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Based on observation, interviews, medical record reviews, personnel record reviews, and the process of complaint investigation, it was determined that the hospital failed to meet this Condition of Participation: Patient Rights to protect and promote the rights of each patient. Refer to A0144, A0194, A0196, A0202, A0206, and A0214 for details.

Based on observations, staff interviews, personnel file reviews, policy review, and review of event Root Cause Analysis, the hospital failed to ensure the rights of every patient to receive care in a safe setting.

The findings include:

On August 1, 2011, this surveyor was touring the hospital patient care units. On one unit the surveyor noted that two patient safety tracking rounds on the safety check board were not completed as per the hospital policy. The safety checks were to be completed every thirty minutes. The safety check board showed a census on the unit at the time was 22 and no patients had been checked for two successive checks. When the Chief Nurse Executive (CNE) was asked about this omission of safety checks, she stated: "Staff know that this is inexcusable."

On August 2, 2011, the CNE presented the hospital's Root Cause Analysis (RCA) of the patient event investigated. The RCA showed that Registered Nurse RN that responded to the behavioral code was not current in her training. Her Cardio Pulmonary Resuscitation (CPR) training had expired May 2011 and her Therapeutic Options of Virginia (TOVA) the aggressive behavior intervention program the hospital uses for all appropriate staff involved in direct patient care was also not current. The RCA showed a Psychiatric Nurse Assistant (PNA) responding to the behavioral code was not currently up to date with CPR or TOVA training. And lastly, the RCA showed security staff persons that responded to the behavioral code were not current with their CPR.

On August 2, 2011, the surveyor was reviewing personnel files. Of fourteen personnel files reviewed, four files failed to demonstrate documentation that the staffs' training in CPR was current. The policy for CPR shows that 100% of direct care staff will be trained at orientation and every two years thereafter. Of the fourteen personnel files reviewed, five failed to reflect documentation that the staffs' training in TOVA was current. The policy for frequency of TOVA training shows it to be completed annually.

On August 2, 2011, while interviewing the Training Coordinator and Director of Quality, it was revealed to the surveyor that the overall compliance for staff CPR training was 88.47%. Out of 399 full time and part time employees, 46 staff members were non compliant with CPR training. The information provided also revealed that the hospital showed only 91.89% compliance with TOVA training.

Based on clinical record review, staff interview, personnel record review, a review of facility policies and procedures, and during the course of a complaint investigation, the facility staff failed to ensure the safe implementation of restraints. The facility restraint education and training program was inadequate. All staff members did not receive any training or did not have a current competency training in the safe application of restraints. All current patients had the potential to be affected by this deficient practice. One patient, Patient #1 was restrained by staff members who had no documented training in restraint application or this training was not current. All staff members were not current in CPR certification.

Findings:

On 8/01/2011 and 08/02/2011 two medical facilities inspectors investigated the death of Patient # 1, who had been physically restrained by the facility staff, during or immediately preceding his death. This event occurred on 6/6/2011. Two employees who responded to and participated in the restraint event and subsequent CPR, did not have current CPR training or TOVA (therapeutic options of Virginia- an aggressive behavior intervention program utilized by this hospital).

The facility policy regarding restraints and TOVA, stated the training was required for "all employees who's positions require direct contact or potential contact with patients or residents..." The hospital policy regarding CPR (Cardiopulmonary resuscitation) stated that all direct care staff were required to have current CPR certification. The facility Director (CEO), the Director of Quality Assurance (QA) and the Director of Nursing (CNE) were interviewed on 8/01/2011 at 5:00 p.m. The CNE stated that the policies applied to each person who responded to the restraint of Patient # 1, on 6/6/2011 including the Psychiatric Nursing Assistants (PNA), physician's, registered nurses and psychiatric practical nurses. The Director acknowledged that every staff member who responded to the event on 6/6/2011, which involved Patient #1, were not current in the required training. The Director also stated that the facility did not audit the remaining facility staff, and he did not know if other employees were current in required training throughout the facility-"We did not audit everyone." The Director could not ensure at this time, that each staff member currently deployed to every unit, was current in CPR and TOVA/Restraint applications.

The facility's training curriculum for restraint application and the safe physical management of aggressive patients (TOVA) was reviewed. The TOVA training did not include information to recognize and respond to the signs of physical distress, to include asphyxia, respiratory distress or compromised circulation. The Training Coordinator was interviewed on 8/02/2011 at 9:50 a.m. and evidence of adequate training related to restraints was requested. This evidence was not provided during the survey. The Facility Director and the Director of Nursing were interviewed on 8/02/2011 and evidence of the required training was requested. This evidence was not presented during the survey.

The Facility Director, the Director of Nursing and the Director of Quality Assurance were interviewed on 8/2/2011 at 4:30 p.m. and they acknowledged the above information.


