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Based on interview, record review, and observations, the facility failed to carry out the functions of the governing body in holding itself responsible for compliance with the conditions of participation, and the standards required for participation. The governing body did not take action to separate intensive treatment patients from other patients in the facility. This lead to aggressive and abusive situations for patients. The governing body did not ensure nursing staffing was adequate for all units and failed to ensure separation of nursing staff between certified and non-certified units. The governing body did not take proactive steps to ensure the environment was safe, based on the unique needs of the patient population. Findings include:

IMMEDIATE JEOPARDY

On 1/13/17 at 4:10 p.m., the facility Chief Executive Officer, Chief Financial Officer, Director of Nursing, Director of Clinical Services, Human Resource Director, Director of Quality Improvement, and Administrative Assistant, were notified that an immediate jeopardy existed in the area of Governing body, A043. On 1/13/17 at 4:57 p.m. the facility's Division Administrator was notified of the immediate jeopardy by telephone to include the aforementioned areas.

PLAN TO REMOVE IMMEDIACY

An acceptable plan to remove the immediate jeopardy was received on 1/20/17. The removal of the immediacy was verified onsite by the State Survey Agency on 1/25/17 at 4:35 p.m. Once the immediacy was removed, the deficiency remained at the Condition Level.

Findings Include:

Staff interviews and record reviews between the dates of 11/29/16 and 1/13/16 showed the administrative staff were aware of the co-mingling of the non-certified and certified patient populations on the E-Wing and the Intensive Treatment Units. Further, interviews and record reviews showed that the administrative staff were aware, and made plans to have E-Wing nursing staff provide care for the Intensive Treatment Unit patients. Much of the care provided was conducted when Intensive Treatment patients were in the E-Wing with the certified patients. This mingling of patients and staff lead to increased opportunity for aggression and abuse between patients. See Condition tags A115 and A385.

Staff interviews and record reviews, conducted between 11/29/16 and 1/13/17, showed a lack of effective oversite in the conditions of participation under A115, ensuring patient rights: A385, ensuring adequate nursing staff to provide for the care of the patient population, and preventing the sharing of nursing staff between certified and non-certified units.

Additionally, the facility failed to meet the Conditions of Participation for A528, appropriate oversite of radiologic services in the facility and by contract; and, A747 development and application of an effective infection control program.

During an interview regarding the IJ on 1/13/17 at 5:30 p.m., staff member A met with the survey team in the conference room. The team clarified that the governing body was being included in the IJ, and a governing body plan would need to be included in the facility plan to remove the immediacy. This meeting was requested by the team to ensure staff member A had been made aware of this IJ concern and to clarify any questions staff member A may have had. Staff member A stated he was not aware of whom the governing body would be, but perhaps thought it was himself.

On 1/15/17 at 2:30 p.m., a plan for the governing body IJ concern had not been received. Staff member A was again approached about the need for a plan to remove the immediacy at the governing body level. Staff member A had additional questions on how the governing body functioned as it pertained to the facility. It was then clarified with Staff member A that the governing body would be defined in the policies of the facility, and that these may provide guidance for him. Further, it was discussed that this policy could be located on the facility's online website, if the policy was not available in the building.

Refer to the named conditions of participation and the standards under those conditions for details.

Based on observation, interview, and record review, the facility failed to ensure patients were safe in their environment by co-mingling non-certified and certified patients of the ITU unit and the E-Wing, and by sharing staff between the two units. The facility failed to ensure adequate staffing on all units due to chronic shortage of staff. This practice resulted in patient assaults for 5 (#s 8, 18, 19, 31, and 32) of 38 sampled and supplemental patients, and assaults on patients from the ITU Unit. See tag A145. The facility failed to ensure the bathrooms, built in bathroom fixtures, bedrooms, doors and door handles, fire doors and exits doors, were designed and constructed for the unique needs of the patient population. See tag A144.

IMMEDIATE JEOPARDY

On 1/13/17 at 4:10 p.m., the facility Chief Executive Officer, Chief Financial Officer, Director of Nursing, Director of Clinical Services, Human Resource Director, Director of Quality Improvement, and Administrative Assistant, were notified that an immediate jeopardy existed in the areas of Patient rights, A144 and A145. On 1/13/17 at 4:57 p.m. the facility's Division Administrator was notified of the immediate jeopardy by telephone to include the aforementioned areas.

PLAN TO REMOVE IMMEDIACY

An acceptable plan to remove the immediate jeopardy was received on 1/20/17. The removal of the immediacy was verified onsite by the State Survey Agency on 1/25/17 at 4:35 p.m. Once the immediacy was removed, the deficiency remained at the Condition Level.

Findings Include:

Throughout the survey process, interviews with staff and patients revealed chronic, pervasive, staff shortages. The shortages resulted in co-mingling of patients from the ITU and the E-Unit. Observations were made of the A/B/E units, the Spratt unit, Therapeutic Learning Center, Recovery Center, common areas of the main building and the Chapel. Numerous safety concerns with the design and construction of bathrooms, bathroom fixtures, faucets, float glass mirrors (non-safety glass for pyschiatric patients), door closures, and with door knobs with door locks. See A145 and A392.

Record reviews reflected numerous patient-to-patient verbal and physical assaults on the E-unit, between E-unit and ITU patients. Unless otherwise ordered, all patients had access to the bathrooms on an unsupervised basis anywhere from 15 minutes to one hour. At the 15 minute patient checks, a verbal response was accepted by staff as an adequate indicator of safety from the patients in the bathrooms. Staff said an order from a physician would be required for strict one-on-one observation, and for staff to be present in the bathrooms with the patients. See A144 and A145.

