Covenant Health releases internal review recommendations from Villa Caritas
July 5, 2012
Covenant Health is releasing a number of recommendations being implemented following an internal review at Villa Caritas. The internal review was initiated after a patient’s death in February 2011. Villa Caritas provides health care to seniors with acute care mental health needs.
“As an organization, we are committed to reviewing the circumstances of tragic events and looking for ways to improve our policies, procedures and facilities to reduce risks to all our patients,” says Scott Baerg, VP Operations, Mental Health Services. “This process is not about laying blame; it is about learning and putting that learning into action.”
A full review of patient care processes and the physical space and environment was conducted, which means the recommendations are not directly related to one incident.
The recommendations fall into three main areas: risk assessment, controls over a patient’s access to certain personal items and design features in some rooms. The end goal is improved patient care.
“We have made solid progress implementing many of the recommendations with some complete. Observation levels have been changed and our frontline staff have received training, keeping in mind training needs to be on-going,” says Baerg. “Funding is also in place for the modifications to the physical space, which we expect to start soon.”
The recommendations from the internal review have been shared with the patient’s family and Alberta Health Services.
Villa Caritas Quality Assurance Review Recommendations
1. Standardize policies and procedures for the assessment and management of suicide risk.
2. Change frequency of rounds for patients on close observation to every 15 minutes around the clock.
3. Standardize observation checklist to improve the ability to monitor people who are at increased risk and be able to document accordingly.
4. Standardize Covenant Health’s Mental Health program acute care documentation.
1. Restrict which items can be brought into the facility based on the risk assessment of the patient.
2. Recommend families participate in orientation, which includes a discussion about patient safety processes such as unsafe items.
Modify two rooms on two different units (total of four rooms) for patients at increased risk of suicide.
1. Install closed-type grab rails and enclose plumbing fixtures.
2. Remove towel bars and replace with flip-down hooks designed to support only the weight of a bath towel.
3. Install break-away closet bars.
4. Ensure closets have the ability to lock.
5. Ensure handles in the room are designed so they cannot be used as an anchor point.
6. Shorten call bell cords.
7. Ensure fitted sheets are free of elastic.
8. Replace bathroom mirror with shatter-resistant product.
1. Educate all frontline staff about environmental risk factors and environmental interventions for higher risk patients.
Rayne Kuntz, Media Relations Senior Advisor
W 780.735.9930 C 780.246.2523
Covenant Health is Canada's largest Catholic health care organization with over 14,000 physicians, employees and volunteers serving in 12 communities across Alberta. A major provider in Alberta's integrated health system, Covenant Health works with Alberta Health Services and community partners to positively influence the health of Albertans through a broad range of programs and services. www.covenanthealth.ca