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Based on observation, interview and record review, it was determined the facility failed to ensure an initial comprehensive individualized assessment for restraints was completed for one (1) of ten (10) sampled patients, Patient #3. In addition the facility failed to document on-going assessment required for restraints for two (2) of ten (10) patients, Patients #3 and #4.

The findings include:

Review of the hospital's Policy on Restraints and Seclusion, effective 04/01/11, revealed restraint use was limited to those situations where there was appropriate clinical justification based on a comprehensive assessment. A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint outweighed the risk of not using it. The Restraint Policy also specified the orders for restraints must contain the specific time limits, type of restraint, reason for the restraint, date and time of order.

Observation of Patient (PT) #3, at 07/03/12 at 10:47 AM, and PT #4, on 07/03/12 at 3:15 PM, revealed both patients were wearing soft wrist restraints on both wrists.

1. Record review of PT #3's record revealed there was no individualized comprehensive assessment completed for the initiation of PT #3's restraints on 07/02/12.

Interview with Registered Nurse (RN) #7, on 07/03/12 at 2:24 PM, revealed there was an initial assessment to be completed prior to the application of restraints. Staff were to document what type of interventions were tried before restraints were applied. RN #7 stated she could remember PT #3 having some withdrawals, being difficult to sedate and very agitated.

Interview with the Assistant Nurse Manager, on 07/03/12 at 2:34 PM, revealed the night shift nurse did not document an initial restraint assessment and should have been documented.

2. Record review of PT #3's restraint orders, revealed on day 07/02/12 and 07/03/12, the reason for the restraint was not documented.

Record review of PT #4's restraint order for the day of 07/02/12, revealed the reason for the restraint was not documented.

Interview with RN #8, on 07/03/12 at 3:38 PM, revealed she did not check on the restraint order or the reason for the restraint. RN #8 stated there must be a reason documented on the order for the use of the restraint. She further stated the order for the restraint was not complete.

Interview with RN #7, on 07/03/12 at 2:34 PM, revealed she felt the orders were not complete, as the reason for the application of the restraint was not documented on the order.

Interview with the Assistant Unit Manager, on 07/03/12 at 2:34 PM, revealed she was the one who took the restraint order for PT #3. The Assistant Unit Manager stated the checks were already present on the restraint order sheet when she signed off on the order. She should of made sure the order was completed. The Assistant Unit Manager stated she could not place restraints on just any patient, there has to be a reason for applying a restraint on a patient. She further stated she was ultimately responsible to make sure the nurses were completing documents as ordered.

Interview with Doctor (DR) #1, on 07/03/12 at 2:47 PM, revealed he always looked at the order before he signed off on the orders. DR #1 stated he did not notice the restraint indications were not completed. He further stated he did not place the check marks on the order and there had to be a reason for applying restraints documented.

Interview with the Chief Nursing Officer, on 07/03/12 at 4:39 PM, revealed Managers were responsible for the process of making sure the orders were being completed by the nursing staff. The Chief Nursing Officer further stated nurses should document why the patients were restrained, this was part of the requirement for writing restraint orders.