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Based on policy and procedure review, medical record review and staff interview, the facility failed to provide restraint and seclusion training to staff in accordance with facility policy and procedure for 8 of 8 (P1-P8) personnel records reviewed.

Findings:

1. Policy No. Nursing Administration/Inservices/2.10, titled "Procedure: Inservices", reviewed on 3/2/11 at 12:03 PM, indicated under Procedure section, point 1.e., "Inservices for all nursing staff shall occur covering the following mandatory topics in the frequency indicated...Control Technique Training - annually, practice sessions provided monthly."

2. Review of personnel records on 3/1/11 at 1:35 PM, indicated personnel P1 through P8 lacked documentation of monthly practice sessions in Control Technique Training. P1-P4 and P7 and P8 are Registered Nurses and/or Licensed Practical Nurses and provide direct patient care. P5 and P6 are Psych Techs and provide direct patient care.

3. Personnel P5 was interviewed on 3/1/11 at 1:50 PM and indicated the above mentioned personnel records were lacking documentation of monthly practice sessions in Control Technique Training as required per facility policy and procedure, and this training is also known as Restraint/Seclusion training and also includes Bridge Building training. Psych Techs are also required to have this training even though policy states nursing staff. It applies to all staff providing direct patient care.

Based on observation, document review and interview, the facility failed to maintain the facility to ensure an acceptable level of safety.

Findings include:

1. While touring the facility on 3-2-11 at 1115 hours with #S2 and #S8, two (2) unsecured fire extinguishers were observed on the floor in the maintenance area; twelve (12) unsecured fire extinguishers were observed on top of a metal cabinet in the maintenance area; one (1) unsecured oxygen tank was observed on the floor in the maintenance area.
2. While touring the facility on 3-2-11 at 1120 hours with #S2 and #S8, one (1) unsecured fire extinguisher was observed on the floor in the boiler room.
3. While touring the facility on 3-2-11 at 1125 hours with #S2 and #S8, it was observed that there was no eye wash in the area where caustic chemicals are used for water testing.
4. Review of facility document on 3-2-11 lacked evidence that preventative maintenance was performed on three (3) restraint beds or the dietary ovens.
5. Interviews with #S2 and #S8 on 3-2-11 at 1115 hours, 1120 hours, and 1125 hours respectively confirm the findings of unsecured fire extinguishers and oxygen tank.
6. Interview with #S8 on 3-2-11 at 1315 hours confirms preventative maintenance is not conducted on three (3) restraint beds or the dietary ovens.

Based on document review and interview, the infection control committee failed to develop a system to identify and control communicable diseases of facility personnel for 19 of 19 (#B1 - #B12 and P1-6 and P8) employee files reviewed.

Findings:

1. Review of personnel files on 3-1-11 indicated lack of evidence that a reliable immunization/disease history for rubella, rubeola, and varicella was obtained from 12 of 12 (#B1 - #B12) personnel files reviewed.
2. Review of facility policy titled Employee Health on 3-1-11 indicated the following: Personnel with the following conditions shall not be permitted to administer patient care: Active exanthems: Chicken pox, herpes zoster, measles, rubella.
3. Interview with #S9 on 3-2-11 at 1415 hours confirmed a reliable immunization/disease history is not available for employees #B1 - #B12 and the facility does not have a plan in place to prevent staff without reliable immunization/disease history from caring for patients during a community outbreak of rubella, rubeola, or varicella.
4. Review of employee health records at 1:35 PM on 3/1/11, indicated personnel:
a. P1 (R.N.), P2 (L.P.N.) and P5, (Psych Tech) provide direct patient care and lacked documentation of Rubella, Rubeola, Varicella, and Hep B immunity or vaccination and/or communicable disease history.
b. P3 (R.N.), provides direct patient care and lacked documentation of Varicella immunity or vaccination and/or communicable disease history.
c. P4 (R.N.) and P6 (PT), provide direct patient care and lacked documentation of Varicella and Hep B immunity or vaccination and/or communicable disease history.
d. P8 (Agency R.N.), provides direct patient care and lacked documentation of Rubella, Rubeola, and Varicella immunity or vaccination and/or communicable disease history.





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