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Based on record review and interview, the hospital failed to provide documented evidence to indicate the use of physical restraints was necessary while providing patient care to 1 of 5 patients (Patient #2) whose medical record was reviewed for restraint use. This was evidenced by the treatment team members failure to document Patient #2's condition and/or symptomatology that warranted the use of physical restraints and failure to document the times that Patient #2 was placed in physical restraints and the times that Patient #2 was taken out of restraints. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was admitted to the hospital's rehabilitation unit on 8/05/10. Review of the admission orders dated 8/05/10 revealed that Patient #2's diagnoses included right hemorrhagic CVA, left hemiparesis, decreased ADL's, impaired functional mobility, dysphagia, GERD, hyperlipidemia, and respiratory insufficiency.

Review of the medical record revealed Patient #2 was placed in physical restraints (Posey Vest) on 8/08/10, 8/09/10, 8/10/10, 8/11/10, 8/12/10, 8/13/10, 8/14/10, 8/15/10, 8/16/10, 8/17/10, 8/18/10 & 8/19/10.
? Review of the medical record revealed restraint orders dated 8/08/10 at 8:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/08/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/08/10.
? Review of the medical record revealed restraint orders dated 8/09/10 at 12:00 noon for a Vest to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/09/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/09/10.
? Review of the medical record revealed restraint orders dated 8/10/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/10/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/10/10.
? Review of the medical record revealed restraint orders dated 8/11/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/11/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/11/10.
? Review of the medical record revealed restraint orders dated 8/12/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/12/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/12/10.
? Review of the medical record revealed restraint orders dated 8/13/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/13/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/13/10.
? Review of the medical record revealed restraint orders dated 8/14/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/14/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/14/10.
? Review of the medical record revealed restraint orders dated 8/15/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/15/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/15/10.
? Review of the medical record revealed restraint orders dated 8/16/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/16/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/16/10.
? Review of the medical record revealed restraint orders dated 8/17/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/17/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/17/10.
? Review of the medical record revealed restraint orders dated 8/18/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/18/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/18/10.
? Review of the medical record revealed restraint orders dated 8/19/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation in the medical record to justify the use of physical restraints as the documentation failed to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints on 8/19/10. In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/19/10.

In an interview on 9/03/10 at 1:00 p.m., S3 (RN Patient Care Manager) reviewed the medical record of Patient #2 and confirmed that the medical record failed to contain documentation to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints and failed to contain documentation to indicate the times that Patient #2 was placed in physical restraints and/or the times of restraint removal.

S4 (Registered Nurse) was interviewed on 9/03/10 at 12:15 p.m. S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that she works primarily as the day shift rehabilitation unit charge nurse and stated that she was familiar with Patient #2. S4 reported that Patient #2 had had a stroke and was admitted to the rehabilitation unit on 8/05/10 for rehabilitative services. S4 reported that Patient #2 was alert with poor recall and confusion. S4 explained that Patient #2 was unable to remember safety instructions due to her confusion and poor recall. S4 reported that Patient #2 had left sided weakness and was unable to transfer independently. S4 reported that Patient #2 was initially placed in a Posey vest restraint on 8/08/10 at 8:00 a.m. S4 reported that Patient #2 was placed in a Posey vest restraint while in her wheelchair and was not in a Posey vest restraint while in bed. S4 reported that the Posey vest restraint was used for safety as Patient #2 was at a high risk of falls due to her poor recall of safety instructions and her left sided weakness. S4 reported that Patient #2 had fallen on 8/07/10 and was seen attempting to get out of her chair on multiple occasions despite staff members instructing her to remain in chair for safety. S4 confirmed that the rationale for the use of restraints including Patient #2's behavior that would warrant the use of restraints was not documented in the medical record. S4 also confirmed that the documentation did not include the times the restraints were put on Patient #2 or the times the restraints were taken off Patient #2.

S9 (Registered Nurse) was interviewed on 9/07/10 at 11:45 a.m. S9 reviewed the medical record of Patient #2 and reported that she did remember the patient. S9 reported that she was the nurse who admitted Patient #2 to the rehabilitation unit on 8/05/10. S9 indicated that Patient #2 was impulsive, had a poor memory and had left sided hemiparesis. S9 reported that she was the nurse who initially placed Patient #2 in a Posey vest on 8/08/10 at 8:00 a.m. S9 reported that she had witnessed Patient #2 attempting to get out of her wheelchair without assistance on several occasions on 8/08/10 and stated that she caught her (Patient #2) before falling each time prior to obtaining the order for the restraints on 8/08/10. S9 reported that Patient #2 could not maintain her balance due to her left sided weakness and would fall over sideways when attempting to get out of the wheelchair. S9 reported that Patient #2 was placed in restraints for safety as she was at an increased risk of falling due to her impulsivity, poor recall of safety instructions, and left sided weakness. S9 reported that the restraints were used only when Patient #2 was in her wheelchair. S9 reported that Patient #2 was not in restraints while in bed. S9 reviewed the medical record and confirmed that the rationale for the use of restraints including Patient #2's behavior that would warrant the use of restraints was not documented in the medical record. S9 also confirmed that the documentation did not include the times the restraints were put on Patient #2 or the times the restraints were taken off Patient #2.

