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812 GORMAN AVENUE

ELKINS, WV 26241

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on document review and staff interview it was revealed the facility failed to ensure nursing and security staff completed Crisis Intervention Institute (CII) safety training to provide patient care in a safe setting. This failure was identified in twelve (12) out of twenty-seven (27) nursing staff and five (5) out of five (5) security staff. This failure has the potential to place all patients and staff on the psychiatric unit at risk for injury.

Findings include:

1. A review of policy "Crisis Intervention" with an effective date 10/18 states in part: "All behavioral health and other designated team members will be required to successfully complete CII certification course within their first ninety (90) days of employment and must recertify annually thereafter."

2. A review of the job description for the Registered Nurse (RN), revised 12/28/18, states in part: "Performs Crisis Interventions."

3. A review of the job descriptions for the Licensed Practical Nurse (LPN), revised 10/28/19, certified nursing assistant (CNA), revised 12/28/18, and patient care assistant (PCA), revised 12/28/18, states in part: "Maintains established departmental policies and procedures."

4. A review of the job descriptions from "Psychiatric Medical Care (PMC), Senior Life Solutions" for the RN, LPN, CNA and PCA states in part: "Qualifications, CII training will be provided."

5. A review of the psychiatric unit's staffing list and list of employees who have CII training revealed twelve (12) out of twenty-seven (27) nursing staff and five (5) out of five (5) security staff have not received CII training.

6. An interview with anonymous staff #2 was conducted on 10/29/19 at approximately 8:10 a.m. When asked if staff had what they needed to provide safe care to patients they stated in part: "I've not had any CII Training. Sometimes I have to call security but they are uncomfortable."

7. An interview with the lead employee relations and employment specialist was conducted on 10/29/19 at approximately 2:10 p.m. When asked if CII was a requirement for staff on the psychiatric unit she stated in part: "PMC never notified Human Resources CII was a requirement. ... It was not put in our tracking system."

8. An interview with Nurse Manager (NM) #1 was conducted on 10/29/19 at approximately 2:40 p.m. When discussing CII training requirements of staff working on the psychiatric unit she concurred staff should have received training according to their "Crisis Intervention" policy.