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Based on record review and interview the facility failed to ensure doctors' orders were obtained for the use of restraints for three of three patient records reviewed (ID#1, 5, 11).

Findings Included:

A record review of the facility policy "Restraint and Seclusion Policy" reviewed 06/25/2021, stated restraints must have a physician's order, appropriate clinical justification for the restraint, a start time and a time limit.

Record review of patient (ID#1), medical record revealed the hospitalization was the result of a motor vehicle accident (MVA). Restraints were ordered on 03/01/2022 and were place until 03/16/2022. Further review revealed no physician orders for restraints were initiated for 03/08/22, 03/10/22, 03/13/22, 03/15/22 and 03/16/22.

Record review of patient (ID#5), medical record revealed the hospitalization was the result of a MVA. Restraints were ordered on 04/26/2022, and 05/03/2022 through 05/04/2022. Further review revealed no restraint orders were initiated for 04/27/2022 thru 05/02/2022.

Record review of patient (ID#11), medical record revealed the hospitalization was also the result of a MVA.
Restraints were ordered on 04/27/2022, 05/02/2022, 05/04/2022. Further review revealed no restraint orders were initiated for 04/28/2022 thru 05/01/2022 and 05/03/2022.

Interview with RN staff (ID#51) on 05/04/2022 at 1232, confirmed patients should have physician orders for restraints and the orders should be renewed daily.