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Based on interview and record review the facility failed to ensure restraint training was documented in personnel records of three of three physicians/psychiatrists (Staff Y, Z and AA) as directed by facility policy.

The facility census was 241. The average daily census was 20 on the behavioral health unit (BHU) where staff used an average of almost one restraint per month. This deficient practice had the potential to affect all patients who were restrained on the BHU.

Findings included:

1. Review of the facility's policy titled, "Alternatives to Restraints" dated 01/01/11 showed the following:
-The scope of the policy included all facility employees, physicians, on-site contractors; all affiliated physician practices, members of the medical staff or credentialed allied health professionals;
-The purpose of the policy was to preserve patient rights, safety and dignity;
-The policy directed staff to make the correct determination regarding whether the use of a restraint was clinically justified (for violence or a non-violent purpose);
-A physical restraint was defined as any manual, physical or mechanical device, material or equipment attached or adjacent to the patient's body that the patient cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move the arms, legs, body, head freely.
-Appendix A: Training Requirements: Physicians authorized to order restraint will have a working knowledge of this policy on the use of restraint.

2. Review of the facility's Management Agreement (Provider-Based Program Management) dated 05/23/11 showed the following:
-The facility and a local psychiatric facility entered into a contractual agreement for the local psychiatric facility to operate the behavioral health unit (BHU) in a manner to comply with federal, state and local regulations;
-The local psychiatric facility agreed to recruit and train professional and support staff for the BHU.

3. During an interview on 04/16/13 at approximately 4:10 PM Staff BB, Director of Medical Service stated the following:
-The facility employed three physicians (psychiatrists, Staff Y, Z and AA) on the BHU;
-She maintained credentialing files (personnel records) on all of the facility physicians that included their education records;
-There was no documentation regarding restraint training provided to the three psychiatrists on the BHU;
-There was no specific training regarding restraints in the physician credentialing file.
-Physicians were required to abide by the facility policies.
-Staff Y's, Z's and AA's credentialing file did not show any evidence of specific restraint training.

4. During an interview on 04/17/13 at 8:45 AM Staff E, Vice President of Operations and Staff CC, Vice President for Quality Assurance confirmed the following:
-The local psychiatric facility provided restraint training for the BHU staff;
-The facility did not have any documentation showing Staff Y, Z or AA (BHU physicians/psychiatrists) had any facility provided training regarding restraints.

5, During an interview on 04/17/13 at 9:20 AM, Staff Y, Physician/Psychiatrist stated that he had not received restraint training from the facility. He stated that the other two physician's in his group who practice on the BHU also had not had any training on restraints.




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