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Based on document review and interview, the facility failed to document the appropriate type and/or placement of restraint implemented according to facility policy and procedure for 2 of 2 (#2 and 3) patient medical records reviewed of patients in restraints.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 2/18, indicated on pg. 3, under General Provisions, bulleted point, "A Physician's Order is required to initiate, change, continue, and discontinue restraint. The order must include the type and number of restraints..."

2. Review of patient medical records on 3/14/18 at approximately 1317 hours indicated patient:
A. #2, Restraint Order and Flow Record, Medical, dated 2/16/18 indicated that patient was in soft limb restraints x2, but lacked documentation of where the restraints were placed.
B. #3, Restraint Order and Flow Record, Medical, dated:
a. 2/21/18 indicated that patient was in soft limb restraint x1, but lacked documentation of where the restraint was placed.
b. 3/12/18 lacked a checkmark in the box indicating type of restraint, but a number 1 was placed after soft limb restraint. Documentation under Placement section indicated right and left arm, which contradicts the number 1 placed after soft limb restraint.

3. Staff 8 (Nurse Manager) was interviewed on 3/14/18 at approximately 1339 hours, and confirmed the above-mentioned Restraint Order and Flow Records, Medical, lacked documentation of either the type and/or placement of restraint as required per policy and procedure.

Based on document review and interview, the facility failed to ensure the condition of the patient who is restrained is monitored according to intervals determined by hospital policy for 2 of 2 (#2 and 3) patient medical records reviewed of patients in restraints.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 2/18, indicated on pg. 4, point 2.c)., "On-going assessment includes: Minimally every 2 hours or more frequently if condition warrants, the patient's safety and other needs are assessed and documented on the Restraint Order and Flow Record, Medical...".

2. Review of patient medical records on 3/14/18 at approximately 1317 hours indicated patient:
A. #2, Restraint Order and Flow Record, Medical, dated 2/16/18 indicated that patient was in soft limb restraints x2 and unable to determine time started or ended, but physician time of order was 0800 hours. The flowsheet lacked documentation of Registered Nurse (R.N.) initials and time every 2 hours that the "required assessment was completed and care provided per [facility] policy."
B. #3, Restraint Order and Flow Record, Medical, dated 3/12/18 indicated that patient was in soft limb restraint x1 and unable to determine time started or ended because physician order time is blank. The flowsheet lacked documentation of R.N. initials and time every 2 hours that the "required assessment was completed and care provided per [facility] policy."

3. Staff 8 (Nurse Manager) was interviewed on 3/14/18 at approximately 1339 hours, and confirmed the above-mentioned Restraint Order and Flow Records, Medical, lacked documentation of R.N. initials and time indicating patients in restraints were monitored minimally every 2 hours as required per policy and procedure.