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Based on policy and procedure review, clinical record review and interview, it was determined one (Patient #2) of eight (#2, #5-#9, #14 and #15) Patients was restrained two (05/10/17 and 05/14/17) of eleven (05/04/17 through 05/14/17) days without a Physician's order. Failure to obtain a Physician's order for restraints did not allow the Physician to be knowledgeable regarding the Patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patient #2 on 05/04/17 and 05/14/17. Findings follow:

A. Review of the policy and procedure titled "Restraint and Seclusion Policy" received from the Market Chief Quality Officer at 1430 on 06/26/17 revealed the following under " ...F. NON-VIOLENT/NON-SELF DESTRUCTIVE RESTRAINT/SECLUSION RENEWAL ORDERS:
1. Each order for restraint to ensure physical safety of non-violent or on-self-destructive patient must be renewed: a. Once every calendar day. b. Episode of care (e.g. while IV (intravenous) or tubes are utilized; while on a ventilator) ..."

B. Review of Patient #2's clinical record revealed restraint checks every two hours from 0100 to 0700 on 05/10/17. Review of Patient #2's clinical record revealed no order dated 05/10/17 for restraints. Review of Patient #2's clinical record revealed restraint checks every two hours from 0000 to 1200 and from 1600 to 2200 on 05/14/17. Review of Patient #2's clinical record revealed no order dated 05/14/17 for restraints.

C. During an interview with the Market Chief Quality Officer and the ICU/IMC Clinical Manager at 1135 on 06/28/17 the findings in A and B were verified.

Based on clinical record review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care for eleven ( #1, #2, #3, #4, #5, #6, #7, #9, #10, #12 and #14) of fifteen (#1-#15) Patients in that clinical records did not contain evidence the following Physician's orders were performed: intake and output measured and recorded every one hour and every eight hours, neurological check/assessment measured and recorded every two and four hours, daily weights not recorded, supplement intake not recorded, and patient not turned every two hours. Based on clinical record review and interview, it was determined a RN failed to supervise and evaluate the nursing care for Patient #4 in that high flow oxygen was administered and titrated without Physician's orders. Failure of a RN to ensure performance of and documentation of intake and output, neurological check/assessments, daily weights, supplement intake and the Patient was turned every two hours did not provide the Physicians information needed to make adjustments in the Patient's care. Failure to ensure Physician's orders for oxygen amount and mode of delivery was in place did not allow management and direction by the Physician. The failed practice had the likelihood to affect Patients #1, #2, #3, #4, #5, #6, #7, #9, #10, #12 and #14. Findings follow:

A. Review of Patient #1's clinical record revealed orders authored by Physician #3 on 06/25/17 for intake and output measurement every one hour. Review of Patient #1's clinical record revealed no measurement of intake and output from midnight 06/27/17 until patients death at 0600 on 06/27/17. The above was verified by the ICU/IMC (Intensive Care Unit/Intermediate Care Unit) Clinical Manager during an interview at 0949 on 06/27/17.

B. Review of Patient #2's clinical record revealed Physician's Orders dated 05/07/17 for Glucerna BID (twice daily); Physician's Orders dated 05/08/17 to turn patient every two hours; Physician's Orders dated 05/05/17 to weigh patient daily. Review of Patient #2's clinical record revealed no evidence Patient #2 received Glucerna BID from 05/07/17 until discharge; no evidence the Patient was turned every two hours from 05/08/17 through 05/17/17 and; no evidence the Patient was weighed daily on 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/16/17 and 05/17/17. The above findings were verified by the Market Chief Quality Officer and Director of Critical Care during an interview at 1110 on 06/28/17.

C. Review of Patient #3's clinical record revealed Physician's Orders dated 06/25/17 for intake and output measurement every eight hours and Physician's Orders dated 06/26/17 at 1422 and 1423 for Juven BID and Ensure Enlive BID respectively. Review of Patient #3's clinical record revealed no measurement of intake and output on 06/25/17 and 06/26/17 and no evidence Patient #3 received Juven and Ensure Enlive BID from 06/26/17 through 0700 on 06/27/17. The above findings were verified by the ICU/IMC Clinical Manager during an interview at 1021 on 06/27/17.

D. Review of Patient #4's clinical record revealed Physician's Orders dated 05/10/17 at 1246 for Glucerna BID and Sugar Free Thrive BID. Review of Patient #4's clinical record revealed no evidence Patient #4 received Glucerna and Sugar Free Thrive BID from 05/10/17 through 05/11/17. Review of Patient #4's clinical record revealed no Physician's Orders for oxygen after the Patient was weaned from the ventilator. Nurses initiated, titrated and managed oxygen without Physician's Orders and direction. The above findings were verified by the ICU/IMU Clinical Manager at 1115 on 06/27/17.

