Based on observations, interview and document review, it was determined the facility staff failed to ensure patients and their representatives were provided the contact information to file a complaint or grievance with the state agency (Virginia Department of Health, Office of Licensure and Certification). The findings included: A tour of the child unit was conducted on February 4, 2019 at 2:02 p.m. with Staff Members #1, #2 and #6. The observation revealed posted information regarding patient rights and contact information related to filing complaints and grievances. The information did not include the contact information for the state agency. An interview was conducted on February 4, 2019 at 2:25 p.m. with Staff Member #6 in the presence of Staff Members #1 and #2. The surveyor requested to review the admission information given to the patient's representative. Staff Member #6 provided the admission papers, which included a tri-fold brochure regarding Patient rights, responsibilities and the contact information for filing complaints and grievances. The brochure did not include the contact information for the state agency. Staff Member #6 verified the brochure did not include the state agency's contact information. The surveyor conducted observations of the facility's adolescent unit on February 4, 2019 at 2:32 p.m. with Staff Member #7. The observation revealed the posted rights information did not include contact information for the state agency. During the review of the admission information Staff Member #7 verified the admission pack did not include contact information for filing a complaint/grievance with the state agency. Observations and interviews conducted on February 4, 2019 from 2:47 p.m. through 3:50 p.m. on the facility's eating disorder and adult units revealed the same findings. The surveyor conducted an end of the day interview on February 4, 2019 with Staff Members #1, #2, #4 and #5. The surveyor informed the facility staff of the findings. Staff Member #5 verified the findings and reported the tri-fold brochures were partly a corporation template which had been recently updated. The surveyor requested the facility's policies and procedures for patient rights, and the process for filing a complaint and/or grievance. On February 5, 2019, Staff Member #4 presented the facility's policies: Patient Rights, Human Rights Plan - Part III- Dignity/Grievance Process, Human Rights Plan - Part III- Complaint and Fair Hearing, and Human Rights Plan - Part V- Complaint Resolution, Hearing, & Appeal Procedures- General Provisions. Staff Member #4 and the surveyor reviewed the four (4) policies. Staff Member #4 verified the four (4) policies did not address a process for the patient or the patient's representative to file a complaint or grievance with the state agency. Staff Member #4 verified the four (4) policies did not include contact information for the state agency. The facility did not present additional grievance processes or policies related to the inclusion of the state agency and its contact information prior to exit February 7, 2019.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, it was determined the facility's patient advocate failed to provide a response to complainants within the guidelines provided by the Centers for Medicare and Medicaid Services (CMS) (within seven (7) days) for two (2) of three (3) patients included in the survey sample. (Patients #10, and #12) The findings included: During the entrance conference held on February 4, 2019 at approximately 1:30 p.m., the surveyor requested the facility's complaint/grievance log for the months of September 2018 through February 1, 2019. Staff Member #22 provided navigation of the patients' electronic medical record (EMR) review. Staff Member #4 was present during the EMR reviews conducted February 5 and 6 2019. Patient #10 was admitted voluntarily to the facility on [DATE] for suicidal ideation with a plan. Patient #10 was discharged on [DATE] against medical advice (AMA). Staff Member #4 reported the facility received a letter from the patient's representative regarding an alleged lack of medical care. The surveyor requested to review the complaint investigation documents related to Patient #10. Staff Members #4 presented the documents for review. Staff Member #1, #2 and #3 were present during the interview with Staff Member #4. A review of the facility's complaint and grievance log on February 6, 2019 with Staff Member #4 revealed Patient #10 had not been included on the log. Staff Member #4 verified the findings. Staff Member #4 reported Patient Advocacy personnel had recently developed a new tool to track complaints. Staff Member #4 verified the facility's response letter to the Complainant was dated and sent after seven (7) days. The surveyor obtained Patient #12's name from the facility's complaint log. Patient #12's EMR documented the patient's admission November 26, 2018 and discharge as December 8, 2018. The facility received a complaint related to an incident on December 6, 2018 involving staff and Patient #12. The facility received the complaint on December 7, 2018. The response letter to the family was not sent until December 17, 2018. Staff Member #4 verified the response letter to the complainant was not sent within seven (7) days. Staff Member #4 reported the facility was following the requirements for the mental health-reporting agency, which required written notification to the patient or patient's representative within ten (10) days. The surveyor reviewed the CMS guidelines with Staff Member #4, related to notifying the patient or their representative within a seven (7) day timeframe. On February 5, 2019, Staff Member #4 presented the facility's policy Human Rights Plan - Part III- Dignity/Grievance Process. The policy read in part 2. Process for Resolution of Patient Complaints: a. The patient's grievance shall be communicated by the Chief Executive Officer to appropriate staff for the purpose of further assessment and problem resolution, depending upon the nature and extent of the complaint. This portion of the policy does not indicate a timeframe for response to the patient or patient representative. The Human Rights Plan - Part III- Dignity/Grievance Process policy further separated process pathways regarding complaints alleging abuse/neglect or exploitation by persons outside of the hospital or a hospital employee. For complaints alleging abuse/neglect or exploitation, the policy read in part 4. ... b. The Chief Nursing Officer shall initiate an impartial investigation within 24 hours of receiving a report of potential abuse or neglect ... 