Initial Comments:
An initial validation survey visit was conducted on May 30 and 31, 2024. 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 ABH Pennsylvania Children's Services Inc. Goldsmith Right 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:
An initial validation survey visit was conducted on May 30 and 31, 2024. 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 Children Under Age 21. The census at the time of the visit was eight, and the sample consisted of four residents.
Plan of Correction:
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 for one of three sample Individuals This practice is specific to Resident #3.
Findings include:
Resident #3 :
A review of Resident #3's record completed on 05/30/2024 from approximately 9:30 AM to 10:30 AM, revealed that this resident was restrained on 05/05/2024 at 6:15 AM until
6:19 AM, utilizing a supine-both arms up-3 person restraint.. This restraint was documented on a form titled "Restraint Progress note". Further review of this packet revealed a form titled "Physician Order/Nursing Assessment. Under the section one hour face to face assessment of the physical and psychological well-being, it notes that Resident #3 was assessed by a nurse on 05/05/2024 at 9:15 AM, which exceeded the one hour time frame.
Interview with the Quality Improvement Coordinator on 05/30/2024 at approximately
10:30 AM confirmed that the above face to face assessments of the physical and psychological well-being was not conducted within one-hour post restraint.
Plan of Correction:1. N/A – Face to face assessments were not completed within one hour after the restraint for Resident 3.
2. 3 additional charts reviewed on 5.31.24 confirmed face to face assessments were completed within one hour of initiation of emergency safety intervention.
3. Upon the initiation of a restraint, a call will be placed to the nursing department via walkie talkie or phone to alert the nurse of the restraint so an assessment can occur. When the nurse arrives to the unit for assessment, the nurse will verbally confirm the restraint(s) that were implemented and confirm the time they were initiated to ensure there is no miscommunication about the need for assessment and the assessment is completed in the correct allotment of time. Retraining of nurses of the expectation of one hour face to face assessments will be completed on 6.3.24.
4. The Nurse Manager (or designee) will conduct a first level review within 24 hours for each order of restraint to ensure a face to face assessment was completed by the nurse within one hour of initiation, and not during or prior to discontinuation, of an emergency safety intervention and will submit a copy of the nursing assessment to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Nurse Manager for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 6.3.24.
5. Oversight by Medical Director. For any deficiencies identified during Quality Department's second level review, Nursing Manager will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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