HospitalInspections.org

Based on record review and interview the facility staff failed to follow their policy to ensure a care plan problem was initiated when restraints were applied to a patient or when a patient was placed in seclusion per orders in 3 (Patient #'s 3, 4 and 5) out of 5 restraint/seclusion medical records reviewed out of a total universe of 10.

Findings include:

The facility policy titled "Seclusion or Restraint" ID#8936665 last reviewed on 12/2020 revealed "C. The use of restraint or seclusion may only be used: 2. A seclusion or restraint IPOC (Individual Plan of Care) is initiated when a seclusion restraint episode is initiated and discontinued when the episode is discontinued. 3. An appropriate /corresponding IPOC is initiated/reviewed and modified (as needed) following the resolution of each incident of restraint or seclusion. The MTP (Master Treatment Plan) is reviewed and modified (as needed) at each staffing or sooner as necessary to address the use of seclusion or restraint and methods to prevent it's use in the future. 4. Modifications to the IPOC or MTP are documented."

Review of Patient #3's psychiatric admission note dated 11/30/2020 revealed Patient #3 was admitted for increased aggression toward others and had demonstrated violent behaviors at the treatment facility where s/he had been on a civil commitment (51.20) since 11/16/2020.
Review of the nursing progress notes on 11/30/2020 and 12/1/2020 revealed Patient #3 was placed in seclusion and/or restraints related to aggressive behavior towards other patients and staff at the facility. There was no documented care plan for the use of restraints or seclusion when they were ordered.

Review of Patient #4's psychiatric admission note dated 12/3/2020 revealed Patient #4 was admitted for concern of suicidal and homicidal thoughts made towards staff at the jail where Patient #4 was serving time. Review of the nursing progress note on 12/18/2020 revealed Patient #4 was placed in restraints related to aggressive behavior towards staff. There was no documented care plan for the use of restraints when it was ordered.

Review of Patient #5's psychiatric admission note dated 12/16/2020 revealed Patient #5 was admitted for increased aggression towards staff at the jail where Patient #5 was serving time. Review of the nursing progress notes for 12/21/2020 and 12/25/2020 revealed Patient #5 was placed in seclusion related to aggressive behavior towards other patients and staff at the facility. There was no documented care plan for the use of seclusion when it was ordered.

During an interview with Director of Quality B on 1/4/2021 at 1:46 PM, B stated "An IPOC (Individual Plan of Care) should have been initiated when patient's #3, #4 and #5 were placed in restraints or seclusion per orders and it was not done."


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