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Based on interview, record review and policy review, the facility failed to ensure Medicare patients, or their representative, were notified of their discharge appeal rights for seven current Medicare patients (#3, #4, #6, #7, #8, #10 and #16) and three discharged Medicare patients (#1, #2 and #5) of 10 patients whose medical records were reviewed for the signed Important Message from Medicare (IMM). This deficient practice could affect all Medicare patients by preventing them or their representative from knowing their discharge appeal rights. The Behavioral Health Unit (BHU) census was 17. The hospital census was 18.

Findings included:

1. Record review of the facility policy titled, "Notification of Inpatient Medicare Patients of their Discharge Appeal Rights," dated 07/02/07, showed direction for registration staff to issue to all inpatient admissions an IMM form, providing detailed information about their discharge appeal rights, during business hours. Further direction showed that the emergency room staff will complete the process when the registration office closes. The patient or their representative must sign the first page of the two page document.

2. Record review of Patient's #1, #2, #5, #6, #7, #8 and #10 medical record showed there was no IMM signed by the patient or the patient's representative upon admission.

3. Record review of Patient #3's medical record, showed the IMM form with "pt (patient) unable to sign due to condition" next to the date and time of admission. However, additional documentation in the patient's medical record showed that a family member was contacted and gave consent for Patient #3's admission to the hospital and for verification that her rights and responsibilities had been reviewed with her.

4. Record review of Patient #4's medical record, showed the IMM form with "patients copy" written on the signature line, next to the date and time of admission.

During an interview on 10/27/14 at 1:47 PM, Patient #4, a BHU patient, stated that she was never provided with an IMM, and did not sign an IMM.

5. Record review of Patient #16's medical record, showed the IMM form with "READ" on the signature line next to the date and time of admission. Further review of the medical record showed that the patient signed consent for his admission to the hospital and for verification that his rights and responsibilities had been reviewed with him.

During an interview on 10/27/14 at 3:13 PM, Patient #16, a BHU patient, stated that he was never provided with, read or signed the IMM form.

6. During an interview on 10/30/14 at 11:11 AM, Staff A, Emergency Room (ER) Registration Clerk, stated that the IMM form was provided to the patient by the BHU staff upon the patient's admission to the BHU unit. Staff A stated that all other patients who were admitted to the hospital (other than in the BHU), received the IMM from ER registration staff, and signed the IMM at the time of admission.

During an interview on 10/30/14 at 12:55 PM, Staff L, Social Worker (SW), stated that admission staff thought the BHU staff completed the IMM with the BHU patients upon admission, and BHU staff thought admission staff completed the IMM with the BHU patients upon admission.

Based on interview, record review and policy review, the facility failed to ensure patients or their representative, were given the right to make informed decisions concerning their right to formulate an Advance Directive for four current patients (#4, #6, #8, #10) and three discharged patients (#1, #2, and #5) of 10 patients whose medical records were reviewed for Advance Directives. This deficient practice could affect all patients admitted to the hospital by failing to ensure that the patient's Advance Directives were available to medical staff to ensure that the patient's Advance Directives were followed according to the patient's wishes, and by failing to ensure that patients who had not formulated an Advance Directive had the opportunity to do so. The Behavioral Health Unit (BHU) census was 17. The hospital census was 18.

Findings included:

1. Record review of the facility policy titled, "Advance Directives - Patient Self Determination," dated 12/91, showed that individuals have the right to formulate an Advance Directive, and gave directions for admissions personnel to provide written information concerning the individual's right to formulate an Advance Directive at the time of the patient's admission. The policy further showed that when the Advance Directive information was provided, admissions personnel would document such on the Advance Directive Acknowledgement Form. If the information cannot be provided within 24 hours, or the patient is not in a condition to accept the written information, hospital staff will then attempt to contact a family member, next of kin, guardian, or patient's durable power of attorney to determine if an Advance Directive exists.

2. Record review of Patient's #1, #2, #5, #6, #8, #10 showed that the Advance Directive area on the Conditions of Admission and Consent to Medical Treatment was left blank.

3. Record review of Patient #4's medical record showed no Conditions of Admission or Consent to Medical Treatment, and therefore did not indicate if the the Advance Directive information had been reviewed with the patient.

During an interview on 10/27/14 at 1:47 PM, Patient #4, a BHU patient, stated that she was never asked if she had formulated an Advance Directive, never informed of how to formulate an Advance Directive, or given information about formulating an Advance Directive.

