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Based on record review and interview the facility failed to ensure there was modification of a Restraint Management interdisciplinary plan of care [IPOC] to reflect the use of restraint/seclusion in 4 of 10 seclusion/restraint medical records reviewed (Patient #'s 1, 8, 9 & 10) in a total universe of 10 behavioral health records reviewed.

Findings include:

Record review of policy "216.02 Seclusion or Restraint" #9247025 last revised 5/2021 under Policy #2 revealed "When seclusion or restraint is utilized for a patient, the RN [Registered Nurse] shall initiate a Restraint Management IPOC [interdisciplinary plan of care] if one is not present. a. The RN shall review/update the Restraint Management IPOC for each subsequent seclusion or restraint incident." 3. An appropriate/corresponding IPOC is initiated/reviewed and modified (as needed) following the resolution of each incident of restraint or seclusion."

Review of Patient #1's medical record revealed Patient #1 was a 26-year-old female with a borderline personality disorder who was transferred from an adult resource school for inmates under a NGI status (not guilty by reason of mental disease) order on 6/12/2021.
Restraint Form revealed restraints were initiated on 7/22/2021 at 5:00 PM and discontinued on 7/22/2021 at 9:00 PM. There was no review/update documented in Patient #1's restraint IPOC following the resolution of the restraint episode which ended 7/22/2021 at 9:00 PM.

Review of Patient #8's medical record revealed Patient #8 was a 46-year-old admitted 9/19/2021 for failure to comply with treatment requirement and concerns for safety due to a decline in mental health. Restraint Form revealed restraints were initiated on 10/02/2021 at 3:40 PM and discontinued on 10/02/2021 at 4:05 PM. The restraint IPOC was initiated on 10/04/2021. There was no restraint IPOC documented in Patient #8's medical record on 10/02/2021.

Review of Patient #9's medical record revealed Patient #9 was a 19-year-old admitted 9/19/2021 with impulsive, aggressive, delusional behavior. Restraint Form revealed restraints were initiated on 9/19/2021 at 2:40 PM and discontinued on 9/19/2021 at 4:40 PM. Patient #9's restraint IPOC was initiated 9/19/2021 at 5:52 AM. There was no review/update documented in Patient #9's restraint IPOC following the resolution of the restraint episode which ended 9/19/2021 at 4:40 PM.

Review of Patient #10's medical record revealed Patient #10 was a 34-year-old with a diagnosis of schizoaffective disorder admitted in a manic state. Restraint Form revealed restraints were initiated on 9/14/2021 at 2:50 PM and discontinued 9/14/2021 6:10 PM. At 9 PM he was placed in seclusion, and then put into restraints at 10:00 PM "PT SECLUSION UPGRADED DUE TO INCREASED AGITATION AND HOSTILITY" which were removed 9/15/2021 at 7:00 AM. There was no restraint IPOC in Patient #10's medical record.

On 10/27/2021 at 12:40 PM interview with Health Information Technician (HIT) D, HIT D confirmed there are no review or updates for restraints documented in Patient #1, #8, and #9's IPOCs and no Restraint Management interdisciplinary plan of care [IPOC] documented in Patient #10's medical record stating "not that I can find."

Based on record review and interview, the facility failed to ensure interventions of medications used on an as needed basis (PRN) and the patients reaction to the PRN medication while they were in restraints or seclusion was assessed in the 1 hour face to face assessment in 2 of 6 patients in physical restraints and 1 of 3 patients in seclusion who received PRN medications (Patient #1, #7 & #9) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "216.02 Seclusion or Restraint" #9247025 last revised 5/2021 under Procedure K revealed "When seclusion or restraint is used... the patient must be assessed face to face within one hour after the initiation of the intervention by a physician, LIP [Licensed Independent Practitioner), or a trained RN [Registered Nurse]... The face-to-face evaluation includes... a review of scheduled medications and PRN medications that were administered... one-hour face-to face assessment will also include documentation concerning the patient's: a. Immediate situation. b. Reaction to the intervention. c. Medical and behavioral condition. d. Need to continue or terminate the seclusion or restraint."

Review of Patient #1's medical record revealed Patient #1 was a 26-year-old female with a borderline personality disorder. Restraint Form revealed physical restraints were initiated for aggressive, threatening behavior on 7/22/2021 at 5:00 PM and discontinued on 7/22/2021 at 9:00 PM. On 7/22/2021 at 5:43 PM, Patient #1 received Ativan 2 mg injection. Under "Face to Face Restraints Evaluation" documented by RN J on 7/22/2021 at 10:08 PM, there was no documentation of the medication administration or reaction to the medication intervention noted in the required 1 hour face-to-face restraint assessment.

