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Based on record review and interview the facility failed to document physician orders for four (4) point locked restraints for two (#'s 11 and 12) of three (3) patients reviewed for restraints from a total sample of 12 patients, resulting in the potential for loss of patient rights, risk of injury and risk for negative outcomes. Findings include:

On 5/23/18 at 1330 and 5/23/18 at 1300 a review of the restraint logs dated 1/6/18 to 5/21/18, documented patient #11 had been restrained in locking violent restraints to all four (4) limbs on 5/4/18 from 0940 to 5/4/18 at 1553 (6 hours 13 minutes).

Review of patient #11's closed electronic record with staff B, Director of Accreditation, staff D, third floor manager, and Staff R revealed patient #11 entered the emergency department on 5/3/18 at 1707 for an overdose of Barbiturates. Nursing documentation noted initiation of violent four (4) limb restraints (right and left arms and legs) at 0940. The nursing flow sheet for every 15 minute checks documented the physician was notified and an order was obtained. A verbal order was noted as signed by staff Q on 5/4/18 at 0755. No orders were documented by the physician for renewal of the restraints prior to the expiration of the order in four hours. Review of patient #11's physician orders revealed physician staff Q ordered "Adult violent restraint (18 yrs and older) Locked restraint X 4; Danger to self, Danger to others. Continuous X 4 hours" on 5/4/18 at 1840 and 1841 (the restraints were removed at 1553). Staff D and R confirmed at the time of the record review that no other physician orders were found in the clinical record for restraints for patient #11.

On 5/23/18 at 1538 physician staff Q was interviewed by telephone and stated he recalled patient #11 and the need for restraints. He stated he had seen the patient before the restraints were placed and she was behaving aggressively but had clamed down after he spoke to her. Staff Q stated at that time we were attempting to keep her calm and avoided the need for restraints. He stated after he left patient #11 escalated, was yelling, swung at a nurse and kicked a security guard, and was placed in restraints. When asked about the timing of the orders for restraints Staff Q stated he was rounding and was not free to excuse himself until later when he wrote the orders. He stated after rounding the nurse informed him he needed to document the restraint orders. Staff Q stated he was looking at the orders and was now aware he needed to write the orders and see the patient within 30 minutes.

On 5/23/18 at 1330 and 5/23/18 at 1300 a review of the restraint logs dated 1/6/18 to 5/21/18 documented patient #12 had been restrained in locking violent restraints to all four (4) limbs on 4/17/18 from 0955 to 4/18/18 at 0100 (15 hours).

Review of patient #12's closed electronic record with staff B, staff D, and staff R revealed patient #12 entered the emergency department via ambulance on at 4/17/18 at 0954 with restraints in place for altered and combative behavior following a grand mal seizure. Nursing documentation noted initiation of violent four (4) limb restraints (right and left arms and legs) at 0955. The nursing flow sheet documented the physician was notified and an order was obtained. (No written verbal order was found in the clinical record signed by a physician). Review of patient #12's physician orders revealed physician staff S ordered "Adult violent restraint (18 yrs and older) Locked restraint X 4; Danger to self, Danger to others. Continuous X 4 hours" on 4/17/18 at 1346 and 1730 (within the required 4 hours). An additional order identical to the above orders was documented by another physician on 4/17/18 at 1651. No order for renewal of the restraints before it expired on 4/17/18 at 2155 was documented. Staff D and R confirmed at the time of the record review no other physician orders were found for restraints for patient #12.

Copies of the reviewed documentation were requested and received.

On 5/23/17 at 1015 the facility Chief Nursing Officer staff C stated she understood the concerns found related to restraints and was taking immediate action. She stated all medical staff were educated on restraints in July of 2017. (A copy of the medical staff education was provided by staff B and reviewed).

On 5/23/18 at 1410 physician staff S was interviewed via telephone regarding the restraint orders for patient #12. Staff S stated he recalled the patient and that the initial order may have been a verbal order to the nurse and that he may not have documented it within 30 minutes. He stated the patient had come in with restraints applied in the ambulance and they were continued after arrival. He stated he had training on restraints and understands they must be signed within 30 minutes.

On 5/23/18 at 1310 the facility Vice President of Medical Affairs, staff P was interviewed at the facility regarding restraints. Staff P stated all physician staff receive restraint training as part of their orientation and again yearly, it is covered at the Medical Executive meetings and also included in the medical staff monthly newsletter at the time of the yearly training. Staff P stated the lack of documentation is a concern, adding we know if it is not documented it's not done. He stated all medical staff are aware of and expected to follow the restraint policy.