1. The investigator shall make a final report to the Chief Nursing Officer and the investigating authority and to the human rights advocate within 10 working days of appointment ... 4. In all cases, the Chief Nursing Officer shall provide a written decision, including actions taken as a result of the investigation , within seven working days following the completion of the investigation to the patient or the patient's authorized representative ... The decision shall be in writing and in the manner, format and language that is most understood by the patient ... The surveyor inquired regarding the total time involved with a ten (10) day period to complete the investigation and an additional seven (7) days regarding written notification of the patient or patient's representative. Staff Member #4 verified the timeframe within the policy. Staff Member #4 reported the facility generally completed the process of investigation and notification within ten (10) days. Staff Member #4 stated, We will have to update our policies to reflect the CMS guidelines.
Based on interview and document review, it was determined the facility staff failed to modify the patient's plan of care (Recovery Plan) to reflect the use of physical restraints for two (2) of five (5) restrained patients included in the survey sample. (Patients #7 and #8) The findings included: Staff Member #22 provided navigation of the patients' electronic medical record (EMR) review. Staff Member #4 was present during the EMR reviews conducted February 5 and 6 2019. A review of Patient #7's EMR indicated the patient's admission status as a temporary detention order (TDO) on August 9, 2018. Patient #8 changed his/her admission status to voluntary after his/her hearing on August 13, 2018. Patient #7 scheduled discharge was documented for December 12, 2018. Patient #7's EMR indicated the patient was placed in a physical hold on December 10, 2018. A review of Patient #7's Recovery Plan did not include a modification to reflect the use of restraints. During an interview on February 5, 2019 at 8:45 a.m., Staff Member #22 verified Patient #7's Recovery Plan was not updated to reflect a restraint had been utilized on December 10, 2018. A review of Patient #8's EMR indicated the patient's admission status on January 8, 2019 involved a TDO. Patient #8 was discharged from the facility on January 10, 2019 after being committed during a hearing to a different facility. Nursing staff documented Patient #8 was placed in a physical hold (restraint) on January 8, 2019 and January 10, 2019. A review of Patient #8's Recovery Plan did not include modification to reflect utilization of restraint. During an interview on February 6, 2019 at 9:29 a.m. Staff Member #22 verified Patient #8's Recovery Plan did not have modification to reflect the utilization of a restraint on January 8, 2019 and January 10, 2019. On February 6, 2019, Staff Member #4 reviewed the facility's Restraint policy with the surveyor. Staff Member #4 verified the facility's policy included the need to modify the patient's Recovery Plan once restraints were employed.
Based on interview and document review, it was determined nursing staff failed to obtain a physician's order after restraining one (1) of five (5) restrained patients included in the survey sample (Patient #9). The findings included: Staff Member #22 provided navigation of Patient #9's electronic medical record (EMR) review. Staff Member #4 was present during the EMR review conducted February 6, 2019. A review of Patient #9's EMR documented the patient's date of admission as October 24, 2018. Patient #9's EMR indicated the patient was placed in three (3) separate physical holds on October 31, 2018. Nursing documentation indicated the first physical hold on October 31, 2018 started at 4:55 p.m. and discontinued at 5:20 p.m. with a debriefing. The second documented physical hold started at 5:25 p.m. and discontinued at 5:27 p.m. on October 31, 2018. The third documented physical hold on October 31, 2018 started at 9:40 p.m. and discontinued at 11:00 p.m. with a debriefing. A review of the physician's order for restraints on October 31, 2018 only revealed two (2) orders with documented physician notification, completed face to face and second tier assessment. A review of Patient #9's EMR did not include a physician's order for placing the patient in a physical hold/restraint from 5:25 p.m. to 5:27 p.m. on October 31, 2018. Patient #9's EMR did not contain the required face to face or the second tier assessment for the restraint utilized from 5:25 p.m. to 5:27 p.m. on October 31, 2018. Staff Member #2 acknowledged if staff discontinued one physical hold at 5:20 p.m., then placed the patient in a second physical hold at 5:25 p.m. on October 31, 2018, a new physician's order was needed for the second physical hold. During an interview conducted on February 6, 2019 at 10:02 a.m., Staff Member #2 reviewed Patient #9's EMR. Staff Member #2 stated, A face-to-face and second tier assessment has to be performed for every physical hold. Staff Member #2 reported he/she would check to determine if a paper order was used instead of an electronic physician's order. On February 6, 2019, Staff Member #4 reviewed the facility's Restraint policy with the surveyor. Staff Member #4 verified the facility's policy specified that a new physician's order was needed for each application of a restraint. On February 7, 2018 at approximately 9:00 a.m., Staff Member #4 reported a paper order was not found for Patient #9's physical hold performed from 5:25 p.m. to 5:27 p.m., on October 31, 2018.
