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Based on interview, and record review the hospital failed to protect and promote the rights of patients in the behavioral health unit as evidenced by:

1. Quality Risk Manager (QRM) did not follow hospital policy and procedures (P&P) titled "Patient Elopement [leave a medical facility without permission]" and "Occurrence Reporting & Adverse Event Determination," when one of one sampled patient (Patient 2), with a legal hold due to high risk of self-harm, eloped through the exit doors. This failure resulted in a delay in the investigation of a safe environment in the behavioral health unit. (Refer to A-142)

2. A safe environment for three of four sampled patients (Patient 2, Patient 3 and Patient 4) when:

a. Therapist were not informed of:a. one of four sampled patients' (Patient 1) need for counseling due to staff to patient abuse
b. one of four sampled patients' (Patient 4) need for counseling due to patient-to-patient altercation.
These failures had the potential for Patient 1 and Patient 4 to not have appropriate emotional support.(Refer to A-144)

b. Pharmacy Technician (PT) exited the security door of the behavioral health unit without an escort as required by policy. This failure resulted in Patient 2, with known high risk for suicide, to push PT away from the security doors of the behavioral health unit, elope (run away) from the hospital and the potential to commit self-harm. (Refer to A-144)

3.The hospital policy and procedure (P&P) titled, "Abuse Identifying and Reporting," for two of four sampled patients (Patient 1 and Patient 4), in the behavioral health unit, who experienced abuse when:

a. Mental Health Worker (MHW 1) choked one of four patients (Patient 4) in the behavioral health unit. This failure resulted in Patient 4 experiencing pain and had the potential to result in Patient 4 experiencing mental distress and/or physical injury. (Refer to A-145)

b. MHW 3 continued working with one of four patients (Patient 1) in the behavioral health unit after being accused of committing abuse towards Patient 1. This failure had the potential to cause Patient 1 to experience severe emotional distress and the potential to not receive timely medical treatment and continued abuse. (Refer to A-145)

c. Staff did not report the allegation (accusation) MHW 3 went into Patient 1's room, struck and choked Patient 1 to the hospital's abuse coordinator. This failure resulted in the hospital unable to conduct a timely investigation and protect Patient 1's right to receive care in a safe environment. (Refer to A-145)

d. The hospital Policy and Procedure (P&P) titled "Abuse Identifying and Reporting" did not indicate to report all allegations of abuse. This failure resulted in a delay in an investigation and the potential to prevent abuse. (Refer to A-145)

4. 15 of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 1, CNA 2, and Mental Healthcare Worker [MHW] 8) were not current with required training when:

a. 11 of 20 sampled staff (Registered Nurse [RN] 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 2, and Mental Healthcare Worker [MHW] 8) completed required training for Handle with Care (HWC- verbal and physical de-escalation training). This failure had the potential to result in staff unable to de-escalate unstable situations and the potential to result in unsafe patient care. (Refer A-199)

b. Four of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, CNA 1), completed their annual competency. This failure had the potential to result in unsafe patient care. (Refer A-199)

5. Four of 20 sampled staff (Mental Health Worker [MHW] 5, MHW 6, Clinical Therapist [CT] 1 and Registered Nurse [RN] 1) Basic Life Support (BLS and Advanced Cardiac Life Support (ACLS) certificates were not current

a. MHW 5, MHW 6 and CT 1 did not have current BLS certification.

b. RN 1 did not have current ACLS certification.

These failures had the potential to result in a delay in patient care, and patient safety during a life threatening event. (Refer to A-206)

The cumulative effect of these systemic problems resulted in the facility's failure to monitor and deliver care in a safe environment in the behavioral health unit and in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed follow their policy and procedures (P&P) titled "Patient Elopement [leave a medical facility without permission]" and "Occurrence Reporting & Adverse Event Determination," when one of one sampled patient (Patient 2), with a legal hold due to high risk of self-harm, eloped (leave a medical facility without permission) through the exit doors. This failure resulted in a delay in the investigation of a safe environment in the behavioral health unit.

