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Based on medical record review, staff interview, and review of policies and procedures, it was determined the facility failed to ensure all requirements for physicial restraint use were followed. Physicians' orders for all patients with restraints did not inculde the rationale for use of restraints, or type and number of restraints (A154). Phyicians' orders for restraints were not renewed for all patients who had continuous restraints (A173). The combined effect of this systemic failure resulted in the facility's inability to ensure that no patient would be unnecessarily restrained.

Based on staff interview, medical record review, and review of the policy on restraints, the hospital failed to ensure physicians' orders for restraints included the rationale, type and number for 2 (#1, #2) of 6 sample patients who required restraints. The findings were:

1. Review of the physician's orders for patient #1 showed the physician ordered restraints beginning on 2/26/10 at 1 PM. Review of the nursing notes showed the restraints remained in place continuously until 3/1/10 at 11:50 PM. Review of the 2/27/10 renewal order, timed at 1 PM, showed no rationale for the continued restraints and the type and number of restraints was not identified. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed the rationale for restraints and the type and number of restraints were not included in the physician's orders.

2. Review of 2/13/10 physician's orders, timed at 6:55 AM, for patient #2 showed orders for restraints. Review of the nursing notes revealed the patient had restraints in place from 2/13/10 at 7 AM until 2/22/10 at 8:45 PM and again from 2/23/10 at 11:22 AM until 2/25/10 at 3 PM. Further review of the 2/13/10 physician's order showed there was no rationale for the restraints indicated, and the type and number of restraints were not included. Review of the 2/14, 2/15, 2/16, 2/17, 2/18, and 2/19/10 physician's orders for restraints also failed to include the rationale for restraints or the type and number. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed the rationale for restraints and the type or number were not included in the physician's orders. The quality improvement staff member acknowledged the rationale, type and number were required.

3. Review of the policy on non-violent restraints, #37, effective January 2010, page 6, showed the following instructions: The written physician's order must contain a notation of the indication and rationale for restraints, the type and location of restraints, and duration of the order.

Based on staff interview, review of medical records, and review of the policy on restraints, the facility failed to ensure physicians' orders for restraints were renewed when used continuously for 4 (#2, #3, #4, #5) of 6 sample patients who required ongoing daily use of restraints. The findings were:

Review of the policy on non-violent restraints, #37, effective January 2010, page 6, showed the following instructions: "The LIP [licensed independent practitioner] will perform a face-to-face comprehensive assessment of the restrained patient within 24 hours of restraint initiation and every calendar day thereafter, when restraints are in use. The LIP will verify that restraint use is needed and that less-restrictive means are not appropriate and/or applicable based on the patients physical and psychological assessment and enters a written order into the patient's medical record." The following concerns were noted with regard to how restraints were actually managed:

a. Review of the physician's orders for patient #2 showed orders to restrain the patient were written on 2/13/10 at 6:55 AM because the patient was placed on a ventilator. Review of the nursing notes showed the patient remained in soft restraints from 2/13/10 at 7 AM until 2/22/10 at 8:45 PM. Review of the physician's orders showed there was no renewal order written for continuation of restraints on 2/20/10 or 2/21/10. In addition, review of the nursing notes, validated by the physician's orders, revealed restraints were again ordered and placed on the patient on 2/23/10 at 11:22 AM. Review of nursing notes showed the restraints remained on until 2/25/10 at 3 PM. Review of the physician's orders showed there was no continuation order for restraints on 2/24/10. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed the lack of orders by a physician for those dates.

b. Review of the physician's orders for patient #3 showed an order dated 2/23/10 and timed at 10:15 AM for restraints because the patient was intubated and had been placed on a ventilator. Review of the nursing notes showed the patient remained in restraints from 2/23/10 at 7 AM until 2/27/10 at 5 PM. Review of the physician's orders showed no continuation orders for 2/24, 2/25, or 2/26/10. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed the restraint orders for these days were missing.

c. Review of the 1/16/10 physician's order timed at 6:30 PM for patient #4 showed restraints were ordered because the patient was on a ventilator. Review of the nursing notes revealed the patient had restraints from 1/16/10 at 6:40 PM through 1/19/10 at 9 AM. Review of the physician's orders showed there was no renewal order for restraints on 1/17/10. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed there was no physician's order for the restraint on 1/17/10, as required.

d. Review of the 1/11/10 physician's order timed at 10:15 AM for patient #5 showed soft restraints were ordered because the patient was placed on a ventilator. Review of the nursing notes revealed the patient had restraints from 1/11/10 at 7 AM until 1/19/10 at 7 PM with one 2 hour break on 1/18/10 from 3 to 5 PM while the patient's sister was at the bedside. Review of the physician's orders showed there was no order for 1/16, 1/17, or 1/18/10. Interview with a quality improvement staff member on 3/15/10 at 2:25 PM confirmed there was no physician's order for the restraints on 1/16, 1/17, or 1/18/10, as required.

Based on medical record review, staff interview, and review of hospital policy #37 entitled " Restraint, Non-Violent (medical/surgical), the hospital failed to meet the medical staff requirement of providing quality medical care in regard to restraint orders for 5 (#1, #2, #3, #4, #5) of 6 sample patients who required restraints for medical conditions. The combined results of these failures resulted in non-compliance with this condition. The findings were:
Refer to Federal citation of the Patient Rights Condition, A115. Refer to Federal citation A154 for details related to restraint orders that failed to include the rationale and the type, number, and location of restraints for patients #1 and #2. Refer to Federal citation A173 for details related to the lack of daily written physician orders for the continuous use of restraints for patients #2, #3, #4 and #5.