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Based upon hospital policy review, medical record review and staff interview the hospital staff failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner for 1 of 1 restrained patients reviewed (#6).

The findings include:

Review of hospital policy "Restraint Use for Adults and Children," Policy Number 1.28, effective 01/08, revealed "...V. Procedure ...C. Orders ...6. All orders for restraints must: ...* Be time limited *Be written on the pre-printed (Restraint Order Sticker, Attachment 3). ...*Contain the reason for restraint, type of restraint, physician/LIP signature and date and time of order. ..."

Closed dedicated emergency department (DED) record review on 09/01/2010 for Patient #6 revealed a 40 year-old male admitted to the hospital's DED on 05/04/2010 and discharged on 05/05/2010 with a diagnosis of Poly-Substance Abuse and Narcan-induced withdrawal. Review of DED nursing documentation revealed the patient was restrained from 05/04/2010 at 2355 until 05/05/2010 at 0256 (3 hours and 1 minute). Review of DED physician documentation revealed "pt (patient) given ativan for behavioral control but required restraints temporarily." Review of the DED Physician's Order sheet failed to reveal an order for the application of restraints. Further DED record review revealed no available documentation of an order for the use of restraints written by the ordering physician or other licensed independent practitioner during the patient's DED hospitalization.

Interview with nursing administrative staff on 09/01/21010 at 1400 revealed a physician's order is required for the use of restraints. Interview revealed all restraint orders are to be documented on a restraint order sticker or on a physician's order sheet in the medical record. Interview revealed no documented evidence of an order authenticated by the ordering physician or other licensed independent practitioner authorizing the use of restraints on 05/04/2010 from 2355 until 05/05/2010 at 0256. Interview confirmed the hospital staff failed to follow the hospital's restraint policy.

NC00065160