Findings:

During a review of Patient 2's "Provider Progress Note [PPN]," dated 7/30/24 at 8:16 a.m., the "PPN" indicated, "[Patient 2]...with unknown past psychiatric [mental health] history who was admitted to [Hospital] on a 5250 hold [involuntary 14 day hold] for danger to self after he cut his throat with glass to end his life and stated, "God told me to do it." The patient [Patient 2] was given a preliminary diagnosis of brief psychotic disorder [disconnection from reality], with suspicion of schizoaffective disorder [mental health disease] or schizophrenia [mental health disease] . . .REASONS FOR CONTINUED STAY: AWOLED [Absent Without Leave] from the unit last night. . .The patient's 5250 hold expires today and a 5260 [additional involuntary 14 day hold] hold will be submitted as he remains a danger to himself. The patient has high acute [time-limit] suicide risk assessment. . .The patient has high imminent (ready to happen) risk of suicide and self-harm. Patient is unable to verbalize a viable [workable] plan for self-care and current presentation is evidence that the patient cannot care for himself in a less restrictive setting."

During a review of Patient 2's "Nursing Narrative Note [NNN]," dated 7/29/24 at 18:15 (6:15 p.m.), the "NNN" indicated, "patient [2] follow the pharmacy staff [PT] when staff push numbers on door key pad to open the door and patient kick the door and push the staff away and run in hallway towards dietary department and staff try to hold patient, patient swing on the staff and patient run through dietary exit door."

During a review of Patient 2's "NNN," dated 7/29/24 at 20:54 (8:54 p.m.), the "NNN" indicated, "Pt [Patient 2] came back in the unit @ [at] 20:25 [8:25 p.m.] and pt states 'He ran away because he feel [sic] anxious and he went to his home..."

During an interview on 8/7/24 at 9:03 a.m. with Quality and Risk Manager (QRM), QRM stated when Patient 2 eloped (outside of facility for about 2 hours), she did not report to the Department because Patient 2 returned back to the facility on the same day.

During a review of the facility's policy & procedures (P&P) titled, "Patient Elopement," dated 10/28/22, the P&P indicated, "Patients who leave without informing a member of the healthcare staff; or patients who breach the inpatient unit exit doors...without consent or cause to do so, are considered to have eloped. . .PURPOSE: To ensure that patients held for any combination of Danger to Self, Danger to Others, Grave Disability, or patients retained in the inpatient setting on administration days pending acceptable housing due to conservatorship ("involuntary patient") are returned to appropriate and compelled care as quickly and safety as possible ... "

During a review of the facility's policy & procedure (P&P) titled, "Occurrence Reporting & Adverse Event Determination," dated 5/16/23, the P&P indicated, "PURPOSE: An effective Quality and Patient Safety Program requires optimal reporting of medical/health care occurrences. . .California Department of Public Health: When an event meets the self-reporting provision in Title 22 and California Health and Safety Code Section 1279.1, the Risk Manager or designee will report no later than 5 days after the event has been detected. . .California Code of Federal Regulation (CCR) Title 22 Section 70737: Unusual Occurrences may include but is not limited to. . .unusual occurrence which threatens the welfare, safety, or health of patients, personnel, or visitors."

Based on interview and record review the hospital failed to follow their Policy and Procedures (P&P) to provide a safe environment for three of four sampled patients (Patient 1, Patient 2 and Patient 4) when:

1. The hospital did not inform the therapists of
a. one of four sampled patients' (Patient 1) need for counseling due to staff to patient abuse
b. one of four sampled patients' (Patient 4) need for counseling due to patient-to-patient altercation. These failures had the potential for Patient 1 and Patient 4 to not have appropriate emotional support.

2. Pharmacy Technician (PT) exited the security door of the behavioral health unit without an escort as required by policy. This failure resulted in Patient 2, with known high risk for suicide, to push PT away from the security doors of the behavioral health unit, elope (run away) from the hospital and the potential to commit self-harm.

