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Based on review of documentation and interview it was determined that the facility's governing body failed to ensure patient rights were protected as evidenced by patient #1 being restrained without physician orders on at least four separate occasions. Additionally it was determined that the governing body failed to ensure that hospital policies and procedures had been followed. The failure to ensure that polices were enforced contributed to the patient being improperly restrained.

Findings were:
1.) Patient #1, an inpatient at North Austin Medical Center (NAMC) was found to have been improperly restrained.

Cross refer to:
CFR 482.13(e)(8), 0171- Patient Rights: Restraint Or Seclusion

2.) The governing body failed to ensure that hospital policies and procedures were followed which contributed to the continual improper restraint of patient #1. A review of the medical record of patient #1 revealed that this individual had been improperly restrained on at least four separate occasions without a valid physicians's order. A review of facility policy entitled: "Restraints and Patient Safety Guidelines" stated under the Purpose section on page one: "1. To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use. 3. To provide guidelines for use of least restrictive interventions to avoid restraint use." This same document also stated under the policy section that: "St David's North Austin Medical Center is dedicated to fostering a culture that supports a patient's right to be free from restraint or seclusion. Restraint will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating the use of restraints. The administrative team provides the leadership and organizational accountability for monitoring the safety, appropriateness and necessity of restraint use."

Page two of the policy stated under #5. "Orders for Restraint(s): "a. An order for restraint(s) must be obtained from a physician/LIP who is responsible for the care of the patient prior to the application of restraint(s). The order must specify clinical justification for the restraint(s), the date and time ordered, the duration of use, the type of restraint(s) to be used and behavior-based criteria for release."

This same policy was also found to state: "2) If the patient was released from restraint(s) or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint(s), a new order is required. 3) The RN and approved staff taking a telephone or verbal order for restraint(s) must ensure that the accuracy of the order is verified through the read-back method. The order must specify: Clinical justification for restraint/seclusion, Date and time ordered, Restraint type or seclusion, Duration of order, Behavioral based criteria for release." Under section "5A. Order for Restraint(s) for Non-Violent or Non-Self Destructive Behavior" the statement: "a. Duration of the initial order for restraint(s) may not exceed 24 (twenty) hours for the initial order. d. To continue restraint(s) use beyond the initial order duration, the physician/LIP must see the patient, perform a clinical assessment and determine if continuation of restraint(s) is/are necessary."

Based on observation, review of documentation and interview it was determined that the facility failed to ensure that the rights of patient #1 were protected as the patient had been physically restrained on four separate days without a physical restraint order from a physician.

Findings were:
Patient #1 was found to have been physically restrained without physician orders.

Cross refer to:
CFR 482.13(e)(8), 0171- Patient Rights: Restraint Or Seclusion

Based on observation, review of documentation and interview it was determined that the facility failed to ensure that the rights of patient #1 were protected as the patient had been physically restrained on at least four separate days without a physical restraint order from a physician.

Findings were:
Patient #1 was found to have been restrained without a valid order from a physician.

1.) On the morning of 10/01/2010 at approximately 11:30 am the surveyor visited room #337 of the 3 East Neurological Surgical Specialty Unit of the facility where patient #1 was an inpatient. Upon entering the room patient #1 appeared to be sleeping in his hospital bed and he was observed to be physically restrained. There were soft blue foam wrist restraints on both of his wrists and the right ankle, and these appeared to be secured to the bed. There was a blue foam restraint observed on his left lower extremity but it was not secured to the bed.

Review of the physician's orders section of the medical record revealed no physical restraint order for the date of 10/01/2010.

A chart check had been documented as having been conducted as recently as 10/01/2010 at 0015 hrs, and 0700 hrs and there was no notation that a new order for restraints was needed. The last hard copy physical restraint order found in the medical record was dated 9/27/2010 at 1750 hrs.

2.) Review of the "List Patient Notes" (these list patient notes were found to be where nursing staff document via a narrative format) revealed on 9/30/2010 at approximately 0730 hrs the comment: "Removed restraints and reapplied x 3. Pts door open." At 0947 the comment: "Bathed patient, removed restraints, reapplied x 3-Pt quiet, cooperative." At 1218 hrs the comment: "pt yelling -- Given Ativan. Removed restraints, positioned Pt for lunch. Pt fed with HOB elevated." At 1405 hrs the comment: "pt resting with eyes closed, snoring. Removed restraints, reapplied. Pts door open." At 1453 hrs the comment: "pt talking quietly, repositioned. Removed restraints and reapplied. Brief dry." At 1746 hrs the comment: "Fed Pt 100% Dinner. Changed brief. Pt yelling. Removed restraints, Reapplied. Ativan given." A review of the physicians order section found no physical restraint orders for either 9/29/2010 or 9/30/2010. The most current physical restraint order found in the medical record was dated 9/27/2010 at 1750 hrs.