Based on observation, interview, and record review, the facility failed to ensure the environment was safe for the type of patients served in the facility. The facility failed to design and maintain safe bedrooms, shower rooms and bathrooms in 3 of 3 certified wings in the main building (A, B, and E), the Spratt building, the activities building, recreation therapy, and the chapel areas. Bath, showers, sinks, door (bathroom, bedroom, corridor, and exits), had protruding hardware that could be used as anchor points for strangulation. Mirrors were made of float glass. Eight patients (#s 14, 16, 33, 34, 35, 36, 37, and 38) of 38 sampled and supplemental patients had a history of suicidal ideation and/or previous suicide attempts. Findings include:

1. During observations on 11/30/16 at 11:00 a.m., the patient showers on E-wing were inspected. Seven of seven shower rooms had objects (shower knobs, hooks, faucets, door knobs) which could be used as hanging devices. Also, the mirrors in these rooms were made of glass which could be broken and used for cutting purposes. Patient room doors opened inward, with door stops on the corridor side, but rooms on the end of each unit were not visible from the control room. The mirrors in the patient rooms were made of float glass.

During an interview on 11/30/16 at 4:00 p.m., staff member K stated no one had broken a mirror or tried to hang themselves in any of the showers. He stated that all the door closures had been removed after one patient had tried to hang themselves. Staff member L stated that patients were allowed to use the bathroom unattended for up to an hour, but there were other patients which were checked on every fifteen minutes, and then there were a few patients that were one-on-one observations around the clock.

2. During an observation of the B-Wing bathrooms (B110, B113, B116, B124, B130, B133,) which included shower facilities, showed all of the mirrors were glass. The shower stalls included temperature adjustment knobs and hand held shower head hooks that could potentially be utilized as hanging devices. All doors on the bathrooms locked from the inside.

During an interview on 11/29/16 at 1:10 p.m., staff member R said, if the patient was not on 15 minute checks, they would be allowed up to an hour in the shower. The frequency of checks on the patient would be determined by their assessment at the time. She said if a patient was on a suicide watch, they would be watched all of the time.

During an interview on 11/30/16 at 4:00 p.m., staff member K said he thought the hook in the shower could "possibly" be used as a hanging feature. He said the facility once had an individual try to hang themselves on the outside of a door. He said he could not recall any incident of someone trying to break a mirror and hurt themselves with the glass. He said he had been at the facility for many years.

3. Patient #14 was admitted to the facility with diagnoses including unspecified schizophrenia spectrum. His medical history included diagnoses of bipolar disorder, and depression "in the past."

A review of the patient's Admission Psychiatric Evaluation, dated 11/27/16, read, "The risk for suicide in this setting appeared to be low, however self-injury risk was moderate based on risk factors such as previous head banging and self-harm, situational stressors, gender, marital status, and labile mood."

A review of Seclusion/Restraint progress notes, physician assessment notes, dated 11/28/16 at 1:35 p.m., read, "Suddenly lowered himself and started banging head on floor forcefully. Opened sutures, significant blood on floor...Appears to be responding to internal stimuli. Aggressive and hostile. Continues to attempt to bang head [on the floor]. + SI 'don't want to live."

A review of Seclusion/Restraint progress notes, LIP assessment notes, dated 11/29/16 at 1:40 p.m., read, "Unprovoked, ran from room into milieu and started hitting his head on floor. Suicidal- 'I just want to kill myself.' Voices telling him he's 'worthless' precipitate event. No [abnormal] movements, appears calm, eyes closed, speech logical/linear, normal rate and rhythm, poor judgment- impulsive."

5. Patient #16 was admitted with diagnoses including bipolar disorder and postpartum psychosis.

A review of the patient's Admission Psychiatric Evaluation, dated 11/25/16, read, "episodes of postpartum psychosis and depression, depressive disorder, adult ADHD and self-reported 'co-dependence issues'; one previous suicide attempt and, per patient herself, many past suicidal gestures/threats without intent; and approximately four brief inpatient admissions who presents with [sic] suicidal ideation...She reported a plan to hang herself upside down in the garage, slit [her] throat and bleed out into a bucket."

During observations on 11/29/16 at 10:40 a.m., the patient shower rooms on the A unit were inspected. Eight of eight shower rooms had water faucets which protruded four inches away from the wall. All eight bathrooms had mirrors made of glass, and all bathrooms could be locked from the inside. One bathroom, room A137, had clothing lying on the floor.

During an interview on 11/29/16 at 10:55 a.m., staff member F stated the hospital had had patients attempt suicide by hanging in the past using clothing. The staff member stated all patients on the A unit had unlimited access to the locking bathrooms, unless the patient was a one on one supervision.

During an interview on 11/30/16 at 4:10 p.m., staff member K stated in the past, patients had attempted suicide by hanging from the door closures.

During a continuation of the facility's survey from 1/10/17-1/16/17, a review of the clinical records for patients #s 33, 34, 35, and 36, showed these individuals had a history of attempted suicide or self harm. Each of the residents had free access to the bathrooms throughout the day and night. Unless specifically ordered by the physician, these residents would not be monitored; except for every fifteen minutes if they were considered a level red, which meant they were on fifteen minute checks. Other residents would only be checked on during the one-hour census check.