E. Review of Patient #5's clinical record revealed Physician's Orders dated 05/05/17 at 1507 for Pro Mod supplement 120 QID (four times a day) and orders dated 05/08/17 at 1358 Ensure Enlive TID (three times a day). Review of Patient #5's clinical record revealed no evidence Patient #5 received the Pro Mod 120 from 05/05/17 through 05/06/17 at which point it was discontinued and no evidence Patient #5 received the Ensure Enlive TID from 05/08/17 through discharge at 05/11/17. The above findings were verified by the ICU/IMC Clinical Manger during an interview at 1420 on 06/27/17.

F. Review of Patient #6's clinical record revealed Physician's Orders dated 05/19/17, timed 0037 for neurological checks every two hours. Review of Patient #6's clinical record revealed no evidence the every two hour neurological checks were performed. The above findings were verified by the ICU/IMC Clinical Manger during an interview at 1500 on 06/27/17.

G. Review of Patient #7's clinical record revealed Physician's Orders for the following supplements:
1) Pro Mod QID ordered 04/03/17 at 1457, discontinued (dc'ed) 04/06/17 at 1327;
2) Glucerna BID ordered 04/06/17 at 1325, dc'ed 04/07/17 at 1416;
3) Sugar Free Thrive ordered 04/06/17 at 1325, dc'ed 04/07/17 at 1416;
4) Ensure TID ordered 04/07/17 at 1416, dc'ed 04/15/17 at 1131;
5) Pro Mod 120 QID ordered 04/15/17 at 1130, dc'ed 04/19/17 at 1339;
6) Pro Mod 6 ounces (ozs)/180 cc (cubic centimeter) per day ordered 04/19/17 at 1339, dc'ed 04/20/17 at 1837;
7) Pro Mod 6 ozs/180 cc per day ordered 04/21/17 at 1251, dc'ed 04/27/17 at 1811; and
8) Pro Mod 6 ozs/180 cc per day ordered 04/28/17at 1313, dc'ed 05/01/17 at 0310.
Review of Patient #7's clinical record revealed no evidence the above supplements were given from 04/06/17 through 04/28/17 (04/28/17, 2300 to 0659, 30 ccs were documented) and from 04/28/17 through 05/01/17. The above findings were verified by the ICU/IMC Clinical Manager during an interview at 1536 on 06/27/17.

H. Review of Patient #9's clinical record revealed Physician's Orders dated 06/07/17 at 0959 for intake and output measurements every eight hours and Physician's Orders dated 06/15/17 at 1026 for neurological checks every four hours. Review of Patient #9's clinical record revealed no measurement of intake and output every eight hours from 06/10/17 through 06/12/17, and 06/14/17 through 06/25/17. Review of Patient #9's clinical record revealed no evidence neurological checks were performed every four hours on 06/15/17, and 06/17/17 through 06/23/17. The above findings were verified by the Hospital Educator during an interview at 0923 on 06/28/17.

I. Review of Patient #10's clinical record revealed Physician's Orders dated 06/22/17 at 1423 for Sugar Free Thrive BID and Physician's Orders dated 06/22/17 at 1757 for Patient #10 to be turned every two hours. Review of Patient #10's clinical record revealed no evidence the Sugar Free Thrive was given as ordered from 06/22/17 through 06/27/17 and no evidence Patient #10 was turned every two hours as ordered from 06/22/17 through 06/28/17 at 0700. The above findings were verified during an interview with the Hospital Educator and the Market Chief Quality Officer at 1000 on 06/28/17.

J. Review of Patient #12's clinical record revealed Pysician's Oders dated 06/26/17 at 1445 for Ensure Enlive BID. Review of Patient #12's clinical record revealed no evidence Ensure Enlive was given as ordered from 06/26/17 through 06/28/17 0700. The above findings were verified during an interview with the Market Chief Quality Officer at 1023 on 06/28/17.

K. Review of Patient #14's clinical record revealed Pysician's Oders dated 06/26/17 at 1433 for Ensure Enlive BID. Review of Patient #14's clinical record revealed no evidence Ensure Enlive was given as ordered from 06/26/17 through 06/28/17 0700. The above findings were verified in an interview with the Market Chief Quality Officer at 1147 on 06/28/17.