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Based on record review and interview, staff at this facility failed to document that less restrictive methods were used prior to obtaining orders for bilateral hand mitt restraints in 1 of 10 medical records reviewed (Patient #5).

Findings include:

The facility policy titled, "Restraints (System Wide)," #4388313, dated 5/2017, was reviewed on 4/4/2018 at 11:29 AM. The policy revealed in part, "Alternatives to restraints must be the first consideration in caring for a patient who poses harm to themselves or others. If restraints are necessary, it must be the least restrictive and discontinued at the earliest possible time."

Patient #5's electronic medical record was reviewed on 4/4/2018 at 2:14 PM accompanied by Clinical Outcomes Manager E who confirmed the following finding: The physician orders revealed that Patient #5 had a physician order for left and right secured hand mitts, which were ordered on 2/16/2018 at 8:24 AM. Nursing documentation in the restraint flow sheet for 2/16/2018 failed to document the least restrictive methods used prior to applying these restraints. Per interview with Manager E on 4/4/2018 at 2:20 PM, Manager E stated that the finding was correct, "It is not documented."

Based on record review and interview, staff at this facility failed to obtain physician orders for restraints used prior to their application in 1 of 10 medical records reviewed (Patient #6).

Findings include:

The facility policy titled, "Restraints (System Wide)," #4388313, dated 5/2017, was reviewed on 4/4/2018 at 11:29 AM. The policy revealed in part, "Order needs to be obtained face to face or by telephone prior to restraint application unless in emergent situations.," and "Orders are time limited to 24 hours."

Patient #6's electronic medical record was reviewed on 4/4/2018 at 2:24 PM accompanied by Clinical Outcomes Manager E who confirmed the following finding: The flow sheet for restraints, completed by nursing, revealed that on 2/14/2018 at 8:50 AM Patient #6 was placed in restraints (net bed) for interference with medical treatment. A verbal order for the restraint was not obtained until 9:21 PM on 2/14/2018. The physician did not sign the restraint order until 2/16/2018 at 8:39 PM.

According to nursing documentation on flow sheets and care plan evaluation notes, Patient #6 remained in the net bed until 2/17/2018 when there is a note that the net bed could be discontinued. There are orders for the net bed restraint on 2/14/2018 and 2/16/2018 but no order for the restraint bed on 2/15/2018.

Per interview with Manager E on 4/4/2018 at 2:56 PM regarding no order found for the bed on 2/15/2018, Manager E stated, "Orders can't be more than 24 hours. Period."

Based on record review and interview, staff at this facility failed to notify the attending physician that restraints were needed in 1 of 10 medical records reviewed (Patient #1).

Findings include:

The facility policy titled, "Restraints (System Wide)," #4388313, dated 5/2017, was reviewed on 4/4/2018 at 11:29 AM. The policy revealed in part, "The attending physician must be consulted as soon as possible if the attending physician did not order the restraint."

Patient #1's electronic medical record was reviewed on 4/4/2018 at 12:20 PM accompanied by Clinical Outcomes Manager E who confirmed the following finding: An order for a net bed (net enclosed bed considered a restraint) was obtained on March 16, 2018 at 7:00 PM from a Nurse Practitioner. There is no documentation indicating that staff contacted Patient #1's attending physician to inform the physician of the need for this restraint. Per interview with Manager E on 4/4/2018 at 12:40 PM, Manager E stated that it is within the Nurse Practitioner's scope of practice to write the order, but the Nurse Practitioner is not the attending physician and there is nothing documented to indicate the attending physician was notified.

Based on record review and interview, staff at this facility failed to document patient behavior that prompted the use of restraints and the interventions that were used in 1 of 10 medical records reviewed (Patient #9).

Findings include:

The facility policy titled, "Restraints (System Wide)," #4388313, dated 5/2017, was reviewed on 4/4/2018 at 11:29 AM. The policy revealed in part, "The need for use of restraint is discussed by the RN [Registered Nurse] with patient and/or family (as permitted by patient) to include: 1. Rationale for use; 2. Discontinuation criteria; 3. Patient observation, including monitoring and reassessment; 4. Family participation which could reduce the need for restraints."

Patient #9's electronic medical record was reviewed on 4/4/2018 at 3:16 PM accompanied by Clinical Outcomes Manager E and Director of Regulatory and Accreditation A who confirmed the following finding: Nursing progress notes on 1/9/2018 revealed that Patient #9 was transferred from the medical unit to the intermediate care unit (a higher level of care) at 2:00 PM with bilateral mitt restraints on. There is no documentation prior to 2:00 PM on 1/9/2018 that mitt restraints were applied, or why. There is no care plan for the restraints prior to Patient #9 arriving on the intermediate care unit. Per interview with Manager E and Director A on 4/4/2018 at 3:35 PM regarding these findings, Director A stated, "You're right, there is nothing documented here [prior to 2:00 PM on 1/9/2018]."