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Based on clinical record review, policy and procedure review and Medical Staff Bylaws review, it was determined two (#1-#2) of three (#1-#3) clinical records contained undated and unsigned physician orders for restraints which were not signed within the Facility's timeframes. Failure to date the physician orders did not allow the Facility to ensure authentication of physician orders within the 48 hour timeframe specified by the Facility Medical Staff Bylaws or by the Facility Restraint Policy and Procedure which specified 24 hour timeframe. The failed practice affected two (#1-#2) of three (#1-#3) patients. Findings follow:

A. Review of Patient #1's clinical record revealed two verbal orders for restraints dated 01/31/13 and 02/01/13 without date and time of the physician's signature.

B. Review of Patient #2's clinical record revealed two verbal orders for restraints dated 01/18/13 and 01/19/13 without date and time of the physician's signature.

C. The above findings were verified by the Quality Manager at 1355 on 02/13/13.