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Based on personnel record review, interview, and policy and procedure review, the facility failed to provide an ongoing training program specific to abuse and neglect with related requirements including prevention, intervention, detection, and patient protection from abuse during an investigation for 5 of 5 randomly selected personnel, Staff B, C, D, E and F.

Findings:

Review of the personnel record for Staff B, Therapist showed date of hire 9/20/2018. There was no documentation in the record to show Staff B had completed the required training in abuse and neglect.

Review of the personnel record for Staff C, Mental Health Technician (MHT) showed date of hire 8/20/2018. There was no documentation in the record to show Staff C had completed the required training in abuse and neglect.

Review of the personnel record for Staff D, Registered Nurse (RN) showed date of hire 8/16/2018. There was no documentation in the record to show Staff D had completed the required training in abuse and neglect.

Review of the personnel record for Staff E, Housekeeping Aide showed date of hire 10/29/2018. There was no documentation in the record to show Staff E had completed the required training in abuse and neglect.

Review of the personnel record for Staff F, Driver showed date of hire 10/17/2018. There was no documentation in the record to show Staff F had completed the required training in abuse and neglect.

During an interview with Staff J, Human Resource (HR) Director on 11/1/2018 at 3:45 PM she stated and confirmed that Staff B, C, D, E and F did not have evidence of abuse and neglect training in their personnel files. The HR Director stated she is new in her role and the job was just thrown at her. The HR Director failed to provide a signed orientation check list showing Staff B, C, D, E, and F had completed training in abuse and neglect.

Review of Staff/Patient Boundaries policy and procedure showed an effective date of 4/2007 on page 1 of 5 of the policy it read: During employee orientation, all staff are provided education on appropriate staff/patient interactions and maintenance of professional boundaries. Under letter D read: Springbrook Hospital believes that all patients in its facilities deserve to stay in a safe and protected environment, free from any form of abuse, neglect and misappropriation of property.