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Based on policy review, medical record reviews and staff interviews, the hospital staff failed to ensure 3 of 5 sampled patients had an order for restraints. (Patients #1, #6 and #7).

The findings include:

Review on 08/30/2017 of policy, "RESTRAINTS AND SECLUSION" revised 07/2017 revealed, "PERFORMED BY: ...PURPOSE: ...To be in compliance with current standards and federal guidelines. DEFINITIONS: ... POLICY: ...PROCEDURE: ...A written order, based on an examination of the patient by the MD/DO (Medical Doctor/Doctor of Osteopathy) or LIP (Licensed Independent Practitioner) is entered into the patient' medical record on a daily basis when restrain use is clinically appropriate ...PURPOSE AND USE: ...CONTRINDICATIONS: ...PERFORMANCE IMPROVEMENT: ...STAFF TRAINING: ...ORDERS TO INITIATE RESTRAINT ...Orders for restraints must be renewed on a daily basis ..."

1. Open medical record review on 08/29/2017 revealed on 07/28/2017, Patient #1, a 68 year-old was admitted to the hospital for kidney failure. Review on 08/05/2017, revealed the patient had a medical emergency and the interventions included a breathing tube. As a result of the breathing tube, the patient was ordered and received bilateral wrist restraints. On 08/06/2017, the mental status of the patient was described as awake, alert and confused and both wrists were restrained. Review failed to reveal an order for the restraints.

Interview on 08/29/2017 at 1822 with the Charge Nurse revealed the night shift nurses were responsible for obtaining renewals for restraints orders. Interview revealed the patient(s) should have an order for each restraint day.

Interview on 08/30/2017 at 0915 with the Charge Nurse/Restraint trainer revealed the nurse shift nurses ensured the restraint order renewal form was available for the physician to sign in the morning. Interview revealed each day a patient was restrained, there should be a restraint order. Interview revealed the corrective action would include incorporating review of the restraint order into the restraint training.

Interview on 08/30/2017 at 1408 with the Director of Quality Management revealed nursing practice included no patient should be restrained without a restraint order.

Interview on 08/31/2017 at 1015 with the CNO (Chief Nursing Officer) revealed the on-coming shift and the off-going shift should obtain the restraint renewal order as outlined on the bottom-half of the form. Interview revealed an indication the nursing staff should know the difference between a telephone versus a verbal order and the documentation was a regulatory concern. Interview revealed the corrective action would include staff education related to restraint order documentation.

2. Open medical record review on 08/29/2017 revealed on 08/21/2017, Patient #6, a 53 year-old was admitted to the hospital for Respiratory Failure. Review revealed medical interventions included a breathing tube. Review revealed from 08/21/2017 to 08/29/2017 (9-days), the patient was restrained. On 08/23/2017 and 08/24/2017 (2-days), the patient was restrained due to confusion. Review failed to reveal an order and restraint type for restraint days 08/23/17 and 08/24/2017.

Interview on 08/29/2017 at 1645 with Medical Doctor (MD) #1 revealed the doctor makes patients' rounds, daily, from 1000-1800, on up to 30 patients. Concerns regarding physician order signature requirements for complete medical records and legible documentation were discussed with physicians during a meeting in October 2016. Interview revealed telephone/verbal orders should be signed by the physician giving the order. Interview failed to reveal the doctor signed the telephone/verbal restraint order received on 08/26/2017 at 0800.

Interview on 08/29/2017 at 1822 with the Charge Nurse revealed the night shift nurses were responsible for obtaining renewals for restraints orders. Interview revealed the patient(s) should have an order for each restraint day.

Interview on 08/30/2017 at 0915 with the Charge Nurse/Restraint trainer revealed the nurse shift nurses ensured the restraint order renewal form was available for the physician to sign in the morning. Interview revealed each day a patient was restrained, there should be a restraint order. Interview revealed the corrective action would include incorporating review of the restraint order into the restraint training.

Interview on 08/30/2017 at 1408 with the Director of Quality Management revealed nursing practice included no patient should be restrained without a restraint order.

Interview on 08/30/2017 at 1730 with the Director of Quality Management revealed orders that lacked physicians' signatures were identified in October 2016. Interview revealed the process was audited for 4-months and achieved a compliance rate greater than 90-percent. Interview revealed orders without physicians' signatures were identified as a prior concern.

Interview on 08/31/2017 at 1015 with the CNO (Chief Nursing Officer) revealed the on-coming shift and the off-going shift should obtain the restraint renewal order as outlined on the bottom-half of the form. Interview revealed an indication the nursing staff should know the difference between a telephone versus a verbal order and the documentation was a regulatory concern. Interview revealed the corrective action would include staff education related to restraint order documentation.

3. Open medical review on 08/30/2017 revealed on 08/15/2017, Patient #7 was admitted to hospital for Respiratory Failure. Review revealed from 08/15/2017 to 08/29/2017 (14-days), the patient was restrained. On 08/17/2017, 08/18/2017 and 08/26/2017 (3-days), the patient was restrained, type unknown, without an order. Review failed to reveal an order for 3 of 14-days the patient was restrained.

Interview on 08/29/2017 at 1645 with Medical Doctor (MD) #1 revealed the doctor makes patients' rounds, daily, from 1000-1800, on up to 30 patients. Concerns regarding physician order signature requirements for complete medical records and legible documentation were discussed with physicians during a meeting in October 2016. Interview revealed telephone/verbal orders should be signed by the physician giving the order. Interview failed to reveal the doctor signed the telephone/verbal restraint order received on 08/26/2017 at 0800.

