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Based on observation, patient handbook review, and staff interview the facility failed to inform patients of the toll free complaint hotline for the Ohio Department of Health. This had the potential to affect all inpatients and outpatients who received hospital services.
The inpatient hospital census was 27.

Findings include:

1. On 07/21/14 at 1:00 PM a tour of the facility was completed including the main lobby, the main first floor corridor, the intake unit, the family waiting area, two inpatient units, and the hospital dining room. The observed posted grievance process notices failed to include the toll free complaint hotline for the Ohio Department of Health.

2. Review of the patient handbook presented to patients and families on admission revealed the information failed to include the toll free complaint hotline for the Ohio Department of Health.

On 07/25/14 at 3:45 PM the Executive Vice President, Staff H, confirmed the grievance process notice lacked the toll free complaint hotline for the Ohio Department of Health.

Based on medical record review, policy review and staff interviews, the facility failed to ensure the registered nurse delivered care as ordered for two patients of 31 medical records reviewed (Patient #1 and Patient #26) The hospital census was 27 patients.

Findings include:

1. The medical record of Patient #1 was reviewed on 07/22/14 at 2:00 PM. Patient #1 was admitted to the facility on 03/10/14 with depressive psychotic behavior, hearing voices to kill his/her parents with a knife. The History and Physical indicated Patient #1 had a history of self harming cutting behaviors and had attempted suicide with an overdose two years prior. Review of the physician order by Staff J on 03/10/14 at 3:59 PM revealed Patient #1 was to be observed every 15 minutes.

Review of the 15 minute observation record it was noted that 15 minute checks were not documented from 11:45 PM on 03/15/14 to 7:15 PM on 03/16/14.

The facility policy titled Safety Monitoring and Management (Policy #PC-029) was reviewed on 07/23/14 at 9:00 AM. According to the policy each patient will have a level of observation ordered by the physician. The three levels of observation are Inpatient, Residential, and Constant Observation.

Staff A was interviewed on 07/23/14 at 9:45 AM and stated every patient admitted to the facility has at least an Inpatient level of observation. An Inpatient level of observation involves documentation of every 15 minute observations. Staff A confirmed that documentation of more than 19 hours of observations was missing from Patient #1's medical record.

Review of a Clinical Progress Note on 03/15/14 at 2:43 PM revealed Patient #1 had been self harming all day by repeatedly picking at a scab. It was further documented that Patient #1 verbalized that he/she felt like "killing" people. Patient #1 was given utensils at lunch on 03/15/14 and was noted to be holding the knife with clenched fists while making a growling sound. When a nurse attempted to remove the knife from Patient #1's hand the patient would not let the knife go. Another staff member was able to intervene and remove the knife from the Patient #1's hand. Patient #1 was transferred to another unit on 03/15/14 at 7:30 PM. Patient #1 continued to receive eating utensils on 03/16/14.

A physician order for fingerfoods only with no utensils was written on 04/03/14 at 7:41 AM by Staff J. Patient #1 was given all utensils including a knife for dinner on 04/03/14. This finding was confirmed with Staff A on 07/23/14 at 11:00 AM.


2. Review of the medical record for Patient #26 revealed the patient was admitted on 07/14/14 with diagnoses including psychosis, history of large bifrontal meningioma, and legally blind.

Review of the nursing assessment for 07/14/14 revealed Patient #26 was placed on fall precautions due to weakness, being legally blind, and having hallucinations. Review of the fall risk assessment for 07/14/14 revealed fall precaution measures were not required at this time.

Review of the interdisciplinary treatment plan for 07/15/14 revealed Patient #26 was at risk for falls related to neurological changes as evidenced by report of hallucinations, dizziness, confusion, and decrease in function. The interventions were as follows: staff will encourage Patient #26 to ask for assistance with all ambulation, Patient #26 declined the use of a bed alarm at this time but will ask for assistance, will wear non-slip socks and use his/her wheelchair as needed for ambulation.

