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ALLEGIANCE BEHAVIORAL HEALTH CENTER OF PLAINVIEW
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0196
Based on review of facility documents and staff interview, the facility failed to ensure staff were trained and able to demonstrate competency in restraint and seclusion procedures as part of orientation when Staff #28, MHT, and Staff #32, agency RN, were working independently prior to training.
Findings were:
Review of the Daily Staffing Schedule revealed Staff #28, MHT [Mental Health Technician] worked the unit on 12/30/24, 12/31/24, 1/3/25, 1/4/25, and 1/6/25 with no indication Staff #28 was on orientation. On 1/7/25, the second day of the survey, the Staffing Schedule stated Staff #28 was on orientation.
Staff #28, in an interview on 1/6/25, reported they received computer training regarding restraint and seclusion but there was no competency or hands-on training.
Review of Staff #28's personnel file revealed on-line training that included restraint and seclusion but no documented "Competency - Therapeutic Use of Seclusion & Restraints - CNA/MHT."
Review of the Daily Staffing Schedule revealed Staff #32, agency RN, worked the unit on 1/6/25 and 1/7/25.
Review of Staff #32's personnel file revealed no documented computer, competency, or hands-on restraint and seclusion training.
Staff #2, CNO, in an interview on 1/7/25, reported Staff #28 was placed back on orientation because they had not received competency training related the prevention and use of restraint and seclusion. Staff #2 verified Staff #32 was working independently without completing training related to the prevention and use of restraint and seclusion.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0199
Based on review of facility documents and staff interview, the facility failed to ensure Staff #28 and #32, prior to working independently, demonstrated knowledge in:
(i) techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion.
(ii) in the use of nonphysical intervention skills prior to working independently
(iii) in choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition
(iv) in the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia)
(v) in clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary
(vi) in monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation
(vii) the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.
Findings were:
Review of the Daily Staffing Schedule revealed Staff #28, MHT worked the unit on 12/30/24, 12/31/24, 1/3/25, 1/4/25, and 1/6/25 with no indication Staff #28 was on orientation. On 1/7/25, the Staffing Schedule stated Staff #28 was on orientation.
Staff #28, in an interview on 1/6/25, reported they received computer training regarding restraint and seclusion but there was no competency or hands-on training.
Review of Staff #28's personnel file revealed on-line training that included restraint and seclusion but no documented "Competency - Therapeutic Use of Seclusion & Restraints - CNA/MHT."
Review of the Daily Staffing Schedule revealed Staff #32, agency RN, worked the unit on 1/6/25 and 1/7/25.
Review of Staff #32's personnel file revealed no documented computer, competency, or hands-on restraint and seclusion training.
Staff #2, CNO, in an interview on 1/7/25, reported Staff #28 was placed back on orientation because they had not received competency training related the prevention and use of restraint and seclusion. Staff #2 verified Staff #32 was working independently without completing training related the prevention and use of restraint and seclusion.