HospitalInspections.org

Based on staff interviews, review of seven (7) of seven (7) staff education files, and review of facility policy, procedure, and documents, it was determined that the facility failed to implement their stated plan to re-educate staff to reinforce safe patient handling of a difficult patient following a reportable incident.

Findings include:

Reference: Facility policy titled "Educational/Competency Plan" states, " ... . Policy: Education is a continuous process's designed to ensure the delivery of quality care to individuals and their families. It is based on regulatory, accrediting, organizational, and departmental specific standards. ... . V. Continuing Education Programs: Continuing Education Programs are offered to employees based on staff's and/or Director's identified needs and request, findings from PI [Performance Improvement]/Quality/Risk Activities ... . A copy of the employee's attendance at the program is provided by the employee to the Director and is placed within the employee's Educational file. ... ."

1. On 8/10/2021 at 1:50 PM, upon interview with Staff #4 and Staff #11, the following was indicated:

a. Staff #4 and Staff #11 stated that following an incident involving patient to staff and staff to patient physical contact, which occurred on 7/21/2021, their staff were debriefed on appropriate ways to respond to and handle a difficult patient. Staff #11 stated he/she met with staff to reinforce this through verbal education. Staff #4 and Staff #11 also stated that every staff was instructed that re-education on the module "Handling Difficult Patients in the Behavioral Health Center" was required and that the module was reassigned for them to complete in Net Learning. Furthermore, Staff #4 and Staff #11 stated that this requirement was communicated to the staff during daily safety huddles. Staff #4 states that education completions are tracked on the Staff Member's Net Learning Transcript.

(i) On 8/11/2021 at 10:35 AM, Staff #1 stated that their safety huddles are informal, and they do not keep notes nor any other documentation of the context nor content of the huddles.

2. On 8/10/2021 at 3:00 PM, a facility document dated "7/21/21 8:50 AM" was shared and indicted that a patient (Patient #1) reached behind with his/her left arm, struck staff (Staff #18) and scratched his/her neck. The staff member (Staff #18) responded by striking the patient with an open hand. The police were notified.

a. On 8/11/2021 at 11:00 AM, Staff #5 confirmed that Staff #18 was terminated following this incident in accordance with the Performance Management Decision Guide.

3. Upon staff interviews, the following was indicated:

a. On 8/11/2021 at 11:15 AM, Staff #19 stated that there was an incident involving a patient (Patient #1) and a staff member (Staff #18) in July 2021. The patient was on fall risk and a few staff were needed to monitor him/her. He/she was uncooperative and had aggressive tendencies. He/she was scooting down the hall in his/her chair. Staff #19 stated that him/herself and Staff #7 were trying to redirect the patient and the patient was swinging his/her arms. Staff #18 tried to redirect the patient from swinging and the patient scratched his/her neck and he/she swatted his/her arm away. After the incident, Staff #11 discussed the incident with him/her. Staff #19 was not aware of huddles but stated that off going staff do communicate events/occurrences to incoming staff between shifts. He/she was not aware of being assigned or instructed to complete any new education. He/she stated BEST [Behavioral Emergency Safety Training] is required annually.

b. On 8/11/2021 at 11:30 AM, Staff #7 stated that he/she does not feel that that they have enough training or that opportunities for refreshment to the training's are offered.

4. On 8/11/2021 at 2:30 PM, upon review of the Staff Education files of Staff #7, #8, #9, #18, #19, #20, and #24, the following was unavailable:

a. The facility was unable to produce evidence that re-assignment to complete the Module titled, "Handling Difficult Patients in the Behavioral Health Center" was pending as being assigned to the above staff because of the occurrence of the July 21, 2021 incident.

5. The above findings were confirmed by Staff #1 and Staff #2.