ARTICLE VI
PERMISSIBLE SPECIALIZED
AND
PROHIBITED TREATMENT PROCEDURES
Statement of Principle
Every patient shall only receive approved treatment procedures in accordance with Departmental regulations. this treatment shall be described in his individualized treatment plan and shall be explained to the patient.
2. Specialized Procedures
(c) No patient shall be subject to chemical, physical or psychological restraints, including seclusion, other than in accordance with the policy and procedures which were approved by the medical staff and governing body.
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Observations:
Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to follow it's policy for restraint orders in one (1) of thirteen (13) MRs reviewed. (MR4)
Findings include:
Review on July 30, 2024, of MR4, revealed flow sheet documentation for application of four-point locked restraints on June 15, 2024, at 7:00 PM. Further review of MR4 revealed nursing note for a face-to-face restraint assessment on June 15, 2024, at 7:30 PM " ...for aggressive, erratic behavior... " Review of MR4's physician orders failed to reveal an order for restraint at this time.
Review on July 30, 2024, of facility policy, " Restraint And Seclusion " , revised January 2024, revealed " ...E. ORDERS FOR RESTRAINTS, i) ...Orders should: a) Be for each use of the restraints and related to the a specific episode of the patient ' s behavior ...ii) in an emergency application situation, a RN who has documented Restraint and Seclusion competency may initiate the application of restraint and seclusion prior to obtaining an order ... In this event the order must be obtained either during the emergency application ... or immediately (within a few minutes) after the restraint or seclusion has been applied ... "
Interview on July 30, 2024. at 11:31 AM, with EMP1, confirmed the above findings.
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Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to follow it's policy pertaining to assessment of patients in restraints for one (1) of thirteen (13) MRs reviewed. (MR5)
Findings include:
Review on July 30, 2024, of MR5 revealed orders for restraints to be maintained on June 19, 2024, at 10:30 AM, 2:30 PM, and 6:30 PM. Further review of MR5 failed to reveal documentation of a one-hour face to face patient assessment.
Review on July 30, 2024, of facility policy, " CBM RN 1-Hour Face to Face Assessment of Patients in Restraints or Seclusion " , revised April 2024, revealed " ...Policy ...A 1-hour face-to-face patient assessment must be conducted in person by a Provider, or trained CBM RN ...The fact that the patient ' s behavior warranted the use of a restraint or seclusion indicates a serious medical or psychological need for prompt evaluation of the patient behavior that led to the intervention. The assessment would also determine whether there is a continued need for the intervention, factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to the address the behavior...The trained CBM RN will document the 1-hour face-to-face assessment in the patient ' s record ... "
Interview on July 30, 2024, at 11:47 AM, with EMP1, confirmed the above findings.
| | Plan of Correction - To be completed: 09/20/2024
Center for Behavioral Medicine Nursing Director and Chief Nursing Officer revised the CBM RN 1-Hour Face to Face Assessment of Patient in Restraints or Seclusion policy on August 16, 2024, to reflect the biannual Crisis Prevention Intervention (CPI) training. No other policy changes were made. Education on the policy, the requirements for an order on all patients requiring restraints, and face to face evaluation/documentation will be completed by September 16, 2024, for all RN staff and practitioners. This will be done through staff meeting education for all RN's, emailed education for all RNs and Practitioners, restraint resource binder for RNs, one to one follow up with previously deficient RNs, check list for restraint charting/documentation, and restraint audits and follow up with RNs, if appropriate.
Clinical Nurse Specialist, Unit Director, Unit Supervisor, or Restraint Resource RN will complete an audit of 100% of restraint charts monthly to review order and documentation of face-to-face. Audit compliance will be reported to Quality Improvement Committee for 3 consecutive months of 100% compliance. For any non-compliance, an action plan will be submitted to the Chief Nursing Officer.
The finding and plan of correction will be shared with Quality Improvement Committee. The Chief Nursing Officer is ultimately responsible for the corrective actions and ongoing compliance with this standard. All action will be completed by September 20, 2024.
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