HospitalInspections.org

The Governing Body failed to;

1.) provide a safe environment in the patient recreation areas.
2.) provide safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.
Refer to Tag A0144



29762

The facility failed to;
1.) provide a safe environment in the patient recreation areas.
2.) provide safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.
Refer to Tag A0144



29762

Based on observation and interview, the facility failed to provide a safe environment;
1.) in the patient recreation areas
2.) The facility failed to provide safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.

On 8-2-2016, a tour of buildings 617, 630, and 626 patient recreation areas, was completed with Staff #2, Staff #3, Staff #5, and Staff #26 present. The following were findings that posed hazard to all psychiatric patients:

The electrical panel in the recreation area of building 617 had concrete steps so that the panel could be accessible to maintenance personnel without a ladder. The electrical circuit breaker panel was not secured closed and was accessible to patients, posing an electrical shock hazard.

The patient recreation room had a large-screen television set that was not secured behind Plexiglas or other safety barrier. This presented a hazard of electrical shock or access to glass if broken by a psychiatric patient. The cords to the television set, digital video recorder, and telephone were longer than 12 inches, posing a ligature hazard to psychiatric patients.

There were metal shelves in the patient recreation area that had been recently assembled. The shelves were metal and could be assembled and disassembled without the need for tools. Metal shelving and rails could be easily removed by psychiatric patients and used as a weapon.

The patient recreation area had fluorescent lights that did not have covers. The lights could be broken and glass from the tubes used by a psychiatric patient to harm self or others.

Decorations had been hung from strings greater than 12 inches in the patient recreation area. The strings were left hanging after the decorations had been removed and were accessible to psychiatric patients. This presented a ligature hazard for psychiatric patients.



32143

On 8-2-2016, a tour of buildings 617, 630, and 626 patient recreation areas, was completed with Staff #2, Staff #3, Staff #5, and Staff #26 present. Staff #2, Staff #3, Staff #5 and Staff #26 confirmed the findings.The following were findings that posed hazard to all psychiatric patients:

The gym area had 4 window air conditioning units. The front panels of the units were not secured and were easily removed to use as a weapon.

On 8/2/2016 a tour was conducted in building 516 unit SJU and AU. The facility had submitted a corrective action plan from a previously cited deficiency, to have sitters in the patient dorm bedroom at all times, to supervise the patients until the ceilings are hardened. Review of the patient bedrooms revealed they did not have hardened ceilings and continued to need sitters to monitor the rooms while patients were present. (In the psychiatric setting, this provides a place for psychiatric patients to hide medications, weapons, or other contraband. The metal supports for the drop down ceilings can be easily pulled down and used by psychiatric patients to harm themselves or others.) Staff #2 confirmed that Psychiatric Nurse Assistant (PNA) staff performing direct patient care take Prevention and Management of Aggressive Behavior (PMAB) training to ensure safety for the patients and staff. An interview with staff #5 confirmed the housekeeping and dietary staff did not have current PMAB training but have been assigned to monitor patients in their dorm rooms giving direct care.

Review of the Policy and procedures "Staff Training" revealed, "A. Staff Training
The facility will ensure that all staff are informed of their roles and responsibilities under this policy. Before assuming job duties involving direct care responsibilities, and at least annually, all staff members must receive training and demonstrate competence in:
1.) Identifying the underlying causes of threatening behaviors exhibited by the individual receiving mental health services.
4.) Using de-escalation, medication, self- protection, and other techniques, such as quiet time."

Staff #3 and #5 confirmed identifying the underlying causes of threatening behaviors exhibited by the individual receiving mental health services, using de-escalation, medication, self- protection, and other techniques, such as quiet time are taught in the PMAB training.

An interview was conducted with staff #15, during the tour. Staff #15 was a sitter in the women's dorm room on SJU unit. Staff #15 stated, "I am the sitter for this room while the patients are in here. I'm here to make sure no one hurts themselves. When the patients leave the room I lock the door." Staff #15 reported that she may be the only person in the room with the patients. Staff #15 reported that she works in housekeeping full time and does this for overtime. Staff #15 reported that she did not have current PMBA training. Without appropriate training the staff member and patients are at risk of harm if a behavioral emergency occurs. The staff member would not have the knowledge or tools to help deescalate the situation or to properly hold the patient to prevent injuries.







29762