/07, 01/08, 01/09, 01/11 and 01/12/10.
3) The Physician Orders lacked any further orders for restraints during the time the patient was in restraints.

E. The lack of a physician's order for the restraints from 01/07/10 through 01/12/10 was confirmed during interview with the Clinical Manager of ICU (Intensive Care Unit) at 1000 on 01/15/10. She stated the standard procedure was to apply soft wrist restraints to patients on the ventilator.

Based on clinical record review and interview, it was determined the facility failed to ensure restraint orders for one (#4) of two restrained patients reviewed (#4 and #6) were not "as needed". The failed practice had the potential to affect all restrained patients admitted to the facility. Findings follow:

A. Review of Physician's Orders for Patient #4 revealed an order written on 01/15/10 at 0711 stating "May use soft restraints for patient safety (ie pulling out lines, IV)". The order was not time limited.

B. The Clinical Med/Surge Coordinator confirmed the restraint order was not time limited during interview at 0925 on 01/15/10.

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure ongoing monitoring for one (Patient #4) of two restrained patients reviewed (#4 and #6). The failed practice had the potential to affect all restrained patients in the facility. Findings follow:

A. Review of the Restraint Policy, reviewed 02/07, revealed the nurse was to "Document on Restraint Intervention Flowsheet when care is given and restraints are released. Restraints must be released a minimum of every two hours. This documentation is to include the type of restraint being used, all comfort measures provided to the patient, and any other interventions implemented."

B. Review of the Shift Activity Reports for Patient #4 revealed the patient documentation of "Wrist restraint on right arm". at 2300 on 01/14/15.

C. Review of Physician's Orders revealed an order to initiate restraints at 0711 on 01/15/10.

D. Observation at 0925 on 01/15/10 revealed the patient had a wrist restraint on his right wrist.

E. Review of the clinical record revealed a lack of Restraint Intervention Flowsheets or any restraint monitoring documentation.

F. The lack of evidence of restraint monitoring was confirmed by the Clinical Med/Surge Coordinator at 0925 on 01/15/10.