Review of the clinical progress note for 07/19/14 (no time of entry or signature of discipline) revealed documented evidence Patient #26 bent down on one knee to pick something up off of the floor while in the shower and bumped his/her head on the wall. This was documented as reported by the patient's wife. The documentation revealed Patient #26 had a silver dollar sized raised bump on the right side of forehead, physician was notified and neurological checks were ordered for 24 hours while awake.

Review of the neurological assessment flow sheet revealed a neurological assessment was not implemented until 07/20/14 at 1:30 AM, again at 9:00 AM, 1:00 PM and at 3:30 AM.

Review of a clinical progress note for 07/20/14 at 12:47 PM revealed documented evidence the registered nurse observed Patient #26 to be unsteady on his/her feet at times and fall risk precautions continue. The documentation revealed Patient #26 refused a bed alarm.

Review of the policy and procedure titled "Fall Risk and Precautions" effective 07/01/08, policy number PC-019 and last reviewed 02/14/14 revealed precautions may be implemented by a registered nurse or physician and precautions were including employ a bed/chair alarm if needed. The policy and procedure further revealed if the fall was unwitnessed or a head injury is observed or reported, neurological checks will be performed every four hours for twenty for hours after the fall and neurological checks will be performed every shift for the subsequent three days to assess for residual injury.

This finding was confirmed with Staff A at 3:00 PM on 07/25/14.

Based on observation, medical record review and staff interview, the facility failed to ensure the staff signature included the discipline on the patient treatment plans (A450), failed to ensure medical records were accurate and complete (A467), and failed to ensure medical records were completed within 30 days of discharge (A469). This deficient practice had the potential to affect all patients. The census was 27 patients.

Based on medical record review and interview it was determined the facility failed to ensure staff signatures included the title of the discipline on the patients treatment plans for 30 patients of 31 medical records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30)

Findings include:

Review of the interdisciplinary treatment plans in the medical records for Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30 revealed electronic staff signatures lacked the title of the discipline to indicate who the responsible staff person was for the treatment plan.

This finding was confirmed with Staff A at 3:00 PM on 07/25/14.

30270

Based on medical record review, staff interview, and policy review the facility failed to ensure treatment plans included all treatments ordered and failed to ensure inpatient orders for treatment included the dates and numbers of treatments prescribed for four patients of 31 medical records reviewed. (Patient #14, #16, #17, and #27) The facility census was 27 patients.

Findings include:

1. Electroconvulsive Therapy (ECT) treatment was ordered for Patients #14, Patient #16, Patient #17, and Patient #27. Review of the treatment plans for these patients failed to include the ECT procedure as part of the treatment plan.

On 07/25/14 policy #MS-016; Electroconvulsive Therapy, last revised on 09/28/11, was reviewed. The policy outlined the appropriate clinical care for patients who had ECT procedures. The policy included pre-procedural care, procedural care, and post anesthesia care. The treatment plans reviewed lacked the ECT procedure as part of the patient's treatment plan.

On 07/23/14 at 10:00 AM Staff A confirmed Electroconvulsive Therapy was not documented in patient treatment plans. Staff A indicated ECT was a treatment option frequently used at the hospital.

2. On 07/25/14, ten patient ECT orders for scheduled ECT procedures from 07/21/14 through 07/25/14 were reviewed. The scheduled procedures included both inpatients and outpatients. The outpatient orders were handwritten on physician order sheets. The orders included the date and time written, and the individual dates for each ECT procedure in the ordered series. The inpatient orders were computer generated and documented the date of the order, a start date and start time, a stop date and stop time, and an order duration of 30 days.

On 07/25/14 policy #MS-016; Electroconvulsive Therapy, last revised on 09/28/11, was reviewed. The policy documented pre-procedural ECT care included "the psychiatrist enters orders into the medical record for the ECT procedure, the days of the week, and the number of treatments to be scheduled".

