PM, I 3W .- 1211312013 DEPARTMENT 9F HEALTH AND HUMHN SEHWCES FORM APPREWED WWFE m} DATE WW STATEMENT oF accelerates on} 1x2) cowereuonorr mo em: or connection women: Bums commerce 0 ?129/20 i ii 11 L005 3mm? crew moose. om. once. are coco e34 need. we ATLANTA. GA 30306 we or: PREMDEH on some LAUREL HEIGHTS HOSPITAL PLAN OF CORRECTION SHOULB BE TO THE DEHBENGYJ BUNNY STATEDENT OF iD IE PHEEDED B'i? FULL REGULATORY OR LEG 60%? ?irt) PEEK TAB 003 3?3 000 initial Comments At the time of the curvey. Laurel Heights Hospital was not in compliance with Condition oi Participation 433.354 Sebpart 5: Condition of Participation for the Use of Restraint end in Reel-deeded Treatmeot Facilities Providing impatient Services for htdivmueie UnderAge 21 as reeuit cf the Investigation of complaint #GAthit 83904. This noncompliance caused serious harm to one it] of ten {10} ida'ltified sempied patients. (in ?mono at 2:45 pan. on immediate Jeopardy (Li) situation was identi?ed. The Leadership Team consisting of the Chief Operating Officer (CEO). the Director of Clinical Services (DDS). the Director of Human Resources the Medical Director the Dhector of ?3133de (D001. and a representative of UHS Corporation were informed of tl'tie id on et4115 pm. . matte On 11i29i1? at 10:15am, on Organization Plan emotion and Riot: Reduction Strategies was presented to the surveyors. The Pier; coreieted of the Action Item #1 dieoipiine actions for identi?ed staff directly involved in the incident be teiren to Include written cmnoeting up to tennineticn as determined appropriate pending the completion of the hweotigetice. Evidence of progressive r?st?pitne wiit be heinleined in personnel ?les. Completion date; 11372913. Update: One of the three (3) employees in the incident was terminated on The other two (2) staff remain on UPPUEFI SIGNATURE {x5} pea-E In a 1 Any deficiency ointment ending with an asterisk denotes a de?ciency which the inst?ultm may to from providing it is determined other safeguards provide eutticient protection to the patients. (See instructions; Except for nursing homes. the timings stated above are d?reoiceehte 90 days the date or survey mother or not a plan of correction provided. For riveting homes. theebove ?ndings end piano of carnation are deousaeta 14 days iong the date these documents erect-ode available to the iac?ity. 3 de?ciencies are cited. an approved plan of correction is requisite to continued more" DR PRO WW Mate Evmt Faciity to: If un?t-mating 9393 1 at 12 1? V'Iw?ww? ?at mm N000 Continued From page 1 suspension pending results of the investigation. Action tem#2 Direct care staff will be re-educaled on the facility protocols in conducting appropriate and adequate observation moods including limer observations, accurate documentation. and hand-off communication. Ito-education has been initiated on 11i21f16 and to he completed by 1210316. Staff perforrnence will be monitored through the senior leadership and observation round audits will be concluded in person and camera renew at a minimum of once per shift per unit per week. 112916 Update: in process. The Director of Operations (DOD) continues to provide education and obtain verbal counseling checklist (attached). Staff will be retrained on conducting appropriate and adequate observation rounds including timely observations. accurate documentationI and hand-off communication. Re-education will be conducted during each shift change meeting that is overseen by or designee. Will develop and utilize immediate counseling term for: Leadership Team and Otl'lers to use when doing Leadership Rounds. This will give immediate feedback to the employee and require a signature that the employee has been re-educated. The form will then be turned into HRiManager to determine the appropriate action to address. Date to complete all actions: 1211316. Action item #3 . - Direct care staff will be re-educated on the iacility . protocols regarding sta? dress codes and the presence of personal cell phones. Fits-education has been imitated on 11i21i16 and istc be completed by 1302MB. Staff compliance will be monitored through the senior leadership and 11L005 nos-oars NAME OF PROVIDER GR EIJPPIJER STREET ADDRESS, CITY. STATE. ZIP CODE 934 BRIAROLIFF ROAD. NE LAUREL HEIGHTS HOSPITAL ATLANTA. GA 30306 (are) STATEMENT OF DEFICIENOIES OF CORRECTION