4. During an interview on 10/30/14 at 11:11 AM, Staff A, Emergency Room (ER) Registration Clerk, stated that questions related to a patient's formulation of an Advance Directive, and information provided to the patient related to the Advance Directive, was the responsibility of the BHU staff upon the patient's admission to the BHU unit. Staff A stated that all other patients who were admitted to the hospital were questioned about formulation of an Advance Directive, and provided information related to formulating an Advance Directive by the ER registration staff, who would then document the information on the patient's admission record.

During an interview on 10/30/14 at 1:55 PM, Staff J, Nurse Manager, stated that review of Advance Directive information may fall upon the Emergency Department RN, the BHU RN, the Intake Coordinator or the Social Worker.

Based on observation, interview and record review, the facility failed to ensure that they provided privacy to nine Behavioral Health Unit (BHU) patients (#3, #4, #7, #8, #9, #13, #15, #16 and #19) of nine patient who were:
- Made to sleep in the central corridor of the BHU, in front of other patients and other staff, which prevented adequate rest, relaxation and sleep;
- Not allowed privacy for toileting;
- Forced to change their clothes in the central corridor of the BHU and in front of other patients and staff;
- Not allowed appropriate clothing to sleep in at night.
This had the potential to affect all patients who were admitted to the BHU by preventing them from having personal privacy to rest, sleep and change clothes. The BHU census was 17. The hospital census was 18.

Findings included:

1. Although requested, the facility failed to provide a policy related to patient privacy.

2. During an interview on 10/27/14 at 1:47 PM, Patient #4, stated that:
- She was on line of sight (visible by a staff member at all times) observation because she had tried to hurt herself.
- She was not allowed to go to the bathroom without staff observation.
- On 10/26/14 at 1:00 PM, BHU staff removed some of the patients' beds from their rooms, and brought them into the central corridor (area where patients watch television, dine, and participate in groups) for patients' afternoon naps.
- After nap time, BHU staff returned the patient beds to their rooms and locked the patient doors so patients could not get into their rooms.
- At 8:00 PM, BHU staff removed some of the patient beds from their room and placed them in the central corridor for overnight sleep.
- There were five or six patients that slept in the central corridor every night.
- On 10/26/14, BHU staff left the television (TV) on until 2:30 AM, which prevented her from sleeping.
- She hadn't slept since Friday morning.
- BHU staff made the patients who slept in the central corridor wake up at 5:00 AM, and wouldn't let the patients stay in bed because BHU staff had to clear the central corridor of the patient beds for breakfast.

Record review of Patient #4's medical record showed a physician's order dated 10/25/14 for Level III observation (line of sight), as needed.

3. During an interview on 10/28/14 at 1:30 PM and 4:00 PM, Staff L, Social Worker (SW), stated that she had received many complaints from patients that they could not sleep at night in the central corridor. Staff L stated that the sleeping arrangement was wrong. "They can't sleep". Staff L added that there was no consistency in how Level III Observation patients were managed. Some of the Level III observation patients were allowed to sleep in their room, where others weren't. Staff L stated that the complaints of patients not sleeping had been reported to administration, but nothing had changed.

During an interview on 10/28/14 at 10:15 AM, Staff J, Nurse Manager, stated that when an Observation Level III was written "as needed", it was up to the charge nurse to determine if the patient could sleep in their room, or if they would be required to sleep in the central corridor.

During an interview on 11/10/14 at 7:24 AM, Staff V, Registered Nurse (RN), stated that she had worked in psychiatric care for nine years and that it was not a standard of practice to sleep patients together in a centralized area to monitor them. Staff V stated that she believed most of the patients needed to be in their rooms because they couldn't sleep in the central corridor, and for privacy reasons. Staff V added that many times patients were slept in the central corridor without an order for line of sight observation.

4. During an interview on 10/27/14 at 2:20 PM, Patient #9, stated that:
- He was on line of sight observation because he was court ordered for psychiatric hospitalization.
- He slept in the central corridor.
- BHU staff left the TV on almost all night in the central corridor, to watch football or the World Series.
- The TV was loud and made it hard for patients to sleep.
- BHU staff woke up patients in the central corridor at 5:00 AM, which made him feel tired because he only received about two or three hours of sleep a night.
- BHU staff brought patient beds to the central corridor during the day for nap time.
- At times, BHU staff would observe him using the bathroom, and other times BHU staff did not observe him.
- He was required to change his clothes before bedtime in the central corridor, in front of other patients and staff.
- It bothered him that he didn't have a patient room to go to.