Findings:

1a. During a review of an anonymous complaint dated 7/31/24 received by the California Department of Public Health (Dept), the complaint indicated on 7/30/24, Mental Health Worker (MHW) 3 went into Patient 1' room, struck Patient 1 and then MHW 3 returned to Patient 1's room and choked Patient 1.

1b. During a review of a facility reported incident (FRI) dated 7/31/24 received by the California Department of Public Health (Dept), the FRI indicated on 7/1/24, Patient 3 suddenly and unprovoked hit Patient 4. The FRI indicated on 7/1/24, MHW 2 pushed Patient 4 away from the nurses station. The FRI also indicated Patient 4 was standing near the activity room, when uprovoked MHW 1 ran toward Patient 4 and grabbed him by the throat.

During an interview on 8/5/24 at 1:21 p.m. with Clinical Therapist (CT) 1, CT 1 stated she was not aware of any abuse allegation from the staff. CT 1 stated patients who experienced abuse would benefit from speaking with a therapist.

During an interview on 8/5/24 at 1:38 p.m. with CT 2, CT 2 stated the hospital staff had not asked her to speak with any patient that was a victim of staff to patient alleged abuse.

During an interview on 8/6/24 at 4:19 p.m. with Psych (psychological, mental or emotional state) Program Manager (PPM), PPM stated the hospital did not inform therapists about abuse incidents in order to provide counseling to patients.

During a review of the hospital's P&P titled, "Patient to Patient Altercation," dated 5/23/24, the P&P indicated, "Assess the physical and emotional well-being of the patients involved and provide appropriate medical care or support as needed."

During a review of the hospital's Policy and Procedure (P&P) titled, "Abuse Identifying and Reporting," dated 4/23/24, the P&P indicated, "Patients who are victims of abuse or neglect will be provided counseling and support ...appropriate counseling and treatment should be given as part of the individual's individualized plan of care."


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2. During a review of Patient 2's "Provider Progress Note [PPN]," dated 7/30/24 at 8:16 a.m., the "PPN" indicated, "[Patient 2]...with unknown past psychiatric history who was admitted to [Hospital] on a 5250 hold [involuntary 14 day hold] for danger to self after he cut his throat with glass to end his life and stated, "God told me to do it." The patient [Patient 2] was given a preliminary diagnosis of brief psychotic disorder [disconnection from reality], with suspicion of schizoaffective disorder [mental health disease] or schizophrenia [mental health disease] . . .REASONS FOR CONTINUED STAY: AWOLED [Absent Without Leave] from the unit last night. . .The patient's 5250 hold expires today and a 5260 [additional involuntary 14 day hold] hold will be submitted as he remains a danger to himself. The patient has high acute [time-limit] suicide risk assessment. . .The patient has high imminent (ready to happen) risk of suicide and self-harm. Patient is unable to verbalize a viable [workable] plan for self-care and current presentation is evidence that the patient cannot care for himself in a less restrictive setting."

During a review of Patient 2's "Nursing Narrative Note [NNN]," dated 7/29/24 at 18:15 (6:15 p.m.), the "NNN" indicated, "patient [2] follow the pharmacy staff [PT] when staff push numbers on door key pad to open the door and patient kick the door and push the staff away and run in hallway towards dietary department and staff try to hold patient, patient swing on the staff and patient run through dietary exit door."

During an interview on 8/7/24 at 3:44 p.m. with QRM, QRM stated Pharmacy Technician (PT) did not follow the psychiatric (psych) unit rules that indicate that staff need to be companied in the psych unit for out of safety. QRM stated the PT did not look back to see if Patient 2 was following her, PT put in the code to unlock the door, opened door, and Patient 2 pushed her and left the unit and hospital.

