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Based a review of the policy and procedure, medical records, and interview, it was determined the Administrator failed to require:

1) the physician write an order for the application of restraints for Patient #1; and

2) the register nurse (RN) document receiving a verbal order from the physician, for the application of restraints for Patient #1;

Findings include:

The policy "Restraints/Seclusion - Patients" requires: "...The use of restraint...must be in accordance with the order of a physician...who is responsible for the care of the patient...."

Patient #1 was admitted to the Emergency Department (ED) on 06/29/09, with chief complaint of overdose. The police were in the process of placing the patient in custody, and she had stepped into bathroom to change clothes and later was found unresponsive.

The ambulance staff found her "stiff" and unable to move. She was given Narcan 2 milligrams intramuscular, and began to arouse, and become alert and orientated x4. The patient then became angry and uncooperative, and was brought into the ED, for an evaluation.

The patient remained uncooperative, and combative. She refused to speak with the ED physician, refused to have the registered nurse (RN) draw labs, and began to climb out of bed.

1) On 02/10/11, the Director of Quality Assurance (QA) stated that back in June of 2009, the ED Director had interviewed the ED physician who had cared the patient. He confirmed he had given a verbal order for the nursing staff to apply the restraints, and that he had not written an order.

On 02/10/11, the Director of QA confirmed the ED physician did not write an order or sign a verbal order for the restraints, for Patient #1, as required by policy.

2) The verbal "Restraint Order" form for Patient #1, completed by the RN, had the reason for the complaint, the date, and the RN's signature.

The form did not have the time nor the physician's name who gave the verbal order.

On 02/10/11, the Director of QA confirmed the ED RN did not write a complete verbal order for restraints, to include the physician's name, and time for Patient #1.

Based a review of the policy and procedure, medical records, and interview, it was determined the Administrator failed to require the registered nurse (RN) document safety checks every 2 hours while Patient #1 remained in restraints.

Findings include:

The policy "Restraints/Seclusion - Patients" requires: "...nursing staff will perform patient safety checks every 2 hours including ensuring appropriate placement of the restraint and addressing patient personnel needs...."

The Restraint Flow Sheet for Violent/Self Destructive Behavior form has an area to document "Patient Safety Checks." The form lists safety measures to be addressed by the nursing staff every 2 hours. These safety measures include: physical well-being such as elimination, repositioning, oral intake, skin and oral care; the emotional well being, patient rights, and restraints are applied appropriately.

The nursing notes on 06/29/09, at 2245, revealed: "...Place in restraints....at 0125...Patient discharged into police custody...."

On 02/10/11, the Director of QA confirmed the ED RN did not perform and document safety checks every 2 hours for Patient #1, as required by policy.

Based a review of the policy and procedure, medical records, and interview, it was determined the Hospital failed to require the physician document a face-to-face evaluation of Patient #1, after the restraints were initiated for violent/self destructive behavior according to policy.

Findings include:

The policy "Restraints/Seclusion - Patients" requires: "...When restraints...is used for the management of violent or self destructive behavior...the patient must be evaluated face -to-face within 1 hour after the initiation...by a physician...."

On 02/10/11, the Director of QA confirmed the ED physician did not document a face-to-to evaluation of Patient 1 within an hour of placing the patient in restraints for violent/self destructive behavior.