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Based on the clinical record of reviews, interviews with hospital personnel, and review of hospital policies/procedures, for two of ten patients (P#1, P#3) who utilized restraints, the hospital failed to ensure an active order for restraints was in place. The findings included:

A. Patient #1 (P#1) was admitted to the hospital on 1/10/2012 with congestive heart failure (CHF) and symptoms of increased dyspnea and orthopnea. Review of the Adult Assessment/Interventions form dated 1/12/2012 indicated that P#1 was assessed to be a high risk for falls, scoring a 15 on the fall risk assessment tool (at risk if greater than 4). Physician orders indicated that a non-violent restraint, an enclosure bed, was ordered on 1/12/2012 at 4:00 PM and discontinued on 1/16/2012 at 4:00 PM. Review of the Adult Assessment/Intervention form indicated that although patient assessments regarding the use of the enclosure bed were documented on 1/14/2012 at 7:16 PM and on 1/15/2012 at 9:33 AM, there was no active order for restraints from 1/14/2012 at 4:15 PM through 1/15/2012 at 3:56 PM. Hospital Policy and Procedure titled "Use of Restraints" indicated that physician orders for non-violent restraints is limited to 24 hours. Interview with Nurse Manager #1 on 1/27/2012 at 10:45 AM identified that all orders for medical restraints should be renewed every 24 hours per policy.

B. Patient #3 (P#3) was admitted to the hospital on 12/26/2011 for alcohol (ETOH) intoxication. The patient was placed on a Clinical Institute Withdrawal Assessment (CIWA)for which he/she scored a 16 requiring medication (Lorazepam drip). In addition, P#3 was assessed as a fall risk, scoring 14 on the fall risk assessment tool (at risk if greater than 4). Vital signs record dated 12/27/2011 at 3:30 AM indicated that P#3's behavior included pulling at medical tubes and being unable to follow directions. Physician orders indicated that non-violent 2-point soft restraints were ordered at 12/27/2011 at 3:30 AM, which were set to expire on 12/28/2011 at 3:30 AM. Review of the vital signs record identified that ongoing assessments for the soft wrist restraints continued through 12/29/2011 at 5:00 AM, despite there being no active order for restraints. Hospital Policy and Procedure titled "Use of Restraints" indicated that physician orders for non-violent restraints is limited to 24 hours. Interview with Nurse Manager #1 on 1/27/2012 at 10:45 AM identified that all orders for medical restraints should be renewed every 24 hours per policy.

Based on the clinical record of reviews interviews with hospital personnel, and review of hospital policies/procedures for three of ten patients (P#1, #4, and #9) who utilized restraints, the hospital failed to ensure ongoing assessments/monitoring for a patient in restraints. The findings included:

A. Patient #1 (P#1) was admitted to the hospital on 1/10/2012 with congestive heart failure (CHF) and symptoms of increased dyspnea and orthopnea. Review of the Adult Assessment/Interventions form dated 1/12/2012 indicated that P#1 was assessed to be a high risk for falls, scoring a 15 on the fall risk assessment tool (at risk if greater than 4). Physician orders indicated that a non-violent restraint, an enclosure bed, was ordered on 1/12/2012 at 4:00 PM and discontinued on 1/16/2012 at 4:00 PM. Review of P#1's clinical record from 1/12/2012 through 1/16/2012 identified that restraint assessments were lacking for the time period of 1/14/2012 from 7:00 AM through 4:25 PM. In addition, for the date of 1/15/2012, the only documented restraint assessments were at 9:33 AM and 7:15 PM. Hospital Policy and Procedure titled "Use of Restraints" indicated that for non-violent restraints, monitoring is to occur every two hours at a minimum. Interview with Nurse Manager #1 on 1/27/2012 at 10:45 AM identified that for patients in medical restraints, staff should be assessing and documenting at least every two hours per hospital policy.

B. Patient #4 (P#4) presented to the hospital Emergency Department (ED) on 11/21/2011 at 1:00 AM with altered mental status/crisis evaluation. Nursing note on 11/21/2011 at 12:05 PM indicated that P#4 is screaming, threatening staff, and attempting to climb out of the bed. A nursing note dated 11/21/2011 at 6:09 PM indicated that P#4 was a fall risk and an enclosure bed was ordered for the patient. The ED restraint record lacked restraint assessments between 11/21/11 at 9:34 PM and 11/22/11 at 3:42 AM, while P#4 was utilizing the enclosure bed. Hospital Policy and Procedure titled "Use of Restraints" indicated that for non-violent restraints, monitoring is to occur every two hours at a minimum. Interview with Nurse Manager #1 on 1/27/2012 at 10:45 AM identified that for patients in medical restraints, staff should be assessing and documenting at least every two hours per hospital policy.

C. Patient #9 (P#9) was admitted to the hospital on 12/26/2011 at 12:01 AM presenting with behaviors that included confusion, combativeness, hitting, and climbing out of bed. Review of the Adult Assessment/Interventions form dated 12/26/2011 indicated that P#9 was assessed to be a high risk for falls, scoring a 18 on the fall risk assessment tool (at risk if greater than 4). Physician orders indicated that an enclosure bed was ordered on 12/26/2011 at 4:59 PM. The Restraint Data Collection and Tracking Log indicated that P#9 was placed in an enclosure bed on 12/28/2011 at 12:28 PM. Orders for the enclosure bed were discontinued on 12/30/2011 at 2:00 PM. The clinical record lacked documentation of restraint assessments from the time period of 12/28/2011 at 9:30 PM through 12/29/2011 at 7:20 PM. Hospital Policy and Procedure titled "Use of Restraints" indicated that for non-violent restraints, monitoring is to occur every two hours at a minimum. Interview with Nurse Manager #1 on 1/27/2012 at 10:45 AM identified that for patients in medical restraints, staff should be assessing and documenting at least every two hours per hospital policy.