HospitalInspections.org

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the physician order for restraints included the clinical justification for application of the restraint, the type of restraint, and the time limit for the restraint, for two of ten restraint records reviewed (MR1 and MR2) and failed to ensure that physician orders were obtained for the use of restraints in three of 10 medical records reviewed for restraints (MR1, MR5, and MR8).

Findings include:

Review on December 28, 2011, of the facility policy "Restraints," last reviewed and revised November 2011, revealed "... III Procedure C Physician Orders ... Continued use of restraints greater than 24 hours requires a physician assessment and a written order for renewal. This must occur each calendar day that the restraint remains in use. The order is to contain clinical justification for application of the restraint, the type, and time limit. ... "

1) Review of MR1 on December 28, 2011, revealed the physician order for the restraint did not include the clinical justification for the restraint, the type of restraint, and the time limit for the restraint, on the following dates: December 8 and 13, 2011.

Review of MR2 on December 28, 2011, revealed the physician order for the restraint did not include the clinical justification for the restraint, the type of restraint, and the time limit on the following dates: October 31, 2011, November 4, 10 and 11, 2011 and December 3 and 4, 2011. Review of MR2 on December 28, 2011, revealed the physician order for the restraint did not include the type of restraint on the following date: November 1, 2011.
Review of MR2 on December 28, 2011, revealed the physician order for the restraint did not include the clinical justification for the restraint and the time limit on the following date: December 1, 2011.

An interview conducted on December 28, 2011, at 2:45 PM with EMP1 confirmed that MR1 and MR2, did not contain complete physician orders for the use of restraints for these patients.

2) Review of MR1 on December 28, 2011, revealed documentation on the Restraint Documentation form of the continuous use of right and left upper extremity restraints because of a potential for self harm, on December 10 and 12, 2011, from 12:01 AM through 11:00 PM. Further review of MR1 revealed no physician order for the restraints applied on the following dates: December 10 and 12, 2011.

Review of MR5 on December 28, 2011, revealed nursing documentation on the "Restraint Documentation" form that the patient had bilateral upper extremity restraints applied on August 5, 2011. Further review of MR5 revealed no physician order for the restraints applied on August 5, 2011.

Review of MR8 on December 28, 2011, revealed nursing documentation on the "Restraint Documentation" form that the patient had a right upper extremity restraint applied on September 17, 2011. Further review of MR8 revealed no physician order for the restraint applied on September 17, 2011.

An interview with EMP1 on December 28, 2011, at approximately 2:30 PM confirmed there were no physician orders for restraints applied for MR1, MR5, and MR8 for the restraints and dates noted above.