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Based on observation, interview, and record review it was determined the facility failed to ensure all patients were free from restraints. Observation during a complaint survey revealed Patient #10 was restrained by bilateral hand mittens and bilateral wrist restraints. There was no documented evidence the facility had attempted to discontinue the restraints.

The findings include:

Review of the facility's restraint policy revealed patients have the right to be free from any form of restraint. Restraint is used only when less restrictive interventions are ineffective. The hospital discontinues the restraint at the earliest possible time. A new restraint order is written each calendar day and a re-evaluation must take place before a new order is written.

Review of the facility's policy for verbal orders revealed the verbal order must be cosigned & authenticated by the ordering individual or by another practitioner who is responsible for the care of the patient. The order is to be "authenticated within 48 hours of the time given".

Observation of Patient #10, on 10/11/11 at 4:50 PM, revealed the patient lying in bed with eyes closed. The patient's hands were placed in a mesh type hand mittens that were tied around the patient's wrist. In addition, soft foam wrist restraints were applied to both wrists and tied to the bedframe. The hospital nurse present during the observation attempted to arouse the patient twice by calling the patient's name. No response was received. The patient's eyes remained closed and no verbal sound was hear.

Review of the clinical record revealed the hospital admitted the patient on 09/21/11 with Respiratory Distress. The patient had removed his/her trach and it had to be replaced. The wrist restraints were first ordered on 09/21/11 and continued to be reordered daily. The record revealed the wrist restraints were ordered for the medical reason of "shows inability to follow verbal directions to prevent self-harm and imminent risk of ET tube or Trach removal".

Continued review revealed on 09/24/11, the physician documented the patient's trach's was displaced while wrist restraints were applied. On 09/25/11, the physician ordered hand mittens to augment soft wrist restraints. In addition, the physician ordered Seroquel 25mg per peg-tube every eight hours as needed for agitation. Continued review of the medical record revealed both restraints (bilateral hand mittens and wrist restraints) were ordered and applied from 09/25/11-10/11/11.

Interview with the 5-B Unit Manager, on 10/11/11 at 4:55 PM, revealed the wrist restraints were tied too long and allowed the patient access to the trach. The trach was not dislodged but only moved sideways. The manager stated if the wrist restraints had been tied correctly, the patient would not have been able to reach the trach. She stated the hand mittens were ordered after this incident and she revealed no reduction of the restraints had been attempted.

In addition, review of the restraint orders dated September 26, 27, and 28th revealed verbal orders were received for those restraint orders and were not signed by the physician until 10/11/11, the day of the survey.

Interview with the Unit Manager, on 10/11/11 at 4:55 PM, revealed the nurses flag the medical record with a bright red paper sign to request the physician to sign a verbal order. She stated physicians do not always acknowledge the request and forget to sign the orders. There was an attempt to verbally remind the physician to sign the verbal orders; however, that was not always successful. The physician did not sign the verbal orders until 10/11/11 upon request from nursing staff.