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VALLE VISTA HEALTH SYSTEM
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0196
Based on document review and interview, the hospital failed to ensure documentation of staff competency in the application of restraints for 1 of 2 staff members (N1).
Findings:
1. Policy/procedure titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion - Acute (Seclusion Restraint)" PolicyStat ID: 13731439, Last revised: 05/2023. Indicated assure compliance with all laws, rules and regulations relating to federal and state health care programs. N. Staff Training and Competence Assessment: Medical staff, direct care staff, and RNs are oriented to the standards for the use of restraint/seclusion. Direct care staff are required to attend a nationally recognized physical/aggression management training program, Handle With Care (HWC) and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a in restraints or seclusion.
2. Review of N1 (Mental Health Tech) personnel file lacked Crisis Prevention Intervention (CPI), Handle with Care (HWC) training completed.
3. On 09/25/2023 at approximately 1545 hours, staff A1 (Director of Risk Management & Health Information Management) was interviewed and confirmed that N1 did not have Crisis Prevention Intervention (CPI), Handle with Care training.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0206
Based on document review and interview, the facility failed to ensure that 1 of 2 MHT (Mental Health Technician) staff had documentation of current CPR (cardio pulmonary resuscitation) competence. (Staff N1.)
Findings:
1. Policy/procedure titled, "CPR Certification" PolicyStat ID: 13692370, Last revised: 01/2019 indicated that the facility requires that all clinical personnel hold current training in Cardiopulmonary Resuscitation (CPR) to ensure patient safety. This includes Registered Nurses, Licensed Practical Nurses, Mental Health Technicians, Milieu Specialist, Intake Clinicians, and Therapists. Maintaining current CPR training is a condition of employment for clinical personnel. Employees who fail to maintain current CPR certification will be suspended until certification has been obtained.
2. Review of N1 personnel file lacked CPR training.
3. On 09/25/2023 at approximately 1545 hours, staff A1 (Director of Risk Management & Health Information Management) was interviewed and confirmed that N1 did not have CPR certification completion in his/her personnel file.