Initial Comments:
A recertification survey visit was conducted on February 8 through 10, 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 -Brandywine/Brier Cottage 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 8 thorugh 10, 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 24, and the sample consisted of eight residents.
Plan of Correction:
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 Residents #1, #3, and #4.
Findings include:
A review of the record of Resident #1 on 01/09/2020 between 9:00 AM and 11:00 AM
revealed the following;
Resident #1
-On 12/22/2020, Resident #1 was restrained at 8:47 PM for a duration of 58 minutes. This incident was documented on an emergency safety interventions (ESI) document titled Restraint Progress Note form. Continue review of this restraint packet revealed there is no documented evidence that clinical staff was physically present, continually assessing and monitoring Resident #1 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this ESI.
-On 01/02/2021, Resident #1 was restrained at 5:45 PM for a duration of 7 minutes. This incident was documented on an emergency safety interventions (ESI) document titled Restraint Progress Note form. Continue review of this restraint packet revealed there is no documented evidence that clinical staff was physically present, continually assessing and monitoring Resident #1 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this ESI.
-On 01/17/2021, Resident #1 was restrained at 3:47 PM for a duration of 10 minutes. This incident was documented on an emergency safety interventions (ESI) document titled Restraint Progress Note form. Continue review of this restraint packet revealed there is no documented evidence that clinical staff was physically present, continually assessing and monitoring Resident #1 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this ESI.
Resident #3
On 09/30/2020, Resident #3 was restrained at 4:30 PM for a duration of 8 minutes. This incident was documented on an emergency safety interventions (ESI) document titled Restraint Progress Note form. Continue review of this restraint packet revealed there is no documented evidence that clinical staff was physically present, continually assessing and monitoring Resident #3 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this ESI.
Resident #4
On 12/22/2020, Resident #4 was restrained at 11:05 AM for a duration of 13 minutes. This incident was documented on an emergency safety interventions (ESI) document titled Restraint Progress Note form. Continue review of this restraint packet revealed there is no documented evidence that clinical staff was physically present, continually assessing and monitoring Resident #4 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this ESI.
Interview with the Quality Improvement Manager on 02/10/2021 at approximately
10:00 AM confirmed that there was no evidence that the above mentioned Residents were continually assessed and monitored for their physical and psychological well-beings while in restraint.
Plan of Correction:Core #1: N/A
Core #2: Additional chart audits were completed for clients in restraints of 5 minutes or more with additional deficiencies identified. It was determined that staff were not consistently documenting the 5 minute observations and were not fully aware of the requirement. On 2/12/21, Program Director initiated retraining of all supervisors/staff for monitoring a client's physical and psychological well-being by completing the client observation assessment tool in 5 minute increments as applicable, for duration of restraint.
Core #3: Program Manager will conduct a first level review of restraint packets within 24 hours to ensure 5 minute observations are completed, as applicable. Program Manager will provide immediate feedback and retraining to individual supervisors and staff for any deficiencies.
Core #4: Program Manager will scan a copy of restraint packets to include the 5 minute observation tool as applicable, to the Quality Department for secondary review. Quality Department will also complete weekly audit of all restraints to ensure compliance with completion of 5 minute observations as applicable. Audit results will be provided to Campus Administrator, Program Manager and Program Director of any ongoing identified deficiencies and/or need for retraining.
Core #5: Campus Administrator will be responsible for monitoring compliance with additional retraining and/or disciplinary action to be taken as applicable.
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