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Based on review of clinical records it was determined the Facility failed to ensure physician orders were obtained for restraints for two (#7 and #8) of four (#7-10) restrained patients. Failure to obtain physician orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patients #7 and #8 on the day of survey. Findings follow:

A. Review of the clinical record for Patient #7 revealed he was restrained without physician orders from 0835 on 11/15/12 through 1029 on 11/15/12, from 0841 on 11/17/12 through 12/14 on 11/17/12 and from 1214 on 11/18/12 through 1835 on 11/18/12.

B. Review of the clinical record for Patient #8 revealed he was restrained without physician orders from 2050 on 11/16/12 through 0124 on 11/17/12 and from 0027 on 11/20/12 through 0647 on 11/21/12.

C. The above findings were verified by the Director of Quality Programs for Nursing at 1100 on 11/21/12.

Based on review of policy and procedures, interview and clinical record review it was determined the Facility failed to monitor one (#10) of four (#7-10) restrained patients as required by Facility policy and procedure numbered MS.4.06 and titled Restraints and Seclusion. Failure to monitor and assess restrained patients every two hours per Facility policy and procedure had the potential to allow patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible. The failed practice affected one (#10) current patient 11/21/12. Findings follow:

A. Review of the clinical record of Patient #10 revealed physician's orders for restraints at 0312 on 11/20/12. Review of the Intensive Care Restraint Flowsheet dated 11/20/12 revealed no documentation of restraint monitoring by nursing staff from 1400 through 1900 on 11/20/12. Further review of Patient #10's clinical record revealed Patient #10 was not released from restraints or off the unit during that time period.

B. The above findings were verified by the Director of Quality Programs for Nursing at 1100 on 11/21/12.

Based on clinical record review, policy and procedure review and interview it was determined that six (#1-6) of six (#1-6) patients who underwent operative procedures contained operative reports that did not contain the time of surgery. Review of the policy and procedure titled "Medical Record Documentation Requirements" revealed the policy and procedure did not contain any elements requiring time of surgery to be placed in the operative report. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. The failed practice affected patients #1-6 and all patients who have undergone surgical procedures at the Facility. Findings follow:

A. Review of eight operative reports for six (#1-6) patients revealed the operative reports did not contain the time the surgical procedure was performed. (Patient #2 and #5 had two operative reports in the clinical record.)

B. Review of the "Medical Record Documentation Requirements" revealed the policy and procedure did not contain any elements requiring time of surgery to be placed in the operative report.

C. The above findings were verified by the Director of Coding/Interim Director of Medical Records at 1335 on 11/21/12.