HospitalInspections.org

Based on document review and interview, the Governing Body failed to ensure the hospital implemented a comprehensive and integrated Performance Improvement Plan.
(Cross Refer to QAPI Condition - 482.21)

Findings include:

The facilities Governing Board Bylaws stated on page 2: "The Board of Trustees shall cooperate with and assist the medical staff and other health care professionals providing patient care services, in implementing systems to review and evaluate the quality and efficiency of care delivered within the hospital and receive periodic reports on general findings of specific recommendations resulting from review and evaluation activities."

Administrative policy and procedure #781.100.30 titled "Performance Improvement Program" stated on page 2 under "Authority for the Performance Improvement Plan" that the "Board of Directors shall have the final authority and responsibility for a flexible, comprehensive and integrated Performance Improvement Program."

Administrative policy and procedure #781.100.13 stated at #3: "The Performance Improvement Council shall include all the members of the management team and shall be chaired by the Hospital Medical Director or his designee."

Monthly Performance Improvement Meeting minutes for the current year beginning with meeting of 01/19/10 thru 03/31/2011 did not have attendance of the Medical Director or his designee. Monthly meetings also did not have review of quality indicators for the following hospital departments:
A) Electro Convulsive Therapy (ECT) an in-patient and out-patient service
B) Radiology (a contract service)
C) Laboratory (a contract service)
D) Intensive Outpatient Program -IOP (out-patient service)
E) Partial Hospitalization Program - PHP (out-patient service)

Interview with the hospital Administrator (ID# 1) on 4/21/11 at 1:30 p.m. confirmed the Medical Director was not chairing the Performance Improvement Council and the lack of a comprehensive performance improvement plan that included ECT, Lab, Radiology, IOP, and PHP.

Based on interview and record review the Hospital failed to develop and maintain an effective Hospital-wide quality assessment and performance improvement program. The Hospital failed to involve all hospital departments (Departments not represented in the quality assurance meetings for 2010 and 2011 included: Radiology, Laboratory, Out-patient Electroconvulsive Therapy (ECT) department, Intensive Outpatient Program, and the Partial Hospitalization Program)

Findings include:

Record review of "Performance Improvement" meetings for 2010 and 2011 (1/19/10; 2/16/10; 3/25/10; 4/13/10; 5/18/10; 6/22/10; 7/20/10; 8/17/10; 9/16/10; 10/14/10; 11/6/10; 12/14/10; 1/18/11; 2/15/11; and 3/24/11) revealed no quality indicators / information for the the following departments: Radiology, Laboratory, Out-patient Electroconvulsive Therapy (ECT) department, Intensive Outpatient Program, and the Partial Hospitalization Program

The Director of Quality Assurance (ID# 37) acknowledged 4/21/11 at 11:15 a.m. the Hospital has not established quality indicators for the Radiology, Laboratory, Out-patient Electroconvulsive Therapy (ECT) department, Intensive Outpatient Program, and the Partial Hospitalization Program

Record review of a policy titled "Performance Improvement Program" dated 02/09 stated "Delegation of data collection, measurement, and assessment activities will be assigned to appropriate committees or departments and supported by the Quality Management staff, to meet the goals and objectives. Important outcomes of these activities will be reported to the Quality council. A listing of departments and committees requiring indicators follow: Hospital Departments: Partial Hospitalization... Contract services: Radiology and Laboratory..." The ECT out-patient department was not discussed in the "Performance Improvement Program."