The hospital's policy/procedure titled "Restraints" was reviewed. The policy/procedure documents "Restraints are used for medical/post-surgical management or behavioral management of patients if the use of these interventions is clinically appropriate and adequately justified and documented, and when less restrictive alternative measures are ineffective". The policy/procedure also documents that the documentation is to include "The patient's condition or symptom (s) that warranted the use of restraint or seclusion" and "The patient's response to the intervention(s) used, including the rationale for continued use of the intervention".

Based on record review and interview, the hospital failed to ensure that restraint orders were carried out as written in the medical record for 1 of 5 sampled patients. This was evidenced by the treatment team members failure to ensure that the restraint order was clearly written to indicate when the patient was to be placed in a physical restraint. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was admitted to the hospital's rehabilitation unit on 8/05/10. Review of the admission orders dated 8/05/10 revealed that Patient #2's diagnoses included right hemorrhagic CVA, left hemiparesis, decreased ADL's, impaired functional mobility, dysphagia, GERD, hyperlipidemia, and respiratory insufficiency. This review revealed that Patient #2 was placed in a posey restraint for safety while in her wheelchair from 8/08/10 thru 8/19/10.

S6 (Attending Physician) was interviewed on 9/07/10 at 10:00 a.m. S6 reported that she was Patient #2's attending physician during her hospitalization on the rehabilitation unit. S6 reported that Patient #2 had a right sided hemorrhagic stroke which left her with left sided weakness and cognitive impairment. S6 indicated that Patient #2 was verbal and could answer questions. S6 indicated that Patient #2 did have some confusion and memory impairment. S6 reported that restraints were ordered to be used on Patient #2 for safety purposes as Patient #2 was assessed to be a high risk for falls. S6 indicated the intent of her restraint orders were to place Patient #2 in a Posey vest while in her wheelchair and not while in bed. S6 explained that the Posey vest was used to prevent Patient #2 from falling from her wheelchair. S6 reported that Patient #2 would not always remember her physical limitations and the treatment team members were concerned that she (Patient #2) would be injured from a fall if not restrained to the wheelchair. S6 reported that the restraints were not used while Patient #2 was in bed.

Review of the medical record revealed Patient #2 was placed in physical restraints (Posey Vest) on 8/08/10, 8/09/10, 8/10/10, 8/11/10, 8/12/10, 8/13/10, 8/14/10, 8/15/10, 8/16/10, 8/17/10, 8/18/10 & 8/19/10.
? Review of the medical record revealed restraint orders dated 8/08/10 at 8:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/08/10.
? Review of the medical record revealed restraint orders dated 8/09/10 at 12:00 noon for a Vest to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/09/10.
? Review of the medical record revealed restraint orders dated 8/10/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/10/10.
? Review of the medical record revealed restraint orders dated 8/11/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/11/10.
? Review of the medical record revealed restraint orders dated 8/12/10 at 6:00 a.m. for a Vest to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/12/10.
? Review of the medical record revealed restraint orders dated 8/13/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/13/10.
? Review of the medical record revealed restraint orders dated 8/14/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/14/10.
? Review of the medical record revealed restraint orders dated 8/15/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/15/10.
? Review of the medical record revealed restraint orders dated 8/16/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/16/10.
? Review of the medical record revealed restraint orders dated 8/17/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/17/10.
? Review of the medical record revealed restraint orders dated 8/18/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/18/10.
? Review of the medical record revealed restraint orders dated 8/19/10 at 6:00 a.m. for a Vest and Waist Belt to be used on Patient #2. There was no documentation on the order to indicate that the restraint was to be used only when the patient was in her wheelchair as reported by the patient's attending physician (S6). In addition, there was no documentation to indicate the time Patient #2 was placed in physical restraints or the time of restraint removal on 8/19/10.

In an interview on 9/03/10 at 1:00 p.m., S3 (RN Patient Care Manager) reviewed the medical record of Patient #2 and confirmed that the medical record failed to contain documentation to identify specific behavior that Patient #2 was exhibiting that would require the use of physical restraints and failed to contain documentation to indicate the times that Patient #2 was placed in physical restraints and/or the times of restraint removal. S3 reported that Patient #2 was placed in restraints while in her wheelchair only and not while in bed. S3 reviewed the restraint order and reported that the restraint order did not indicate that the patient should only be in restraints while in wheelchair. S3 confirmed that the order should have been clarified to indicate that the restraints were only to be used while the patient was in her wheelchair.