23040

Based on clinical record review, staff interview, personnel record review, policy and procedure review and during the course of a complaint investigation, the facility staff failed to ensure that all staff were trained and demonstrated competency in the application of restraints, monitoring, assessment and providing care for patients in restraints or seclusion.

Findings:

On 8/01/2011 and 08/02/2011 two medical facilities inspectors investigated the death of Patient # 1, who had been physically restrained by the facility staff, during or immediately preceding his death. This event occurred on 6/6/2011. Two employees (Employee # 1 and # 2) who responded to and participated in the restraint event did not have evidence of current competency training or TOVA (therapeutic options of Virginia- an aggressive behavior intervention program utilized by this hospital). One of these employees (Employee # 2), had no evidence of initial (orientation) training or subsequent training in TOVA. Employee # 2's date of hire was 6/25/2008. Additional employee training records were reviewed on 8/2/2011. Five of fourteen employee records reviewed did not evidence current TOVA training.

The facility policy regarding restraints and TOVA, stated the training was required for "all employees who's positions require direct contact or potential contact with patients or residents..." The facility Director (CEO), the Director of Quality Assurance (QA) and the Director of Nursing (CNE) were interviewed on 8/01/2011 at 5:00 p.m. The CNE stated that the policies applied to each person who responded to the restraint of Patient # 1, on 6/6/2011-to include Employee # 2, a Psychiatric Nursing Assistant and Employee # 3, a Security Guard. The Director acknowledged that every staff member who responded to the event on 6/6/2011, which involved Patient #1, were not current in the required training. The Director also stated that the facility did not audit the remaining facility staff, and he did not know if other employees were current in required training throughout the facility-"We did not audit everyone." The Director could not ensure at this time, that each staff member currently deployed to every unit, was current in TOVA/Restraint applications.

The facility's training curriculum for restraint application and the safe physical management of aggressive patients (TOVA) was reviewed. The TOVA and restraint training did not include information ensure staff were trained to recognize and respond to the signs of physical distress, to include asphyxia, respiratory distress or compromised circulation. The Training Coordinator was interviewed on 8/02/2011 at 9:50 a.m. and evidence adequate training related to restraints was requested. This evidence was not provided during the survey. The Facility Director and the Director of Nursing were interviewed on 8/02/2011 and evidence of the required training was requested. This evidence was not presented during the survey.

The Facility Director, the Director of Nursing and the Director of Quality Assurance were interviewed on 8/2/2011 at 4:30 p.m. and they acknowledged the above information.


23040

Based on clinical record review, staff interview, personnel record review, policy and procedure review, and during the course of a complaint investigation, the facility staff failed to ensure the restraint education and training curriculum included how to recognize and respond to signs and symptoms of physical distress.

Findings:

On 8/01/2011 and 08/02/2011 two medical facilities inspectors investigated the death of Patient # 1, who had been physically restrained by the facility staff, during or immediately preceding his death. This event occurred on 6/6/2011.

The facility policy regarding restraints and TOVA, stated the training was required for "all employees who's positions require direct contact or potential contact with patients or residents..." The training curriculum for restraint application and the safe physical management of aggressive patients (TOVA) was reviewed. The training did not include information to recognize and respond to the signs of physical distress, to include asphyxia, respiratory distress or compromised circulation or other signs of physical distress. The Training Coordinator was interviewed on 8/02/2011 at 9:50 a.m. and evidence adequate training related to restraints was requested. This evidence was not provided during the survey. The Facility Director and the Director of Nursing were interviewed on 8/02/2011 and evidence of the required training was requested. This evidence was not presented during the survey.

The Facility Director, the Director of Nursing and the Director of Quality Assurance were interviewed on 8/2/2011 at 4:30 p.m. and they acknowledged the above information.


23040

Based on clinical record review, staff interview, personnel record review, policy and procedure review, and during the course of a complaint investigation, the facility staff failed to ensure all appropriate staff had CPR training. All current patients had the potential to be affected by this deficient practice. One patient, Patient #1, required CPR. Five of fourteen employees reviewed did not have current CPR certification.

Findings:

On 8/01/2011 and 08/02/2011 two medical facilities inspectors investigated the death of Patient # 1, who had been physically restrained by the facility staff, during or immediately preceding his death. This event occurred on 6/6/2011. Two employees (# 1 and #2) who responded to and participated in the restraint event and subsequent CPR, did not have current CPR training.

Twelve additional employee training (total of 14) records were reviewed on 8/2/11. Five of fourteen employees, #1, #2, #3, #4, #5, did not have current CPR certification.

The hospital policy regarding CPR (Cardiopulmonary resuscitation) stated that all direct care staff were required to have current CPR certification. The facility Director (CEO), the Director of Quality Assurance (QA) and the Director of Nursing (CNE) were interviewed on 8/01/2011 at 5:00 p.m. The CNE stated that the policies applied to each person who responded to the restraint of Patient # 1, on 6/6/2011 including the Psychiatric Nursing Assistants (PNA), and security. The Director acknowledged that every staff member who responded to the event on 6/6/2011, which involved Patient #1, were not current in the required training. The Director also stated that the facility did not audit the remaining facility staff, and he did not know if other employees were current in required training throughout the facility-"We did not audit everyone." The Director could not ensure at this time, that each staff member currently deployed to every unit, was current in CPR.

