HospitalInspections.org

Based on interview and record review the facility failed to ensure completion of restraint application training for two (AA and BB) of six employee records reviewed, resulting in the potential harm to ten patients requiring restraint application at the time of survey. Findings include:

On 09/25/18 at 1430 the Director of Nursing (staff E) was queried regarding restraint/seclusion and management of violent behaviors. Staff E stated, "all direct care employees are trained and have annual competencies for restraint application. We are currently in the process of training ALL staff in BVP (behavioral violence prevention), our previous training was CPI (crisis prevention and intervention). Staff should have CPI or BVP training documented."

On 09/26/18 at 1330 Director of Risk Management Compliance & Insurance (staff D) stated, "we cannot find documentation for the security officers BVP (behavioral violence prevention) training or restraint competencies. The Immediate supervisor is on his honeymoon and the Director of security is on vacation. We are looking through their offices now."

On 09/26/2018 at 1430 personnel records for Security staff AA and Security staff BB were reviewed. Records revealed a hire date for Security Guard staff AA to be 04-17-17. No record of Restraint application competency or CPI/ BVP (behavioral violence prevention) was found.
The hire date for Security Guard (staff BB) was documented as 02-26-18. No record of Restraint application competency or CPI/ BVP (behavioral violence prevention) training documentation was found.

On 09/26/18 review of "Security officer Job description" documented under "JOB SUMMERY, performs security services, including, ...Enforces policy and procedure." Under "EDUCATION, EXPERIENCE, TRAINING 1.BVP within 6 months of hire and maintain current annually."
Review of Policy subject "Restraint/Seclusion" revealed the following "revised 6/20/16" Page two "RESTRAINT: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely." Page seven "SCOPE: Physician, Registered Nurse, ..., Security..
1. This policy and procedure is in effect for all departments and services in the acute care facility. 2., 3., 4., 5., 6. Leadership assures that the appropriate training is provided to those staff who are responsible for the application and monitoring of restraints."