Based on interview and document review, it was determined nursing staff failed to obtain orders for blood glucose monitoring for one (1) of one (1) diabetic patient included in the survey sample (Patient #10). The findings include: Staff Member #22 provided navigation of Patient #10's electronic medical record (EMR) review (A diabetic patient). Staff Member #4 was present during the EMR review conducted February 6 2019. Patient #10's EMR documented his/her facility admission as 2:23 a.m. on December 12, 2018. The admission documents indicated Patient #10 was diagnosed with Type I Diabetes. Intake information gathered from the transferring hospital listed on the facility's Disposition and Follow-Up form dated 12/6/18 at 10:12 p.m., which read in part Spoke to ED [Emergency Department] RN [Registered Nurse]: (symbol for the word no) insulin pump BS [blood sugar] 278 waiting for Lantus med (insulin) to come to floor from pharmacy to give. Informed Adol. [Adolescent] unit of pt.'s latest BS. Patient #10's intake information did not specify whether Patient #10 received the dose of insulin prior to leaving the transferring hospital. A review of the Intake Nursing entry at 3:12 a.m. on December 7, 2018 included an initial set of vital signs, but did not include a blood glucose level. Nursing documented speaking with Staff Member #23 at 3:13 a.m., and receiving recommendations to admit to the adolescent unit. The intake information did not include orders for glucose monitoring. A scanned RN Skin Assessment upon Arrival to the Unit dated 12/7/18 with a unit arrival time indicated as 3:45 a.m. documented two (2) facility staff performed the skin assessment. Both employees designated their title as Tech. The RN Skin Assessment upon Arrival to the Unit form documented Patient #10 had a PEX Com (glucose monitoring device) located on the back of the patient's right arm. Patient #10's initial nursing assessment summary completed on the adolescent unit December 7, 2018 at 5:00 a.m. documented Patient #10's interaction with staff. A review of the Adolescent Unit nursing documentation from 0500 (5:00 a.m.) through 0800 did not indicate a conversation with the admitting psychiatrist occurred. The nursing assessment documented awareness at 6:09 a.m. and that Patient #10 had a history of Diabetes. A review of nursing documentation did not address the patient's diabetes or monitoring of blood glucose levels. A review of the Physicians Orders form scanned into Patient #10's EMR revealed the first telephone order was timed at 9:40 a.m. on December 7, 2018. The order read TO [telephone order] [Staff Member #23's name] transfer Pt [Patient] to [Staff Member #24's name]. The second order on the Physicians Orders form was dated December 7, 2018 at 9:40 a.m., read in part TO: [Staff Member #24's name] Discharge pt AMA [against medical advice] to follow up at [Name of a partial hospital program]. The physician order form provided to the surveyor did not address the patient's history of diabetes. An interview was conducted on February 6, 2019 at 3:14 p.m. with Staff Member #19. Staff Member #19 reported he/she had reviewed Patient #10's EMR. Staff Member #19 reported he/she had cared for Patient #10 on the day shift starting at 7 a. Staff Member #19 remembered Patient #10 as being anxious, uneasy, and not wanting to be in the hospital. The surveyor asked regarding Patient #10's glucose monitoring. Staff Member #19 stated, First we need an order placed in [name of charting system] that will show us what we need to do. It populates the time for the medications. That is how it is done. Staff Member #19 reported that without an order the electronic charting system would not trigger times for medications or monitoring like glucose checks or blood pressure checks. Staff Member #19 reported not being aware of the patient's implanted blood glucose scanner. Staff Member #19 stated, We had not been trained here on how to use the scanning device, there was no order to use the scanning device. Staff Member #19 stated, Blood sugar checks should be taken on admission, and insulin orders obtained. That did not happen in this case. Staff Member #19 reported the physician was called and the patient's care was transferred to a physician familiar with the patient. Staff Member #19 reported the patient and his/her family member requested to leave and the physician was contacted and provided an AMA discharge with follow-up. An interview was conducted on February 6, 2019 at 3:24 p.m. with Staff Member #16. Staff Member #16 