HospitalInspections.org

Based on clinical record review, policy review and interview, it was determined the facility failed to ensure patients were not restrained without a physician's order for one (#5) of three (#3-#5) patients with restraints, and failed to ensure physician's verbal orders were timed and dated when they were signed for one (#3) of three (#3-#5) patients with restraints. Restraining patients without a physician's order did not ensure the restraint was necessary and was the least restrictive intervention. Failure to ensure restraint orders were dated and timed did not ensure orders were signed within the 24 hour window as specified per policy. Findings follow.

A. Review of policy titled, "Restraint and Seclusion" stated, "The physician or credentialed PA/APN (Physician Assistant/Advanced Practice Nurse) countersigns telephone orders within 24 hours."

B. Review of clinical records revealed the following:
1) Patient #3 - four of four verbal orders for restraints were not dated and timed as to when they were signed.
2) Patient #5 had evidence of restraint monitoring on 06/06/16 at 1800 through 06/07/16 at 0345 with no order for restraints.

C. During an interview on 10/19/16 at 1206, the Director of Quality/Risk confirmed the verbal orders were not dated and timed, and confirmed the evidence of restraint monitoring without an order.