HospitalInspections.org

Based on a revisit review, it was determined that the hospital failed to implement a Plan of Correction re-training to improve Restraint/Seclusion interventions for which the Performance Improvement Council was responsible.


Interview with multiple staff on 9/12/2017 revealed differing responses to the question regarding staff re-training on restraint and seclusion. Interview with a staff nurse in the emergency department on the morning of 9/12 revealed she had no new restraint/seclusion training, and that she expected to receive general annual training in October 2017.
Interview with a quality representative in the afternoon of 9/12 revealed that "huddles" had been done with nursing to disseminate re-training information, though a subsequent request for training logs revealed no logs were kept by which to monitor which RN's had huddle training and which had not.

A request for employee file training documentation revealed that no new training had been added to any RN employee files related to restraint and seclusion.

Review of the hospital Plan of Correction revealed three "Rounds of training" regarding approved restraint devices, and training and competency. However, no evidence of such training was found.

Based on this, the hospital failed to implement restraint and seclusion training as described in the Plan of Correction