5. During an interview on 10/27/14 at 2:46 PM, Patient #7 stated that:
- She was line of sight observation.
- She was required to sleep on a hospital bed at night, in the hallway.
- She had only been allowed in her room two times since admission to change clothes.
- She was required to undress in the hallway one time to change clothes. "Anyone could have seen me".
- During nap time, she was not allowed to go to her room to sleep, and although BHU staff pulled out some patient beds into the central corridor, hers was not one of them.
- BHU staff left the TV and lights on all night, which kept her awake and made her feel exhausted.
- She typically slept nine hours at home, but only got five or six hours of sleep on the BHU.
- She was not able to use the bathroom in her room, and therefore had to use the central corridor bathroom to brush her teeth and wash her face.
- Patients who slept in the central corridor were required to get up at 5:00 AM, because the BHU staff "have to get our beds put up to serve food", while patients who slept in their room were able to sleep until 6:15 AM.

6. During an interview on 10/29/14 at 1:40 PM, Staff E, RN, stated that patients who were on line of sight observation weren't able to take naps after lunch unless they wanted to lay down on one of the couches in the central corridor. Staff E stated that even if they wanted to sleep on the couches, there weren't enough couches for everyone to lay on that were required to stay in the central corridor area during nap time.

7. During an interview on 10/27/14 at 3:13 PM, Patient #16 stated that:
- He was on line of sight observation for recent thoughts of hurting his family.
- He slept in the hallway at night, but was unable to sleep because the TV and lights were left on, because he could hear people walking around, and because one of the patients screamed out all night.
- He was given a room when he was admitted, but was not allowed in the room, and was required to undress in the hallway of the BHU at night.
- During the night, he slept in his boxer shorts, and when he had to use the bathroom, he would walk around the unit in his boxer shorts, in front of other patients, while he tried to find an unlocked bathroom to use. This caused him a lot of "strain".
- If he had pajama pants, he would wear them.
- He had additional clothes in his hospital room, but the room was locked and he could not get to them.

8. During an interview on 10/29/14 at 10:00 AM, Staff P, Technician (Tech), stated that night shift staff should place patients in hospital gowns when the patients go to bed. Staff P stated that she didn't believe the patients were placed in gowns at night, because when she came on shift this morning, there were only two hospital gowns in the dirty clothes hamper, which were the same gowns from the previous day shift.

9. Observation on 10/28/14 at 4:40 AM, showed Patients #8, #3, #15, #9, #13 and #19 lying on hospital beds, recliners and a couch in the central corridor area. One light was on in each of the three halls, and all lights were on in the nurses' station.

During an interview on 10/28/14 at 4:50 AM, Staff B, BHU Charge Nurse, stated that Patient #8, #3, #15, #9 and #13 were required to sleep in the central corridor because they were line of sight observation, and because there weren't enough technicians (techs, similar to a nursing assistant) to be one-to-one (one staff member observes one patient at all times) in the patients' rooms. Staff B stated that line of sight observation patients included patients who were suicidal, homicidal, on oxygen or at high risk for falls. Staff B did not know why patient #19 was sleeping in the central corridor, because he was not "line of sight" observation.

10. During an interview on 10/28/14 at 6:00 AM, Staff B stated that Patient #14 had been sleeping in the hall throughout the night, but was moved to his room because he continually yelled while patients were trying to sleep.

Record review of Patient #14's medical record, showed a physician's order dated 10/23/14 for Level III observation (line of sight).

11. During an interview on 10/28/14 at 6:50 AM, Staff D, Tech, stated that patients who were on line of sight observation could not sleep in their room because they were required to be in the line of sight of staff at all times. Staff D stated that they have had up to 11 or 12 patients on line of sight observation, and couldn't have that many staff working so patients could sleep in their own rooms. Staff D stated that patients who slept in the central corridor got "really agitated" when Patient #14 stated to yell. "He does it all the time when people are trying to sleep". Staff D stated it was hard for patients to sleep in the central corridor, and that Patient #9 only slept about three hours a night since he had been admitted.

