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Based on policy and procedure review, clinical record review and interview, it was determined the plan of care for three of three (#11, #12 and #13) restrained patients was not modified to reflect the use of restraints as outlined in policy and procedure. Failure to include the use of restraints in the plan of care did not allow staff to assess the need for restraints, plan interventions to use less restrictive measures, and evaluate the patient's response to those measures in order to release the patient from restraints at the earliest and safest time. The failed practice affected Patients #11, #12 and #13. Findings follow:

A. Review of the policy and procedure titled "Restraint Use Policy and Procedure," received on 08/14/18 showed the use of restraints was to be in accordance with a written modification to the patient's plan of care.

B. Review of Patient #11's clinical record showed an order dated 06/23/18 for soft wrist restraints. Review of the plan of care showed no mention of restraint usage. During an interview with the Director of Quality Services at 10:50 AM on 08/16/18 the above was verified.

C. Review of Patient #12's clinical record showed an order dated and timed for 06/20/18, 9:00 PM for restraints. Review of the plan of care showed no mention of restraint usage. During an interview with the Director of Quality Services at 11:44 AM on 08/16/18 the above was verified.

D. Review of Patient #13's clinical record showed no orders for restraints. Review of the clinical record showed restraint check documentation every one hour from 06/07/18 through 06/11/18. Review of the plan of care showed no mention of restraint usage. During an interview with the Director of Quality Services at 11:46 AM on 08/16/18 the above was verified.

Based on policy and procedure review, clinical record review and interview, it was determined the one (#13) of three (#11, #12 and #13) patients were restrained without physician's orders and one (#11) of three (#11, #12 and #13) patient's restraint order was not dated and timed as outlined in policy and procedure. Failure to obtain a physician's order for restraints and failure to date and time physician's restraint orders did not allow the physician to be knowledgeable regarding the patient's need for restraints, the time restraints were initiated and did not allow the facility to be in compliance with its policy and procedure. The failed practice affected Patient #13 and #11. Findings follow:

A. Review of the policy and procedure titled "Restraint Use Policy and Procedure," received on 08/14/18 showed use of restraints was only in accordance with a written order for restraints and the written order for restraints must state the date and time.

B. Review of Patient #13's clinical record showed restraints were initiated at 7:00 AM on 06/07/18 and discontinued at 8:11 AM on 06/11/18. Review of the clinical record showed no orders for restraints on any of the days Patient #13 was restrained. During an interview with the Director of Quality at 11:46 AM on 08/16/18 the above findings were verified.

C. Review of Patient #11's clinical record showed restraints were initiated at 6:00 PM on 06/22/18 and discontinued at 3:05 PM on 06/24/18. Review of the clinical record showed two restraint orders in the chart. The first restraint order was not timed but was dated 06/23/18. The physician's signature was dated 06/23/18 but was not timed. The second restraint order was not timed or dated. The physician's signature was dated 06/24/18. During an interview with the Director of Quality at 10:50 AM on 08/16/18 the above findings were verified.