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The facility failed to ensure that patients had properly executed physicial restraint orders, in accordance with regulations and facility policy. See findings at A-0164.

Review of the facility policy titled "Restraint Use" (#200-1, revised 7/10) revealed the following statements under A. Medical and Surgical Guidelines for Restraints" that do not provide a clear definition of when restraints may be applied.

3b. "If the patient's presenting behavior is usual for the patient and they are not a threat to themselves or others, restraints will not be utilized. If restraints are used for patients in these situations, the physician and/or RN may determine..."

4b. "If restraints are instituted emergently based on a significant change in the patient's condition, the physician will be notified immediately and an order obtained."


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Based on record review and interview the facility failed to ensure restraint orders for patients are completed according to policy for 2 of 2 (#10, #11) patients. Findings include:

On 8/9/10 at approximately 1015 during a tour of the unit identified as the Surgical Intensive Care Unit (SICU) patient #10's medical record was reviewed and was found to have a form titled "Physician Order Medical/Surgical Restraints" that consisted of a restraint order dated 8/9/10 but without a time indicating when the physician signed the order. Underneath the physician's signature line it is written "MUST BE SIGNED WITHIN 1 HOUR OF INITIATION." Staff #G was queried regarding the time of the physician's signature and she took the form down the hall to ask the nurse that was responsible for the patient at that time and the form came back with the time of 0800. Staff #G was queried about the time written in and stated "I wrote that in after I spoke with the nurse." Staff #G was then queried if that time was to be written and indicated by the physician signing the form and staff #G stated "I guess you're right, that is for the physician."

On 8/9/10 at approximately 1015 during a tour of the unit identified as the Surgical Intensive Care Unit (SICU) patient #11's medical record was reviewed and was found to have a form titled "Physician Order Medical/Surgical Restraints" that was absent of a physician's order that indicated the placement of restraints (which extremity to apply) and the time limit (either 24 hours or a specified time in hours). Staff #G was queried regarding the incomplete physician's order and stated "that should have been identified, that is part of the physician's order."

On 8/10/10 at approximately 0830 review of the facility's policy and procedure titled "Restraint Use" it is written under the section title "II. Policy" under the eighth bullet point "Orders are time-limited; this does NOT mean that restraints must be applied for the entire length of time the order in in effect." Under the section titled "IV. Procedure 4. d." it is written "A written order utilizing the Restraint Physician Order, Medical/surgical Restraints (see Attachment A), will be completed. NOTE: Do not use regular physician order forms; use the Physician Order, Medical/Surgical Restraints. i. The order must include the following elements: Reason for the restraint; Type of restraint; Placement of restraint; Length of time the restraint is authorized for in hours, not to exceed 24 hours.