During an interview on 8/7/24 at 4:17 p.m. with PT, PT stated on 7/29/24 she was going out of the psych unit, she pushed the code to unlock door. PT stated Patient 2 came so quickly that she did not have time to close the door. PT stated she was not being escorted in the psych unit. PT stated she goes in and out of the unit. PT stated the facility had not provided her any training.

During an interview on 8/7/24 at 4:20 p.m. with Chief Nursing Officer (CNO), CNO stated PT should not have had the code to the psych unit.

During a video record review on 8/7/24 with QRM and CNO, the surveillance video record dated 7/29/24 at 6 p.m. was reviewed. Patient 2 sat cross-legged on the floor next to the door on the right side of the nursing station. PT, without an escort, walked towards the door on the right side of the nursing station, PT did not ask any staff to escort her through the door. PT entered the code for the door to unlock, Patient 2 got up fast, pushed PT out of the way. MHW 10 attempted to stop Patient 2 from exiting the unit.

During a review of the Hospital wide memo (HWM) dated 2/22/24, at 3:32 pm, the HWM indicated "TEAM! If you ever need to go to the Psych [psychiatric, mental health] Unit (i.e. lab, pharmacy, housekeeping, dietary) Please make sure you go accompanied with a MHW, and as soon as you are done taking care of the patients' needs you are to leave the unit."

During a review of the hospital's P&P titled "Patient Elopement [unauthorized leaving of a medical facility]" dated 10/27/2022, the P&P indicated "Purpose: To ensure that patients held for any combination of Danger to Self, Danger to Others, Grave Disability ...This police shall instruct staff on how to respond when a patient leaves the inpatient unit without authorization ...If an involuntary patient has eloped and is not observed on the hospital grounds the nursing staff shall call local law enforcement to report ..."

During a review of the hospital's Policy and Procedure (P&P) titled, "Abuse Identifying and Reporting," dated 4/23/24, the P&P indicated, "Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Abuse Identifying and Reporting," for two of four sampled patients (Patient 1 and Patient 4), in the behavioral health unit, who experienced abuse when:

1. Mental Health Worker (MHW 1) choked a one of four patients (Patient 4) in the behavioral health unit. This failure resulted in Patient 4 experiencing pain and had the potential to result in Patient 4 experiencing mental distress and/or physical injury.

2. MHW 3 continued working with one of four patients (Patient 1) in the behavioral health unit after being accused of committing abuse towards Patient 1. This failure had the potential to cause Patient 1 to experience severe emotional distress and the potential to not receive timely medical treatment and continued abuse.

3. Staff did not report the allegation (accusation) MHW 3 went into Patient 1's room, struck and choked Patient 1 to the hospital's abuse coordinator. This failure resulted in the hospital unable to conduct a timely investigation and protect Patient 1's right to receive care in a safe environment.

4. The hospital Policy and Procedure (P&P) titled "Abuse Identifying and Reporting" did not indicate to report all allegations of abuse. This failure resulted in a delay in an investigation and the potential to prevent abuse.

Findings:

1. During an interview on 8/7/24 at 2:49 p.m. with MHW 4, MHW 4 stated she was in the hallway in the behavioral health unit and saw MHW 1 running down the hallway towards a patient that was yelling. When she (MHW 4) entered the lobby area, she (MHW 4) saw Patient 4 on the floor. MHW 4 stated she spoke to Patient 4 in his native language, to calm down. MHW 4 stated Patient 4 told her he was in pain because MHW 1 was holding him down.

During a record review on 8/7/24 at 3:56 p.m. with Quality and Risk Manager (QRM), Patient 4's Security Footage (SF) in the behavioral health unit, dated 7/1/24, was viewed. The SF showed the following:
Patient 4 standing in front of the nurses' station in the behavioral health unit, talking to the nurses on the other side of the counter. MHW 2 came towards Patient 4, wrapped her arms around Patient 4 and moved him outside the yellow and black lines. MHW 1 ran from the hallway towards the lobby area of the behavioral health unit and placed his pointed finger on Patient 4's chest. When Patient 4 put his hand on MHW 1's arm, MHW 1 moved his hand to Patient 4's neck in a choke-like grip Patient 4 then swung his other arm towards MHW 1's face. MHW 1 tackled Patient 4 to the floor.