scat PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACT ION SHOULD BE GONE-HIGH TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 000 Event Facility ID 005 "continuation sheet Page 2 of 12 1 EU I u- -- h-4-I I ?uh-t! I II I'hl'l'l DI?!!th A 11L005 3-me camels NAME or PROVIDER OR SUPPLIER STREET ADDRESS. crrv. STATE. ZIP coca 934 BRIARCLIFF ROAD. NE LAUREL HEIGHTS H05 I AL ATLANTA. GA 30306 per) In summer STATEMENT OFOEFICIENCIEs to PROVIDER-s PLAN OF CORRECTION as; pears): MUST BE PRECEOEO BY FULL PREFIK (EACH CORRECTIVE ACTION SHOULD BE me REGULATORY CR TAG TO THE APPROPRIATE WE DEFICIENCY) 000 000 Continued From page 2 observation round audits will be conducted in person and camera review at a minimum of once per shilt per unit per week. 11129116 Update: In process. DOD continUes to provide education and obtain verbal counseling checklist (attached). Reviewed and provided a cepy of Dress Code and Guidelines for Professional Conduct. Professional Conduct Policy will be adopted and approved by Medical Executive committee and trained to all employees by 121121116. Action Item#4 Automated Extemal De?brillators (AEO) machine will be relocated to Unit 7. Nursing and direct care staff will be re-educated on the locations of medical equipment including the AED machine to be completed by 12111316. Update 11119116: AED machines were relocated to provide access to all staff on- 11i23i16. Education with staff began on 11123161 and is on track by 12.112116. Attestations w?l be housed in HR ?le. Action Item #5 Nursing and direct care staff will be re?educated on the facility protocols regarding noti?cation, response and sta? miss for and medical codes. Competencies wiil be documented and maintained in the personnel ?les. Re-edution to be completed by 12102116. Update 11i19i16: Two nurses per shift have been assigned to respond to code Blues including bringing RED and Emergency bag. Leadership Team will review and update Code 10 and Code Blue Policies to include evaluation of individual competencies for direct care employees. Will include a schedule of Code Blue drills OMS-256110249) Prevlous Versions Obsolete Ewmt 1 Faciity 1D: PRTFOllttilld "continuation-I sheet Page 3 of 12 IUEN I I IUN Hun-nous: I Ut" [Ul? i 11L005 em?? 11/29/2016 NAME OF 0R SUPPLIER smear ADDRESS. crnr. ZIP copE 934 BRIARCLIFF ROAD. NE LAUREL HEIGHTS HOSPITAL ATLANTA GA 30306 summer or DEFICIENCIES In Psovmse's PLAN OF CORRECTION 5 DEFICIENCY MUST ea PeachEo av FULL PREFIX (seer-I CORRECTIVE SHOULD BE mtg-gnarl neeumroar De Leo TAG. GROSS-REFERENCED To THE APPROPRIATE WE 000 000 Continued From page 3 and quarterly Code Ten drills and scenarios. Will review and update policy In Pl Educate Staff on updated policies by 1312116. Action Item#6 Unit 7 direct care staff will be re-aducated on the management of aggressive behavior techniques including Mindset and Verbal tie-escalation by 1316.115. Revised date of completion 1302116. 11128116: Critical Guidelines for Physicai intervention were reviewed with staff on duty and oncoming shifts. email 11130116 Update: All direct care staff will be re-edecated on the management of aggressive behavior techniques and Verbal [Jo-escalation by 01181117. Action item #7 A Performance improvement Team on the facility policies and practice regarding restraint and seclusion will be established by 11130l16. Team members wilt include the identi?ed senior leaders and direct care staff. 11f1 91'16 Update: Meeting is Scheduled with an array of team members from different departments for 1 1:30:16. Action item #8 Staff will be re-edueated regarding the prohibition of parking personal vehicles in identi?ed fire lanes. Ree-education to be completed by 121102116. 