Initial Comments:
A validation survey was conducted September 16-18, 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.
Plan of Correction:
Initial Comments:
A validation survey was conducted September 16, 2019, through September 18, 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 nine and the sample consisted of six individuals.
Plan of Correction:
483.358(g)(3) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Each order for restraint or seclusion must include] the emergency safety intervention ordered, including the length of time for which the physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion authorized its use.
Observations:
Based on record reviews and interview it was determined that the facility failed to ensure that orders for restraints included a specific length of time permitted by the practitioner. This applied to three (#1, #5, #6) of six individuals in the survey sample. Findings included:
Record reviews were completed for Individuals #1 and #6 on September 16, 2019. The record review revealed that Individual #1 experienced a restraint on July 6, 2019. The record review revealed that Individual #6 experienced a restraint on August 24, 2019. The orders for these restraints failed to reveal a specific length of time allowed by the ordering practioner.
Record review was completed for Individual #5 on September 17, 2019. The record revealed that Individual #5 experienced restraints on the following dates: July 22, 2019, one restraint; March 26, 2019, one restraint. The orders for these restraints failed to reveal a specific length of time allowed by the ordering practioner.
On September 17, 2019, at 1:45 PM, a interview was completed with the nursing supervisor for residential services. The nursing supervisor for residential services confirmed that the nurses failed to accurately document the specific length of time for the above listed restraints, when the order was obtained from the physician.
Plan of Correction:Nursing Staff will ensure that all restraint orders received from the Psychiatrist will be documented to include only the length of time the Practitioner ordered.
The Nursing Staff were notified via email, and verbal communication on 9/16/2019. It will also be reviewed at the Nursing Meeting on 10/9/2019.
On 10/1/19 the ordering Psychiatrist was notified by email of the use of exact times instead of a 30 minute order for:
Client #1 - 2 restraints on 7/6/19,
Client #5 - 1 restraint on 3/26/19 and
1 restraint on 7/22/19,
Client #6 - 1 restraint on 8/24/19
Monitoring for compliance will be done by the QA Auditor during the Agency's regular compliance audits.
Random audits will also be performed by the Supervisor of Residential Nursing.
Completion Date: 9/16/2019
|