HospitalInspections.org

Based on observation, interview, policy review and document review, the facility failed to ensure patient safety due to a lack of training in first aid techniques and certification in the use of cardiopulmonary resuscitation and restraint/seclusion crisis intervention for the Hospital Public Safety Officers (HPSO) and Public Safety Assistants (PSA) and failed to ensure the security of the patient care area/milieu during a psychiatric emergency. Patients, staff and visitors were placed at risk for serious harm and/or injury.

See findings under Tag # 0144, #0199 and #0206.

Based on surveillance video review and interview, the facility failed to ensure patient safety, specifically, the patient care area was not secured by staff during two psychiatric emergencies. As a result, patients, staff and visitors were placed at risk for serious harm and/or injury.

Findings Include:

Review on 02/25/16 at 10:30 AM of the psychiatric unit surveillance video revealed two separate incidents which occurred on 02/20/16:
- At 07:23 PM Patient #1 assaulted Patient #5. Patient #1 was taken by staff to the other end of the hall. From 07:23 PM to 07:34 PM other psychiatric patients were observed walking up and down the hallway, going near both patients and/or just "hanging out" in the hallway while Patient #1 remained agitated. Staff did not secure the patient care unit to ensure the safety of all the other patients on the unit during the psychiatric emergency.
- From 08:13 PM to 08:39 PM Patient #1 is walking in and out of the TV lounge, speaking to the staff standing in the hallway. There are 3 other patients in the TV lounge. At 08:44 PM Staff #7 who is a HPSO and other staff members attempt to restrain Patient #1. An altercation ensures with Patient #1 kicking and grabbing at Staff #7. Staff #7 attempts to place handcuffs on Patient #1. Patient #1 bites Staff #7 on the right arm. At 08:46 PM Staff #7 strikes Patient #1 in the face three times. A staff member pulls Staff #7 away from Patient #1, placing her in a chair. Staff #7 is then removed from the TV lounge. Staff are able to move Patient #1 to the other side of the room (out of video range). Staff failed to remove the three patients in the lounge prior to the confrontation with Patient #1, putting them a risk for injury and/or trauma.

Interview on 02/25/16 at 10:45 AM with Staff #5 revealed there is no formal protocol or policy related to staff securing the patient care unit during a psychiatric emergency.

Based on surveillance video review, interview, document review and policy review the facility did not provide preventing and managing crisis situations (PMCS) training to all appropriate staff, specifically, Hospital Public Safety Officers (HPSO) and Hospital Public Safety Assistants (PSA). As a result, patients, staff and visitors were placed at risk for serious harm and/or injury.

Findings Include:

Review on 02/25/16 at 10:30 AM of the psychiatric unit surveillance video dated 02/20/16 revealed at 08:44 PM Staff #7 who is a HPSO and other staff members attempt to restrain Patient #1. Patient #1 is kicking and grabbing at Staff #7. Staff #7 attempts to place handcuffs on Patient #1. Patient #1 bites Staff #7 on the right arm. At 08:46:57 PM Staff #7 strikes Patient #1 in the face three times. A staff member pulls Staff #7 away from Patient #1, placing her in a chair. Staff #7 is then removed from the TV lounge.

Interview on 02/25/16 at 11:20 AM with Staff # 4 revealed the last 2 classes for new HPSO's did not receive Preventing and Managing Crisis Situations (PMCS) training. Staff #7 was hired about 6 months ago and did not receive the training.

Review on 02/26/16 of policy "Preventing and Managing Crisis Situation (PMCS) Training" last revised 2/2015 and policy "Restraint and Seclusion: PSY-071" last revised 12/2014 indicates HPSO's and PSA's are required to attend the 2 day initial PMCS class during orientation and an annual PMCS class.

Review on 02/26/16 of HPSO personnel files for Staff #7, Staff #9 and Staff #10 revealed their job descriptions indicate they are to assists staff in controlling and restraining clients under the directions of professional personnel and receive New York State Office of Mental Health PMCS training during the probationary period. No evidence was found to indicate Staff #7 or Staff # 9 received PMCS training. Staff # 10 received PMCS training 10/1/12.

Review on 02/26/16 of the HPSO/PSA PMCS training list revealed 5 other HPSO's who have not received PMCS training. Additionally, 26 of 62 HPSO/PSA have not received PMCS training within the last year.

Review on 02/26/16 of policy "Preventing and Managing Crisis Situation (PMCS) Training" last revised 2/2015 and policy "Restraint and Seclusion: PSY-071" last revised 12/2014 indicates HPSO's and PSA's are required to attend the 2 day initial PMCS class during orientation and an annual PMCS class.

Based on policy review, document review, and interview, the facility does not require training in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification for Hospital Public Safety Officers (HPSO) or Hospital Public Safety Assistants (PSA) who utilize restraint and seclusion techniques. As a result, patients and staff were placed at risk for serious harm and/or injury.

Findings Include:

Review on 02/26/16 of policy "Preventing and Managing Crisis Situation (PMCS) Training" last revised 2/2015 and policy "Restraint and Seclusion: PSY-071" last revised 12/2014 indicates HPSO's and PSA's are required to attend the 2 day initial PMCS class during orientation and an annual PMCS class.

Review on 02/26/16 of policies revealed no evidence of a policy for training of staff on first aid techniques and certification in the use of cardiopulmonary resuscitation.

Review on 02/26/16 of HPSO personnel files for Staff #7, Staff #9 and Staff #10 revealed job descriptions do not require first aid techniques and certification in the use of cardiopulmonary resuscitation and/or similar training as required by regulation. No evidence was found to indicate Staff #7, Staff #9 or Staff #10 have first aid techniques and certification in the use of cardiopulmonary resuscitation training.

Interview on 02/26/16 at 4:15 PM with Staff # 1 revealed HPSO and PSA's are not required to have first aid techniques and certification in the use of cardiopulmonary resuscitation or have similar training.

Based on medical record review and policy review, nursing staff did not supervise and evaluate the care for Patient #3, specifically, the provider was not notified of a blood glucose reading below 50. Failure to notify the provider could potentially result in adverse patient events.

Findings Include:

Review on 02/29/16 of the nursing note dated 11/22/15 at 08:34 AM revealed at 07:30 AM, Patient # 3's fasting glucose sugar is 43. There is no evidence in the medical record indicating the provider was notified.

Review on 02/29/16 of policy "Diabetes Mellitus, Care of the Patient: NUR-043" last revised 09/2015 and policy "Glucose: Blood Monitoring at the Bedside: NUR-070 " last revised 08/2014 revealed staff are to report blood glucose readings to the provider that are less than 50.

Based on medical record review and policy review, the provider failed to document the assessment of Patient #5 after being assaulted by another patient. There was a potential Patient #5 could have been seriously injured.

Findings Include:

Review on 02/25/16 of the nursing note for Patient #5 dated 02/20/16 at 07:30 PM indicated another patient (Patient #1) grabbed Patient #5 by the hair, forcing her to the ground and kicked her. The Nurse Practitioner came to assess Patient # 5.

Review on 02/16/16 of policy "Assessment and Reassessment of Patients: CLIN-003" last revised 09/2015 revealed the physician reassessment will be documented in the progress note section of the medical record.