11f19f16: Email blast sent to sit employees. Announoe in shift change report. Identi?ed plant operations and Leadership Team to enforce non-compliance. Action item #9 Complete a thorcuh Investigation into reported Previous Versions Obsolete Event 1 ?me if continuation sheet Page 4 of 12 A. ?was 11129.!2016 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CUBE LAUREL HEI GSPITAL - 934 BRIARCLIFF ROAD. NE GHTS - I ATLANTA. on scene {it-i) 10 SUMMARY STATEMENT OF In PLAN OF CORRECTION g? PREFIX OEFICIENOY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTNE ACTION SHOULD HE TAG REGLLATORY OR LSC IDENTIFYING TAG CROSS-REFEREMSED TO THE APPROPRIATE DEFICIENCY) 000 Continued From page4 phone issues regarding access and dropped calls from Unit 7. ?none Update: Completed. Veri?ed that we have adequate capacity to manage all incoming and outgoing phone calls. - By submitting this Plan of Correction, the Action Item #1 0 Hospital does not agree that the facts alleged All staff will be roe-educated on the Critical are true or admit that it violated the rules. The Guidelines for Physical Intervention as well as Hospital submits this Plan of Correction to provided Mindset Handbook of Visual Depictions document the actions it has taken to address Of Appropriate Technique" of Physical Restraint. . the citations and the. allegation of de?ciencies Documentation will he maintained in personnel with respect to compliance with Conditions of ?les by minim: Participation for hospitals. Update: This process was started means The IJ was removed on 11129116 at 10:15 am. 100 100 483.354 USE OF RESTRAINT AND SECLUSION mm Support 3: Condition of Participation tor the Use of Restraint and Seclusion in The DON, Medical Director, and Director of Clinical Services Residential Treatment Facilities PI?OVidlng reviewed and revised the policy for Seclusion and Restraint Inpatient Services for Individuals {Policy it ensure inclusion of all of the Under Age Twenty One. requirements in the rule. The revised policy was approved by the Goveming Body on use 16. This CONDITION is not met as evidenced by: The elements of the revised policyr include (Tags 11-127; 128; Based on review of the tacil'rhrs policies and 132; 140; 145; 149; 150; 153; 154; 155; 156; procedures. medical records 0). employee - An order for restraint or seclusion must not be mitten as a {1135 Grademal ?les: 12 arid 13). standing orch or on an its-needed basis. ?manta P5 0f the Staff and Patient Restraint or seclusion must not result in harm or injury to the interviews. observations and review of facility residant seclusion and restraint data. it was determined . Mammy?), safety intervention must be pat-formed in a mat the faculty falied to ensure the Safe?! 0f a manner that is safe, proportionate, and appropriate to the severity Patient during a restraint resumn? in the death Oi of the behavior, and the resident's chronological and the patient. A Condition was cited at N-Ott'itl and developmental age; sin; gem?; physical, medical; and 9" Immediate was can? a? condition; and personal history (including any history 1 ?Edith at 4:15 pm. The facility provided an ofph?ical or sexual abuse)_ acceptable Credibie Allegation of Compliance on . Gris-2561mm) Previous Versions Obsolete Fac?ianD:PRTFOii1ii?? "continuation sheet Page 5 of 12 -l u. nut-uni ?Hun-nuns. 11L005 some illi29l2016 NAME ol= on sum:le smear ADDRESS, crrv. stars. are GDDE 934 BRIARGLIFF ROAD. NE LAUREL HEIGHTS HOSPITAL ATLANTA. GA 30306 (x4) ID SUMMRY STATEMENT til: DEFICIENCIES lD anomalies PLAN OF CORRECTION as] PREFIX DEFICIENCY MUST es PRECEDED sY ruu. connecnve ACTION SHOULD es trio. Rectum?on on Lee IDENTIFYING INFORMATION) TAG. CROSS-REFERENCED To tits APPROPRIATE WE DEFICIENCY) 100 loo Continued From page 5 I Orders for restradnt or seclusion must he a physician, :11 :23? :1 it 430'31? 13; 12;, ?If permitted by the State and the facility to order restraint or enc safety N-154. N-155. N-156, and N-165 resuited i? . I . EEFRLI I 51 . th In the Condition non-compliance to he made. lied?? mg.? 3mm? . . require at inpatient servrces for bene?ciaries under age 21 are - . provided under the direction of a physician: Findings were' - Within 1 hour ofttle initiation of the emergency safety . . . a I rd inhervention a physician, or trained in the use of emergency this safety interventions and penmttetthy the sbtaete and the .faClili]! to facility for evaiuation and treatment of various ?ig?r?lmg ?Wham? ?mpth and ?we? behav'm? welibeing ofthc resident, including but not limited Patient #1 was currently receiving intensive to . behavior therapy and multiple-efforts to increase ?111? ?Siam? and 1?53l'9h?91??gm?11 Stan?s; hisilher functional behaviors such as coping skills 2) The I I and communication since the time of admission 3) aPPumt?nBSS ?fth? Intervention measures; and three (3) years previously. Patient #1 was 4) Any complications resulting from the intervention. currently in the custody of