Initial Comments:
A validation survey was conducted March 13-15, 2024, to determine compliance with the requirements of the 42 CFR Part 441, Subpart D Regulations for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was 11 and the survey sample consisted of six individuals. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted March 13-15, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was 11 and the survey 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 review and interview, it was determined that the facility failed to ensure that all orders for emergency safety interventions (ESI) included the specific restraints and specific length of time for which the intervention is permitted by the ordering physician. This applied to one (#6) of 6 individuals in the survey sample. Findings included:
Record review for Individual #6 was completed on March 15, 2024. This review revealed the following:
1. Individual #6 experienced an ESI on September 16, 2023. This review revealed a ESI physician order for a seated single person cradle without leg assist. This review also revealed that facility staff implemented a seated single person cradle with leg assist.
Interview with the director of nursing (DON) on March 15, 2024, at 9:54 AM confirmed that the restraint used by staff was not included in the order from the physician.
2. Individual #6 experienced an ESI on September 18, 2023. This review revealed a ESI physician order for a two person upper torso. This review also revealed that facility staff additionally implemented a supine four person extended arm.
Interview with the DON on March 15, 2024, at 9:56 AM confirmed that the restraint used by staff was not included in the order from the physician.
3. Individual #6 experienced an ESI on October 23, 2023 at 2:10 PM that lasted for one hour. This review revealed two ESI physician orders at 2:10 PM and 2:40 PM for a multi person supine and multi person cradle. This review also revealed that facility staff additionally implemented a transport. Further review failed to reveal that the orders included the specific length of time that the interventions were permitted.
Interview with the DON on March 15, 2024, at 10:02 AM confirmed that the length of time permitted and the transport restraint used by staff were not included in either above order from the physician.
4. Individual #6 experienced an ESI on January 12, 2024. This review revealed a ESI physician order for a seated single person cradle. This review also revealed that facility staff additionally implemented a supine multi person extended arm.
Interview with the DON on March 15, 2024, at 10:10 AM confirmed that the restraint used by staff was not included in the order from the physician.
Plan of Correction:Sarah Reed acknowledges that in each instance referenced regarding Individual #6 that the orders were deficient, either due to missing restraint positions and/or specific length of times of those interventions were missing.
All nursing staff will be retrained during their individual supervision during the month of April. During the May nursing staff meeting, the Nursing Director will review the necessary elements of a complete restraint order.
Each week, effective 3/27. The Residential Nursing Supervisor will audit the restraint orders for completion and ensure that the information therein is consistent with the restraint incident form, the face-to-face evaluation, and the nurse's note.
The Director of Nursing is responsible for the monitoring of monitoring of this corrective action plan. She will with a monthly review of the nursing supervisor's audits. Through 10/1/24
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 review and interview, it was determined that the facility failed to ensure within 24 hours of all emergency safety interventions that a face to face debriefing discussion occurs with the individual. This applied to three (#1, #3, and #6) of six individuals in the survey sample. Findings included.
1. (a) Record review was completed for Individual #1 on March 15, 2024. This review revealed Individual #1 experienced a restraint on November 6, 2023. Review of the individual debriefing meeting following this restraint failed to reveal documentation that it was completed within 24 hours.
Interview with the senior director of residential services (SDRS) on March 15, 2024, at 9:52 AM confirmed that there was no documentation that the individual debriefing occurred within 24 hours of the restraint.
1. (b) This review also revealed Individual #1 experienced a restraint on August 19, 2023. Review of the individual debriefing meeting following this restraint revealed that the documention for the individual debriefing following this restraint was beyond 24 hours.
Interview with the SDRS on March 15, 2024, at 9:50 AM confirmed that the individual debriefing occurred beyond 24 hours of the restraint.
2. Record review was completed for Individual #3 on March 15, 2024. Individual #3 experienced a restraint on January 1, 2024. Review of the individual debriefing meeting following this restraint failed to reveal documentation that it was completed within 24 hours.
Interview with the SDRS on March 15, 2024, at 10:30 AM confirmed that there was no documentation that the individual debriefing occurred within 24 hours of the restraint.
3. Record review was completed for Individual #6 on March 15, 2024. Individual #6 experienced a restraint on November 1, 2023. Review of the individual debriefing meeting following this restraint failed to reveal documentation that it was completed within 24 hours.
Interview with the SDRS on March 15, 2024, at 10:19 AM confirmed that there was no documentation that the individual debriefing occurred within 24 hours of the restraint.
Plan of Correction:Sarah Reed acknowledges that in each of the cases mentioned regarding Individuals #1, #3, and #6 the individual debriefs were not documented to show that they occurred within 24 hours of the restraint.
By February 29, All residential teams received retraining on restraint procedures.
The Restraint Incident Report was revised on 2/14/2024 and the fields "Actual Date" and "Actual" Time were added to the form in the individual debrief section. This occurred because sometimes the individual debrief occurs within the 24-hour period, but the documentation of the debrief occurs outside the 24-hour period. Staff will use these fields to document the time of the child debrief and the time stamp document to the note when the staff member documented the individual debrief.
The Residential Unit Managers have put a system in place to audit the restraint forms daily. One step in the audit process is to ensure that each person listed as a restraint participant or observer is also listed in the debrief process. This auditing process was implemented on 2/17/2024.
