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Based on interview, observation, and record review the facility failed to ensure one hour face to face assessments are completed within a timely manner for two of two patients (Patient 26 & 32).

This failure placed the patient at risk for not being accurately assessed for change of condition and safety while in seclusion.

Findings:

During a review of Patient 26's "Psychiatric Evaluation (PE)" dated 5/5/24, the PE indicated Patient 26 was admitted as an inpatient on a 5150 (legal hold) for DTS (danger to self) and DTO (danger to others).

During a review of Patient 26's orders dated 8/2024, an order was entered 6/12/24 at 8:20 a.m. for Resident 26's seclusion/restraint (S/R) (interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), the order indicated, "Continuation S/R". There was no evidence of the type of seclusion/restraint in the physician's order. There was no indication of an initial order for seclusion restraints.

During review of Patient 26's one hour face to face assessment document dated 6/12/24, the face to face assessment indicated the "Initiation of intervention (seclusion the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) was 6/12/24 at 4:20 a.m., the "Face to Face assessment" was 6/12/24 at 5:23 a.m. p.m.

During a review of Patient 26's orders dated 8/2024, an order was entered on 7/2/24 at 9 p.m. for Resident 26's seclusion/restraint. There was no evidence of the type of restraint in the physician order.

During a review of Patient 26's one hour face to face assessment document, dated 7/2/24, the face to face assessment indicated the "Initiation of intervention (seclusion) was at 7/2/24 at 5:16 p.m., the Face to Face assessment was 7/2/24 at 6:25 p.m.

During a review of Patient 32's "Psychiatric Evaluation (PE)" dated 7/16/24, the PE indicated Patient 32 was admitted as an inpatient voluntarily for auditory hallucinations (the perception of hearing sounds or voices that aren't there.).

During a review of Patient 32's orders dated 8/2024, an order was entered 7/19/24 at 4:57 p.m. for seclusion/restraint. The order indicated physical restraint (a coercive approach that involves restricting a patient's movement to prevent harm to themselves or others), maximum duration four hours.

During a review of Patient 32's one hour face to face assessment document, dated 7/19/24, the face to face assessment indicated the "Initiation of intervention was 7/19/24 at 6:29 p.m., the Face to Face assessment was 7/19/24 at 6:29 p.m., "Treatment Recommendations" discussed with medical staff 7/2/24 at 4:51 p.m. Type of intervention indicated physical restraint and seclusion.

During an interview on 8/21/24 at 3:49 with Director of quality management (DQM), the DQM stated the order for Patient 32 on 7/19/24 did not include seclusion, the nurse did not put "yes" when took the verbal order. The DQM confirmed the face to face assessment should have been completed within one hour.

During an interview on 8/21/24 at 4:07 p.m. with Registered Nurse (RN) A, RN A stated if need hands on then a physical restraint order was needed, if seclusion a seclusion order was needed. The face to face assessment is completed when patient was already out of seclusion once they calm down. The order should have indicate the type of restraint.

During a review of the facility's policy and procedure titled, "Restraint and Seclusion, dated 1/2024, the policy and procedure indicated, "The order shall indicate the reason and maximum duration". "Orders for physical restraints shall not exceed 30 minutes". "Seclusion may only be ordered by a Practitioner". "A licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient with in one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the intervention. If the in-person evaluation is conducted by a trained Registered Nurse, the Registered Nurse must consult with the attending/covering practitioner as soon as possible, but not to exceed one hour ...".