the Department of Staff must document the intervention in the resident?s record. Family and Children Services That doomnentation must be completed by the end of the shin in which the intervention occurs. If the intervention does not end Review of the Nursing Progress Notes revealed during the shift in winch it began, documentation must be that on the day in question. the nurse was called completed during the shift in which it ends. Documentation must to assess patient #1 as the patient was include all of the following: agressive toward a peer as evidenced by patient 1) Each order for restraint or seclusion as required in paragraph #1 hitting a peer. Patient #1 required a physical . oft-111's section. "As stated in Each Order for hold/restraints 2 due to Nether aggressive . restraint et seclusion must include? through behavior. The nurse went into the medication emergency safety intervention curtailed,r mom to prepare a medication that was ordered including the length of time for which the physician Dt? other as needed for aggressiqu ?he? a "Code Blue" licensed practitioner permitted by the state and the facility to {an announcement ?at '5 ?sad for a order restraint or seclusion authorized its use" and cardiopulmonary [heartiiungs] arrest happening to associated Guidance. a patient in a hospital or clinic and requiring 2) The emergent?, safe?. sim??on that required the resident to team to to a location to begin resuscltettve be restrain DI Putin seclusion. 9mm) was announcad' The nurse ran to the 3) The name ofsta?'invoived in the emergency safety location and found that cardiopulmonary innervation. resuscitation (CPR) was being performed on 4) The facility must maintain a record Ofcach emergency sat-ct), patient 911 was nailed and CPR was situation, the interventions used, and their outcomes. continued until Emergency Medical Technicians (EMTs) arrived and took over the care of patient Previous Versions Obsolete Facility Io: PRTFotlt tics ltoontinuatim sheet Page at 12 . g?n I-ll . 11L005 all?? ll!29l2016 NAME OF UR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 934 BRIARCLIFF ROAD. NE LAUREL HEIGHTS HOSPITAL ATLANTA. GA scene (my to SUMMARY STATEMENT or to PLAN or common gs] PREFIX (EACH MUST es Peacenso ev FULL PREFDK (Elton SHOULD ea couFLE?noN no REGULATORY on Lee IDENTIFYING preeminent mo To THE APPROPRIATE WE 100 100 Continued From page Review of the TransferiEritergency Services Progress Note revealed that the patient became unresponsive with no breathing noted and that CPR was initiated. Patient#1 was transferred via ambulance to a local hospital. Efforts to resuscitate patient #1 were unsuccessful and the patient was pronounced deceased by the receiving hospital. An autopsy was pending with a possible diagnosis of aspiration. Review of patient #1's holdirestraint data revealed that for the previous two (2) months. patientit?t had four (4) holdsirestraints-one in September 2016 and three in October 2015 No previous holdsirestraints were present for November 2016. Review of the data from the two (2) holds that occurred on the day in question revealed that no physician orders or documentation of de?escalat'ron attempts were present. Review of the facility's policy and prooedme entitled 'Seclusion and Physical HoldiRestraint." Policy CRFM4109DW. revised revealed that it was the policy of the facility to utilize seclusion and physical holdireslraint only_ as the last resort in the presence of patient behaviors which are imminentiy threatening the safetyI of others or the safety of the patient Less restrictive interventions are attempted as soon as evidence of behavioral andlor verbal escalation occurs. Only when these early interventions tail andlor the patient has esleted so quickly as to be physically out of control is seclusion or physical holdlrestraint initiated. These emergency intervention procedures are never to be used as a means of coercion, discipline. retaliation or for the convenience of staff. All seclusion and physical holdsirestraints require an 5) The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must sign the restraint or seclusion order in the resident's record as soon as possible. 6) Document in the resident's record the date and time the team physician was consulted. 