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Based on record review and interview patient care staff placed the index patient in restraints without an order from medical staff.

Findings:

-Review of the medical record completed on 6/7/2021 revealed the patient was placed in restraints on 9/13/2020 at approximately 2151. There was no order in the medical record from a physician or other medical provider for restraint.

-Review of hospital policy entitled "Restraints" (last revision 5/30/2018) on 6/9/2021 revealed that the use of a restraint requires a Physician/Provider order. The orders for restraint application must include clinical justification, type of restraint device, duration of restraint and date and time of physician/provider signature.

-The hospital's Accreditation and Regulatory Coordinator confirmed on interview on 6/9/2021 at 3:45 PM
that a physician/provider order was not obtained for the index patient.

Based on medical record review and interview patient care staff failed to document on going assessment and monitoring of the index patient during the time the patient was in restraints (9/13/2020 from 2151 to 2358).

-The patient's medical record lacked a completed patient restraint flowsheet, that would indicate restraints were used/required for this timeframe and that the patient was safe.

-Review of hospital policy entitled "Restraints" (last revision 5/30/2018) on 6/9/2021 revealed that patient care staff will demonstrate, through their documentation in the patient's health record, that the restraint intervention used is the least restrictive intervention that protects the patient's safety and that the use of restraint is based on individual assessments of the patient. Assessments and documentation of these assessments are ongoing, in order to demonstrate a continued need for restraint.

-The Regulatory affairs coordinator stated on interview on 6/9/2021 at 3:45 pm that there was no patient restraint flowsheet in the medical record and could not verify that one was completed.

Based on record review and interview, the facility did not ensure that a face-to-face evaluation was completed in accordance with facility policy. Not completing a face to face evaluation could compromise patient and staff safety.

Findings include:
Review on 6/9/2021 of policy "Restraints" (last revision 5/30/2018) revealed that a physician is to evaluate the patient within one hour of the initiation of the restraints. The Physician/Provider needs to complete a comprehensive assessment, including a physical assessment to identify medical conditions that may be causing behavior changes in the patient.

Medical record review on 6/7/2021 revealed no documentation to indicate that a physician conducted a face to face evaluation within one hour or at anytime of the application of 4-point restraints for the index patient on 9/13/2020.

Interview on 6/9/2021 at 3:45 pm with the facility's Accreditation and Regulatory Coordinator confirmed the above findings.

Based on Medical record review, it was determined that the facility did not ensure the medical record was accurate and complete.

Findings include:

On 9/13/2020, a urine toxicology was ordered. There was no test result in the record or documentation why this test was not obtained.