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Based on record reviews and interviews, the facility failed to ensure the physician documented the basic requirements during evaluation of the one-hour face to face assessment after the initiation of the interventions for 2 of 5 patients' (Patient #4 and #13) reviewed with documented personal/physical restraints.

Specifically, Patient #4 and #12's face to face evaluations completed by Physician A failed to contain the required documentation during the evaluation, as following;
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

Findings included:

Review of the facility's standard operating procedure: C-18, revised 05/18 titled, "Restraint or Seclusion as Behavioral Intervention" indicated the following in part;
Page 2, procedures for the Physician Evaluation of the Patient in Restraint of Seclusion indicates the physician performs a "face-to-face evaluation" of the individual to determine the necessity for the behavioral restrain/seclusion order and document in the medical record. The physician ordering the restraint or seclusion must conduct a "face-to-face evaluation of the patient no later than one (1) hour after restraint or seclusion is initiated. The name of the physician and the time this evaluation is conducted is noted in a Progress Note.

Further review of the procedures revealed there was not any further specific guidelines to ensure the evaluation of the patient included the following basic requirements:
1.) the patient's immediate situation,
2.) the patient's reaction to the intervention,
3.) the patient's medical and behavioral condition, and
4.) the need to continue or terminate the restraint or seclusion.


Review of Patient #4's restraint records revealed the following:

Physician A's face to face assessment/progress note dated 7/17/18 at 08:05 AM indicated the following documentation:
"Became aggressive and could not be redirected. Placed in restraint as LRA [least restrictive alternative]. Seen F2F [face to face] 0330."
The face to face assessment did not contain all of the required documentation during evaluation.

Review of Patient #12's restraint records revealed the following:

Physician A's face to face assessment/progress note dated 12/10/18 at 08:06AM indicated the following documentation:
"Became aggressive and could not be redirected. Placed in restraint as LRA [least restrictive alternative]. Seen F2F
[face to face] 1500." No injuries noted. Attending notified."
The face to face assessment did not contain all of the required documentation during evaluation as specified above in the regulatory requirement.


During an interview on 12/11/18 at 09:50 AM with the Quality Management Registered Nurse (QM/RN) confirmed the above findings for Patient #4 and Patient #12's restraint documentation completed by Physician A. The QM/RN stated these similar concerns had been identified during internal audits and this physician had been notified of the required documentation necessary for face to face assessment evaluations. The QM/RN stated the facility may need to designate a template to ensure all the required elements of the face to face assessment were thoroughly documented by the physician.

Based on observation, interview, and record review the hospital failed to meet the requirement to ensure the facility and equipment were maintained to ensure an acceptable level of safety and quality.

Specifically;
1.) The Pharmacy had laminate counter tops that were chipped with exposed wood.
2.) The Pharmacy also had chipped and missing pieces of floor tiles.
3.) The Physical Therapy area had a physical therapy mat that was taped to cover a tear in the mat.
4.) The adolescent unit had floor drains in the bathroom that were clogged with standing water.
5.) The adolescent unit's clean linen storage for patients had clean linen lying in a room on a bench uncovered and unprotected.

Findings included:

During a tour of the Pharmacy department on 12/11/18 at approximately 9:45 a.m. revealed the following:

1.) Missing pieces of countertop laminate, revealing particle board underneath. The countertops were not wipeable surfaces to minimize on infection control.

2.) Chipped and missing pieces of floor tiles throughout the pharmacy.

Interview on 12/11/18 with the facility Assistant Director of Nurses confirmed the above findings.


During a tour of the physical therapy department on 12/12/18 at approximately 10:00 a.m. revealed the following:

3.) A physical therapy mat had tape covering a possible tear in the mat. The edges of the tape were sticky and had fuzzy particles sticking to those edges. The mat was no longer a wipeable surface to minimize infection control.


Interview on 12/12/18 with the facility Director of Rehab Services confirmed the above findings.

During a tour of the bathroom area of the adolescent unit at 10:15 am on December 12,2018 the following was observed:

4.) One of the floor drains in the bathroom was clogged and standing water was notice on that drain area. Towels which were soaked were around the drain to keep the water from flowing out into a general area.

During a tour of the clean linen storage area of the adolescent unit at 10:05 am on December 12, 2018 the following was observed:

5.) The clean linen for patient use was lying in a room on a bench uncovered and unprotected from dust; environmental/industrial contaminants.

Interview with the Nurse Manager (RN) of the adolescent unit during the tour of the area at both 10:05 am and 10:15 am on December 12, 2018 confirmed the above findings, and this surveyor was told that there was a work order request made to maintenance about the stopped up drain in the bathroom. Staff member could not explain when the call was made or if this was a continuous problem. Later it was verified by maintenance staff that a work order for the drain was not reported before the time of this survey.

Further interview with the nurse manager explained that clean linen storage was centrally stored on the 2nd floor of the adolescent unit and brought downstairs to the patient area and placed in this room. The nurse manager could not give an explanation of who or why the linen was placed uncovered in the room that was toured. No evidence was provided that this requirement was met in these two findings.


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