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Based on interview and record review the facility failed to modify three patients' treatment plans (Patients #1, #2, and #3), of three patients' treatment plans reviewed, to reflect the use of restraints (any manual method, physical or mechanical device that immobilizes or reduces the ability of an individual to move his/her arms, legs or body freely). Patients in restraints are placed at a higher risk for injuries or death. This failure had the potential to affect all patients requiring a restraint as staff would not be aware of the goals and/or interventions to prevent future restraint use. The facility identified six patients required restraints in the prior 90 days (04/28/14 through 07/28/14). The facility census was 24.

Findings included:

1. Record review of the facility's policy titled, "Individualized Treatment Plan," dated 06/21/02, showed the following:
- Any significant change in a client's condition should trigger a full or partial Individualized Treatment Plan (ITP) review.
- List all identified problems.
- Problems must be added or changed according to clinical conditions between scheduled ITP's.
- If a patient develops a new problem, and is not due for a regular ITP review, the new problem is developed with goals and interventions as usual.
- Interventions are actions by the staff that increase, decrease, change or alter the client's behaviors.
- The Social Worker is primarily responsible for developing/modifying the plan.

Record review of the facility's policies titled, "Restraint Protocol," and "Restraints," revised 06/01/14, showed immediately after any patient has been in restraints, a debriefing with the patient and staff shall be done to assess how the restraint usage could have been avoided, and any necessary changes to the ITP. And, the patient's treatment team shall review modifications to the ITP made following the restraint use within seven days and develop a permanent plan for dealing with the issues that led to the use of restraint.

2. Record review of a restraint order dated 04/30/14, showed Patient #1 was manually held for one minute related to an attempt to shred another patient's shirt and tie the fabric around his waist. The patient failed to respond to redirection.

3. Record review of the Staff Debriefing form, dated 04/30/14, showed staff failed to identify any additional interventions in avoiding future restraint episode.

4. Record review of the patient's ITP, developed on 03/21/14, showed no reference to this restraint episode, no restraint problem, no obtainable restraint goals and/or interventions to prevent future restraint episodes.

5. Record review of a restraint order dated 06/21/14, showed Patient #1 was manually held for five minutes related to tying his pants too tight around his waist. The patient's circulation was constricted and Patient #1 was biting and hitting staff while they were trying to loosen his pants.

6. Record review of the Staff Debriefing form, dated 06/21/14, showed staff failed to identify any additional interventions to avoid future restraint episodes.

7. Record review of the patient's ITP, developed on 03/21/14, and updated on 06/17/14, showed no reference to this restraint episode, no restraint problem, no restraint goals and/or interventions to prevent future restraint episodes.

8. Record review of an ITP Review Note, dated 06/23/14, showed the treatment team met and discussed the restraint episode on 06/21/14. There was a reference to updating the behavior management plan; however, staff failed to address specific, obtainable goals and interventions to prevent future restraint use, and failed to modify the patient's ITP.

9. Record review of a restraint order dated 07/03/14, showed Patient #1 was manually held for about five minutes related to putting his belt on too tight. The patient's circulation was constricted and staff had to hold the patient while his belt was loosened, because the patient was combative.

10. Record review of the Staff Debriefing form, dated 07/03/14, showed staff failed to identify any additional interventions to avoid future restraint episodes.

11. Record review of the patient's ITP, developed on 03/21/14, and updated on 06/17/14, showed no reference to this restraint episode, no restraint problem, no restraint goals and/or interventions to prevent future restraint episodes.

12. Record review of an ITP Review Note, dated 07/07/14, showed the treatment team met and discussed the restraint episode on 07/03/14. Staff failed to address specific, obtainable goals and interventions to prevent future restraint use, and failed to modify the patient's ITP.

13. Record review of a restraint order dated 07/18/14, showed Patient #2 was manually held for approximately five minutes because the patient was yelling at a peer.

14. Record review of the Staff Debriefing form, dated 07/18/14, showed staff failed to identify additional interventions to avoid future restraint episodes.

15. Record review of the patient's ITP, developed on 06/24/14, and updated on 07/22/14, showed no reference to this restraint episode, no restraint problem, no obtainable restraint goals and/or interventions to prevent future restraint episodes.

16. Record review of a restraint order dated 07/11/14, showed Patient #3 was manually held for approximately nine minutes because the patient was aggressive with staff while they were trying to draw blood for diagnostic testing.

17. Record review of the Staff Debriefing form, dated 07/11/14, showed staff failed to identify additional interventions to avoid future restraint episodes.

18. Record review of the patient's ITP, developed on 07/01/14, showed no reference to this restraint episode, no restraint problem, no obtainable restraint goals and/or interventions to prevent future restraint episodes.

19. During an interview on 07/29/14, at 10:33 AM, Staff D, Medical Director, agreed ITP's should be modified with restraint episodes.

20. During an interview on 07/29/14, at 11:30 AM, Staff J, Behavior Analyst, stated that behavior modification plans required guardian consent; however, felt the ITP could be modified in the interim.

21. During an interview on 07/29/14, at 12:20 PM, Staff K, Licensed Social Worker, stated that it was the social workers' responsibility to modify the ITP as necessary, after the team meeting. Staff K stated the ITP could be modified with a problem, obtainable goal, and appropriate interventions.

Based on interview and record review the facility failed to provide education or training and require demonstrated knowledge to staff on first aid techniques for patients placed in restraints for three of three staff training records reviewed (Staff F, G and Q). Patients in restraints are placed at a higher risk for injuries or death. This had the potential to affect all patients placed in restraints. The facility census was 24.

Findings included:

1. Record review of staff members' personnel, training files showed no documentation that they received first aid education or training for patients placed in restraints. All of these employees could potentially provide care and/or apply restraints to patients.

2. Record review of educational records for staff included:
- Staff F, Psychiatric Technician (psych tech);
- Staff G, psych tech;
- Staff Q, Registered Nurse (RN).

3. Record review of the facility's Professional Assault Crisis Training (Pro-Act) manual failed to include first aid education or training for employees.

4. During an interview on 07/29/14, at 10:33 AM, Staff D, Medical Director, stated that staff received nothing specific to first aid training related to restraint use.

5. During an interview on 07/29/14, at 3:05 PM, Staff N, Psych Tech II, stated that she had not received any first aid training related to restraint use.

6. During an interview on 07/29/14 at 3:12 PM, Staff O, RN, stated that she had not received any first aid training related to restraint use.