Based on record review and interview, facility's registered nurse failed to supervise the care of patients to ensure staff implement every 15 minutes suicidal monitoring as ordered by the physician in the treatment plan for 3 of 8 patients on precaution of a sample of 36 patients. #s1, 5 and 19

Findings:

Review of the facility's current policy and procedure on Suicide precaution # 760-500.32 revised 05/09 directed staff as follows: " Patients exhibiting a high risk potential for suicide by: verbalization of intent, exhibiting suicidal tendencies; or recent history shall be placed on suicide precautions. The patient shall be observed every 15 minutes and the observation documented on the " Special Observation Record " . Documentation shall occur in the progress notes by the RN every shift. Any unusual occurrence shall be immediately documented. "


Patient # 1
Review on 04/19/11 of patient #1 ' s clinical record Demographic Data/ Psychiatric assessment dated 01/13/2011 revealed the patient was admitted to the facility on 01/13/2011 with chief complaint " I want to die. "
Review of a psychosocial history dated 01/13/2011 revealed the following documentation: " Attempted suicide took overdose of pills - took 5 pills and was caught. Tried to hang myself. "

Further review of the patient ' s clinical record revealed a physician ' s order dated 1/12/2011 and transcribed 01/13/2011 for Suicidal and Elopement precaution and unit restriction first 24 hours.

Review of a physician ' s progress note dated 01/14/2011 revealed the following documentation: " BK of multiple attempts of Suicide. Monitor pt very closely. "

Review of patient #1 ' s observation record for 01/14/2011 from 5:30 p.m. to 10:15 p.m. revealed no evidence that the patient was monitored every 15 minutes as ordered by the physician The sections on the observation record which indicted patient monitoring were blank from 5:30 p.m. to 10:30 p.m.

Patient #5
Review on 04/20/2011 of patient #5 ' s clinical record revealed the patient was admitted to the facility on 03/16/2011 with admitting diagnosis of Mood Disorder .
Review of the patient ' s history and physical dated 03/17/2011 documented that " pt started a fire yesterday in his bathroom . He has a history of two previous fires "

Review of the patient ' s clinical record revealed an initial admitting order dated 03/16/2011 for Assault precaution and unit restriction first 24 hours.

Subsequent review of the patient ' s clinical record revealed a physician ' s order dated 03/20/2011 for " TO. R/T unpredictability. "

Review of the patient ' s observation record Q 15 minutes dated 03/20/2011, revealed no indication documented that the patient was monitored every 15 minutes from 3:15 p.m. to 06:40 p.m.

On 04/20/2011 at 4:00 p.m. in facility's conference room, the surveyor notified facility's director of nursing that patient #S 1 and 5 were not monitored every 15 minutes as ordered by the physician. The director of nursing reviewed patients #S 1 and 5's clinical records and confirmed that Q 15 minutes monitoring was not done as ordered by the physician.

Patient #19
Patient # 19 was observed at the nurses ' station on 04/20/2011 at 9:15 a.m. receiving medication.
The patient was alert and responded appropriately to questions asked by the nurse.

Review of the patient ' s clinical record ( history and physical ) revealed she was admitted to the facility on 04/08/2011 with diagnosis of Bipolar Disorder and General Anxiety Disorder.


Review of the patient ' s master treatment plan dated 04/10/2011 documented " Violence Aggression. "
Review on 04/20/2011 of the patient ' s clinical record ( Physician ' s admitting order ) dated 04/07/2011 revealed orders for for unit restriction first 24 hours and suicide precaution

Subsequent review of the patient ' s clinical record revealed a physician ' s order dated 04/17/2011 for " TO. R/T unpredictability. "

Review of the patient ' s observation record Q 15 minutes dated 04/17/2011, revealed no indication documented that the patient was monitored every 15 minutes from 9:45 p.m. to 11:00 p.m.

During an interview with facility ' s charge nurse on 04/20/2011 at 9:15 a.m. the surveyor asked the charge nurse to define T/O. The charge nurse said T/O means transitional observation done every 15 minutes on patients.

The charge nurse reviewed the patient ' s clinical record with the surveyor and confirmed that there was no indication in the record that the patient was monitored every 15 minutes as ordered.

