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I. Based on medical record review and interview with the staff, the hospital physician failed to write appropriate restraint orders in 1 of 10 medical records, noted in P2's medical record. Failure to write appropriate restraint orders may impose harm to the Patient and does not assure that nursing will safely apply restraints to the patient.

Findings:
1. On 09/14/2010, during an interview with the Medical Staff Service Director. S/he explained that physicians are instructed not to write PRN Restraint Orders(on an as needed basis). Also, the investigator on 09/14/2010 observed in the Medical Records dictation room that signs were posted in the computer cubicle areas stating that, " No PRN " restraint orders were to be written in the patient records by the physicians.

2. Review of P2's documentation noted on the history and physical documented on 08/30/2010 read the following: The 65 year old patient had a myocardial infarction and suffered a cardiac arrest while in a motor vehicle accident. The Emergency Services Techs initiated ACLS protocol in the field and transported the patient to the Emergency Department for further care. The patient was admitted to the Critical Care Services Unit and later the patient was transferred to the medical unit.

3. Further review noted on P2's nursing progress dated 09/14/2010 documented the patient became up-set, began striking out at staff and fell out of bed. Nursing staff contacted the Security personnel who came to the patient's room. The nurse also contacted the physician and obtained restraint orders. The patient was placed in wrist and ankle soft restraints and the patient was monitored during the night. On 09/15/2010 at 7:10 AM the day shift RN evaluated the patient's condition and took the patient out of restraints.

4. Review of the physician's orders documented on 09/15/2010 at 9:00 AM. It determined the physician wrote the following order on the Adult Order Sheet that read: During the daytime, please remove the patient's soft restraint when
the patient is out of bed in a chair. Also, a note in black bold letters located on the top of the order sheet documented the following: DO NOT ORDER: Restraints PRN.

5. During an interview with the Accreditation Director confirmed the physician's order was a PRN order and explained that physicians were not to write PRN restraint orders. The physician failed to follow the state and federal restraint regulations as written.

I. Based on review of hospital policy, interview with administration staff, and review of Medical Staff committee minutes, the hospital failed to implement the required physicians' restraint/seclusion training program.

Failure to provide the required restraint/seclusion training to the providers does not assure the hospital is concerned about patients' physical safety regarding the use of the restraint/seclusion interventions.

Findings:
1. Review of the hospital Restraint/Seclusion policy # 8720.070 was approved by administration on 03/25/2010. The policy discussed that (LIP) Licensure Independent Practitioners authorized to order restraint or seclusion will have working knowledge regarding the restraint/seclusion policy.

2. On 09/14/2010, the investigator interviewed the Medical Staff Service Director. The director reported the Medical Staff providers were not required to complete the hospital's restraint training program. The investigator asked were the providers required to read the hospital's restraint/seclusion policy. The director replied "no" because this was not a requirement. The investigator then asked was a copy of the hospital restraint policy placed in the provider's credential packet for review when physicians were completing the Medical Staff credentialing process. The director provided a credential packet to the investigator for review. On 09/14/2010 the investigator reviewed the providers credential packet and a copy of the hospital restraint/seclusion policy was not found in the packet.

3. The director made reference that the hospital Medical Staff was addressing mandatory physicians education issues. S/he reported on 05/04/2010 the Medical Staff documented in the Medical Staff Executive Committee Meeting
Minutes how physicians could meet the mandatory federal educational requirements (to include restraint training). The document read that training would be implemented by using a specific electronic web line program. The web line program needed to be linked electronically to the web link credentialing process. The director confirmed that currently, the Medical Staff does not have required
restraint program for physicians to complete.

4. The hospital failed to follow the hospital restraint policy as written and failed to meet the minimum restraint requirements stated in medicare Patient Rights regulations regarding physician restraint training.