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Based on document review and interview, the facility failed to obtain an order for restraints for 1 of 1 (#2) patients resulting in the potential for a loss of the patient rights. Findings include:

On 11/23/15 at approximately 1500 during review of the medical record under the restraint documentation for patient #2 it was revealed that the patient was put in a physical hold by four staff on 11/20/15 on two occassions from 0007 until 0009 (3 minutes) and from 0010 until 0025 (15 minutes). No order could be provided for the physical holds.

On 11/23/15 at approximately 1515 during an interview with staff D this surveyor asked if the facility obtained an order for the restraint. Staff C replied "No, we do not obtain orders for physical holds unless they are 15 minutes or greater."