HospitalInspections.org

Based on interview and document review the facility failed to ensure that the physician order for the restriction of a patients freedom of movement was renewed in writing at least every twenty four (24) hours, for one of one (patient #6) patients in restraint/restriction of freedom records reviewed, resulting in the potential for unauthorized use of restraint/seclusion/restriction of rights for all patients treated at this facility. Findings include:

On 04/05/2018 at 1530 during record review for patient #6 (the only use of restraint in the last 6 months) it was found that there was no physician order for the continuing use of "Specialized Intervention-24 hour door lock" on 2/17/2018.
This physician ordered restriction was documented on 2/16/2018 and 2/18/2018. Progress notes indicated that the 24 hour door lock was continued on 2/17/2018 without a physician order.

On 04/05/2018 at 1600 staff A was asked if an order was required to continue locking the patients door to prevent her from entering her room. Staff A stated "Yes, every 24 hours."

On 04/05/2018 at 1615 the policy titled "Restriction of Patients Rights" #RI06 dated revised 03/15 was reviewed. On page one of two under D. it states "Any order for restriction is reviewed at least daily. If not renewed at that time by a physician order, the order for restriction expires automatically. If renewed, it must be renewed in writing at intervals no greater that every twenty-four (24) hours."

Based on interview and document review the facility failed to ensure that all direct care staff are trained and competent in the use of restraint and seclusion in two of five (staff E and L) personnel records reviewed, resulting in the potential for untrained staff to unsafely or improperly restrict freedom of all patients treated at this facility. Findings include:

On 04/05/2018 at 1600 during document review of personnel records staff E and staff L were missing documentation of annual competencies for the year 2017. The competencies's missing included: 1. Seclusion and Restraint Training, 2. Annual Skills Update Modules 1,2,3, 3. Preventing Workplace Violence, 4. Code of Conduct.

On 04/05/2018 at 1700 staff N the director of Human Resources was asked about the missing competencies. Staff N stated "I do not really have anyway to make annual training's mandatory."

On 04/05/2018 at 1730 the policy titled "Competency Assessment Program" #HR15 dated revised 12/31/2015 was reviewed. On page 2 of 3 under 5. it states "The competence of staff is assessed annually through completion of the hospitals Annual Skills Update (ASU) modules...must demonstrate competency in Crisis Prevention and Seclusion and Restraint and Patient Rights annually."