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Based upon hospital restraint policy review, medical record review and staff interview the nursing staff failed to ensure a physician's order was obtained for the use of restraints for 1 of 4 restrained patients reviewed (#1).

The findings include:

Review of hospital policy "Use of Restraints" policy number 365, revised 06/05/2007, revealed "Medical and Surgical Situation....Restraint Assessment/Restraint Orders: ...4. ...The LIP (Licensed Independent Practionier) is notified within 12 hours of the initiation of restraint and a verbal or written order is obtained. ...5. ...A written order based on exam by a L.I.P. is written within 24 hours of the initiation of restraint. ...8. ...Restraint Flow sheet must be used to document LIP orders for restraint..."

Closed medical record review for Patient #1 revealed an 89 year- old male admitted on 05/11/2010 and discharged on 05/16/2010 with a diagnosis of community-acquired pneumonia, atrial fibrillation with rapid ventricular response (irregular heart beat), congestive heart failure, renal insufficiency and diabetes. Record review revealed nursing documentation the patient was restrained from 05/11/2010 at 2053 until 05/12/2010 at 2300 (26 hours and 7 minutes) and on 05/14/2010 at 0800 until 1300 (5 hours). Review of the "Restraint Flowsheet - Acute Medical and Surgical Care" forms dated 05/11/2010 at 2053, 05/12/2010 at 0800 and 05/14/2010 (not timed) respectively, revealed no documented evidence of an order authenticated by the ordering physician authorizing the use of restraints on 05/11/2010, 05/12/2010, and 05/14/2010. Review of the physician's signature line on the restraint flowsheets revealed the lines were blank. Further record review revealed no available documentation of an authenticated physician's order for the use of restraints on the aforementioned dates.

Interview with nursing administrative staff on 05/26/2010 at 1152 revealed a physician's order is required for the use of restraints. Interview revealed verbal orders for restraints must be authenticated by the ordering physician within 12 to 24 hours. Interview revealed all restraint orders are to be documented on the restraint flowsheet. Interview revealed the "Restraint Flowsheet - Acute Medical and Surgical Care" forms dated 05/11/2010 at 2053, 05/12/2010 at 0800 and 05/14/2010 (not timed) respectively, revealed no documented evidence of an order authenticated by the ordering physician authorizing the use of restraints on 05/11/2010, 05/12/2010, and 05/14/2010. Interview confirmed the physician's signature lines on the restraint flowsheets were blank. Interview confirmed the nursing staff failed to follow the facility's Use of Restraints Policy.

NC00063484