HospitalInspections.org

Based on interview and record review the facility failed to provide abuse training prior to physically working in the facility with staff and patients for 4 of 5 sampled employees (Employee 9, 10, 11, 12).

Findings include:

On 8/26/2022 At 10:30 AM, the Director of Human Resources (HR) indicated hospital orientation which consist of abuse training was performed for new staff on the second week of each month. The Director of HR indicated some new employees would start on the units with the preceptor before going through class orientation. The Director of HR indicated if the new employee started working on the floor with a preceptor without going through the orientation class, a handbook would be provided to the employee. The handbook consisted of general employment policies, performance standards, benefits, and hospital resources. The new employee would sign and confirm receiving the handbook. The handbook did not have abuse training.

The Director of HR indicated there was online abuse training, which was completed during orientation, but newly hired employees were allowed to start working on the unit with their preceptor and patients while the online training was completed at a later date.

Employee 9 started working on the unit on 01/24/2022. Employee 9 started in-class orientation which consisted of abuse training on 02/08/2022. The employee completed their on-line abuse training on 02/12/2022.

Employee 10 started working on the unit on 06/20/2018. Employee 10 started in-class orientation which consisted of abuse training on 07/10/2018. On-line abuse training was not offered back in 2018.

Employee 11 started working on the unit on 07/29/2020. Employee 11 started in-class orientation which consisted of abuse training on 09/08/2020. The employee completed their on-line abuse training on 09/17/2020.

Employee 12 started working on the unit on 07/30/2021. Employee 12 started in-class orientation which consisted of abuse training on 08/10/2021. The employee completed their on-line abuse training on 08/07/2021.

On 8/26/2022 At 10:30 AM, the Director of HR indicated Employee 9, 10, 11, 12, started working on the unit with their preceptor and with patients without receiving abuse training first.

Based on record review, interview and policy review, the facility failed to ensure a clinician updated a patient's treatment plan after a patient-to-patient incident for 1 of 26 patients (Patient 1).

Findings include:

On 8/10/2022, the facility admitted Patient 1 with a legal hold for a recent suicide attempt.

On Friday, 8/12/2022 at 3:45 PM, Patient 2 assaulted Patient 1.

On 8/12/2022 at 5:42 PM, a physician ordered Patient 1 transferred to an emergency department where the patient had tenderness of the left temporal area and mid cervical spine. A physician prescribed medication for the discomfort, and the patient returned to the facility.

On 8/26/2022 in the morning, the Assistant Director of Nursing indicated the patient was moved to a different unit and monitored more closely among other interventions, but none of the clinicians updated the treatment plan after the incident.

Although the treatment team met for weekly updates:

Procedure D. Progress in Treatment, Provision #4 of the Interdisciplinary Treatment Team Meeting and Treatment Plan Update policy revealed the Social Worker shall document treatment team members identified additional and/or new treatment problems, findings, and/or needs.

There was no documented evidence the facility required clinicians to update treatment plans after a significant patient to patient incident.