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Based upon hospital policy review, open medical record review and staff interview the hospital staff failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner for 2 of 2 restrained patients reviewed (#8, #3).

The findings include:

Review of current hospital policy "Patient Restraint Policy" revised August 2009, revealed "Acute medical and surgical non-psychiatric care *Restraint is used upon the order of a licensed independent practitioner ...*Continued use of restraint beyond the first 24 hours is authorized by a licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified. *Physician orders for restraints must be renewed every calendar day with the renewal being based on the physician's examination of the patient. ...No prn orders can be given or received for restraints. If the reason for restraint changes, a new order must be received."

1. Open record review on 09/29/2010 for Patient #8 revealed an 87 year-old male admitted to the hospital on 09/16/2010 with a diagnosis of Hypotension (low blood pressure) and hypothermia (low body temperature). Record review revealed the patient was restrained on multiple days from 09/18/2010 until 09/29/2010 (date of survey).

Record review of a Restraint Order (sticker) signed by a physician on 09/19/2010 at 0430 revealed an order for restraint renewal was written for the continued use of restraints. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." Review of nursing documentation revealed the patient was restrained until 09/19/2010 at 1100. Review of nursing documentation revealed the patient was removed from restraints on 09/19/2010 at 1100 and remained out of restraints until 09/19/2010 at 2000 (8 hours 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 2000 on 09/19/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 09/20/2010 at 0830, 12 hours and 29 minutes later. Record review revealed the patient was restrained from 09/19/2010 at 2000 until 09/20/2010 at 0829 (12 hours and 29 minutes) without a physician's order.

Interview on 09/30/2010 at 1000 with nursing management staff revealed a physician's order is required to place a patient into a restraint. Interview revealed restraint orders for acute medical surgical non-psychiatric care patients are renewed every calendar day. Interview revealed a calendar day is defined by the date and not by the hours. Interview revealed a preprinted restraint order sticker is placed into the patient's chart to document the initial order for restraint and to prompt the physicians to renew the orders for restraints if indicated. Interview revealed preprinted at the top of the restraint order sticker is the verbiage No PRN (as needed) orders to be issued. All restraint orders are time limited to 24 hours. Interview revealed when an initial or renewal restraint order is obtained the order is time limited to the calendar day and not more than 24 hours. Interview revealed a patient can be placed into and removed from restraints multiple times throughout the calendar day without the nursing staff having to obtain an order each time the patient is restrained, but there must be a current initial or renewal restraint order obtained for that calendar day. Interview confirmed the above findings from the medical record review of Patient #8.

2. Closed record review on 09/29/2010 for Patient #3 revealed an 79 year-old male admitted to the hospital on 07/11/2010 with a diagnosis of Altered Mental Status, Sepsis, Hypotension (low blood pressure), Blood loss anemia, Gastrointestinal bleeding, and Non-ST elevation Myocardial Infarction (heart attack). Record review revealed the patient was restrained on multiple days from 07/11/2010 until discharge on 07/30/2010.

Review of a preprinted Restraint Order (sticker) signed by a physician on 07/15/2010 (not timed) revealed an order for restraint renewal was written for the continued use of restraints. Review of the physician's order revealed the prescribing physician failed to time the restraint order when written. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." (Per hospital policy and staff interview, the restraint order is time limited to the calendar date written, but not more than 24 hours. Therefore, the restraint order written on 07/15/2010 (not timed) expired at 2359 on 07/15/2010). Record review revealed nursing documentation the patient was in restraints from 0000 on 07/16/2010 until 0014 on 07/17/2010 (24 hours 14 minutes) without documented evidence of a physician's order for restraints on calendar date 07/16/2010.

Review of nursing documentation revealed the patient was continually restrained with soft wrist restraints from 0000 on 07/20/2010 and remained restrained until the restraints were discontinued at 0800 on 07/20/2010. Review of nursing documentation revealed the patient was removed from restraints at 0800 and remained out of restraints until 1200 (1 hour 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 1200 on 07/20/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 07/21/2010 (not timed). Record review revealed the patient was restrained from 07/20/2010 at 1200 until 07/21/2010 (start of new calendar day) at 0000 (11 hours and 59 minutes) without a new physician's order for restraint renewal.

Review of a preprinted Restraint Order sticker revealed a written physician's order dated 07/21/2010 (not timed) for renewal of restraints. Review of nursing documentation revealed the patient was continually restrained with soft wrist restraints from 0000 on 07/21/2010 and remained restrained until the restraints were discontinued at 1400 on 07/21/2010. Review of nursing documentation revealed the patient was removed from restraints at 1400 and remained out of restraints until 1600 (1 hour 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 1600 on 07/21/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 07/22/2010 (not timed). Record review revealed the patient was restrained from 07/21/2010 at 1600 until 07/22/2010 (start of new calendar day) at 0000 (7 hours and 59 minutes) without a new physician's order for restraint renewal.

