HospitalInspections.org

Based on record review, document review and staff interviews it was revealed the facility failed to ensure all patients have the right to be free from restraints, of any form, imposed as a means of coercion, discipline, convenience or retaliation by the staff (see Tag A 154). The facility also failed to ensure the use of restraints in accordance with a physician's order (see Tag A 168); failed to ensure orders for the use of restraints must never be written as a standing order ( see Tag A 169); failed to follow their own policy for orders for restraints for non-violent patients (see Tag A 173); failed to ensure restraints be discontinued at the earliest possible time (see Tag A 174); and failed to ensure all physicians authorized to order restraints have a working knowledge of the hospital policy regarding the use of restraints (see Tag A 176).

A. An Immediate Jeopardy (IJ) to Patient Rights (Care in a Safe Setting) was called on 1/7/20 at 11:30 a.m. due to the facility failed to ensure the use of restraints in accordance with a physician's order; failed to ensure orders for the use of restraints must never be written as a standing order; failed to follow their own policy for orders for restraints for non-violent patients; failed to ensure restraints be discontinued at the earliest possible time; and failed to ensure all physicians authorized to order restraints have a working knowledge of the hospital policy regarding the use of restraints.

B. Harm or Potential Harm: The potential for a likely serious adverse outcome due to a lack of physician/nursing knowledge and implementation of training provided.

C. Immediacy: There is no evidence for physician training for restraint/seclusions and nursing staff failed to follow the facility policy for restraints and seclusions.

D. An immediate plan of correction was received and sent to the State agency program director. It was accepted and the facility abated the IJ on 1/7/20 at 4:45 p.m..

Based on record review and staff interviews it was revealed the facility failed to ensure all patients have the right to be free from restraints, of any form, imposed as a means of coercion, discipline, convenience or retaliation by the staff. This failure was identified in six (6) of six (6) restraints records reviewed (patient #1, 2, 3, 4, 5 and 8). This failure has the potential to adversely affect all patients.


Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was placed in soft wrist restraints on 12/23/19 at 2:07 a.m. and remained in restraints until 12/30/19. The initial order for restraint was obtained at 2:07 a.m. on 12/23/19 and was acknowledge by the physician on 12/23/19 at 7:53 a.m. No electronic or written physician signature noted on the order.

The second order for restraints for 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as a telephone order verbal/read back (TORV/RB) on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order was obtained to discontinue restraints on 12/23/19 and stated: "DISCONTINUE RESTRAINTS, Date 12/23/19, Time 2:25 p.m." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. Patient #1 was never removed from the restraints per nursing documentation. No electronic or written physician signature noted on the order.

A third order for restraints dated 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1600, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/24/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/24/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 10:14 a.m. The order was acknowledged on 12/24/19 at 10:25 a.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/25/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/25/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/25/19 at 3:57 p.m. The order was acknowledged on 12/25/19 at 4:22 p.m. The patient was in restraints five (5) hours and fifty-seven (57) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/26/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/26/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/26/19 at 3:15 p.m. The order was acknowledged on 12/26/19 at 3:25 p.m. The patient was in restraints five (5) hours and fifteen (15) minutes before an order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/27/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/27/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/27/19 at 1:31 p.m. The order was acknowledged on 12/27/19 at 1:32 p.m. The patient was in restraints three (3) hours and thirty-one (31) minutes before the restraint order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/28/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/28/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/28/19 at 4:36 p.m. The order was acknowledged on 12/28/19 at 4:46 p.m. The patient was in restraints six (6) hours and thirty-six (36) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/29/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/29/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/29/19 at 7:27 p.m. The order was acknowledged on 12/29/19 at 7:58 p.m. The patient was in restraints for nine (9) hours and twenty-seven (27) minutes before an order was obtained. No electronic or written physician signature noted on the order.
.
2. A review of the medical record for patient #2 revealed nursing documentation dated 12/24/19 at 6:49 a.m. that stated in part: " ...Called Dr. and he ordered restraints ..." There were no restraint orders signed by the physician in the record. Patient #2 was in restraints for two (2) hours on 12/24/19.

