HospitalInspections.org

Based on record review, observation and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services due to being a danger to themselves and/or others. This deficient practice had the potential to affect all 15 current inpatients receiving care in the hospital.

Findings:

Review of the hospital's "Safety Inspection of All areas" policy (revised 4/24/15) revealed in part:
Policy: Areas of the facility shall be inspected on a monthly basis to ensure that safety standards are being met, that when deficiencies are found corrective action is taken.
Purpose: To monitor physical environment to ensure compliance with standards.
Procedure: Safety Coordinator Trains designee to perform inspections of all areas on a monthly basis ...
Completes Hospital Safety Walkthrough Audit form
If any identified risks cannot be immediately resolved, due to matters beyond the hospital's control, the hospital will utilize 24 hours Safety Designee to make continuous rounds until risks has been resolved. Assigned staff member will be educated on high risks safety and ligature areas ....

Review of the hospital's policy titled,"Nursing - Patient Care: Levels of Observation", Policy number: NU432A, revealed in part: D. The following precautions are to be considered when clinically indicated in assignment of patient care levels. 1. Suicide Precautions: Used when a patient communicates or gives evidence that an attempt is possible as evidenced in the nursing assessment.

Review of the Design Guide for the Built Environment of Behavioral Health Facilities, Edition 7.2, published April 2017, by the FGI (Facilities Guidelines Institute), revealed in part: Patient showers and bathtubs are of major concern. In our opinion, patients should only use bathtubs while under direct supervision of staff. The obvious hazard of potential drowning plus the added risks from valves and fill spouts are problematic.

Review of the current inpatient census for 2/12/18 revealed 4 current inpatients (Patients #1, #2, #3, #10) were on suicide precautions with every 15 minute documented observation checks.

An observation of patient rooms and the entire patient environment of care conducted on 2/12/18 from 10:00 a.m. - 11:30 a.m. revealed the following:

Shower Room
On 2/12/18 at 10:00 a.m. an observation was made of a 30 ml (milliliter) cup full of light pink liquid, unlabeled as to the contents of the cup (identified as bath soap by S2DON).

Bathtub Room:
On 2/12/18 at 10:05 a.m. an observation of the bath tub room revealed the following:
a) Bath tub faucet (one L- shaped lever) handle- potential ligature anchor point/ligature risk.
b) Full size bath tub - potential burn, drowning risk.

In an interview on 2/12/18 at 10:10 a.m., S2DON verified the observed safety risks in the Bathtub Room and Shower Room.

On 2/14/18 at 2:30 p.m., in an interview with S10RN, he stated the patients on fall precautions were the only patients required to have direct supervision while bathing. When asked if that included patients on suicide precautions, S10RN explained the MHT would remain outside the door of the shower room and/or bath tub room to allow the patients privacy to bathe or shower themselves alone. He stated the MHTs would frequently monitor them. S10RN verified the bath tub faucet handle was a ligature risk and there could be a possibility of a patient drowning in the bathtub.

In an interview on 2/15/18 at 2:30 p.m. with S2DON, she confirmed the only patients directly observed by staff when bathing in the hospital's bathtub were patients who had been identified as at risk for falls or patients that were on 1:1 and Close Observation levels of supervision. S2DON further confirmed patients who were on suicide precautions with documented q 15 minute checks were allowed to bathe without being maintained in direct line of sight supervision of staff. S2DON indicated staff sat outside of the closed door.

Room 16
a) loose screw on right side back of toilet;
b) exposed pipes under the sink and lavatory- potential ligature anchor point/ligature risk

In an interview on 2/12/18 at 10:15 a.m. with S8PlantOps, he verified the above safety risks in the patients' environment of care.

Rooms 15, 17, 18, 19, 20, 21, 22, and 24
a) triple level vent noted in the ceiling- potential ligature anchor point/ ligature risk;
b) exposed angle iron under bathroom counter, exposed water lines and lavatory - potential ligature anchor point/ligature risk

In an interview on 2/12/18 at 10:30 a.m. with S2DON, she verified the above referenced safety risks in the patients' environment of care.

In an interview on 2/12/18 at 11:05 a.m. with S3COO, she confirmed all patient rooms, except Room #16 had the triple level vents. S3COO also confirmed all patient rooms had exposed angle iron under bathroom counter, exposed water lines and lavatory and agreed these were safety risks in the patients' environment.

Rooms 17, 19, 20, 21, 22, and 24
Elongated sink faucet with a height protruding enough to facilitate potential ligature/potential ligature anchor point. S3COO verified the observation and agreed the sink faucet was tall enough to be a potential anchor point for ligature. S3COO confirmed all 9 patient rooms (Rooms 15 - 22 and Room 24) were equipped with the same faucets.

