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Based on document review, medical record review and interview it was revealed the facility failed to ensure one (1) of fourteen (14) (patient #4) patients who had a diagnosis of Intellectual Developmental Disorder (IDD) was free from mechanical restraints. This failure to keep the patient free from mechanical restraint use has the potential to affect all patients with a diagnosis of IDD. (See tag A 154).

Based on document review, medical record review and interview it was revealed the facility failed to ensure one (1) of fourteen (14) (patient #4) patients who had a diagnosis of Intellectual Developmental Disorder (IDD) was free from mechanical restraints. This failure to keep the patient free from mechanical restraint use has the potential to affect all patients with a diagnosis of IDD.

Findings include:

1. A review of the facility policy entitled 'Guidelines for Restraints and Seclusions,' effective date 9/13/19, revealed in part: "Note: The use of seclusion or mechanical restraint for developmentally disabled clients is strictly prohibited. Only procedures developed in accordance with standards of the Accreditation Council on Services for People with Disabilities such as "time-out" may be used for the developmentally disabled client..."

2. A review of the medical record for patient #4 on 10/13/21 revealed the patient was agitated and stating she was going to kill herself, was attempting to choke herself by placing her hands around her neck and was punching the wall in the bathroom. She was placed in a physical hold and mechanical restraints. The physical hold restraint was from 9:23 p.m. to 9:25 p.m. and the four (4) point mechanical restraint was from 9:25 p.m. to 9:26 p.m. The mechanical restraints were released when the patient became calmer.

3. An interview conducted with Registered Nurse (RN) #1 on 10/26/21 at 8:35 a.m. revealed she did not know the patient had a diagnosis of IDD.

4. An interview was conducted with the Director of Nursing on 10/27/21 at approximately 10:30 a.m. and she concurred with the above findings.

Based on medical record review, document review and interview it was revealed Registered Nurse (RN) #1 failed to follow hospital policy by placing one (1) of fourteen (14) patients (patient #4) who had a diagnosis of Intellectual Developmental Disorder (IDD) in mechanical restraints. This failure to ensure patients with IDD were not placed in mechanical restraints has the potential to affect all patients with IDD.

Findings include:

1. A review of the medical record for patient #4 on 10/13/21 revealed the patient was agitated and stating she was going to kill herself, was attempting to choke herself by placing her hands around her neck and was punching the wall in the bathroom. She was placed in a physical hold and mechanical restraints. The physical hold restraint was from 9:23 p.m. to 9:25 p.m. and the four (4) point mechanical restraint was from 9:25 p.m. to 9:26 p.m. The mechanical restraints were released when the patient became calmer.

2. A review of the facility policy entitled 'Guidelines for Restraints and Seclusions' effective date 9/13/19 revealed in part: "Note: The use of seclusion or mechanical restraint for developmentally disabled clients is strictly prohibited. Only procedures developed in accordance with standards of the Accreditation Council on Services for People with Disabilities such as "time-out" may be used for the developmentally disabled client ..."

3. A review of an email dated 10/25/21 from the Nurse Manager of the N2 Unit to the Director of Nursing revealed RN #1 stated the computers were down when patient #4 was placed in mechanical restraints. She was reminded to use the Kardex in the future for diagnosis information.

4. An interview conducted with RN#1 on 10/26/21 at 8:35 a.m. revealed she did not know the patient had a diagnosis of IDD.

5. An interview was conducted with the Director of Nursing on 10/27/21 at approximately 10:30 a.m. and she concurred with the above findings.

Based on medical record review, document review and interview it was revealed the facility failed to update the Master Treatment Plan when the patient had a change of condition in three (3) out of four (4) patients, patient #7, 9 and 10, reviewed on Unit Charlie-Two (C2). This failure has the potential to negatively impact all patients transferred to Unit C2 for care.

Findings include:

1. A record review was conducted for patient #7. The patient was diagnosed with COVID-19 and transferred to the C2 Unit on 10/16/21. On 10/21/21 at 2:38 p.m. an addendum in the Master Treatment Plan states, "MHT (Mental Health Technician) will meet with (patient #7) 1x (once) per week, or as needed, on C2 to provide active-listening with reality-based discussion. This to aid in promotion of goal-oriented behaviors for enhanced daily living." No additional updates to the treatment plan or mention of the COVID-19 diagnosis were in the Master Treatment Plan. The patient remains on the C2 Unit.