explained the intake process. Staff Member #16 reported remembering Patient #10. Staff Member #16 stated, We received a call looking for a bed for a sixteen (16) year old diabetic. At the time I took the call, the patient's blood sugar was elevated 278. That's too high I reported to the doctor that the patient was medially unstable. I called the hospital and they reported waiting for Lantus insulin from their pharmacy. I called the adolescent unit nurse to make [him/her] aware of the blood sugar and their pending administration of insulin. The surveyor asked if the facility received with the patient information that the Lantus insulin had been administered. Staff Member #16 reported the transferring hospital did not provide documentation of the insulin. Staff Member #16 stated, We do not allow patients to come until they're stable. The clinicals, labs any testing is supposed to come over before the patient arrives. We gather the appropriate documents to ensure the patient is stable. An interview was conducted on February 5, 2019 at 5:35 p.m. with Staff Member #13. Staff Member #13 remembered Patient #10 arrived on the adolescent unit early morning December 7, 2018. Staff Member #13 stated, I had worked over form evening to nights. I was leaving at 3:00 a.m. I started the admission and the consents. Staff Member #13 reported Patient #10's family member was present during his/her part of the admission process. Staff Member #13 reported Patient #10 was very anxious with distorted thinking. Staff Member #13 reported Patient #10's anxiety increased when he/she realized his/her family member had left the unit. When the surveyor questioned regarding the patient's elevated blood glucose level or if Patient #10 had received insulin prior to arrival. Staff Member #13 stated, I didn't question the previous information from intake. First, because the patient should be medically stable before they get to the unit. By the time they arrive on the unit, they should have been medically cleared. We don't accept medically fragile patients. Staff Member #13 reported the nurse assigned to medications handles medical issues like medications, glucose monitoring, or following up on blood pressures. An interview was conducted on February 7, 2019 at 7:46 a.m., with Staff Member #14. Staff Member #14 reported remembering Patient #10. Staff Member #14 reported Patient #10 was admitted to the unit sometime around 4:00 in the morning. Staff Member #14 remembered Patient #10 had diabetes and a special monitor. Staff Member #14 reported Patient #10's family member explained to the nurses that the patient had an implanted scanner and how to use it. Staff Member #10 reported Patient #10 was never at ease, refused food and drink. Staff Member #14 reported patient #10 was focused on calling his/her family member and wanted to go home. Staff Member #14 stated, We have special rules regarding using the phone at night, as soon as it was time. We allowed [him/her] to call home. Staff Member #14 stated, The nurses take care of the medical needs. I manage the milieu. I make sure the patients are contained, the unit is safe. I take vital signs, record meal and snack intake. I'm there to de-escalate when needed. A telephone interview was conducted on February 7, 2019 at 11:00 a.m., with Staff Member #21. Staff Member #21 reported remembering Patient #10 from December 7, 2018. Staff Member #21 stated, I remember [him/her] being extremely anxious. I had floated to the adolescent unit that morning and took over the admission. Staff Member #21 reported the other nurse had been scheduled to leave at 3:00 a.m. Staff Member #21 reported Patient #10's family member had written out the patient's insulin instructions. Staff Member #21 stated, No one mentioned to me the patient had an implanted glucose scanner. Staff Member #21 reported Patient #10 was anxious, hard to understand, and would not settle down. Staff Member #21 stated, We try to encourage all new admissions to lay down and try to sleep if only for a few hours. Their day has usually been rough. Staff Member #21 reported Patient #10 would not go to his/her room but stayed at the nurse's station. Staff Member #21 reported the intake nurse had received initial orders from Staff Member #23 for the patient's admission and medications. Staff Member #21 reported the internal medicine physician generally ordered medications for medical conditions. Staff Member #21 stated, There were no orders for insulin and no medications administered when I left at the change of shift.