Interview on 09/30/2010 at 1000 with nursing management staff revealed a physician's order is required to place a patient into a restraint. Interview revealed restraint orders for acute medical surgical non-psychiatric care patients are renewed every calendar day. Interview revealed a calendar day is defined by the date and not by the hours. Interview revealed a preprinted restraint order sticker is placed into the patient's chart to document the initial order for restraint and to prompt the physicians to renew the orders for restraints if indicated. Interview revealed preprinted at the top of the restraint order sticker is the verbiage No PRN (as needed) orders to be issued. All restraint orders are time limited to 24 hours. Interview revealed when an initial or renewal restraint order is obtained the order is time limited to the calendar day and not more than 24 hours. Interview revealed a patient can be placed into and removed from restraints multiple times throughout the calendar day without the nursing staff having to obtain an order each time the patient is restrained, but there must be a current initial or renewal restraint order obtained for that calendar day. Interview confirmed the above findings from the medical record review of Patient #3.

Based upon hospital policy review, medical record review and staff interview the hospital staff failed to ensure the orders for the use of restraints are not written as a standing order or on an as needed basis for 2 of 2 restrained patients reviewed (#8, #3).

The findings include:

Review of current hospital policy "Patient Restraint Policy" revised August 2009, revealed "Acute medical and surgical non-psychiatric care *Restraint is used upon the order of a licensed independent practitioner ...*Continued use of restraint beyond the first 24 hours is authorized by a licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified. *Physician orders for restraints must be renewed every calendar day with the renewal being based on the physician's examination of the patient. ...No prn orders can be given or received for restraints. If the reason for restraint changes, a new order must be received."

1. Open record review on 09/29/2010 for Patient #8 revealed an 87 year-old male admitted to the hospital on 09/16/2010 with a diagnosis of Hypotension (low blood pressure) and hypothermia (low body temperature). Record review revealed the patient was restrained on multiple days from 09/18/2010 until 09/29/2010 (date of survey).

Review of a preprinted Restraint Order sticker revealed a telephone physician's order obtained by a registered nurse on 9/18/2010 at 0430 for an initial order for restraints. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." Review of nursing documentation revealed the patient was continually restrained with soft wrist restraints from 0430 on 09/18/2010 and remained restrained at 0430 on 09/19/2010 when the 24 hours time limit expired on the initial restraint order. Further record review revealed a Restraint Order (sticker) signed by a physician on 09/19/2010 at 0430 revealed an order for restraint renewal was written for the continued use of restraints. Review of nursing documentation revealed the patient remained restrained until 09/19/2010 at 1100 (an additional 6 hours and 30 minutes). Review of nursing documentation revealed the patient was removed from restraints on 09/19/2010 at 1100 and remained out of restraints until 09/19/2010 at 2000 (8 hours 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 2000 on 09/19/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 09/20/2010 at 0830, 12 hours and 29 minutes later. Record review revealed the patient was restrained from 09/19/2010 at 2000 until 09/20/2010 at 0829 (12 hours and 29 minutes) without a new physician's order.

Interview on 09/30/2010 at 1000 with nursing management staff revealed a physician's order is required to place a patient into a restraint. Interview revealed restraint orders for acute medical surgical non-psychiatric care patients are renewed every calendar day. Interview revealed a calendar day is defined by the date and not by the hours. Interview revealed a preprinted restraint order sticker is placed into the patient's chart to document the initial order for restraint and to prompt the physicians to renew the orders for restraints if indicated. Interview revealed preprinted at the top of the restraint order sticker is the verbiage No PRN (as needed) orders to be issued. All restraint orders are time limited to 24 hours. Interview revealed when an initial or renewal restraint order is obtained the order is time limited to the calendar day and not more than 24 hours. Interview revealed a patient can be placed into and removed from restraints multiple times throughout the calendar day without the nursing staff having to obtain an order each time the patient is restrained, but there must be a current initial or renewal restraint order obtained for that calendar day. Interview revealed the nursing management staff was unaware a new order was needed each time a patient was removed from and placed back into restraints. Further interview revealed the nursing management staff never considered their current practice to be a form of PRN (as needed) orders. Interview confirmed the above findings from the medical record review of Patient #8.

2. Closed record review on 09/29/2010 for Patient #3 revealed an 79 year-old male admitted to the hospital on 07/11/2010 with a diagnosis of Altered Mental Status, Sepsis, Hypotension (low blood pressure), Blood loss anemia, Gastrointestinal bleeding, and Non-ST elevation Myocardial Infarction (heart attack). Record review revealed the patient was restrained on multiple days from 07/11/2010 until discharge on 07/30/2010.