Review of Patient #7's medical record revealed Patient #7 was a 21-year-old admitted 8/15/2021 with a history of bipolar disorder after being noncompliant with medications and failure to comply with treatment. Restraint Form revealed seclusion was initiated for striking staff and threatening behavior on 8/17/2021 at 10:00 AM and discontinued on 8/17/2021 at 3:00 PM. On 8/17/2021 at 11:39 AM, Patient #7 received Haloperidol 5 mg and diphenhydramine 50 mg injections. Under "Face to Face Restraints Evaluation" documented by RN Q 8/17/2021 at 11:11 AM, there was no documentation of the medication administration or reaction to the medication intervention noted in the required 1 hour face-to-face restraint assessment.

Review of Patient #9's medical record revealed Patient #9 was a 19-year-old admitted 9/19/2021 with impulsive, aggressive, delusional behavior. Restraint Form revealed physical restraints were initiated for aggressive threatening behavior on 9/19/2021 at 2:40 PM and discontinued on 9/19/2021 at 4:40 PM. On 9/19/2021 at 3:34 PM, Patient #9 received diphenhydramine 50 mg injections in each thigh. Under "Face to Face Restraints Evaluation" documented by RN R on 9/19/2021 at 4:47 PM, there was no documentation of the medication administration or reaction to the medication intervention noted in the required 1 hour face-to-face restraint assessment. .

On 10/26/2021 at 3:38 PM during interview with Nurse Clinician E, Nurse E stated medications and the patient's response to the medications should be documented under interventions in the one hour face-to-face documentation. Nurse E confirmed "I didn't see it" documented in Patient #1, #8 and #9 restraint form log under the interventions in the one hour face to face documentation.

Based on record review and interview, the facility failed to follow its policy and procedures by failing to ensure that the attending provider responsible for the care of the patient documents the consult of the 1-hour face-to-face evaluation in 1 of 10 patients who were placed in seclusion or restraints (Patient #10) in a total of 10 seclusion or restraint medical records reviewed.

Findings include:

Record review of policy "216.02 Seclusion or Restraint" #9247025 last revised 5/2021 under Procedure K revealed "When seclusion or restraint is used... the patient must be assessed face to face within one hour after the initiation of the intervention by a physician, LIP [Licensed Independent Practitioner], or a trained RN [Registered Nurse]... If the one-hour face-to-face evaluation is completed by a trained RN, the physician is contacted as soon as possible after the face-to-face evaluation is completed... before writing a new order for the use of restraint or seclusion, a physician or LIP must see and assess the patient.

Record review of policy "Documentation Guidelines" #9003838 last revised 12/2020 under Medical Services revealed "The Admission Note - Physician shall be recorded in the Medical Record within 24 hours of admission."
Review of Patient #10's medical record revealed Patient #10 was a 34-year-old with a diagnosis of schizoaffective disorder admitted 9/12/2021 at 10:05 PM in a manic state. The Restraint Form revealed restraints were initiated on 9/14/2021 at 2:50 PM and discontinued on 9/14/2021 at 6:10 PM. Under "Face to Face Restraints Evaluation" documentation revealed Advanced Practice Nurse Practitioner (APNP) O was the attending provider notified by the RN R on 9/14/2021 at 4:04 PM. There was no admission note documented in the medical record.

Patient #10 was placed in seclusion on 9/14/2021 at 9:00 PM and placed in restraints 9/14/2021 at 10:00 PM, which were discontinued on 9/15/2021 at 7:00 AM. Under "Face to Face Restraints Evaluation" it was documented that APNP P was contacted as the attending provider by RN on 9/14/2021 at 10:00 PM. There was no physician or LIP assessment documented after inititiation of the restraint orders.

On 10/27/2021 at 12:40 PM during an interview with Psychiatrist (MD) I, MD I stated documentation of notification of the face-to-face assessment is the responsibility of the provider who gave the restraint order or the attending physician in their next daily progress note.

On 10/27/2021 at 2:20 PM during interview with Health Information Technician (HIT) D, HIT D confirmed she "couldn't find" an attending provider assessment note documented in Patient #10's medical record.