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Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to ensure a physician's order was obtained for restraints for three (#17-#19) of seven (#14-#20) patients in restraints. Failure to obtain physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints. The failed practice had the potential to affect any patient in restraints. Findings included:

A. Record review of the facility's policy titled "Restraints and Seclusion Policy," with a revision date of 04/26/16 showed the physician responsible for the care of the patient was authorized to order a restraint. Physicians were the only licensed independent practitioners allowed to order restraint or seclusion. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 10:55 AM.
B. Record review of Patient #17's clinical record on 10/26/17 showed the patient was in restraints on 09/11/17 from 10:15 PM to 11:14 PM. There was no evidence a physician ordered the use of restraints. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 10:55 AM.
C. Record review of Patient #18's clinical record on 10/26/17 showed the patient was in restraints on 09/17/17 from 4:00 PM to 6:42 PM. There was no evidence a physician ordered the restraints. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 11:15 AM.
D. Record review of Patient #19's clinical record on 10/26/17 showed the patient was in restraints on 10/01/17 from 8:55 AM to 11:11 AM. There was no evidence a physician ordered the restraints. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 11:25 AM.

Based on policy and procedure review and interview, it was determined the facility failed to ensure physicians who ordered restraint application had evidence of a working knowledge of the facility's policy and procedure regarding the use of restraints for four of four (#1-#4) physicians reviewed. The failed practice did not ensure the physician's were followed the facility's established policy and procedure regarding the use of restraints. The failed practice had the potential to affect any patient in restraints. Findings included:

A. Record review of the facility's policy titled, "Restraints and Seclusion Policy," with a revision date of 04/26/16 showed physicians authorized to order restraint and seclusion must have a working knowledge of hospital policy regarding restraint and seclusion as evidence by documented review and education on the hospital's restraint policy. The findings were confirmed in an interview with the Chief Quality Officer on 10/25/17 at 3:35 PM.
B. A request was made to the Chief Quality Officer on 10/25/17 for evidence of Physician #1-#4's acknowledgement of the hospital's policy regarding the use of restraints and seclusion. In an interview with the Chief Quality Officer on 10/25/17 at 3:35 PM, she stated there was no evidence of acknowledgement of the policy and procedure for the use of restraints and seclusion for Physician #1-#4. She confirmed Physician #1-#4 could order the use of restraints and seclusion.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to ensure one (#18) of four (#15, #17, #18 and #20) patients restrained for the management of violent behavior was evaluated face-to-face within one hour after the initiation of the restraint by a physician. The failed practice did not ensure the physician evaluated the patient's behavior that warranted the use of restraints to determine the continued need for the restraints. The failed practice had the potential to affect all patients on which restraints were used for violent behavior. Findings included:

A Record review of the facility's policy titled, "Restraints and Seclusion Policy," with a revision date of 04/26/16 showed for the use of restraints for violent self-destructive behavior a physician performed an in-person evaluation within one hour of initiation of restraints and provides a written or verbal order. The face-to-face evaluation must be documented within one hour of initiating a restraint.
B. Record review of Patient #15's clinical record showed orders for leather wrist restraints for violent self-destructive behavior from 04/17/17 at 11:00 PM to 04/18/17 at 7:00 AM. There was no evidence a one hour face-to-face evaluation was performed by a physician. The findings were confirmed in an interview with the Chief Nursing Officer on 10/26/17 at 12:50 PM.
C. Record review of Patient #20's clinical record showed orders for restraints for violent self-destructive behavior from 10/18/17 at 5:40 AM to 10/19/17 4:00 AM. The physician's one hour face-to-face evaluation was not performed until 10/18/17 at 11:50 AM. The findings were confirmed in an interview with the Director of the Intensive Care Unit and Cardiovascular Intensive Care Unit on 10/26/17 at 11:50 AM. He confirmed the one hour face-to-face evaluation was not performed within one hour of the implementation of the restraints for violent self-destructive behavior.

Based on clinical record review, policy and procedure review and interview, it was determined a Registered Nurse failed to assess the patient for signs of injury associated with the application of restraints, nutrition/hydration, circulation and range of motion, vital signs, hygiene and elimination, physical and psychological status and comfort, cognitive functioning, readiness for discontinuation of restraint, whether less restrictive methods are possible, changes in the patient's behavior or clinical condition needed to initiate the removal of restraints or whether the restraint had been appropriately applied, removed or reapplied every 15 minutes while the patient was in restraints for violent behavior for one (#18) of four (#15, #17, #18 and #20) patients placed in restraints for violent behavior. The failed practice placed the patient at risk of skin breakdown, dehydration, adverse effects related to poor circulation and continuation of the restraints when no longer applicable to the patient's behavior. The failed practice had the potential to affect all patients placed in restraints for violent behavior. Findings included:

A. Record review of the facility's policy titled, "Restraints and Seclusion Policy," with a revision date of 04/26/16 showed a qualified Registered Nurse must assess the patient at established time frames. Assessment included signs of injury associated with the application of restraints, nutrition/hydration, circulation and range of motion, vital signs, hygiene and elimination, physical and psychological status and comfort, cognitive functioning, readiness for discontinuation of restraint, whether less restrictive methods are possible, changes in the patient's behavior or clinical condition needed to initiate the removal of restraints or whether the restraint had been appropriately applied, removed or reapplied. Documentation of the patient's status for violent self-destructive patients in restraints was to be done every 15 minutes. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 11:15 AM.
B. Record review of Patient #18's clinical record showed the patient was placed in restraints for violent behavior on 09/17/17 at 4:00 PM and was removed on 09/17/17 at 6:41 PM. There was no evidence a Registered Nurse assessed the patient every 15 minutes for signs of injury associated with the application of restraints, nutrition/hydration, circulation and range of motion, vital signs, hygiene and elimination, physical and psychological status and comfort, cognitive functioning, readiness for discontinuation of restraint, whether less restrictive methods are possible, changes in the patient's behavior or clinical condition needed to initiate the removal of restraints or whether the restraint had been appropriately applied, removed or reapplied. The findings were confirmed in an interview with the Emergency Room Director on 10/26/17 at 11:15 AM.