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Based on record review and interviews staff failed to ensure the Attending Physician was notified as soon as possible after a restraint was ordered by a different Practitioner in 1 of 5 medical records reviewed with restraints (Patient (PT) #13) in a total sample of 10 records reviewed.

Findings Include:

Review of Policy and Procedure titled, "Seclusion or Restraint" last revised 05/2021 revealed the following:
-If the one-hour face-to-face evaluation is completed by a trained Registered Nurse (RN), the physician is contacted as soon as possible after the face-to-face is completed.
-For patients who are not in seclusion or restraint for longer than 24 hours, the physician or LIP shall review each incident a minimum of the next calendar day.

Per review of Pt #13's medical record, Pt #13 was a 26 year old admitted to the inpatient Psychiatric unit on 06/12/2021 with a history of self-harm behaviors and aggression towards others. Review of Pt #13's Admission Notes revealed Physician U was the attending physician. Review of Pt #13's restraint orders revealed Physician's Assistant (PA) V ordered Pt #13's restraints on 07/22/2021 at 5:05 PM. Per review of Pt #13's medical record there was no documented evidence that Attending Physician U was informed of PA V ordering restraints for Pt #13.

Per interview with RN N on 11/17/2021 at 11:50 AM, RN N stated he/she was unable to find documentation that provided evidence of Attending Physician U being informed/aware that Pt #13 was placed in restraints. RN N stated that there should be documentation in the medical record showing that the Attending Physician was aware of the restraint episode.

Based on record review and interview staff failed to ensure that the Registered Nurse (RN) consulted the Attending Physician or other Licensed Independent Practitioner (LIP) after conducting a face-to-face evaluation of restraints in 4 of 5 medical records reviewed with restraints ordered (Patient (Pt) #2, Pt #7, Pt #8, Pt #13) in a total sample of 10 medical records reviewed.

Findings Include:

Review of Policy and Procedure titled, "Seclusion or Restraint" last revised 05/2021 revealed the following:
-If the one hour face-to-face evaluation is completed by a trained RN, the physician is contacted as soon as possible after the face-to-face evaluation is completed.
-For patients who are not in seclusion or restraint for longer than 24 hours, the physician or LIP shall review each incident a minimum of the next calendar day.

Review of Pt #2's medical records revealed the physician ordered restraints on 08/05/2021 from 7:17 AM to 9:16 AM (RN completed the face-to face) and there was no documented evidence that the RN consulted with the attending physician after completing the face-to-face. Review of Pt #2's medical record revealed the physician ordered restraints on 08/06/2021 from 9:32 AM to 11:31 AM (RN completed the face-to-face) and there was no documented evidence that the RN consulted with the attending physician after completing the face-to-face.

Review of Pt #7's medical records revealed the physician ordered restraints on 10/12/2021 from 9:33 AM to 11:32 AM (RN completed the face-to-face) and there was no documented evidence that the RN consulted with the attending physician after completing the face-to-face.

Review of Pt #8's medical records revealed the physician ordered restraints on 11/03/2021 from 7:55 AM to 9:54 AM (RN completed the face-to-face) and there was no documented evidence that the RN consulted with the attending physician after completing the face-to-face.

Review of Pt #13's medical records revealed the physician ordered restraints on 07/22/2021 from 7:55 AM to 9:54 AM (RN completed the face-to-face) and there was no documented evidence that the RN consulted with the attending physician after completing the face-to-face.

Per interview with RN N and Health Information M on 11/17/2021 during medical record reviews from 9:40 AM to 11:50 AM, RN N stated that they were unable to find documented evidence of the RN consulting with the physician after completing the face-to-face evaluation for the above patients. Per RN H and Health Information M, the RN should be consulting with the physician as per policy but this was not documented.

Based on record review and interviews the facility failed to ensure that all patient care staff are trained and able to demonstrate competency in restraints and seclusion in 1 of 2 Patient Care Technicians (PCT) personnel files reviewed (PCT O) in a total sample of 5 personnel files reviewed.

Findings include:

Review of policy and procedure titled, "Crisis Prevention and Management Program" last revised 12/2019 revealed, "Staff who implement CPM (Crisis Prevention Management) techniques, apply restraints, monitor or provide care for patients in restraint or seclusion, or obtain orders for seclusion or restraint shall receive training during the CPM Refresher Training which is updated every 2 years and trained to all staff prior to the implementation of the next Refresher Course.

Review of PCT O's personnel files revealed PCT O's most recent CPM Refresher Course was 05/24/2013 (approximately 8 years ago), and the "CPM: Train the Trainer" course was completed 12/04/2012 (approximately 9 years ago).

Per interview with PCT O on 11/16/2021 at 10:35 AM, PCT O is a trainer for CPM (Crisis Prevention Management) and has been working as a PCT in mental health for 17 years.

Per interview with Director of Nursing (DON) X on 11/17/2021 at 10:25 AM, the CPM training is revised every other year and everyone should be scheduled for the 2 day training. DON X confirmed that there was no documented evidence of PCT O completing a CPM Refresher Course every 2 years. When asked how do you know that PCT O is competent on the application of restraints, DON X replied, "I don't know that he is competent."