The Sr. Director of Residential Services is responsible for the monitoring of the corrective action plan. The Sr. Director will review the audit reports on a monthly basis to ensure that the audit system is effective. (Through 10/24)
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 interviews, it was determined that the facility failed to ensure that all staff that participated in an emergency safety intervention also participated in the post-intervention debriefing within 24 hours. This applied to six of six individuals in the survey sample. Findings included:
1. (a) A record review was completed on March 15, 2024, for Individual #1. This review revealed that Individual #1 was involved in restraints on November 6, 2023, and March 4, 2024. This review failed to reveal documentation that the staff debriefing occurred within 24 hours.
During an interview with the senior director of residential services (SDRS) completed on March 15, 2024, at 9:52 AM, the SDRS confirmed that that there was no documentation that the staff debriefing occurred within 24 hours of the restraints.
1. (b) This review also revealed that Individual #1 was involved in restraints on October 14, 2023, and March 4, 2024. This review failed to reveal that all of the staff that participated in the restraints also participated in the staff debriefings.
During an interview with the SDRS completed on March 15, 2024, at 9:52 AM, the SDRS confirmed that not all staff that participated in the restraints also participated in the staff debriefing.
1. (c) This review also revealed that Individual #1 was involved in a restraint on August 19, 2023. This review revealed that the staff debriefing after the restraint occurred beyond 24 hours.
During an interview with the SDRS completed on March 15, 2024, at 9:50 AM, the SDRS confirmed that the staff debriefing occurred beyond 24 of the restraint.
2. A record review was completed on March 15, 2024, for Individual #2. This review revealed that Individual #2 was involved in a restraint on November 12, 2023. This review failed to reveal that all of the staff that participated in the restraint also participated in the staff debriefing.
During an interview with the SDRS completed on March 15, 2024, at 10:29 AM, the SDRS confirmed that not all staff that participated in the restraint also participated in the staff debriefing.
3. (a) This review revealed that Individual #3 was involved in a restraint on January 23, 2024. This review failed to reveal that all of the staff that participated in the restraint also participated in the staff debriefing.
During an interview with the SDRS completed on March 15, 2024, at 10:33 AM, the SDRS confirmed that not all staff that participated in the restraint also participated in the staff debriefing.
3. (b) A record review was completed on March 15, 2024, for Individual #3. This review revealed that Individual #3 was involved in a restraint on January 1, 2024. This review failed to reveal documentation that the staff debriefing occurred within 24 hours.
During an interview with the SDRS completed on March 15, 2024, at 10:30 AM, the SDRS confirmed that that there was no documentation that the staff debriefing occurred within 24 hours of the restraints.
4. A record review was completed on March 15, 2024, for Individual #4. This review revealed that Individual #4 was involved in a restraint on February 12, 2024. This review failed to reveal that all of the staff that participated in the restraint also participated in the staff debriefing.
During an interview with the SDRS completed on March 15, 2024, at 9:58 AM, the SDRS confirmed that not all staff that participated in the restraint also participated in the staff debriefing.
5. A record review was completed on March 15, 2024, for Individual #5. This review revealed that Individual #5 was involved in a restraint on February 18, 2024. This review failed to reveal that all of the staff that participated in the restraint also participated in the staff debriefing.
During an interview with the SDRS completed on March 15, 2024, at 9:56 AM, the SDRS confirmed that not all staff that participated in the restraint also participated in the staff debriefing.
6. (a) A record review was completed on March 15, 2024, for Individual #6. This review revealed that Individual #6 was involved in restraints on September 14, 2023, September 18, 2023, October 23, 2023, November 1, 2023. This review failed to reveal documentation that the staff debriefing occurred within 24 hours.
During an interview with the SDRS completed on March 15, 2024, at 10:20 AM, the SDRS confirmed that that there was no documentation that the staff debriefing occurred within 24 hours of the restraints.
6. (b) This review revealed that Individual #6 was involved in restraints on October 23, 2023, at 2:10 PM, October 23, 2023, at 3:06 PM, November 3, 2023, November 22, 2023, at 4:53 PM, November 22, 2023, at 6:56 PM. This review failed to reveal that all of the staff that participated in the restraints also participated in the post-intervention debriefings.
During an interview with the SDRS completed on March 15, 2024, at 10:19 AM, the SDRS confirmed that not all staff that participated in the restraints also participated in the staff debriefing.
Plan of Correction:Sarah Reed acknowledges that the staff debriefs mentioned in reference to Individuals #1, #2, #3, #4, #5, and #6 did not document that all staff members involved in the restraint were participants in the staff debrief.
All residential teams were retrained in the restraint documentation procedure by 2/29/24.
The Restraint Incident Report was revised on 2/14/2024 the fields "Actual Date" and "Actual" Time were added to the form in the staff debrief section. This occurred because sometimes the staff debrief occurs within the 24-hour period, but the documentation of the debrief occurs outside the 24-hour period. Staff will use these fields to document the time of the staff debrief and the time stamp document to the note when the staff member documented the staff debrief.
The Residential Unit Managers have put a system in place to audit the restraint forms daily. One step in the audit process is to ensure that each person listed as a restraint participant or observer is also listed in the debrief process. This auditing process was implemented on 2/17/2024.
The Sr. Director of Residential Services is responsible for the monitoring of this action plan. Each month the Sr. Director will review the auditing reports to ensure the auditing system is being followed as designed. (Through 10/1/24)
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