Screws in open faced shelving unit (6 screws total) non- temper resistant. S3COO verified the observation and confirmed all 9 patient room shelving units (Rooms 15 - 22 and Room 24) were secured with the same screws.

Rooms 17 and 20
Metal coils/conduit from air conditioning unit to AC switchplate box separated from the wall widely enough to provide a potential ligature anchor point. S3COO verified finding during observation.

Room 17
Metal faceplate covering the switchbox for the AC unit was noted to be hanging by loosely by one screw. Upon further inspection, the faceplate fell off of the switchbox leaving a square of metal, approximately the size of a slice of bread, and a loose screw potentially accessible to the patient. S3COO was immediately informed of the findings and the metal faceplate and screw were handed to her to remove from the patient's room. A loose, protruding screw (3/4 of the way out) screw was also noted on the left side of the ovebed light. S3COO also verfied this finding during the observation.

Visitation Room
Several long hanging wires from the mounted television- presents potential for ligature risk (verified by S2DON on 2/15/18 at 9:45 a.m.)

Outside smoking area
On 2/12/18 at 11:45 a.m. a tour of the outside smoking area revealed a loose board on the right corner of the fence- potential elopement/safety risk. S12MHT verified the board was loose during the observation.


Ante-room outside of shower area:
On 2/15/18 at 9:50 a.m. an observation of the ante-room near the shower and tub revealed a metal cabinet with a pad lock and latch, which is a ligature risk. Also, the cabinet is not attached to the wall, rocks with little effort and could tip over. During the observation S2DON and S5HRDir verified the cabinet could easily tip over and the padlock and latch is a ligature risk.






34161




38777

Based on record review and interview, the hospital failed to report alleged allegations of abuse to LDH (Louisiana Department of Health) within 24 hours of receipt of the allegation for 1 (#15) of 1 sampled patients reviewed for grievances alleging abuse/neglect.

Findings:

Review of the hospital policy titled,"Patient Complaints and Grievances" policy number: PR05, revealed in part: H. Delivery of a response: I. Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the Administrator or designee and to LDH within 24 hours.

Review of the hospital's complaints and grievances revealed the following grievance filed by Patient #15 on 12/23/17 alleging sexual abuse by S14MHT. Further review of the grievance documentation revealed the following, in part:
Patient #15 alleged S14MHT had told the patient to go to her room so he could take a picture of her breasts. Patient #15 also alleged S14MHT had taken a picture of her naked when she was showering and that he had pulled out his penis and had made her perform oral sex. Patient #15 alleged she had not complained about performing oral sex because she had been scared.

In an interview on 2/12/18 at 2:30 p.m. with S3COO, she indicated she had not reported the above-referenced allegations to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of discovery, because she had investigated the complaint and had found it to be unsubstantiated.

Based on record review and interview, the hospital failed to ensure the use of restraints was documented in the patients' plan of care or treatment plan for 2 (#4,#5) of 2 total patients' medical records reviewed for restraints out of a total patient sample of 18.

Findings:

Patient #4
Review of a document titled Physician's Order Sheet for Seclusion/Restraints revealed Patient #4 was placed in 2 point restraints from 9:25 p.m. to 9:35 p.m. on 2/9/18 for the safety of others due to agitated behavior, assaultive behavior and disruptive behavior that had not responded to staff verbal intervention. Patient #4 had also been given chemical adjunction support in the form of an injection of Geodon 20 mg (milligrams), Ativan 2 mg IM (Intramuscular). Additional review of the medical record revealed no modification had been made to Patient # 4's treatment plan to reflect the use of physical restraints on the patient on 2/9/18.

In an interview on 2/15/18 at 11:20 a.m. with S2DON, she verified the treatment plan for Patient #4 had not been modified to reflect the use of physical restraints on Patient #4 on 2/9/18. .

Patient #5
Review of a document titled Physician's Order Sheet for Seclusion/Restraints revealed Patient #5 was placed in 4 point restraints from 8:00 p.m. to 8:59 p.m. on 2/9/18 for the safety of others due to agitated behavior that had not responded to staff verbal intervention and offer of the quiet room. Patient #5 had also been given chemical adjunction support in the form of an injection of Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM. Additional review of the medical record revealed no modification had been made to Patient # 5's treatment plan to reflect the use of both physical and chemical restraints on the patient on 2/9/18.

In an interview on 2/15/18 at 11:09 a.m. with S2DON, she verified the treatment plan for Patient #5 had not been modified to reflect the use of both physical and chemical restraints on Patient #5 on 2/9/18. .



