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Based on interview, clinical record review, and review of the facility's policy, it was determined the facility failed to ensure proper procedure was followed as required per policy and regulation as evidenced by failure to obtain a new Physician's order when a restraint was discontinued and then reapplied for one (1) of ten (10) sampled patients (Patient #10).

The findings include:

Review of facility's policy entitled, "Restraint/Seclusion", Section E (10), effective date 11/01/10, revealed an episode of restraint began with the initiation of the restraint intervention and continued until the restraint was discontinued. Also, the policy stated each episode of restraint must be accompanied by a new Physician's order for the restraint.

Review of the clinical record for Patient #10 revealed he/she was admitted on 05/16/12 with diagnoses which included Chest Pain, Hypertension and Chronic Obstructive Pulmonary Disease (COPD). Further review of the record revealed Patient #10 had an initial Physician's order for soft wrist restraints on 05/18/12 at 6:04 AM. Documentation on the "Nonbehavioral Restraint Flowsheet" showed Patient #10 had restraints on from 05/18/12 at 8:00 AM until 11:00 AM, episode one (1); from 05/19/12 at 10:10 AM until 10:40 AM, episode two (2); from 05/19/12 at 11:00 PM until 05/20/12 at 6:00 AM, episode three (3); and from 05/20/12 at 7:30 PM until 05/21/12 at 6:30 AM, episode four (4). Continued review of the record revealed no documented evidence that additional Physician's orders were obtained for soft wrist restraints for episodes 2, 3, or 4. The next Physician's order for soft wrist restraints was on 05/21/12 at 6:55 AM.

Interview with the Accreditation and Regulatory Affairs Director, on 05/21/12 at 5:50 PM, revealed when restraints were discontinued and then reapplied, a new episode began, and a new Physician's order for restraints should have been obtained.

Based on interview, clinical record review, and review of the facility's policy, "Restraint/Seclusion, Attachment A, Nonviolent Non Self Destructive Restraint Pathway," Section E (10), effective date 11/01/10, it was determined the facility failed to ensure correct procedure was followed per facility policy in renewing restraint orders as evidenced by the failure to obtain a Physician's order for restraint renewal every twenty-four (24) hours for one (1) of ten (10) sampled patients (Patient #1).

The findings include:

Review of facility policy, "Restraint/Seclusion, Attachment A, Nonviolent Non Self Destructive Restraint Pathway," Section E (10), effective date 11/01/10, revealed if restraint use continued to be justified, a renewal order from the Physician must be obtained every twenty-four (24) hours. Such renewal or new order must be issued no less often than once each calendar day.

Review of the clinical record of Patient #1, revealed he/she was admitted on 05/11/12 with diagnoses which included Dehydration and Severe Mental Retardation. The record further revealed Patient #1 had two (2) Physician's orders for bilateral soft wrist restraints; one (1) order on 05/12/12 at 2:54 AM, and one (1) order on 05/14/12 at 5:53 AM. Further review of the record revealed Patient #1 was in bilateral soft wrist restraints on 05/13/12 without the required renewal order by the Physician.

Interview with the Accreditation and Regulatory Affairs Director, on 05/21/12 at 5:50 PM, revealed that per the facility's policy, a Physician's order for renewal of restraints was required daily or every twenty-four (24) hours.

Based on interview, clinical record review, and review of facility's policy, "Restraint/Seclusion, Attachment A, Non Violent Non Self Destructive Restraint Pathway," Section E (10), effective date 11/01/10, it was determined the facility failed to ensure correct procedure was followed in monitoring restrained patients as evidenced by Registered Nurse (RN) #3 failing to document as required per policy for one (1) of ten (10) sampled patients (Patient #1).

The findings include:

Review of facility's policy, "Restraint/Seclusion, Attachment A, Non Violent Non Self Destructive Restraint Pathway," Section E (10), effective date 11/01/10, revealed patients in restraints must be assessed every two (2) hours by the nurse, and this assessment must be documented on the restraint flowsheet.

Review of the clinical record for Patient #1 revealed he/she was admitted on 05/11/12 with diagnoses which included Dehydration and Severe Mental Retardation. Record review revealed Patient #1 was placed in bilateral soft wrist restraints on 05/12/12 at 3:00 AM. There was no documentation on the "Nonbehavioral Restraint Flowsheet" from 05/12/12 at 6:24 PM until 05/13/12 at 8:00 AM. RN #3 was Patient #1's nurse from 7:00 PM on 05/12/12 until 7:30 AM on 05/13/12. The only documentation by RN #3 for the restraints was in the Progress Notes on 05/12/12 at 7:39 PM and on 05/13/12 at 1:39 AM.

Interview with RN #3, on 05/19/12 at 5:40 PM per telephone, revealed she was aware she did not chart on the "Nonbehavioral Restraint Flowsheet" every two (2) hours as required per policy for Patient #1 from 05/12/12 at 7:00 PM until 05/13/12 at 07:30 AM. She stated she simply forgot. RN #3 also revealed she had been instructed during orientation and annually thereafter on the required use of the restraint flowsheet and on proper use of restraints.