HospitalInspections.org

Based on a review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that orders were written for the use of restraints for two of three medical records reviewed (MR1 and MR 2).

Findings include:

A review of the facility's "Non Violent/Non Self-Destructive Restraint Use" policy, last reviewed June 2012, revealed "... II Policy: Based on the assessed needs of the patient and after exhausting other options, restraints may be applied according to the process outlined in this procedure. A restraint order must be obtained prior to the application of the restraints. In some situations, the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application of the restraint. In this situation, the order must be obtained during the application or immediately (without time interval) after the restraint has been applied. If the attending physician is not available, an order is obtained from the covering physician, PA, or CRNP ... A Physician Order - 1. Type of restraints(i.e. soft, locked). 2. Must be signed, dated and timed daily. 3. Reason for application - cannot just state "patient safety". 4. Physician verbal or written order documented on Restraint Order form or CPOE will be accepted. 5. Specified Professional Personnel (SPP) (Certified Registered Nurse Practitioner, (CRNP)Physician Assistant (PA), Certified Nurse Midwife (CNM) may communicate a restraint order from their responsible physician and specify the name of the ordering physician who will then co-sign the order within 24 hours ..."

A review on July 23, 2014, of MR1 revealed that the patient was placed in bilateral soft wrist restraints for non-violent behavior on May 28, 2014, at 2200 until May 29, 2014, at 0001. Further review of the medical record revealed no documentation of physician's orders for restraint usage.

A review on July 23, 2014, of MR2 revealed that the patient was placed in bilateral soft wrist restraints for non-violent behavior on January 10, 2014, at 2000 until January 11, 2014, at 0600. Further review of the medical record revealed no documentation of physician's orders for restraint usage.

An interview conducted on July 23, 2014, at 3:00 PM with EMP2 confirmed that no physician order was obtained to initiate the use of the physical restraints for MR1 and MR2