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Based on observation, interview and record review the facility failed to provide patients with the phone numbers of the State agency if they wanted to file a grievance. This would affect all patients. The facility census was 65.

Findings included:

1. Observation on 03/14/12 at 10:00 AM showed a bulletin board on the wall of 2C nursing unit. The bulletin board showed notices of numbers for patients to call if they had a grievance. The State agency number was not listed.

2. Record review of the undated Patient Handbook provided by the administration did not list the State agency numbers for patients to call if they had a grievance.

During an interview on 03/14/12 at 10:20 AM Staff C, Director of Clinical Treatment and Alternative Services, stated that the State agency numbers were not contained in the Patient Handbook or on the bulletin board in order for a patient to call if they had a grievance.

Based on interview, restraint training review, and personnel file review, the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to restraint use. This failure impacts all patients placed in restraints. The facility census was 65.

Findings included:

1. During an interview on 03/14/12 at 12:30 PM, Staff T, Clinical Nurse Educator, stated that he does the orientation for new nursing staff (Nurses and Psychiatric Assistants). Staff T stated that Psychiatric Assistants are trained on four topics related to first aid (how to ask patients questions about their medical problem, seizures, bleeding and burns). Staff T stated that training was done only at the time of hire and is not specific to restraint situations. Staff T stated that nurses do not get this training because nurses should know how to perform first aid.

During an interview on 03/12/12 at 3:30 PM Staff C, Director of Clinical Treatment, stated that Psychiatric Assistants would be the staff assigned to observe patients in restraints.

2. Record review of the facility restraint training showed no first aid training related to restraint use. From 12/12/11-3/12/12 there were 33 physical restraint holds and 16 mechanical restraints applied to patients.

Record review of Staff J, Psychiatric Assistant, personnel file showed no first aide training related to restraint use.

Record review of Staff K, RN, personnel file showed no first aid training related to restraint use.

Record review of Staff M, RN, personnel file showed no first aid training related to restraint use.

Record review of Staff N, Psychiatric Assistant, personnel file showed no first aid training related to restraint use.

Record review of Staff O, Psychiatric Assistant, personnel file showed no first aid training related to restraint use.

Record review of Staff P, Psychiatric Assistant, personnel file showed no first aid training related to restraint use.

Record review of Staff Q, Psychiatric Assistant, personnel file showed no first aid training related to restraint use.

Record review of Staff R, RN, personnel file showed no first aid training related to restraint use.



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