HospitalInspections.org

Based on record review and interview the hospital failed to perform a face to face evaluation within one hour of initiation of seclusion/restraint for 2(#2 and #3) of 4(#1, #2, #3, and #4) reviewed records of patients placed in seclusion/restraint.

Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 09/20/2022 with a diagnosis of major depressive disorder, autistic disorder, oppositional defiant disorder, insomnia, and parent-biological child conflict and was discharged on 01/19/2023.

Further review revealed Patient #2 was placed in seclusion on 12/22/2022 at 8:50 p.m. Patient #2 was then placed in restraint chair on 12/22/2022 at 9:30 p.m. Patient #2 was released from restraint chair and seclusion on 12/22/2022 at 10:40 p.m. The one hour face to face evaluation occurred on 12/22/2022 at 11:34 p.m. The physician was notified of the one hour face to face evaluation on 12/22/2022 at 11:44 p.m.

In an interview on 01/31/2023 at 3:07 p.m. S1ADON verified the one hour face to face evaluation was not completed within one hour of the initiation of seclusion.

Patient #3
Review of Patient #3's medical records revealed an admission date of 12/08/2022 with a diagnosis of bipolar disorder and was discharged on 12/22/2022.

Further review revealed Patient #3 was placed in seclusion on 12/21/2022 at 10:25 p.m. Patient #3 was released from seclusion on 12/21/2022 at 11:25 p.m. The one hour face to face evaluation occurred on 12/21/2022 at 11:35 p.m. The physician was notified of the one hour face to face evaluation on 12/21/2022 at 11:30 p.m.

In an interview on 02/01/2023 at 11:10 a.m. S2ADON verified the one hour face-to-face evaluation was not conducted within one hour of the initiation of seclusion.

Based on record review and interview, the hospital failed to ensure nursing care plans were revised to meet the patient's needs. This deficiency is evidenced by failure of the nursing staff to revise the nursing care plan for 4 (#1, #2, #3, and #4) of 5 (#1-5) records reviewed for care plan completeness.

Findings:

Review of the hospital's policy titled "Treatment Planning; Integrated/Multidisciplinary" revealed in part, revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, and limitations, and physician's orders. Revising the plan based on changes in condition and physician's orders. All physician orders will be incorporated into the Treatment Plan.

Patient #1
Review of Patient #1's medical record revealed Patient #1 was placed in seclusion on 12/13/2022 at 11:38 a.m. Review of Patient #1's plan of care revealed no new interventions implemented and no changes after the documented placement in seclusion.

In an interview on 01/30/2023 4:02 p.m. S1ADON verified Patient #1's plan of care was not revised after Patient #1 was placed in seclusion.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was placed in seclusion on 12/21/2022 at 6:30 a.m. and was placed in seclusion/restraint on 12/22/2022 at 8:50 p.m. Review of Patient #2's plan of care revealed no new interventions implemented related to the seclusion/restraint.

In an interview on 02/01/2023 at 11:14 a.m. S2ADON verified Patient #2's plan of care was not revised to include interventions related to seclusion/restraint.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was placed in seclusion on 12/21/2022 at 10:25 p.m. Review of Patient #3's plan of care revealed no new interventions implemented related to the seclusion.

In an interview on 02/01/2023 at 11:08 a.m. S2ADON verified Patient #3's plan of care was not revised to include interventions related to seclusion.

Patient #4
Review of Patient #4's medical record revealed Patient #4 was placed in restraint chair on 01/19/2023 at 5:30 p.m. Review of Patient #4's plan of care revealed no new interventions implemented and no changes after the documented placement in restraints.

In an interview on 02/01/2023 at 11:06 a.m. S2ADON verified Patient #4's plan of care was not revised after Patient #4 was placed in restraints.