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Based on document review and interview, for one of two patients (Pt. #1) reviewed for restraints, the Hospital failed to ensure that the use of restraints was in accordance with the order from a physician responsible for the care of the patient.

Findings include:

1. The Hospital's policy titled, "Utilization of Restraint and Seclusion" dated 09/27/18 was reviewed. The policy included, "the use of restraint and seclusion will occur only after alternatives have been deemed ineffective ...Orders: a) Use of restraint is based upon the order of a physician, including medical staff or house staff, or other appropriately privileged clinical team member, including an Advanced Practice Clinician; ...c) When an RN initiates restraint, an order will be obtained from a physician as soon as possible (within 30 minutes) after the restraint is initiated."

2. On 08/27/19 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital with a diagnosis of chest pain with shortness of breath. Pt. #1 was transferred to a rehabilitation unit on 06/20/19 at 9:18 PM and was discharged home with home health services on 07/01/19.

- The nursing progress notes by Registered Nurse (E #10) dated 06/13/19 at 9:19 PM, included, "Received pt. (Pt. #1) from 8 tower (Oncology Unit). Pt. became agitated at around 3:30 PM, taking off his gown, pulled out his condom catheter, tele monitor, trying to get out of bed, scratching and biting staff. Ativan (sedative) IV (Intravenous) given. Son was notified, OK to place restraint, until he gets to the unit. Restraints applied but was removed immediately within 15 mins. (Minutes)." The clinical record lacked documentation of a Physician order for restraints.


3. On 08/28/19 at approximately 12:41 PM, an interview was conducted with the Registered Nurse (E #10). E #10 stated, "The son preferred to be called all the time regarding the patient (Pt. #1) care. Patient was very anxious, confused, agitated, jumping out of bed, and scratched the staff and that time I had to call the RRT [Rapid Response Team] and notified the physician about the patient condition. I received telephone order to place patient on restraints. But, I forgot to document it in the chart."

4. On 08/28/19 at approximately 1:00 PM, an interview was conducted with the Clinical Manager (E #11). E #11 stated, "We noted the restraints physician order was not documented in the patient chart, when we did the restraints auditing. We have coached the nurse to make sure to document the physician order even if the restraints is used for one minute."