HospitalInspections.org

Based on policy review, medical record review and staff interview it was determined the facility failed to ensure verbal/telephone orders for restraint/seclusion were authenticated by the physician in four (4) of seven (7) patients who were ordered restraints/seclusion (patients #1, 2, 5 and 11). This failure has the potential to negatively impact patient safety for all patients who are placed in restraint/seclusion at the facility.

Findings include:

1. Review of the hospital policy entitled "Seclusion and Restraint", last revised 4/25/17, revealed it states, in part: "The physician must also "authenticate" a telephone restraint/seclusion order by signing, dating and timing the order."

2. A review of the medical record for patient #1 revealed orders for restraint/seclusion were not authenticated by the physician for 1/7 and 1/10/17.

3. A review of the medical record for patient #2 revealed orders for restraint/seclusion were not authenticated by the physician for 4/11, 4/29, 5/10 and 5/22/17.

4. A review of the medical record for patient #5 revealed orders for restraint/seclusion were not authenticated by the physician for 2/4, 2/5, 2/18, 2/24 and 3/20/17.

5. A review of the medical record for patient #11 revealed orders for restraint/seclusion were not authenticated by the physician for 1/7/17.

6. The above findings were reviewed with the Director of Nursing during an interview on 7/11/17 at 3:08 p.m. and she agreed with the findings.