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Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that verbal / telephone orders for restraints contained the name of the ordering physician for 1 of 3 (#1) selected medical records.

Findings were:

Review of medical record #1 revealed the patient was in restraints a total of 48 days. On hospital days #5, 7, 8, 9, 10, 14, 15, 18, 20, 29, 30, 31, 32, 33, 34, 35, 38, 43, 45, and 46 the nurses had obtained a verbal / telephone order but had failed to document the ordering physician's name.

Review of the facility's policy entitled "Restraints (Limitation of Movement", policy number AD3.31, last reviewed 01/10, revealed verbal orders were to contain the name of the ordering physician.

On 02/06/13 at 10:00 a.m. in the Conference Room, the Director of the Critical Care Unit and the Progressive Care Unit (interview #1), the CNO (interview #4), and the Quality Director (interview #7 reviewed the above restraint orders and confirmed that the nurses failed to document the ordering physician's name.