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Based on record review, the facility failed to follow their own policy and procedure for obtaining time limited orders for restraints from the physician for one of one patients (#1). Restraint and Seclusion of Patients.

Review of policy #1600.112, titled " Behavioral Health Center /Restraint and Seclusion of Patients, Statements 25,26, 28, and 30 revealed the following:
" #25. If criteria for release has not been met by the time limit on mechanical restraint or seclusion, the RN calls the physician and receives a telephone or verbal order to continue the seclusion or restraint for up to: 1hour (child 8 or under), 2 hours (9-17), 4 hours (18 and older). Physical restraints may never be continued. If the patient still does not meet behavioral criteria for release after the time frame for the continuation, calls the physician and obtains a new order. 26. The Physician comes back to the facility, assesses the patient, documents findings and authenticates the verbal order. 28. The RN releases the patient from seclusion or restraint as soon as: Behavioral criteria are met, the patient falls asleep. and returns patient ' s belongings that were removed. 30. The RN assists the patient to reintegrate back into the community milieu for 30 minutes after release and documents the interventions used and the patient ' s response in the progress notes. "

Review of Multidisciplinary Progress Notes (MDPN) by Registered Nurse (RN) #6 for 12/09/2011, timed 10:30 revealed the patient attacked a staff member and was placed in restraints and seclusion. Review of second entry in the MDPN by RN #6, timed 11:35 revealed patient continues to be aggressive, agitated and threatening. Patient remains in restraint and seclusion. Review of third entry in the MDPN by RN #6, timed 13:45 (1:35PM) revealed patient continues to be upset, yelling, cursing and unwilling to cooperate with treatment. Review of fourth entry in the MDPN by RN #6 had no time. Entry revealed " Patient still in seclusion and Behavioral still the same, yelling, cursing to self and at staff " . Review of fifth entry of the MDPN by RN #6, timed, 16:00 (4:00PM) revealed " Patient transferred to RSH (Rusk State Hospital) per physician ' s order " .

Review of the Restraint/Seclusion Monitoring Log (log) (a form with check offs used by staff to monitor patient and restraints every fifteen minutes) was initiated by staff #6 at 10:50 AM and revealed a RN assessment was done and a physician assessment was done. No other entries were made by staff #6. An entry on the log at 14:30 (2:30PM) revealed a physician assessment was done. No documentation was found in the medical record of the physician ' s findings for the assessment.

Review of " Physician ' s Orders for Restraint/ Seclusion " by physician #7 revealed restraint and seclusion for up to 4 hours beginning at 10:30AM and ending by 14:30 (2:30PM), type of restraint, physical hold to body net (holding the patient with force and applying a net type of restraint that restricts patient ' s movement). The order dated 12/09/2011and timed 10:45 AM. No other orders to continue restraint were documented in the patient ' s chart. Reviewed order written by #7 at 3:45PM revealed " (1) Transfer to RSH. (2) Change to observation status " .

Further review of the patient ' s chart revealed no order was obtained to continue the restraints after the first four hours. RN #6 failed to call for a verbal order to continue the restraints and physical restraints were continued. Order was received at 3:45PM, change to observation status. No evidence of documentation of an RN assessment or documentation of a change in the patient ' s behavioral status. No evidence of an attempt to reintegrate the patient into the social environment.

During an interview at 3:00pm in the Administration Conference room Staff #1 confirmed there was no physician ' s order to continue the restraint and seclusion of the patient.

Based on record review and interview the facility failed to follow their own policy and procedure on Restraint and Seclusion of Patients. The facility failed to obtain a physician ' s order for the continuation of restraint and seclusion of 1 of 1 patients reviewed.

Review of policy 1600.112, titled " Behavioral Health Center /Restraint and Seclusion of Patients, Statements 25,26,28,and 30 revealed the following:
" 25. If criteria for release has not been met by the time limit on mechanical restraint or seclusion, calls the physician and receives a telephone or verbal order to continue the seclusion or restraint for up to: 1hour (child 8 or under), 2 hours (9-17), 4 hours (18 and older). Physical restraints may never be continued. If the patient still does not meet behavioral criteria for release after the time frame for the continuation, calls the physician and obtains a new order. 26. The physician comes back to the facility, assesses the patient, documents findings and authenticates the verbal order. 28. The RN releases the patient from seclusion or restraint as soon as: Behavioral criteria are met, the patient falls asleep. and returns patient ' s belongings that were removed. 30. The RN assists the patient to reintegrate back into the community milieu for 30 minutes after release and documents the interventions used and the patient ' s response in the progress notes. "

Review of Multidisciplinary Progress Notes (MDPN) by Registered Nurse (RN) #6 for 12/09/2011, timed 10:30 revealed the patient attacked a staff member and was placed in restraints and seclusion. Note ends with " See Restraint Packet paper work " . Review of second entry in the MDPN by RN #6, timed 11:35 revealed patient continues to be aggressive, agitated and threatening. Patient remains in restraint and seclusion. Note reads " See Restraint/ incident paper work " Review of third entry in the MDPN by RN #6, timed 13:45 (1:35PM) revealed patient continues to be upset, yelling, cursing and unwilling to cooperate with treatment. Review of fourth entry in the MDPN by RN #6 has no time. Entry revealed " Patient still in seclusion and Behavioral still the same, yelling, cursing to self and at staff " . Review of fifth entry of the MDPN by RN #6, timed, 16:00 (4:00PM) revealed " Patient transferred to RSH (Rusk State Hospital) per physician ' s order " .

Review of the Restraint/Seclusion Monitoring Log (log) (a form with check offs used by staff to monitor patient and restraints every fifteen minutes) was initiated by staff #6 at 10:50 AM and revealed a RN assessment was done and a MD assessment was done. No other entries were made by staff #6. An entry on the log at 14:30 (2:30PM) revealed a physician assessment was done. No documentation was found in the medical record of the physician ' s findings for the assessment.

Review of " Physician ' s Orders for Restraint/ Seclusion " by physician #7 revealed restraint and seclusion for up to 4 hours beginning at 10:30AM and ending by 14:30 (2:30PM), type of restraint, physical hold to body net (holding the patient with force and applying a net type of restraint that restricts patient ' s movement). The order dated 12/09/2011and timed 10:45. No other orders to continue restraint were documented in the patient ' s chart. Reviewed order written by #7 at 3:45PM revealed (1) Transfer to RSH. (2) Change to observation status.

Further review of the patient ' s chart revealed no order was obtained to continue the restraints after the first four hours. RN #6 failed to call for a verbal order to continue the restraints and physical restraints were continued. Order was received at 3:45PM, change to observation status. No evidence of documentation of an RN assessment or documentation of a change in the patient ' s behavioral status.

During an interview at 3:00pm in the Administration Conference room Staff #1 confirmed there was no physician ' s order to continue the restraint and seclusion of the patient.