The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

THEDACARE REGIONAL MED CTR - NEENAH 130 2ND ST NEENAH, WI 54956 July 16, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure there was a face to face documented within 1 hour of initiation of restraint in 4 of 7 restraint medical records reviewed (Patient #'s 1, 3, 4, & 10) in a total universe of 10 inpatient behavioral health records reviewed.

Findings include:

Patient #1 was admitted on [DATE] after attempted overdose. A physical restraint (4 point leather) and locked seclusion was ordered on [DATE] at 10:45 AM discontinued at 11:45 AM, restarted at 12:30 PM, and discontinued at 2:00 PM. There was a "progress note" completed by physician on 3/2/2019 at 12:40 PM. On 3/3/2019 restarted at 11:00 AM, discontinued at 2:00 PM. The chemical restraint was started on 3/2/2019 at 11:00 AM and discontinued at 11:50 AM, restarted at 1:10 PM and discontinued at 2:00 PM. On 3/3/2019 restarted at 10:13 AM. There was no documented face to face assessment completed by a physician within 1 hour of initiation of physical/chemical restraint and seclusion.

Patient # 3 was admitted on [DATE] with an admitting diagnosis of bi polar disorder. A chemical restraint was ordered on [DATE] at 8:43 AM, 2:20 PM and 5:20 PM. There was no documented face to face assessment completed by a physician within 1 hour of initiation of restraint/seclusion.

Patient # 4 was admitted on [DATE] with an admitting diagnosis of mania. A physical restraint was administered on 6/11/2019 at 10:34 PM. There was no documented face to face assessment within 1 hour of initiation of chemical restraint.

Patient # 10 was admitted on [DATE] with an admitting diagnosis of mania. A chemical restraint was administered on 6/25/2019 at 8:30 AM. There was no documented face to face assessment within 1 hour of initial of chemical restraint.

The above findings were confirmed in interview with Regulatory Manager C and Director of Nursing D on 7/15/2019 at 4:15 PM who, when asked expectation documentation stated "There should be a physician note being done when face to face is completed after restraint is started."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure there was a documented face to face within 1 hour after the initiation of a restraint/seclusion that included patient's immediate situation, patient reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint/seclusion in 4 of 7 restraint medical records reviewed (Patient #'s 1, 3, 4 &10) in a total universe of 10 behavioral health records reviewed.

Findings include:

Patient #1 was admitted on [DATE] after attempted overdose. A physical restraint (4 point leather) and locked seclusion was ordered on [DATE] at 10:45 AM discontinued at 11:45 AM, restarted at 12:30 PM, and discontinued at 2:00 PM. There was a "progress note" completed by physician on 3/2/2019 at 12:40 PM. On 3/3/2019 restarted at 11:00 AM, discontinued at 2:00 PM. The chemical restraint was started on 3/2/2019 at 11:00 AM and discontinued at 11:50 AM, restarted at 1:10 PM and discontinued at 2:00 PM. On 3/3/2019 restarted at 10:13 AM. There was no documented face to face assessment including patient's immediate situation, patient reaction to intervention, medical and behavioral conditions and the need to continue or terminate intervention completed by a physician within 1 hour of initiation of chemical restraint.

Patient # 3 was admitted on 4/28/2019 with an admitting diagnosis of bi polar disorder. A chemical restraint was ordered on [DATE] at 8:43 AM, 2:20 PM and 5:20 PM. There was no documented face to face assessment including patient's immediate situation, patient reaction to intervention, medical and behavioral conditions and the need to continue or terminate intervention completed by a physician within 1 hour of initiation of chemical restraints.

Patient # 4 was admitted on [DATE] with an admitting diagnosis of mania. A physical restraint was administered on 6/11/2019 at 10:34 PM. There was no documented face to face assessment including patient's immediate situation, patient reaction to intervention, medical and behavioral conditions and the need to continue or terminate intervention completed by a physician within 1 hour of initiation of chemical restraint.

Patient # 10 was admitted on [DATE] with an admitting diagnosis of mania. A chemical restraint was administered on 6/25/2019 at 8:30 AM. There was no documented face to face assessment including patient's immediate situation, patient reaction to intervention, medical and behavioral conditions and the need to continue or terminate intervention completed by a physician within 1 hour of initiation of chemical restraint.

