HospitalInspections.org

Based on interview and record review, the hospital failed to provide a safe environment for patients, staff and visitors by not ensuring that the staff receive training in the use of physical restraints. This failed practice places patients, staff, and visitors at risk. The findings are:

A. On 09/01/15 at 9:20 am, during interview both the Risk Management Director and Human Resources Director stated that the hospital has not provided its employees any training on the use of physical restraints. Both directors stated that staff are currently trained on mechanical and chemical restraint only. There is one certified trainer on staff who is qualified to teach a physical restraint training CPI (crisis prevention intervention).

B. On 09/01/15 at 9:30 am, during interview Tech Maintenance 1 / Hospital Security stated that his training in the application of physical restraints consisted of his attendance at an instructor course for CPI in March of 2015. Tech Maintenance 1 / Hospital Security also stated he had not yet facilitated a training for the hospital. He further stated he had never taught the course before and that his training in CPI had lapsed for about 2 years when he took the instructor course.

C. Review of employee training records, including those of licensed and unlicensed personnel, revealed no training on the use of physical restraint was offered or completed.

D. Review of the hospital policy titled "Restraint and Seclusion" revealed the following: "Hospital staff members who assess patients for restraint or who apply restraint shall receive training using return demonstration and teach-back methodologies in the following topics as appropriate to the patient population served."

Based on interview and record review, the hospital failed to ensure that the staff receive training in the use of physical restraints. This failed practice places staff, patients and others at risk. The findings are:

A. On 09/01/15 at 9:20 am, during interview both the Risk Management Director and Human Resources Director stated that the hospital has not provided its employees any training on the use of physical restraints. Both directors stated that staff are currently trained on mechanical and chemical restraint only. There is one certified trainer on staff who is qualified to teach a physical restraint training CPI (crisis prevention intervention).

B. On 09/01/15 at 9:30 am, during interview Tech Maintenance 1 / Hospital Security stated that his training in the application of physical restraints consisted of his attendance at an instructor course for CPI in March of 2015. Tech Maintenance 1 / Hospital Security also stated he had not yet facilitated a training for the hospital. He further stated he had never taught the course before and that his training in CPI had lapsed for about 2 years when he took the instructor course.

C. Review of employee training records, including those of licensed and unlicensed personnel, revealed no training on the use of physical restraint was offered or completed.

D. Review of the hospital policy titled "Restraint and Seclusion" revealed the following: "Hospital staff members who assess patients for restraint or who apply restraint shall receive training using return demonstration and teach-back methodologies in the following topics as appropriate to the patient population served."

Based on interview and record review, the hospital failed to ensure that the staff receive training in the use of physical restraints. This failed practice places staff, patients and others at risk. The findings are:

A. On 09/01/15 at 9:20 am, during interview both the Risk Management Director and Human Resources Director stated that the hospital has not provided its employees any training on the use of physical restraints. Both directors stated that staff are currently trained on mechanical and chemical restraint only. There is one certified trainer on staff who is qualified to teach a physical restraint training CPI (crisis prevention intervention).

B. On 09/01/15 at 9:30 am, during interview Tech Maintenance 1 / Hospital Security stated that his training in the application of physical restraints consisted of his attendance at an instructor course for CPI in March of 2015. Tech Maintenance 1 / Hospital Security also stated he had not yet facilitated a training for the hospital. He further stated he had never taught the course before and that his training in CPI had lapsed for about 2 years when he took the instructor course.

C. Review of employee training records, including those of licensed and unlicensed personnel, revealed no training on the use of physical restraint was offered or completed.

D. Review of the hospital policy titled "Restraint and Seclusion" revealed the following: "Hospital staff members who assess patients for restraint or who apply restraint shall receive training using return demonstration and teach-back methodologies in the following topics as appropriate to the patient population served."

Based on interview, record review and observation, the hospital failed to identify opportunities for improvement and changes that will lead to improvement. This failed practice can lead to poor quality of care. The findings are:

A. On 09/03/015 at 9:30 am, during interview the Material Management Director stated that the hosptial is tracking and trending the use of an electronic system for finding Material Safety Data Sheets (MSDS). This is done by sampling employees on a monthly basis, asking them if they know how to access information on the hospital computers.

1.On 09/03/015 at 9:45 am, during interview the Case Management Director was asked if she knew where to obtain MSDS information. She stated that she did. Upon further questioning, the Director of Case Management acknowledged that she had been sampled within a couple of weeks. When asked, the Material Management Director stated that the hospital did not have a mechanism in place to track who or how often the same personnel were sampled.