3.) Review of the "List Patient Notes" revealed on 9/29/2010 at approximately 0730 hrs the comment: "Report received from night shift. Patient is in bed sleeping. Restraints x 3. In no apparent distress. Door left open." A review of the physicians order section found no physical restraint orders for either 9/28/2010 or 9/29/2010. The most current physical restraint order found in the medical record was dated 9/27/2010 at 1750 hrs.

4.) Review of the "List Patient Notes" revealed on 9/21/2010 at approximately 1100 hrs the comment: "Restraints Monitor." There was no physical restraint order found which covered this time period.

5.) Review of the "List Patient Notes" revealed on 9/19/2010 at approximately 1625 hrs the comment: "3-point restraints in place." There was no physical restraint order found which covered this time period. The prior 24 hour physical restraint order from 9/18/2010 expired at 1520hrs on 9/19/2010.

6.) Review of the "List Patient Notes" revealed on 9/18/2010 at approximately 1215 hrs the comment: "Pt hit tech (name of tech here), on her head with his hand. Pt appeared calm, remained non-verbal. Will keep Pt in W/C for lunch. Lap belt in place. Door wide open." The next entry for the same date at 2052 hrs stated: "Charge RN found Pt in W/C in hallway. When approached, Pt yells He's leaving, using profanity. Pt taken back to his room. Pt uncooperative, yells he's going to hit. Security called. Haldol PRN given. Security assisted to place Pt back in bed. Foot restraints & 1 hand restraint in place. Door wide open." A review of the Physical Restraint Order Sheet for 9/18/2010 had under the area listing they types of restraints checkmarks in the boxes for "Side rails x 4" and "Limb restraint x 3." A choice which was not checked but available was "Wheelchair Lap Belt/Safety Belt." The prior 24 hour physical restraint order from 9/16/2010 expired at 0700hrs on 9/17/2010. Additonally at 945hrs on 9/18/2010 staff documented: "BLE (bilateral lower extremities) restraints in place since patient has HX (history) of trying to kick. Will keep retraints in place." There was no physical restraint order found which covered this time period.

7.) Review of the "List Patient Notes" revealed on 9/17/2010 at approximately 1920 hrs the comment: "Pt has x3 ankle restraints on. Side rails x 4." The most current physician restraint order found prior to this date/time was a restraint order from 9/16/2010 at 0700 hours. The next physical restraint order found in the physician order section was dated and timed at 9/18/2010 at a time which is illegible (appears to be 3:20p) The patient was therefore restrained without a valid order as the order from 9/16 would have expired at 0700 hours on 9/17/2010. From 0700 hrs on 9/17/2010 until 9/18/2010 at 3:20hrs there was no restraint order found in the medical record which covered this time period.

8.) Review of the "List Patient Notes" revealed on 9/15/2010 at approximately 1426 hrs the comment: "Removed wrist restraints for 30 minutes while RN at bedside. Applied lotion to hands and wrists. Restraints reapplied." The most current physician restraint order found prior to this date/time was a restraint order from 9/13/2010 at 1600 hours. The next physical restraint order found in the physician order section was dated and timed at 9/15/2010 at 2000 hrs. The patient was therefore restrained without a valid order from 1600 hrs on 9/14/2010 until 2000hrs on 9/15/2010 as there was no restraint order found in the medical record which covered this time period. An addendum to the nursing note dated 9/15/2010 at 1802 hrs stated: "Removed 4 point restraints immediately after talking with charge nurse."

9.) Review of the "List Patient Notes" revealed on 9/11/2010 at approximately 0655 hrs the comment: "Pt in 2 point restraints." The previous 24 hour physical retraint order from 9/9/2010 expired at 0130 on 9/10/2010.

10.) Review of the "List Patient Notes" revealed on 9/10/2010 at approximately 0730 hrs the comment: "Wrist restraints in place." The previous 24 hour physical retraint order from 9/9/2010 expired at 0130 on 9/10/2010, thus there was a six hour period when the patient was restrained without a physician's order.

Review of additional documentation found in the medical record revealed comments concerning use of restraints to include:

Review of patient assessment for the 9/28/2010 AM revealed the comment on page three: "Restraints- ORDERED, IN USE " Restraint risk factors were listed as: "cannot follow directions, pulls at medical devices, unsafe attempts at mobil. Aggressive/combative." The same comments were found for the 9/28/2010 PM assessment. A review of the physicians order section found no physical restraint orders for either 9/28/2010 or 9/29/2010. The most current physical restraint order found in the medical record was dated 9/27/2010 at 1750 hrs.