Review of the facility's policy A-104, titled Restraints and Seclusion-Acute Care, dated reviewed 12/1/17 documented the following: Purpose: To minimize risk of injury where there is risk of potential patient harm from unrestrained movement; ensure utilization of the least restrictive form of restraint for the shortest period of time; protect patient's rights, dignity, and well-being during restraint use; and provide guidelines for the usage, implementation, monitoring and discontinuation of restraints by trained staff. . . (page 6 of 15) Violent or destructive 2. Initiation/Implementation (violent) a. Prior to restraint application/seclusion initiation, obtain an order. The RN (registered nurse) obtains an order from the physician. . .within 30 minutes. The order includes the following information: 1) Time and date of the order 2) Time limit 3) Clinical justification for restraint/seclusion 4) Type of restraint/seclusion used 5) Any contraindications to restraints/seclusion. . .e. Orders for restraints/seclusion are limited to *Patients 18 and older-4 hours. . .f. Restraints/seclusion may be renewed, at the intervals indicated above, for up to 24 hours. An order is placed for each renewal. . .

Based on record review and interview the facility failed to document physician face to face assessments within one hour for patients in violent restraints for one (#11) of three (3) patients reviewed for restraints from a total sample of 12 patients, resulting in the potential for loss of patient rights, risk of injury and risk for negative outcomes. Findings include:

On 5/23/18 at 1330 and 5/23/18 at 1300 a review of the restraint logs dated 1/6/18 to 5/21/18, documented patient #11 had been restrained in locking violent restraints to all four (4) limbs on 5/4/18 from 0940 to 5/4/18 at 1553 (6 hours 13 minutes).

Review of patient #11's closed electronic record with staff B, Director of Accreditation, staff D, third floor manager, and Staff R revealed patient #11 entered the emergency department on 5/3/18 at 1707 for an overdose of Barbiturates. Nursing documentation noted initiation of violent four (4) limb restraints (right and left arms and legs) at 0940. Staff Q, a hospitalist documented a progress note on 5/4/18 at 1213 which documented patient #12 was examined, history and lab review was done and noted patient #12 was combative, physically aggressive towards staff, was given antipsychotic medication and placed in restraints. The note was cosigned by a hospital Medical Physician. No documentation was noted related to the patient's reaction to the restraints or to the need to continue or terminate the restraints. A psychiatric consult on 5/4/18 at 1031 did not include documentation of the patient's reaction to the restraints or the need to continue or terminate the restraints. No additional documentation of a 1 hour face to face examination every four hours with the continuation of the restraints were found. This was confirmed at the time of the clinical record review with staff D and R.

On 5/23/18 at 1538 physician staff Q was interviewed by telephone and stated he recalled patient #11 and the need for restraints. When queried regarding the one hour face to face assessment requirements staff Q stated he had seen the patient before the restraints were placed and she was behaving aggressively but had clamed down after he spoke to her. Staff Q stated at that time we were attempting to keep her calm and avoided the need for restraints. He stated the patient had later become combative and aggressive towards staff and was placed in restraints. Staff Q stated he was rounding and unable to excuse himself at the time for the assessment. He stated he had seen the patient prior to the restraint application and documented and now understood the requirements and need to document the one hour face to face assessment.

Copies of the reviewed documentation were requested and received.

On 5/23/17 at 1015 the facility Chief Nursing Officer staff C stated she understood the concerns found related to restraints and was taking immediate action. She stated all medical staff were educated on restraints in July of 2017.

On 5/23/18 at 1310 the facility Vice President of Medical Affairs, staff P was interviewed at the facility regarding restraints. Staff P stated all physician staff receive restraint training as part of their orientation and again yearly, it is covered at the Medical Executive meetings and also included in the medical staff monthly newsletter at the time of the yearly training. Staff P stated the lack of documentation is a concern, adding we know if it is not documented it's not done. He stated all medical staff are aware of and expected to follow the restraint policy.

Review of the facilities policy A-104, titled Restraints and Seclusion-Acute Care, dated reviewed 12/1/17 documented the following: Purpose: To minimize risk of injury where there is risk of potential patient harm from unrestrained movement; ensure utilization of the least restrictive form of restraint for the shortest period of time; protect patient's rights, dignity, and well-being during restraint use; and provide guidelines for the usage, implementation, monitoring and discontinuation of restraints by trained staff. . . (page 6 of 15) c. The qualified prescriber. . .completes a face to face evaluation within 1 hour of implementation to evaluate the: 1) Patient's immediate situation 2) Patient's reaction to the intervention 3) Patient's medical and behavioral condition 4) Need for continuation or termination of restraint. . .in the state of Michigan, only a physician may perform the face to face evaluation. . .In the state of Michigan, a face to face evaluation by the physician is required with every renewal or new order. . .