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Based on medical record review, review of hospital policy and staff interviews, the hospital failed to meet the requirement because the hospital was unable to provide documentation that restraint competencies were met for all staff members that provided care for Patient #1 with a restraint and with a complaint regarding restraints.

Findings Include:

A. Review of the medical record in part for Patient #1 on 12/04/18 at 12:00 p.m. in an office revealed in part that on 06/23/18 at 2248, Staff #3 completed a Face to Face Evaluation within 1 hour of Patient #1 having been placed in a chair restraint on 06/23/18 with a start time of 2210.

B. The hospital policy #10011 entitled, "Restraint and Seclusion," with an original publication date of January 1996 was reviewed on 12/06/18 at 12:10 p.m. in an office and stated the following in part:

Staff Training and Competence
1. Staff is to be trained and competent to minimize the use of restraint/seclusion and to assure their safe use.
2. Staff is to be trained of the associated risks of both its use and nonuse.
3. Staff will have validated restraint/seclusion competencies before they participate in any use of restraints.
4. Nursing staff are trained and demonstrate competency during nursing orientation and annually.

To minimize the use of restraint/seclusion, all direct care staff and any other staff involved in the use of restraint/seclusion receive ongoing training in and demonstrate an understanding of the following.

1. The underlying causes of threatening behaviors exhibited by the patients ...
2. That sometimes a patient may exhibit an aggressive behavior that is related to a patient's medical condition and not related to his/her emotional condition.
3. How staff behaviors can affect the behaviors of patients.
4. De-escalation, mediation, self-protection and other techniques such as voluntary time-out.
5. How to recognize signs of physical distress ...

SAMA training (or a program equivalent) is required for all clinical (LVN, RN, MHT) behavioral health staff. SAMA training includes physical holding techniques, the application, and removal of mechanical restraints. The viewpoint of patients who have experienced restraints/seclusion are incorporated into staff training and education, as appropriate, in order to help staff better understand all aspects of restraints/seclusion.

C. During a telephone interview of Staff #3 on 12/06/18 at 3:36 p.m., Staff #3 confirmed that Patient #1 was her patient on 06/23/18 and she completed the Face to Face Evaluation within 1 hour of the patient being placed in a chair restraint.

During an interview of S#1 on 12/10/18 at 10:35 in an office, S#1 was unable to provide restraint competency documentation for Staff #3, the nurse who completed a Face to Face Evaluation within 1 hour of Patient #1 having been placed in a chair restraint on 06/23/18. During an interview of Staff #1 on 12/11/18 at 10:25 a.m. in an office, Staff #1 confirmed that neither she, human resources nor the education department could provide restraint competency documentation for Staff #3.