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Based on review of medical records and staff interview it was determined the hospital failed to ensure nursing performed a written modification to the patient's plan of care when employing the use of restraints in five (5) of five (5) medical records reviewed for restraints (#1A, 2, 6, 7 and 8). This has the potential to negatively affect patients by nursing not documenting the change in a patient's condition. Findings include:

1. Patient 1A was placed in bilateral wrist restraints on 1/20/10 and discontinued on 1/22/10. There was no written modification to the care plan.

2. Patient #2 was placed in bilateral wrist restraints on 9/22/10 and discontinued on 9/23/10. There was no written modification to the care plan.

3. Patient #6 was placed in bilateral wrist restraints on 1/16/10 and discontinued 1/17/10. There was no written modification to the plan of care.

4. Patient #7 was placed in bilateral wrist restraints on 12/16/10, discontinued on 12/17/10, reapplied on 12/19/10 and discontinued on 12/20/10. There was no written modification to the plan of care.

5. Patient #8 was placed in bilateral wrist restraints on 12/13/10 and discontinued on 12/14/10. There was no written modification to the plan of care.

6. These medical records were reviewed with the Nursing Director of the 8th floor, in the afternoon of 2/8/11 and the morning of 2/9/11 and she agreed with these findings.

Based on review of medical records and staff interview it was determined the hospital failed to ensure physicians are writing orders for medical/surgical restraints in three (3) of five (5) medical records reviewed for restraints (# 1A, 7 and 8). This has the potential to negatively affect patients by the inappropriate use of restraints. Findings include:

1. Patient #1A was placed in bilateral wrist restraints on 1/20/10 and they were discontinued on 1/22/10. There were no physician orders for the use of restraints.

2. Patient #7 was placed in bilateral wrist restraints on 12/16/10 and they were removed on 12/17/10. There was no physician order for the use of restraints.

3. Patient #8 was placed in bilateral wrist restraints on 12/13/10 and they were removed on 12/14/10. There was no physician order for the use of restraints.

4. These medical records were reviewed with the Nursing Director of the 8th floor, in the morning of 2/9/11 and she agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing developed and kept current a nursing care plan in eleven (11) of eleven (11) medical records reviewed (#1A,1B, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This has the potential to negatively affect all patient care needs by not developing appropriate nursing interventions in response to those needs. Findings include:

1. Hospital policy titled Plan Of Care (Initiation), last reviewed/revised 01/08, states in part: "Biophysical assessments and routine patient care are documented on the daily patient care record."

2. Patient #1A was admitted to the hospital on 1/20/10 and discharged on 1/29/10. There was no care plan found in the medical record.

3. Patient #1B was admitted to the hospital on 2/5/10 and discharged on 3/2/10. There was no care plan found in the medical record.

4. Patient #2 was admitted to the hospital on 9/22/10 and discharged on 9/28/10. There was no care plan found in the medical record.

5. Patient #3 was admitted to the hospital on 11/29/10 and discharged on 12/6/10. There was no care plan found in the medical record.

6. Patient #4 was admitted to the hospital on 5/10/10 and discharged on 5/20/10. There was no care plan found in the medical record.

7. Patient #5 was admitted to the hospital on 11/30/10 and discharged on 12/6/10. There was no care plan found in the medical record.

8. Patient #6 was admitted to the hospital on 1/13/10 and discharged on 2/1/10. There was no care plan found in the medical record.

9. Patient #7 was admitted to the hospital on 12/16/10 and discharged on 12/29/10. There was no care plan found in the medical record.

10. Patient #8 was admitted to the hospital on 12/13/10 and discharged on 12/20/10. There was no care plan found in the medical record.

11. Patient #9 was admitted to the hospital on 1/27/10 and discharged on 2/8/10. There was no care plan found in the medical record.

12. Patient #10 was admitted to the hospital on 1/19/10 and discharged on 1/26/10. There was no care plan found in the medical record.

13. During an interview conducted with the Director of the 8th floor in the afternoon of 2/8/11 and the morning of 2/9/11, she agreed with these findings. She also revealed there are "grease" boards in each patient care room and nursing is to write an intervention daily and staff then can work towards achieving a goal for the day. At the end of each shift, nursing then documents in the electronic medical record whether the patient achieved the goal for the day or not. She related the reasoning was, the 'grease boards' gave the patient and their families more opportunities to be involved in the care each day.