HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training for one (1) of five (5) nursing staff who were involved in patient restraints (Patient 3R).

Findings:

Stephen Memorial Hospital's "Restraint and Seclusion Program" policy, last reviewed 07/2023, states in part, "All staff who are involved with the application of a restraint, implementation of seclusion, providing care for a patient in restraint or seclusion, or with assessing and monitoring the condition of the restrained or secluded patient, will receive training based on their duties and responsibilities, initially (prior to performing restraint application) and on an ongoing basis by individual site policy".

1. Registered Nurse ("RN") #1 was involved in the care of the following patient who was restrained:

- Patient 3R was in restraints from 11:11 PM on 1/24/2023 through 6:07 AM on 1/25/2023.

The surveyor requested to review RN #1's training records.

As of 9/12/2023, there was no evidence provided to the surveyor that indicated RN #1 had completed the eLearn and Hands-On training on restraints that is required per hospital policy.

On 9/12/2023 at 11:00 AM, the Clinical Educator confirmed this training requirement for all nursing staff.

On 9/12/2023 at 1:30 PM, the Senior Director of Quality and Safety confirmed that there was no documentation of RN# 1's restraint training.