During an interview on 10/28/14 at 6:00 AM, Staff C, Tech, stated that it was hard for patients to sleep in the hall at night because the halls were very loud. "See how my voice echoes?" Staff C stated that patient rooms were a better place for patients to sleep because it was dark and quieter. Staff C stated that staff received a lot of complaints from patients that they couldn't sleep. Staff C stated that during the night, patient admissions were completed in the central corridor area. During this time, the vital machine would beep, and staff were required to talk to the patient to get the admission information, which woke everyone up. Staff C added that because the hospital was small, there wasn't enough staff to do one-to-one observation with line of sight observation patients, and therefore the patients had to sleep in the central corridor.

During an interview on 10/28/14 at 2:40 PM, Staff M, SW, stated that she received patient complaints quite often that the patients couldn't sleep while in the central corridor. "I'm sure it affects them and mental health outcomes". Staff M stated that the patients who slept in the central corridor were tired, irritable and didn't participate in groups because of lack of sleep.

During an interview on 10/29/14 at 9:40 AM, Staff O, Certified Nurses' Aide (CNA), stated that when she received patient reports, that patients were reported to get little sleep.

During an interview on 10/29/14 at 10:00 AM, Staff P, Tech, stated that patients complained they didn't get enough sleep in the central corridor and that she worried about the patient's privacy when they slept in front of others.

During an interview on 10/29/14 at 3:45 PM, Staff U, Tech, stated that, "We make people sleep line of sight (in the central corridor), who can't even get out of chairs or their bed. Just because they're on oxygen tubing doesn't mean they're going to harm themselves".

Based on observation, interview, record review and policy review, the facility failed to ensure that psychiatric patients were provided care in a safe setting on the Behavioral Health Unit (BHU), when required 15 minute safety rounds were not completed per facility policy for six patients (#4, #7, #10, #12, #14 and #16) of six patients who were reviewed for completion of safety rounds, and when the facility failed to ensure the documentation of 15 minute safety rounds in their medical record for one discharged patient (#5) of 16 patient records reviewed . This deficient practice could affect all patients on the BHU and had the potential to lead to unrecognized patient injury or self harm. The BHU census was 17. The hospital census was 18.

Findings included:

1. Record review of the facility's policy titled, "Special Precautions Patient Observation Record," revised 09/14, showed directions for the BHU staff to monitor and observe patients on regular 15 minute timeframes to ensure they are medically stable, safe and receiving appropriate treatment. Each patient will have documentation entered onto the Special Precautions Patient Observation Record.

2. During an interview on 10/27/14 at 1:47 PM, Patient #4 stated that she was admitted because she tried to hurt herself by drinking antifreeze, and was line of sight (visible by a BHU staff member at all times) observation. Patient #4 added that BHU staff don't do 15 minute safety rounds, "they sit on their ass".

During an interview on 10/28/14 at 5:00 AM, Patient #4 stated that on the night shift of 10/26/14, she observed two male technicians (techs, similar to a nurse aide), laid down and slept on the couch.

3. During an interview on 10/27/14 at 2:20 PM, Patient #9 stated he was line of sight observation and under a court order and that BHU staff didn't do 15 minute safety rounds. Patient #9 stated that he had seen staff round on patients "maybe" every hour.

4. During an interview on 10/27/14 at 2:46 PM, Patient #7 stated that she was line of sight observation and that BHU staff didn't do 15 minute safety rounds. "Sometimes (they round on patients) every one hour".

5. During an interview on 10/27/14 at 3:13 PM, Patient #16 stated:
- He was on line of sight observation for recent thoughts of hurting his family;
- He slept in the hallway at night;
- That BHU staff didn't do 15 minute safety rounds. "Staff don't come back to where I sleep very often".

6. During an interview on 10/30/14 at 1:55 PM, Staff J, Nurse Manager, stated that he was made aware of staff sleeping and that it had been addressed in a staff meeting seven months ago.

During an interview on 10/29/14 at 10:00 AM, Staff P, Tech, stated that Staff Q, Tech, would brag to her that he slept on the night shifts when he worked.

During an interview on 10/29/14 at 3:45 PM, Staff U, Tech, stated:
- Occasionally there were missing 15 minute patient observations from the previous night shift;
- Staff J and Staff N, Director of the BHU, were made aware of the missing 15 minute observation documentation;
- A night shift staff member was recently found asleep while at work.

During an interview on 10/29/14, Staff R, Licensed Practical Nurse (LPN), stated that it was common knowledge that techs slept during the night shift, and that everyone was aware of it. Staff R stated that Staff T, Tech, was recently found asleep by a day staff member, but there was no follow through by management.