Based on the review of clinical records for 5 (five) patients for whom restraints were used, and staff interviews, the facility staff failed to ensure that restraint orders were obtained immediately, within a few minutes, after the restraint of 1 (one) patient (Patient #6), that the physician orders for emergency safety intervention were consistent with procedures documented by facility staff for one patient (Patient #6), and that physician orders were authenticated for one patient (Patient #7). Findings include: 1. Documentation from 2/11/2016 at 0345 (3:45 AM) was that a physical hold was initiated for Patient #6 at 0300 (3:00 AM), was discontinued at 0305 (3:05 AM), and that the attending physician was not notified because Multiple attempts made to notify attending physician (physician's name), but were unsuccessful. (Physician's name) was notified and a restraint order obtained after 1 (one) hour. (Physician's name) notified at 0410 (4:10 AM). Staff Member #1 stated the following regarding the above findings at 3:20 PM on 9/28/16: There is no order for restraint. We knew there wasn't one on there, because (the nurse) talked to (physician's name). The supervisor's report dated 2/11/16 documents Attempted to call (physician's name) to get order x 1 hr without success. Contacted (name of Staff Member #4 (four)), AOC (Administrator on call), and then received order from (physician's name) at 0410 (4:10 AM). At 0630 (6:30 AM) we have not heard from (physician's name). Incident report completed. 2. The surveyor noted a physician telephone order in Patient #6's record dated 2/7/16 at 1320 (1:20 PM) for a physical hold for up to 2 (two) hours for aggressive behavior; however, the record lacked documentation of a hold at 1320 on 2/7/16 in the nurses notes. There was documentation by the nurse related to a physical hold, soft restraints x 4 (four) and seclusion beginning at 0125 (1:25 AM) on 2/7/16. The supervisor's report dated 2/7/16 documented (Patient's name) required IM/hold/locked seclusion at 0125 (1:25 AM)-assaulting staff. Unit had some difficulty contacting (physician's name) between 2330 (11:30 PM) and 0150 (1:50 AM) but he did eventually call back and gave orders for additional meds. In an interview on 9/28/16 at 2:55 PM, Staff Member #1 stated the nurse did not use military time, but that is the order that goes with that documentation, that nurse no longer works here. Documentation by the nurse in the restraint monitor section of the EMR (electronic medical record) was that restraint was applied at 0125 (1:25 AM) on 2/7/16, restraints used were soft x's 4, physical holding, seclusion; restraint discontinued at 0515 (5:15 AM). The restraint/seclusion narrative note dated 2/7/16 at 0527 (5:27 AM) documented 2 physical holds on 2/7/16 (#1 and #2); documentation in the Patient Notes was that #1 began at 0125 (1:25 AM) and ended at 0127 (1:27 AM); #2 began at 0211 (2:11 AM), and ended at 0213 (2:13 AM). A mechanical restraint is documented in the narrative note with a begin time of 0322 (3:22 AM) and end time of 0515 (5:15 AM). There is documentation in the narrative note of 3 (three) episodes of seclusion on 2/7/16 ( #1,2,3). #1 episode of seclusion was documented as beginning at 0127 (1:27 AM) and ending at 0210 (2:10 AM); #2 episode of seclusion was documented beginning at 0213 (2:13 AM) and ending at 0230 (2:30 AM); #3 episode of seclusion was documented as beginning at 0235 (2:35 AM) and ending at 0320 (3:20 AM). There was no documentation in the narrative nursing note of a restraint after the seclusion ended at 0320 (3:20 AM); however, the restraint monitor documentation is that restraints were applied on 2/7/26 at 0125 (1:25 AM) and discontinued on 2/7/16 at 0515 (5:15 AM). The Seclusion/Restraints observation check sheet documentation between 0125 (1:25 AM) and 0515 (5:15 AM) does not include a code for mechanical restraint, which is inconsistent with narrative nurses note. The Seclusion/Restraint observation check sheet documented physical holds at 0125 (1:25 AM), 0211 (2:11 AM), and at 0320 (3:20 AM) in conjunction with seclusion. Circulation checks are documented at 0210 (2:10 AM), and ROM (range of motion) at 0320 (3:20 AM). The Seclusion/Restraint observation check sheet documents seclusion off and on between 0127 (1:27 AM) and 0250 (2:50 AM). Seclusion is then documented every 5 (five) minutes continuously between 0255 (2:55 AM) and 0515 (5:15 AM) (total of 2 hours 20 minutes). Physician orders for restraint which were in the medical record and available for the surveyor to review for 2/7/16 included: (#1) date: 2/7/16, time: 1320 (1:20 PM) T.O. (telephone order) (physician's name) (nurse's name) RBV (read back verbal order) 1. Give Zyprexa 5 (five) mg (milligrams) IM (intramuscular) for agitation Q6 (six) hrs (every 6 hours) PRN (as needed), may start at 2:00 AM on 2/7/16. 2. Give benedryl {sic}50 mg IM for agitation PRN Q6 hrs, may start at 2:00 AM on 2/7/16. 