HospitalInspections.org

Based on interviews and record review, the hospital failed to provide a safe environment for patients by not ensuring that the staff receive training on the use of physical restraints (use of one's physical body/extremities to prevent or limit another person's movement). This failed practice places the health and well-being of patients, visitors, and others at risk of injury from patients who may become physically aggressive. The findings are:

A. Review of the incident reports dated 03/01/15 through 08/31/15 revealed two separately recorded occurrences involving the same patient on 08/14/15, in which the patient was physically restrained. In the first occurrence, documentation indicated that the patient "had punched tech [technician] across his face, knocking his glasses off his face and continued to become more and more agitated and violent," and the patient was "restrained by tech and visitors." In the second instance, the patient "assaulted Therapy Tech when Therapy Tech came between Patient and other patient guests, other patient's guests put patient down on the floor and restrained him until further security arrived."

B. On 09/09/15 at 2:45 pm, during interview RN #1 in B.I. unit 500 (Brain Injury Unit) stated that she has not received any formal training on physical restraint use. She stated she has only received training on mechanical restraint (a device made of fabric, leather, or other material -- such as a safety vest, hand and wrist straps, and mittens -- that hinders a patient's movement) and chemical restraint (the use of psychotropic, hypnotic, or antianxiety medication to control a patient's movement).

C. On 09/09/15 at 2:50 pm, during interview Patient Care Tech (Technician) #1 stated that she has not received any formal training on physical restraint use. Patient Care Tech #1 added that she has been an employee of the hospital for about 10 years.

D. On 09/10/15 at 7:30 am, during interview Patient Care Tech #2 from the 400 Unit stated she has been working at the hospital for about 10 years. She stated she occasionally works in the Brain Injury Unit when they are short-staffed. She stated that she received Mandt Training (Behavioral Intervention / Restraint Training) between 3-5 years ago but has not been recertified nor has she received any other training in restraint use.

Based on interviews and record review, the hospital failed to ensure that the staff receive training on the use of physical restraints (use of one's physical body/extremities to prevent or limit another person's movement). This failed practice places the health and well-being of patients, visitors, and others at risk of injury from patients who may become physically aggressive. The findings are:

A. Review of the incident reports dated 03/01/15 through 08/31/15 revealed two separately recorded occurrences involving the same patient on 08/14/15, in which the patient was physically restrained. In the first occurrence, documentation indicated that the patient "had punched tech [technician] across his face, knocking his glasses off his face and continued to become more and more agitated and violent," and the patient was "restrained by tech and visitors." In the second instance, the patient "assaulted Therapy Tech when Therapy Tech came between Patient and other patient guests, other patient's guests put patient down on the floor and restrained him until further security arrived."

B. On 09/09/15 at 2:45 pm, during interview RN #1 in B.I. unit 500 (Brain Injury Unit) stated that she has not received any formal training on physical restraint use. She stated she has only received training on mechanical restraint (a device made of fabric, leather, or other material -- such as a safety vest, hand and wrist straps, and mittens -- that hinders a patient's movement) and chemical restraint (the use of psychotropic, hypnotic, or antianxiety medication to control a patient's movement).

C. On 09/09/15 at 2:50 pm, during interview Patient Care Tech (Technician) #1 stated that she has not received any formal training on physical restraint use. Patient Care Tech #1 added that she has been an employee of the hospital for about 10 years.

D. On 09/10/15 at 7:30 am, during interview Patient Care Tech #2 from the 400 Unit stated she has been working at the hospital for about 10 years. She stated she occasionally works in the Brain Injury Unit when they are short-staffed. She stated that she received Mandt Training (Behavioral Intervention / Restraint Training) between 3-5 years ago but has not been recertified nor has she received any other training in restraint use.