Review of a preprinted Restraint Order (sticker) signed by a physician on 07/15/2010 (not timed) revealed an order for restraint renewal was written for the continued use of restraints. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." Review of the physician's order revealed the prescribing physician failed to time the restraint order when written. (Per hospital policy and staff interview, the restraint order is time limited to the calendar date written, but not more than 24 hours. Therefore, the restraint order written on 07/15/2010 (not timed) expired at 2359 on 07/15/2010). Review of nursing documentation dated 07/16/2010 at 0000 revealed the patient was continually restrained with soft wrist restraints from 0000 on 07/16/2010 until 0014 on 07/17/2010 (24 hours 14 minutes later). Further review revealed a restraint order signed by a physician on 07/17/2010 at 0015 was written for the continued use of restraints. Record review failed to reveal any available documentation of a physician's restraint order for renewal was obtained by the nursing staff or written by a physician on 07/16/2010. Record review confirmed the patient was restrained without evidence of a physician's restraint order from 0000 on 07/16/2010 until 0014 on 07/17/2010 (24 hours 14 minutes).

Review of a preprinted Restraint Order sticker revealed a written physician's order dated 07/20/2010 (not timed) for renewal of restraints. Review of nursing documentation revealed the patient was continually restrained with soft wrist restraints from 0000 on 07/20/2010 and remained restrained until the restraints were discontinued at 0800 on 07/20/2010. Review of nursing documentation revealed the patient was removed from restraints at 0800 and remained out of restraints until 1200 (1 hour 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 1200 on 07/20/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 07/21/2010 (not timed). Record review revealed the patient was restrained from 07/20/2010 at 1200 until 07/21/2010 (start of new calendar day) at 0000 (11 hours and 59 minutes) without a new physician's order for restraint renewal.

Review of a preprinted Restraint Order sticker revealed a written physician's order dated 07/21/2010 (not timed) for renewal of restraints. Review of nursing documentation revealed the patient was continually restrained with soft wrist restraints from 0000 on 07/21/2010 and remained restrained until the restraints were discontinued at 1400 on 07/21/2010. Review of nursing documentation revealed the patient was removed from restraints at 1400 and remained out of restraints until 1600 (1 hour 59 minutes later) at which time the patient was restrained with soft wrist restraints by nursing staff. Record review failed to reveal any available documentation the nursing staff obtained a new physician's order for restraints at 1600 on 07/21/2010 when the patient was placed back into soft wrist restraints. Further record review revealed the next restraint order was written by a physician on 07/22/2010 (not timed). Record review revealed the patient was restrained from 07/21/2010 at 1600 until 07/22/2010 (start of new calendar day) at 0000 (7 hours and 59 minutes) without a new physician's order for restraint renewal.

Review of a preprinted Restraint Order (sticker) electronically signed by a physician on 08/03/2010 at 2221 for 07/25/2010 (not timed) revealed an order for restraint renewal was written for the continued use of restraints. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." Review of the physician's order revealed the prescribing physician failed to time the restraint order when written. (Per hospital policy and staff interview, the restraint order is time limited to the calendar date written, but not more than 24 hours. Therefore, the restraint order written on 07/25/2010 (not timed) expired at 2359 on 07/25/2010). Review of nursing documentation dated 07/24/2010 at 1915 revealed restraints were discontinued. Further review revealed the patient remained out of restraint from 1915 on 07/24/2010 until 0930 on 7/26/2010 (38 hrs 14 mins later) when the patient was placed back into restraints. Record review revealed no documented evidence the patient was in restraints on calendar date 7/25/2010 (24 hours), when the order for restraints was written (a PRN order).

Review of a preprinted Restraint Order (sticker) signed by a physician on 07/29/2010 at 0718 revealed an order for restraint renewal was written for the continued use of restraints. Review of the order revealed at the top of the sticker "Restraint Order No PRN orders to be issued. All restraint orders are time limited to 24 hours." Review of nursing documentation dated 07/28/2010 at 1000 revealed restraints had been discontinued at 1000, 21 hours and 18 minutes prior to the physician writing the restraint order renewal on 07/29/2010 at 0719. Record review revealed no documented evidence the patient was in restraints on 07/29/2010 from 0718 until 7/30/2010 at 0718, the time period when the order for restraints (a PRN order) was written.

Interview on 09/30/2010 at 1000 with nursing management staff revealed a physician's order is required to place a patient into a restraint. Interview revealed restraint orders for acute medical surgical non-psychiatric care patients are renewed every calendar day. Interview revealed a calendar day is defined by the date and not by the hours. Interview revealed a preprinted restraint order sticker is placed into the patient's chart to document the initial order for restraint and to prompt the physicians to renew the orders for restraints if indicated. Interview revealed preprinted at the top of the restraint order sticker is the verbiage No PRN (as needed) orders to be issued. All restraint orders are time limited to 24 hours. Interview revealed when an initial or renewal restraint order is obtained the order is time limited to the calendar day and not more than 24 hours. Interview revealed a patient can be placed into and removed from restraints multiple times throughout the calendar day without the nursing staff having to obtain an order each time the patient is restrained, but there must be a current initial or renewal restraint order obtained for that calendar day. Interview revealed the nursing management staff was unaware a new order was needed each time a patient was removed (discontinued) from and placed back into restraints. Further interview revealed the nursing management staff never considered their current practice to be a form of PRN (as needed) orders. Interview confirmed the above findings from the medical record review of Patient #3.

NC00065870