QA Investigation Results

Pennsylvania Department of Health
DEVEREUX FOUNDATION - BENETO CENTER - BRANDYWINE - SHRADER
Health Inspection Results
DEVEREUX FOUNDATION - BENETO CENTER - BRANDYWINE - SHRADER
Health Inspection Results For:


There are  2 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


A validation survey was conducted on May 7-8, 2015. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart G regulations for Psychiatric residential treatment facilities of under age 21. The census at the time of the survey was 10, and the sample consisted of four residents who had been restrained.












Plan of Correction:




483.358(d) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse, while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must verify the verbal order in a signed written form in the resident's record. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.



Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that verbal orders for restraint were obtained during or immediately after the emergency situation ended, and counter-signed by the ordering physician within the timeframe designated by facility policy, for two of four sample Individuals. This practice is specific to Residents #1 and #4.

Findings include:

1. A review of the record of Resident #1 revealed that he had been restrained on 10/15/2014. This incident was documented on an emergency safety interventions (ESI) progress note, which is the first page of a packet utilized by the facility to document all aspects of an ESI. The progress note indicates that the ESI was initiated at 5:31 PM and discontinued at 5:32 PM. Page two of the packet is titled physician order/nursing assessment, and provides direction and space for staff to record the name of the physician contacted to issue verbal orders for the restraint, when the order was obtained, and when it was countersigned by the ordering physician. For the ESI noted above, an entry on page two of the packet notes that the ordering physician was not notified of the restraint until 10/21/2014, and did not sign the restraint order until 10/23/2014.

A review of facility policy and procedures revealed a document titled Restraint Use in Residential Treatment and Educational Services, dated 09/2001 and last revised 03/2012. Under procedures in this policy, section II is titled ordering a physical restraint. Paragraph (b) of this section directs that as soon as the restraint situation is deemed safe, the staff or supervisor will contact the nurse who will communicate with the physician to obtain an order for the restraint utilized.

2. A review of the record of Resident #4 revealed that he had been restrained on 08/29/2014, from 10:53 AM until 10:57 AM. Documentation on page two of the ESI packet notes that verbal orders were obtained for this ESI at 11:45 AM. However, the ordering physician did not countersign this verbal order until 09/03/2014 at 5:00 PM, five days after the ESI occurred.

Additional review of the facility policy and procedures for restraint usage, noted above, revealed that paragraph (e) of section II (ordering restraint) directs that the attending/treating physician shall be contacted and informed of the use of the restraint as soon as possible but no later than 24 hours from the time of the restraint. The attending/treating physician will co-sign the order as evidence of consultation within 72 hours.

Interview with the facility's director of quality improvement (QI) on 05/07/2015 at approximately 10:45 AM confirmed that verbal orders for ESI for Resident #1 on 10/15/2014 did not conform to the time frames specified by facility policy and procedures. Likewise, the director of QI confirmed that the co-signing of verbal orders for Resident #4 for the ESI of 08/29/2014 did not conform to the time frames specified by facility policy and procedures.











Plan of Correction:

For individual #1 evidence that a physician's order was not obtained during or immediately following incident of restraint on (date) was not obtained.

Current policy/procedures requires physician orders for the use of any restraint regardless of the length of time of the intervention. Procedure requires nursing staff to obtain an authorization for each restraint. A retraining will occur by May 31, 2015 with the Program Director, Program Supervisors and staff on the requirement regarding informing the nurse on duty immediately during or following an episode of restraint. The Director of Nursing will provide training reminders to the Nurses regarding asking the question "Did a restraint occur?" when a client is presented for assessment. Signage will be created for the Nursing Stations as well as the Residential and Educational supervisors offices to remind all parties of the need to communicate restraints immediately and clearly.

The Nurse Manager/designee and Program Director/designee are conducting a first level review for each order of restraint (within 24hours) to ensure that all documentation is complete for each order. If a variance is discovered, the Nurse Manager/designee or Program Director/designee, will provide follow-up with the respective staff and provide retraining and/or progressive discipline as indicated.

Quality Management Representative will audit restraints monthly to log that notification for orders occurred and data will be shared with the Leadership team.

Oversight will be provided by the Residential Services Director and Executive Director with data review by the Leadership team at the center level quality improvement meeting (PICC).

Verbal Orders:
Doctor's orders for restraint for individuals # 4 revealed that physician's verbal orders were not countersigned within the 72 hour timeframe for counter signature by the physician. The information was provided to the physician for immediate review and follow up.