38777

Based on quality plan review and interview the hospital failed to identify opportunities for improvement and changes related to patient safety that would lead to improvement in quality of patient care. This deficient practice was evidenced by the hospital's failure to identify safety risks in the inpatient Psychiatric Hospital's environment of care as problems to be addressed through the hospital wide QAPI program.

Findings:

Review of the hospital's QAPI plan revealed no documented evidence that issues identified by the survey team related to safety risks in the inpatient Psychiatric Hospital's environment of care was identified as a problem to be addressed through the hospital wide QAPI program.

In an interview on 2/15/18 at 4:00 p.m. with S3COO, she confirmed the issues identified by the survey team related to safety risks in the inpatient Psychiatric Hospital's environment of care had not been identified as a problem to be addressed through the hospital wide QAPI program. S3COO agreed the issues with safety risks in the inpatient Psychiatric Hospital's environment of care should have been identified as problems to be addressed through the hospital's QAPI plan.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1) Failure of the RN to ensure a patient (#8) who had scored as being at high risk for suicide on the hospital's suicide risk assessment tool had been placed on suicide precautions for 1 (#8) of 10 (#1- #10) current sampled inpatients reviewed out of a total patient sample of 18; and

2) Failure of the RN to ensure a patient (#10) who had scored as being at high risk for suicide on the hospital's suicide risk assessment tool had orders for suicide precautions on the admission physician's orders for 1 (#10) of 10 (#1- #10) current sampled inpatients reviewed out of a total patient sample of 18; and

3) Failure of the RN to ensure a patient (#10) received a complete nursing assessment prior to be sent out to receive a higher leverl of care for 1 (#10) of 1 patients reviewed who had been sent acute out for a higher level of care out of a total patient sample of 18.

Findings:


1) Failure of the RN to ensure a patient (#8) who had scored as being at high risk for suicide on the hospital's suicide risk assessment tool had been placed on suicide precautions.

Review of the hospital policy titled," Suicidal Patient Protocol", Policy number: NU443, revealed in part: I. Policy: It is the policy of this hospital to provide a safe and therapeutic environment when dealing with patients who may be at greater risk for suicide potential. III. Assessment of Suicide Risk: C. All patients admitted to this hospital will undergo a suicidal risk assessment as part of the nursing assessment. D. 2. if the patient is at potential risk for suicide he/she may be placed at a higher level of observation per physician/licensed independent practitioner orders to ensure safety of the patient.

Review of the hospital's suicide risk assessment tool revealed the following, in part: Suicide Risk Assessment Critical Factors: if starred factors ( previous suicide attempts and organized plan for suicide) and/or three or more risk factors are circled, then consider high risk for suicide. Further review revealed a high risk for suicide score indicated suicide precautions should be initiated.

Review of Patient #8's medical record revealed the patient's legal status was court ordered admission with an admission date of 2/9/18 at 9:20 a.m. Further review revealed the patient had a history of depression and was described as prone to rage, agitated, easily triggered, and hopeless with mood swings.

Review of Patient #8's Suicide Risk Assessment revealed the patient had a score of 4 with one starred item: a previous suicide attempt times 1. The score indicated the patient was considered at high risk for suicide; however the patient was marked as moderate risk for homicide/aggression and the choices for suicide and suicide precautions had been marked as void. The patient was placed on homicide/aggression precautions with q 15 minute checks.

In an interview on 2/15/18 at 10:55 a.m. with S2DON, she verified, after review of Patient #8's medical record, that the patient scored a four on the Suicide Risk Assessment and had also had a prior suicide attempt which placed him at high risk for suicide. S2DON confirmed the patient should have been placed on suicide precautions as well as homicide/aggression precautions. S2DON verified suicide precautions had not been initiated on Patient #8.



2) Failure of the RN to ensure a patient (#10) who had scored as being at high risk for suicide on the hospital's suicide risk assessment tool had orders for suicide precautions on the admission physician's orders.

Review of Patient #10's medical record revealed the patient was admitted on 2/5/18 with diagnoses that included Major Depressive Disorder, Suicidal Ideations, Alcohol use disorder and Cocaine use disorder.

Review of the Nursing Admit Note dated 2/5/18 at 9:00 p.m. indicated the following:
Precautions identified: included Q15 minutes checks and suicidal ideations ....

Review of the Nursing Assessment dated 2/5/18 at 9:00 p.m. indicated the following: Initiate Suicide Precautions.

Review of the Physician's Admission Order Sheet dated 2/5/18 at 9:50 p.m. indicated Patient #10 was ordered to be on Fall Precautions, Detox Precautions and Q15 monitoring. Further review of the admit orders revealed Suicide/Self Harm Precautions had not been ordered.

