HospitalInspections.org

Based on record review and interviews, the Governing Body failed to ensure a hospital policy was implemented in relation to annual restraint training for 2 of 6 staff reviewed (Staff #1 and Staff #6).

Finding:

The hospital's policy titled "Restraints", in Section IV. Staff Education, indicated the following: "B. All staff that has direct patient contact (RN, CNA) will receive ongoing education and training regarding the use of restraints. The ongoing education will be directed by review of restraint incidents, review of previous focuses, new products and new policies and will occur annually."

Staff #1 and Staff #6 had no documentation that they had completed the annual restraint training.

During an interview with the Chief Quality Officer, on 4/16/19 at approximately 1:07 PM, she stated that in 2018 the Chief Nursing Officer left and the Nurse Educator left and she could only do two jobs. There was no skills fair held in May 2018.

During an interview conducted with the Chief Nursing Officer, on 4/16/19 at approximately 2:41 PM, she stated that the restraint training is accomplished by attending the annual skills fair held each May. She confirmed that Staff #1 and Staff #6 had no documentation that they had completed the annual restraint training.