3. A review of the medical record for patient #3 revealed a restraint order dated 12/6/19 at 10:00 a.m. that stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/6/19 at 7:33 p.m. The order was acknowledged on 12/6/19 at 7:43 p.m. The patient was restrained nine (9) hours and thirty-three (33) minutes before an order was obtained. The physician's signature was 12/7/19 at 8:57 a.m.

An order for restraints dated 12/8/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/8/19 at 7:14 p.m. The order was acknowledged on 12/8/19 at 8:00 p.m. The patient was restrained nine (9) hours and fourteen (14) minutes before an order was obtained. The physician's signature was 12/8/19 at 8:22 p.m.

An order for restraints dated 12/11/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/11/19 at 11:28 a.m. The order was acknowledged on 12/11/19 at 11:32 a.m. The patient was restrained one (1) hour and twenty-eight (28) minutes before an order was obtained. The physician's signature was noted on 12/12/19 at 7:17 a.m.

An order for restraints dated 12/12/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/12/19 at 10:32 a.m. The order was acknowledged on 12/12/19 at 10:33 a.m. No physician signature noted on the order.

Upon discharge to hospice, there was no documentation the patient's restraints were ever removed before discharge.

4. A review of the medical record for patient #4 revealed a restraint order dated 12/2/19 at 03:36 a.m. It stated "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 2:37 p.m. The order was acknowledged on 12/3/19 at 2:38 p.m. The patient was restrained thirty-five (35) hours and two (2) minutes before an order was obtained. The physician's signature was noted on the order.

An order for restraints dated 12/2/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/2/19 at 2:37 p.m. The order was acknowledged on 12/2/19 at 3:20 p.m. with the physician's signature on 12/2/19 at 7:03 p.m. The patient was restrained four (4) hours and thirty-seven (37) minutes before an order was obtained.

An order for restraints dated 12/3/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 10:41 a.m. The order was acknowledged on 12/3/19 at 10:42 a.m. with the physician's signature on 12/3/19 at 2:30 p.m.

A review of the nursing discharge summary dated 12/5/19 at 12:47 p.m. reveals the patient was placed in soft limb restraints X 2 with no order from the physician. The nursing documentation did not document when the restraints were discontinued.

5. A review of the medical record for patient #5 revealed a restraint order dated 12/21/19 at 10:00 a.m. It stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/21/19 at 5:58 p.m. The order was acknowledged on 12/21/19 at 6:43 p.m. with the physician signature on 12/22/19 at 4:11 a.m. The patient was restrained seven (7) hours and fifty-eight (58) minutes before the order was obtained.

An order for restraints dated 12/24/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 12:11 p.m. The order was acknowledged on 12/24/19 at 12:11 p.m. with the physician's signature on 12/24/19 at 7:28 p.m. The patient was restrained for two (2) hours and eleven (11) minutes before the order was obtained.

A review of the nursing discharge summary revealed on 12/25/19 at 10:00 a.m. restraints were still being used on the patient with no physician order and no documentation of when the restraints were discontinued.

6. A review of the medical record for patient #8 revealed patient #8 was placed in soft wrist restraints on 1/3/20. No order for restraints for 1/4/20 was noted in the medical record. Patient #8 was in restraints from 1/3/20 to 1/7/20.

7. A review of the policy titled Restraint Management, effective 05/2018, stated in part: "Continued use of restraint beyond the first 24 hours is authorized by a physician, clinical psychologist or other authorized licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified."

8. A review of the Restraint Guidelines dated 2019, Orientation and Nursing Competencies stated in part: "Non-Violent Restraint Order-Restraints orders only valid for 24 hours, must obtain new order every 24 hours-Renew Restraints at 10 a.m.-Physicians must co-sign telephone order for restraint within 24 hours."

9. An interview was conducted with the Director of Quality and Patient Safety on 1/8/19 at approximately 3:30 p.m. He concurred restraint orders were not documented as per policy.

