HospitalInspections.org

Based on observation, interviews and documentation review, it was determined the facility failed to taken actions aimed at measuring its success in training and assessing competency of staff who conduct small group therapeutic activities for two (2) of two (2) patients, Patients #1 and #2 .

The findings include:

The therapy schedule for two (2) patients, Patients #1 and #2, were reviewed at various times on 2/27/18 and 2/28/18. The schedule included such activities as; goals group, small group, anger management, active listening personal strengths, problem solving and self-esteem. The Director of Nursing stated, "The groups are ran by nurses or behavioral counselors. The nurses could be RN's or LPN's (registered nurses or licensed practical nurses). The groups are all over seen by the charge nurse."

Both the Chief Executive Officer and the Director of Nursing stated, "The staff receive training on hire related to conducting groups with the patients and then go through competencies every year."

On 2/27/18 at approximately 11:20 A.M. Patient #2 was observed on the unit with three (3) other people sitting at a table. Two of the three were patients and they were painting each others' nails. Patient #2 was observing not participating in the activity. Per Patient #2's schedule, this was "Small Group" time.

Patient #2 was interviewed on 2/27/18 at approximately 11:25 A.M. and stated, "There is a lot of downtime here. I don't need downtime it gives me time to think. I need more therapy not time to think. I have group therapy once per day and Individual therapy for 30 to 45 minutes two times per week."

Review of Patient # 2's schedule shows group therapy is 45 minutes Monday through Friday and 45 minutes on Sunday. Patient #2 was admitted on 1/29/18 with the diagnoses of Anorexia Nervosa; Restricted Type, Obsessive Compulsive Disorder, Malnutrition, Rule Out Body Dysmorphic Disorder and Dysthymia v/s Depression.

On 2/28/18, four (4) personnel files were reviewed. Two of the personnel were Behavioral Counselors and two were registered nurses. None of the files indicated the staff had received training in conducting any type of group and there were no current or past competencies noted in their files.

Review of the Quality Assurance and Performance Improvement (QAPI) and interviews revealed the facility failed to address the areas of groups or activities conducted by staff who by education or job description are not trained to deal with patients who have such diagnoses as Obsessive Compulsive Disorder and/or Out Body Dysmorphic Disorder and Dysthymia v/s Depression. There was no indication the hospital staff had taken actions aimed at measuring its success in educating and training staff who were newly hired and assess existing staff while tracking their performance.