- Complaint #AR000029294 was in compliance.
- Regs out of compliance –
- N134 – Failed to ensure that a physician’s order for a physical restraint was obtained and documented for 1 client.
- POC – All nursing employees will be re-educated by the DON on ESI documentation standards, ESI packets will be reviewed daily, facility will report ongoing compliance rates during daily leadership meeting, and a physician’s order was obtained and documented on 12/19/22 for client 1.
- A revisit was conducted on 03.30.23, and the facility was still not in substantial compliance with the following participation requirements:
- N142 – Facility failed to ensure an order for a physical and chemical restraint was not received at the same time for 3 clients and a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- POC – Facility will conduct mandatory re-education in-service for all RNs and LPNs led by the DON (ESI Documentation, Obtaining and Documenting Physician Orders, Physician Transcribing and Authentication Policy, ESI Policy). Daily chart audits will be conducted, DON will discuss daily compliance rate in Quality/Safety Meeting, and compliance rates will be documented/submitted in monthly Quality Patient Dashboard.
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PRLU or OLTC
Complaint Survey with POC, Revisit Survey with POC