HospitalInspections.org

Based on staff interview and review of hospital policies and personnel restraint training records, it was determined the hospital failed to ensure 6 of 27 direct care staff (#2, #5, #22, #23, #24, and #25) were current in restraint competencies. This directly impacted one patient (#2) reviewed who was restrained by a staff member whose Mandt certification had expired. It had the potential to compromise the quality and safety of patient care. Findings include:

A hospital policy, "Restraints," dated 6/10/09, referred to the "Mandt training" for information related to restraint interventions, such as the "Staff Holding Technique," and the "Transport Technique". The hospital restraint-related policy, "Mandt Training," dated 8/21/09, described Mandt training as a non-violent crisis intervention system designed to facilitate the safest environment for patients and staff and to protect the rights and dignities of hospitalized patients. Day 1 of training focused on conceptual aspects, such as how to build healthy relationship, communication, conflict resolutions, etc., while Day 2 focused on technical skills (including restraint procedures) required. After completing both days, employees received certification in the training. The certification required renewal after 12 months.

During an interview with the Director of Staff Development on 1/28/10 at 10:40 AM, she explained that all direct care staff were expected to receive "Mandt" training at hire and annually thereafter. Some of the staff were only required to complete the first day while others were required to complete both days of training.

When asked for information to verify staff's current restraint competencies, the Director of Staff Development presented a roster of 27 direct care staff. During an interview on 1/28/10 at 2:15 PM, she stated that in reviewing staff education records, she found that 6 out of 27 employees (#2, #5, #22, #23, #24, and #25) were not current on their annual recertification for Mandt training. Two of the employees were RNs (#2 and #5) while 4 of the employees were non-RN clinical staff (#22, #23, #24, and #25). There was evidence in the restraint records that one of the RNs (Staff #2) had restrained Patient #2 on 3 occasions (12/13/09, 12/28/09, 12/29/09) after his annual certification of Mandt training had expired June 30th, 2009. Restraint documentation for a restraint incident that occurred on 12/13/09 involving Staff #2 and Patient #2, documented Patient #2 sustained a "bruised lip" as a result of restraint. During an interview with the Director of Staff Development on 1/28/10 at 11:30 AM, she stated that Staff #2 should not have participated in restraining patients until he was recertified.

During an interview on 1/28/10 at 11:50 AM, the Director of Nursing also confirmed the lapse in Staff #2's Mandt training certification.

Based on staff interview and review of hospital policies, and personnel records, it was determined the hospital failed to ensure 9 out of 27 direct care staff (#8, #9, #11, #14, #16, #17, #22, #23, and #27) had evidence of current CPR certification. It also failed to ensure that 27 out of 27 direct care staff (#s 1-27) had evidence of first aid training specific to the needs of restrained patients. This had the potential to compromise the quality and safety of patient care. Findings include:

Surveyors requested evidence of current CPR competencies for direct care staff. During an interview with the Director of Staff Development on 1/28/10 at 2:45 PM, she stated that 9 out of 27 direct care staff (#8, #9, #11, #14, #16, #17, #22, #23, and #27), all of whom were non-RN clinical staff, were not current on their CPR certification. She explained that it had not been their policy or practice to require non-RN clinical staff to have current CPR certification. She stated she did not realize it was a requirement.

She also stated, during the above referenced interview, that she was not aware of the requirement that all direct care staff involved with restraints were required to have first aid training. She explained that the hospital had not provided or tracked first aid training with any staff. Therefore there was no evidence of first aid training for the 27 employees (#s 1-27) who provided direct patient care. During the interview, the Director of Staff Development and the Director of Nursing stated they would develop and deliver appropriate first aid training to direct care staff in order to be in compliance with the requirements.

A hospital policy, "Restraints," dated 6/10/09, stated that an appropriate number of staff would be available at all times who were competent to initiate first aid and CPR. It did not specifically state that all staff involved with caring for restrained patients were expected to be current in CPR certification and be trained in first aid. During an interview on 1/28/10 at 2:45 PM, the Director of Nursing stated he would update the policy to more accurately reflect the requirement for all direct care staff to have first aid and CPR training.