2. A record review was conducted for patient #9. The patient was diagnosed with COVID-19 and transferred to the C2 Unit on 10/14/21. On 10/15/21 at 12:38 p.m. an addendum in the Master Treatment Plan states, "MHT will meet with (patient #9) 1x/per week, or as needed, on C2-COVID Unit to support current goals set (MXIV) to promote positive tx (treatment) and discharge success. To provide support and encouragement while residing on isolation unit to promote positive mental health." No additional updates to the treatment plan or mention of the COVID-19 diagnosis were in the Master Treatment Plan. The patient remains on the C2 Unit.

3. A record review was conducted for patient #10. The patient was diagnosed with COVID-19 and transferred to the C2 Unit on 10/08/21. On 10/15/21 at 12:17 p.m. an addendum in the Master Treatment Plan states, "MHT will meet with (patient #10) 1x/week (once a week), or as needed, on C2-COVID Unit to encourage him to share his thoughts and feelings with active listening, identify triggers that causes impulsive behaviors and/or depressive thoughts and develop healthy coping strategies to deal with situations." No additional updates to the treatment plan or mention of the COVID-19 diagnosis were in the Master Treatment Plan. The patient remains on the C2 Unit.

4. A policy titled "Treatment Plan," last revised 06/2019, was reviewed. The policy states in part: "Guidelines: ...New medical/psychiatric concern(s) will be documented by adding a Treatment Plan addendum to the Master Treatment Plan."

5. An interview was conducted with the Clinical Services Director (CSD) on 10/25/21 at 12:30 p.m. When asked about updating the Master Treatment Plans when a patient is diagnosed with COVID-19, the CSD stated, "The patients are not transferred to a different treatment team. They keep the same treatment team, so when they are done in quarantine and can move back to the previous unit, it ensures continuity of care. No transfer staffing is done to update the treatment plan."

6. An interview was conducted with the Chief Nursing Officer (CNO) on 10/26/21 at 11:00 a.m. Regarding the treatment plans of the patients diagnosed with COVID-19, the CNO stated, "There was no additional documentation updating the plan except the MHT note to see the patient 1x/week on Unit C2."

7. An interview was conducted with the Director of Advanced Practice Practitioners and the Chief Medical Officer (CMO) on 10/27/21 at 10:00 a.m. Regarding updating the Master Treatment Plans when a patient tests positive for COVID-19, the CMO stated, "The update was not done due to no changes in actual treatment or assessment. The goals and the treatment team remain the same." The CMO concurred a COVID-19 diagnosis would be a change in condition.

Based on medical record review, document review and interview it was revealed the facility failed to ensure patients received physical therapy (PT) services on the COVID-19 Unit, Unit Charlie-Two (C2) in one (1) out of four (4) patients (patient #10) reviewed on Unit C2. This failure has the potential to negatively impact all patients transferred to Unit C2 for care.

Findings include:

1. A record review was conducted for patient #10. The patient received a PT evaluation on 10/08/21 at 3:00 p.m. The PT evaluation stated, "Frequency: 1-3x/wk (one to three times per week). The patient was diagnosed with COVID-19 and transferred to the C2 Unit on 10/08/21. No additional notes were found regarding PT treatment. The patient remains on the C2 Unit.

2. An interview was conducted with the Chief Nursing Officer (CNO) on 10/26/21 at 11:00 a.m. Regarding physical therapy notes for patient #10, she stated, "No additional notes were found after the evaluation."

3. An email was reviewed on 10/26/21 at 1:30 p.m. The email was received from the physical therapist regarding PT provided on the COVID-19 Unit C2. The email stated, "During this pandemic while the patient is in the quarantine process, the medical community has established a standard of care to hold non-emergent medical care (physical therapy, speech therapy, etc..) until the patient's quarantine is over. This is followed by most hospitals including (other acute hospital facility). I confirmed this with (medical doctor); we agreed on the need to implement and to continue this precaution at (this facility). (Physical Therapist)."

4. An interview was conducted with the Director of Advanced Practice Practitioners and the Chief Medical Officer (CMO) on 10/27/21 at 10:00 a.m. Regarding the PT not being continued on the COVID-19 Unit (C2), the CMO stated, "The physical therapist refuses to go onto the COVID unit."