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Based on interview, record review, and facility policy review, it was determined the facility failed to ensure an order for a restraint for one (1) of thirty (30) sampled patients (Patient #24) was obtained immediately after application of the restraint.

The findings include:

Review of the facility's policy titled, "Use of Restraints", with an effective date of 08/15/11, revealed if circumstances warranted, restraints could be implemented for the protection of the patient without immediately obtaining a Physician's Order, so long as an order was obtained as soon as practical thereafter, no later than eight (8) hours after the intervention was implemented.

Review of Patient #24's medical record revealed an admission date of 08/01/12, and admission diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD). Review of the Nurse's Assessment form dated 08/04/12, timed 6:38 AM revealed the nurse documented Patient #24 was disoriented, unable to follow commands, and was removing medical devices. At 7:00 AM the nurse documented soft wrist restraints were applied.

Review of the Physician's Orders revealed no documented evidence an order for the restraints was obtained within eight (8) hours as per facility policy. Further review of the Physician's Orders revealed an order for the restraints was obtained on 08/04/12 at 8:30 PM, thirteen (13) and a half hours after the restraints were applied.

Interview, on 08/17/12 at 9:00 AM, with the Vice President of Quality and Resource Management revealed telephone/verbal orders for restraints should be obtained within eight (8) hours of the application of the restraint.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each order for a restraint was renewed as authorized by hospital policy, for one (1) of thirty (30) sampled patients.

The findings include:

Review of the facility's policy titled "Use of Restraints", dated 08/15/11, revealed a restraint order was "time limited to a maximum of twenty-four (24) hours for restraints applied for medical and post-surgical management".

Clinical Record review revealed the facility admitted Patient #21 on 08/09/12 with diagnoses which included Chronic Obstructive Pulmonary Disease, Pneumonia and Respiratory Failure. Review of the Physician's order, dated 08/10/12, revealed the patient required bilateral upper extremity restraints for protection of tubes used for medical management of the patient's condition. Continued review revealed no subsequent Physician order for the restraints until 08/12/12, forty-eight (48) hours later.

During interview, on 08/16/12 at 3:50 PM, Registered Nurse (RN) #8 confirmed there was no re-order for the restraints on 08/11/12. He stated there should have been an order given on 08/11/12, or every twenty-four (24) hours per hospital policy.

Interview with the Unit Manager, on 08/16/12 at 3:55 PM, revealed there should have been a restraint re-order provided on 08/11/12. A review of written and computer-generated orders confirmed no re-order for restraints was given on 08/11/12. She verified hospital policy mandated a new order be obtained every twenty-four (24) hours.

Interview with the Director of Critical Care, on 08/17/12 at 2:09 PM, revealed restraint orders were time-limited to twenty-four (24) hours and a new order had to be obtained daily.

Based on interview, record review, and the facility's policy review, it was determined the facility failed to ensure Physicians reviewed and authenticated telephone verbal orders in accordance with facility policy for two (2) of thirty (30) sampled patients (Patients #7 and #24).

The findings include:

1. Review of the facility policy titled, "Use of Restraints", with an effective date of 08/15/11, revealed verbal/telephone orders for restraints should be authenticated by signature of the Physician within twenty-four (24) hours.

Review of Patient #24's medical record revealed an admission date of 08/01/12, and admission diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD). Review of the Physician's Orders revealed a telephone/verbal order dated 08/05/12, timed 8:30 PM for soft wrist restraints times twenty-four (24) hours to prevent patient from pulling tubes out. Continued review of the order, on 08/17/12, revealed no documented evidence the Physician had reviewed and authenticated the 08/05/12 telephone/verbal order for the restraint.

Additionally, review revealed a telephone/verbal order dated 08/04/12 for bilateral soft wrist restraints times twenty-four (24) hours to keep the patient from removing medical equipment which was not authenticated by the Physician until 08/06/12.

Interview, on 08/17/12 at 2:09 PM, with the Director of Critical Care Services revealed Physicians should sign telephone/verbal order for restraints within twenty-four (24) hours per facility policy.

2. Review of the facility's policy titled "Orders for Medications, Treatments, and Procedures", with an effective date of 07/08/10, revealed the practitioner who issued the order or the attending Physician authenticates verbal orders within forty-eight (48) hours.

Further review of Patient #24's medical revealed telephone/verbal orders, dated 08/01/12 and 08/09/12, that had not been signed by the Physician as of 08/17/12. In addition, review of the Physician's Orders revealed orders not signed within forty-eight (48) hours which included an order dated 08/04/12 timed 12:01 PM that was not signed by the Physician until 08/07/12; orders dated 08/04 timed 3:50 AM, 4:00 AM, 4:26 AM, 5:35 AM, 6:05 AM, and 6:35 AM that revealed the Physician electronically signed the orders on 08/16/12; an order dated 08/09/12 timed 3:30 PM that was signed by the Physician on 08/15/12; an order dated 08/10/12 timed 6:49 AM that was not signed by the Physician until 08/14/12; and orders dated 08/11/12 timed 6:49 AM, 7:12 AM, 7:30 AM, 10:47 AM, that revealed the Physician had electronically signed the orders on 08/14/12. Review of an additional order dated 08/11/12 timed 1:05 PM was not signed by the Physician until 08/15/12.

3. Review of Patient #7's medical record revealed an Admission date of 08/09/12, and admission diagnoses of Ileostomy. Further review revealed telephone/verbal orders dated 08/10/12 and 08/11/12 that had not been signed by the physician as of 08/16/12.

Interview, on 08/17/12 at 2:09 PM, with the Director of Critical Care Services revealed telephone/verbal orders should be signed within forty-eight (48) hours as per the facility's policy.