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Based on record review and interview the facility failed to ensure staff was trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring and assessment of patients with maladaptive behaviors.

The failure to ensure staff was trained and able to demonstrate competency in restraining and secluding patients has the potential to affect the safety and well-being of all patients admitted to the facility.

Findings include:

Review of five facility employee personnel files revealed all five employees did not have current Crisis Prevention Institute (CPI is a training in safe management of disruptive and assaultive behavior).

Review of Staff #1's personnel file revealed no current CPI training. Further review revealed Staff #1 was hired 05/13/2013.

Review of Staff #3's personnel file revealed no current CPI training. Further review revealed Staff #3 was hired 05/06/2011.

Review of Staff #4's personnel file revealed no current CPI training. Further review revealed Staff #4 was hired 05/13/2013.

Review of Staff #6's personnel file revealed no current CPI training. Further review revealed Staff #6 was hired 02/13/2013.

Review of Staff #7's personnel file revealed no current CPI training. Further review revealed Staff #7 was hired 06/13/2013.

Interview on 01/28/2014 at 3:10 pm with Staff #2 revealed that the facility is no longer using CPI anymore. Staff #2 also stated that the facility will be using S.E.C.U.R.E., A Safe Emergency Control Understanding and Redirecting the Elderly. Staff #2 revealed that S.E.C.U.R.E. is an intervention used to identify major behavioral problems associated with the elderly patient and appropriate interventions. Staff #2 also revealed that the facility has been delinquent on providing its employees with CPI and S.E.C.U.R.E. training. Staff #2 stated that Staff #1, #3, #4, #6 and #7 does not have current CPI and S.E.C.U.R.E. training.

Review of Staff #1, #3, #4, #6 and #7's job descriptions dated February 2006 revealed that some sort of facility approved nonviolent crisis intervention training certification must remain current and updated.

Based on observation, interview and record review the facility failed to maintain the condition of the physical plant and the overall hospital environment in good repair.

The failure to maintain the facility in good condition has the potential to affect the safety and well-being of all patients admitted to the facility.

Findings include:

Observation on 01/28/2014 at 9:43 am in the facility ' s Patient Hygiene Room (424) revealed towels and bed linens were on a shelf next to the shower uncovered and exposed. In the bathroom, tissues that appeared to be used were observed on top of what staff identified as clean towels.

Interview on 01/28/2014 at 9:44 am with Staff #2 revealed that patients are brought into the Patient Hygiene Room to shower. Staff #2 stated that the towels and bed linens on the shelf next to the shower were clean. Staff #2 also stated that the facility does not cover the clean towels and bed linens in the Patient Hygiene Room.

Observation on 01/28/2014 at 10:00 am in the facility ' s dining room revealed missing/broken laminate on the countertops with exposed wood. Further observations of the dining room revealed pieces of dry wall missing on the bottom of the wall next to the refrigerator. There was an area of exposed wire and sheetrock on the wall, approximately 3 feet X 3 inches in size. A portion of baseboard was observed peeling off the wall. These areas of missing laminate and cracks in the drywall prevent effective cleaning and disinfection.

In the dining room the plastic containers for silverware were observed to have visible dust in the bottom of the containers. The dust indicated ineffectively cleaning.

At the end of the patient hallway a section of the baseboard, approximately 4 feet long was missing from the wall.

In seclusion room there were two tears observed in the carpet, approximately 3 inches in length.

In the smoking room there were several gouges observed to the drywall, approximately 2 X 2 inches and 3 feet X 2 inches. Creating an entry way for pests.

During a tour of the facility on 01/28/13 the following safety issues were observed:
In the patient dayroom a phone jack was observed that was loose from the wall with exposed wires and screws observed. In the dining room a light fixture was observed with no cover, with the bulbs exposed. These two issues presented a risk for patient injury at the facility.

The above observations were confirmed with staff member # 2 on 01/28/13.