7) Clinical sts?? trained in the use of emergency safety interventions must be physically present, continually assessing. and monitoring the physical and well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention. Staff ?nancier: The Director of Nursing, Director of Risk Management. Director of Education. Therapeutic Foster Care. Chief Financial Of?cer. Director ofAdmissions, Director of Clinical Scnriocs, and Director of Operations or their began retraining all direct care staff, nursing staff, medical staff, and LIPs on revised policy [315115. Completion date is 12/25! 16. The following elements were emphasized during the rc-cducation: An order for restraint or seclusion must not be. written as a standing order or on an tie-needed basis. Restraint or seclusion must not result in harm or injury to the resident and must he used onlyr I An emergency safety intervention must be perfumed in a manner that is safc, proporti coats. and appropriate to the severity of the behavior, and the resident's chronological and developmental ago; size; gender; physical, medical, and condition; and personal history (including any history of physical or sexual abuse). - Orders for restraint or seclusion must be by a physician. permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient services for bene?ciaries under age 21 are provided under the direction of a physician. FORM Previous Versims Obsolete Event ?193511911 Faci?tr ID: "continuation street Page 7 oi 12 .33 I?ll-o IHJ new?idol. 11 L005 Wm? nail/told NAME OF PROVIDER on SUPPLIER STREET mosses. crr'r. STATE. ZIP LAUREL HOSPITAL 93" BRIARCUFF I m" NE ATLANTA. GA. 30306 my to SUMMARY STATEMENT OF in HAN or no Parale DEFICIENCY MUST BE er FULL (EACH CORRECTIVE ACT ION SHOULD BE mm? rite REGULATORY on Lac m3 To THE APPROPRIATE ?m 100 100 Continued From page 7 initial order from a physician; and if required. an extension from a physician. - Within 1 hour of the initiation of the emergency safety intervention :1 physician, or RN trained in use of emergency safety interventions and permitted by the state and the facility to assess the physical and wclihcing of residents. must conduct a face-tO-faoc assessment of the physical and wellheing ?fth: resident, including but not limitedl Emergency Safetyr Interventions (ESls) will be performed in a manner that is safe. proportionate, and appropriate to the severity of the behaviors. and the patient?s chronological and to I . . developmental age: size. gender. physical, 1} The resident's physical and status; medical and conditions and personal 23? Th5 ?s'd?im 5 history {including any history of phyeil or sexual 3) The appropriateness of the intervention matures: and abuse). Precautions should be taken to prevent a 4) All? resulting from the intm?n??n- pa?ent or staff from sustaining a physical gr - Staff must document the in the resident's record. during these emergency documentation must b3 sampletcd bytho Mid ofthe Shil? ill intervention procedurea Within 1_hom of the . which the intervention occurs. If the intervention does not end initiation of seclusion or physical hoidi?restraint. dining Shift in ?mail it began: menm?on mum hit the patient's physical and completed during the shift in which it ends. Doctunentation must well-being will be assessed by a physician or include all of the fattening: licensed professional. The patient's rights. 1} Order ?ll" ?strain! or 35 Tali?de in Paragraph dignity. safety. and wail-being will he maintained. of this section. "As stated in Each Order for 3. Manual Holdeestrain means the application restraint or seclusiOn must include? through of physical force. without the use Of any deitiesI - emergency safety intervention ordered, for the purpose of restricting the free movement including the length of time for which the physician or other of a patient?s body. licensed practitioner permitted by the state and the facility to order restraint or seclusion authorized its use? and associated All clinical staff employed at the facility receive Guidance. training in an approved ESI Course. Staff - 2) The emergencyr safety situatiOn that required the resident to consistently use these techniques to die-escalate be restrained or put in. seclusion. agitated or aggressive patient. Prior to seclusion 3} The name of sta??invoivcd in the emergency safety or physii restraint. all other methods of - intervention, depreciation principles and facility practice are 4} The ?mility must maintain a record of each mum-gem); safety ?5611- A refit??Sher training arid Gompet?nci' situatiOn, the interventions used, and their outcomes. easement are required twice a year for each . 