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Based on medical record review, policy review, and staff interview, the facility failed to ensure patients had physician orders for non-violent restraints according to policy and procedure for two of two patients reviewed who had restraints (Patient #9 and #10). There was a total of ten medical records reviewed. The patient census was 566.

Findings include:

Review of the Miami Valley Restraint Policy Unit II: Specific Patient Care Routines Policy (Current Review 10/21/15) is to establish a system policy and procedure that will ensure a high level of patient safety while preserving patients' dignity, rights, and well being. A restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. A verbal or electronic order is required from the Qualified Licensed Independent Practitioner (LIP) or LIP's designee who is primarily responsible for the patient's care at the time or immediately (within a few minutes) after the restraint is applied. Non-Violent or Non-Self-Destructive Behavior Restraints are time limited orders and renewal orders occur every 24 hours no later than 7:00 PM.

1. Review of the medical record for Patient #9 revealed the patient was admitted to the trauma intensive care unit on 06/17/18 following a motorcycle crash collision. The patient sustained multiple injuries resulting in acute hypoxic respiratory failure which required intubation, traumatic subdural hematoma, right pulmonary contusion, and right facial laceration. Review of the the nursing flowsheets noted restraints were being documented every two hours beginning 06/17/18 at 8:00 PM. The medical record revealed there was no physician order for bilateral soft wrist restraints until the following morning on 06/18/18 at 8:53 AM.

This finding was confirmed with Staff B on 06/19/18 at 11:32 AM.

2. Review of the medical record for Patient #10 revealed the patient was admitted to the intensive care unit following a multi trauma motorcycle versus motor vehicle collision. The patient sustained multiple life threatening injuries that included skull base fractures, bilateral pneumothoraces, multiple bilateral rib fractures, and internal lacerations with hemorrhage. Review of the nursing flowsheets noted bilateral soft wrist restraints were applied on 05/21/18 through 06/05/18. The medical record lacked physician orders for bilateral soft wrist restraints on 05/23/18, 05/24/18, 05/25/18, 05/30/18, 05/31/18, 06/03/18, and 06/04/18.

The patient was removed from restraints on 06/05/18. A new order obtained on 06/06/18 and soft wrist restraints were in place through 06/13/18. The medical record lacked a physician order for bilateral soft wrist restraints on 06/07/18, 06/11/18, and 06/12/18.

This finding was confirmed with Staff B on 06/19/18 at 11:47 AM.