Based on observation, interview and record review, facility nursing staff failed to administer medication as prescribed by the physician in 1 of 5 patients observed during morning medication pass . Patient # 20

Findings:

On 04/20/2011 at 9:30 a.m. patient # 20 was observed at the nursing station of unit 3 receiving morning medication of Lexapro 10 mg tablet orally

Review on 04/20/211 of patient # 20 " s clinical record revealed a physician ' s order dated 04/19/2011 to " DC Seroquel. Seroquel XR 300 mg po Q 1900. "

Review of the patient ' s Medication Administration Record revealed documentation that Seroquel XR 200 mg and Seroquel XR 300 mg orally were administered at 1900 hours and 2100 hours respectively on 04/19/2011.

On 04//20/2011 at 10:00 a.m. the surveyor informed the charge nurse that patient #20 had an order to discontinue Seroquel 200mg and start Seroquel 300mgs XR orally at 19:00 hours. The order for Seroquel 200 mgs was still on the medication administration record, it was not discontinued. The new order for Seroquel XR 300 mg was transcribed to the Medication Administration Record. Documentation on the Medication Administration Record indicated that Seroquel 200mgs and Seroquel XR 300mg 300 mgs were administered to the patient.
The charge nurse reviewed the patient ' s record with the surveyor and confirmed that Seroquel 200 mgs was not discontinued as prescribed by the physician.

Based on record review and interview, the facility failed to ensure patient's medical record was complete in 1 of 5 medical records reviewed for medication #4

Findings

Patient #4
Review of the patient #4's clinical record revealed she was admitted to the facility on 03/09/11 and discharged on 03/24/11 .

Review of the patient's record revealed a physician 's order dated d 03/14/2011 for D/C Seroquel . Seroquel 400 mgs Po QHS.

Review of the patient ' s record revealed no indication that Seroquel 400 mg po QHS was administered.
There was no evidence of a Medication Administration Record in the patient ' s record.

On 04/20/2011 at 3: 30 p.m. the surveyor requested evidence of a Medication Administration Record from the Director of Medical Record. He said he checked his loose record and could not locate it.

During an interview with facility's Director of Nursing on 04/21/2011 at 11:00 a.m. in the conference room, the surveyor requested a copy of the patient's Medication Administration Record. The Director of Nursing stated that she could not locate the patient's Medication Administration Record.

Based on observation, interview, and record review the hospital failed to:
1) dispose of single dose vials of medication once opened on 2 of 2 nursing units (second and third floors) and the Electro Convulsive Therapy (ECT) department crash cart
2) Remove multidose vials of medication after 28 days once opened in the ECT department

Findings include:

Observation 4/20/11 at 1:30 p.m. revealed the following:

Second Floor Medication Room: Inside a drawer was a 10ml vial of Sterile Water that had been previously opened. The label read "singe dose - no preservatives."

Third Floor Medication Room: Inside a drawer was three (3) vials of Sterile Water that had been previously opened. The labels read "single dose - no preservatives."

Electro Convulsive Therapy (ECT) department crash cart: inside a drawer was a 50ml multi-dose vial of Lidocaine that had been previously opened. The vial was not dated as to when it was first opened. Also inside the drawer was a 20ml multi-dose vial of Labetalol that had been previously opened and dated 10/5/10.

The Pharmacist (ID# 25) acknowledged 4/20/11 at 1:40 p.m. that all single dose vials of medication should be discarded once opened and that multi-dose vials of medication should be discarded after 28 days once opened. The Pharmacist stated that the pharmacy policies needed to be updated to reflect the proper use of single and multi-dose vials of medication.

Record review of a policy titled "Pharmacy Department Operational Standards" dated 5/20/10 revealed no policy for single dose vials of medication.

An Immediate Jeopardy (IJ) was identified 4/19/11 at 1:35 p.m. and Administration was notified. A Plan of Correction drafted by the Administrator was reviewed and it was determined the plan was acceptable on 4/21/11 at 3 p.m. The IJ was downgraded to a non-immediate jeopardy.

Based on observation, interview, and record review the Hospital failed to ensure metal shower rods were "break-away" on the 2nd and 3rd patient floor bathrooms therefore presenting a patient safety risk.