Based on interviews and record review, the hospital failed to ensure that the staff receive training on the use of physical restraints (use of one's physical body/extremities to prevent or limit another person's movement). This failed practice places the health and well-being of patients, visitors, and others at risk of injury from patients who may become physically aggressive. The findings are:

A. Review of the incident reports dated 03/01/15 through 08/31/15 revealed two separately recorded occurrences involving the same patient on 08/14/15, in which the patient was physically restrained. In the first occurrence, documentation indicated that the patient "had punched tech [technician] across his face, knocking his glasses off his face and continued to become more and more agitated and violent," and the patient was "restrained by tech and visitors." In the second instance, the patient "assaulted Therapy Tech when Therapy Tech came between Patient and other patient guests, other patient's guests put patient down on the floor and restrained him until further security arrived."

B. On 09/09/15 at 2:45 pm, during interview RN #1 in B.I. unit 500 (Brain Injury Unit) stated that she has not received any formal training on physical restraint use. She stated she has only received training on mechanical restraint (a device made of fabric, leather, or other material -- such as a safety vest, hand and wrist straps, and mittens -- that hinders a patient's movement) and chemical restraint (the use of psychotropic, hypnotic, or antianxiety medication to control a patient's movement).

C. On 09/09/15 at 2:50 pm, during interview Patient Care Tech (Technician) #1 stated that she has not received any formal training on physical restraint use. Patient Care Tech #1 added that she has been an employee of the hospital for about 10 years.

D. On 09/10/15 at 7:30 am, during interview Patient Care Tech #2 from the 400 Unit stated she has been working at the hospital for about 10 years. She stated she occasionally works in the Brain Injury Unit when they are short-staffed. She stated that she received Mandt Training (Behavioral Intervention / Restraint Training) between 3-5 years ago but has not been recertified nor has she received any other training in restraint use.

Based on interviews, observation and record review, the dietary director failed to ensure that the dietary supervisor (1) implemented safety practices for food handling and training programs for such practices, and (2) conducted tracking and trending of food service practices for inclusion in the hospital-wide quality assurance program. This failure has the potential to give rise to foodborne illness among patients and thereby affect their health and well-being. The findings are:

A. On 09/09/15 at 8:40 am, observation of the dining area/food preparation area revealed the following:
1. Test strips for water sanitation and chlorine levels were not being used on a daily basis. No logs were present nor could any be produced by the Dietary Supervisor from previous days, weeks or months. There was a container affixed to the wall on the right of the three-compartment sink which contained a roll of test strips. The Dietary Supervisor opened the box and confirmed that she was not aware of its last use.
2. Inspection of the refrigerator and freezer revealed that food had not been dated or labeled with date of receipt. This included various types of food, including ground beef, vegetables, pastries, and pre-prepared food items such as jello and pudding. When asked, the Dietary Supervisor stated that she would label the food with date of receipt once she has time.
3. Cabinets under serving area were in need of cleaning. Crumbs of unknown food products were found throughout the cabinets.

B. On 09/09/15 at 8:40 am, during an interview, Dietary Staff Member #1 stated that she was unaware there was an analog thermometer inside the refrigerator and freezer. Dietary Staff Member #1 stated that she was solely relying on the external digital thermometer to log the temperatures and was unaware that the temperature indicated by the internal thermometer would provide confirmation of accurate readings for temperature.

C. On 09/09/15 at 11:11 am, during an interview, both the Chief Financial Officer (CFO) and the Dietary Director stated that there were no issues in the dining/food preparation area. The Dietary Director stated that at this time (for the past year) they were not trending any issues as they felt they did not have any. When asked, the Dietary Director stated that she had not been involved with training nor was she aware of any training conducted with the dietary staff.


D. Review of the Dietary Supervisor's job description dated 12/04/14 revealed the following under Summary of Job Duties: "Supervises, oversees and coordinates the daily operations for assigned area(s) to include but not limited to employee scheduling and training, food preparation, receiving and services." Under "Essential Job Functions," the job description states, "Responsible for training and ensuring employees are adhering to food preparation regulations and standards."