Based on record review, document review and staff interviews it was revealed the nursing staff failed to ensure the use of restraints were in accordance with a physician's order. This failure was identified in six (6) of six (6) restraint records reviewed, (patient #1, 2, 3, 4, 5 and 8). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was placed in soft wrist restraints on 12/23/19 at 2:07 a.m. and remained in restraints until 12/30/19. The initial order for restraint was obtained at 2:07 a.m. on 12/23/19 and was acknowledge by the physician on 12/23/19 at 7:53 a.m. No electronic or written physician signature noted on the order.

The second order for restraints for 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as a telephone order verbal/read back (TORV/RB) on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order was obtained to discontinue restraints on 12/23/19 and stated: "DISCONTINUE RESTRAINTS, Date 12/23/19, Time 2:25 p.m." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. Patient #1 was never removed from the restraints per nursing documentation. No electronic or written physician signature noted on the order.

A third order for restraints dated 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1600, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/24/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/24/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 10:14 a.m. The order was acknowledged on 12/24/19 at 10:25 a.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/25/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/25/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/25/19 at 3:57 p.m. The order was acknowledged on 12/25/19 at 4:22 p.m. The patient was in restraints five (5) hours and fifty-seven (57) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/26/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/26/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/26/19 at 3:15 p.m. The order was acknowledged on 12/26/19 at 3:25 p.m. The patient was in restraints five (5) hours and fifteen (15) minutes before an order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/27/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/27/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/27/19 at 1:31 p.m. The order was acknowledged on 12/27/19 at 1:32 p.m. The patient was in restraints three (3) hours and thirty-one (31) minutes before the restraint order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/28/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/28/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/28/19 at 4:36 p.m. The order was acknowledged on 12/28/19 at 4:46 p.m. The patient was in restraints six (6) hours and thirty-six (36) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/29/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/29/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/29/19 at 7:27 p.m. The order was acknowledged on 12/29/19 at 7:58 p.m. The patient was in restraints for nine (9) hours and twenty-seven (27) minutes before an order was obtained. No electronic or written physician signature noted on the order.
.
2. A review of the medical record for patient #2 revealed nursing documentation dated 12/24/19 at 6:49 a.m. that stated in part: " ...Called Dr. and he ordered restraints ..." There were no restraint orders signed by the physician in the record. Patient #2 was in restraints for two (2) hours on 12/24/19.

3. A review of the medical record for patient #3 revealed a restraint order dated 12/6/19 at 10:00 a.m. that stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/6/19 at 7:33 p.m. The order was acknowledged on 12/6/19 at 7:43 p.m. The patient was restrained nine (9) hours and thirty-three (33) minutes before an order was obtained. The physician's signature was 12/7/19 at 8:57 a.m.

An order for restraints dated 12/8/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/8/19 at 7:14 p.m. The order was acknowledged on 12/8/19 at 8:00 p.m. The patient was restrained nine (9) hours and fourteen (14) minutes before an order was obtained. The physician's signature was 12/8/19 at 8:22 p.m.

An order for restraints dated 12/11/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/11/19 at 11:28 a.m. The order was acknowledged on 12/11/19 at 11:32 a.m. The patient was restrained one (1) hour and twenty-eight (28) minutes before an order was obtained. The physician's signature was noted on 12/12/19 at 7:17 a.m.

An order for restraints dated 12/12/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/12/19 at 10:32 a.m. The order was acknowledged on 12/12/19 at 10:33 a.m. No physician signature noted on the order.

Upon discharge to hospice, there was no documentation the patient's restraints were ever removed before discharge.

4. A review of the medical record for patient #4 revealed a restraint order dated 12/2/19 at 03:36 a.m. It stated "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 2:37 p.m. The order was acknowledged on 12/3/19 at 2:38 p.m. The patient was restrained thirty-five (35) hours and two (2) minutes before an order was obtained. The physician's signature was noted on the order.

An order for restraints dated 12/2/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/2/19 at 2:37 p.m. The order was acknowledged on 12/2/19 at 3:20 p.m. with the physician's signature on 12/2/19 at 7:03 p.m. The patient was restrained four (4) hours and thirty-seven (37) minutes before an order was obtained.

An order for restraints dated 12/3/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 10:41 a.m. The order was acknowledged on 12/3/19 at 10:42 a.m. with the physician's signature on 12/3/19 at 2:30 p.m.