Retraining of physicians on procedural requirement on authentication (verification) of verbal orders for restraint within 72 hours will occured on 5/13/15 during the Medical staff meeting. Physicians are required to sign and authenticate all restraint orders within 72 hours. When necessary to meet the 72 hour deadline, the nurse on duty will fax/scan the verbal orders to the psychiatrist for authentication and return to the program for filing in the client record. Psychiatrist schedule, provided by administrative support, will have scheduled time for authentication of verbal orders as a reminder to complete task. Nursing department will aid in facilitation of obtaining signatures as needed.

The nurse manager (or designee) is conducting a first level review of the face-to-face assessment daily for each order of restraint within 24 hours of the ordered restraint.

The Program Director will conduct a review of the restraint paperwork prior to 72 hour post-restraint and request immediate completion of any missing paperwork related to orders.

Quality Management Representative will audit restraint documentation monthly to ensure that notification for orders occurred and data will be shared with the Leadership team.

Medical Director has oversight for physicians and their documentation.



483.358(f) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-

(1) The resident's physical and psychological status;

(2) The resident's behavior;

(3) The appropriateness of the intervention measures; and

(4) Any complications resulting from the intervention.


Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within one hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological well-being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the Resident. This practice is specific to Resident #1.

Findings include:

A review of the record of Resident #1 revealed that he had been restrained on 10/15/2014. This incident was documented on an emergency safety interventions (ESI) progress note, which is the first page of a packet utilized by the facility to document all aspects of an ESI. The progress note indicates that the ESI was initiated at 5:31 PM and discontinued at
5:32 PM. Page two of the packet is titled physician order/nursing assessment, and provides direction and space for staff to record the name of the physician or nurse completing the face-to-face assessment within one hour of the ESI, and the date/time the assessment was conducted. For the ESI noted above, the assessment was completed on 10/21/2014.

A review of facility policy and procedures revealed a document titled Restraint Use in Residential Treatment and Educational Services, dated 09/2001 and last revised 03/2012. Under procedures in this policy, section VIII is titled evaluation and re-evaluation during physical restraint, continuation of restraint. Paragraph (a) of this section directs that within one hour of the initiation of any physical restraint, a licensed professional must conduct a face-to-face assessment of the physical and psychological well-being of the client.

Interview with the facility's director of quality improvement (QI) on 05/07/2015 at approximately 10:45 AM confirmed that for this ESI incident for Resident #1, the face-to-face assessments did not occur within the time frame specified by facility policy.








Plan of Correction:

For Residents # 1 identified restraints showed a lack of documentation surrounding the one hour face to face assessments.

Current policy/procedure indicates face to face assessments are to be completed by a licensed professional within one hour of restraint. The assessment will include but is not limited to: individual's physical and psychological status (mental status), behavior, appropriateness of the intervention measures and any complications resulting from the intervention. This assessment will be documented on the current form and will include the date and time of the face-to-face assessment. Director of Nursing and nursing leaders provided feedback to all professional staff for face-to-face assessments to be completed within one hour of restraint.

A retraining will occur by 6/15/15 with the Program Director, Program Supervisors and staff on the requirement regarding informing the nurse on duty immediately during or following an episode of restraint. The Director of Nursing will provide training reminders to the Nurses regarding asking the question "Did a restraint occur?" when a client is presented for exam. Signage will be created for the Nursing Stations as well as the Residential and Educational supervisors offices to remind all parties of the need to communicate restraints immediately and clearly.

The Nurse Manager (or designee) and Program Director are conducting a first level review for each order of restraint (within 24 hours) to ensure that all documentation is complete for each order. If a variance is discovered, the Nurse Manager or Program Director, will provide follow-up with the respective staff and provide retraining and/or progressive discipline as indicated

Oversight will be provided by the Director of Nursing and Residential Services Director.



483.358(g)(3) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
[Each order for restraint or seclusion must include] the emergency safety intervention ordered, including the length of time for which the physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion authorized its use.


Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that each order for restraint includes the emergency safety intervention ordered, including the length of time for which the physician authorized its use. This practice
is specific to Resident #1.