The inpatient ECT orders for Patient #14, #16, and #27 lacked documentation of the dates and number of treatments in the prescribed series.

On 07/25/14 at 12:30 PM Staff A confirmed the inpatient orders did not follow hospital policy of including the number of treatments to be scheduled under the order.

Based on review of the medical record delinquency report, staff interview, and policy review the facility failed to ensure medical records were completed within 30 days of discharge. This affected 398 medical records reported as delinquent from July 2013 through June 2014. The facility census was 27 patients.

Findings include:

On 07/23/14 at 2:15 PM the facility's medical record department was reviewed including an interview with the Health Information Management (HIM) Supervisor; Staff C. Staff C provided the medical record statistics from July 2013 through June 2014 which documented 398 delinquent medical records with an annual delinquency rate of 33.17 percent.

On 07/23/14 at 2:15 PM Staff C confirmed the medical record statistics including the facility's average monthly discharge rate of 140.3 and the annual delinquency rate of 33.17 percent. The quarterly delinquency rates documented 38.3 percent for the first quarter, 58.7 percent for the second quarter, 27.3 percent for the third quarter, and 8.3 percent for the fourth quarter.

On 07/24/14 facility policy #1M-026, Record Monitoring and Delinquency Reporting, last revised on 06/09/11 was reviewed. The policy defined a delinquent medical record as one not completed 30 days after a patient discharge. Medical Staff Rules and Regulations documented failure to comply with timely completion may result in disciplinary action including suspension of some or all of the practitioner's clinical privileges.

On 07/25/14 at 2:30 PM the Clinical Medical Director; Staff G, indicated two physicians had received disciplinary action for delinquent records during the past 12 month. Staff G also confirmed the annual delinquency rate of 33.17 percent for the facility.

Based on observation, policy review, and staff interview, the facility failed to ensure medications were locked per facility policy. This had the potential to affect all patients receiving care in the electroconvulsive therapy (ECT) room. The hospital census was 27.

Findings include:

Observation of the anesthesia cart in the Electroconvulsive Therapy Room on 07/21/14 at 3:30 PM revealed a lever with the word locked on the left side and unlocked on the right side. The lever was pointing toward the left side indicating the cart was locked. The drawers of the cart were easily opened on attempt revealing the cart was accessible and unlocked. The first drawer contained approximately 15 medications including a pre-filled syringe of Atropine, a 10 mg bottle of Lidocaine, and three bottles of Esmolol.

Staff H was interviewed on 7/21/14 at 3:30 PM and reported if the drawers aren't completely closed, even when the lever is in the locked position, the drawers are able to be opened and medications accessed. Staff H stated that staff are responsible for checking the cart to ensure it is locked.

The facility policy titled Medication Storage was reviewed on 07/22/14 at 8:45 AM. According to the policy staff are instructed that all floor stock medications will be secured by a locked cabinet/cart or under direct observation and accessible only to authorized individuals. These facts were confirmed with Staff A on 07/22/14 at 11:00 AM.

Based on observation, interview and document review, the facility failed to have a two hour fire wall between buildings, failed to maintain the ratings of its smoke and/or fire barriers, failed to have doors that resist the passage of smoke into the corridor, failed to have fire drills under varying, random times, failed to have each delayed egress door release upon fire alarm activation and failed to have exit signage on the path of egress. (A709) The cumulative effect of these systemic findings resulted in the facility's inability to ensure the environment for all patients, staff, and visitors is safe from fire. The facility's census was 27 patients.

Findings include:

See A709.

Based on observation, interview, and document review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 27 patients.

