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Based on hospital policy and procedure review, medical record review and staff interview, the facility staff failed to update a patient's plan of care (POC) for the use of restraints in 1 of 2 records reviewed of patients in restraints (#6).

The findings include:

Review on 03/16/2022 of the hospital's "RESTRICTIVE INTERVENTIONS" policy, revised 11/2019 revealed ..."D. The plan of care reflects an assessment of the patient to include the need for restraint, interventions and goals associated with the use of restraint ... V. PLANNING ... D. Develop a plan of care to address needs of the patient in restraint ... VIII. DOCUMENTATION ... C. Document response to the plan of care on the Interdisciplinary Plan of Care ..."

Review on 03/17/2022 of the hospital's "Interdisciplinary Care Planning and Documentation" policy, effective 08/17/2021 revealed, "I ... To continues to meet the patient's unique needs, the plan is maintained and revised based on the patient's response ... 3. Reassessment/Evaluation a. The reassessment of the patient's plan of care will be ongoing throughout hospitalization and updated when there is a change in patient's condition, diagnosis, and needs ..."

Medical record review of patient #13 revealed a 16-year-old patient admitted on 01/31/2022, under Involuntary Commitment following behavioral issues at home, with diagnoses including depressive disorder, oppositional defiant disorder, patient-child relational problem, post-traumatic stress disorder, cannabis use. Review of the restraint documentation revealed that the patient was placed in 4-point "Heavy Duty" restraints on 02/18/2022 at 1755, following "Severely aggressive" and "violent, destructive" behavior to prevent harm to self or others. Review of the POC failed to reveal modification to plan following the use of restraints.

Interview with administrative nursing staff #1 on 03/17/2022 at 1400 revealed that there was no modification to patient's plan of care following the use of restraints.

Based on hospital policy and procedure review, medical record review, and staff interview, the facility failed to ensure a one-hour face-to-face assessment was documented after a restrictive intervention for 1 of 2 sample patients (#13).

The findings include:

Review on 03/16/2022 of the hospital's "RESTRICTIVE INTERVENTIONS" policy, revised 11/2019 revealed "I. Violent/Self-destructive Restraint Orders ... 3. A face to face evaluation of the patient is to occur within one (1) hour of application of restraint (even if the restraint is removed within 1 hour of application) ... The face to face evaluation of the patient includes the patient's immediate situation, patient's reaction to the intervention, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion ..."

Medical record review of patient #13 revealed a 79-year-old patient admitted on 02/20/2022 with altered mental status, urinary tract infection, Parkinson's disease, and acute toxic metabolic encephalopathy. Review of a physician's order by MD #1 revealed the patient was placed in 4-point, "Violent/Self Destructive", soft restraints on 02/22/2022 at 0642 for "Aggressive, threatening" and "hitting security, delusional" behavior. Review of the restraint documentation revealed the restraints were discontinued at 1000. Record review revealed no documentation of a face-to-face assessment within one hour after the intervention.

Interview on 03/17/2022 at 1015 with administrative nursing staff #1 revealed there was no documentation in the electronic medical record of a face-to-face assessment of the patient's condition within one hour after the restrictive intervention on 02/22/2022 at 0642.

Telephone interview on 03/25/2022 at 1400 quality assurance staff #1 and the Medical Director (MD #2) for the hospitalist group revealed MD #1 was not available for interview. MD #2 shared, "We could not find a face-to-face evaluation for the 0642 restraint."

Based on hospital policy and procedure review, medical record review, "RESTRICTIVE INTERVENTION ADVISORY COMMITTEE" meeting minutes review, and staff interviews, the hospital failed to develop and implement quality improvements to promote the delivery of quality patient care with one hour face to face assessments of patients placed in violent restraints.

The findings include:

Review on 03/16/2022 of the hospital's "RESTRICTIVE INTERVENTIONS" policy, revised 11/2019 revealed "I. Violent/Self-destructive Restraint Orders ... 3. A face to face evaluation of the patient is to occur within one (1) hour of application of restraint (even if the restraint is removed within 1 hour of application) ... The face to face evaluation of the patient includes the patient's immediate situation, patient's reaction to the intervention, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion ..."

Review on 03/17/2022 of meeting minutes from the "RESTRICTIVE INTERVENTION ADVISORY COMMITTEE" dated 10/12/2020 revealed, " ... Violent Restraint Sept. [September] Face to Face by a Provider 70% - Room for Opportunity. Action Plan was asked by the units not doing so well Suggestion: Partner with a unit that is doing well ..." Review of meeting minutes from the "RESTRICTIVE INTERVENTION ADVISORY COMMITTEE" dated 04/12/2021 revealed, " ... Other concern is face to face timeliness. Documentation opportunities with non-regular staff. Biggest risk point is violent restraint documentation ..."

Review on 03/17/2022 of the Quality Assurance Performance Improvement (QAPI) data for restraints revealed compliance with one-hour, face-to-face assessment following violent restraint use was not included in the quality improvement activities. Review of the QAPI data revealed the hospital failed to measure actions taken to improve compliance with one-hour, face-to-face assessments and to track performance to ensure that improvements were sustained.

Interview on 03/17/2022 at approximately 1500 with quality assurance staff #1 revealed the hospital's Restrictive Intervention Advisory Committee had been working on improving compliance with the one-hour face to face assessment following implementation of violent restraints. Interview during review of the "RESTRICTIVE INTERVENTION ADVISORY COMMITTEE" meeting minutes revealed quality assurance staff #1 acknowledged the 70% compliance rate included in the 10/12/2020 meeting minutes and continued opportunities for improvement included in the 04/12/2021 meeting minutes and shared that there was no additional data available for review in follow up of the identified improvement opportunities indicated in the meeting minutes.

NC00186168
NC00185432