3. Special treatment orders Place pt. (patient) in hold up to 2 hour(s), STAT (immediately), for aggressive behavior. To be re-evaluated every 2 hours, up 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able remain calm, no longer aggressive to staff and no longer destroying property. In an interview on 9/28/16 at 2:55 PM, Staff Member #1 stated the nurse did not use military time, but that is the order that goes with that documentation, that nurse no longer works here. (#2) date: 2/7/16; time: 0320 (3:20 AM) T.O. (physician's name) (nurse's name) RBV Special treatment procedure Place pt. in hold up to 2 hour(s), STAT (immediately), for aggressive behavior. To be re-evaluated every 2 hours, up 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able remain calm, no longer aggressive to staff and no longer destroying property. 2. May give Zyprexa 2.5 mg IM for agitation one time at 6:30 AM if pt remains aggressive or self injurious. There were no orders for seclusion or mechanical holds available for review in the EMR for Patient #6 for the above episodes of restraint which had been documented for 2/7/16. Documentation on the Seclusion/Restraints observation check sheet, the restraint monitor, and the narrative nursing notes was not consistent. On 9/28/2016 at 2:55 PM Staff Member #1 told the surveyor that (nurse's name) must have included all restraints in this order instead of getting orders for each; the order doesn't match the event. The order is for a hold, but event was seclusion. We were aware that there were problems with this record in February. That nurse no longer works here. 3. Nursing notes in Patient #6's EMR for 2/17/16 documented the following regarding physical holds, mechanical restraint, and locked seclusion of Patient #6 on that date: A. A physical hold for Patient #6 was initiated at 1800 (6:00 PM), and was discontinued at 1815 (6:15 PM). A second physical hold for Patient #6 was documented between 2145 (9:45 PM) and 2150 (9:50 PM). B. Patient #6 was placed into locked seclusion between 2151 (9:51 PM) and 2229 (10:29 PM). C. Patient #6 was placed in a mechanical hold from 2230 (10:30 PM) until 2300 (11:00 PM). Facility staff uses a Special treatment procedure stamp for restrictive intervention orders for a verbal physician order for restraint. The stamps have blanks so that the nurse may fill in the type of restraint, how long the intervention is to last, the unsafe behavior requiring restraint, and criteria as to when a patient may be released from the emergency safety intervention. The Special treatment procedure stamp corresponding to the safety interventions order for Patient #6 was dated 2/24/16 at 1845 (6:45 PM) as a Late entry for 2/17/16, and included the following information: Physical restraint up to 2 hours, STAT for being a danger to self and others. To be re-evaluated every 2 hours, up to 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able to no longer danger to self and others. The order was was signed by the physician on 2/25/16 at 8:50 AM. There were no physician orders for locked seclusion or mechanical restraint found in Patient #6's EMR. The Seclusion/Restraints observation check sheet dated 2/17/16, time in 21:45 (9:45 PM), time out 23:00 (11:00 PM) includes documentation that at 9:45 PM Patient #6 was in a physical hold; at 10:00 PM he/she was placed into seclusion, medication was administered, and he/she was threatening; at 10:15 PM Patient #6 was in seclusion and threatening. At 10:30 PM and 10:45 PM it was documented that Patient #6 was in 4 point restraints, threatening, and at 11:00 PM, 4 point restraints were discontinued. There were no staff initials documented beside the codes written in on the check sheet. The documentation in the nursing notes for 2/17/16 does not correspond with the documentation on the Seclusion/Restraint observation check sheet. The supervisor's note dated 2/17/16 documented the following: Code BERT called x 2 due to behavior (destructive/threatening). IM (intramuscular) Zyprexa, Benadryl given, restraint bed to prevent harm. IM Ativan. Unable to reach (physician's name) for 1/2 (half) hour tonight. Code BERT is a team of staff assigned to respond to behavioral issues within the hospital. 4. During an interview with Staff Member #4, the Assistant Administrator, on 9/29/16 at 2:00 PM regarding restraint orders obtained more than one hour after the ESI (emergency safety intervention) was initiated and missing ESI orders, he/she stated We recognized that this was a problem, we just spoke to staff about this. We did a review of restraints to see if there was a problem. There was a period where we had a couple of misses, we are aware of that. 5. While interviewing Staff Member #3, the CNO (Chief Nursing Officer) on 9/29/16 at 3:50 PM, he/she stated the following I started here the end of April, I am aware of the seclusion and restraint issues, it was the first thing I noticed when I came here. We have conducted Part 1 application of restraint training, and have planned Part 2 regarding paperwork, regulations, order renewals, etc.; we are retraining the supervisors and managers for face to face assessments. We have CPI (Crisis Prevention Institute) trainers, five have been through a new training, all will be recertified. Once done, we will