During an observation of the B-Unit on 1/10/17 at 8:23 a.m., all mirrors in the bathroom/shower rooms were 18-inch by 36-inch float/tempered glass. All bathroom door handles could be locked from the inside. The shower handles were a single lever water control handle which extended 3.5 inches away from the wall, and were thirty-six inches from the floor. Several bathrooms had a shower wand hook which extended 2 inches from the wall, and all water diverter handles extended 3 inches from the wall. Exit doors had door stops which extended into the corridor. One exit door at the end of the corridor had a closed-loop door handle. All bedroom doors opened into the room and had door stops on the corridor side. These door stops were not visible from the control room when the patient room doors were open. At times staff were not always seen in the hallway.

During an observation of the A-Unit on 1/10/17 at 8:48 a.m., all mirrors in the bathroom/shower rooms were 18-inch by thirty-six inch float/tempered glass All bathroom door handle could be locked from the inside. The shower handles were a single lever water control handle which extended 3.5 inches away from the wall, and were sixty-six inches from the floor. Several airflow vents on the ceiling had louvered vents. Exit doors had door closer which extended into the corridor, and four fire safety doors had door closers extending into the corridor. All bedroom doors opened into the room and had door stops on the corridor side. These door stops were not visible from the control room when the patient room doors were open. At times staff were not always seen in the hallway.

During an observation on 1/10/17 at 8:57 a.m., two white towels had been left on the floor of the bathroom. These towels were not picked up off the floor during the tour of the unit, and could be used as a ligature. At 9:05 a.m., one white towel had been left on a hook of a bathroom. This towel was left in the bathroom during the tour.

During an observation on the Spratt Unit on 1/11/17 at 9:15 a.m., the seclusion room showers contained dual handle faucets which extended 4 inches from the wall. The shower heads were not ligature-resistant and extended five inches away from the wall. These items could be used for an anchor point to use in a suicide attempt.

During an interview on 1/10/17 at 10:00 a.m., staff members U and DD stated patients had pulled mirrors off the walls, in the past, but none of the mirrors had broken. Staff member DD stated louvered vents were only replaced when ruined when patients pulled them down. Staff member DD said that although the current mirrors were not easily broken, they did have a soft spot and would break. Staff member U stated items are replaced with more resistant material when ruined.

During an observation/interview of the Spratt unit on 1/10/17 at 10:25 a.m., staff member U stated the mirror in room 13 had been torn off the wall in the bathroom by a patient. The mirror had not yet been replaced. The bathroom mirror in room seventeen was broken and had been broken for some time, and had not been replaced.

During an observation of the Spratt Unit on 1/10/17 at 10:43 a.m., all mirrors in the patient bathrooms and common shower areas were 12-inches by 12-inches polished stainless steel. However, these mirrors could be repositioned to tilt downward and could pose as a hanging hazard. Hallway doors had door closers which extended into the corridor.

During an interview on 1/10/17 at 11:00 a.m., staff member EE stated the patients had unlimited, and unsupervised, use of the common area bathroom/shower rooms. She stated the bathroom/shower rooms were kept locked and patients needed to request access when needed. She said that some of the patients needed a setup, but that they were independent in the shower. She said if they were not on the bath list they were considered to be independent. There were patients on the units with a history of health issues related to water consumption.

During an observation of the Spratt Unit on 1/10/17 at 11:00 a.m., in the women's shower room, in the 3rd shower bay, and in the middle bay of the Men's shower room, the following were able to be used as anchor points: A grab bar with a slide, a shower wand resting in the bar, and a water diverter which lead to the auxiliary shower head.

During an interview on 1/10/17 at 11:10 a.m., staff member FF said she was a traveler. She said, I know they have a code system for who can go out. However, the staff member was unable to confirm if the facility had one for the shower.

During an observation of the Activities/ Recreational building bathrooms on 1/10/17 at 11:35 a.m., the mirrors were 18-inch by thirty-six inch float/tempered glass. Each toilet stalls had coat hooks screwed onto the stall door. Exit doors had door closers which extended into the bathroom.

During an interview on 1/11/17 at 11:35 a.m., staff member X stated that 15 minute check of a person in a bathroom, on a fifteen minute check, would not always be visualized, and verbal responses from the patient would be acceptable. Staff member X said that patient #38 had locked herself in the bathroom and when staff were able to open the bathroom door, the patient had ripped the mesh shower chair backing off of the shower chair and wrapped it around her neck. The mesh had to be cut away from the patient's neck.

During an interview on 1/11/17 at 11:50 a.m., staff member Y stated that level red patients, unless specified by the physician, would be allowed in the bathroom, unsupervised, for up to 15 minutes. A visual check was not always conducted.

During in interview on 1/11/17 at 12:00 p.m., staff member V stated level red patients were checked every 15 minutes, and unless authorized by a nurse or a physician, continual observation was not conducted. The staff member stated, patient #37 had recently attempted suicide in his bedroom. The patient had barricaded himself in the bedroom and his roommate alerted staff that he could not open the bedroom door. When staff were able to enter the bedroom, patient #37 was lying on the floor with his belt lying next to him. It was believed he had tried to hang himself from the bedroom door knob. This patient was considered a level green, which would have meant the patient was on a one hour check.

During an interview on 1/11/17 at 12:20 p.m., staff member BB stated all patients were checked on every 15 minutes up to one hour. She stated all patients on the A unit had unlimited access to the locking bathrooms, unless the patient was a one on one visual supervision.

During an interview on 1/11/17 at 12:28 p.m., staff member CC stated that level red patients, unless specified by the physician, would be allowed in the bathroom, unsupervised, for up to 15 minutes. A visual check was not always conducted.