During a review of the hospital document titled "Patient Rights-Hospital Wide" the document indicated "A patient's rights shall include but not be limited to ...12. Receive care in a safe setting, free from verbal or physical abuse or harassment ..."

During a review of the hospital's policy and procedure (P&P) titled, "Abuse Identifying and Reporting," dated 4/8/24, the P&P indicated, "Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected."


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2. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, "[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care."

During an interview on 8/1/24, at 10 a.m. with QRM, QRM stated the hospital was not aware of this abuse accusation and the hospital would start an investigation. QRM stated if a patient was annoying an MHW, the MHW needed to switch off with another MHW.

During an interview on 8/7/24 at 10:36 a.m. with MHW 10, MHW 10 stated on 7/30/24, Patient 1 was trying to get past MHW 4 to reach the exit of the behavioral health unit; MHW 3 sat in a chair in the hallway, MHW 3 jumped up from the chair several times and redirected Patient 1 with a stern voice. MHW 10 stated she thought MHW 3 was getting fed-up from constantly redirecting Patient 1. MHW 10 stated she thought MHW 3 was a little irritated that Patient 1 did not listen to him.

During an interview on 8/7/24 at 12:56 p.m. with QRM , QRM stated MHW 3 continued to work in the behavioral health unit during the investigation.

During a review of MHW 3's Working Schedule Spreadsheet (WSS) for the behavioral health unit, dated August 2024, the "WSS" indicated on 8/1/24 "Sick" 8/2/24, 8/3/24, and 8/4/24 "Night", 8/5/24 blank (not scheduled) and MHW 3 worked Day shift on 8/6/24.

During a review of Patient 1's "Provider [doctor] Progress Note [PPN]," dated 7/30/24 at 8:46 a.m. the "PPN" indicated Patient 1 was a conserved (legally appointed responsible party) 53-year old male, with intellectual disabilities (below average ability in reasoning, social skills and self-care), and schizoaffective disorder bipolar type (mental health disease). Reasons for stay included: Due to psychosis (mental health illness), unpredictable behavior, labile (rapid, exaggerated changes) mood, intermittent behavioral agitation, the patient remains a danger to himself and others. Due to psychosis, the patient remains a gravely (disabling psychiatric condition), disabled adult."

During a review of the hospital's policy and procedure (P&P) titled, "Abuse Identifying and Reporting," dated 4/8/24, the P&P indicated, "PURPOSE: To provide procedures for investigating, reporting, and following up when an allegation of patient abuse of neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred in our facilities. To provide procedures for notifying external agencies of allegation of abuse, as required. . .POLICY. . .Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred."

3. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, "[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care."

During an interview on 8/1/24 at 10 a.m. QRM stated she was not aware of an allegation that on 7/30/24, MHW 1 abused Patient 1 in the behavioral health unit until the Department informed her on 8/1/24.

During a review of the hospital P&P titled "Abuse Identifying and Reporting" dated 4/8/24, the P&P indicated "Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken ...The hospital also recognizes that persons with mental illness are vulnerable and are at risk for abuse or neglect ...Employees who witness or have knowledge of suspected patient abuse during admission shall immediately report it to the Charge Nurse. If for some reason, the employee believes they cannot or should not inform the charge Nurse, the employee may contact the Director of Nursing, Risk Management, Quality, Risk or their designee or the Medical Director or their designee directly ...The Charge Nurse will gather initial facts and include the findings in an occurrence report ..." The P&P does not provide a procedure for reporting abuse after admission.

4. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, "[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care."

During an interview on 8/5/24 at 9:47 a.m. with QRM, QRM stated she did not do a self-report to the Department because the SF in the behavioral health unit, dated 7/30/24, did not show anything regarding the alleged abuse between MHW 1 and Patient 1.

