HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion-as part of orientation; and subsequently on a periodic basis consistent with hospital policy

Findings included:

Facility policy entitled, "Restraints/ Seclusion" stated in part,
"DEFINITIONS ...
Qualified Nurse: A registered nurse (RN) who has completed the required restraint/seclusion training and competency assessment provided for RNs during the initial orientation period in Safe Effective Care Understanding Redirection of the Elderly), and in ongoing reorientation sessions for SECURE training ...

TRAINING REQUIREMENTS ...
2. A RN who is deemed to be a qualified nurse and who will be responsible for initiating restraints must complete the facility's restraint/seclusion training offered during orientation and renewed through ongoing reorientation. Competency documentation shall be contained within the RN's educational file."

Review or personnel files for nursing staff revealed that 2 of 5 nursing staff members did not have annual restraint re-education on restraints or face to face evaluation training documented for 2021.

* Staff member #10 last had documented restraint training on 04/24/20. This nurse documented on the one seclusion episode that occurred at the facility in 2021. In interview on 04/27/22, this staff member verified they last completed restraint training at a "corporate meeting in June 2020". They had no documentation to reflect an annual restraint training after 04/24/20.
* Staff member #20 (agency nurse) had no documented restraint training in their personnel file. In interview on 04/27/22 staff member #9 (Human Resources) verified this agency nurse had no documented restraint training. Staff member #20 was working on the unit on 04/27/22 as the charge nurse. As charge nurse, this staff member needs appropriate restraint training to safely apply restraint and seclusion should a behavioral emergency arise at the facility.

Based on a review of documentation and interview, the facility director of nursing services failed to provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).

Findings included:

Review of the one agency nurse employed by the facility for the past year (staff member#20), revealed this employee had an "Orientation Agenda" dated and signed on 02/22/22. However, this form had no dates for each topic, scores, or trainer initials present to indicate an actual orientation was provided when this nurse was initially assigned to this facility as an agency nurse.

In interview on 04/27/22, staff member #9 (Human Resources) verified the orientation agenda for this agency nurse was not complete appropriately.

Based on observation and interview, it was determined that the physical plant was not maintained to ensure the safety of its staff and patients.

Findings were:

Facility policy entitled "Infection Control--Plant Operations" stated in part "Plant Operations has the responsibility for the function of the physical plant to provide a safe environment for patients and staff.. Plant Operations adheres to all policies set by the Infection Control Committee and provides them with information related total hospital surveillance and preventative measures."

Tour of the facility on 4/26/22 revealed the following deficits:

* Baseboards and protective vinyl coverings on wall corners had been ripped from the wall by a patient and had not been repaired at the time of the tour.
* Patient rooms had exposed pipes under sinks that could pose a ligature risk
* Patient beds were not secured to the floor which could allow the patients to use the beds as barricades or to create ligature points by turning the beds on their sides or its end.

The above items were confirmed by the CEO during tour of the facility on 4/26/22.

Based on a review of documentation and interview the facility failed to enforce their written fire control plan that contained provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel and guests; evacuation; and cooperation with fire fighting authorities.

Findings included:

Facility policy entitled, "Emergency Preparedness Plan" stated in part,
"4. The following codes will be used to identify types of emergencies and will be paged by the telephone operator of the host hospital by stating the code name and the location three (3) times. Example ...
G. CODE RED: Fire. This code is paged with the location."

Facility based policy entitled, "Staff Training" stated in part,
"2. On-going yearly training will occur through the use of emergency drills as follows:
A. Code Red drills on each shift at least quarterly."

The facility Chief Executive Officer (CEO) provided copies of "Environment of Care Safe Six (6) Monthly Reports"to the survey team, indicating that fire drills were conducted on 08/13/21 and 10/04/21.

In interview on 04/27/22, the CEO verifies that facility had participated in fire drills in conjunction with the separately licensed hospital located in the same building, however they did not have any documentation to reflect this participation. Based on the documentation provided, it appears that fire drills were not conducted at the facility on each shift per quarter per policy and no fire drills had been conducted for the calendar year 2022.

Based on record review and interviews, the hospital failed to designate a qualified infection control professional as required by the hospital Infection Control Policy #126.

Findings:

The policy entitled, "Infection Control Policy #126," adopted 09/01/09, stated in part, "Qualifications of Staff: The infection control Coordinator is:
-Is required to have 2 or more years experience in the field of Infection Control and microbiology.
-Is recommended to have membership in the Texas Society of Infection Control Practitioners(TSICP)"

In an interview with RN #3 on the morning of 04/27/22, when asked if she was in charge of the infection control program, she stated, "Yes, I became the Infection Control Nurse as of April 2021 when it was identified there was no one designated. I am also the employee health nurse." She was then asked if she had any training or certification in Infection Control. She stated, "No, but I reached out to my corporate infection control manager last month and she has provided me with the list of training requirements and I am currently beginning to complete the self training."

Review of Staff #3's employee file revealed it did not contain current training, certification or annual skills assessment for infection control. The document titled, "Allegiance Speciality Hospital Annual Competency Clinical Skills Assessment" revealed the section for Infection Control Coordinator was not completed for Staff #3, the designated Infection control coordinator.

Based on observation and interview, it was determined that the facility did not always practice effective infection control.

Findings were:

Tour of the facility on 4/26/22 revealed the following:

* Ceiling tiles throughout the facility were stained and sagging, indicating water damage.
* In the exam room, a chair with shredded vinyl was noted. The CEO disclosed that the hospital had little storage space and unusable furniture was stored in the exam room. Chipped floor tiles were also observed in the exam room.
* The patient dining room had chipped laminate on the countertops, which made cleaning the countertops thoroughly impossible.
* The washing machine and dryer used to wash patient clothes was checked for cleanliness during the tour. The lint trap on the dryer was found to be full. Wet clothes were found in the washing machine. Staff could not identify who the clothes belonged to. The Charge Nurse was unaware of how to sanitize the machines between use.

The above infection control findings were confirmed by the CEO on 4/26/22.

Based on a review of documentation and interview, the facility failed to conduct and document exercises to test the emergency plan annually.

Findings included:

Facility based "Emergency Operations Plan" that indicated "This plan covers license year 2020-2021" stated in part,
"Plan Review and Maintenance
Plan Review
The EOP will be reviewed and updated annually incorporating: the latest NIMS elements, data collected during actual and exercise plan activation, changes in the hazard vulnerability assessment, changes in emergency equipment, changes in external agency participation, etc. ...
Exercises
The Allegiance Behavioral Health Center of Plainview must test it's plan and operational readiness at least annually. The hospital must participate in a mock disaster drill at least annually. Also the hospital must conduct a paper-based, tabletop exercise at least annually (41 CFR 482.15)."

In interview on 04/26/22 and 04/27/22 the Chief Executive Officer verified the facility had not conducted any disaster drills in 2021 or 2022 due to "CoVid". Per regulations and policy, a disaster plan drill/rehearsal should be conducted at least one time per year.