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Based on record review and interview, the Hospital policy and procedures for restraint orders were not in accordance with the order of a physician or other licensed independent practitioner (LIP) as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law for 1 of 2 restrained patients (#37), in a total sample of 16. Findings include:

Review of the Hospital's policies and procedures titled "Restraint for Medical/Surgical Care", revised 1/21/16, indicated a registered nurse may initiate a medical-surgical restraint but must obtain an order within one hour from the LIP. The policy did not address the initiation by the nurse in the context of an emergency restraint for the protection of the patient and/or staff.

1. For Patient #37, the hospital was not compliant with its policy or the regulations.

Record review indicated that for Patient #37, the 30 minute assessment off medical surgical restraints, dated 2/28/16, indicated the patient remained calm the entire 30 minutes out of the wrist restraint. The nurse manager signed the assessment but failed to indicate whether the patient should remain in or out of restraints. On 2/29/16, the registered nurse initiated an order for wrist restraints at 8:00 A.M., that was signed by the LIP at 10:00 A.M., over one hour after the nurse initiated the order.