During an interview on 8/7/24 at 9:21 a.m. with QRM, QRM stated the hospital's policy and procedure on reporting alleged abuse indicates that if it was an actual event then they will report it to the Department, other than that it will not be reported to CDPH. QRM stated she needed MHW 9 to tell her she saw MHW 3 hit Patient 4.

During an interview on 8/7/24 at 12:56 p.m. with QRM, QRM stated she viewed the behavioral health unit SF, dated 7/30/24, on 8/1/24. QRM stated she did not speak with Patient 1 because he was developmentally delayed, and Patient 1 needed to be more stable before being spoken with. QRM stated she notified CNO and reviewed the behavioral health unit footage. QRM stated she did not inform anyone other than the CNO.

During a review of the hospital P&P titled "Abuse Identifying and Reporting" dated 4/8/24, the P&P indicated "Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken ...The hospital also recognizes that persons with mental illness are vulnerable and are at risk for abuse or neglect ...Immediate actions that may be necessary to protect patients ..."

During a review of the hospital document titled, "Patient Rights-Hospital Wide," undated, the document indicated, "A patient's right shall include...12. Receive care in a safe setting, free from verbal or physical abuse or harassment."

Based on interview, and record review, the hospital failed to ensure 15 of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 1, CNA 2, and Mental Healthcare Worker [MHW] 8) were current with required training when:

1. Eleven of 20 sampled staff (Registered Nurse [RN] 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 2, and Mental Healthcare Worker [MHW] 8) completed required training for Handle with Care (HWC- verbal and physical de-escalation training). This failure had the potential to result in staff unable to de-escalate unstable situations and the potential to result in unsafe patient care.

2. Four of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, CNA 1 MHW 7), completed their annual competency (required skills). This failure had the potential to result in unsafe patient care.

Findings:

1. During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant [HRA], HRA stated staff need to be current with required training as per policy.

During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as Handle with Care. CNO stated he had not recently reviewed if there were any overdue critical dates for active staff.

During an interview on 8/6/24 at 1:40 p.m. with CNO, CNO stated the facility scheduled HWC training every other Thursday. CNO stated either Human Resources (HR) or he looked at whoever was on the schedule (those pending re-certification or new hires) All those employees would stay for the eight or nine hours for the training.

During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated if any staff are actively working on the floor and have critical dates that are expired, the staff should be removed from the floor according to policy.

During a review of the facility's critical dates spreadsheet [CDS], undated, the "CDS" indicated the following:

RN 5's did not have HWC training;
RN 6's HWC expiration date 1/24/24;
RN 7's HWC expiration date 6/7/23;
RN 8's HWC expiration date 6/21/23;
RN 9's HWC expiration date "DUE"; (need to be renewed)
RN 10's HWC expiration date 5/4/24;
RN 11's HWC expiration date 11/23/23;
RN 12's HWC expiration date "DUE";
RN 13's HWC expiration date 6/27/24;
CNA 2's HWC expiration date "DUE";
MHW 8's HWC expiration date 12/1/23.

During a review of the facility's policy & procedure (P&P) titled, "PROACT/Handle with Care/CPI Training," dated 11/02/2022, the P&P indicated, "PURPOSE: To ensure the safety of employee and patients. . .SCOPE: All Hospital Staff. . .COMPLIANCE RESPONSIBILITY: Managers. . .POLICY: Employees assigned in departments that have potential safety risks are required to have. . .Handle with Care (HWC). . .Training. These departments are: 1. Psychiatric [mental or behavioral health] Unit 2. Medical Surgical Unit."

2. During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant [HRA], HRA stated staff need to be current with required training as per policy.

During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as competencies [required skills]. CNO stated he had not recently reviewed if there were any overdue critical dates for active staff.

During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated if any staff are actively working on the floor and have critical dates that are expired, the staff should be removed from the floor if according to policy.

