HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that staff failed to obtain an order for the use of restraints for 1 of 1 restrained patients (Patient #2) in the sample. Findings include:

The hospital policy entitled "Restraints, Guidelines for Use, Non-Violent or Non-Self-Destructive Behavior (Formerly Medical-Surgical Restraints)" stated, "...Obtain an order for restraints...The Registered Nurse may initiate medical/surgical restraint in order to protect the safety of the patient, staff or others. A verbal or written order will be obtained from the physician or designee immediately (within a few minutes) after the initiation..."

Review of Patient #2's medical record revealed:

1. "Restraint Record Nonviolent/Non-self-destructive Management" documentation revealed the following:

3/4/16
2:00 PM - 10:00 PM: Restrained with 2 wrist and 2 ankle restraints

3/11/16
2:00 PM - 4:00 PM: Restrained with 2 wrist restraints

3/12/16
6:00 PM - 10:00 PM: Restrained with 2 wrist and 1 ankle restraint

3/13/16
12:00 AM - 2:00 PM: Restrained with 2 wrist and 1 ankle restraint

3/15/16
4:00 PM - 10:00 PM: Restrained with 2 wrist restraints

2. No evidence of a physician order for restraints for these time periods.

On 4/19/16 at 12:45 PM, Nurse Manager A reviewed the medical record and confirmed these findings.