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Based on hospital policy and procedure review, medical record review, and staff interview the hospital failed to obtain an initial physician order for restraints for 1 of 4 patients restrained (Patient #2).

The findings include:

Review of the hospital's "Restraints and Seclusion" policy, Number NH-PC-PS-1690, revised 03/2012 revealed "...4. Order required - a. Individual order required - The use of restraint or seclusion must be in accordance with the individual order of a practitioner who is responsible for the care of the patient. orders must never be written as a standing order or on an as needed bases (PRN)....e. Emergency situations - In an emergency situation, trained staff may initiate restraint application. An order must be obtained either during the emergency application or immediately (within a few minutes) after the restraint has been applied. ..."

Open medical record review of Patient #2 revealed a 74 year old male admitted 03/15/2014 with acute respiratory failure and transfusion dependent anemia. Record review revealed the patient was intubated and reaching for the endotracheal tube despite verbal direction. Review revealed the patient was restrained with soft wrist restraints and the RN (Registered Nurse) signed the Restraint/Seclusion Nursing Assessment and Physician Orders form on 03/20/2014 at 1100. Further review revealed the space for the telephone order signature was left blank, with no documentation that a physician was immediately notified or a telephone order obtained. Continued review revealed a physician signed the form on 03/21/2014 at 0800 (21 hours after the restraint was initiated).

Interview on 03/27/2014 at 1535 with the Nursing Unit Leader (UL) of Unit #2 revealed the policy requires immediate physician notification of a restraint and that usual nursing practice is to the call the physician at the time the form is completed. Interview revealed nursing does not generally sign the form as a verbal order. Interview revealed that the UL was not present when the restraint was initiated and that she could not provide any additional information to validate if the physician was immediately notified or a verbal order received. Interview confirmed there was no other documentation available.