A review of the nursing discharge summary dated 12/5/19 at 12:47 p.m. reveals the patient was placed in soft limb restraints X 2 with no order from the physician. The nursing documentation did not document when the restraints were discontinued.

5. A review of the medical record for patient #5 revealed a restraint order dated 12/21/19 at 10:00 a.m. It stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/21/19 at 5:58 p.m. The order was acknowledged on 12/21/19 at 6:43 p.m. with the physician signature on 12/22/19 at 4:11 a.m. The patient was restrained seven (7) hours and fifty-eight (58) minutes before the order was obtained.

An order for restraints dated 12/24/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 12:11 p.m. The order was acknowledged on 12/24/19 at 12:11 p.m. with the physician's signature on 12/24/19 at 7:28 p.m. The patient was restrained for two (2) hours and eleven (11) minutes before the order was obtained.

A review of the nursing discharge summary revealed on 12/25/19 at 10:00 a.m. restraints were still being used on the patient with no physician order and no documentation of when the restraints were discontinued.

6. A review of the medical record for patient #8 revealed patient #8 was placed in soft wrist restraints on 1/3/20. No order for restraints for 1/4/20 was noted in the medical record. Patient #8 was in restraints from 1/3/20 to 1/7/20.

7. A review of the policy titled Restraint Management, effective 05/2018, stated in part: "Continued use of restraint beyond the first 24 hours is authorized by a physician, clinical psychologist or other authorized licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified."

8. A review of the Restraint Guidelines dated 2019, Orientation and Nursing Competencies stated in part: "Non-Violent Restraint Order-Restraints orders only valid for 24 hours, must obtain new order every 24 hours-Renew Restraints at 10 a.m.-Physicians must co-sign telephone order for restraint within 24 hours."

9. An interview was conducted with the Nurse Manager of Four (4) North and director of the second floor nursing staff on 1/7/19 at approximately 2:15 p.m. They stated all non-violent orders for restraints must be renewed every twenty-four (24) hours.

10. An interview was conducted with the Director of Quality and Patient Safety on 1/8/19 at approximately 1:30 p.m. He concurred restraints were applied to patients without appropriate orders.

Based on record review, document review and staff interviews it was revealed the nursing staff failed to ensure orders for the use of restraints were not written as a standing order. This failure was identified in four (4) of six (6) restraint records reviewed (patient #1, 3, 4 and 5). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was placed in soft wrist restraints on 12/23/19 at 2:07 a.m. and remained in restraints until 12/30/19. The initial order for restraint was obtained at 2:07 a.m. on 12/23/19 and was acknowledge by the physician on 12/23/19 at 7:53 a.m. No electronic or written physician signature noted on the order.

The second order for restraints for 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as a telephone order verbal/read back (TORV/RB) on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. The patient was in restraints six (6) hours and thirty-nine (39) minutes before an order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/24/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/24/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 10:14 a.m. The order was acknowledged on 12/24/19 at 10:25 a.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/25/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/25/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/25/19 at 3:57 p.m. The order was acknowledged on 12/25/19 at 4:22 p.m. The patient was in restraints five (5) hours and fifty-seven (57) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/26/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/26/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/26/19 at 3:15 p.m. The order was acknowledged on 12/26/19 at 3:25 p.m. The patient was in restraints five (5) hours and fifteen (15) minutes before an order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/27/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/27/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/27/19 at 1:31 p.m. The order was acknowledged on 12/27/19 at 1:32 p.m. The patient was in restraints three (3) hours and thirty-one (31) minutes before the restraint order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/28/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/28/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/28/19 at 4:36 p.m. The order was acknowledged on 12/28/19 at 4:46 p.m. The patient was in restraints six (6) hours and thirty-six (36) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/29/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/29/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/29/19 at 7:27 p.m. The order was acknowledged on 12/29/19 at 7:58 p.m. The patient was in restraints for nine (9) hours and twenty-seven (27) minutes before an order was obtained. No electronic or written physician signature noted on the order.