(from a total of 34 patient bath rooms; 27 bathrooms had metal shower rods mounted inside the fiberglass shower that were bolted to the fiberglass / not break-away.
Second floor bathrooms: 201, 202, 203, 204, 250, 252, 253, 254, 255, and 257,
Third floor bathrooms: 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 312, 350, 352, 353, 354, 355, and 357)

Findings include:

Observation rounds the morning of 4/19/11 revealed the following non-break-away metal shower rods with a 1/4 inch gap between the metal bar and the top of the fiberglass shower enclosure:
Second floor rooms: 201, 202, 203, 204, 250, 252, 253, 254, 255, 257.
Third floor rooms: 350, 352, 353, 354, 355, 357

Observation rounds the morning of 4/19/11 revealed the following non-break-away metal shower rods with a 1 inch gap between the metal bar and the top of the fiberglass shower enclosure:
Third floor rooms: 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 312

The Administrator (ID# 1) acknowledged 4/19/11 at 10:30 a.m. that recently most of the plastic break-away shower rods were replaced with metal rods. The Administrator further stated the new metal shower rods did not come with any installation instructions pertaining to psychiatric hospitals.

Interview 4/19/11 at 12:30 p.m. with the Maintenance Manager (ID# 3) revealed he completed installing the metal shower rods about two months ago and they are bolted to the fiberglass shower enclosure. The Maintenance Manager stated the old plastic break-away shower rods were replaced because patients would use them as weapons.

Record review of a policy titled "Management of the Environment of Care" dated 01/08 stated "IntraCare Hospitals goal is to provide a safe, functional, and effective environment for patients, staff members, and other individuals in the hospital....The Safety Committee of IntraCare Hospital has oversight responsibility over the implementation, monitoring and reporting annually to the Governing Board."

Record review of "Risk Management Meetings" (Safety meetings) from July 2010 to March 2011 revealed no concerns related to the newly installed metal shower rods.

Record review of a policy titled "Patient Safety Team" dated 02/09 stated "IntraCare Hospital shall maintain a specialized Patient Safety Team to monitor areas of patient safety... The Patient Safety Team shall ensure the education of patients relating to their care, monitor areas of patient care that are likely to pose a risk to patient safety, and report findings with recommendations for corrective actions to the Hospital Risk Management Committee and Medical Executive Committee."

Based on observation, interview and record review the facility failed to ensure dietary staff maintains a cleaning schedule to ensure kitchen equipment, countertops, ledges and floors were clean and free of dust, grease and dirt: The facility failed to ensure non washable food was stored in a manner to prevent contamination. This failed practice had the potential to adversely affect all patients on census, citing one of one kitchen.

Findings:

Observation on 4/20/10 between the hours of 8 am and 8:45 am in the dietary suite revealed the following information:

There were three containers with bulk flour, sugar, and rice located on the floor at close proximity (approximately 2 feet) to the three compartment sink used for pot and pan washing. The containers were placed at a level below the sink posing the risk of contaminating the contents of the containers with dirty water when the sink is used.

Further observation in the kitchen on 4/20/11 at 8:20 am revealed the tiled floor was dirty with crumbs; grease and build up of dirt especially in the corners, under the dish washer, and counters.
The equipment in the kitchen including three refrigerators, the sides of the stove, window panes, the dish washer, ledges and counter tops had heavy build up of dust webs, grease, crumbs and food splatter.

The temperature logs for the refrigerators and two freezers were missing temperature information for April 9-15 and April 18-20.

During an interview on 4/20/11 at 8:35 am in the kitchen with Staff # 37 (Dietary supervisor), she stated there was a weekly cleaning schedule that staffs did not follow. She further stated the temperature for the refrigerators and freezers should be checked daily and the results logged on the temperature chart.

Review of the facility ' s Dietary Policy revised 2003 stated:
" The dietary services department establishes and enforces infection control policies and procedures to minimize the possibility of food contamination and the transfer of infection.

Food is stored at least six (6) inches above floor level to protect against contamination by cleaning or accidental flooding. Food is stored away from overhead pipes.