During an interview on 1/11/17 at 8:40 a.m., staff member V stated, we are in the process of changing over all of the vents to be flush with the ceiling. He stated, some of the vents throughout the facility had not yet been replaced. At 8:55 a.m., he stated that he thought the mirrors were tempered glass, but tempered glass could still be broken.

A review of the facility's Suicide Precautions policy, revised 4/2016, page 2 of 3, read, "E. Two levels of suicide precautions will be used to address the risk factors presented by the patient. 1. MINIMAL SUICIDE PRECAUTIONS will be implemented for patients who present with a significant risk for suicide or self-injurious behaviors...b. Staff will make visual contact with the patient every 15 minutes or as otherwise specified in the LIP's order and document on the Observation Flow Sheet."

A review of the facility's Treatment and Leisure Pass policy, revised 11/2015, pages 1 and 2 or 5, read, "D. The granting of these privileges is a treatment team decision documentation by a written order from a Licensed Independent Practitioner (LIP) and referenced in the patient's medical record. Treatment Teams will use a color coded system to designate the patient's current treatment and leisure pass privileges, as follows: a. Red- No treatment or leisure pass authorized. b. Yellow- Treatment or leisure pass with staff escort. c. Green- Treatment or leisure pass without staff escort."

A review of the facility's Close Observation policy, revised 5/2016, read, "A. Licensed Independent Practitioner (LIP): ...3. Specify Close Observation by 1:1 observation, or by 15 minute visual checks. Written orders for 1:1 observation should specify 1:1 with constant supervision, close proximity, i.e. six feet, line of sight, discreet, specified area, and specified sleep status...2. 15 minute checks: a. Staff will visualize the patient on 15 minute checks at a minimum of every 15 minutes. b. Staff will document the patient's behavior and the whereabouts of the patient every 15 minutes. c. Documentation is to be done in real time on the Observation Flow Sheet, do not pre enter the times prior to visualizing the patient. d. Staff will monitor and record patient behaviors and immediately report any changes in condition or circumstances that may affect the status of a precaution level to the RN. e. If a patient cannot be located right away notify the RN immediately. f. Staff will carry the close observation flow sheet with them the duration of the assignment. g. Direct care staff will document the patient's behavior once every 8 hour shift in the progress notes of the patient's medical record."

















34603

Based on interview, and record review, the facility failed to provide for the safety of the patient population on the E-Unit (a certified unit), and the ITU (a non-certified unit). The facility intermingled E-Unit patients and ITU patients, on the E-Unit. The facility also intermingled staff between the two units due to the scheduled planning of the facility, and chronic staff shortage. The patients lacked adequate supervision, which resulted in ongoing harassment between patients, including physical, verbal, and emotional abuse. Findings include:

During an interview on 1/10/17 at 4:15 p.m., staff member T stated the ITU patients frequently targeted the E-Unit patients, especially the developmentally disabled population. She said the developmentally disabled population were especially vulnerable to abuse from the other patients, and the facility was seeing more developmentally disabled patients since another (state facility) was in the process of closing. She said E-Unit staffing is responsible for the ITU. She said staffing depends on the census and unit acuity, and a minimal staff is set up, which included two RNs, a medication nurse and five psych techs. She said there was no set staffing for the ITU, and all of the staffing was set up for the E-Unit. Staff member T said if there were patients in the ITU, that was just an extra load for the staff. She said that when the rooms of the ITU Unit were decertified, that left no close observation rooms available for the E-Unit patients. If an E-Unit patient required a close observation placement, they had to be discharged from the E-Unit and moved to another unit.

Staff member T said that tonight (1/10/17) there was only one RN, and a medication nurse. There were eight techs. During this shift there were five one-on-one patients, leaving only three techs to cover the other patients. These techs also had other assignments, such as 15 minute checks and hourly census checks. She said when there were that many one-on-one patients staff hardly provided any visual supervision of the day rooms. Staff member T said a couple of weeks back she was the only nurse on the floor and covered the E-Unit, ITU, and the medication pass for two days. Staff member T said additional techs should be added when there are one-on-one patients. There were currently five one-on-one patients.

Review of staffing schedules between the dates of 12/10/16 to 12/30/16, for all units, showed chronic and frequent variation from the facilities "Ideal MSH Staffing Guidelines."

Review of the incident reports on the E-Unit showed the following physical and verbal altercations between E-Unit and ITU patients:

NOTE: The E-Wing (certified unit) and ITU (uncertified unit) were staffed as if they were the same unit making isolating staffing of one unit from the other impossible.

A record review of facility incidents prior to the survey showed on 10/4/16 at 7:00 p.m., patient #32 was struck on the back of his head by an ITU patient. Based on "Ideal Staffing," the two units were short two RNs and one tech. There were five one-on-one patients, which would normally have required additional tech coverage.

On 12/9/16 at 1:20 p.m., an ITU patient was punched by patient #19 while standing at the nurses station in the E-Unit. Based on "Ideal Staffing," the two units were short two RNs and three techs. There were two one-on-one patients, both from the ITU, which would normally have required additional staffing.

On 12/27/16 at 11:05 a.m., an ITU patient, "became assaultive towards peers and staff in the day hall (E-Unit)." At 11:05 a.m., based on "Ideal Staffing," the two units were short two RNs and two techs. There were two one-on-one patients, both from the ITU, which would normally have required additional coverage.

