HospitalInspections.org

Based on document review, policy review, and interview, in three of three credential files, the facility does not require physicians to participate in an education and training program that protects the patient's right to the safe implementation of restraint or seclusion (Staff M, Staff O, and Staff R).

Findings include:

Review of the "Medical Staff Rules & Regulations," dated 2016, revealed the primary medical provider must conduct an in-person patient assessment and write/sign the order for restraint or seclusion. The policy does not include training/education requirements for physicians for the utilization of safe restraint and seclusion implementation.

Review on 01/29/25 of credential files for Staff (M), Medical Director, Staff (O), Psychiatrist, and Staff (R), Physician, revealed no evidence of education/training for the utilization of safe restraint and seclusion implementation.

Interview on 01/30/25 at 10:00 AM with Staff (A), Vice President Patient Care Services, revealed physicians do not receive restraint and seclusion training.

Interview on 01/30/25 at 10:00 AM with Staff (A), Vice President Patient Care Services, verified the above findings.

Based on policy review, document review, and interview, in four of four personnel files, the hospital failed to ensure clinical staff are evaluated every year (Staff D, Staff H, Staff K, and Staff L).

Findings include:

Review of the policy "Performance Appraisals," last revised June 2012, indicated staff development needs are assessed organizationally, departmentally, and individually. These appraisals are conducted annually and include the following components: review of objective criteria on job descriptions and performance standards, review of in-service education record and other staff development initiatives, review of process improvement initiatives or performance improvement plans, and individual staff feedback on their performance for the period.

Review on 01/29/25 of the personnel files for Staff (D), Registered Nurse, hired on 04/30/20 and Staff (L), Registered Nurse, hired on 10/01/24 revealed that they have not been evaluated during their employment at the hospital.

Review on 01/29/25 of the personnel file for Staff (H), Licensed Practical Nurse, revealed that their last evaluation was in 2021. Review of the personnel file for Staff (K), Registered Nurse, revealed that their last evaluation was in 2019.

Interview on 01/29/25 at 11:00 AM, Staff (A), Vice President of Patient Care Services, revealed that staff evaluations are not being completed yearly per policy.

Based on observation and interview, the facility does not maintain mattress upholstery to be free from tears.

Findings include.

Observation on 01/28/25 at 10:15 AM in the electroconvulsive therapy room, revealed the mattress on the exam table had two large tears, and many small tears exposing the foam mattress pad. One large tear had duct tape running from side to side. The duct tape had pulled away from the material and mattress pad was exposed. In the laboratory technician room, the exam table in was missing vinyl material from both corners at the foot of the table. The mattress padding was exposed.

Interview on 01/28/25 at 10:15 AM with Staff (I), Facilities, verified these findings.

Based on document review and interview, the facility did not review and update their emergency preparedness plan annually and did not conduct a risk assessment using an all-hazard approach.

Findings include:

Review on 01/29/25 of the facility "Emergency Preparedness Plan," dated 2016, revealed no evidence of an annual review and/or evidence of a risk assessment using an all-hazards approach.

Interview on 01/29/25 at 09:00 AM with Staff (I), Facilities, revealed that the facility has not completed a risk assessment annually.

Interview on 01/30/25 at 10:00AM with Staff (A), Vice President Patient Care Services, verified the above findings.