The same comments were found on the 9/29/2010 PM patient assessment. On the AM nursing assessment the comment: "NOT ORDERED, NOT IN USE." was found.

Review of patient assessment for 9/30/2010 AM revealed the comment on page three: "Restraints- ORDERED, IN USE" Restraint risk factors were listed as: "cannot follow directions, pulls at medical devices, unsafe attempts at mobil. Aggressive/combative." The same comments were found for 9/30/2010 PM assessment. A review of the physicians order section found no physical restraint orders for either 9/29/2010 or 9/30/2010. The most current physical restraint order found in the medical record was dated 9/27/2010 at 1750 hrs.

A review of facility policy entitled: "Restraints and Patient Safety Guidelines" stated under the Purpose section on page one: "1. To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use. 3. To provide guidelines for use of least restrictive interventions to avoid restraint use." This same document also stated under the policy section that: "St David's North Austin Medical Center is dedicated to fostering a culture that supports a patient's right to be free from restraint or seclusion. Restraint will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating the use of restraints. The administrative team provides the leadership and organizational accountability for monitoring the safety, appropriateness and necessity of restraint use."

Page two of the policy stated under #5. "Orders for Restraint(s): "a. An order for restraint(s) must be obtained from a physician/LIP who is responsible for the care of the patient prior to the application of restraint(s). The order must specify clinical justification for the restraint(s), the date and time ordered, the duration of use, the type of restraint(s) to be used and behavior-based criteria for release."

This same policy was also found to state: "2) If the patient was released from restraint(s) or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint(s), a new order is required. 3) The RN and approved staff taking a telephone or verbal order for restraint(s) must ensure that the accuracy of the order is verified through the read-back method. The order must specify: Clinical justification for restraint/seclusion, Date and time ordered, Restraint type or seclusion, Duration of order, Behavioral based criteria for release." Under section "5A. Order for Restraint(s) for Non-Violent or Non-Self Destructive Behavior" the statement: "a. Duration of the initial order for restraint(s) may not exceed 24 (twenty) hours for the initial order. d. To continue restraint(s) use beyond the initial order duration, the physician/LIP must see the patient, perform a clinical assessment and determine if continuation of restraint(s) is/are necessary."

During an interview with the Chief Nursing Officer on 10/01/2010 it was confirmed that there was no hardcopy physician order for physical restraint found in the chart for the date of 10/01/2010.

Based on review of documentation it was determined that the facility failed to ensure that verbal orders were used infrequently as 10 of 15 physical restraint orders were telephone/verbal orders.

Findings were:
1.) The facility was found to frequently use telephone/verbal orders for physical restraint. A review of the medical record of patient #1 revealed that in the physician order section there were 15 "Physical Restraint Order Sheets" found. Of these 15 physical restraint 10 were found to be verbal/telephone orders (dates were: 9/27/2010, 9/26/2010, 9/25/2010, 9/23/2010, 9/22/2010, 9/20/2010, 9/19/2010, 9/16/2010, 9/15/2010, 9/13/2010).

2.) An additional 22 telephone/verbal orders were also found in the physician order section of the medical record for patient #1(dates were: 9/29/2010, 9/26/2010, 9/17/2010, 9/17/2010, 9/17/2010, 9/16/2010, 9/15/2010, 9/15/2010, 9/15/2010, 9/15/2010, 9/15/2010, 9/14/2010, 9/14/2010, 9/14/2010, 9/14/2010, 9/14/2010, 9/10/2010, 9/9/2010, 9/9/2010, 9/9/2010, 9/9/2010, 9/8/2010).

A review of facility policy entitled: "Written Verbal and Telephone Orders" stated on page two under #2. Verbal/Telephone Orders: "Verbal Orders are discouraged."

Based on review of documentation it was determined that the facility failed to ensure that nursing staff properly documented receipt of verbal orders.

Findings were;Nursing staff did not document which nurse had taken a verbal order. A review of A review of the "Physical Restraint Order Sheet" from 9/25/2010 was found to not have a physician signature. This order was taken as a TOV (telephone order verified). In the area where the Physician/LIP Signature is supposed to be written there was the comment: "TOV" followed by "Dr." (and the name of a physican). There was no documentation as to which nurse had actually taken this telephone order.

A review of facility policy entitled: "Written Verbal and Telephone Orders" stated on page two under #2. Verbal/Telephone Orders: "Verbal Orders are discouraged. In the event that a verbal order must be utilized, follow the guidelines listed below." Among the listed guidelines was the statement: " The Verbal/Telephone order will be written on the physician order sheet by the person receiving the order and noting the date and time received, the name of the LIP issuing the order and the receiver's name and title."