5) The physician or otlter licensed practitioner permitted by the clinical Empl?vee- a state and the facility to Order restraint or secluSiOn must sign the i - - restraint or Order in the resident?s record as soon as Review of the incident 1.Iidao on 11l28f16 at 2:15 pmibia P-m- and 11?29?13 at 1&3? am- i" the 6] Document in the resident's record the date and time the team Conference Room: revealed that on 11:20:15 at Physician was consulted_ 12:11 pm. the patient Is noted to he in the hallwaylust outsid Of hisiher room where a table - 3'Oi?lhl Obsolete Event Tamil 1 Farm), In: pRTpum m5 mn?ma?m Shem Page 3 of 12 A. BUILDING 1 none Ills/2016 NAME OF PROVFDER 0R SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 934 eemncurr none. NE . LAUREL HEIGHTS Hos A GA 30306 (X4) ID SUMMARY STATEHENT OF DEFICIENCIEB ID PLAN DF g? PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BB 130 TAG REGULATORY DR LSG IDENTIFYING TAG TO THEAPPROPRIATE 100 Continued From page 3 was observed to have been placed. The patient was noted to struggle physilty with a staff member and the staff member was noted to be straddling the patient by sitting on the patient?s mldsection at 12:12:33. Another staff member was noted to be kneeling next to the patient at 12:12:43. At 12:13:33, observed approaching the two staff members and the patient. At 12:14:40 the MHA (#21 was seen getting off the patient. Continued review of the video revealed the MHA was noted to be en the patient's back with the patient facing the ground at 12:1?:23. The patient was noted to be struggling, and the MHA was seen holdln the patient?s arms above hisfher head. the MHA was observed to continue struggling with the patient while the patient remained face down until 12:20:01 when the MHA was observed turning the patient over. The patient appeared to be unconscious. The MHA appeared to be yelling and staff was noted to be running in the video. The MP and RN were observed running into the day room at 12:20:45. CPR was initiated at 12:21:03. The AED anived and was placed on the patient at 12:24:10. EMS arrived at 12:36:47, and the patient was transported out the day room by EMS at 12:45:15. During an interview with Director of Recreation Therapy (ORT, Employee and Mind Set Instructor on 11f28/16 at 3:11 pm. in the Conference RoomI the BET revealed that hefshe was a certi?ed Mindset Program (a physical restraint program used in crisis prevention} Instructor. The CRT stated that hefshe provides the staff with training for physical restraint holds and methods of de-esoalation used in the facility. The ORT stated that the correct way to administer a horizontal was to have no less than two (2) 7) Clinical sta??trsined in the use of emergency safety interventions must be physically present, continually assessing. and monitoring the physical and welt-beta of the resident and the safe use of restraint throughout the duration of the emergency safety intervention Monitoring 100% of restraintfseclusion documents are monitored by the Director of Risk or designee to cosine that all elements are correctly completed within 24 home. Any variation in practice will result in additional training andior disciplinary action up to and including termination. Aggregate date is reported to the Quality Council and Medical Executive Committee and Governing Board quarterly. Besgonsible Barons Director of Nursing; Risk Manager; Director of Clinical Services; Director of Operations; Medical Director 101] We! All facility staff were J's-educated on Critical Guidelines for Physical Intervention, which included a review of commrmication skills, protective skills, and therapeutic holds. The review provided Mindset Handbook of Visual Depictions of Appropriate Technique of Physical RestraintI as well as, included the following: 1. Use Communication ?rst. Communication is the ?rst and least restrictive approach towards preventing aggression. 