The above findings were confirmed in interview with Regulatory Manager C and Director of Nursing D on 7/15/2019 at 4:15 PM who, when asked expectation of care plan documentation stated "There should be a physician note being done when face to face is completed after a restraint is started."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure there was modification of inpatient plan of care to reflect the use of restraint/seclusion in 5 of 7 restraint medical records reviewed (Patient #'s 2, 3, 4, 9 & 10) in a total universe of 10 behavioral health records reviewed.

Findings include:

The facility document titled "Restraints (Non-behavioral and Behavioral)" #838 last reviewed on 11/6/2018 was reviewed on 7/15/2019. This document revealed "7. Monitoring and Reassessment: Documentation-Initiate/review Individualized Care Plan."

The facility document titled "Documentation/Charting" #647 last reviewed 7/26/2018 was reviewed on 7/15/2019. This document revealed "PATIENT CARE PLAN: The Registered Nurse is accountable to initiate care plan(s) for the nursing discipline, and update the care plan(s) as patient needs change, which include the elements of assessment, diagnosing, planning, intervention, and evaluation. Accountability for completing goal evaluations, as they apply to the Patient Care Plan, rests with the entire interdisciplinary team working with the patient. The Registered Nurse is accountable to complete goal evaluations for the nursing discipline every shift and as needed as patient condition warrants."

Patient # 2 was admitted on [DATE] with an admitting diagnosis of agitation and paranoid behaviors. A chemical restraint and 4 point leather physical restraint was ordered on [DATE] at 8:30 PM. There was no documented addition to the care plan for the use of chemical and physical restraint.

Patient # 3 was admitted on [DATE] with an admitting diagnosis of bi polar disorder. A chemical restraint was ordered on [DATE] at 8:43 AM, 2:20 PM and 5:20 PM. There was no documented addition to the care plan for the use of restraint/seclusion.

Patient # 4 was admitted on [DATE] with an admitting diagnosis of mania. A chemical restraint was administered on 6/8/2019 at 1:08 AM, 4:20 AM and 10:36 PM. There was no documented addition to the care plan for the use of chemical restraint.

Patient # 9 was admitted on [DATE] with an admitting diagnosis of Psychosis. A chemical restraint was administered on 5/21/2019 at 4:50 PM and on 5/22/2019 at 8:10 AM. There was no documented addition to the care plan for the use of chemical restraint.

Patient # 10 was admitted on [DATE] with an admitting diagnosis of mania. A chemical restraint was administered on 6/25/2019 at 8:30 AM. There was no documented addition to the care plan for the use of chemical restraint.

The above were confirmed in interview with Regulatory Manager C and Director of Nursing D on 7/15/2019 at 4:15 PM who, when asked expectation of care plan documentation stated "They should be putting a care plan problem on every time a restraint (physical or chemical) is initiated."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure there was a written physician order for the use of restraints in 1 of 7 restraint charts reviewed (Patient #8) in a total universe of 10 behavioral health medical records reviewed.

Findings include:

The facility document titled "Restraints (Non-behavioral and Behavioral)" number 838 last reviewed 11/6/2018 was reviewed on 7/15/2019. This document revealed "Order requirements: a. An order must be obtained for each restraint episode. b. PRN or Standing orders for restraints are NOT acceptable. c. The RN may initiate the restraint in an emergency but the physician's order must be obtained IMMEDIATELY. d. Consulting providers, along with attending provider, can renew a restraint order."

Patient # 8 was admitted on [DATE] with an admitting diagnosis of depression without suicidal ideation. A "Progress Note" completed by Physician G on 5/9/2019 revealed "Since [he/she] threatened staff with physical harm and said, "I will take all of you on." After this comment was made, I gave the order to administer injections with a physical hold necessary." There was no written physician order documented for the use of physical hold and chemical restraint on 5/9/2019 at 10:08 AM.

The above finding was confirmed by Manager of Regulatory C on 7/16/2019 who stated "the only order" was documented in physician progress note.