2. A review of the medical record for patient #3 revealed a restraint order dated 12/6/19 at 10:00 a.m. that stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/6/19 at 7:33 p.m. The order was acknowledged on 12/6/19 at 7:43 p.m. The patient was restrained nine (9) hours and thirty-three (33) minutes before an order was obtained. The physician's signature was 12/7/19 at 8:57 a.m.

An order for restraints dated 12/8/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/8/19 at 7:14 p.m. The order was acknowledged on 12/8/19 at 8:00 p.m. The patient was restrained nine (9) hours and fourteen (14) minutes before an order was obtained. The physician's signature was 12/8/19 at 8:22 p.m.

An order for restraints dated 12/11/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/11/19 at 11:28 a.m. The order was acknowledged on 12/11/19 at 11:32 a.m. The patient was restrained one (1) hour and twenty-eight (28) minutes before an order was obtained. The physician's signature was noted on 12/12/19 at 7:17 a.m.

An order for restraints dated 12/12/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/12/19 at 10:32 a.m. The order was acknowledged on 12/12/19 at 10:33 a.m. No physician signature noted on the order.

3. A review of the medical record for patient #4 revealed a restraint order dated 12/2/19 at 03:36 a.m. It stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 2:37 p.m. The order was acknowledged on 12/3/19 at 2:38 p.m. The patient was restrained thirty-five (35) hours and two (2) minutes before an order was obtained. The physician's signature was noted on the order.

An order for restraints dated 12/2/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/2/19 at 2:37 p.m. The order was acknowledged on 12/2/19 at 3:20 p.m. with the physician's signature on 12/2/19 at 7:03 p.m. The patient was restrained four (4) hours and thirty-seven (37) minutes before an order was obtained.

An order for restraints dated 12/3/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 10:41 a.m. The order was acknowledged on 12/3/19 at 10:42 a.m. with the physician's signature on 12/3/19 at 2:30 p.m.

4. A review of the medical record for patient #5 revealed a restraint order dated 12/21/19 at 10:00 a.m. It stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/21/19 at 5:58 p.m. The order was acknowledged on 12/21/19 at 6:43 p.m. with the physician signature on 12/22/19 at 4:11 a.m. The patient was restrained seven (7) hours and fifty-eight (58) minutes before the order was obtained.

An order for restraints dated 12/24/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 12:11 p.m. The order was acknowledged on 12/24/19 at 12:11 p.m. with the physician's signature on 12/24/19 at 7:28 p.m. The patient was restrained for two (2) hours and eleven (11) minutes before the order was obtained.

A review of the nursing discharge summary revealed on 12/25/19 at 10:00 a.m. restraints were still being used on the patient with no physician order and no documentation of when the restraints were discontinued.

5. A review of the policy titled Restraint Management, effective 05/2018, stated in part: "Continued use of restraint beyond the first 24 hours is authorized by a physician, clinical psychologist or other authorized licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified."

6. A review of the Restraint Guidelines dated 2019, Orientation and Nursing Competencies stated in part: "Non-Violent Restraint Order-Restraints orders only valid for 24 hours, must obtain new order every 24 hours-Renew Restraints at 10 a.m.-Physicians must co-sign telephone order for restraint within 24 hours."

7. An interview was conducted with the Nurse Manager of Four (4) North and director of the second floor nursing staff on 1/7/19 at approximately 2:15 p.m. They stated all non-violent orders for restraints must be renewed every twenty-four (24) hours. The director of the second floor nursing staff stated: "All the nurses are instructed to write restraint orders for 10:00 a.m."

8. An interview was conducted with the Director of Quality and Patient Safety on 1/7/20 at approximately 9:30 a.m. He concurred all the orders appear to be standing orders.

Based on record review, document review and staff interviews it was revealed the nursing staff failed to follow the hospital policy for renewal of non-violent restraint orders. This failure was identified in five (5) of six (6) restraint charts reviewed (patient #1, 3, 4, 5 and 8). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the policy titled Restraint Management, effective 05/2018, stated in part: "Continued use of restraint beyond the first 24 hours is authorized by a physician, clinical psychologist or other authorized licensed independent practitioner renewing the original order or issuing a new order if restraint continues to be clinically justified."