During a review of the facility's critical dates spreadsheet [CDS], undated, the "CDS" indicated the following:
RN 2's annual department (dept) competency due 10/31/23;
RN 3's annual dept competency due 7/9/24;
RN 4's annual dept competency due 10/31/23;
CNA 1's annual dept competency due 10/31/23;
MHW 7's annual dept competency due 10/31/23;

During a review of the hospital's P&P titled, "Assessment of Competency," dated 10/21, the P&P indicated, "POLICY: It is the responsibility of [NAME of Hospital] to assure the competence of each staff member. . .PROCEDURE: Annual competency assessment. . .a. Successful completion of unit/department specific critical competency skills assessment. 2. Staff members. . .they may not provide patient care identified as requiring unit/department specific critical competency skills unless they successfully completed competency requirements for those skills."

Based on interview, and record review the facility failed to ensure four of 20 sampled staff (Mental Health Worker [MHW] 5, MHW 6, Clinical Therapist [CT] 1 and Registered Nurse [RN] 1) had the ability to respond to life saving emergencies for when MHW 5, MHW 6 and CT 1 did not have current Basic Life Support (BLS-life support training) and RN 1 did not have current Advanced Cardiac Life Support (ACLS-advanced life support training).

This failure had the potential to result in a delay in patient care, and patient safety during a life threatening event.

Findings:

During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant (HRA), HRA stated staff need to be current with BLS, and ACLS required training as per policy.

During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as BLS, annual competencies [required skills], and Handle with Care (technique to safely manage disruptive, aggressive and self-destructive behaviors). CNO stated he had not recently reviewed if there were any overdue critical [important] dates for active staff. CNO stated the facility had a code [emergency response/lifesaving team] team. CNO stated he does not know if someone who had an expired BLS could be working on the floor.

During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated according to policy, if any staff were actively working on the floor with expired critical dates, the facility should remove the employee from the floor.

During a review of the facility's critical dates spreadsheet [CDS], undated, the "CDS" indicated the following:

MHW 5's BLS expiration date is 4/30/24;
MHW 6's BLS expiration date is 3/31/24;
CT 1 did not have a BLS;
RN 1's ACLS expiration date is Not applicable "NA";

During an interview on 8/6/24 at 1:50 p.m. with CNO, CNO stated MHW 5 and MHW 6 were still working with expired BLS. CNO stated MHW 5's BLS expired on 4/30/24 and MHW 6's BLS expired 3/31/24.

During a review of the facility's P&P titled, "BLS/ACLS Requirements," dated 12/02/2022, the P&P indicated, "PURPOSE: In order to ensure maximum safe, efficient and effective patient care, all employees involved in direct patient care are required to become proficient in cardiopulmonary resuscitation (CPR, life support training) in the event resuscitation measures need to be initiated. . .SCOPE: All Personnel. . .COMPLIANCE RESPONSIBILITY: HR, Managers. . .POLICY. . .Delinquency of CPR cards can result in temporary suspension of the employee without pay and the use of PTO. The employee will not be scheduled to work until proof of current certification is provided to the department manager. . .PROCEDURE. . .BCLS Recertification: Each direct patient contact employee shall recertify his/her BCLS card every two (2) years, at least 30 days before expiration. . .ACLS Certification: All RNs who are hired into departments that require ACLS shall be ACLS certified prior to employment. . .medsurg/tele [general hospital unit]. . .ACLS Recertification: All RNs shall recertify their ACLS care every two (2) years, at least 30 days before expiration."

During a review of the facility's P&P titled, "Assessment of Competency," dated 10/21, the P&P indicated, "POLICY: It is the responsibility of [Hospital] to assure the competence of each staff member. . .PROCEDURE: Annual competency assessment. . .a. Successful completion of unit/department specific critical competency skills assessment. 2. Staff members. . .they may not provide patient care identified as requiring unit/department specific critical competency skills unless they successfully completed competency requirements for those skills."