On 12/27/16 at 5:30 p.m., an ITU patient hit patient #8. Based on "Ideal Staffing," the two units were short two RNs and two techs. There were two one-on-one patients, both from the non-certified unit, which would normally have required additional tech coverage.

During an interview on 1/11/17 at 10:30 a.m., staff members D and M said, "We have minimum numbers of staffing in our heads. Technically speaking, the numbers on the work sheet are what would be ideal staffing. When it (the schedule) calls for two RNs and we only plan for one RN, it was because that was all the staff we had. We spend a lot of time hiring traveling nursing staff. If we don't have enough nurses, the E-Unit nurse covers the ITU. The ITU people (patients) do come out (on to E-Unit), usually with a one-on-one. "My boss said we could have the LPN pass meds to both units." Staff member D and M said, "Oh ya the patients from ITU can get aggressive with patients on the E-Unit."

Based on record review and interview, the facility failed to ensure all radiologists providing interpretive radiologic services were credentialed and granted privileges in the hospital. This could have affected all patients receiving radiological services at the facility. Findings include.

Contract # 13-333-74503-0, was offered by the facility as the radiology services contract between the [contract hospital] and DPHHS. The contract covered PAC services, and did not delineate who would interpret x-rays, or how the credentialing process for radiologists would be conducted between the two entities.

During an interview on 12/2/16 at 12:00 p.m., staff member Q said, "[Contracted hospital] does all of the readings and interpretations, and sends back information. I don't think credentialing is in the contract. We are assuming [contracted hospital] radiology is assuring the credentialing."

During an interview on 12/2/16 at 11:30 a.m., staff member P said, "No, we don't have radiologists here, so there is not a credentialing criteria for a radiologist." At 1:10 p.m., staff member P said, "The facility did not conduct credentialing for anyone [radiologists from tele-medicine hospital], and they [the contracted hospital] did not make any recommendations."

During an interview on 12/2/16 at 1:15 p.m., staff member B said, the facility did not credential the radiologist from [contracted hospital].

On 12/2/16 the DON who supervised radiology, was unavailable for interview.

During an interview on 12/2/16 at 1:39 p.m., a discussion was held with staff member A, regarding the lack of evidence of credentialing for the tele-medicine radiologists, and lack of appropriate oversite in radiology services. Staff member A said he was unable to provide any historical perspective with which to draw insight on this matter, and no further information or documentation was offered.

Based on interview, record review, and observation, the staffing on the E-Wing and ITU were shared between the units; inadequate staffing levels was identified on all units which affected all of the patient population. Findings include:

IMMEDIATE JEOPARDY

On 1/13/17 at 4:10 p.m., the facility Chief Executive Officer, Chief Financial Officer, Director of Nursing, Director of Clinical Services, Human Resource Director, Director of Quality Improvement, and Administrative Assistant, were notified that an immediate jeopardy existed in the areas of Nursing services, A392. On 1/13/17 at 4:57 p.m. the facility's Division Administrator was notified of the immediate jeopardy by telephone to include the aforementioned areas.

PLAN TO REMOVE IMMEDIACY

An acceptable plan to remove the immediate jeopardy was received on 1/20/17. The removal of the immediacy was verified onsite by the State Survey Agency on 1/25/17 at 4:35 p.m. Once the immediacy was removed, the deficiency remained at the Condition Level.

Findings Include:

Observation, and interviews with staff and patients, showed a lack of sufficient numbers of staff to adequately monitor, supervise, and provide for the safety of patients. See A115, and A145. E-Wing (a certified unit) and ITU (an uncertified unit) shared nursing staff, and also suffered from chronic nursing shortages. Review of the daily staffing schedule showed chronic and insufficient staffing on all units to meet the needs of the patient population. The facility provided a compilation of what was considered to be ideal staffing on the units, and this level of staffing was consistently not met. See A392.

Based on record review, interview, and observation, the facility failed to ensure adequate numbers of nursing staff and other personnel, were available on the units. Staff failed to follow their assigned duties at the time of an incident involving a patient breaking three windows at the control station. Staff failed to carry out physician's orders to trim nails every two weeks, as tolerated, for 1 patient (#1) out of 38 sampled and supplemental patients. This area of concern was identified in a complaint and can effect all patients. Findings include:

1. During an interview on 1/10/17 at 4:15 p.m., staff member T stated patients on the ITU and E-Unit had greater opportunity to assault and harass one another because of staffing shortages. She said the developmentally disabled population were especially vulnerable to abuse from the other patients, and the facility was seeing more developmentally disabled patients since another (state facility) was in the process of closing. Staff member T stated only one RN and a medication nurse had been scheduled for that evening's shift. There were eight psych techs and five one-on-one patients, leaving only three psych-techs to cover the rest of the other twenty-one patients, and perform various other duties. Staff member T said a couple of weeks back she was the only nurse on the floor and covered the E-Unit, ITU, and the medication pass, for two days. She said that by far the most difficult part of the job was the staffing shortage.

A review of the staff assignment schedule for the E-Unit/ITU on 1/10/17 showed that at 6:00 p.m., five techs were assigned to one-on-one patients, two techs were assigned to escort patients to dinner, and one tech was assigned to conduct the census check. This schedule would have left no free techs for general supervision of patients (5 ITU and 21 E-Unit patients). There was one RN on staff. Of the patients receiving one-on-one observation, four were patients from the non-certified ITU unit.