Findings include:

K18 Failed to have doors protect corridor openings from smoke
K25 Failed to maintain the ratings of its fire and/or smoke barriers
K50 Fire drills not held under varying conditions on the second shift
K22 Failed to have paths of egress with exit signage
K34 Delayed egress door failed to open upon alarm activation
K11 Two hour wall not between buildings

30270

Based on observation, staff interview, and policy review the facility failed to ensure Food and Nutritional Services maintained a safe and sanitation surveillance program for kitchen equipment and food products and failed to ensure all prepared, opened, and stored food items were properly labeled with expiration dates. The facility also failed to ensure staff followed the current employee health policy related to tuberculosis testing. This had the potential to affect all patients, visitors, and staff. The hospital census was 27 patients.

Findings include:

1. On 07/21/14 from 10:00 AM to 11:45 AM a tour was completed of the hospital kitchen. The sanitation of all dishware, glassware, eating utensils, pots, pans, and cooking utensils was reviewed as well as the food temperature monitoring program. The facility failed to provide evidence of an ongoing sanitation surveillance program for the dishwasher and the three sink sanitation system. The facility also failed to provide evidence of an ongoing food temperature surveillance program.

The dishwasher was observed during one wash cycle to sanitize through a high temperature rinse at or above 185 degrees. A dishwasher temperature log to monitor sanitation was requested. The Food and Nutrition Supervisor, Staff I, stated the facility did not maintain evidence of an ongoing dishwasher temperature monitoring program.

The three sink sanitizer system was observed filled with water, cleanser, and sanitizer. An observation of testing the sanitizer level was made utilizing test strips. The sanitizer solution was found to be within an acceptable level for sanitation. A three sink sanitation log to monitor sanitation was requested. Staff I stated the facility did not maintain evidence of an ongoing sanitizer monitoring program.

Foods were observed being cooked for lunch including grilled chicken. An observation of the food temperature checks was completed. All food temperatures observed were within acceptable ranges. The food temperature logs were requested. Staff I stated the facility did not maintain evidence of an ongoing food temperature monitoring program.

Stored foods were observed in coolers, refrigerators, and freezers. Multiple foods were observed in opened packages without date labels. Items observed opened and unlabeled in the refrigerators included black been vegetarian burger patties, hamburger patties, deli ham, sausage patties, and multiple containers of cooked and raw vegetables. Prepared items found in coolers without labels to indicate the date prepared or the date of expiration included vegetarian wraps, single serving tuna salad containers, single serving salads, and numerous deserts and fruit cups. Staff I confirmed all food items identified lacked labels to indicate when opened or prepared and date of expiration.

On 07/22/14 hospital policies #FN-006; Sanitation, revised on 05/29/14, and #FN-005 Purchasing, Receiving and Storage, revised on 05/28/14, were reviewed. The Sanitation policy documented pots, pans and other cooking utensils must be cleaned and sanitized utilizing a manual three compartment sink procedure or a mechanical ware washing machine procedure. The thee compartment sink procedure included a third sanitizing sink. The policy documented the sanitizer was to be tested utilizing test strips to ensure the solution was properly calibrated. The mechanical dishwasher procedure included a final rinse at or above 180 degrees Fahrenheit. The Purchasing, Receiving and Storage policy documented all food products stored in a container other than the original package must be labeled and all prepared food labels "must be marked with the common product name, who prepared the food, the date prepared and the expiration date."

2. Personnel files of two Registered Nurses, Staff K and Staff L, and one Physician, Staff M, were reviewed on 07/23/14 at 10:30 AM. None of the staff were noted to have had a tuberculosis test. Staff B was interviewed and revealed it was facility policy that staff receive a tuberculosis test on hire only. Staff B further reported because the facility was determined to be at low risk for tuberculosis, the decision was made not to require annual tuberculosis testing.

The facility policy titled Employee Health (Policy #HR-020) was reviewed on 07/23/14 at 11:30 AM. According to the policy tuberculosis testing will be done annually to ensure employees don't have tuberculosis that could be transmitted to patients or other employees. These facts were confirmed with Staff B on 07/23/14 at 11:40 AM.