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Based on review of QAPI activities for restraints, it was determined that the facility failed to ensure implementation of its Plan of Correction (PoC) for restraint monitoring from the full federal survey completed 6/7/12.

Findings include:

1. On 12/10/12, the facility's QA was reviewed for restraint monitoring. There was no evidence that the facility implemented its PoC. The facility's PoC from the 6/7/12 full federal survey indicated that the facility would review 30 medical records per month and if results are 95% or higher, the monitoring and review of 30 medical records will then be done on an ongoing quarterly basis to ensure the following:

a. Chemical Restraint is not used on patients.

b. Patients are in the correct restraint ordered.

c. Documentation is completed to indicate food and fluids were offered to a restrained patient.

d. Every 15 minute checks of patients restrained is documented as completed.

e. Assessments and interventions are documented when a patient is restrained.

2. The QA reviewed indicated that the facility reviewed 27 charts in July and 32 charts in August.

a. The data collected for July 2012 and August 2012 was not aggregated to ascertain if the monitoring results were 95% or higher to determine if the facility could decrease the monitoring to a quarterly basis, or if the results were less than 95% and the facility needed to continue monthly monitoring. This was confirmed by Staff #8.

b. There was no evidence of chart monitoring for restraint use for September, October, and November 2012. Staff #1 and Staff #8 confirmed on 12/10/12 at 1:45 PM that there was no monitoring done for these months.

c. Staff #8 provided random monitoring sheets that he/she completed on 33 charts in the month of October. Staff #8 confirmed that this monitoring was not aggregated and was not incorporated into the main QA activity for restraints.

Based on review of QAPI activities for restraints, it was determined that the facility failed to ensure implementation of its Plan of Correction (PoC) for restraint monitoring from the full federal survey completed 6/7/12.

Findings include:

1. On 12/10/12, the facility's QA was reviewed for restraint monitoring. There was no evidence that the facility implemented its PoC. The facility's PoC from the 6/7/12 full federal survey indicated that the facility would review 30 medical records per month and if results are 95% or higher, the monitoring and review of 30 medical records will then be done on an ongoing quarterly basis to ensure the following:

a. Chemical Restraint is not used on patients.

b. Patients are in the correct restraint ordered.

c. Documentation is completed to indicate food and fluids were offered to a restrained patient.

d. Every 15 minute checks of patients restrained is documented as completed.

e. Assessments and interventions are documented when a patient is restrained.

2. The QA reviewed indicated that the facility reviewed 27 charts in July and 32 charts in August.

a. The data collected for July 2012 and August 2012 was not aggregated to ascertain if the monitoring results were 95% or higher to determine if the facility could decrease the monitoring to a quarterly basis, or if the results were less than 95% and the facility needed to continue monthly monitoring. This was confirmed by Staff #8.

b. There was no evidence of chart monitoring for restraint use for September, October, and November 2012. Staff #1 and Staff #8 confirmed on 12/10/12 at 1:45 PM that there was no monitoring done for these months.

c. Staff #8 provided random monitoring sheets that he/she completed on 33 charts in the month of October. Staff #8 confirmed that this monitoring was not aggregated and was not incorporated into the main QA activity for restraints.