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Based on document review, observation, and staff interview, the acute care hospital staff failed to ensure the nursing staff obtained an order for 3 of 4 patients reviewed with restraints (Patient #1, Patient #2 and Patient #3) from the patient's physician each calendar day while the patient was in restraints. The hospital administrative staff identified 2 patients in the intensive care unit (ICU) with restraints at the time of the entrance conference.

Failure to obtain an order for the restraints each calendar day could potentially result in the nursing staff applying the restraints for inappropriate reasons or without the physician's knowledge.

Findings included:

1. Review of the policy, "Restraint - Nonviolent or Medical/Surgical," revised 5/2016, revealed the following, "The physician/[Licensed Independent Practitioner, such as an Advanced Registered Nurse Practitioner] must ... write [an] order every calendar day if [the] restraint is renewed beyond 24 hours."

2. Review of Patient #1's closed medical record revealed that the nursing staff failed to obtain a physician's order for Patient #1's restraints on 2 of 19 days (10/23/16 and 10/30/16) Patient #1 was in restraints.

3. Observations made at various times on 12/12/16, 12/13/16, and 12/14/16 revealed the nursing staff had applied restraints to both wrists of Patients #2 and Patients #3.

4. Review of Patient #2's open medical record revealed that the nursing staff failed to obtain a physician's order for Patient #2's restraints on 2 of 4 days (12/11/16 and 12/12/16) Patient #2 was in restraints.

5. Review of Patient #3's open medical record revealed that the nursing staff failed to obtain a physician's order for Patient #3's restraints on 5 of 7 days (12/9/16, 12/10/16, 12/11/16, 12/12/16, and 12/13/16) Patient #3 was in restraints.

6. During an interview on 12/14/16 at 1:00 PM, the Chief Nursing Officer acknowledged the nursing staff failed to obtain a physician's order on the dates specified for Patient #1's, Patient #2's and Patient #3's restraints.

Based on document review, observation, and staff interview, the acute care hospital administrative staff failed to ensure the nursing staff obtained a physician's counter-signature on telephone or electronic orders for physical restraints for 3 of 4 patients with restraints (Patient #1, Patient #2, and Patient #4) within the 24 hour timeframe specified by the hospital policy. The hospital administrative staff identified 2 patients in the Intensive Care Unit (ICU) with restraints at the time of the entrance conference.

Failure to obtain a physician's counter-signature within 24 hours could potentially result in the nursing staff applying the restraints without the physician's knowledge.

Findings included:

1. Review of the policy, "Restraint - Nonviolent or Medical/Surgical," revised 5/2016, revealed the following, "The physician/[Licensed Independent Practitioner, such as an Advanced Registered Nurse Practitioner] must ... write [an] order every calendar day if [the] restraint is renewed beyond 24 hours. The order form MUST (emphasis in original) be completed and timed in the physician's or licensed independent practitioner's (LIP's) handwriting)."

2. Review of Patient #1's closed medical record revealed the physician failed to counter-sign the order for restraints within 24 hours of the nurse placing the electronic order for 12 of the 19 restraint orders (10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/22/16, 10/23/16, 10/24/16, 10/27/16, 10/28/16, 10/29/16, 10/30/16, 10/31/16).

3. Observations made at various times on 12/12/16, 12/13/16, and 12/14/16 revealed the nursing staff had applied restraints to both wrists of Patients #2 and Patients #4.

4. Review of Patient #2's open medical record revealed the physician failed to counter-sign the order for restraints within 24 hours of the nurse placing the electronic order for 1 of 2 restraint orders (12/13/16).

5. Review of Patient #4's open medical record revealed the physician failed to counter-sign the order for restraints within 24 hours of the nurse placing the electronic order for 1 of 1 restraint order (12/13/16).

