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Based on review of policies and procedures, medical records, and staff interviews it was determined the facility failed to ensure that 7 of 7 treatment plans were updated, after the patient was secluded and/or restrained. This deficient practice poses a potential risk of failing to implement alternative approaches to physical intervention and potential patient injury.

Findings Include:

The policy titled "Seclusion Policy" revealed: "...seclusion use must be in accordance with a written modification to the patient's plan of care at the time of initiating interventions and alternative to seclusion use...."

The policy titled "Restraint, Physical" revealed: "...the treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent reoccurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion...."

Medical records for patients #6 through #12, who had been secluded and/or restrained during hospitalization revealed that 7 of 7 treatment plans had not been updated or modified after the patient was secluded and/or restrained as required by facility policies.

Employee #3 confirmed during an interview conducted on 07/22/19, that the treatment plans had not been updated.

Based on review of policies and procedures, medical records, and staff interviews it was determined the facility failed to ensure the attending physician was notified of patient seclusion and/or restraint incidents for 9 of 12 incidents per facility policy. This deficient practice poses the potential risk of inadequate care due to the Attending Physician not having all pertinent information to properly treat the patient.

Findings Include:

The policy titled "Restraint, Physical" revealed: "...the attending/covering practitioner will be contacted during the initiation of restraint or immediately after...."

The policy titled "Seclusion Policy" revealed: "...When seclusion is ordered by someone other than the patient's treating physician, he or she must be consulted within 30 minutes of implementation...."

The Medical Staff Rules and Regulations revealed: "...a practitioner will be notified as soon as possible thereafter to obtain order. In the event that the Practitioner or other party initiating the restraint is not the patient's Attending Physician, the initiation of Restraint or Seclusion shall be followed by consultation with the patient's Attending Physician (documented to include date and time) as soon as possible...."

Documentation contained within 12 of 15 Seclusion/Restrain packets revealed that the packets failed to identify that the attending physician for Patients #6-12 was contacted, as required by facility policies.

Employee #3 confirmed during an interview conducted on 07/22/19, that s/he was not aware the attending needed to be consulted, and therefore it was not being done.

Based on review of policies and procedures, medical records, and staff interviews it was determined the facility failed to ensure that a valid order was documented for 9 out of 15 Seclusion/Restraint packets reviewed. This deficient practice poses the potential risk of unnecessary and unlimited seclusion and/or restraint and patient harm.

Findings Include:

The policy titled "Seclusion Policy" revealed: "...seclusion time limits for each episode must be specified in the order and follow federal and state requirements...."

The policy titled "Restraint, Physical" revealed: "...the order shall indicate the reason and maximum duration of restraint...."

Documentation contained within fifteen Seclusion/Restraint packets revealed that a time limit for the seclusion or restraint order was missing in 9 of 12 packets for Patient #'s 6-12, as required by facility policies.

Employee #3 confirmed during an interview conducted on 07/22/19, that the Seclusion/Restraint packets were incomplete.

Based on review of policies and procedures, medical records, and staff interviews it was determined the facility failed to ensure that 15 of 15 patients received a required one hour face-to-face evaluation completed per facility policy. This deficient practice poses the potential risk that a change in the medical or psychological condition of the patient will not be identified.

Findings Include:

Policy titled "Seclusion Policy" revealed: "...A physician, credentialed nurse, or LIP must document a face-to-face assessment within 1 hour of implementation of seclusion. The 1-hour face-to-face evaluation includes both a physical and behavioral assessment of the patient that must be conducted by a qualified practitioner within the scope of their practice. An evaluation of the patient's medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, drugs and medications, most recent lab results, ect...during the face-to-face assessment, the qualified practitioner will evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition; and the need to continue or terminate the seclusion...."

The policy titled Restraint, Physical" revealed: "...a practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restrain 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...."

Review of the Medical Staff Rules and Regulations revealed "...a Practitioner must see and evaluate the need for Restraint or Seclusion within one (1) hour after initiation of the Restraint or Seclusion and upon being released form Restraint or Seclusion...."

Documentation contained within fifteen Seclusion/Restraint packets revealed that 15 of 15 packets failed to show evidence of a complete one hour face-to-face evaluation. There was no documentation that the patient's history, labs, medications, or assessments had been reviewed as required by facility policies. Additionally, 15 of 15 face-to-face evaluations were documented as having been completed at the same time the order for seclusion and/or restraint was obtained.

Employee #2 confirmed during an interview conducted on 07/22/19, that the face-to-face evaluations were not completed per facility policy.

Based on review of policies and procedures, medical records, and staff interviews it was determined the facility failed to ensure 15 of 15 verbal orders for seclusion and/or restraint were signed per facility policy. This deficient practice poses the potential risk for error when the medical record does not confirm the validity of physicians' orders.

Findings Include:

The Medical Staff Rules and Regulations revealed the following related to telephone orders: "...signed promptly (if practitioner dictating the order is the patient's Attending Physician, the order may be signed either by the Attending Physician or by any designee of the Attending Physician who is covering for the Attending...."

Fifteen Seclusion/Restrain packets revealed that 15 of 15 verbal orders were not signed by the Attending Physician, as required by facility policy.

Employee #2 confirmed during an interview conducted on 07/22/19, that the Seclusion/Restraint packets were missing signed verbal orders.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined the facility failed to develop a facility-based risk assessment prior to developing the facility emergency plan. Failure to develop emergency plans based on facility-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency, if specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:

The requested risk assessment of the Emergency Plan was reviewed on July 16, 2019. The Emergency Plan did not have the documented facility-based risk assessment.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was no documentation to review for a facility-based risk assessment.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for tracking of staff and sheltered patients during an emergency. Failure to adequately track patients and staff during an emergency could lead to harm to both patients and staff if staff and patient location/whereabouts are not known.


Findings include:

The facility Emergency Plan specifically relating to the facility process for the tracking of sheltered/evacuated patients and staff during an emergency was reviewed on July 16, 2019. The emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

The Director of Risk/PI and the Director of A&R confirmed during an exit conference on July 16, 2019, the emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm for both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The facility Emergency Plan related to a process for sheltering patients and staff during an emergency was reviewed on July 16, 2019. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The Director of Risk/PI and the Director of A&R confirmed on July 16, 2019, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop an emergency policy and procedure at alternative care sites may cause harm to the patients during an emergency if the needs of the patients are not met.

Findings include:

The requested policy and procedures to describe its role in providing care at alternate care sites during an emergency was reviewed on July 16, 2019. The Emergency Plan did not have the documented policy and procedures to describe its role in providing care at alternate care sites during an emergency.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 16, 2019, that there was no documentation to review to describe its role in providing care at alternate care sites during an emergency.

Based on review of the facility Emergency Plan (EP), and staff interview, it was determined the facility failed to develop an emergency officials contact list. Failure to have an emergency officials contact list during an emergency could lead to harm to both patients and staff if specific Federal, State, Tribal, Regional, and Local Emergency Preparedness staff or other sources of assistance are not known if the need to contact them should arise.

Findings include:

The requested emergency officials contact list of the Emergency Plan was reviewed on July 16, 2019. The Emergency Plan did not have the documented emergency officials contact list.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 16, 2019, that there was no documentation to review of the emergency officials contact list.