HospitalInspections.org

Based on observation, interview and review of policies and procedures the facility has currently closed visitation to patients at the hospital related to Covid-19 and has not opened visitation.

Findings:
During an observation upon entrance to the facility on 4/4/2022 at 8:55 AM there were signs posted stating No visitation related to Covid-19.

Review of the facility visitation pamphlet provided to patients upon admission indicate that patients can receive visitors on Tuesday and Thursday 7:00-8:00 PM and Sundays 2:00-3:00 PM.

During an interview conducted on 4/4/2022 at 1:35 PM, the Director of Risk Management stated, "We have visitation scheduled at specific times related to our patient population. This is a secured setting and visitation is limited to those times.

During an interview conducted on 4/7/2022 at 2:30 PM the Director of Nursing (DON) stated" We do not have visitation at this time. We have been closed to visitation and do none. It is within our policies to promote visitation. You would have to speak to [Administrators name] about that, it started before I became DON."

During an interview conducted on 4/8/2022 at 10:45 AM the Executive Director stated, "We have been very proud of our response to Covid-19 and have not had any patient-to-patient transmission. This is in part to our diligence in limiting visitation. We currently have no visitation and have until May to start this up again. But I did not think we had to follow those regulations as we are a psychiatric hospital. "

Review of the Policy and Procedure Titled "Visitation" Policy ref [reference] 190-01, Procedure: 700-02, last revision date of May 2021 read: "A. Purpose To establish guidelines within the hospital which are consistent with good consumer care as well as hospital security. As a short term, crisis- oriented facility, the maintenance of family and community support is held to be important and beneficial to the recovery and long-term stability of the consumer. B. Procedure: I .... Normal visiting hours for adults shall be Tuesday and Thursday from 7:00 PM to 8:00 PM and Sundays from 2:00 PM to 3:00 PM. II. A consumers right to receive visitors can be restricted by Life stream but only under the written order by the medical practitioner and documentation as to the reason(s) for the restriction. This documentation shall be given to the consumer, the consumers family, guardian, guardian advocate, representative, human rights advocacy committee member or attorney. This restriction must be reviewed every seven days."

Based on observation interview and record review the facility failed to ensure that outdated or unusable medications were not available for patient use in 2 out of 3 medication rooms reviewed.

Findings:

During an observation on 4/5/2022 at 10:00 AM with the Director of Nursing (DON) of Medication Room #2 there was one clear medication cup with three medications in them, there were no patient identifiers and medications were not labeled with the medication name and dosage. There was one clear medication cup with thirteen pills in the cup with no patient identifier and medications were not labeled with the medication name and dosage. There was one opened and undated bottle of Lidocaine 2% with no date opened and no patient identifier and one bottle of Sensitive eyes Saline with an open date of 11/10/2021.

During an observation on 4/5/2022 at 10:15 AM of Medication Room #3 there was one cup of medication with five medications in it with no patient identifier and medications were not labeled with the name and dosage, one cup of medications that contained six pills with no patient identifier and medications were not labeled with name or dosage. There was one opened bottle of Lantus insulin with an open date of 3/4/2022 and one opened bottle of Lantus insulin with no date opened or expiration date.

During an interview on 4/5/2022 at 10:30 AM the Director of Nursing stated, " They should never prepour medications and all medications pulled should have the name of the consumer, name of the medication and dose of the medication. All expired medications should not be available for use and should be thrown out."

Review of the policy and procedure titled "Authorized area for Outdated and unusable drugs" Policy ref 200-01 Approval date: April 2021 read: A. Purpose: To provide for an authorized area for outdated and unusable drugs within the secure setting of the pharmacy. Procedure: I. All outdated medications shall be pulled from stock and placed in a clearly marked, authorized area for outdated drugs and replaced by the pharmacy staff. III. It shall be the pharmacist's responsibility to dispose of expired drugs. B. Nursing staff shall implement a safeguard of inspecting all drug expiration dates prior to signing for retrieval from the pharmacy."

Based on interviews and policy and procedure review, the facility failed to have its therapeutic diet manual approved by the dietitian and medical staff.

Findings:

During an interview on 04/04/2022 at 1:30 PM, the Vice President of Building Services stated, "Our dietitian and medical staff are supposed to approve our therapeutic diet manual, and the document of approval is attached to the front of the manual."
When asked why no documentation of approval was attached to the front of the manual, Vice President of Building Services stated stated, "I am not sure what happened to it. It is lost."


During an interview on 04/05/2022 at 1:40 PM, the facility's Dietitian confirmed the findings and stated, "We have a new diet manual that we will approve. I don't know where the approval of our current diet manual is.

Review of the facility's policy titled: "Therapeutic Diets and Diet Instructions" with a revision date of February 2020 states, "The Florida Dietetic Association's Diet Manual has been adopted by the medical staff and approved by the consultant dietitian for center use. The manual specifies standards for nutritional care and specifies specific nutritional deficiencies of any diet not in compliance with the RDA's (Recommended Dietary Allowance).