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Based on medical record review and staff interview, the provider failed to ensure treatment plans for restraints and/or seclusion were modified to reflect individual interventions after episodes of restraint/seclusion for 3 of 9 sample patients (#3, #11, #31) reviewed for restraints/seclusion. The findings were:

1. According to nursing documentation dated 8/17/11 at 12:20 PM, patient #3 required a physical hold restraint because s/he was "...psychotic and easily agitated .." Review of the treatment plan for seclusion and/or restraints showed it was a generic plan with no individualized interventions. There was no evidence the trigger[s] for the patient's behavior was[were] identified, that alternative coping strategies were developed and implemented, or that the patient ever recognized the inappropriateness of the behavior. The DON and clinical director confirmed the treatment plan was not individualized on 8/23/11 at 1:30 PM.

2. Review of the "Restraint/Seclusion Order/Record" showed patient #11 was physically held by one staff member on 6/4/11 from 2 PM until 2:08 PM after the patient attempted to hit a peer. Review of the treatment plan to "eliminate use of seclusion and/or restraints", initiated on 6/5/11, showed strategies for healthy methods to sublimate emotions and alternative coping strategies were circled as the plan. There was no evidence individualized strategies were identified and implemented. Furthermore, continued medical record review showed the patient was again physically held for one minute on 6/18/11 at 4:15 PM after s/he physically assaulted a peer. Review of the 6/19/11 treatment plan to "eliminate use of seclusion and/or restraints" showed the same generic plan was indicated. Again, individualized interventions were lacking. On 8/23/11 at 1:30 PM the DON and clinical director verified the lack of an individualized, effective treatment plan.

3. Review of the medical record for patient #31 showed s/he required a physical hold restraint on 7/14/11 from 7:40 PM to 7:48 PM (eight minutes). The restraint was required for out of control behaviors including destruction of furniture. Review of the care plan written after this episode showed it did not reflect what triggered the patient's out of control behavior and no individualized interventions to prevent future episodes were identified. On 8/23/11 at 1:30 PM the DON and clinical director verified the lack of an individualized, effective treatment plan.

Based on staff interview and review of the restraint/seclusion record and nursing documentation, the facility failed to ensure the one hour face to face evaluation was documented in the record for 1 of 9 sample patients (#3) reviewed for restraints/seclusion. The findings were:

According to the restraint/seclusion record, patient #3 was placed in seclusion at 1:10 PM on 8/17/11. Further review showed the one-hour face-to-face evaluation was documented as occurring at 4 PM that day. Review of submitted information showed, and interview with the clinical director on 8/31/11 at 9:40 AM confirmed, that RN #1 conducted the evaluation within the one-hour time frame and apprised the physician of the results; however, she failed to document the evaluation in the medical record.

Based on observation, medical record review, staff interview, and review of instructions for use, the provider failed to ensure medications were administered correctly during 1 of 18 medication passes. This failure resulted in an error rate of 5.5 percent (%) and affected sample patient #2. The findings were:

On 8/22/11 patient #2 was observed after requesting to use his/her Albuterol inhaler. This observation showed LPN #1 handed the inhaler to the patient then returned to the task she was performing before the resident requested the inhaler. The LPN did not instruct the patient on how to use the inhaler and she did not observe him/her using it. The patient correctly inhaled once at 5:15 PM, waited thirty instead of sixty seconds, and inhaled a second time. Review of the medical record showed two inhalations of Albuterol were ordered on an as needed basis, but a waiting period was not indicated. However, review of instructions on use of the medication showed the user should wait one minute between inhalations. Interview with the LPN at this time revealed she thought all patients knew they were to wait one minute between inhalations.

Based on medical record review and staff interview, the facility failed to ensure accurate documentation of information for 3 of 31 sample patients (#3, #11, #31) reviewed. The findings were:

1. Review of the medical record for patient #3 revealed the following concerns with documentation of restraints and seclusion on 8/17/11:
a. Refer to A-0184 for details regarding documentation of the required one-hour face-to-face evaluation.
b. RN #1 documented she notified the attending physician of the intervention on 8/17/11 at 4 PM. Review of information faxed by the facility and interview with the clinical director on 8/31/11 at 9:40 AM revealed the RN notified the physician appropriately, but did not document it in the record.

2. Review of the "Restraint/Seclusion Order/Record" forms dated 6/4/11 for patient #11 indicated chemical restraints were used, but the documentation was inaccurate as follows: The documentation showed a "now order" was not used; instead the words, "PRN order", were written beside "now order" and Ativan 2 milligrams (mg) intramuscularly (IM) PRN and Haldol 10 mg IM PRN were listed as the medications that were administered. Review of submitted information showed, and interview with the clinical director on 8/31/11 at 9:40 AM confirmed, these medications were not administered as chemical restraints but as a later intervention accepted by the patient to help him/her control his/her actions.
Further review of the medical record for patient #11 showed chemical restraints were again utilized on 6/18/11. The following inaccurate documentation was noted:
a. Orders were written at 4:15 PM for Haldol 5 mg IM PRN and Ativan 2 mg IM PRN. Interview with the clinical director on 8/31/11 at 9:40 AM revealed, and review of submitted information confirmed, these medications were not administered as chemical restraints but as a later intervention accepted by the patient to help him/her control his/her actions.
b. The "seclusion/restraint flow sheet" had been stamped with another patient's name. That patient's name had been crossed off, but patient #11's name was not written on the form.

3. Review of the restraint/seclusion order/record for patient #31 showed the patient had out of control behaviors on 7/14/11 which required a physical hold (restraint). Review also showed the patient received Geodon 20 mg IM as a chemical restraint. However, continued review of the form and interview with the DON on 8/25/11 at 5 PM revealed the Geodon was administered after the restraint episode as a physician ordered PRN medication and was not used as a chemical restraint.

Based on staff interview, the provider failed to ensure staff were educated on organ donation issues. The findings were:
During an interview on 8/24/11 at 10:13 AM, the director of clinical services was unsure if education related to organ donation issues had been provided for staff. However, she stated she would check with the organ procurement organization, to see if they had an attendance roster. After checking with the procurement organization, the director reported on 8/25/11 at 2:30 PM that there was no evidence of providing education for the staff.