Interview on 08/29/2017 at 1822 with the Charge Nurse revealed the night shift nurses were responsible for obtaining renewals for restraints orders. Interview revealed the patient(s) should have an order for each restraint day.

Interview on 08/30/2017 at 0915 with the Charge Nurse/Restraint trainer revealed the nurse shift nurses ensured the restraint order renewal form was available for the physician to sign in the morning. Interview revealed each day a patient was restrained, there should be a restraint order. Interview revealed the corrective action would include incorporating review of the restraint order into the restraint training.

Interview on 08/30/2017 at 1408 with the Director of Quality Management revealed nursing practice included no patient should be restrained without a restraint order.

Interview on 08/30/2017 at 1730 with the Director of Quality Management revealed orders that lacked physicians' signatures were identified in October 2016. Interview revealed the process was audited for 4-months and achieved a compliance rate greater than 90-percent. Interview revealed orders without physicians' signatures were identified as a prior concern.

Interview on 08/31/2017 at 1015 with the CNO (Chief Nursing Officer) revealed the on-coming shift and the off-going shift should obtain the restraint renewal order as outlined on the bottom-half of the form. Interview revealed an indication the nursing staff should know the difference between a telephone versus a verbal order and the documentation was a regulatory concern. Interview revealed the corrective action would include staff education related to restraint order documentation.

Based on policy and procedure review, medical staff bylaws and medical record review, staff and physican interviews, the facility staff failed to ensure physician telephone orders were authenicated for 2 of 5 samped patients (Patient #2 and #6).

The findings include:

Review on 08/29/2017 of facility "Orders, Physician" policy, revised 01/01/17 revealed, ""....C. Written Orders - All written orders are to be dated and timed.... D. Authentication: The reasonable practitioner or another licensed independent practitioner within the same group practice or specialty....shall authenticate, time and date all orders promptly, ...."

Review on 08/30/2017 of the facility "Medical Staff Bylaws...." approved 03/31/2017 revealed, "....C. Medical Records 1. ....6. All clinical entries in the patient's medical record shall be accurately.... and authenticated. ...."

1. Closed medical record review on 08/29/2017 for Patient #2 revealed a 39 year-old was admitted on 06/28/2017 for IV antibiotic therapy for a post-operative, right shoulder infection and bacteremia. Review of physician orders revealed a telephone order on 07/07/2017 at 1100 by MD #2 for wound management consult written by the facility's wound care nurse (WCN). Further review revealed a telephone order on 07/07/2017 at 1345 by MD #1 for wound care treatment/care written by the facility's wound care nurse (WCN). Review revealed the three orders were not authenticated per facility policy and medical staff bylaws.

Interview on 08/29/2017 at 1645 with Medical Doctor (MD) #1 revealed "concerns" regarding physician order authentication, requirements for a "complete medical record" and other topics were discussed with physicians during a Medical Staff meeting in an October 2016 meeting and are ongoing conversations during meetings. Interview revealed all telephone orders "must be authenticated". Interview revealed the order written 07/07/2017 at 1345 was not authenticated and did not meet policy and medical staff bylaws requirements, or supervisory expectation.

Interview on 08/31/2017 at 1015 with the Director of Nursing (DON) revealed "all" telephone orders "should be authenticated". Interview revealed telephone orders written on 06/28/2017 and 07/07/2017 were not authenticated and did not meet policy and medical staff bylaws requirements, or supervisory expectation.








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2. Open medical record review revealed on 08/21/2017, Patient #6, a 53 year-old was admitted to the hospital for Respiratory Failure. Review revealed from 08/21/2017 through 08/29/2017 (8 days), the patient was restrained due to confusion and potential disruption of medical equipment. Review revealed on 08/26/2017 at 0800, the nurse obtained a telephone/verbal restraint order from MD #1. Review failed to reveal MD #1 signed and dated the 08/26/2017 restraint order.

Interview on 08/29/2017 at 1645 with Medical Doctor (MD) #1 revealed the doctor makes patients' rounds, daily, from 1000-1800, on up to 30 patients. Concerns regarding physician order signature requirements for complete medical records and legible documentation were discussed with physicians during a meeting in October 2016. Interview revealed telephone/verbal orders should be signed by the physician giving the order. Interview failed to reveal the doctor signed the telephone/verbal restraint order received on 08/26/2017 at 0800.

Interview on 08/30/2017 at 1730 with the Director of Quality Management revealed orders that lacked physicians' signatures were identified in October 2016. Interview revealed the process was audited for 4-months and achieved a compliance rate greater than 90-percent. Interview revealed orders without physicians' signatures were identified as a prior concern.

Interview on 08/30/2017 at 1010 with the Health Information/Credentialing Manager revealed in July 2017, orders that lacked physicians' signatures were identified and a new process was implemented. Interview revealed the new process involved color-coded the medical records to differentiate between the need for a physician versus mid-level signature. Interview revealed the plan was to randomly select, non-physician specific, 10-medical records for review to ensure orders did not lack physicians' signatures. Interview revealed the audit information would be provided to the CEO (Chief Executive Officer), CNO (Chief Nursing Officer) and the identified physician. Interview revealed the manager was unable to provide information on all components of the auditing process.