Temperature checks are documented daily for refrigerated and frozen storage to ensure storage units meet storage temperature guidelines as outlined in the Department ' s Food Storage Policies and Procedure.

A cleaning schedule is posted weekly with specific duties to assure equipment, work surfaces and storage units are maintained at a high standard of cleanliness. Training is provided to appropriate personnel regarding correct interpretation of the cleaning schedule, cleaning procedures and cleaning agents to be used. "

Based on record review and interview the facility failed to
ensue the personnel at the facility designated to notify LifeGift of a patient death and provide necessary information were trained in the referral process, citing two (2) of two designated personnel at the facility staff #s 1 and 2.

Findings:

Review of the facility ' s Organ and Tissue Donation policy dated February 2010 revealed:
" The Administrator or Nursing Supervisor shall be designated as the persons responsible for notifying Life Gift upon each death and providing the necessary information for the referral. "

Review of the LifeGift Donation Center agreement with the facility dated 1/28/10 gave the following information :

" LifeGift agrees to be the sole referral source of the hospital for all organ and tissue placement.

Life gift agrees to assist in training of hospital personnel who are involved in the referral process. Life Gift shall conduct periodic in-service education programs for administrative and professional personnel at hospital regarding the referral and maintenance of potential organ and or tissue donors " .

Review of personnel files for Staff # 1(Administrator) and Staff # 2 (Director of Nursing) revealed no information on their training records that they had the required training on organ procurement.


During an interview on 4/20/11 at 10:45 am in the conference room at the facility with Staff # 1, he stated he was designated to inform LifeGift when there was a death, however he did not receive any training regarding organ procurement.
According to Staff # 1 his understanding was that his only responsibility was to inform lifeGift of a death.

During an interview on 4/19/11 at 2:35pm at the facility with Staff # 2, she stated no one at the facility was ever trained in organ procurement procedure.
According to Staff # 2, she will ensue that all required personnel were trained.

Based on interview, observations, review of hospital policy and review of 39 clinical records the facility failed to ensure compliance with 482.60 which requires compliance with Conditions of Participation for Hospitals.
Findings:

Cross Refer to: B 100

Based on interview, observations, review of hospital policy and review of 39 clinical records the facility failed to ensure compliance with required Conditions of Participation 482.12 Governing Body; 482.21 QAPI; 482.41 Physical Environment.
Findings:


482.12 CONDITION: GOVERNING BODY NOT MET

Based on document review and interview, the Governing Body failed to ensure the hospital implemented a comprehensive and integrated Performance Improvement Plan.

Findings include:

The facilities Governing Board Bylaws stated on page 2: "The Board of Trustees shall cooperate with and assist the medical staff and other health care professionals providing patient care services, in implementing systems to review and evaluate the quality and efficiency of care delivered within the hospital and receive periodic reports on general findings of specific recommendations resulting from reivew and evaluation activities."

Administrative policy and procedure #781.100.30 titled "Performance Improvement Program" stated on page 2 under "Authority for the Performance Improvement Plan" that the "Board of Directors shall have the final authority and responsibility for a flexible, comprehensive and integrated Performance Improvement Program."

Administrative policy and procedure #781.100.13 stated at #3: "The Performance Improvement Council sahll include all the members of the management team and shall be chaired by the Hospital Medical
Director or his designee."

Monthly Performance Improvement Meeting minutes for the current year beginning with meeting of 01/19/10 thru 03/31/2011 did not have review of quality indicators for the following hospital departments:


482..21 CONDITION: QAPI NOT MET

Based on interview and record review the Hospital failed to develop and maintain an effective Hospital-wide quality assessment and performance improvement program. The Hospital failed to involve all hospital departments (Departments not represented in 2010 and 2011 quality assurance meetings included: Radiology, Laboratory, Out-patient Electroconvulsive Therapy (ECT) department, and the Out-patient Partial Hospitalization program)

Findings include:

Record review of "Performance Improvement" meetings for 2010 and 2011 (1/19/10; 2/16/10; 3/25/10; 4/13/10; 5/18/10; 6/22/10; 7/20/10; 8/17/10; 9/16/10; 10/14/10; 11/6/10; 12/14/10; 1/18/11; 2/15/11; and 3/24/11) revealed no quality indicators / information for the the following departments: Radiology, Laboratory, Out-patient Electroconvulsive Therapy department, and the Out-patient Partial Hospitalization program.

