Initial Comments:
This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act survey conducted on December 7, 2022, at Conemaugh Memorial Medical Center. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.
Plan of Correction:
5100.15 (a) REQUIREMENT
Treatment Plan Content and Availability
Name - Component - 00
5100.15 CONTENTS OF TREATMENT PLANS
Actual requirement is 5100.15 (b)
(a) The treatment plan shall indicate what less restrictive alternatives were considered and why they were not utilized. If the plan provides for restraints, the basis for the necessity for such restraints must be stated in the plan under Chapter 13 (relating to us of restraints in treating patients/residents.)
Observations:
Based on review of facility documents and medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policies to ensure that the use of restraints were documented on the patient's treatment plan in four of four medical records (MR1, MR2, MR3 and MR4).
Findings Include:
Conemaugh Memorial Medical Center ... PolicyStat ID 12733407 ... Policy Area: Behavioral Health ... Patient Rights Mental Health policy and procedure dated November 2022. "Purpose To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights, and involvement of patient. Policy No patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while a patient is on the unit. ... ."
Conemaugh Memorial Medical Center ... PolicyStat ID 11584097 ... Policy Area: Nursing ... Restraint for Violent Destructive Behavior Policy policy and procedure dated April 2022. "Philosophy ... Restraint and seclusion interventions are implemented only as a last resort ... Non-physical interventions are the preferred method of intervention ... Provider Orders: ... 4.
... Types of Violent and Destructive behavior Restraints ... Physical Hold ... Twice as tough x 4 locked - blue (smaller) = wrists; red (larger) = ankles ... Remember when applying 4 point restraints-you must use twice a tuff locked. ... Points of Emphasis ... The treatment team reviews alternative strategies relative to behaviors that require the use of restraint or seclusion. ... Written modification to the patient's plan of care occurs with every restraint or seclusion usage. ... ."
Conemaugh Memorial Medical Center ... PolicyStat ID 1164721 ... Policy Area: Behavioral Medicine ... Multi-disciplinary Treatment Planning Process policy and procedure dated March 2022. "Purpose To ensure plans for care, treatment and service are individualized to meet the patient's unique needs and circumstances Points of Emphasis ... A. Each patient admitted to the unit has an individualized written treatment plan that is based on multi-disciplinary clinical assessments. ... B. Treatment planning is the structured process by which identified problems are resolved via specific goal-oriented treatment interventions. Continued care needs are identified as part of the treatment planning process. C. Key elements essential to all stages of treatment planning include the following: ... 10. Treatment plans are updated with any changes in the patients treatment. ... ."
1. Review of MR1 was conducted with EMP1 on December 7, 2022, at approximately 10:30 AM which revealed documented evidence that the patient was placed in a physical hold on November 15, 2022, from 4:40 PM until 5:04 PM and then restrained with Twice as Tough restraints at 5:05 PM until 6:30 PM. MR1 failed to reveal documented evidence of the physical hold and/or Twice as Tough restraints on the patient's treatment plan.
EMP1 confirmed the above finding.
2. Review of MR2 was conducted with EMP1 on December 7, 2022, at approximately 10:30 AM which revealed documented evidence that the patient was placed in a physical hold on October 19, 2022, from 10:32 AM until 10:50 AM and then restrained with Twice as Tough restraints at 10:46 AM until 2:43 PM. MR1 failed to reveal documented evidence of the physical hold and/or Twice as Tough restraints on the patient's treatment plan.
EMP1 confirmed the above finding.
3. Review of MR3 was conducted with EMP1 on December 7, 2022, at approximately 10:30 AM which revealed documented evidence on August 6, 2022, that the patient was restrained with Twice as Tough restraints at 9:35 AM until 12:15 PM. MR1 failed to reveal documented evidence of the Twice as Tough restraints on the patient's treatment plan.
EMP1 confirmed the above finding.
4. Review of MR4 was conducted with EMP1 on December 7, 2022, at approximately 10:30 AM which revealed documented evidence that the patient was placed in a physical hold on November 28, 2022, from 4:45 AM until 4:56 AM and then restrained with Twice as Tough restraints at 4:56 AM until 7:00 AM. MR1 failed to reveal documented evidence of the physical hold and/or Twice as Tough restraints on the patient's treatment plan.
EMP1 confirmed the above finding.
Plan of Correction:Overview: The treatment plan shall indicate what less restrictive alternatives were considered and why they were not utilized. When restraints are deemed necessary, a treatment plan will be completed to indicate the less restrictive measures that were attempted prior to utilizing restraints. Any change in treatment is identified and documented in a timely manner. The process is that the Charge Nurse notifies the Nurse Manager immediately when a restraint occurs. The Charge Nurse identifies the staff responsible for updating the treatment plan and/or completing a restraint treatment plan during restraint debrief. The restraint plan should identify the least restrictive alternatives that were considered prior to implementing the restraint. The Nurse Manager/Nurse Educator will check for accuracy and completion of the restraint documentation on every event of restraint use.
The entire treatment plan format will be revised to ensure plans for care, treatment, and services are individualized to meet the patient's unique needs and circumstances. The Nurse Manager/Nurse Educator will be educating the Nurses (RNs) and Social Workers (SWs) to include the restraint treatment plan to the patient's original treatment plan for each restraint episode beginning 12/26/22. This training will be completed by 1/13/23. Concurrently while staff are being re-educated on the necessity to ensure a treatment plan has been developed for restraint episodes, the Nurse Manager and Administrative team will revise the overall treatment planning for all treatment plan areas on the unit. This process began on 12/20/22 and will be completed by 2/14/23.
Education: The Multi-disciplinary Treatment Planning Process policy and the Restraint for Violent Destructive Behavior policy will be reviewed with the RNs and Social Workers starting on 12/26/22 and completed 1/13/23. The Nurse Manager/Nurse Educator will provide this education by 1/13/23. The RNs and SWs will sign an education record verifying they have received the education.
Compliance and Monitoring: A chart audit will be completed for each restraint/treatment plan episode compliance effective immediately. When the new treatment plan format is implemented 3/1/23, chart audits will include the new process completed for each restraint episode noting treatment plan compliance. The audit will follow the department of health (DOH) sustainability grid with monthly audits until 100% compliance is assessed for 4 months, followed by four quarterly audits with a 100% compliance. as outlined above per the DOH grid. The corrective action process will be initiated for any staff member demonstrating noncompliance with the treatment plan process.
Committee Report Out: A report will be provided to the Performance Excellence Steering Committee on January 11, 2023, February 8, 2023, March 8, 2023, April 12, 2023, May 10, 2023, and June 14, 2023 and to the Performance Excellence Committee on January 18, 2023, February 15, 2023, March 15, 2023, April 19, 2023, May 17, 2023, and June 21, 2023.
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