HospitalInspections.org

Based on document review, record review and staff interview it was determined the hospital failed to ensure the nursing staff followed the support team policy, pertaining to staff debriefing and form completion following a Crisis Consultant Group (CCG) hold, for three (3) of the four (4) records reviewed in which patients underwent a CCG hold (patients #1, 7 and 9). Failure to debrief staff and complete/submit the appropriate form following a CCG hold has the potential to negatively impact the safety of both patients and staff during a CCG incident.

Findings include:

1. Review of the hospital policy entitled, "Support Team", effective 11/16/15, revealed the policy states, in part: "Any anomalies or issues during a support call will be addressed during debriefing...The NCC or designee is responsible for holding a debriefing with staff members involved in any incident of seclusion/restraint. The post-incident debriefing will occur as as soon as possible after each incident. Discussion will include precipitating factors to the event, lesser measures taken, identify steps in the process that could have prevented the use of seclusion/restraints, and discuss any problem issues of patient or staff injury, damage of property etc. The NCC or designee will complete the CCG debriefing form and route the form to the Nurse Manager. The Nursing Department will compile data from the debriefing forms and forward the results to the CQI Committee according to the quarterly reporting calendar."

2. Review of the medical record for patient #1 revealed there was an incident on 12/2/15 involving a CCG hold. There was no documentation in the record to indicate a CCG debriefing staff form was completed and submitted to the Nurse Manager, per policy.

3. Review of the medical record for patient #7 revealed the patient had multiple incidents involving a CCG hold. There was no documentation in the record to indicate a CCG debriefing staff form was completed and submitted to the Nurse Manager, per policy.

4. Review of the medical record for patient #9 revealed the patient had multiple incidents involving a CCG hold. There was no documentation in the record to indicate a CCG debriefing staff form was completed and submitted to the Nurse Manager, per policy.

5. On 12/30/15, support team meeting logs were requested for review to determine whether staff had been debriefed following a CCG hold. After checking with the Interim Chief Nurse Executive, the Chief Compliance Registered Nurse stated there were no records of staff debriefing for the above noted records.

6. Health Service Worker (HSW) #1 was interviewed on 12/28/15 at 11:25 a.m. and stated he was not offered a debriefing following a CCG hold he participated in on 12/2/15.

7. HSW #2 was interviewed on 12/28/15 at 12:23 p.m. and he stated he was not offered a debriefing following a CCG hold he participated in on 12/2/15.

8. HSW #3 was interviewed on 12/30/15 at 8:04 a.m. and he stated he was not offered a debriefing following a CCG hold he participated in on 12/2/15.

9. The above findings were reviewed and discussed with the Chief Compliance Registered Nurse on 12/30/15 at 12:31 p.m. and she concurred with the findings. She stated that after every CCG hold the patient and staff should be provided debriefing, and she concurred the above noted records had no documentation of staff debriefing following a CCG hold.