A review of the "Ideal MSH Staffing Guidelines," which was developed by the nursing department, and provided by the facility, were as follows:

E-Unit
2 RNs, 1 medication nurse
5 psych-techs

ITU
1 RN
4 psych-techs

A review of staffing for Units A, B, on 1/10/17 at 6:00 p.m., showed the following staffing variances:

The" Ideal MSH Staffing Guidelines", compared to actual staffing-

A Unit- Two RNs and one medication nurse, five psych-techs.
Actual staff- One RN and one medication nurse, six total psych-techs.
There were two one-on-one patients, which would have required additional psych-techs for the safety of the patients.

B Unit- Two RNs and one medication nurse, five psych-techs.
Actual staff- One RN, one medication nurse, five psych-techs.
On this shift there were two one-on-one patients, which would have required additional psych-techs for safety of the patients.

During an interview on 1/11/17 at 10:30 a.m., staff members D and M said, We have minimum numbers of staffing in our heads. Technically speaking the numbers on the work sheet are what would be ideal staffing. When it calls for two RNs and we only plan for one RN, it is because that was all the staff we had. We spend a lot of time hiring traveling nursing staff. If we don't have enough nurses, the E-Unit nurse covers the ITU. The ITU Unit people (patients) do come out (on to E-Unit), usually with a one-on-one. My boss said we could have the LPN pass meds to both units. Staff members D and M said, "Oh ya" the patients from ITU can get aggressive with patients on the E-Unit.

SEE A 145 for details of patient safety related to staffing.

2. A Review of staffing schedules between the dates of 12/10/16 to 12/30/16, for all units, showed chronic and frequent variation from the facilities, "Ideal MSH Staffing Guidelines."

3. Patient #1 was admitted to the facility with diagnoses of end stage Alzheimer's disease, dementia with behavioral disturbance, and a history of falls. Patient #1 required assistance with all of his activities of daily living. The patient was not interviewable.

Review of patient #1's physician order, dated 10/5/16, reflected staff was to trim his nails every two weeks, as tolerated.

Review of patient #1's medication administration record, dated 9/29/16-10/26/16, reflected a physician's order to trim nails every two weeks as tolerated. The box, dated 10/5/16, contained an X with no staff signature. No other documentation was on the record to reflect that the nail care had been completed.

Review of patient #1's medication administration record, dated 10/27/16-11/23/16, reflected a physician's order to trim nails every two weeks as tolerated. No documentation was reflected on the record indicating the nail care had been provided.

During an interview on 11/29/16 at 11:10 a.m., staff member I stated that if the nail care was not documented on the medication administration record, it was not done. She stated staff are required to document refusals if the patient refuses care.

4. During an observation after the IJ was called and monitoring was being conducted, the following occurred in the facility on 1/16/17 at 1:20 p.m. Two psych-techs and two security guards were sweeping up broken glass from the floor in front of the control station, the floor in the control station, and in the nurse room of A-Unit.

During an interview on 1/16/17 at 1:23 p.m., staff member BB stated a patient had broken three windows at the control station at 1:10 p.m., using his bedside table. She stated glass was everywhere, and one psyche-tech had been cut on her hand by flying glass.

During an observation and interview on 1/16/17 at 1:30 p.m., staff assigned to the A-Unit were each asked where they were physically located when the incident occurred, and the following responses were given:

-Staff member HH, the RN, was in the nursing room;

-Staff member JJ, the medication nurse, was in the medication room;

-Staff member GG said that he was on the floor conducting resident checks. He said that he had been the first one on the scene to intervene when the patient started breaking the windows. Staff member GG was hit on the head by the patient;

-Staff member II, a psych-tech, was in the control room and was injured by flying glass;

-Staff member LL, a psych-tech, was in the control room;

-Staff member BB, a psych-tech, was in the nursing room, finishing her lunch;

-Staff member KK, a psych-tech, was in the nursing room, on the computer. Staff member KK said, staff member GG had been conducting the patient checks that had been assigned to him; and,

-Staff member MM, a psych-tech, was in the nursing room seated at the computer. She was monitoring a one-on-one patient.

During the incident, only one psych-tech, GG, was actively on the floor to monitor the 28 patients who were located in the day hall, at the nurses station, and other areas of the A-Unit. That psych-tech was conducting patient checks.

Based on observation, interview and record review, the facility failed to ensure schedule II narcotics were secured properly in the Spratt unit medication room. Findings include:

During an observation on 12/2/16 at 11:25 a.m., a brown paper bag with a box of 5-25 mcg Fentanyl patches, 2 cards of Ambien, and 1 card of Lomotil were sitting on a counter in the medication room.

During an interview on 12/2/16 at 11:30 a.m., staff member H stated she did not realize the brown paper bag with the above medications was sitting on the counter. Staff member H stated the nurse before her was probably going to return it to pharmacy and left it on the counter. She stated the Fentanyl should have been double locked and not sitting in a bag on the counter.

Review of the facility policy and procedure titled Controlled Substances, under the heading Security and Storage, reflected schedule II controlled substances are double locked or stored in an automated dispensing device with appropriate controls in place to assure accountability.

Based on observation, interview and record review, the facility failed to meet professionally approved standards in providing radiologic services, by not developing and implementing policies and procedures. The facility failed to inspect equipment in accordance with manufacturer's recommendations, failed to assure the tele-medicine radiologists were credentialed and privileged in the hospital, and did not identify an individual with radiologic education to provide oversite. The facility failed to conduct quality assessment and improvement activities for radiologic services. Findings include:

1. The facility failed to develop and implement professionally based policies and procedures for radiology services. See A535.