The Director of Quality Assurance (ID# 37) acknowledged 4/21/11 at 11:15 a.m. the Hospital has not established quality indicators for the Radiology department, the Laboratory department, the Out-patient Electroconvulsive Therapy department, or the Out-patient Partial Hospitalization program.

Record review of a policy titled "Performance Improvement Program" dated 02/09 stated "Delegation of data collection, measurement, and assessment activities will be assigned to appropriate committees or departments and supported by the Quality Management staff, to meet the goals and objectives. Important outcomes of these activities will be reported to the Quality council. A listing of departments and committees requiring indicators follow: Hospital Departments: Partial Hospitalization... Contract services: Radiology and Laboratory..." The ECT out-patient department was not discussed in the "Performance Improvement Program."


482.41 CONDITION: PHYSICAL ENVIRONMENT NOT MET

An Immediate Jeopardy (IJ) was identified 4/19/11 at 1:35 p.m. and Administration was notified. A Plan of Correction drafted by the Administrator was reviewed and it was determined the plan was acceptable on 4/21/11 at 3 p.m. The IJ was downgraded to a non-immediate jeopardy.

Based on observation, interview, and record review the Hospital failed to ensure metal shower rods were "break-away" on the 2nd and 3rd patient floor bathrooms therefore presenting a patient safety risk.

(from a total of 34 patient bath rooms; 27 bathrooms had metal shower rods mounted inside the fiberglass shower that were bolted to the fiberglass / not break-away.
Second floor bathrooms: 201, 202, 203, 204, 250, 252, 253, 254, 255, and 257,
Third floor bathrooms: 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 312, 350, 352, 353, 354, 355, and 357)

Findings include:

Observation rounds the morning of 4/19/11 revealed the following non-break-away metal shower rods with a 1/4 inch gap between the metal bar and the top of the fiberglass shower enclosure:
Second floor rooms: 201, 202, 203, 204, 250, 252, 253, 254, 255, 257.
Third floor rooms: 350, 352, 353, 354, 355, 357

Observation rounds the morning of 4/19/11 revealed the following non-break-away metal shower rods with a 1 inch gap between the metal bar and the top of the fiberglass shower enclosure:
Third floor rooms: 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 312

The Administrator (ID# 1) acknowledged 4/19/11 at 10:30 a.m. that recently most of the plastic break-away shower rods were replaced with metal rods. The Administrator further stated the new metal shower rods did not come with any installation instructions pertaining to psychiatric hospitals.

Interview 4/19/11 at 12:30 p.m. with the Maintenance Manager (ID# 3) revealed he completed installing the metal shower rods about two months ago and they are bolted to the fiberglass shower enclosure. The Maintenance Manager stated the old plastic break-away shower rods were replaced because patients would use them as weapons.

Record review of a policy titled "Management of the Environment of Care" dated 01/08 stated "IntraCare Hospitals goal is to provide a safe, functional, and effective environment for patients, staff members, and other individuals in the hospital....The Safety Committee of IntraCare Hospital has oversight responsibility over the implementation, monitoring and reporting annually to the Governing Board."

Record review of "Risk Management Meetings" (Safety meetings) from July 2010 to March 2011 revealed no concerns related to the newly installed metal shower rods.

Record review of a policy titled "Patient Safety Team" dated 02/09 stated "IntraCare Hospital shall maintain a specialized Patient Safety Team to monitor areas of patient safety... The Patient Safety Team shall ensure the education of patients relating to their care, monitor areas of patient care that are likely to pose a risk to patient safety, and report findings with recommendations for corrective actions to the Hospital Risk Management Committee and Medical Executive Committee."