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Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the patient's care plan had written modifications to include the use of restraints. The facility failed to ensure the patients plan of care was reviewed and updated in writing with the applications of restraints for one (1) of ten (10) sampled patients (Patient #3).

The findings include:

Review of the facility's policy, titled "Restraint Guidelines", dated 06/01/10, section: "Directions for Restraint Use Non-Violent, Non Self-Destructive", revealed there were four (4) nursing steps to utilize restraints. These steps were to be utilized for the applications of restraints. Step #4 was the "Plan of Care" and should include: results of patient assessment, desired behavior or outcome for patient to be free of restraints, frequency of reassessment if outside required frequency, criteria for restraint removal, parameters for assessment/intervention, nursing interventions, intervention response, restraint status and discontinue criteria met or not met and the reason.

Review of the medical record revealed, Patient #3 was admitted by the facility on 04/01/12 at 8:40 AM with diagnoses which included Memory Loss, Diminished Balance and Headache. Further review of the record revealed a verbal Physician's order was obtained for the application of restraints on 04/19/13 at 8:20 PM with no documentation found the Plan of Care was modified to include the use of restraints.

Interview with Registered Nurse (RN) #1, on 05/03/13 at 3:50 PM, revealed the Care Plan should have been updated to include the use of restraints for Patient #3 and for all patients in restraints.

Interview with RN #3, on 05/03/13 at 3:35 PM, revealed the Pathways (Plan of Care) should be modified to include the use of restraints for any patient that requires restraints.

Interview with Administrative Director of Orthopedics #7, on 05/01/13 at 3:25 PM, revealed there was no documented evidence the Critical Pathway (Plan of Care) for Patient #3 was modified for the use of restraints on 04/19/13 and the Clinical Pathway (Plan of Care) should have been added.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each order for restraint applications was initiated by a Licensed Independent Practitioner (LIP) responsible for the care of the patient and authorized to order restraints by hospital policy in accordance with State Law. The facility failed to ensure each patient had a restraint order initiated by a LIP for two (2) of ten (10) sampled patients (Patient # 3 and Patient #4).

The findings include:

Review of the facility's policy, titled "Restraint Guidelines", dated 06/01/12, revealed a licensed independent practitioner must give orders for restraints. Further review of the facility's policy revealed, Physicians and Advance Registered Nurse Practitioners (ARNP) were authorized to write restraint orders.

Review of the medical record revealed, Patient #3 was admitted by the facility on 04/01/12 at 8:40 AM with diagnoses which included Memory Loss, Diminished Balance and Headache. Further review of the record revealed, a verbal Physician's order was obtained for the application of restraints on 04/19/13 at 8:20 PM. Further review of the medical record revealed no documentate evidence the verbal order was signed by the Physician ordering the restraints.

Review of the medical record revealed, Patient #4 was admitted by the facility on 04/18/13 at 1:08 AM with diagnoses which included Chest Pain. Further review of the medical record revealed, a verbal Physician's order for restraints was received on 04/20/13 at 11:50 PM, from a Physician's Assistant (PA).

Interview with Registered Nurse (RN) #3 on, 05/03/13 at 3:45 PM, revealed the order for restraints must come from the Physician or ARNP. Further interview revealed a Physician's Assistant can not order restraints.

Interview with Registered Nurse (RN) #1, on 05/03/13 at 3:50 PM, revealed the order for restraints must be initiated by a Physician or ARNP. Further interview revealed a Physician's Assistant can not order restraints.

Interview with the Director of Third Floor South, on 05/03/13 at 1:45 PM, revealed the Physician or ARNP should initiated the order for restraints and the order should have been completed with a signature of the ordering Licensed Independent Practitioner, per the facility's policy.