HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP) it was determined that the facility failed to obtain a renewal order for the use of restraints for four of 10 medical records reviewed (MR1, MR2, MR3 and MR9).

Findings include:

Review of "Restraint and Seclusion Date: May 30, 2011" revealed "VIII. Use of Restraints for Non Violent/Non Self-Destructive Behavior ... A. Physician's order (written/computerized provider order entry or 'CPOE') A physician order is required for restraint use. ... 4. Orders for use of restraints for Non-Violent or Non Self-Destructive patients are renewed every calendar day."

1) Review of MR1 revealed that the patient was in restraints on August 20, 2011, at 3:28 AM. Further review of MR1 revealed that the next documented time that the patient was in restraints was on August 20, 2011, at 3:28 PM, and continued to remain in restraints until 11:28 PM. Additional review of MR1 revealed no documented evidence of a physician's order for the restraints, for the calendar day of August 20, 2011.

2) Review of MR2 revealed that the patient was in restraints from August 20 to September 7, 2011. Further review of MR2 revealed no documented evidence of a physician's order for the restraints, for the calendar days of September 3 and September 5, 2011.

3) Review of MR3 revealed that the patient was in restraints from August 14 to August 22, 2011. Further review of MR3 revealed no documented evidence of a physician's order for the restraints, for the calendar days of August 18, 20, 21, and 22, 2011.

4) Review of MR9 reveled that the patient was in restraints from August 29 to August 30, 2011. Further review of MR9 revealed no documented evidence of a physician's order for the restraints, for the calendar day of August 30, 2011.

5) Interview with EMP1 on September 14, 2011, at approximately 12:20 PM confirmed the above findings and revealed "No, there are missing orders."