HospitalInspections.org

Based on observation, medical record review, and staff interview, the facility failed to ensure master treatment plans with interventions, measurable goals, and reassessments were modified for 2 of 2 sample patients (#4, #5) who required seclusion for management of destructive behaviors. The findings were:

1. Review of the medical record showed patient #4 was admitted with diagnoses that included post traumatic stress disorder. Review of the restraint/seclusion record dated 7/10/17, showed staff used a seclusion intervention when the patient hit staff and other patients and kicked the doors. Further review showed within 30 minutes the physician was contacted, and the face-to-face was completed. This review revealed seclusion was used from 8:41 PM to 8:46 PM, and the patient was monitored throughout that time. Review of the master treatment plan, dated 7/10/17, showed the goals remained unchanged and the only intervention was to keep the patient from other patients. Observation on 7/11/17 at 4:04 PM revealed the patient hit the physician, tore the shower curtain in the bathroom, and kicked and hit staff. Continuous observation revealed the patient was in seclusion from 4:06 PM until 4:08 PM. Review of the restraint/seclusion record, dated 7/11/17, showed within 30 minutes the physician was contacted, the face-to-face was completed, and the patient was monitored throughout the seclusion time. Review of the master treatment plan, dated 7/11/17, showed interventions and goals were not modified with measures or actions staff planned to implement to address the problem and timeframes for evaluating restraint/seclusion interventions and goals were lacking.

2. Review of the medical record showed patient #5 was admitted with diagnoses that included anxiety and depression. Review of the restraint/seclusion record, dated 7/8/17, showed staff used a seclusion intervention when the patient attacked staff, tied clothing around his/her neck, and punched the walls. Further review showed within 30 minutes the physician was contacted, and the face-to-face was completed. This review revealed seclusion was used from 5 PM to 6:05 PM, and the patient was monitored throughout that time. At 6:05 PM the patient was calm and received Ativan and Haldol. Review of the master treatment plan, dated 7/8/17, showed the interventions consisted of two statements: Patient was mad about involuntary admission status, and patient to be calm and the patient will cooperative with staff in order to maintain safety. Further review of the master treatment plan showed the interventions described the patient's mood and behavior, but did not include implementing measures or actions that addressed the problem. This review also revealed timeframes for evaluating restraint/seclusion interventions and goals were lacking.

3. Interview with the chief nursing officer on 7/12/17 at 4:30 PM revealed they did not have a specific guideline or procedure for developing and revising master treatment plans. She further stated treatment plans were discussed during new employee orientation, but additional inservice education and training was not provided thereafter.