11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at N/A N/A 100% 100% N/A 100% appropriate intervals and signed by RN? Baseline 1Q 2Q 3Q 4Q Data Elements YTD Target 4Q2016 2017 2017 2017 2017 12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is N/A N/A 75% 100% N/A 88% time ended for S/R completed and signed by RN 13. On Form #407 Seclusion & Restraint Monitoring and Assessment 15 minute checks are completed at appropriate intervals, N/A N/A 100% 100% N/A 100% with Pt’s behavior documented in behavioral terms as it pertains to release criteria, times, dated, and initialed by staff? 14. On Form #407 Seclusion & Restraint Monitoring and 100% Assessment did each staff member N/A N/A 75% 0% N/A 36% that initialed 15 minute checks complete last page of form with signature and title? 15. Were debriefings DB1 & DB2 completed at appropriate times? 99% 89% 96% 99% 100% 96% 16. Is patient debriefing in the chart? 89% 93% 94% 99% 100% 97% 19. Was Form 470 TX Focused Treatment Plan Review completed 88% 91% 92% 95% 93% 93% within 24 hours? Overall Compliance 93% 92% 94% 89% 96% 93% Data Analysis: Baseline data compiled August 2015, with updates to Seclusion and Restraint procedure, forms, and audit tool occurring since that time. The 1Q2017 showed a compliance rate of 92%, a 1% decrease from 4Q2016 and a 4% increase from baseline. Four elements increased and 4 elements decreased with negligible statistical impact. The 2Q2017 shows an overall compliance of 94%, a 2% increase from 1Q2017 and 6% above baseline. Seven elements increased while none decreased. The 3Q2017 shows an 89% overall compliance, a 5% decrease from 2Q2017 and 3% above baseline. Four elements increased, three
11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN? N/A N/A 100% 100% N/A 100% Target Data Elements Baseline 4Q2016 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 100% 12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN N/A N/A 75% 100% N/A 88% 13. On Form #407 Seclusion & Restraint Monitoring and Assessment 15 minute checks are completed at appropriate intervals, with Pt’s behavior documented in behavioral terms as it pertains to release criteria, times, dated, and initialed by staff? N/A N/A 100% 100% N/A 100% 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? N/A N/A 75% 0% N/A 36% 15. Were debriefings DB1 & DB2 completed at appropriate times? 99% 89% 96% 99% 100% 96% 16. Is patient debriefing in the chart? 89% 93% 94% 99% 100% 97% 19. Was Form 470 TX Focused Treatment Plan Review completed within 24 hours? 88% 91% 92% 95% 93% 93% Overall Compliance 93% 92% 94% 89% 96% 93% Data Analysis: Baseline data compiled August 2015, with updates to Seclusion and Restraint procedure, forms, and audit tool occurring since that time. The 1Q2017 showed a compliance rate of 92%, a 1% decrease from 4Q2016 and a 4% increase from baseline. Four elements increased and 4 elements decreased with negligible statistical impact. The 2Q2017 shows an overall compliance of 94%, a 2% increase from 1Q2017 and 6% above baseline. Seven elements increased while none decreased. The 3Q2017 shows an 89% overall compliance, a 5% decrease from 2Q2017 and 3% above baseline. Four elements increased, three
4Q2017.docx