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Based on record review and interview, the facility failed to ensure medical records contained completed seclusion and restraint interventions and evaluations for two patients (#2 and #3), out of 10 patients. Specifically, the facility failed to: 1) ensure documentation for Patient #2's restraint and seclusion interventions and follow-up were completed; 2) ensure Patient #3 received debriefing after a seclusion; and 3) ensure Patient #3 was assessed on the effects of the intervention and strategies used to prevent repeat use of seclusion. This failed practice had the potential to place all patients (based on a census of 97), who required restraint or seclusion, at risk for not having their medical, psychological, and psychosocial needs addressed after a seclusion and/or restraint.

Findings:

Patient #2

Record review on 4/1-2/25, revealed Patient #2 was admitted to the facility with diagnoses that included post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD - a neurodevelopmental disorder with symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation), and intermittent explosive disorder (IED - repeated, sudden bouts of impulsive aggressive, violent behavior or angry verbal outbursts).

Review of the Patient #2's "North Star Behavioral Health Seclusion and Restraint" packet, dated 1/25/25, revealed the following sections had missing information/signatures:

- The "Seclusion/Restraint/Chemical Restraint Order" had no transcribing nurse signature.

- The "Post Intervention Face to Face Evaluation," in the notification section, the nurse supervisor was left blank; and in the Administrative Debriefing, the reviewing nurse supervisor was left blank.

Review of the Patient #2's "North Star Behavioral Health Seclusion and Restraint" packet, dated 2/13/25, revealed in the "Administrative Debriefing," the reviewing nurse supervisor was left blank.

Patient #3

Record review on 4/1-2/25, revealed Patient #3 was admitted in the facility with diagnoses that included ADHD and major depressive disorder (MDD - mood disorder).

Review of Patient #3's "North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing," dated 2/20/25 at 10:45 AM, revealed the only documentation on the form was Licensed Nurse (LN)#2's signature.

Review of Patient #3's "North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing," dated 2/20/25 at 11:27 AM, revealed the only documentation on the form was LN #2's signature.

Review of Patient #3's "North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing," dated 2/20/25 at 3:10 PM, revealed the only documentation on the form was LN #2's signature.

During an interview on 4/2/25 at 1:10 PM, LN #1 stated the "North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing," form should have been completed by any staff member the patient felt comfortable talking to. LN #1 further stated the unit nurse reviews all the restraint/seclusion forms after the intervention to ensure they were completed. LN #1 stated that all restraint/seclusion forms should be completed within 24 hours.

During an interview on 4/2/25 at 3:11 PM, when asked if Patient #2's and #3's seclusion and restraint forms should had been completed, the Chief Nursing Officer (CNO) stated they should not be blank and were expected to be completed within 24 hours by the unit nurse. The CNO stated the nursing supervisors reviewed all documentation of restraints and seclusions to ensure forms had been completed. The CNO further stated the supervisor would reach out to the appropriate LN if documentation was not completed. The CNO stated that she compiled all the data from the restraints and the seclusions forms for monitoring and tracking. The CNO further stated if the nursing supervisor missed identifying that the restraint/seclusion forms were not completed, she would follow up with that nursing supervisor. The CNO further stated, "we have identified a gap."

Review of the facility's "North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Restraint Debriefing" form, dated 5/13/24, revealed; "Initiation of Intervention . . . To be completed within 24 hours of intervention, Debriefing Completed. . . Did Patient/Resident request that family/significant other be involved in debriefing? No Yes, Comments: Interventions to involve family: Staff involved in Debrief . . . 1. Patient/Resident perception of events/triggers leading to intervention: 2. Patient/Resident description of what happened to cause behaviors: 3. Patient/Resident perception of anything that could have been done differently: 4. Did the Patient/Resident feel his/her well-being, psychological comfort, and right to privacy were maintained? Yes No If no, explain: 5. Was . . . trauma experienced by the Patient/Resident? No Yes If yes, describe counseling provided: 6. Strategies to prevent repeat use of intervention and/or to address factors contributing to the incident: Additional Comments: Staff Leading the Debrief, Name: Signature: Date: Time."

Review of the facility's policy, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion - Acute, PC112," dated 7/2023, revealed; ". . . Physical Restraints: the application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely . . . Seclusion: the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not . . . Policy . . . The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained . . . Procedures . . .10. Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion. The patient and staff participate in a debriefing session following the restraint/seclusion episode. The patient and, if appropriate, the patient's family, participate with the staff who were involved in the episode and who are available, in a debriefing about each episode of restraint/seclusion use. The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode 1. The debriefing is used to: 1. Identify what led to the incident and what could have been handled differently; 2. Ascertain that the individual's physical well-being, psychological comfort, and right to privacy were addressed; 3. Counsel the individual involved for any trauma that may have resulted from the incident, and 4. When indicated, modify the treatment plan. 2. Information obtained from debriefing is used in performance improvement activities. 13. Documentation of use of restraint/seclusion . . . 12. Debriefing of the patient with staff. 2. Data is collected on all restraint/seclusion episodes . . . 10. Results of the debriefing 3. Analysis of data includes particular attention to: 1. Multiple instances of restraint/seclusion use experienced by a patient within a 12 hour time frame . . ."
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Based on record review and interview, the facility failed to ensure the medical records contained a completed treatment plans (plans of care, after the initial treatment plan upon admission, that outlined a patient's inpatient treatment to include diagnoses, short term and long term goals of identified problems to address during treatment, and discharge planning goals) for eight patients (#'s 2, 3, 5, 6, 7, 8, 9 and 10), out of 10 sampled patients.
Specifically, the patient's treatment plans did not have signatures of the interdisciplinary team who reviewed the treatment plans, and it did not have signatures of the patient and/or guardian after the clinician discussed the treatment plans with them.
This failed practice had the potential to not inform the patients and/or guardians of their treatment progress and response to treatment. Additionally, this failed practice had the potential to not provide the necessary services at the patient's discharge.

