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Based on medical record review, the facility failed to ensure that all orders for restraints are dated, timed and authenticated by the medical staff ordering the restraint. Specifically, 8 of the 10 medical records reviewed, the documentation was inconsistent on the restraint order sheet for entry of date, time and authentication.

Findings:

All of the following medical records involved the application of soft restraints.

MR #1 documented 3 restraint orders: 2 orders were not signed, dated or timed; 1 was not timed. A telephone order for a PICC line was not signed by the ordering physician.

MR #2 documented 2 restraint orders. Neither order was signed, dated or timed.

MR #3 documented 4 restraint orders: 1 order was not signed, dated or timed; 2 orders were not timed.

MR #4 documented 14 restraint orders: 8 orders were not signed, dated or timed; 1 order was not dated; 5 orders were not timed.

MR #5 documented 7 restraint orders on the order set 5755/5758. 2 orders had the checkbox for time duration left blank; 1 order was not signed or timed.

MR #6 documented 9 restraint orders: 4 orders were not dated or timed; 1 order was not timed.

MR #7 documented 3 restraint orders: 1 order was not signed, dated or timed; 2 orders were not dated or timed.

MR #9 documented 2 restraint orders: 2 orders were not signed, dated or timed