QA Investigation Results

Pennsylvania Department of Health
CORNELL ABRAXAS 1 - PIONEER DORM 1
Health Inspection Results
CORNELL ABRAXAS 1 - PIONEER DORM 1
Health Inspection Results For:


There are  2 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

A monitoring survey was conducted October 30, 2017, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. At the time of the survey the census was eight.




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 the verbal order for an emergency safety intervention (ESI) was signed by the nurse that received it. This applied to one (#1) of two individuals in the survey sample. Findings included:

Record review for Individual #1 was completed on October 30, 2017. This review revealed that Individual #1 experienced an ESI on August 15, 2017. Review of the order for this ESI failed to reveal that the verbal order given by the physician was signed by the nurse.

During an interview on October 30, 2017, at 12:10 PM, with the quality and compliance specialist, it was confirmed that the verbal order was not signed by the nurse who took the order from the physician.





Plan of Correction:

Abraxas I will ensure all verbal restraint orders are signed by the nurse who receives the verbal restraint order from the physician.

On November 2, 2017, the Program Manager and Quality & Compliance Specialist met with the Nurse Manager to review individual #1's restraint order from August 15, 2017. The Nurse Manager was reminded that all restraint orders must include the signature of the nurse who receives the restraint order from the physician.

By November 22, 2017, the Nurse Manager will meet with all nurses who receive verbal orders to review the process. Moving forward, the nurse who receives the restraint order from the physician will double check the order to verify they have properly completed the restraint order, to include signing the restraint order.

Beginning the week of December 4, 2017, the Program Manager will review all restraint orders on a weekly basis. If deficiencies are found in a restraint order, the Program Manager will notify the Facility Director who will then meet with the Nurse Manager to identify the documentation breakdown and document the meeting in a supervisory conference note. Every supervisory conference note will be filed by the Facility Director.

Beginning January 1, 2017, the Quality & Compliance Specialist will review all restraint orders on a monthly basis to confirm the findings of the Program Manager's review are accurate. The Program Manager and Quality & Compliance Specialist will formally report the results of these reviews to the Leadership Team once a month for the next three months. If there is 100% compliance during those three months, reporting during Leadership Meetings will occur once every six months.



483.358(g)(2) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
[Each order for restraint or seclusion must include] the date and time the order was obtained; and



Observations:



Based on record review and interview it was determined that the facility failed to ensure that the verbal order for an emergency safety intervention (ESI) included the date and time the order was received by the by the nurse. This applied to two (#1 and #2) of two individuals in the survey sample. Findings included:

Record review for Individual #1 was completed on October 30, 2017. This review revealed that Individual #1 experienced an ESI on July 16, 2017. Review of the order for this ESI failed to review that the verbal order included the time the order was received by the nurse. This record review further revealed that Individual #1 experienced an ESI on August 15, 2017. Review of the order for this ESI failed to reveal that the verbal order included the date and time the order was received by the nurse.

Record review for Individual #2 was completed on October 30, 2017. This review revealed that Individual #2 experienced an ESI on July 5, 2017. Review of the order for this ESI failed to review that the verbal order included the time the order was received by the nurse.

During an interview on October 30, 2017, at 12:10 PM, with the quality and compliance specialist, it was confirmed that the above verbal orders for Individual #1 and #2 were not correctly documented by the nursing staff to included the date and time the order was received.





Plan of Correction:

Abraxas I will ensure all restraint orders include the date and time of which the order was obtained.

On November 2, 2017, the Program Manager and Quality & Compliance Specialist met with the Nurse Manager to review individual #1's restraint order from July 16, 2017, and individual #2's restraint order from July 5, 2017. The Nurse Manager was reminded that all restraint orders must include the date and time the order was obtained.

By November 22, 2017, the Nurse Manager will meet with all nurses who receive verbal orders to review the process. Moving forward, the nurse who obtains the restraint order from the physician will double check the order to verify the date and time the order was obtained is properly documented on the restraint order.

Beginning the week of December 4, 2017, the Program Manager will review all restraint orders on a weekly basis. If deficiencies are found in a restraint order, the Program Manager will notify the Facility Director who will then meet with the Nurse Manager to identify the documentation breakdown and document the meeting in a supervisory conference note. Every supervisory conference note will be filed by the Facility Director.

Beginning January 1, 2017, the Quality & Compliance Specialist will review all restraint orders on a monthly basis to confirm the findings of the Program Manager's review are accurate. The Program Manager and Quality & Compliance Specialist will formally report the results of these reviews to the Leadership Team once a month for the next three months. If there is 100% compliance during those three months, reporting during Leadership Meetings will occur once every six months.



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 length of time for which the intervention was permitted by the ordering practioner. This applied to one of two individuals ( #2) in the survey sample. Findings included:

Record review for Individual #2 was completed on October 30, 2017. This review revealed that Individual #2 experienced an ESI on July 5, 2017. Further review failed to reveal that the order for the ESI included the specific length of time the ESI was permitted.

Interview with the quality and compliance specialist on October 30, 2017, at 12:10 PM, confirmed that the specific length of time permitted for Individual #2's ESI was not included in the order.








Plan of Correction:

Abraxas I will ensure all restraint orders include the specified type of restraint permitted to be implemented for a resident experiencing a restraint.

On November 2, 2017, the Program Manager and Quality & Compliance Specialist met with the Nurse Manager to review individual #2's restraint order from July 5, 2017. The Nurse Manager was reminded that all restraint orders must include the permitted restraints authorized by the physician to be utilized during the restraint.

By November 22, 2017, the Nurse Manager will meet with all nurses who receive verbal orders to review the process. Moving forward, the nurse who receives the restraint order from the physician will double check the order to verify the authorized restraints from the physician are properly documented on the restraint order.

Beginning the week of December 4, 2017, the Program Manager will review all restraint orders on a weekly basis. If deficiencies are found in a restraint order, the Program Manager will notify the Facility Director who will then meet with the Nurse Manager to identify the documentation breakdown and document the meeting in a supervisory conference note. Every supervisory conference note will be filed by the Facility Director.

Beginning January 1, 2017, the Quality & Compliance Specialist will review all restraint orders on a monthly basis to confirm the findings of the Program Manager's review are accurate. The Program Manager and Quality & Compliance Specialist will formally report the results of these reviews to the Leadership Team once a month for the next three months. If there is 100% compliance during those three months, reporting during Leadership Meetings will occur once every six months.