Findings:

Patient #2

Record review on 4/1-2/25 revealed Patient #2 was admitted to the facility with diagnoses that included post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD - neurodevelopmental disorder with symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation), and intermittent explosive disorder (IED - repeated, sudden bouts of impulsive aggressive, violent behavior or angry verbal outbursts).

Review of Patient #2's multiple treatment plans revealed:

- Treatment plans, dated 1/29/25, 2/5/25, 3/5/25, and 3/19/25, revealed no patient and guardian signatures;
- The treatment plan, dated 1/29/25, revealed no clinician and nurse signature; and
- The treatment plan, dated 3/5/25, revealed no clinician signature.

Patient #3

Record review on 4/1-2/25 revealed Patient #3 was admitted in the facility with diagnoses that included ADHD and major depressive disorder (MDD - a mood disorder).
Review of Patient #3's treatment plan, dated 1/27/25, revealed no nurse or patient and guardian signatures.

Patient #5

Record review on 4/1-2/25, revealed Patient #5 was admitted to the facility with a diagnosis of ADHD.

Review of Patient #2's multiple treatment plans revealed:

- Treatment plans, dated 1/22/25, 1/29/25, 2/12/25, 2/19/25, 2/26/25, 3/5/25, and 3/19/25, revealed no patient and guardian signatures; and

- The treatment plan, dated 1/22/25, revealed no provider and nurse signature.

Patient #6

Record review on 4/1-2/25, revealed Patient #6 was admitted to the facility with diagnoses that included MDD, reactive attachment disorder (RAD - a childhood psychiatric condition that can make it difficult to form lasting relationships and show affection), and oppositional defiant disorder (ODD - A childhood disorder that causes defiant and disobedient behavior to authority figures).

Review of Patient #6's multiple treatment plans revealed:

- Treatment plans, dated 12/3/24 and 12/11/24, revealed no nurse signature;

- The treatment plan, dated 12/23/24, revealed no patient, guardian, nurse and clinician signatures;

- A treatment plan, undated, revealed no patient, guardian, and nurse signatures; and

- The treatment plan, dated 1/3/25, revealed no guardian, provider, and nurse signatures.

Patient #7

Record review on 4/1-2/25, revealed Patient #7 was admitted to the facility with diagnoses that included IED, and MDD.

Review of Patient #7's treatment plan, dated 1/20/25, revealed no patient and guardian signatures.

Patient #8

Record review on 4/1-2/25, revealed Patient #8 was admitted to the facility with diagnoses that included PTSD and RAD.

Review of Patient #8's treatment plan, dated 3/11/25, revealed no patient and guardian signatures.

Patient #9

Record review on 4/1-2/25, revealed Patient #9 was admitted to the facility with diagnoses that included PTSD and active stress reaction disorder (ASRD- mental health condition with symptoms of intrusive memories, avoidance, and hyperarousal).

Review of Patient #9's treatment plan, dated 3/19/25, revealed no patient and guardian signatures.


Patient #10

Record review on 4/1-2/25, revealed Patient #10 was admitted to the facility with diagnoses that included ADHD and unspecified cognitive disorder (brain's ability to process and store information).

Review of Patient #10's treatment plan, dated 3/21/25, revealed no nurse and provider signatures.

During an interview on 4/2/25 at 2:25 PM, Mental Health Clinical Therapist (MHCT) stated the treatment plan was reviewed weekly with the treatment team, patient and caregiver. During the meeting, goals were developed and modified to meet the patient's needs. If the guardian was unable to attend, then a phone call follow up was conducted to discuss the weekly meeting and the discharge plan. The MHCT stated the treatment plans should be signed by all members of the team. He/she further stated if the guardian was unable to attend and updated over the phone, then that should have been documented on the treatment plan. He/she stated the patient was always involved but did not always sign the treatment plan.

Record review of the facility's "Interdisciplinary Treatment Plan" dated 11/2024, revealed; "Policy . . . each patient/resident have a written, comprehensive, assessment-based, and individualized treatment plan that drives the treatment process, guides the patient/resident toward achieving goals/objectives, monitors progress, and establishes a sound discharge plan for continued success after completing treatment. Expectations . . . the plan shall describe assessment-based patient/resident strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient/resident progress in meeting treatment goals and objectives. . . Procedure . . . 1. . . the treatment team shall further develop the ITP into a Master Treatment Plan (MTP). . . The team will consist of the physician, the RN, the clinical therapist, patient/resident, guardian, and representatives from other clinical disciplines . . . IX. The patient/resident and guardian signs the Treatment Plan after review with a member of the treatment team. . . The clinical therapist is responsible for obtaining signatures from all treatment team members. . . If the parent/guardian of a child is unable to attend the face-to-face meeting in person, then the clinical therapist shall discuss the plan over the telephone and annotated the discussion date/time on the treatment plan signature sheet and in a progress note. If a patient/resident refuses or declines to attend a scheduled treatment team meeting, the clinical therapist is responsible for documenting this refusal on the MTP/U and in a progress note. . ."
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