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Based on medical record review, interview and policy and procedure review the facility failed to ensure that four (#3, #4, #9 and #11) out of four restrained patients had an order by a physician or physician assistant. This has the potential for inappropriate use of restraints.
Findings include:

On 11/19/13 at approximately 1230 during medical record review of patient #3 it was revealed that the patient was placed in restraints on 11/16/13 without a physician's order. On 11/19/13 at approximately 1230 during review of patient #4's medical record it was revealed that the patient was placed in restraints on 11/15/13. Nursing documentation showed the patient continued to be restrained up to and including the date of survey. No continuing orders for restraints could be located for 11/16/13 and 11/17/13. Staff B confirmed these findings for patient #3 and patient #4, lacking physician orders for restraints, while assisting with navigation of their respective electronic medical records.


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On 11/19/13 at approximately 1230 during review of patient #9's medical record it was revealed that the patient was placed in restraints on 11/15/13 and continued to be restrained up to the date of survey. The patient did not have an order for continuation of restraints for 11/17/13. Staff L confirmed this finding while assisting with navigating through the medical record, stating "Yes an order is missing for that time."

On 11/20/13 at approximately 0945 during review of patient #11's medical record it was revealed that the patient was restrained on two separate occasions during her emergency center visit on 7/6/13. Review of the physician's orders for this encounter revealed that no orders for restraints were obtained. During interview on 11/20/13 at approximately 1230 staff A was queried as to if any physician's orders for restraints could be located, to which she replied, "No."

On 11/20/13 at approximately 1100 during policy review it was revealed in the policy titled "Restraint" dated 10/4/11 states under section B, #2 "Each episode of restraint use shall be initiated: i. Upon the order of a physician or physician's delegate....who is responsible for the patient..." Further review of the Non-Violent Physical Restraint Order revealed in the section labeled Comments "Restraint order must be renewed every calendar day."