2. A review of the Restraint Guidelines dated 2019, Orientation and Nursing Competencies stated in part: "Non-Violent Restraint Order-Restraints orders only valid for 24 hours, must obtain new order every 24 hours-Renew Restraints at 10 a.m.-Physicians must co-sign telephone order for restraint within 24 hours."

3. A review of the medical record for patient #1 revealed patient #1 was placed in soft wrist restraints on 12/23/19 at 2:07 a.m. and remained in restraints until 12/30/19. The initial order for restraint was obtained at 2:07 a.m. on 12/23/19 and was acknowledge by the physician on 12/23/19 at 7:53 a.m. No electronic or written physician signature noted on the order.

The second order for restraints for 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as a telephone order verbal/read back (TORV/RB) on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order was obtained to discontinue restraints on 12/23/19 and stated: "DISCONTINUE RESTRAINTS, Date 12/23/19, Time 2:25 p.m." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. Patient #1 was never removed from the restraints per nursing documentation. No electronic or written physician signature noted on the order.

A third order for restraints dated 12/23/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/23/19, Time 1600, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/24/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/24/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 10:14 a.m. The order was acknowledged on 12/24/19 at 10:25 a.m. No electronic or written physician signature noted on the order.

An order for restraints dated 12/25/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/25/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/25/19 at 3:57 p.m. The order was acknowledged on 12/25/19 at 4:22 p.m. The patient was in restraints five (5) hours and fifty-seven (57) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/26/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/26/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/26/19 at 3:15 p.m. The order was acknowledged on 12/26/19 at 3:25 p.m. The patient was in restraints five (5) hours and fifteen (15) minutes before an order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/27/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/27/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/27/19 at 1:31 p.m. The order was acknowledged on 12/27/19 at 1:32 p.m. The patient was in restraints three (3) hours and thirty-one (31) minutes before the restraint order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/28/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/28/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/28/19 at 4:36 p.m. The order was acknowledged on 12/28/19 at 4:46 p.m. The patient was in restraints six (6) hours and thirty-six (36) minutes before the order was obtained. No electronic or written physician signature noted on the order.

An order for restraints dated 12/29/19 stated: "RESTRAINT NON-VIOLENT PATIENT, Date 12/29/19, Time 1000, SOFT LIMB X 2." The nursing staff documented the order as TORV/RB on 12/29/19 at 7:27 p.m. The order was acknowledged on 12/29/19 at 7:58 p.m. The patient was in restraints for nine (9) hours and twenty-seven (27) minutes before an order was obtained. No electronic or written physician signature noted on the order.

4. A review of the medical record for patient #3 revealed a restraint order dated 12/6/19 at 10:00 a.m. that stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/6/19 at 7:33 p.m. The order was acknowledged on 12/6/19 at 7:43 p.m. The patient was restrained nine (9) hours and thirty-three (33) minutes before an order was obtained. The physician's signature was 12/7/19 at 8:57 a.m.

An order for restraints dated 12/8/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/8/19 at 7:14 p.m. The order was acknowledged on 12/8/19 at 8:00 p.m. The patient was restrained nine (9) hours and fourteen (14) minutes before an order was obtained. The physician's signature was 12/8/19 at 8:22 p.m.

An order for restraints dated 12/11/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/11/19 at 11:28 a.m. The order was acknowledged on 12/11/19 at 11:32 a.m. The patient was restrained one (1) hour and twenty-eight (28) minutes before an order was obtained. The physician's signature was noted on 12/12/19 at 7:17 a.m.

An order for restraints dated 12/12/19 at 10:00 a.m. states: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/12/19 at 10:32 a.m. The order was acknowledged on 12/12/19 at 10:33 a.m. No physician signature noted on the order.

Upon discharge to hospice, there was no documentation the patient's restraints were ever removed before
discharge.

5. A review of the medical record for patient #4 revealed a restraint order dated 12/2/19 at 03:36 a.m. It stated "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 2:37 p.m. The order was acknowledged on 12/3/19 at 2:38 p.m. The patient was restrained thirty-five (35) hours and two (2) minutes before an order was obtained. The physician's signature was noted on the order.

