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Based on policy review, clinical record review and interview, it was determined the facility failed to ensure restraint orders were renewed daily (during weekends) per facility policy for three (#6, #8 and #9) of three patients reviewed who were currently restrained. The failed practice had the potential to affect all patients placed in restraints in the hospital. Evidence follows:

A. Review of the Restraints and Seclusion Policy (revised 06/10), revealed a physician or licensed independent practitioner examined the patient daily and renewed the order for restraints daily based on the examination.

B. Review of the Restraint Order/Assessment Sheets for Patient #6 revealed the following:
1. The Registered Nurse (RN) Assessment portion of the forms was completed on 09/11 and 09/12/10. The physician's order for restraints on 09/11 and 09/12/10 was written on Monday, 09/13/10 at 0300.
2. The RN Assessment portion of the forms was completed on 09/18 and 09/19/10. The physician's order for restraints on 09/18 and 09/19/10 was written on Monday, 09/20/10 at 1126.

C. Review of the Restraint Order/Assessment Sheets for Patient #8 revealed the following:
1. The RN Assessment portion of the forms was completed on 09/11 and 09/12/10. The physician's order for restraints on 09/11 and 09/12/10 was written on Monday, 09/13/10 at 1441.
2. The RN Assessment portion of the forms was completed on 09/18 and 09/19/10. The physician's order for restraints on 09/18 and 09/19/10 was written on Monday, 09/20/10 at 1120.

D. Review of the Restraint Order/Assessment Sheets for Patient #9 revealed the following. The RN Assessment portion of the forms completed on 09/18 and 09/19/10 contained the physician's order written on Monday, 09/20/10 at 1127.