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Based on facility policy review, observation, record review and interview the facility failed to obtain a restraint order for one (Patient #1) of two restraint records reviewed. The facility census was 41.

Findings included:

1. Review of facility policy R02-N titled "Restraints and Seclusion" revised June 2010 showed the following direction on page 5: "Orders for restraints must be renewed on a daily basis".

2. Observation of Patient #1 on 02/03/11 at 11:15 AM, showed the patient had both hands restrained with soft wrist restraints.

3. Record review of Patient #1's current medical record on 02/03/11 at 11:25 AM, showed no current physician order to restrain patient. The most recent order to restrain patient was dated 02/02/11 at 00:01, (12:01 AM).

4. During an interview on 02/03/11 at 11:30 AM, Staff F, Director of Case Management, stated that there should be a physician order for restraint for 02/03/11.

Based on facility policy review, record review and interview the facility failed to ensure restraint orders were completed according to the facility policy for one (Patients #2) of two restraint records reviewed. The facility census was 41.

Findings included:

1. Review of facility policy titled "Restraints and Seclusion" revised June 2010 showed the following direction on page 5: The order for restraint may never be written as a standing order or as needed basis (PRN).

2. Record review of Patient #2's current medical record showed an order sheet titled Restraint Order/Assessment Sheet, dated and signed 01/30/11. There was no indication on this restraint order sheet as to what type of restraint was being ordered. This omission would have allowed the nurse to apply whatever type of restraint he/she felt was indicated.

3. During an interview on 02/04/11 at 11:15 AM, Staff G, Chief Nursing Officer stated that the physician should have indicated the type of restraint being ordered or the nurse should have clarified the physician restraint order.