2. Only use a physical restraint or hold as a last resort when the child is: a. ?aming themselves it. Hamlin someone else c. There is a high probability of harm if not physically prevented FORM Predoustierstons Obsolete Event 1 Facililr iD: If continuation sheet Page 9 at 12 tut?dun runl Itut?l?llulun. bUll'll'Ll: EU 11 L005 linoleum NAME or PROVIDER on SUPPLIER srneernooness. cri'v. STATE. ZIP cone 934 anthems-?F ROAD. NE LAUREL HEIGHTS HOSPITAI. ATLANTA, GA 30306 (x4; is SUMMARY STATEMENT or- DEFICIENCIES Pact/loans PLAN or CORRECTION PREFIX (EACH DEFICIENCY war as Pneceoao av FULL Pearls (EACH ACTION snoum ea con?nes m; REGULATORY on Lee msoeunnou] TAG cacas-aaraeenceo To THE WE 100 100 Continued From page 9 staff members administering the hold. The DRT further stated that the patients breathing, airway. and simulation were to be monitOred at all times while the patient is in a hold. The DRT stated that the patient was to be placed laterally (on hisiher side) while on the ground or floor. The DRT stated that holding a patient in a face-down position was contraindicated as it could cause undue pressure to the chest and abdomen and restrict resplrations. The DRT stated that it a patient verbalized or indicated in any way that they were havin dif?culty breathing, the staff member was to release the patient immediately. The DRT also stated that there would never be a situation that would justify a patient being held facedown and straddled. The DRT further stated that all staff receive a two (2) day. fourteen (14) hour full course on physical holds and tie-escalation. and that all employees received a slit month refresher course that was approximately four and a half hours. The DRT stated that a six hour annual training Is also given. The DRT added that the testing included a demonstration and a written test. and if any staff member needed further instruction or practice. it was always offered during the courses. During the course of the interview, the DRT was asked to view the video of the incident for the ?rst time. which the DRT agreed to do. The following portion of the interview was conducted after the . viewing of the interview. When asked ifthe MHA should have straddled the patient with hisfher weight, the DRT stated that placing weight on the patient was not appropriate. When asked the DRT explained that placing weight on the patient in that way could constrict the patient?s breatl'Ilng 3. Whenever possible, avoid going to the ?oor with a child and never use a horizontal restraint without assistance: Going to the ?oor without assistance increases the probability of injury for staff and the child. 4. Never intentionally in?ict harm andfpain onto a child-avoid using paint 0 maintain a restraint. - Any use of pain or joint pressure can result in physical and injury to the child and will reduce trust. It teaches that it is acceptable to in?ict pain to get results. 5. Communicate to the child that you are trying to keep them safe. 6. Never place a towel, blanket, or other covering over a child's head during a hold. It can interfere with breathing. Never lie on top of a child is: avoid provocative body positions: putting your weight on a child can constrict breathing and it can rc-Irauntatizc. Never hold a child between the legs or have any type of genital contact. 3. Never hold a child?s bead still dining aphysical restraint. The sentinel spine can be injured. 9. Never place your elbow, kites, or foot onto any part of a child?s body when holding them on the floor. Never rest your entire body weight on a child when trying to contain them on the floor. 10. During a physical restraint, always monitor the child?s: - Circulation or skin color - Respiration or breathing - Any other signs of physical distress *If there is physical distress. .ADIUST or RELEASE THE HOLD 11. Do not threaten, or try to discipline a child during a physical restraint; 12. Avoid engaging in general conversation with co-workers during a physical restraint; the focus should be on helping the child regain control can coarsening-es) Previous Versions Obsolete Evehll?t'l??Wl?: Facilinri?: If continuation sheet Page 10M ?12 nil-4 II I our? lUl'I II I EU ABUILDING 11 L005 3mm? ?ail/2016 ems on success smear ADDRESS. crrv. sure 21? coca LAUREL HEIGHTS HOSPITAL 934 Rom ATLANTA. GA 30306 on) ID sunmev STATEMENT or In Pnovnsn's mm or: CDRHECTIDN eEFtcusncv user as PRECEDED av FULL rasax (EACH connecer Adrien secure as con?rm TAG REGULATORY 0R L50 IDENTIFYING TAG CROSS-REFEREQCED TO THE APPROPRIATE