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Based on interview and document review, the hospital failed to ensure restraint orders were obtained from a physician or independent licensed practioner (LIP) each time restraints were initially applied and/or re-applied for 1 of 7 patients (P5) reviewed with restraints.

Findings include:

P5's History and Physical, dated 12/21/17, identified admission diagnoses of generalized weakness, acute kidney failure, and was admitted into the hospital's Intensive Care Unit (ICU).

P5's nursing Progress Note, dated 1/1/18, at 8:02 a.m. indicated soft wrist and leg restraints had been initiated due to P5 attempting to pull out his nasogastric tube, nasal cannula, bending his leg containing a arterial line, and attempting to punch a staff member. The note identified, "MD will be updated during rounding."

P5's Restraint Flow Sheet identified the restraints were initiated on 1/1/18, at 8:00 a.m., and discontinued on 1/1/18, at 10:00 a.m. The flow sheet contained a line to document obtaining a daily restraint order; noting, "MD Informed."

P5' nursing Progress Note, dated 1/2/18, at 1:04 a.m. indicated soft wrist restraints were re-applied as P5 was attempting to pull out lines and bend his right leg containing an arterial line. The note identified, "[Physician] notified."

A Palliative Care Follow- Up Note, dated 1/1/8, at 3:59 p.m. identified P5 had confusion and agitation during the night, which had started the previous night. The Palliative Care Note indicated the confusion and agitation was due to delirium, noting, "Not surprising given the severity of his illness, his frailness and prolonged ICU care."

P5's Restraint Flow Sheet identified the restraints were re-initiated on 1/2/18, at 1:00 a.m. The flow sheet contained a line to document physician notification; noting the physician had been notified via phone.

P5's Order Review contained one order for nonviolent restraints obtained on 1/2/18, at 8:28 a.m. P5's medical record lacked physician orders for restraints with the initial application and subsequent application of restraints.

P5's current care plan, dated 1/1/18, identified, "Patient will remain safe and physical needs will be addressed during restraint use." The care plan directed, "Obtain MD (medical doctor) order prior to or immediately after initiation of restraints."

During interview on 1/4/18, at 11:00 a.m. registered nurse (RN)-A and patient care director (PCD)-A stated the facility attempted to use the least restrictive device possible and attempted to get an order prior to applying restraints; however, if restraints were applied emergently, an order should be obtained immediately after the application. RN-A reported they attempted to get an order within an hour from a provider. RN-A further reported there should be an order upon initiating restraints and needed a new order when restraints are discontinued and re-initiated.

A facility policy entitled Restraints- Non-Violent Behavior (Med-Surg Restraints), dated 7/16, instructed, "In an emergency, the RN (registered nurse) may apply restraints, but then must notify and obtain an order form the LIP immediately after the restraint(s) have been applied and patient safety ensured."

Based on observation, interview, and record review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K321, K324, K325, K362 and K923 for additional information.