2. The facility failed to perform preventative maintenance on the Bennett/Quantum/Fuji X-ray equipment, in accordance with manufacturer's recommendations. See A537.

3. The facility failed to assure credentialing and privileging of radiologists, and failed to identify an individual with education in radiology to conduct oversite in the radiological services area. See A546.

4. During an interview on 12/2/16 at 10:00 a.m., staff member D said she did not think any quality improvement projects were being conducted in the medical department, which would include x-ray.

During an interview on 12/2/16 at 9:00 a.m., staff member C said, "We do not have a quality improvement program for radiology."

Based on interview and record review, the facility failed to adopt and implement radiological policies and procedures to protect patients. This practice had the potential to adversely affect any resident utilizing radiological services. Findings include:

1. During an interview on 12/1/16 at 9:35 a.m., staff member C said, a hand written document titled, Radiology Positioning and Projections, was the facility's "only" policy and procedure related to radiography. The document described body positioning to be used during radiography.

Another document titled "[Facility] Diagnostic Tests, Preparation," and dated 8/15/2002, was provided by staff member D. The document showed preparations for radiologic diagnostic tests. Many of the tests included in the preparations document were not currently being conducted at the facility, like flouro-barium studies, intravenous pyelogram, sigmoidoscopy, and CT Scan.

A review of the policy and procedure titled, "[Facility] Medical Clinic Services," showed that the "X-ray technician" was responsible for providing x-rays in accordance with a limited permit license.

During an interview on 12/2/16 at 9:00 a.m., staff member C said there were no other policies and procedures for radiology, other than general hospital policies and procedures. Staff member C could not produce policies and procedures for monitoring, safety equipment, or exposure meters. She said, "All we have for policy and procedures are the protocols that were given to us by [another hospital]." Staff member C was unable to identify which professional organization's standards were used to guide the policies and procedures for radiology in the facility.

The facility radiologic services failed to address most areas requiring policies and procedures which should include, but is not limited to:

-ALARA, as low as reasonably achievable, and other safety protocols;
-Policies and protocols to identify patients at high risk for adverse events;
-Equipment and supplies, such as proper fire equipment;
-Training required by personnel permitted to enter areas where radiologic services are provided;
-Training and qualifications required for personnel;
-Required safety equipment;
-Clear and easily recognizable signage;
-Periodic inspections of radiology equipment, exposure meters and badges;
-Limitations on access to areas; and,
-Appropriate shielding.

2. During an observation on 12/2/16 at 9:00 a.m., staff member C was unable to point out any posted safety signage in the radiological services area.

During and interview on 12/2/16 at 9:00 a.m., staff member C said there was no safety signage in the x-ray area. Staff member C said, "We do not have any safety signage."

Based on interview and record review, the facility failed to inspect equipment in accordance with manufacturer's recommendations. This practice had the potential to affect any patient receiving radiological services. Findings include:

During an interview on 12/2/16 at 9:00 a.m., staff member C said a gentleman out of Helena inspects the facility's equipment, and they do the inspection on the aprons.

A review of the [business name] preventative maintenance invoice for the Bennett/Quantum/Fuji X-ray Equipment, showed preventative maintenance was last conducted on 9/10/15 for this equipment.

During a phone call on 12/2/16 at 2:45 p.m., business owner NF1 said, the hospital calls him when they need him to conduct the preventive maintenance on the x-ray equipment. He said the manufacturer's (Quantum) written recommendations for preventative maintenance on the x-ray machine was every 12 months. NF1 said this equipment was not on any kind of alternate maintenance schedule.

Based on interview and record review, the facility failed to have an identified radiologist, who was credentialed and privileged through the hospital, to interpret x-rays. The facility did not have an identified individual who was educated and experienced in radiology, to supervise the radiology services. Findings include:

During an interview on 12/2/16 at 9:00 a.m., staff member C said she was supervised by staff members D and M, who are nurses. She said [contract hospital] read the facility's X-rays, and had a protocol for them to follow for the x-rays. Staff member C said the [contract hospital] never came on site, unless it was for an information technology problem. She said, "We had [physician]. He was certified in radiology, but he moved to [town]. [New physician] replaced him, but he doesn't have the training."

During an interview on 12/2/16 at 10:15 a.m., staff member D said she had spoken to staff member N, and they did not realize that the person who oversaw radiology needed to have training in radiology.

Contract (# 13-333-74503-0), was offered by the facility as the radiology services contract between the [contract hospital] and DPHHS. The contract covered PAC services, and did not delineate who would interpret x-rays, or how the credentialing process for radiologists would be conducted between the two entities.

During an interview on 12/2/16 at 11:30 a.m., staff member P said, "No, we don't have radiologists here, so there is not a credentialing criteria for a radiologist." At 1:10 p.m., staff member P said, "The facility did not conduct credentialing for anyone [radiologists from tele-medicine hospital], and they [the hospital] did not make any recommendations."

During an interview on 12/2/16 at 1:15 p.m., staff member B said, the facility did not credential the radiologist from [contract hospital].

During an interview on 12/2/16 at 12:00 p.m., staff member Q said, "[Contract hospital] does all of the readings and interpretations, and sends back information." She said, "They [tele-medicine hospital] come down and do training if there is a problem. They are not actual supervisors to the department. They would not be responsible for policy and procedure, or have input into the area." Staff member Q said, "I don't think credentialing is in the contract. We are assuming [contract hospital] radiology is assuring the credentialing."