WEE 100 100 Continued From page 10 taff Education and cause undue inlury to in patient. The DRT added that the MHA should never have approached the patient alone. and the MHA should have asked for assistance. When asked If MHA was holding the patient correcting while administering a horizontal hold. the MHA indicated the hold was not done correctly or appropriately. When asked why the DRT stated the MHA should have never been on the patients baclt. When asked why the DRT indicated the weight at the MHA could cause undue injury to the patient and restrict breathing. The DRT stated that the staff has been taught to release the patient if the hold cannot be applied correctly. The DRT added that the staff members who were observing and assisting the hold should have alerted the MHAthat the hold was not being handled correctly. During an interview with the Director of Nursln (DON) on 1 ozone at 1:55 p.rn. In the . Conference Room, the DON revealed that the ?rst time the patient was restrained at approximately 12:11 pm. on 11i20i16. no MD order for the restraint was obtained due to the ongoing situation with the patient. The DON stated that a?er second restraint hold in the day room. the RN was trying to get a medication to administer to the patient. and a code blue was called. The DON stated that subsequently. an order for the resh'aintwas never obtained. During an interview with the MD on 1 1&the Conference Room. the MD stated heishewas informed about the . restraint afterthe incident, butthe MD stated lie/she had never been called about obtaining an order for the restraint. The MD explained that orders that needed to be signed were placed in hisiher box. When asked if the MD had received any paperwork regarding the restraint for the I Unit 7 direct care staff were rc-educated by Codi?ed Mindset Instructors on the management of aggressive behavior techniques including the review of communication protective skills, and therapeutic holds, as well as, verbal dc- escalation. Mindset Skills Assessments were reissued. Unit ?3 retaining was completed as of 1217! 16 100% of active facilityr staff has been re-edncatcd on the Critical Guidelines for Physical Intervention, as well as, provided Mindset Handbook of 1 it"isual Depiction: of Appropriate Technique of Physical Restraint as of 12316116. Monitoring Certi?ed Emergency Safety Intervention Instructors or dcsignce will review 100% of physical holds that are viewable on surveillance camera to review correct use of trained techniques. identi?ed as not meeting standards for correct tochniquc will be provided additional training in individual or group settings. Ongoing non-compliance will be addressed through disciplinary action up to and including Aggregate data is reported to the Quality Council, Medical Executive Committee and quarterly to the Governing Body. Responsible Persons Director of Nth-sing; Risk Manager; Director of Clinicnl Services; Director of Operations; Certi?ed Emergency Safety Intervention insuuctors PrevlottsVerslonsOhcoiete Eusntl'DJ?BWli "continuation sheet Page 11 of 12 IFIUH I M'l Humuun. I m? A BUILDING I 11 L005 1112912015 NAME OF PROVIDER 0R SUPPUER STREET ADDRESS. CITY. STATE. ZIP CODE - 934 BRIARCLIFF ROAD. NE LAUREL HEIGHTS HOSPITAL ATLANTA. GA 30306 {it-I511!) SUMMARY STATEMENT CIF GEFICIENCIES PLAN OF CORRECTION g5] PREFIX DEFICIENCY MUST BE FREDEDED BY FULL GORREGTWE ACTION SHOULD BE TAG REGULATORY DR L5G lDENTIF?t'lith TAG TO THE APPROPRIATE DEFICIENCY) 100 bl 100 Continued From page 11 patient on 11I2iDi16, the MD stated helshe had not Review of the videotape and Interview with the Mindset instructor (employee during the viewing of the videotape revealed that the hoidsirestraints on the tiavr in question with patient #1 were done incorrectly. The facility was unable to tell the surveyors how often or even if the videos of the milieu were reviewed on a regular basis in order to assure that the holdairestreinte perfom'ied by the staff were done properly. Review of the employee ?les revealed that all employees involved In the incident had received holdlrestraint training according to the facility?s policy, but the facility failed to monitor whether staff were performing those according to their Mindset training. - ens-2557:0299) Previous Versions Obsolete Evan: mam-I1 Ifoontinuation sheet Page 12 at 12