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Based on document review and interview it was determined that for 1 (Pt #4) of 2 clinical records reviewed for restraints, it was determined the Facility failed to ensure that a physician's order was obtained for the application of restraints.

Findings include:

1. Policy entitled "Use of Restraints and Seclusion" (Revised 9/2013) indicated "Addendum B -Orders for Restraints or Seclusion 3. The order should be entered before the initiation of Restraints or Seclusion except in an emergency. 4. In an emergency, a patient may be placed in Restraint or Seclusion to eliminate the immediate risk, and then an order obtained within one (1) hour of application of the Restraint or Seclusion."

2. On 1/6/16 at approximately 9:30 AM the Restraint Log book of the Behavioral Health Unit (3 West) was reviewed. The log indicated that Pt #4 was placed in restraints on three (3) different occasions:
-12/11/15 from 8:30 AM to 9:38 AM
-12/15/15 from 8:45 AM to 10:00 AM and 11:55 AM to 2:00 PM.

3. On 1/6/16 the clinical record of Pt #4 was reviewed. Pt #4 was a 26 year old male admitted on 12/9/15 to the Behavioral Health Unit (3 West) with diagnoses of schizophrenia, suicidal and homicidal ideation. Pt #4's clinical record lacked a physician's order for the restraint application for 12/11/15 and 12/15/15 from 8:45 AM to 10:00 AM.

4. On 1/6/16 at approximately 1:00 PM the findings were discussed with the Nurse Manager of the Behavioral Health Unit (E #1). E #1 stated Pt#4's chart did not contain a physician's order for the dates of 12/11/15 or 12/15/15 (8:45 AM to 10:00 AM). E #1 stated it was not clear if Pt #4 was actually in restraints on 12/15/15 at 8:45 AM due to the lack of required documentation.

Based on document review and interview it was determined that for 1 (Pt #4) of 2 clinical records reviewed for restraints, the Hospital failed to ensure the patient was evaluated within one hour after the application of restraint in accordance with policy.

Findings include:

1. Policy entitled "Use of Restraint and Seclusion (Revised 9/2013) indicated "For the Behavioral Health Units Only 4. Initial Evaluation A Physician LIP (Licensed Independent Practitioner), trained registered nurse or physician assistant, must see the patient face to face within one (1) hour after the initiation of Restraints or Seclusion to evaluate the patient."

2. On 1/6/16 the clinical record of Pt #4 was reviewed. Pt #4 was a 26 year old male admitted on 12/9/15 to the Behavioral Health Unit (3 West) with diagnoses of schizophrenia, suicidal and homicidal ideation. Pt #4's clinical record contained a physician's order dated 12/15/15 at 12:00 PM for seclusion and 4 point locked restraints. Pt #4's clinical record also contained a preprinted form titled "Assessment by LIP within One hour of Occurrence" dated 12/15/15 and signed by a LIP but lacked the time Pt #4 was assessed after the application of restraints.

3. On 1/6/16 at approximately 1:00 PM the findings were discussed with the Nurse Manager of the Behavioral Health Unit (E#1). E#1 stated patients are to be evaluated within an hour after the application of restraints. E #1 stated the document in Pt #4's clinical record failed to include the time the assessment occurred.