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Based on observation and staff interview, the facility does not ensure that he the integrity of the building is maintained to ensure the safety of the staff, visitors, and patients. Specifically, water damaged ceiling tiles are not replaced.

Findings Include:

Observations on 04/04/23 between 1100 AM to 01:30 PM, on 04/05/23 between 10:30 AM to 01:30 PM and on 04/06/23 between 09:00 AM to 12:00 PM, revealed ceiling tiles in the first floor janitor's closet (also lacking a ceiling tile), first floor corridor adjacent to janitor's closet and above the fire doors, lady's restroom adjacent to first floor janitor's closet, and oxygen storage room had evidence of water damage. These water damage ceiling tiles must be replaced to eliminate the possibility of mold/mildew growth and other contaminates that may be present.

Interview on 04/06/23 at 11:50 AM with Staff (F), Facilities Director, verified this finding.

Based on policy review, document review, and interview, the facility does not provide patient- centered training/education of staff on the use of restraint and seclusion. Lack of training could lead to staff being unprepared in an emergency situation and/or a patient adverse event.

Findings Include:

Review of policy "Restraints/Urgent Care Center," last revised 03/2023 revealed there is no restraint usage in the Urgent Care Center (UCC). In the unexpected event that a patient's behavior may necessitate further intervention to protect the patient from causing harm to self or staff, and initial de-escalation techniques by staff have been unsuccessful, a CODE GRAY (Security) will be paged overhead, and local law enforcement (Cuba Police Department) will be contacted immediately to respond. The UCC Medical Director will be notified by the onsite UCC Provider, and the patient will be transferred to a higher level of care facility as necessary. The policy does not provide guidance to staff on how to respond to an immediate physical threat of harm by a patient to self or to others (physical and/or medical restraints), while waiting for a security/police response.

Review of policy "Restraints/Medical Care Unit," last revised 03/2023 revealed Cuba Memorial Hospital is a restraint free facility. There is no restraint usage on the Medical Care Unit (MCU). In the unexpected event that a patient's behavior may necessitate further intervention to protect the patient from causing harm to self or staff, and initial de-escalation techniques by staff have been unsuccessful, a code GRAY (Security) will be paged overhead, and local law enforcement (Cuba Police Department) will be contacted immediately to respond. The patient's attending provider will be notified, provider orders obtained, and the patient will be transferred to a higher level of care facility as necessary. The policy does not provide guidance to staff on how to respond to an immediate physical threat of harm by a patient to self or to others (physical and/or medical restraints), while waiting for a security/police response.

Review of policy "CODE GRAY-Procedure for calling Security," last revised 03/2023 revealed during switchboard working hours, if there is a need for security the switchboard should be notified to page "Code Gray, report to area where help is needed". All male personnel on duty should report to scene of incident to assist. Switchboard should also contact local, county, or State Police/911. After switchboard working hours any person in need of security assistance can page a "Code Gray and report to area where help is needed" by using the pager on the phone system (dial #79, give code and location and repeat 5 times). The nursing supervisor should respond with any personnel available. Maintenance staff if on duty, will respond. The nursing supervisor will make the decision whether or not a 911 call should be made. The policy does not address staff response where an immediate physical threat of harm by a patient is imminent, and/or there is a delay in response by security or local law enforcement.

Review on 04/06/23 of document "Top 10 De-escalation Tips for Health Care Professionals" (a seven-page pamphlet discussing de-escalation techniques) with an accompanying six question quiz, revealed seven staff members completed the training/quiz in 2022.

Review on 04/06/23 of staff training document "Code Gray read and sign" dated 02/2023 revealed all facility staff signed, attesting to reading the Code Gray policy.

Review on 04/06/23 of document "Cuba Memorial Hospital, Annual Mandatory Education" (no date) revealed a section titled "Safety, including a Code Gray and how to announce a Code," however the annual mandatory education does not include how to respond to a patient when immediate physical threat of harm to self or to others is imminent, while waiting for a security/police response.

Interview on 04/06/23 at 08:45 AM with Staff (U), Nurse Educator, indicated staff have been educated within the past month on the code gray policy and are trained on de-escalation techniques in the annual training. In addition, under the "abuse" title in the annual training it indicates a "no hands-on approach" with patients in the facility. Staff (U) indicated if there is a combative patient, staff can call a code gray and call the police, call a provider for orders, stay with the patient, provide a 1:1 observation, and use de-escalation techniques. However, staff are not trained on restraints where a threat of physical harm by a patient to self or to others is imminent, while waiting for a security/police response.

Interview on 04/06/23 at 09:10 AM with Staff (V), RN, MCU and Staff (D), Inpatient Nurse Manager and at 09:30 AM with Staff (W), PA, UCC, Staff (X), RN, UCC, and Staff (Y), RN, UCC, revealed if they encountered a combative patient, they would try to de-escalate a patient by talking to them, using distraction. or providing a 1:1 observation. All staff indicated they could call a provider for orders, call a code gray as well as the police. However, Staff (V), (D), (W), (X) and (Y) indicated they have not been trained on restraints to respond to a patient where immediate physical threat of harm to self or to others is imminent, while waiting for a security/police response.

Interview on 04/06/23 at 11:00 AM with Staff (A), Chief Executive Officer/Chief Operating Officer, verified this finding.