Initial Comments:
A validation survey was conducted January 3-5, 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 13 and the sample consisted of six residents. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted January 3-5, 2024, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was 13 and the sample consisted of six residents.
Plan of Correction:
483.358(d) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse, while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must verify the verbal order in a signed written form in the resident's record. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all verbal orders for restraints were verified and signed by the ordering physician. This applied to one of six restraints reviewed. Findings included:
Record review for Individual #2 was completed on January 4, 2024. This review revealed that Individual #2 experienced a restraint on November 3, 2023. Review of the verbal order for this restraint failed to reveal that it was verified and signed by the ordering physician.
Interview with the director of nursing on January 4, 2024, at 12:30 PM, confirmed that the verbal order for the restraint that occurred on November 3, 2023, was not verified and signed by the ordering physician.
Plan of Correction:1. The verbal order was not verified by the ordering physician since the nurse who recorded the verbal order in the electronic health record did not route the order to the ordering physician to sign. The verbal order has since been verified by the ordering physician on 1/4/24.
The nurse who failed to reroute the order will receive retraining by 1/28/24.
2. How will the facility identify other individuals having the potential to be affected by the same practice?
The Director of Nursing will retrain all nurses on the protocols for routing a verbal restraint order in the EHR for the physician's signatures. This will occur at the February 8, 24, Nurses' staff meeting. Any nurse who was not in attendance, will be retrained during individual supervision by 2/28/24.
3. The Medical Record Team Manager will create a report that will allow the nursing team to self-audit the routing of restraint orders for completion by Jan 31, 2024.
The Director of Nursing will designate a nurse to run the above-mentioned report weekly and then send alerts to the physician. Ongoing.
4. The Director of Nursing will conduct monthly audits all restraint orders for completion. Ongoing.
5.The Associate Vice President of QAQI is responsible for the monitoring of the Corrective Actions.
483.360 STANDARD
CONSULTATION WITH TREATMENT TEAM PHYSICIAN
Name - Component - 00
If a physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion orders the use of restraint or seclusion, that person must contact the resident's treatment team physician, unless the ordering physician is in fact the resident's treatment team physician. The person ordering the use of restraint or seclusion must-
(a) Consult with the resident's treatment team physician as soon as possible and inform the team physician of the emergency safety situation that required the resident to be restrained or placed in seclusion; and
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that the physician that ordered a restraint contacted the individual's treatment team physician. This applied to one of six restraints reviewed. Findings included:
Record review for Individual #2 was completed on January 4, 2024. This review revealed that Individual #2 experienced a restraint on November 3, 2023. This review failed to reveal documentation that the ordering physician for this restraint contacted the treatment team physician for this individual to inform them of the restraint.
Interview with the director of nursing on January 4, 2024, at 12:30 PM, confirmed that there was no documentation that the ordering physician, for the restraint that occurred on November 3, 2023, contacted the treatment team physician to inform them of the restraint.
Plan of Correction:1.The verbal order not was routed from the prescribing physician to the treatment team physician. This was due to the nurse not starting the routing chain per protocol. The verbal order has since been verified by the treatment team physician on 1/4/24.
The nurse who failed to reroute the order will receive retraining by 1/28/24.
2. How will the facility identify other individuals having the potential to be affected by the same practice?
The Director of Nursing will retrain all nurses on the protocols for routing a verbal restraint order in the EHR for the physician's signatures. This will occur at the February 8, 24, Nurses' staff meeting. Any nurse who was not in attendance, will be retrained during individual supervision by 2/28/24.
3. The Medical Record Team Manager will create a report that will allow the nursing team to self-audit the routing of restraint orders for completion by Jan 31, 2024.
The Director of Nursing will designate a nurse to run the above-mentioned report weekly and then send alerts to the physician. Ongoing.
4.The Director of Nursing will conduct monthly audits all restraint orders for completion. Ongoing.
5. The Associate Vice President of QAQI is responsible for the monitoring of the Corrective Actions.
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 that a face to face discussion was completed with the individual within 24 hours after the use of an emergency safety intervention. This applied to three of six restraints reviewed. Findings included:
A record review was completed for Individual #1 on January 4, 2024. This review revealed that Individual #1 experienced an emergency safety intervention on October 5, 2023. This review failed to reveal a date and time for documentation of the debriefing following this restraint.
A record review was completed for Individual #2 on January 4, 2024. This review revealed that Individual #2 experienced an emergency safety intervention on November 3, 2023. This review failed to reveal a date and time for documentation of the debriefing following this restraint. Further review revealed that Individual #2 experienced an emergency safety intervention on November 4, 2023. The documentation for the face to face debriefing was completed with Individual #2 and dated November 8, 2023, at 1:40 AM.
Interview with the associate vice president of compliance (AVPC) on January 5, 2025, at 8:35 AM, confirmed that there was no documentation that face to face debriefings occurred with Individuals #1 and #2 for the above three restraints within 24 hours of each restraint. The AVPC further stated that the documentation for Individual #2's face to face on November 8, 2023, at 1:40 AM was most likely reflective of the time the information was entered in the electronic record rather than when the debriefing actually occurred with the individual.
Plan of Correction:1. The residential unit staff members who initiated the identified restraints for Individuals #1 and #2, will be retrained that they must document the actual date and the actual time of the client debrief, and that this debrief must occur within 24 hours of the restraint. The restraint forms cannot be ethically amended as too much time has passed for those staff to recall when the debriefing took place. By 1/28/24
2. All residential staff members will be retrained that they must document the actual date and the actual time of the client debrief, and that this debrief must occur within 24 hours of the restraint. This will occur during each unit's monthly staff meetings. All staff who are not in attendance at their staff meeting, must be training during a documented individual supervision. By 2/29/24.
3. The Restraint form was modified on 1/11/24 to include the fields "Actual Date" and "Actual Time" in the Client Debrief section.
4.The Unit Managers will conduct weekly restraint audits. (Ongoing, no end date)
5. The Associate Vice President of QAQI will monitor this corrective action plan.
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 review and interview, 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. This applied to two of six restraints reviewed. Findings included:
A record review was completed on January 4, 2024, for Individual #2. This review revealed that Individual #2 was involved in a restraint on November 3, 2023, and on November 4, 2023. This review failed to reveal the dates and times that the staff involved in both restraints participated in post-intervention debriefings.
An interview was conducted with the associate vice president of compliance (AVPC) on January 5, 2024, at 8:35 AM. The AVPC confirmed that there was no documentation that the staff involved in either of the above mentioned restraints participated in post-intervention debriefings within 24 hours of the restraints.
Plan of Correction:1. The residential unit staff members who initiated the identified restraints for Individual #2, will be retrained that they must document the actual date and the actual time of the staff debrief, and that this debrief must occur within 24 hours of the restraint. The restraint forms cannot be ethically amended as too much time has passed for those staff to recall when the debriefing took place. By 1/28/24
2. All residential unit staff members will be retrained that they must document the actual date and the actual time of the staff debrief, and that this debrief must occur within 24 hours of the restraint. This will occur during each unit's monthly staff meetings. All staff who are not in attendance at their staff meeting, must be training during a documented individual supervision. By 2/29/24
3. The Restraint form was modified on 1/11/24 to include the fields "Actual Date" and "Actual Time" in the Staff Debrief section.
4. The Unit Managers will conduct weekly restraint audits. (Ongoing, no end date)
5. The Associate Vice President of QAQI is responsible to monitor the corrective action plan.
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