14. On Form #407 Seclusion & Restraint Monitoring and Assessment did each staff member that initialed 15 61% 68% 68% minute checks complete last page of form with signature and title? 15. Were debriefings DB1 & DB2 completed at 100% 83% 83% appropriate times? 16. Is patient debriefing in 75% 100% 100% the chart? 19. Was Form # 470 TX Focused Treatment Plan 86% 83% 83% Review completed within 24 hours? Overall Compliance 85% 89% 89% First quarter FY2017 comparison to fourth quarter FY2016 (new baseline) shows Data Analysis: a 4% increase; 6 elements increased, 4 elements decreased, and 2 stayed the same. There were 89%; 10 total seclusion events this quarter with totals of July: Knox 1, Hamlin 1, Chamberlain 1, for a total of 3; August: Knox 0, Hamlin 0, and Chamberlain 2, for a total of 2; September: Knox 4, Hamlin 1, Chamberlain 0, for a total of 5. Unit totals for 1Q2017 overall compliance are: Know 83% with 5 events, Hamlin 96% with 2 events, and Chamberlain 90% with 3 events. Action Plan: Nursing staff remains below goal and will continue to audit the documentation of patient seclusions on a monthly basis and re-evaluate quarterly and yearly. Nursing
14. On Form #407 Seclusion & Restraint Monitoring and Assessment did each staff member that initialed 15 minute checks complete last page of form with signature and title? 61% 68% 68% 15. Were debriefings DB1 & DB2 completed at appropriate times? 100% 83% 83% 16. Is patient debriefing in the chart? 75% 100% 100% 19. Was Form # 470 TX Focused Treatment Plan Review completed within 24 hours? 86% 83% 83% Overall Compliance 85% 89% 89% Data Analysis: First quarter FY2017 comparison to fourth quarter FY2016 (new baseline) shows 89%; a 4% increase; 6 elements increased, 4 elements decreased, and 2 stayed the same. There were 10 total seclusion events this quarter with totals of July: Knox 1, Hamlin 1, Chamberlain 1, for a total of 3; August: Knox 0, Hamlin 0, and Chamberlain 2, for a total of 2; September: Knox 4, Hamlin 1, Chamberlain 0, for a total of 5. Unit totals for 1Q2017 overall compliance are: Know 83% with 5 events, Hamlin 96% with 2 events, and Chamberlain 90% with 3 events. Action Plan: Nursing staff remains below goal and will continue to audit the documentation of patient seclusions on a monthly basis and re-evaluate quarterly and yearly. Nursing
1Q2017.docx