HospitalInspections.org

Based on review of the personnel file for one of the mental health associate, it was determined that the hospital failed to ensure an applicant for employment was eligible for employment.

On October 18, 2013 the surveyor reviewed the personnel file of a mental health associate, employee #1. The personnel file was incomplete lacking high school education verification. The employee's personnel file contained an unofficial transcript. The hospital stated they had sent two verification requests regarding the employee's education and that they were informed that the school the employee attended was no longer in existence. The hospital sent a request to the school district but had not received a reply. At the time of the survey there was no official verification of the employee's education. The standard level background investigation includes the following:
? Analyzed Social Security Number Search
? County Criminal Records Search
? Statewide Sexual Offenders Registry Searches
? National Sex Offenders Database Search
? Education History Verification
? Basic Employment History Verification
The hospital failed to verify employee #1' s educational background. The employee has been working at the hospital since 2/13/12 and at time of survey, the Human Resource Department had not verified the employee's education.

Based on review of 1 out of 13 medical records, it was determined that while the nurse performed the face to face evaluation, the nurse fails to address the patient's medical and behavioral condition as required by this regulation as evidenced by:.

Patient #3 was placed in seclusion on October 3, 2013 at 1:45 PM. The face-to-face was completed at 2:10 PM by the nurse. Although the face-to-face was performed in a timely manner the face-to-face evaluation failed to include all required elements. The documentation regarding the patient's behavioral and medical condition was incomplete. The nurse documented that the patient was alert and oriented x4 with no physical distress. On October 4, 2013 the patient was again placed in seclusion at 11:50 AM and 4:24 PM for assaulting staff. The face-to-face was again incomplete due to insufficient behavioral and medical evaluation.

Based on review of the facility ' s restraint and seclusion policies and procedures on 10/18/13 revealed that a policy for death reporting of patients in restraints and seclusion could not be found. In addition, a log for patients in soft wrist restraints could not be located in the facility's tracking documentation. Interview of the facility's Director of Health Information on 10/18/13 at 4 pm revealed that: 1) the facility has not had any deaths in restraints; 2) there was a lack of awareness or knowledge about the required soft wrist restraint tracking log; and 3) confirmed that there was no policy and procedure that outlined these requirements.