HospitalInspections.org

Based on interview and record review, the facility failed to document behavioral restraint application training competency for 1 (F) of 6 security staff files reviewed, resulting in the potential for less than optimal patient outcomes for all patients placed in behavioral restraints. Findings include:

On 12/8/20 at approximately 1000, interviews with Security Officers F and G in the Emergency Department revealed that security staff placed behavioral restraints on patients after ordered by the physician and/or by the nurse in an emergency. The behavioral restraints used at the facility were padded plastic restraints with Velcro, some were imitation leather, and they were in the possession of security staff. Interview with Manager O, on 12/9/20 at approximately 1000, verified that security officers were called to place behavioral restraints on patients in the Emergency Department, and nursing staff monitored and checked the patients. Security Manager O verified that he and Security Officer F had recently placed behavioral restraints on patients.

On 12/9/20 at 1400, review of Security Staff files revealed that Security Officer F lacked documentation of training competency on behavioral restraint application. Further review of five additional Security Staff files revealed documentation of Behavioral Violence Prevention (BVP) and restraint training. On 12/10/20 at approximately 1000, interview Security Manager O again with security staff files, verified lack of documented BVP and restraint training for Security Officer F.

On 12/10/20 at 1030, review of the job description title "Public Safety/Security Officer, revised 7/2019" documented, " Education, experience, training...1. BVP with 6 months of hire and maintain current annually..." On 12/0/20 at 1045, Security Manager O verified that he was not able to locate documentation of BVP training for Security Officer F, with a hire date of 2016.

Based on record review and interview, the facility failed to document pressure sore interventions for 3 (#17, #18, #19) of 3 patients reviewed at risk for pressure sores, resulting in the potential for less than optimal outcomes for patients with integument concerns. Findings include:

On 12/10/20 at 1100, record review with Staff T revealed that patient #17 was a 65-year-old female admitted on 12/2/20 at high risk for pressure sore development (Braden Score = 11) and/or worsening of the current sacral pressure sore. The nursing care plan (NCP) identified skin integrity as a concern but no interventions were documented. This was verified by Staff T. On 12/10/20 at 1130, the patient's nurse was not available for interview regarding interventions or documentation of interventions on the NCP.

On 12/10/20 at 1110, record review with Staff T revealed that patient #18 was 66-year-old male admitted on 12/8/20 with pressure sore on his coccyx and was at high risk for pressure sore development (Braden Score = 12) and/or worsening of the current sore. The NCP identified skin integrity as a concern but no interventions were documented. This was again verified with Staff T. On 12/10/20 at 1140, interview with the patient's Nurse W revealed that the patient was "on a specialty mattress and turned from side to side, as much as tolerated due to his shortness of breath." When queried about the lack of interventions documented on the NCP, Nurse W had no explanation.

On 12/10/20 at 1115, record review with Staff T revealed that patient #19 was a 38-year-old male admitted to the facility on 10/20/20 with no observable pressure sore, but at moderate risk for pressure sore development (Braden Score = 16). There were no documented NCP interventions until 10/28/20 when a sacral/coccyx pressure sore consult documented a sore of 5 centimeters (cm) x 4 cm x 0. On 12/10/20 at approximately 1430, interview with the Chief Nursing Officer Q verified that the NCP did not have integument interventions documented until after 10/28/20 but not prior. He stated, "They didn't document the interventions."

On 12/10/20 at 1445, review of the facility policy titled "Nursing Documentation in the Medical Record, dated reviewed 11/27/18" documented, ..."Plan of Care: To be initiated upon admission then reviewed, modified and narrative note every shift... Interventions/Plan of Care Orders: Qualified actions directed at the patient that are steps to achieve the desired outcome and are individualized."

Additionally, review of the facility policy titled "Skin Integrity, dated reviewed 12/2018" documented..."The Braden Scale is used on admission and each shift to evaluate the patient's risk of developing pressure ulcers. Patients with a Braden score of 18 or less are at risk of developing pressure ulcers. For Braden scale of 18 (or less) implement prevention measures..."