retrain all staff. We also have a BERT (behavioral response team) team to respond to incidents. It as gotten better since I've been here, we have had fewer restraints, that data has improved. CPI is an international training organization committed to best practices and safe behavior management methods that focus on prevention. One area CPI specializes is nonviolent crisis intervention, teaching practical skills and strategies to safely manage disruptive or difficult behavior while balancing the responsibilities of care. (https://www.crisisprevention.com/Specialties; accessed on 10/6/16 at 12:10 PM) 6. A review of the medical record for Patient #7, who was discharged from the facility on 8/11/16, revealed a telephone order written on 8/1/16 at 0835 (8:35 AM) which had not been authenticated by the physician on 9/29/16 when the surveyor reviewed the medical record. 7. A review of Patient #7's medical record revealed the following telephone orders documented on 8/2/16 which had not been authenticated by the physician on 9/29/16 when the surveyor reviewed the medical record: A. 2 (two) telephone orders documented on the physician order sheet for 8:30 (does not specify AM or PM) (1) for physical hold and (2) for locked seclusion. B. 1 (one) telephone order documented on the physician order sheet for 1930 (7:30 PM) for a physical hold. Patient #7 was discharged from the facility on 8/11/16. 8. A review of Patient #7's medical record by the surveyor revealed telephone orders received by the nurse on 8/9/16 at 1030 (does not specify AM or PM) for a physical hold and seclusion. The physician order page had been stamped with the following: Authenticated by (physician's name) on 8/19/2016 at 08:12:22 AM; Patient #7 was discharged from the facility on 8/11/16. At 1:30 PM on 9/29/16 Staff Member #1 stated This was before I started going around looking at all the charts for Joint Commission. Staff Member #1 further responded on 9/29/16 at 1:45 PM stating The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters. At 1:50 PM on 9/29/16 Staff Member #4, the Assistant Administrator, added We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward. Findings were discussed with Staff Members #1 and #4 on multiple dates at times throughout the survey process, and again on 9/29/16 between 4:00 PM and 4:30 PM with Staff Members #1, 4, and other members of administration. The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9. Zyprexa - an antipsychotic medication used to treat agitation (tense, overanxious, hostile) that occurs with schizophrenia and bipolar mania. It is also used in combination with other drugs to treat depression. The medication can help decrease hallucinations and help the patient think more clearly and feel less agitated. (www.drugs.com accessed 10/6/16 at 4:50 p.m.) Benadryl - (Diphenhydramine) is an antihistamine used in psychiatric medicine to treat phenothiazine drug-induced abnormal muscle movement (side effects). It is also used in general medicine to treat allergies, allergic reactions, motion sickness, insomnia, cough, and nausea. (www.drugs.com accessed 10/6/16 at 4:50 p.m.)
Based on clinical record review, facility document review and staff interview, the facility staff failed to ensure 2 (two) patients (Patient #3 and #6) who were placed in restraints did not remain in the restraints longer than the required time, based upon age, without a new order. The findings included: 1. Review of the clinical record for Patient #3 revealed on 9/11/15 the patient was actively self-injuring by banging head against wall and cutting self on leg. Patient stated, I cannot help myself and refused to stop the self injurious behavior.... The record evidences Patient #3 was placed in mechanical restraint at 20:45 (8:45 p.m.) and the end time was documented as 2330 (11:30 p.m.)- 2 (two) hours and 45 minutes. Patient #3 was between the age of 9 and 17 years of age. The physician's order dated 9/11/15 at 2100 (9:00 p.m.) read as follows: Place pt (patient) in mechanical restraint up to 2 (two) hours STAT (immediately) for being a danger to self. To be reevaluated every 2 (two) hours, up to 24 hours per hospital policy. Discontinue restrictive intervention when pt is no longer a danger to self and others. Review of the facility policy and procedure for Patient Restraint and Seclusion evidenced: ...B. Order for Restraint with Violent or Self Destructive Behavior: a. Physicians orders for restraint or seclusion must be time limited and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint must not exceed:...2. 2 hours for children and adolescents aged 9 to 17 years...b. To continue restraint or seclusion beyond the initial order duration, the RN (registered nurse) determines that the patient is not ready to release and calls the ordering physician to obtain a renewal order... On 9/28/16 at 2:20 p.m., the surveyor discussed the finding with Staff Member #1 and 4. Staff Member #1 stated, I cannot find a second order for the restraint, and there is no restraint check sheet for the observation checks. The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.
