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Based on staff interviews, medical record reviews and review of restraint policy, the facility failed to ensure restraints were used with the order of a physician in accordance with facility policy. This affected three of four patients (Patients #8, #10 and #4) reviewed with non violent safety restraints. The current census was 124 patients.

Findings include:

Review of the facility policy titled "Restraint Policy", last reviewed 05/17, revealed the following on 11/02/17: Non Violent Safety Restraints, Ordering of restraint for non violent/safety. Orders obtained to address a patient's medical care related needs (safety) that are evidenced by non violent or not destructive behavior are considered in full force and effect up to one calendar day. Which includes the day the order was obtained. If a patient remains in restraint for more than one calendar day, then a new order must be obtained.
If a restraint is discontinued prior to the expiration to the original order a new order must be obtained prior to reinitiating the use of restraint.

1. Patient #8's medical record review was completed with Staff C and Staff E on 11/02/17. This record review revealed the patient was placed in bilateral soft wrist restraints on 10/29/17 through 11/02/17 to prevent pulling out the ventilator tube and medical lines.

The physician's (Staff F) order on 10/31/17 at 6:52 AM revealed a four hour duration order for kicking and hitting. Staff F also ordered the bilateral soft wrist restraints on 11/01/17 at 4:34 AM for a four hour duration, and on 11/02/17 at 4:04 AM a four hour duration.

Per the medical record review, the patient was placed continuously in the bilateral wrist restraints on 10/31/17 through 11/02/17 at 10:00 AM (at the time of the medical record review) after the daily physician's orders had expired each day.

This was confirmed with Staff C and Staff E during the medical record review. Both staff stated the physician's order for the non violent restraints should have been ordered for 24 hours and not a four hour duration. Both staff confirmed the nursing staff who reviewed the orders and provided care for the patient on 10/31/17 through 11/02/17 should have clarified the physician's non violent restraints orders from four hours to 24 hours per facility policy.

2. Patient #10's medical record review was completed with Staff C and Staff E on 11/02/17. This record review revealed a physicians's order by Staff F on 11/01/17 at 10:25 PM for non violent bilateral wrist restraints to prevent pulling tubes and lines. The physician ordered the restraints for an eight hour duration at the time the patient was intubated. The next physician's order for the bilateral wrist restraints was on 11/02/17 at 7:26 AM. The medical record review revealed Patient #10 remained in the restraints after the physician's order expired on 11/02/17 at 6:25 AM until re-ordered at 7:26 AM.

At the time of the medical record review, Staff C and Staff E confirmed the restraints were used without a physician's order on 11/02/17 for Patient #10.

3. Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 10/31/17 with diagnoses of attempted suicide by carbon monoxide poisoning. The patient presented at the facility's emergency department and was intubated (tube inserted into throat) and placed on mechanical ventilation (breathing machine). The physician's order directed Patient #4 to be placed in four point soft restraints due to the patient's history of attempting to pull out the endotracheal tube as well as other medical equipment used to care for the patient.

Review of the physician's order written by Staff F revealed the order was initiated on 10/31/17 at 11:30 PM for six hours or until 5:30 AM. Review of the medical record revealed the patient remained in four point soft limb restraints (both upper and lower restraints) until 11/01/17 at 9:16 AM when a new order was received. Patient #4 remained restrained for approximately 3.75 hours without a physician's order.

This finding was confirmed in interview with Staff E on 11/02/17 at 1:41 PM.




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