HospitalInspections.org

Based on observation, interview and record review, the Facility's Governing Body failed to ensure that contracted services were provided in a safe manner.

The facility failed to provide orientation and training to contracted dietitian.

(Citing Dietitian employee ID # 54)

Findings:

Review on 10/31/2018 of the current facility's procedure titled "Allied Health Orientation" revised 07/2017 requires orientation, training acknowledgment of policies and procedures, patient right, patient safety, infection control, HIPPA ....etc.
Review on 10/30/2018 at 3:00 PM along facility's Director of Risk Management, Employee ID #53 of Employee's #54 personnel file no documentation of any employees training or orientation was found.

During an interview on 10/30/2018 at 3:15 PM employee ID #53 stated "She should have done the initial orientation and the annuals. Because she is a contracted staff and allied health, she must have fallen through the cracks somehow. She is credentialed through Medical Staff."

During a tour of the PICU (Psychiatric Intensive Care Unit) and adjacent office area on 10/30/2018 at 10:00 AM with Chief Executive Officer (CNO) Employee ID #52, PICU was observed to be a 36 bed unit with male and female patients. Unit was observed with two wings consisting of 18 beds on each wing, an open central common area adjacent to the front of the nurse's station, group therapy room and patient privacy rooms. It was observed a locked door in the front of the nursing station led to an office area were consultation for patient and staff was used.

Observation on 10/31/2018 at 1:00 PM of the video clip of the staff lounge and physician office area Employee ID #54 was observed walking patient ID #1 to the staff lounge. No other staff were observed to be in the area. Further observations identified Patient ID #1 hurriedly leaving the staff lounge walking approximately 30 feet and pulling the fire alarm and running out the door.

Employee ID #52 asked if it was acceptable for the dietitian to have brought Patient ID #1 from the patient care area to the employee's breakroom for the dietary consultation. CNO stated "No, Employee ID #54 should not have brought the patient back to the employee break room, she should have talked with him in the patient care area. The patient came out of the room and pulled the fire alarm and when the fire alarm is pulled the magnetic doors automatically unlock in this area and the patient was able to opened the door to the outside area got out of the fence." CNO stated the Patient ID # 1 tried to jump the fence (wooden picket fence approximately 6 feet tall) but could not then he ran into the fence and broke 2 boards and slid his body through the broken boards left the facility property. CNO stated that she had talked to Employee ID #54 and told she should have not brought the patient back here, isolated her and the patient and was not safe for either.

Interview on 10/30/2018 at 4:00 PM Dietitian Employee ID #54 was asked about the elopement of Patient ID #1. Employee ID #54 stated that she had received a dietary consult on the patient and there were no rooms available on the PICU for her to do the consultation. Employee ID #54 stated she decided to bring the patient to the back and use the staff breakroom for privacy. Employee ID #54 stated, "I should not have brought the patient back to the breakroom and office area it is to isolated".

Interview on 10/31/2018 at 9:00 AM with CEO verified that Employee ID #54 should not have taken Patient ID #1 back to the office area. CEO stated that area is not set up for patients and used as a break area and office area. CEO confirmed Employee ID #54 should have been required to complete the allied health orientation and training and it was not done. Employee ID #54 stated they had already identified the issues with the dietitian and will educate all staff on only seeing patient in the patient care areas. CEO stated that Patient#1 had been a voluntary admit to the hospital for drug addiction for Xanax and could have left at any time. There was no hold on the patient."