7. During an interview on 10/28/14 at 6:00 AM, Staff B, Charge Nurse, stated that Patient #14 had been sleeping in the hall throughout the night because he was on line of sight observation, but was moved to his room because he continually yelled while patients tried to sleep. Staff B stated that Patient #14 was on line of sight observation and that when he was moved to his room, Staff C, Tech, observed the patient from the hallway for safety.

During an interview on 10/28/14 at 6:00 AM, Staff C stated that Patient #14 was moved to his room, which was in the 200 hall, around midnight. The patient was given a medication for sedation, and then he calmed down. Staff C stated that she stayed in Patient #14's room and observed him until about 3:30 AM, but then had to round on other patients and help get other patients ready for the day, so Patient #14 was left without line of sight observation.

During an interview on 10/28/14 at 10:15 AM, Staff J, Nurse Manager, stated that Patient #14 was on line of sight observation, and should have had someone outside of his door while the patient was in his room, for line of sight observation.

8. During an interview on 10/28/14 at 5:30 AM, Patient #4 stated that she was able to sleep in her room, which was located in the 200 hall, during the night of 10/27/14 (previous nights, the patient was required to sleep in the central corridor for line of sight observation).

9. During an interview on 10/28/14 at 4:55 AM, Patient #7 stated that she was able to sleep in her room, which was located in the 200 hall, during the night of 10/27/14 (previous nights, the patient was required to sleep in the central corridor for line of sight observation).

10. During an interview on 10/28/14 at 6:40 AM, Patient #16 stated that he was able to sleep in his room, which was located in the 200 hall) during the night of 10/27/14 (previous nights, the patient was required to sleep in the central corridor for line of sight observation).

11. Review of recorded video surveillance for 10/28/14, showed the following activity of Staff C:
- From 12:30 AM to 12:37 AM, sat at a table and documented, in the central corridor;
- From 12:46 AM to 1:11 AM, sat in the central corridor;
- From 1:17 AM to 1:28 AM, sat at a table and documented, in the central corridor;
- From 1:30 AM to 1:38 AM, stood at the nurses' station, sat down on a couch, moved and sat at a table, all in the central corridor, and then went back to the nurses' station;
- From 1:40 AM to 1:45 AM, sat at a table in the central corridor;
- From 1:47 AM to 1:58 AM, sat and folded patient clothes at a table in the central corridor;
- From 2:03 AM to 2:18 AM, sat at a table in the central corridor, and then moved to the nurses' station;
- Did not remain in Patient #14's room or in the hall outside of the patient's room for line of sight observation (as previously reported by Staff B and Staff C);
- Did not enter the hall where Patient #4, #7, #14 and #16's rooms were located between 1:17 AM and 1:38 AM, between 1:40 AM and 1:58 AM, 2:02 AM and 2:22 AM.

12. Record review of Patient #4's medical record showed a nurse's admission note dated 10/25/14, that indicated prior to admission, the patient had become suicidal, took over-the-counter sleeping aids and antifreeze before she was brought to the Emergency Department (ED). A physician's order dated 10/25/14, showed the patient was on Level III observation. Review of the patient observation record dated 10/27/14 from 7:00 PM until 7:00 AM (10/28/14), showed that Staff C documented Patient #14 was in her room, in her bed and sleeping at 1:30 AM, 1:45 AM, and 2:15 AM.

13. Record review of Patient #7's medical record showed a Master Treatment Plan dated 10/24/14, which indicated that the patient's number one problem was suicide ideation. The Master Treatment Plan was signed by a physician, a nurse and therapist. Review of the patient observation record dated 10/27/14 from 7:00 PM until 7:00 AM (10/28/14), showed that Staff C documented Patient #7 was in her bed in her room at 1:30 AM, 1:45 AM and 2:15 AM

14. Record review of Patient #14's medical record showed a physician's order dated 10/23/14 for Level III observation (line of sight). A psychiatric evaluation dated 10/23/14, showed that the patient was admitted for Alzheimer dementia with delusions, psychotic disorder, and impulse control disorder. Review of the patient observation record dated 10/27/14 from 7:00 PM until 7:00 AM (10/28/14), showed that Staff C documented Patient #14 was in his bed in his room at 1:30 AM, 1:45AM and 2:15 AM.