On 12/2/16, the final day of the survey, the DON who supervised radiology was unavailable for interview.

During an interview on 12/2/16 at 1:39 p.m., a discussion was held with staff member A, the administrator, regarding the lack of evidence of credentialing for the tele-medicine radiologists, and lack of appropriate oversite in radiology services. Staff member A said he was unable to provide any historical perspective with which to draw insight on this matter, and no further information or documentation was offered.

Based on observation and interview, the facility failed to ensure the kitchen storage area was properly illuminated and that lighting was properly shielded in food preparation areas. Findings include:

During an observation on 11/27/16 at 9:30 a.m., the large storeroom and the preparation areas of the kitchen were inspected. The storeroom was not illuminated properly as two of four ceiling mounted light fixtures were lit, leaving two opposite corners of the room dark. There were no end caps on several light fixtures over food preparation areas. Two other light fixtures had light shields which were broken.

During an interview on 11/28/16 at 9:30 a.m., staff member J stated that she did not know if the other two light fixtures in the store room worked at all. She knew that the light fixtures over the preparation areas had to have new end caps installed to properly shield the lights.

Based on interview, record review, and observation, the facility failed to effectively design, implement, and evaluate an infection control program. This practice had the potential to affect all patients and staff at the facility. Findings include:

1. The facility failed to appoint an infection control specialist, with specialized training in infection control. See A748.

2. The facility failed to exhibit proper glove use during perineal care, and facility failed to implement and evaluate the infection control program. See A749.

3. The facility failed to identify the deficient functioning of the infection control program, and failed to devote adequate time and resources to the infection control process. See A756.

Based on interview, the facility failed to appoint an infection control specialist, with specialized training in infection control. This practice had the possibility to adversely affect all patients. Findings include:

During an interview on 11/30/16 at 11:40 a.m., staff member D said she was the appointed infection control officer. She said she had a BSN, but had no additional infection control training outside of nursing. Staff member D has been the infection control officer since May 2012.

Based on observation, interview and record review, the facility failed to exhibit proper glove use during perineal care for 1 (#24) out of 30 sampled patients. The facility staff failed to implement and evaluate the infection control program. This practice had the potential to affect all residents. Findings include:

1. Patient #24's medical record reflected diagnoses of incontinence, obesity, left cardiovascular accident, and diabetic neuropathy. The patient required assistance with transfers, and his activities of daily living to include hygiene and toileting.

During an observation on 12/1/16 at 9:05 a.m., staff member G provided perineal care to patient #24. Staff member G washed his hands and donned clean gloves. The patient was incontinent of stool. During perineal care, staff member G touched and used the cleansing solution bottle with his contaminated glove. After providing perineal care, staff member G picked up the patient's pants, adjusted his bedding, and placed a pillow under his head. Staff member G then removed his gloves and placed them in the trash.

During an interview on 12/1/16 at 9:30 a.m., staff member G stated he should have removed his gloves and washed his hands immediately after providing perineal care to patient #24.(1)

Review of the facility nursing procedure titled Incontinent Briefs and Pads reflected, under Disposal of incontinent briefs/pads, staff will follow universal precautions for washing hands and wearing gloves.

REFERENCE

(1)Handwashing, Hand Antisepsis, and gloving CDC recommendations

Gloves should be used as an adjunct to , not a substitute for handwashing.
...3. Change gloves during care of a single client when moving from one procedure to another. (This is critical when moving from a contaminated to a clean body site.)

Sandra F. Smith et al. Clinical Nursing Skills. Basic to Advanced Skills. Sixth Ed. Pearson Prentice Hall. 2004. Ch 14 pg 383.


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2. During an interview with staff member D, the infection control officer, she said the facility had not conducted statistical analysis of infection control data. She said, "I am quite behind on that." Staff member D said the facility did not utilize an infection control criteria, such as McGeer's Criteria. She said the facility did not develop a trending tool, such as facility mapping, but did review the ongoing infection/antibiotic list for possible trends.

Staff member D said the Prevention Coordinating Group was supposed to meet on a quarterly basis. She said, "We are significantly behind on the meeting. I don't think we have met in over a year, but the infections reports do go to the medical staff at least quarterly." She said she did not generally hear anything back from the medical committee.

Staff member D said the current quality improvement plan for infection control was to get the quarterly meeting up and running, and to continue to work with the pharmacy in developing the statistical reports.

A review of the Infection Prevention and Control Plan showed the plan included the elements necessary to monitor, conduct surveillance, trend, analyze, and plan for infection control prevention and staff education. The facility failed to implement all of the elements of the infection control plan.

Based on interview and record review, the facility failed to identify the deficient functioning of the infection control program, and failed to devote adequate time and resources to the infection control process. This practice had the potential to affect all patients. Findings include:

During an interview on 11/30/16 at 1:30 p.m., staff member D, the infection control officer, said she had not compiled statistical infection control data in "quite a while." She said the Infection Control Group had not met in over a year. She said that although the medical staff review the list of infections and antibiotics used, she did not generally hear back from the medical staff regarding infection control.

Staff member D said the facility had switched to a new infection control reporting system that the pharmacy designed.

A review of the comprehensive pharmacy report from 4/2016 to 9/2016 (most current date), showed the facility compiled data regarding infected site, and organism. The facility did not determine statistical significance, did not determine if the infections were health care acquired, did not determine if an infection met a criteria for treatment-such as McGeer's, and did not determine the infectious organisms sensitivity to the prescribed antibiotic. The facility did not identify possible trends in infection control data.