Systemic Failures Added Up to Inability to Ensure Appropriate Seclusion and Restraint

The Centers for Medicare and Medicaid Services (CMS) found that The Vines Residential Treatment Center failed to meet the condition of participation that policies and procedures for restraint and seclusion must meet federal guidelines. CMS wrote, “the cumulative effect of the systemic failures resulted in the facility’s inability to ensure appropriate use of seclusion and restraint.” These “systemic failures” included the use of standing orders for seclusion or restraint, simultaneous use of seclusion and restraint, the absence of signed written orders for each instance of seclusion or restraint, a lack of assessments of residents following seclusion or restraint episodes, the lack of documented justification of the need for seclusion or restraint, failure to keep a cumulative log for all emergency safety situations, failure of staff involved in seclusion and restraint episodes to participate in debriefings related to the episodes, and inadequate training for staff in seclusion and restraint techniques.

All 15 staff records reviewed at the facility showed an absence of training in time out procedures. Six staff who were interviewed all had different understandings of time out. Additionally, 5 out of 12 staff had no documentation of demonstrated competency in restraint and seclusion before participating in an intervention of seclusion or restraint. 3 out of 12 staff had no record of the required semiannual demonstration of competency in restraint and seclusion. The Chief Nursing Officer confirmed that the facility did not require staff to demonstrate competency as part of their initial training and the Director of Human Resources said that the facility’s instructors in restraint and seclusion were new hires who were not aware of the requirement for semiannual demonstration of competency.

In order to correct the deficiencies found by CMS, the facility revised its Restraint and Seclusion policy, Restraint/Seclusion order form and Behavior Intervention Report to reflect the required procedures and documentation. The Chief Nursing Officer developed logs for restraint and seclusion and for time out. Training on the new policies and procedures was provided to all physicians, nurses and direct care staff, and auditing procedures were set up to monitor 100% of restraint and seclusion events. Management also developed new training modules that included demonstration of competency and provided the training to all direct care staff and nursing staff.