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Based on medical record review and staff interview, the hospital failed to ensure a physician's order was obtained for the application of restraints. This affected one of ten medical records reviewed, (Patient #2).

Findings included;

The medical record for Patient #2 was reviewed on 12/29/10. The medical record revealed the patient was placed in two point restraints on 09/17/10. The documentation of the restraint lacked information regarding what limbs the restraints were applied or the time of application. The restraint order form was completed, also with no time, but lacked signature of the ordering physician. This information was verified with hospital administrative staff at the time of exit on 12/29/10 at 2:00 P.M.

Based on medical record review and staff interview, the hospital failed to ensure physicians followed the medical staff bylaws and dated and timed all entries in the medical record. This affected one of ten medical records reviewed, (Patient #10).

Findings included:

The medical record for Patient #10 was reviewed on 12/28/10 and 12/29/10. The medical record revealed the patient was admitted to the hospital on 09/03/10 for appendicitis. The patient was subsequently taken to the operating room and an appendectomy was performed. The medical record contained evidence of physician's orders to transfer the patient to the recovery room after surgery. The entry also contained orders for the patient's medications, diet and intravenous fluids. The medical record contained evidence of a physician's order to transfer the patient to "floor" on 09/04/10. The order lacked documentation of the time of the order by the physician. Further review of the medical record contained evidence of an order for narcotic pain medication, bladder scan and insertion of a Foley catheter. The order lacked documentation of the date the order was given by the physician.

The medical staff rules and regulations, rule number 2.01.06 was reviewed. The rule stated; "Documentation must be dated, time, and signed by the attending physician." These findings were confirmed with Employee A on 12/29/10 at 1:30 P.M.