Findings include:

A review of the record of Resident #1 revealed that he had been restrained on 10/15/2014. This incident was documented on an emergency safety interventions (ESI) progress note, which is the first page of a packet utilized by the facility to document all aspects of an ESI. The progress note indicates that the ESI was initiated at 5:31 PM and discontinued at 5:32 PM. Page two of the packet is titled physician order/nursing assessment, and provides direction and space for staff to record the name of the physician contacted to issue verbal orders for the restraint, when the order was obtained, and the specific type of restraint to be utilized and the time frame for which the restraint is to be used. For the ESI noted above, there are no entries on page two of the packet documenting the emergency safety intervention ordered, including the time authorized for its use.

A review of facility policy and procedures revealed a document titled Restraint Use in Residential Treatment and Educational Services, dated 09/2001 and last revised 03/2012. Under procedures in this policy, section IV is titled contents of restraint orders. Paragraph (c) of this section states that orders for restraint must be documented on the emergency safety interventions physician order/nursing assessment form.

Interview with the facility's director of quality improvement (QI) on 05/07/2015 at approximately 10:45 AM confirmed that the documentation of the ESI described above lacked the requisite element of specific emergency safety intervention ordered, including the time authorized for its use.











Plan of Correction:

Current procedure and restraint forms require and have an entry space to indicate the length of time of the order of restraint.

A retraining will occur by June 15, 2015 with the Program Director, Program Supervisors and staff on the requirement regarding informing the nurse on duty immediately during or following an episode of restraint. The Director of Nursing will provide training reminders to the Nurses regarding asking the question "Did a restraint occur?" when a client is presented for exam. Signage will be created for the Nursing Stations as well as the Residential and Educational supervisors offices to remind all parties of the need to communicate restraints immediately and clearly.

The Nurse Manager (or designee) and Program Director are conducting a first level review for each order of restraint (within 24 hours) to ensure that all documentation is complete for each order. If a variance is discovered, the Nurse Manager or Program Director, will provide follow-up with the respective staff and provide retraining and/or progressive discipline as indicated.

Quality Management Representative will audit restraints monthly to ensure that notification for orders occurred and data will be shared with the Leadership team.

Oversight will be provided by Residential Services Director and Executive Director with data review by the Leadership team at the center level quality improvement meeting (PICC).



483.362(a) STANDARD
MONITORING DURING AND AFTER RESTRAINT

Name - Component - 00
Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention.



Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention. This practice is specific to Resident #1 and #4.

Findings include:

A review of the record of Resident #1 revealed that he had been restrained on 11/20/2014 from 6:00 PM until 6:12 PM, and again on 04/08/2015 from 8:30 AM until 8:38 AM. A review of the record of Resident #4 revealed that he had been restrained on 01/12/2015 from 8:35 AM until 8:47 AM. These incidents were documented on an emergency safety interventions (ESI) progress note, which is the first page of a packet utilized by the facility to document all aspects of an ESI. Page three of the packet is titled client observation, and provides direction and space for staff to record their observations of the Resident's physical and psychological status at five minute intervals. For each of these restraint incidents, there was no evidence (no page three) that staff were continually assessing and monitoring the physical and psychological well-being of the resident throughout the duration of the ESI.

A review of facility policy and procedures revealed a document titled Restraint Use in Residential Treatment and Educational Services, dated 09/2001 and last revised 03/2012. Under procedures in this policy, section VII is titled monitoring during physical restraint. Paragraph (b) of this section directs that the supervisor (observer) will document vital signs and responsiveness, range of motion every 5 minutes utilizing the ESI Client Observation form.

Interview with the facility's director of quality improvement (QI) on 05/07/2015 at approximately 10:50 AM confirmed that for these ESI incidents for Residents #1 and #4, the five minute assessments required over the duration of the ESI were not documented in accordance with facility policy.







Plan of Correction:

Current procedure and restraint forms require that the physical observations of the client are to occur at 5 minute intervals. All staff are being re-educated in practice standards durng twice annual Safe and Positive Approaches restraint training.

Program Director/Education Director will receive a review of expectations for observations to occur every five minutes by 6/15/15. They will conduct a first level review for each order of restraint (within 48 hours) to ensure that all documentation is complete for each order. The Program Director/Education Director will assure documentation is completed even if it is completed as a late entry. Additional there will be supervisory follow up in place on meeting the required timeframe up to and including progressive disciplinary actions.

Quality Management Representative will audit restraints monthly to ensure that notification for orders occurred and data will be shared with the Leadership team.

Oversight by Executive Director and Program Leaders.