6. During an interview on 12/13/16 at 10:00, the Chief Nursing Officer stated the ICU nurses placed the order for the restraints in the electronic medical records when they applied the restraints. The medical records staff review the patient's medical record after the patient discharged from the hospital. The medical records staff identifies any orders that require the physician to counter-sign them and requested the physician to sign the order in the electronic medical record. The physician had 30 days to sign any orders in the electronic medical record. The medical records staff did not realize the hospital's policy required the physician to counter-sign restraint orders within 24 hours after the nurse placed the restraints.

Based upon document review, observation, and staff interview, the acute care hospital administrative staff failed to ensure the physicians documented the patient was in restraints and the clinical justification for the restraints in the physician's daily dictation for 4 of 4 patients reviewed (Patients #1-4). The hospital administrative staff identified 2 patients in the Intensive Care Unit with restraints at the time of the entrance conference.

Failure to ensure the physicians documented the patient was in restraints and the indication for the restraints in the daily dictation could potentially allow the nursing staff to apply restraints without the physician's knowledge and without the physician monitoring the patient to ensure the safe and appropriate use of restraints in the hospital.

Findings included:

1. Review of the policy, "Restraint - Nonviolent or Medical/Surgical," revised 5/2016, revealed the following, "Documentation of [the] restraint and [the] clinical justification MUST (emphasis in original) be documented in the physician progress notes. This includes the initial application and each subsequent renewal for one continuous episode."

2. Review of Patient #1's closed medical record revealed the physicians failed to document Patient #1 was in restraints and the clinical justification for the restraints in their progress notes on 19 of 19 days Patient #1 was in restraints (10/12/16 through 10/30/16).

3. Observations made at various times on 12/12/16, 12/13/16, and 12/14/16 revealed the nursing staff had applied restraints to both wrists of Patients #2 and Patients #3. Observations made at various times on 12/13/16 and 12/14/16 revealed the nursing staff had applied restraints to both of Patient #4's wrists.

4. Review of Patient #2's open medical record revealed the physicians failed to document Patient #2 was in restraints and the clinical justification for the restraints in their progress notes on 4 of 4 days Patient #2 was in restraints (12/10/16 through 12/13/16).

5. Review of Patient #3's open medical record revealed the physicians failed to document Patient #3 was in restraints and the clinical justification for the restraints in their progress notes on 6 of 6 days Patient #3 was in restraints (12/8/16 through 12/13/16).

6. Review of Patient #4's open medical record revealed the physicians failed to document Patient #4 was in restraints and the clinical justification for the restraints in their progress notes on 1 of 1 day Patient #4 was in restraints (12/13/16).

7. During an interview on 12/14/16 at 1:00 PM, the Chief Nursing Officer acknowledged the physicians failed to document in their progress notes that the nursing staff applied restraints on the patients and the physicians failed to document the clinical justification for the use of the restraints.


1. Review of the policy, "Restraint - Nonviolent or Medical/Surgical," revised 5/2016, revealed the following: "The physician/[Licensed Independent Practitioner, such as an Advanced Registered Nurse Practitioner] must ... write [an] order every calendar day if [the] restraint is renewed beyond 24 hours."

2. Review of Patient #1's closed medical record revealed that the nursing staff failed to obtain a physician's order for Patient #1's restraints on 2 of 19 days (10/23/16 and 10/30/16) Patient #1 was in restraints.

3. Observations made at various times on 12/12/16, 12/13/16, and 12/14/16 revealed the nursing staff had applied restraints to both wrists of Patients #2 and Patients #3.

4. Review of Patient #2's open medical record revealed that the nursing staff failed to obtain a physician's order for Patient #2's restraints on 2 of 4 days (12/11/16 and 12/12/16) Patient #2 was in restraints.

5. Review of Patient #3's open medical record revealed that the nursing staff failed to obtain a physician's order for Patient #3's restraints on 5 of 7 days (12/9/16, 12/10/16, 12/11/16, 12/12/16, and 12/13/16) Patient #3 was in restraints.

6. During an interview on 12/14/16 at 1:00 PM, the Chief Nursing Officer acknowledged the nursing staff failed to obtain a physician's order on the dates specified for Patient #1's, Patient #2's, Patient #3's, and Patient #4's restraints.