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Based on medical record review and staff interview, the hospital failed to ensure a physician's order was obtained each day a patient was placed in restraints. This affected three of eight patients reviewed in restraints, (Patient #5, #6 and #8). The total sample size was ten medical records.

Findings included;

The medical record for Patient #5 was reviewed on 01/11/10 and 01/12/10. The medical record revealed the patient was admitted on 12/15/09 for Respiratory Failure. The medical record further revealed the patient had been placed in soft limb restraints to both ankles at various times throughout his/her hospital admission to prevent injury from the patient kicking at staff and the bed rails. A total of twenty five days were noted to contain evidence the patient was placed in restraints and orders obtained for their use. Further review of the medical record revealed evidence the patient was documented on the restraint flow sheet as being in ankle restraints to both legs on 01/06/10. The medical record lacked evidence of a physician's order for the ankle restraints on 01/06/10. These findings were confirmed by Employee A on 01/13/10 at 11:00 A.M.

The medical record for Patient #6 was reviewed on 01/12/10. The patient was admitted on 01/08/10 with diagnoses including Respiratory Failure. The medical record revealed the patient was in soft limb restraints to both wrists at the time of admission to the hospital at 11:45 A.M. The medical record revealed the restraints were left in place by hospital staff, but lacked evidence a physician's order was obtained for their use until 01/09/10. The patient was observed in the wrist restraints on 01/11/10 to prevent the patient from pulling at lines and tubes. These findings were confirmed by Employee A on 01/13/10 at 11:00 A.M.

The medical record for Patient #8 was reviewed on 01/12/10. The patient was admitted on 12/15/09 for Bacteremia (blood infection). The medical record revealed narrative nursing notes on 01/08/10 that stated; "restless, pulling at tubing and lines. repositioned, bilateral (right and left) mitts applied, waist restraint intact. Observed attempting to move under waist restraint OOB (out of bed)". Review of the medical record revealed the patient had been ordered to be in a waist restraint the previous day, 01/07/10. Further review of the medical record revealed the restraint order given by the physician on 01/08/10 at 1:00 P.M. was for right and left wrist restraints, and did not include the waist restraint or the hand mitts. The medical record revealed evidence the patient removed the hand mitts without assistance twenty minutes after they were placed on by the nurse. These findings were confirmed by Employee A on 01/13/10 at 11:00 A.M.

Based on medical record review, review of hospital policy and staff interview, the hospital failed to ensure monitoring of patients in restraints was documented every two hours as required by the hospital's policy. This affected three of eight patients reviewed with restraints in place (Patient #1, #6 and #9).

Findings included;

The medical record for Patient #1 was reviewed on 01/11/10. The record revealed the patient was admitted on 12/28/09. The medical record further revealed the patient was ordered to be in soft limb restraints to both wrists on 12/28/09. The order was renewed each day by the patient's physician. The restraint flow sheet for 01/07/10 lacked documentation that the patient's restraints were monitored from 10 A.M. until 7 P.M.

The medical record for Patient #6 was reviewed on 01/12/10. The record revealed the patient was admitted on 01/08/10 for diagnoses including Respiratory Failure. At the time of the medical record review at 7:15 A.M. on 01/12/09, the restraint flow sheet was noted to be blank. The patient was observed to be in wrist restraints at the time of the medical record review on 01/12/10, at 7:15AM. The medical record review also revealed an order for the use of wrist restraints for 01/11/10 to 01/12/10, signed by the physician on 01/11/10 at 12:59 P.M.

The medical record for Patient #9 was reviewed on 01/12/10. The record revealed the patient was admitted on 11/17/09. The restraint flow sheet for 01/11/10 at 7:00 A.M. to 01/12/10 at 6:00 A.M. was blank. The medical record revealed the patient was ordered to have a left wrist restraint throughout most of his/her admission, including an order signed by the physician on 01/11/10 at 2:00 P.M. for 01/11/10 to 01/12/10. The patient was observed in a left wrist restraint by the surveyor on 01/12/10 at 7:05 A.M.

The hospital policy for restraints was reviewed on 01/12/10. The policy number is 201-21-036.8. The section titled monitoring stated "monitoring will include, but is not limited to, the assessment of peripheral circulation, sensation, movement, and skin integrity. Patients will be assessed for evidence of skin breakdown and impaired circulation/sensation related to a restraint at least every two hours. Patients will be offered food/fluid, toileting, and hygiene at least every two hours. PROM (passive range of motion) exercises or position changes will be provided at least every two hours. Patients will be assessed for pain at least every two hours." The policy further stated "Results of patient monitoring are documented on the appropriate monitoring flowsheet."

These findings were confirmed by Employee A on 01/13/10 at 11:00 A.M. Employee A was unable to present evidence of monitoring of Patient #1, #6 or #9 during the time periods in which the restraint flow sheet was not completed.