15. Record review of Patient #16's medical record showed a Psychiatrist note dated 10/25/14, indicated the patient was admitted with anxiety and suicidal ideation, and was afraid of harming himself, family members or someone else. A physician order dated 10/24/14, showed the patient was on Level III observation. Review of patient observation record dated 10/27/14 from 7:00 PM until 7:00 AM (10/28/14), showed that Staff C documented Patient #16 was in his bed in his room at 1:30 AM, 1:45 AM and 2:15 AM.

Staff C was found to have documented observation of Patient #4, #7, #14 and #16 at times when she was observed on video surveillance not to be in the vicinity of the patient or the patient's room.

16. Record review of Patient #5's medical record showed a History and Physical dated 09/17/14 which indicated that the patient was admitted to the BHU after an attempted overdose on her prescription medications. Although requested, the facility failed to provide patient observation records for her BHU admission between 09/16/14 and 09/18/14.

17. Record review of a census sheet and concurrent interview with Staff F, LPN, showed Patients #10 and #12 were indicated to be patients who were allowed to sleep in their room on the night of 10/26/14, which were located in the 200 hall.

18. Review of recorded video surveillance for 10/26/14 to 10/27/14, along with concurrent interview with Staff H, Risk Manager, showed that none of the staff who were assigned to complete patient observations entered the 200 hall from 10/26/14 at 9:41 PM until 11:13 PM. Staff H verified that no staff were observed entering the 200 hall from 9:41 PM until 11:13 PM, but stated "I have no doubt the checks (patient observations) are being done".

19. Record review of Patient #10 and #12's observation records showed that both patients were documented in their room, in their bed and sleeping at 9:45 PM, 10:00 PM, 10:15 PM and 10:30 PM by Staff D, Tech, and documented in their room, in their bed and sleeping at 10:45 PM and 11:00 PM, by Staff K, Nurses' Aide.

20. During an interview on 10/28/14 at 6:50 AM, Staff D stated that the techs were required to complete 15 minute rounds (patient observations) on every patient, even those who were line of sight observation, and that the 15 minute rounds were always done.

21. During an interview on 10/29/14, Staff R, Licensed Practical Nurse, stated that she had witnessed Staff S, Tech, documenting 15 minute observations before she had done them, and reported it to management. Staff R stated that management had spoken with Staff S about documenting the 15 minute checks ahead of time, but Staff R found Staff S continued to document 15 minute observations before she had done them. Staff R added that there was a lack of management and no follow-through, so people didn't do what they were supposed to do.

22. Record review of Staff S's employment file showed no disciplinary record.

23. During an interview on 10/30/14 at 1:55 PM, Staff J, Nurse Manager, stated that face checks (patient observations) were most important for patient safety. Staff J stated that he was never made aware that face checks weren't done.

Based on observation, interview and record review the facility failed to provide restraint education that included first aid techniques for two staff (C and W) of two staff whose education records were reviewed for restraint training. Patients in restraints are placed at a higher risk for injuries or death. This had the potential to affect all patients placed in restraints. The facility census was 18.

Findings included:

1. During an interview and concurrent observation on 10/30/14 at 11:07 AM, Staff W, Registered Nurse (RN), stated that she received annual restraint education, but the education did not include first aid training. Staff W stated that Emergency Department (ED) staff occasionally placed patients in restraints, or cared for patients who were brought into the ED in restraints. Staff W revealed both leather and soft-wrist restraints in ED storage areas.

2. Record review of Staff W's education record showed that she completed a computer based module for restraint training and CPI training, but there was no additional restraint training listed on Staff W's education record.

Record review of Staff C's, Technician (similar to a nurses' aide), education record showed that she completed a computer based module for restraint training and CPI training, but there was no additional restraint training listed on Staff C's education

3. Record review of a printed, computer-based training module titled, "Restraints", showed it did not contain first aid training.

During an interview on 10/30/14 at approximately 1:15 PM, Staff X, Human Resource Director, stated that the computer based education module did not contain first aid techniques used for patients in restraints. Staff X verified that there was no additional restraint training or education offered to hospital staff, other than Crisis Prevention Intervention (CPI, non-violent measures safe management of disruptive and assaultive behaviors) training, which was held by Staff J, Nurse Manager.

4. Record review of a CPI training manual, provided by Staff J, showed no education related to first aid techniques used with patients in restraints.

During an interview, Staff J stated that he trained hospital staff in CPI, and verified that it did not contain first aid education.