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Based on interview and record review, the facility failed to ensure that its restraint policy was followed when physicians' orders for two of 15 sampled patients did not include the indications for the use of physical restraints, and the care plan for one of these patients (Patient 42) was not revised following the use of restraints. This failure impacted the patients' right to be free from restraints. (Patients 42 and 45).

Findings:

1. A review of Patient 42's record disclosed that he was admitted on 4/27/12 with diagnoses that included pneumonia and heart failure. There was a physician's order, dated 5/24/12, for a soft lap belt to be used as a restraint. There was no clinical indication for the use of this restraint included in the physician's order. Restraints were used until 5/28/12. A review of the care plan disclosed that it had not been updated to reflect the use of the restraints during this period.

The facility's policy titled, "Restraint Use," revised 3/12, was reviewed. It read, "A physician order must meet the following criteria: include reason for restraint, be in accordance with a written modification to the patient's plan of care."

During a concurrent interview and record review on 5/30/12 at 2 pm, Administrative Nurse (Admin) Y confirmed the physician's initial order did not include the indications for the restraint use for Patients 42 and 45, and that the care plan had not been revised to include the use of restraints for the period of time they were used, for Patient 42.



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2. On 5/30/12 at 8:30 a.m., the record for Patient 45 was reviewed. The record included orders for restraints, a soft lap belt, on 4/16/12 and 4/17/12. The facility used a specific order set for restraints which included different areas with check boxes to indicate the reason for using restraints, the type of restraints, the duration, and when the restraints should be discontinue. Both orders were written and signed by the physician, but did not include the "Clinical indications for Restraints." The order form had four indications to choose from plus another one where the prescriber can add his/her rational under "others." None of these boxes were checked, and there were no written notes from the prescribers under that last indication "other."

Review of the facility's policy titled, "Restraint Use: LATC," and created 10/2008, revealed the following: "the order for restraint shall include the type of restraints to be applied and shall be based on specific behaviors that indicate restraints." The policy read: "A physician order must meet the following criteria. Include reason for the restraint."