Initial Comments:
A validation survey was conducted October 21- 24, 2019, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. There were no deficiencies identified.
Plan of Correction:
Initial Comments:
A validation survey was conducted October 21 - 24, 2019, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was 15 and the sample consisted of six individuals.
Plan of Correction:
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 it was determined that the facility failed to ensure that post intervention debriefings for residents were completed within 24 hours. This applied to two (#1, #5) of six individuals in the sample who experienced restraints. Findings included:
Record review for Individual #1 and #5 was completed on October 23, 2019, and revealed the following:
1. Record review revealed that on May 29, 2019, Individual #1 experienced a restraint. Further review revealed that the debriefing regarding this restraint with Individual #1 did not occur until June 3, 2019.
2. Record review revealed that on July 18, 2019, Individual #5 experienced a restraint. Further review revealed that the debriefing regarding this restraint with Individual #5 did not occur until July 21, 2019.
Interview with the residential director on October 24, 2019, at 9:15 AM, confirmed that the debriefings for Individuals #1 and #5 were completed beyond the required 24 hour time frame.
Plan of Correction:It is the Policy of Sarah Reed Children's Center that all staff and clients involved in a client restraint participate in a staff/client debrief session within 24 hours of the event.
Staff who initiate a Restraint Form will be responsible for initiating and completing documentation of client and staff debriefings after a restraint including signing off on attendance.
The shift Supervisor will ensure that both client and staff participate in the debriefs and all Restraint Form documentation is completed by the end of the shift.
The Unit Manager/designee will audit the forms for completion within 24 hours.
The Director of Residential reviewed this with Unit Mangers after deficiencies were noted on 10/24/2019.
The QA auditor will monitor Restraint Forms for completion.
Full implementation will be by 11/1/2019.
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 record reviews and interview it was determined that the facility failed to ensure that staff debriefing meetings include all the staff involved in the restraint, and occurred within 24 hours of the intervention. This applied to two individuals (#1, # 6) of six individuals in the survey sample. Findings included:
Record reviews for Individuals #1 and #6 were completed on October 23, 2019. These reviews revealed the following:
1. a. Individual # 1 experienced two restraints (11:46 AM and 11:51 AM) on July 21, 2019. Record review revealed no date was documented to verify when the debriefing was completed.
1. b. Individual # 1 experienced a restraint on May 29, 2019. The staff debriefing for this restraint was completed on June 3, 2019.
2. a. Individual # 6 experienced a restraint on October 10, 2019. Record review revealed no date was documented to verify when the debriefing was completed.
2. b. Individual #6 experienced a restraint on September 28, 2019. The staff debriefing for this restraint was completed on October 6, 2019.
2. c. Individual #6 experienced a restraint on June 2, 2019. Record review revealed two of four staff who participated in the restraint, participated in the debriefing.
2. d. Individual #6 experienced a restraint on October 20, 2019. Record review revealed three of four staff who participated in the restraint, participated in the debriefing
Interview with the nurse manager was completed October 24, 2019, at 9:45 AM. At this time, it was confirmed that Individual #1 and #6 experienced emergency safety interventions on the above dates, and the staff debriefing meetings for the restraints were not completed within the 24 hour time frame, and did not involve all staff participating in the restraints.
Plan of Correction:It is the Policy of Sarah Reed Children's Center that all staff and clients involved in a client restraint participate in a staff/client debrief session within 24 hours of the event.
Staff who initiate a Restraint Form will be responsible for initiating and completing documentation of client and staff debriefings after a restraint including signing off on attendance.
The shift Supervisor will ensure that both client and staff participate in the debriefs and all Restraint Form documentation is completed by the end of the shift.
The Unit Manager/designee will audit the forms for completion within 24 hours.
The Director of Residential reviewed this with Unit Mangers after deficiencies were noted on 10/24/2019.
The QA auditor will monitor Restraint Forms for completion.
Full implementation will be by 11/1/2019.
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