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Based on a review of documentation and interview the facility failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care.

Findings included:

Facility based policy entitled, "Proper use and Monitoring of Restraint, emergency Medications and Seclusion" stated in part,
"11.0 Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion/emergency medications were indicated. a review and modification of the treatment plan is indicated. Based upon the consultation with the attending physician or LIP, information gathered from the debriefing with the patient, and the face-to-face evaluation, the therapist shall review and update the treatment plan within 8 hours. The updated treatment plan shall reflect:
11.1 The identification of an assessed problem associated with the use of restraint/seclusion/emergency medications, if problem has not been previously identified.
11.2 Goals related to prevention of the further use of restraint/seclusion/emergency medication
11.3 Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned.
11.4 Review of the plan with the patient.
11.5 The full treatment team will review the treatment plan updates regarding use of restraint/seclusion during their next meeting and make any needed revisions/updates."

Review of the medical record for Patient #7 revealed this patient had 12 episode of restraint while inpatient.

Treatment Team Plan documentation for Patient #7 included the following:
The Treatment Plan Problem Sheet dated 11/09/21 did not list restraints.
The Initial Nursing Treatment Plan dated 11/09/21 listed "assaultive/aggressive" but did not list restraints.
The only other treatment plans were initiated on 11/08/21 for falls, history of hypertension, and UTI. Another plan was initiated on 11/10/21 to limit sodium to 2 grams daily."

There was no treatment plan update addressing the multiple episodes of restraint for this patient per facility policy and regulatory requirements. The above findings were verfied on 02/16/22 in interview with staff members #1 and 3.

Based on a review of documentation and interview, the facility failed to ensure that all medical record entries were complete, as evidenced by failing to consistently document dietary nutrition intake according facility policy.

Findings included:

Facility policy entitled, "Monitoring Patients at Mealtime" stated in part, "8. Staff will document % of meal eaten for each patient, on the graphics form in the designated space."

Review of 10 medical records revealed 2 patients with incomplete documentation of their nutritional intake/% of meals eaten per facility policy:

The medical record for Patient #7 (inpatient from 11/04/21 to 11/19/21) revealed the following dates had missing nutritional intake/meals documented:
11/06/21 no dinner documented
11/08/21 no lunch or dinner
11/09/21 no meals documented
11/10/21 only breakfast 100%
11/11/21 only breakfast 60%
11/12/21 no meals documented
11/13/21 no meals 0% lunch
11/14/21 only breakfast 60%
11/17/21 no meals documented
11/18/21 only dinner 90%

3 of the 15 days the patient was inpatient had no meal intake documented.


The medical record for Patient #8 (inpatient from 11/07/21 to 11/26/21) revealed the following dates had missing nutritional intake/meals documented:
11/07 Breakfast 95%
11/08 Breakfast 100%
11/09 None documented
11/10 Breakfast 0%
11/11 None documented
11/12 None documented
11/13 None documented
11/14 Breakfast 0 %
11/15 Breakfast 15 %
11/16 Breakfast 80%
11/17 None documented
11/18 None documented
11/19 None documented
11/20 None documented
11/21 None documented
11/22 0% Breakfast
11/23 0% Breakfast
11/24 0% Dinner
11/25 0% Breakfast and 0% Dinner
11/26 Refused Breakfast

Actual nutritional meal intake was only documented on 4 of 20 days the patient was at the facility.

Based on the above incomplete documentation in patient medical records, it appears nutritional meal intake was not consistently documented on patients, per facility policy. Due to this missing/incomplete and inconsistent documentation, it cannot be established the patients nutritional needs were effectively being met at the facility.

The above findings were verfied with staff member #1 at the facility on 02/16/22.

Based on a review of documentation and interview, the facility failed to ensure the frequency of progress notes was recorded at least weekly for the first 2 months, containing recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient ' s progress in accordance with the original or revised treatment plan.

Findings included:

Facility policy entitled, "Interdisciplinary Treatment Plans" stated in part,
"10.0 The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed weekly."

Patient #4 was also inpatient at the facility from 11/06/21 to 11/26/21 and only the following treatment planning documented: The Initial Nursing Treatment Plan dated 11/09/21 listed "assaultive/aggressive" but did not list restraints.
The only other treatment plans were initiated on 11/08/21 for falls, history of hypertension, and UTI. Another plan was initiated on 11/10/21 to limit sodium to 2 grams daily.

Per regulations and facility policy the treatment plan should have been reviewed weekly. The above findings were verified on 02/16/22 with staff member #1.