2. There was documentation in the narrative nursing note of 3 (three) episodes of seclusion for Patient #6 on 2/7/16. The first seclusion was documented as beginning at 0127 (1:27 AM) and ending at 0210 (2:10 AM); the second seclusion was documented beginning at 0213 (2:13 AM) and ending at 0230 (2:30 AM); the third seclusion episode was documented as beginning at 0235 (2:35 AM) and ending at 0320 (3:20 AM). Documentation on the 2/7/16 Seclusion/Restraints Observation Check Sheet conflicted with the nursing note, evidencing that Patient #6 was in seclusion continuously from 2:55 AM until 5:15 AM, when it was documented that seclusion ended. 3. Documentation in the 2/25/16 nurse's note was that Patient #6 was placed in seclusion twice on that date. The first episode of seclusion was initiated at 15:45 (3:45 PM) and ended on 2/25/16 at 1815 (6:15 PM); the second episode began at 2000 (8:00 PM), and ended at 2245 (10:45 PM). Findings were discussed with Staff Members #1 and #4 on multiple dates at times throughout the survey process. The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.
Based on clinical record review, staff interview and review of facility documents, the facility staff failed to ensure the data collected which identified opportunities for improvement and changes was used to take action to implement changes and ensure that improvements were sustained and that the data monitored the effectiveness of the safety of services and quality of care. The findings included: During the review of the Quality Program, the surveyor discussed with facility Staff Member #4 (Assistant Administrator/Quality) and Staff Member #1 the tracking, data collection and monitoring of restraint/seclusion use for the facility. During the survey areas of concern were identified by the survey team related to the use of restraint and seclusion which included: Obtaining physician orders, orders that were consistent with procedures, authentication of orders, and time limits for orders. At 1:30 p.m. on 9/29/16, Staff Member #1 stated, in regards to the orders, This was before I started going around looking at all the charts for Joint Commission...I have only been reviewing the data, I have not been doing an audit of the orders. Staff Member #1 further responded on 9/29/16 at 1:45 p.m., stating The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters. On 9/29/16 at 1:50 p.m., Staff Member #4, the Assistant Administrator, added We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward. On 9/29/16, at 3:10 p.m., Staff Member #4 stated the staff member who was looking at the restraint orders had left in February, and another person was hired in August but was looking at the orders retrospectively. During that time there were some changes in leadership and no one was in the office (Quality)...but the team has finally gotten back into their roles... Staff Member #1 and #4 stated they had identified issues in February, however, the team identified continued problems with the restraint documentation that continued in August charting. The survey findings were discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.
Based on clinical record review, staff interview and review of facility documents, the facility staff failed to ensure the data collected which identified opportunities for improvement and changes was used to take action to implement changes and ensure that improvements were sustained. The findings included: During the review of the Quality Program, the surveyor discussed with facility Staff Member #4 (Assistant Administrator/Quality) and Staff Member #1 the tracking, data collection and monitoring of restraint/seclusion use for the facility. During the survey areas of concern were identified by the survey team related to the use of restraint and seclusion which included: Obtaining physician orders, orders that were consistent with procedures, authentication of orders, and time limits for orders. At 1:30 p.m. on 9/29/16, Staff Member #1 stated, in regards to the orders, This was before I started going around looking at all the charts for Joint Commission...I have only been reviewing the data, I have not been doing an audit of the orders. Staff Member #1 further responded on 9/29/16 at 1:45 p.m., stating The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters. On 9/29/16 at 1:50 p.m., Staff Member #4, the Assistant Administrator, added We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward. On 9/29/16, at 3:10 p.m., Staff Member #4 stated the staff member who was looking at the restraint orders had left in February, and another person was hired in August but was looking at the orders retrospectively. During that time there were some changes in leadership and no one was in the office (Quality)...but the team has finally gotten back into their roles... Staff Member #1 and #4 stated they had identified issues in February, however, the team identified continued problems with the restraint documentation that continued in August charting. The survey findings were discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.
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