HospitalInspections.org

21893

Based on medical record review, staff interview, and review of the Medical Staff Rules and Regulations; the facility failed to ensure all verbal orders for restraints were signed by the physician within 24 hours. This affected one of six medical records reviewed with restraint usage (Patient 5). A total of six medical records were reviewed.

Findings include:

The medical record for Patient 5 was reviewed on 03/07/13. The patient was admitted on 02/22/13. The medical record contained an order dated 03/01/13 at 1:33 AM for soft wrist restraints and side rails up times four. The medical record contained an order dated 03/02/13 at 8:47 PM for a vest restraint and side rails up times four. The medical record contained an order dated 03/03/13 at 03:55 AM for a vest restraint, soft wrist restraints, and side rails up times four. The medical record contained an order dated 03/05/13 at 6:22 AM for a vest restraint, soft wrist restraints, and side rails up times four. These four orders lacked a physician's signature or authentication as of the morning of 03/07/13. This was verified by Staff A at the time of the record review.

The Medical Staff Rules and Regulations were reviewed on 03/07/13. The Rules and Regulations stated that orders for restraints must be signed or authenticated by the responsible physician within one day.

This is a Re-Cite.