Initial Comments:
A recertification survey visit was conducted on February 22 through 24, 2021. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
The Devereux Foundation-Mapleton/Main facility is in compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
Plan of Correction:
Initial Comments:
A recertification survey visit was conducted on February 22 through 24, 2021. 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 for residents under the age of 21. The census at the time of the visit was sixteen, and the sample consisted of six residents.
Plan of Correction:
483.358(a) STANDARD
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure orders for restraints were ordered by a physician or other licensed practitioner permitted by the State and the facility for one (1) of six (6) sample Residents who were restrained. This practice is specific to Resident #2.
Findings include:
A review of the records for Resident #2 was completed on 02/23/2021 from approximately 9:00 AM to 10:00 AM. A review of the documentation dated 12/27/2020 revealed a document titled, Restraint Progress Note. This document revealed that Resident #2 was restrained,on that date using the Standing 2-arm control with 2 persons safety intervention, for 2 minutes from 11:38 AM until 11:40 AM. Further review of this information noted that there was no evidence that a physician, or other licensed practitioner permitted by the State ordered the use of this restraint.
Interview with the compliance director on 02/23/2021, at approximately 11:00 AM, confirmed that the facility was unable to verify that a physician's order was obtained for the use of a restraint for Resident #2 on 12/27/2020.
Plan of Correction:Core #1: N/A
Core #2: On 2/25/21, subsequent chart audits were completed reviewing all physician's orders for current clients for past 6 months. Additional deficiencies were identified and it was determined that staff failed to communicate to the nurse that a restraint had occurred, resulting in no notification by the nurse to the physician for an order for restraint.
Core #3: On 3/1/21 Program Director initiated retraining of all supervisors to ensure there is clear communication to the nurse when a restraint occurs. Program Director (or designee) will conduct a first level review of restraint packets within 72 hours to confirm nursing was notified to obtain physician's order and will provide immediate feedback and retraining to individual supervisors and staff for failure to notify nursing.
Core #4: Program Director will scan a copy of restraint packet within 72 hours to the Quality Department for secondary review. Quality Department will also complete weekly audit of all restraints to ensure compliance with results provided to the Program Director and Assistant Executive Director for any ongoing identified deficiencies and/or need for retraining.
Core #5: Assistant Executive Director will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable
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 record review and interview with administrative staff, the facility failed to ensure that the physician or other licensed practitioner permited by the state and the facility to order restraint must verify the verbal order in a signed written form in the resident's record for two of six sample individuals who were restrained. This is specific to Residents #4 and #5.
Findings include:
A review of the record for Resident #4 and Resident #5 was completed on 02/17/2021 from approximately 9:30 AM to 11:00 AM, and revealed the following information:
1. A review of the record of Resident #4 record revealed six emergency safety intervention (ESI) packets. Continued review revealed two documents titled, Restraint Progress Notes that indicated that this resident was restrained on 12/12/2020 from 8:35 PM to 8:39 PM and on 12/13/2020 from 4:26 PM to 4:30 PM. A review of a document titled, Physician Order/Nursing Assessment revealed that on each occasion, the facility nurse received va verbal order from the attending psychiatrist on 12/12/2020 at 8:45 PM for the use of a 4 person supine restraint, and on 12/13/2020 at 5:30 PM for the use of a 3 person supine restraint. Further review of these two documents revealed that neither verbal order for restraints on 12/12/2020 or 12/13/2020 were counter-signed by the ordering physician.
2. A review of the record for Resident #5 revealed a document titled, Restraint Progress Notes that revealed this resident was restrained on 02/19/2021 at 11:38 AM. A review of a document titled, Physician Order/Nursing Assessment revealed the facility nurse received a verbal order from the attending psychiatrist on 02/19/2021 at 1:00 PM for the use of a 3 person supine restraint. Further review of this document revealed that the verbal order for this restraint on 02/19/2021 was not counter-signed by the ordering physician.
Interview with the Quality Management Coordinator on 02/23/2021 from approximately 10:00 AM to 12:00 PM confirmed that the ordering physician failed to counter-sign the three identified verbal orders noted above.
Plan of Correction:Core #1: N/A
Core #2: On 2/25/21, subsequent chart audits were completed reviewing all physician's orders for current clients for past 6 months. Additional deficiencies were identified and it was determined that nursing failed to flag the physician's order to be counter-signed by the ordering physician.
Core #3: On 3/1/21 Director of Nursing initiated retraining of nursing staff to ensure orders are signed within 72 hours. Director of Nursing will conduct a first level review of physician's orders/nursing assessments within 72 hours of restraints to ensure orders are signed and will provide immediate feedback and retraining to individual nurses for failure to flag and obtain physician's signature.
Core #4: Quality Department will complete weekly audit of all restraints to ensure orders are counter-signed with audit results provided to the Director of Nursing and Assistant Executive Director for any ongoing identified deficiencies and/or need for retraining.
Core #5: Assistant Executive Director will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable.
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 (ESI) 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 #2.
Findings include:
A review of the record of Resident #2 revealed that she had been restrained on 08/23/2020. 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 9:10 PM and discontinued at 9:12 PM. Page two of the packet is titled Physician Order/Nursing Assessment. In further review of this document it was noted that the one hour assessment of the physical and psychological well-being was documented as completed on 8/23/2020 at 9:06 PM, before the restraint was initiated.
Further review noted that Resident #2 was again restrained on 12/27/2020. 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 12:27 PM and discontinued at 12:29 PM and applied again at 12:30 PM and discontinued at 12:32 PM. Further review revealed that there was no documentation that the one hour assessment of the physical and psychological well-being was conducted by the nurse.
