HospitalInspections.org

Based on a review of clinical records, facility documentation and interviews with staff, the facility failed to ensure the right to care in a safe setting.

Findings were:

On 12-14-13 at approximately 5:00 pm, patient #1 eloped from the child/adolescent unit's courtyard by climbing and jumping over the fence during outdoor recreation time. The patient was returned to the unit shortly after 5:30 pm by law enforcement personnel. No documentation was found in the clinical record for patient #1 to indicate that he was searched for contraband after his return to the unit.

Approximately 5 minutes after his return to the unit, patient #1 placed staff #13 in a choke hold and held a rusty fork to her neck.

Facility policies #NAR 25 titled Patient Searches while in Needs Assessment and Referral and #1.10.09 titled Patient Searches revealed no instructions regarding safety searches of patients for contraband or weapons following their return to the facility after an elopement.

In an interview with staff #17 on 2-4-14, she was asked if the facility had created a policy following this incident that would provide instructions for searching the patient following an elopement. Although staff #17 produced a policy (not yet approved by the Governing Body), the policy contained no provisions for searching a patient returning after an elopement and removing contraband harmful to staff members and other patients on the unit.

The above was confirmed in an interview with the Director of Health Information, Corporate Directors of Clinical Services, PI/Risk Manager, Chief Executive Officer and Director of Nursing the afternoon of 2-5-14 in the facility conference room.

Based on a review of documentation, the facility failed to ensure the patient's right to safe implementation of restraint or seclusion by trained staff.

Findings were:

Facility policy #HR-EP titled Competency - Initial & Annual states, in part, "II. PROCEDURE: ...2. On an annual basis, according to schedules developed by training and development, the staff member must: ...g. Attend Handle with Care training appropriate to their level of patient care."

Facility policy #SS 01.06.01 NSG 01.05.04 titled Handle with Care states, in part, "POLICY: All staff involved in direct patient care will be trained in therapeutic interventions to control dangerous or self injurious behaviors. The method used at River Crest Hospital is Handle with Care. Training will be required annually and is the responsibility of the employee. Training must be completed within 30 days of hire."

A review of the personnel file for staff #13 revealed that her Handle with Care training had been completed within 30 days of her hire date of 5-1-12 but retraining did not occur until
1-1-14.

The above was confirmed in an interview with the Director of Health Information, Corporate Directors of Clinical Services, PI/Risk Manager, Chief Executive Officer and Director of Nursing the afternoon of 2-5-14 in the facility conference room.

Based on a review of clinical records and facility documentation, the facility did not maintain an adequate number of registered nurses, licensed practical nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program.

Findings were:

A review of the staffing grid, patient census and assignment sheet for 12-14-13 on the child/adolescent unit revealed that the census was 15 patients on the 2nd shift (2pm to 10pm). One of the patients was on a 1:1 observation level. Of the remaining 14 patients, 4 were to be observed on line-of-sight precautions. For 14 patients, the staffing grid called for:
? 1 Registered Nurse
? 1 Licensed Vocational Nurse
? 2 Mental Health Technicians

Actual staffing on the 2nd shift, child/adolescent unit was as follows:
? 1 Registered Nurse
? 1 Licensed Vocational Nurse
? 1 Mental Health Technician

On 12-14-13 at approximately 5:00 pm, patient #1 eloped from the child/adolescent unit's courtyard by climbing and jumping over the fence during outdoor recreation time. The patient was returned to the unit shortly after 5:30 pm by law enforcement personnel. No documentation was found in the clinical record for patient #1 to indicate that he was searched for contraband after his return to the unit.

Approximately 5 minutes after his return to the unit, patient #1 placed staff #13 in a choke hold and held a rusty fork to her neck.

The above was confirmed in an interview with the Director of Health Information, Corporate Directors of Clinical Services, PI/Risk Manager, Chief Executive Officer and Director of Nursing the afternoon of 2-5-14 in the facility conference room.