HospitalInspections.org

Based on staff interview, document review, and policy and procedure review, the Direct Care Worker (DCW) named in complaint failed to ensure that he provided care for the patient in an environment that a reasonable person would consider to be safe on one of one days of complaint.

Findings Include:

Review of facility's "Special Observation Procedures" from the "Forensic Services Program Manual" revealed that "by building security policy, a staff member may not enter a patient's room without another staff present except in cases of imminent danger to patient safety."

During an interview on 10/21/2021 at 1:00 p.m., the Registered Nurse (RN) confirmed a staff member may not enter a patient's room without another staff present. RN also reveals that on the night in question, the DCW was seen on video letting the patient out of his room, at least two (2) times, while being the only staff member on the ward. RN reports, also, that DCW could be seen, on video, entering the complainant's room alone.

During an interview on 10/21/2021 at 2:43 p.m., the Safety and Investigative Services (SAIS) investigator reported that the DCW admitted to letting patient out of his room/cell on several occasions while he was the only staff member on the unit, as well as, entering the patient's room alone. According to the "Special Operations Procedures" and building security, this is neither safe for the patient or the DCW.

Review of the DCW's Training History, revealed the DCW had MANDT training on 2/11/2021. This training focuses on preventing, de-escalating, and intervening when the behavior of an individual poses a harm to themselves or to others. DCW was not following training when he allowed patient to exit his room/cell or while entering patient's room/cell without another staff member present.

During Exit Conference on 10/21/2021 at 3:53 p.m., survey findings were discussed.

On 10/26/2021 at 4:49 p.m. the investigative findings of SAIS Investigator at facility were submitted for review.