2. On 09/03/015 at 9:50 am, during interview Med [medical] Surgical Floor Tech [technician] #1 was asked if she knew where to obtain MSDS information. She stated there was a binder in a closet on the floor. When asked, the Med Surgical Floor Tech #1 did not know her user name or password for the computers and stated she had not logged onto the computers in a long time as she was uncomfortable using them.

3.On 09/03/015 at 9:55 am, during interview Housekeeper #1 was asked if she knew where to obtain MSDS information. She stated there was a binder in a closet on the floor. She did not know her user name or password either. She further stated she was uncomfortable using a computer. When asked, she stated she had been an employee of the hospital for at least 10 years.

B. On 09/03/015 at 9:55 am, during an interview the Material Management Director was asked if there was anything that needed to be changed regarding access to computer information. She replied, "We need to track better who we have spoken with, also what other needs the hospital has in order to assure employees know how to use the computers."

C. On 09/03/015 at 9:55 am, during interview the Quality Analyst Manager acknowledged that the hospital needs to put a training program in place on basic computer skills.

Based on record review and interviews, the hospital failed to follow its process and criteria to be used for evaluation of candidates for medical staff membership and privileging as outlined in its bylaws. This failed practice could lead to inappropriate privileging of medical staff which in turn could result in physicians and practictioners being unable to provide adequate and appropriate services consistent with scope of practice. The findings are:

A. On 09/02/15 at 12:45 PM, during interview the Quality Management Analyst confirmed that there was a break in the system for credentialing.

B. Review of the hospital's bylaws revealed the following:
1.Initial appointments are reviewed by the Department Chair and upon approval the Department Chair makes recommendation of appointment and membership to the Credentials Committee for approval.
2. The Credentials Committee reviews the files and upon approval makes recommendation of appointment and membership to the Medical Executive Committee (MEC) for approval.
3. The MEC reviews the files and upon approval makes its recommendation of appointment and membership to the Governing Board for final approval and appointment and membership to the medical staff.
4. Review of 24 of 24 credential files revealed that the Department Chair was reviewing the files and signing off for approval after (rather than before) the files had been reviewed and approved by the Credentials Committee.

Based on observation, interview and record review, the hospital failed to successfully develop and implement a hospital-wide infection control program. This deficient practice could potentially contribute to exposing patients, staff and visitors to infections and/or communicable diseases. The findings are:

A. On 09/02/15 at 9:00 am, during observation of an environmental cleaning of a discharged patient's room the following was witnessed:
Housekeeper #1 sprayed Oxiver (a cleaning solution) on the furniture and surface areas and immediately wiped the Oxiver off, not allowing a 5- minute wet time, per the manufacturer's instructions.

B. On 09/02/15 at 9:00 am, during interview, when asked about wet time, Housekeeper #1 stated, "I think it is 3 minutes but I am not sure."

C. Record review of the Safety Data Sheet for Oxiver five 16 concentrate revealed the following:
1. Disinfects and cleans walls, stainless steel, glazed porcelain, plastic surfaces and other hard, nonporous surfaces using patented technology.
2. Let solution remain on surface for a minimum of 5 minutes.
3. Wipe and allow to air dry.
4. Prepare a fresh solution if the solution becomes visibly dirty or diluted.

Based on interview and record review, the hospital failed to have in place a standard process for notifying patients (or their representative if applicable) that they may request a discharge planning evaluation and that the hospital will conduct one upon request. This failed practice does not provide the opportunity for the hospital to correctly identify changes in the patient's condition which may require additional information when the patient is being discharged. The findings are:

A. On 09/02/15 at 9:15 am, while working on the Patient Safety Initiative (PSI) packet, the Case Management Director stated that the hospital did not have a policy in place to notify patients that they may request a discharge evaluation. The Director of Case Management stated, "We are currently working on a policy that will specify that a patient can request a discharge evaluation."

B. The Quality Analyst Manager was present during the interview and she confirmed that they are working on this policy.

Based on interview and record review the hospital failed to designate a qualified Director of Rehabilitation Services. This failed practice is likely to cause a lack of medically related supervision and would likely impact appropriate care for patients. The findings are:

A. On 09/03/15 at 8:00 am during interview, the Director of Rehabilitation Services stated that she was also the Director of Human Resources and that she has a Master of Business Administration degree with a background in financial banking. The Director of Rehabilitation Services stated she is not a therapist.

B. On 09/03/15 at 2:00 pm during interview, the Chief Executive Officer confirmed that the Director of Rehabilitation Services is not a therapist.

C. Review of the hospital's Management Job Description for Director of Therapy Services dated 03/13 revealed that the Director of Therapy Services must have a current NM license in Physical or Occupational Therapy or Speech/Language Pathology.