HospitalInspections.org

Based on review of facility policy and procedure, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure behavioral unit staff were qualified and demonstrated competency by participating in a seclusion/restraint skills lab annually per facility policy for four of four nursing personnel files reviewed hired greater than 12 months (PF1-4).

Findings include:

Review of facility policy and procedure on October 16, 2015, revealed, "SHARON REGIONAL HEALTH SYSTEM ... Process/Title: Restraints Policy # 20 ... Originated: 1/92 ... Revised: ... 4/11 ... Definitions: Qualified Staff - Qualified staff refers to all hospital personnel who have completed the hospital-wide, annual Seclusion/Restraint Skills Lab and demonstrated appropriate competency."

Review of personnel files on October 16, 2015, at 12:00 PM revealed that four of four nursing personnel files lacked evidence of annual seclusion/restraint skills lab competency.

PF1 was hired on 6/13/2011, and contained an annual seclusion restraint skills lab competency dated 6/2/14.

PF2 was hired on 3/10/2006, and contained an annual seclusion restraint skills lab competency dated 6/4/14.

PF3 was hired on 8/20/2012, and contained no annual seclusion restraint skills lab competency.

PF4 was hired on 1/9/2012, and contained no annual seclusion restraint skills lab competency.

Interview with EMP3 on October 16, 2015, at 3:30 PM confirmed the above findings. When surveyor asked EMP3 if it was acceptable for annual competencies to be completed late, he/she replied, "I would prefer that it not be."

Based on review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that care assignments were made in accordance with the individual needs of patients on the Behavioral Health Unit; including, but not limited to, two of two patients requiring one-to-one observation (PT1 and PT3).

Findings include:

Review of the Sharon Regional Health System Behavioral Health Services Policy # 12.001, "Suicide Risk Assessment & Reassessment for Behavioral Health Services," originated March 2015, revealed, "Definitions ... One to One (1:1): Consists of one to one staff observation with a patient never farther away than arm's length. ... Procedure ... Level 1 Imminent Risk- One-to-One Observations ... Staff Responsibilities: The patient will remain within arm's length of the staff member at all times. ... If a patient is placed on 1:1 observation the designated team should assess the acuity of the milieu and determine the need for additional resource allocation. If additional resources are needed, the Manager on call should be consulted. ... e. Grooming/Hygiene: ... The assigned staff remains in arms length of the patient during toileting and bathing. The staff member should be of the same sex as the patient when possible. In the event the same sex staff person is not available, two staff members must be present. ... h. Group Attendance: ... the 1:1 assigned staff member remains with patient during all activities."

1. Review of facility computer print-out census sheets for the Inpatient Behavioral Health Unit on October 3, 2015, revealed a combined census of fourteen patients, ten adults and four adolescents.

2. Review of staffing documentation for October 2, 2015, at 11:00 PM through 7:00 AM on October 3, 2015, revealed two combined nursing staff present on the Adolescent and Adult sections of the Adult Inpatient Behavioral Health Unit. Additional review revealed that between 4:15 AM and 6:45 AM, there were two patients (MR1/PT1 and MR3/PT3) on one-to-one observation. Further review of staffing documentation did not reveal a third staff member present between 4:15 AM and 6:45 AM on October 3, 2015.

3. Review of MR1/PT1 revealed that on the morning of October 3, 2015, PT1 was ordered one-to-one monitoring, and every fifteen minutes (Q15 min.) checks.

Review of a Behavioral Health Patient Observation form for MR1, dated October 3, 2015, revealed no 15-minute entries for PT1 between 4:15 AM and 6:45 AM.

4. Review of MR3/PT3 revealed that on the morning of October 3, 2015, PT3 was documented as being monitored one-to-one, and every fifteen minutes (Q15 min.).

Review of a Behavioral Health Patient Observation form for MR3, dated October 3, 2015, revealed no 15-minute entries for PT3 between 4:15 AM and 6:45 AM.

5. On October 16, 2015, at 11:30 AM, when asked if the definitions and procedures for Policy 12.001 applied to any orders for 1:1 etc., EMP11 stated, "Yes. It is the newest policy." When asked if, per the policy, could a staff member watch more than one 1:1 patient, EMP11 stated, "No. Not by the policy." When further asked if only two staff were assigned for both sides (one staff for Adolescent and one staff for Adult sections of the Adult Inpatient Behavioral Health Unit) with more than one patient ordered 1:1, would the two staff be available to monitor/care for other patients, EMP11 stated, "No. ... They would not."

6. On October 16, 2015, at 11:50 AM, when asked if there was any documentation that a third staff member was present or assigned to monitor MR1 (1:1) between the hours of 4:15 AM and 6:45 AM on October 3, 2015, EMP11 stated. "Not yet. That is what we are trying to figure out." (On October 16, 2015, at 4:00 PM, no documentation was provided that PT1 was observed as a 1:1, or that additional staff were present on October 3, 2015, between the hours of 4:15 AM and 6:45 AM.)

7. At approximately 12:21 PM on October 16, 2015, when asked if two staff assigned to two 1:1 patients, in addition to other patients, met [his/her] expectation for one-to-one observations, as ordered for PT1 and PT3, EMP4 stated, "It's a problem. ... I found out about that problem [October 3, 2015 staffing], ... staffing the next day. ... I was not happy. ..."