Interview with the quality management coordinator on 02/17/2021 at approximately
11:00 AM confirmed that the one hour medical assessment for the restraint on 08/23/2020 was not conducted within the hour time frame, and that there was no documentation that a one hour medical assessment had been completed for the restraint that occurred on 12/27/2020.
Plan of Correction:Core #1: N/A
Core #2: Subsequent chart audits were completed reviewing all nursing assessments for current clients for past 6 months. Additional deficiencies were identified and it was determined in some instances, nurses were present during the restraint and documenting time of assessment as time they arrived and began observation. It was also determined that in some instances, due to staff failure to notify nursing of a restraint, nursing assessment was not completed.
Director of Nursing had initiated a retraining on 11/2/20 of all nursing staff clarifying F2F assessments to be completed within one hour following release of restraint. On 3/1/21 Program Director initiated retraining of all supervisors for clear communication to the nurse when a restraint occurs to ensure medical assessment is completed within one hour of restraint.
Core #3: Program Director (or designee) is conducting first level reviews within 72 hours of each restraint to ensure nursing was notified of restraint and assessments were completed within one hour following release of the restraint. Immediate feedback and retraining will occur for deficiencies.
Core #4: Program Director will scan a copy of restraint packets within 72 hours to the Quality Department for secondary review. Quality Department will also complete weekly audit of all restraints to ensure compliance and results provided to the Program Director, Director of Nursing and Assistant Executive Director for any ongoing identified deficiencies and/or need for retraining.
Core #5: Assistant Executive Director will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable
483.370(a) STANDARD
POST INTERVENTION DEBRIEFINGS
Name - Component - 00
Within 24 hours after the use of the restraint or seclusion, staff involved in an emergency safety intervention and the resident must have a face-to-face discussion. This discussion must include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the wellbeing of the resident. Other staff and the resident's parent(s) or legal guardian(s) may participate in the discussion when it is deemed appropriate by the facility. The facility must conduct such discussion in a language that is understood by the resident and by the resident's parent(s) or legal guardian(s).
The discussion must provide both the resident and staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the resident, or others that could prevent the future use of restraint or seclusion.
Observations:
Based on record reviews and interview with administrative staff the facility failed to ensure that post emergency safety intervention (ESI) debriefings for residents were completed within 24 hours. This practice is specific to Resident #3.
Findings include:
A review of the record for Resident #3 was completed on 02/23/2021, between 9:00 AM and 11:00 AM, and revealed the following:
Resident #3 was restrained on 01/13/2021. 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 3:19 PM and discontinued at 3:20 PM. Page three of the packet is titled client debriefing. The client debriefing listed all the staff involved in the ESI. However the debriefing did not occur until 01/14/2021 at 4:50 PM, beyond 24 hours post-restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
Interview with the quality improvement manager on 02/23/2021, at approximately 10:30 AM, confirmed that per facility policy, the debriefings for Resident #3 did not occur within the required 24 hour time frame.
Plan of Correction:Core #1: N/A
Core #2: On 2/25/21 subsequent chart audits were completed reviewing all client/staff debriefings for current clients for past 6 months. Additional deficiencies were identified.
Core #3: Program Director initiated retraining on 3/1/21 of all supervisors regarding requirement for client/staff debriefings being completed within 24 hours of restraint occurring. Program Director (or designee) is conducting first level review within 72 hours of each restraint to ensure client/staff debriefings were completed within 24 hours. Immediate feedback and retraining will occur for deficiencies.
Core #4: Program Director will scan a copy of restraint packets within 72 hours to the Quality Department for secondary review. Quality Department will also complete weekly audit of all restraints to ensure client/staff debriefing compliance and audit results provided to the Program Director and Assistant Executive Director for any ongoing identified deficiencies and/or need for retraining.
Core #5: Assistant Executive Director will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable
483.370(b) ELEMENT
POST INTERVENTION DEBRIEFINGS
Name - Component - 00
Within 24 hours after the use of restraint or seclusion, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session that includes, at a minimum, a review and discussion of -
483.370(b)(1) The emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention;
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session to discuss the precipitating factors that lead up to the intervention. This practice is specific to Resident #3.
Findings include:
1. A review of the record of Resident #3 revealed that she had been restrained on 01/13/2021. 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 3:19 PM and discontinued at 3:20 PM. Page four of the packet is titled staff supervisor/SPA trainer debriefing. The staff supervisor/SPA trainer debriefing listed all the staff involved in the ESI, but the debriefing did not occur until 01/14/2021 at 9:15 PM, beyond 24 hours post-restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
Interview with the quality improvement manager on 01/23/2021 at approximately 10:45 AM confirmed that per facility policy this debriefing was not completed within 24 hours of the restraint incident,
Plan of Correction:Core #1: N/A
Core #2: On 2/25/21 subsequent chart audits were completed reviewing all staff/supervisor debriefings for current clients for past 6 months. Additional deficiencies were identified.
Core #3: Program Director initiated retraining on 3/1/21 of all supervisors regarding requirement for staff/supervisor debriefings being completed within 24 hours of restraint occurring. Program Director (or designee) is conducting first level review within 72 hours of each restraint to ensure staff/supervisor debriefings were completed within 24 hours. Immediate feedback and retraining will occur for deficiencies.
Core #4: Program Director will scan a copy of restraint packets within 72 hours to the Quality Department for secondary review. Quality Department will also complete weekly audit of all restraints to ensure staff/supervisor debriefing compliance and audit results provided to the Program Director and Assistant Executive Director for any ongoing identified deficiencies and/or need for retraining.
Core #5: Assistant Executive Director will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable
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