An order for restraints dated 12/2/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/2/19 at 2:37 p.m. The order was acknowledged on 12/2/19 at 3:20 p.m. with the physician's signature on 12/2/19 at 7:03 p.m. The patient was restrained four (4) hours and thirty-seven (37) minutes before an order was obtained.

An order for restraints dated 12/3/19 at 10:00 a.m. stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/3/19 at 10:41 a.m. The order was acknowledged on 12/3/19 at 10:42 a.m. with the physician's signature on 12/3/19 at 2:30 p.m.

A review of the nursing discharge summary dated 12/5/19 at 12:47 p.m. reveals the patient was placed in soft limb restraints X 2 with no order from the physician. The nursing documentation did not document when the restraints were discontinued.

6. A review of the medical record for patient #5 revealed a restraint order dated 12/21/19 at 10:00 a.m. It stated: "Restraint Non-Violent, Pulling at Tubes/IV/Dressings/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/21/19 at 5:58 p.m. The order was acknowledged on 12/21/19 at 6:43 p.m. with the physician signature on 12/22/19 at 4:11 a.m. The patient was restrained seven (7) hours and fifty-eight (58) minutes before the order was obtained.

An order for restraints dated 12/24/19 at 10:00 a.m. stated: "Restraint Non-Violent, Disoriented/Confused, Soft Limb X 2." The nursing staff documented the order as TORV/RB on 12/24/19 at 12:11 p.m. The order was acknowledged on 12/24/19 at 12:11 p.m. with the physician's signature on 12/24/19 at 7:28 p.m. The patient was restrained for two (2) hours and eleven (11) minutes before the order was obtained.

A review of the nursing discharge summary revealed on 12/25/19 at 10:00 a.m. restraints were still being used on the patient with no physician order and no documentation of when the restraints were discontinued.

7. A review of the medical record for patient #8 revealed patient #8 was placed in soft wrist restraints on 1/3/20. No order for restraints for 1/4/20 was noted in the medical record. Patient #8 was in restraints from 1/3/20 to 1/7/20.

8. An interview was conducted with the Nurse Manager of Four (4) North and director of the second floor nursing staff on 1/7/19 at approximately 2:15 p.m. They stated all non-violent orders for restraints must be renewed every twenty-four (24) hours. The director of the second floor nursing staff concurred it appeared orders for restraints were not received per policy.

9. An interview was conducted with the Director of Quality on 1/8/20 at approximately 1:00 p.m. He concurred restraint orders for non-violent restraints were not obtained as per policy..

Based on record review and staff interviews it was revealed the nursing staff failed to discontinue restraints at the earliest possible time regardless of the length of time of the order. This failure was identified in one (1) of six (6) restraint records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was placed in soft wrist restraints on 12/23/19 at 2:07 a.m. and remained in restraints until 12/30/19. The initial order for restraint was obtained at 2:07 a.m. An order was obtained to discontinue restraints on 12/23/19 which stated: "DISCONTINUE RESTRAINTS, Date 12//23/19, Time 2:25 p.m." The nursing staff documented the order as TORV/RB on 12/23/19 at 4:39 p.m. The order was acknowledged on 12/23/19 at 4:39 p.m. Patient #1 was never removed from the restraints per nursing documentation.

2. An interview was conducted with the Director of Quality and Patient Safety on 1/7/19 at 10:10 a.m. He concurred the patient was never removed from restraints.

Based on record review and staff interviews it was revealed the facility failed to ensure all physicians authorized to order restraints have a working knowledge of hospital policy regarding the use of restraints. This failure has the potential to adversely affect all patients.

1. An interview was conducted with the Director of Quality and Patient Safety on 1/7/19 at 10:10 a.m. He stated, "No training is conducted with the physicians regarding hospital policy on the use of restraints."

2. A review of the medical staff bylaws dated 2019 stated in part: "PATIENT RESTRAINT ORDERS All medical staff members shall abide by federal law, Joint Commission standards and all hospital policies pertaining to restraints and seclusion."