The Facility Director, the Director of Nursing and the Director of Quality Assurance were interviewed on 8/2/2011 at 4:30 p.m. and they acknowledged the above information.


23040

Based on staff interviews and during the course of a complaint investigation, the facility staff failed to report a death associated with the use of a restraint for one patient, Patient # 1.

The findings included:

On August 1, 2011, two Medical Facilities Inspectors (MF) interviewed the hospital Director of Quality Assurance (DQ) and the hospital Chief Executive Officer (CEO). When asked why it took so long to report the death following a patient restraint, the DQ said she thought the regulation applied to mechanical restraints and not physical restraints. The CEO stated, "We know better now."

On August 2, 2011 the surveyor requested for the DQ to provide a copy of the Death Report. The report revealed the death of the patient occurred on June 6, 2011 and the Death Report was dated thirty two days later on July 8, 2011.

Based on staff interviews, review of staff training records, annual evaluations and hospital policies, the hospital's Quality Improvement Organization failed to incorporate quality indicator data to assure staff were being adequately trained.

The findings included:

On August 2, 2011 a Medical Facilities Inspector (MFI) was interviewing the Training Coordinator. She was asked about how staff training records were handled. She explained that she ran a staff training record sheet and distributed it to department heads/supervisors/managers on a quarterly basis. This staff training record sheet lists all staff coming up for annual updates or recertifications. She also said this data ends up with the Quality Improvement Committee (QIC) every quarter. When asked if she attended the Quality meetings she said she did not.

On August 2, 2011 the Director of Quality (DOQ) provided some training record data to the MFI. This data revealed that of three hundred and ninety nine full and part time staff, forty six were noncompliant with their Cardiopulmonary Resuscitation (CPR) training. Of fourteen randomly selected personnel files to review, four were noncompliant with their CPR training. The hospital Root Cause Analysis (RCA) revealed that two staff having responded to the patient code event on June 6, 2011 were not up to date with their CPR training. This data also revealed that only 89.85% of the level three employees were current in their Therapeutic Options of Virginia (TOVA) training for Aggressive Behavior Intervention Program. Level three employees are staff whose positions require hands on treatment to patients. The Hospital Instruction Number 3225 (Policy) on page three states, "The maintenance of certification and scheduling employees for decertification is the responsibility of department heads that will review the certification status of their employees on a regular basis and enroll employees in decertification classes in order to prevent lapses in certification." In Hospital Instruction Number 3266 (Policy) on refresher training/continuing education, page one shows the frequency for TOVA training as "annually." Of fourteen randomly selected personnel files to review, five were not current in their TOVA training. The hospital RCA revealed that two of the staff responding to the patient code on June 6, 2011 were not up to date with their TOVA Training.

On August 2, 2011, the surveyor was discussing staff training with the Director of Quality (DQ) and hospital Chief Executive Officer CEO). The surveyor asked if all staff training records had been looked at after the patient event of June 6, 2011, and were they current at present. The CEO replied that not everyone was audited for compliance after the event and that they did not look at that as a part of the RCA.

On August 2, 2011, four Employee Work Profiles also known as Performance Evaluations(PE) were selected to review. Three out of four of the PE did not address staff being delinquent in their training.
One employee's PE signed on October 22, 2010 states under the Re-Evaluation Information plan for improvement section "Maintain Mandated In-Services." This employee responded to patient code event on June 6, 2011. His hire date was June 25, 2008 and their was no evidence provided that he had ever completed CPR or TOVA. On page one section F of the PE it states "attends mandated in-services as assigned." One Security Staff PE stated on page two section I that, "all training is kept up to date." This employee was hired on December 10, 2002 and there was no evidence he had ever taken CPR till July 7, 2011. This training took place a month after the event. Another PE reviewed of a security staff that responded to the patient event on June 6, 2011 showed the training was not up to date as well. The PE was signed October 8, 2010 and on page two section I it states, "all training is kept up to date." In addition this employee was given a Written Notice on July 10, 2009 for not attending inservice or following supervisors instruction.

Based on observation and staff interviews the hospital executive staff failed to ensure that the ongoing program for quality improvement was being properly implemented and well maintained.

The findings included:

On August 2, 2011, the surveyor was interviewing the hospital Chief Executive officer (CEO) and the Director of Quality (DOQ). The surveyor questioned them if all staff training records had been looked at after the patient event of June 6, 2011 and were all staff current at the present time. The CEO replied that not everyone was audited for training compliance after the event and that they did not look at this aspect as part of the Root Cause Analysis they had conducted.