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Based on document review and interview, it was determined that for 2 (Pt #7 and 8) of 4 clinical records reviewed for restraints, the Hospital failed to ensure a physician's restraint order was obtained.

Finding include;

1. Policy entitled "Restraint Use-Violent/Self-Destructive Behavior and Nonviolent/Non-Self Destructive Behavior" (Revised 6/2014) indicated " Policy...Restraints...are initiated only on an individual order by a physician..Procedure 3. An order from the physician is to be obtained, if possible, prior to the application of the restraint. d. Physician orders are good for 24 hours. If the restraint is released/discontinued before the calendar day order expires, a new order must be obtained to reapply restraint".

2. Pt # 7 was a 65 year old male admitted on 12/18/15 with diagnosis of chest pain and right lower zone pneumonia. Pt. #7's clinical record contained a preprinted form titled, "Non-Violent/Non-Self Destructive Restraint Order" dated 12/21/15 at 9:00 PM, the form contained a physician's signature that indicated "my signature indicates that I have performed a face-to-face (re)assessment of the patient. However the form was not filled out to indicate: alternatives used prior to restraints, indications for the restraints, type of restraints, restraints location, and time limit. Pt #7's restraint flowsheet indicated the patient remained in restraints from 12/20/15 at 9:00 PM thru 12/22/15 at 12:00 PM (a total of 39 hours). Pt #7's clinical record did not contain a physician's order for restraints on 12/21/15.

3. The clinical record for Pt #8 was reviewed on 12/23/15. Pt #8 was a 22 year old male admitted to the Intensive Care Unit on 12/21/15 with a diagnosis of overdose. The restraint monitoring sheet dated 12/21/15 at 8:00 PM, indicated soft cuff restraints were applied. Pt#8's clinical record lacked a physician's order for the initiation of the restraint on 12/21/15 at 8:00 PM.

4. On 12/22/15 at 1:45 PM the findings were discussed with E#1 (Clinical Specialist, Educator). E#1 stated Pt #7's clinical record did not contain a physician's order for restraints for 12/21/15.

5. On 12/23/15 at 10:45 AM the findings were discussed with E #2 (Clinical Specialist). E #2 stated a physician's order for Pt #8 should have been obtained for the application of restraints on 12/21/15.

Based on document review and interview, it was determined that for 1 (Pt #8) of 4 clinical records reviewed for restraints, the Hospital failed to ensure that restraints were not used as a standing order.

Finding includes:

1. Policy entitled "Restraints Use Violent/Self-Destructive Behavior and Nonviolent/Non Self-Destructive Behavior" (Revised 6/2014) indicated "Procedure 1. Reasons for restraints use: a. Restraints..is used only when warranted by the patient behavior that threatens the safe provision of clinical care or the physical safety of the patient...2. a. Restraints are applied...based on an individual order of a physician, clinical psychologist or other licensed independent practitioner. b. Standing orders or PRN (as needed) orders are not to be used for restraints...d. Physicians orders are good for 24 hours. If the restraints is released/discontinued before the calendar day order expires, a new order must be obtained to reapply a restraint.

2. The clinical record for Pt #8 was reviewed on 12/23/15. Pt #8 was a 22 year old male admitted to the Intensive Care Unit on 12/21/15 with a diagnosis of overdose. Pt #8's clinical record contained a preprinted physician's order form for restraints (Non-violent/ Non-self destructive Restraint order) dated 21/21/15 at 3:00 PM for "soft cuff restraints" to the right and left wrists. The restraint monitoring sheet dated 12/21/15, indicated that the soft cuff restraints were not applied until "12/21/15 at 20:00" (8:00 PM).

3. On 12/23/15 at approximately 10:20 AM the Regulatory Compliance Manager( E #12) stated at the time the restraint was ordered for Pt #8, the patient was heavily medicated and did not require being in restraints.

4. On 12/23/15 at approximately 10:45 AM E #2 was interviewed the Clinical Specialist/Educator ( E #2) was interviewed. E #2 stated the restraint order for Pt #8 had been obtained in the Emergency Department (ER) prior to arriving to the Intensive Care Unit (ICU). E #2 stated it was unclear if the restraint had been applied in the ER, because Pt #8 had been administered propofol (anesthetic/sedation medication).

E #2 stated the restraint orders are good for 24 hours if restraints are in use. E #2 stated "ideally the restraint order should have been discontinued" and when they were required a new order should have been obtained. E #2 stated the nurse thought she was covered since there was an order (12/21/15 at 8:00 PM the initial restraint order) and failed to obtain a new order when the restraints were actually applied. E #2 stated it was anticipated that Pt #8 would require the usage of restraint, therefore the restraint order was not discontinued at that time.

Based on document review and interview, it was determined that for 1 of 4 (Pt#7) clinical records reviewed for restraints, the Hospital failed to ensure a physician's restraint renewal order was obtained after 24 hours of restraint use.

Findings include;

1. Restraints entitled "Restraint Use- Violent/Self Destructive Behavior and Nonviolent/Non Self-Destructive Behavior (Revised 6/2014) indicated "Restraints ...are initiated only on an individual order by a physician...Procedure 3. c. After the first 24 hours, the physicians must evaluate the patient face to face to determine continued need the restraint. d. Physician orders are good for 24 hours. If the restraint is released/discontinued before the calendar day order expires, a new order must be obtained to reapply a restraint."

2. Pt # 7 was a 65 year old male admitted on 12/18/15 with diagnoses of chest pain and right lower zone pneumonia. Pt #7 was initially placed in restraints (safety vest and soft cuffs to upper extremities and left ankle) on 12/20/15 at 9:00 PM with a physician's order. The order expired on 12/21/15 at 9:00 PM. Pt #7's restraint flowsheet indicated Pt #7 remained in restraints from 12/20/15 at 9:00 PM thru 12/22/15 at 12:00 PM (a total of 39 hours), without a restraint renewal order.

3. On 12/23/15 at approximately 10:45 AM E #2 (Clinical Specialist/Educator) was interviewed, E #2 stated Pt #7's electronic version did not contain a physician's order for restraints. E #2 stated an electronic order for restraints is not the practice and that the paper form is used until the software for electronic restraint orders is in place.

Based on document review and interview, it was determined that for 1 (Pt #7) of 4 clinical records reviewed for restraints, the Hospital failed to ensure the assessments during restraints were documented as required per policy.


Finding include;

1. Policy entitled "Restraint Use - Violent/Self-Destructive Behavior and Nonviolent/Non-Self destructive Behavior" (Revised 6/2014) indicated "Procedure 5. b. For nonviolent/non-self-destructive patient, monitoring of the patient's behavior and physical needs/status is conducted and documented at least every two hours."

2. Pt # 7 was a 65 year old male admitted on 12/18/15 with diagnoses of chest pain and right lower zone pneumonia. Pt #7's clinical record contained a physician's order dated 12/20/15 at 9:00 PM for restraints (safety vest and soft cuff to upper extremities and left ankle). Pt #7's restraint flowsheets lacked documentation of the assessment of the restraints from 12/21/15 at 20:00 PM to 12/22/15 at 6:00 AM (total of 14 hours).

3. On 12/22/15 at approximately 1:45 PM E #11 (Registered Nurse) was interviewed. E #11 stated "we (nurses) are required to document the restraint assessment every 2 hours."

4. On 12/22/15 at approximately 1:50 PM the findings were reviewed and discussed with E #1 (Clinical Specialist/Educator). E #1 stated nurses are instructed to document every two on the restraint assessment. E#1 acknowledged there was a lack of documentation in the restraint assessment.