HospitalInspections.org

Based on review of policies, medical records, and interviews with staff, the facility failed to provide a face to face within 1 hour after a violent restraint intervention for 1 of 1 patient with violent restraints. (Patient #22)

The findings include:

Review on 12/12/2024 of policy titled "Restraints, Violent or Self-Destructive" with revision date of 07/2023, revealed "Purpose: To provide guidelines regarding the utilization of restraints for patient behavioral emergencies. Policy: A. Physical restraints may be imposed when there is imminent risk of a patient physically harming him/her-self or others and/or when patients are severely aggressive or display destructive behavior...M. Provider visits for Physical Restraints: 1. The provider must see the patient face-to-face within 1 hour after the intervention of physical restraints (either physical restraints or physical hold). a. If the patient's behavior resolves prior to the arrival of the provider performing the 1-hour face-to-face evaluation, the provider is still required to see the patient face-to-face within the hour. b. The evaluation must include: 1. Patient's immediate situation 2. Patient's reaction to the intervention. 3. Patient's medical and behavioral condition. 4. The need to continue or terminate the restraint."

Review on 12/12/2024 of a closed medical record of Patient #22 revealed a 27 year-old female that presented to the Emergency Room on 09/06/2024 with Altered mental status. Patient #22's prior medical history revealed a history of asthma and bipolar disorder. Review of the physician's orders revealed an order for a therapeutic hold restraint dated 09/07/2024 at 1430. Review revealed Patient #22 was placed in a therapeutic hold from 1439-1441. Review of the documentation revealed no provider face-to-face evaluation within 1 hour of the restraint.

An interview with the provider was not obtained. The provider was not available.

Interview on 12/12/2024 at 1400 with Manager #9 revealed no face-to-face documentation by a provider.

Interview on 12/12/2024 at 1635 with Manager #8 revealed no face-to-face documentation by a provider. The interview revealed the policy was not followed.

Based on policy review, observation, personnel file review, staff schedule review, and staff interviews, the hospital failed to ensure current certification was maintained in Pediatric Advanced Life Support (PALS) for 1 of 3 Unit A Registered Nurse (RN) personnel files reviewed requiring PALS certification according to hospital policy (RN #4).

The findings include:

Review on 12/12/2024 of hospital policy "Education, Orientation, and Training," effective 03/24/2024, revealed, "... H. Pediatric Advanced Life Support (PALS) ... This certification is mandatory for nurses in ... [Unit A] ... 1. All teammates are required to meet established mandatory requirements according to policies ... These mandatory requirements include, but are not limited to, certifications (i.e. ... PALS ...) ... Teammates whose certifications ... have expired may not work beginning at midnight on the date of expiration ..."

Observation on 12/10/2024 at 1023 revealed RN #4 was working on Unit A.

Review on 12/12/2024 of RN #4's personnel file revealed RN #4's PALS certification expired on 10/31/2024. Review failed to reveal evidence of PALS certification renewal after 10/31/2024.

Review on 12/12/2024 of RN #4's schedule revealed RN #4 worked the following dates: 11/01/2024, 11/06/2024, 11/07/2024, 11/08/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/29/2024, 11/30/2024, 12/01/2024, 12/05/2024, 12/06/2024, 12/09/2024, 12/10/2024, and 12/11/2024 (20 of 42 days since PALS certification expired).

Interview on 12/10/2024 at 1025 with RN #4, while on tour of Unit A, revealed the RNs on Unit A maintained PALS certification because the unit occasionally received surgical pediatric patients.

Interview on 12/12/2024 at 1419 with Training Specialist #2 revealed PALS certification was required for RN #4 and the certification was expired. Training Specialist #2 revealed RN #4 was enrolled in a certification renewal class prior to the expiration date but cancelled the enrollment. Interview revealed RN #4 was enrolled in a PALS renewal class on 01/23/2025 (84 days after expiration). Training Specialist #2 revealed staff should not work with an expired certification per hospital policy. Training Specialist #2 stated a monthly report with staff certification expiration dates was sent to unit leaders. Interview revealed unit leaders were responsible for following up with staff members.

Interview on 12/12/2024 at 1520 with the Chief Nursing Officer (CNO #1) revealed RN #4 should have renewed the PALS certification prior to the expiration date. CNO #1 stated the expired PALS certification would not prevent RN #4 from working because there were other PALS certified staff members available for emergency situations. Interview revealed CNO #1 would follow up with the Director for Unit A (Director #3) regarding a plan for RN #4's expired PALS certification and appropriate assignments on Unit A.

Director #3 was unavailable for interview.

NC00185397; NC00186155; NC00186953; NC00193569; NC00199004; NC00200550