On 2/14/18 at 2:30 p.m., in an interview with S10RN, he reviewed Patient #10's chart and verified the Physician's order on admit should have contained orders for Suicidal Precautions. S10RN reported an LPN had taken the telephone orders for the patient's admission.


3) Failure of the RN to ensure a patient (#10) received a complete nursing assessment prior to being sent out to receive a higher lever of care.


Review of Patient #10's medical record revealed the patient had been admitted on 2/5/18 with diagnoses that included Major Depressive Disorder, Suicidal Ideations, Alcohol use disorder, and Cocaine use disorder.

Review of the 24 Hour Daily Nursing Assessment & Group Note dated 2/12/18 at 7:30 a.m. revealed in part, Patient #10 reported abdominal pain and nausea, vomiting, low energy and weak, flat. ...New order to send patient to an area ER for evaluation....signed by S10RN. Further review of the note revealed a complete thorough nursing assessment had not been conducted because the assessment lacked an assessment of pain level, and bowel sounds.

On 2/14/18 at 2:30 p.m., in an interview with S10RN, he reviewed Patient #10's chart and verified he had not conducted a complete nursing assessment prior to sending Patient #10 to the Emergency Room.



34161

Based on record reviews and interview, the hospital failed to ensure identified medication errors were documented in the patient's medical record for 2 (#17 #18) of 2 patients reviewed for medication errors.

Review of the hospital's "Medication Variances" policy (NU504) revealed in part:
I. Policy: It is the policy of "hospital" to provide pharmaceutical therapy to its patients in the safest, most efficacious manner possible to provide the highest degree of therapeutic benefit and enhance patient outcomes.
III. Procedure: D. The licensed person who discovers the medication variance shall document the following statement in the patient's clinical record.

Review of Medication Error Report for Patient #17 with a PI Coordinator signature date of 12/27/18 revealed in part: on 12/26/17 Patient #17 was ordered to receive as needed Haldol with Ativan and Benadryl. The details of the event indicated Patient #17 had only received Ativan.

Review of Medication Error Report for Patient #18 with a PI Coordinator signature date of 12/18/17 revealed in part: on 12/13/17 Patient #18 was ordered to receive Seroquel 800 milligrams po QHS. The details of the event indicated the medication was not transcribed onto the MAR.

On 2/15/18 at 2:30 p.m., Patient #17's and #18's medical record was reviewed with S2DON. S2DON verified there was no documentation in the nurse's notes acknowledging the medication errors.

Based on observation and interview, the hospital failed to ensure facilities, supplies, and equipment was maintained to ensure an acceptable level of quality and safety.

Findings:

Review of the hospital's "Safety Inspection of All areas" policy (revised 4/24/15) revealed in part:
Policy: Areas of the facility shall be inspected on a monthly basis to ensure that safety standards are being met, that when deficiencies are found corrective action is taken.
Purpose: To monitor physical environment to ensure compliance with standards.
Procedure: Safety Coordinator Trains designee to perform inspections of all areas on a monthly basis ...
Completes Hospital Safety Walkthrough Audit form.

On 2/12/18 at 10:10 a.m., an observation was made of the hospital's physical environment with S2DON. The following observations were made and verified by S2DON:

Group Therapy/Dining Room
a. Dust on the walls
b. Thick layer of dust on bulletin board (felt made curtain)
c. Dull flooring, stained tiles, black stained base boards
d. Trash and debris around the perimeter of the flooring
e. Holes in the wall above the sink left by removal of screws

Visitation Room
a. A/C vent noted to have a coating of dust and rust
b.Dull flooring
c. On 2/12/18 at 11:00 a.m. the ceiling vent in the commons area in front of the nurse's station was noted to have rust.
In an interview on 2/12/18 at 11:40 a.m. S2DON and S12MHT verified the above findings.

Shower Room, Bathtub Room and Anteroom:
a. The tile floor in the Ante Room, Shower Room, Bath Tub room was covered with dried white residue throughout.
b. Rusted door frame on bathtub room.
c. Anteroom Supply closet: doors were rusted and contained dark grayish black build up inside the bottom of the cabinet doors.

Back Patio and Outside Smoking Area:
a. blue metal picnic table in disrepair. (Verified by S2DON on 2/15/18 at 9:45a.m.)
b. 2/12/18 at 11:45 a.m. a tour of the outside smoking area revealed a loose board on the right corner of the fence.
S12MHT verified the board was loose during the observation.

Room 18
During an observation on 2/12/18 at 10:30 a.m. of Room 18 the bathroom vent was not working. S2DON confirmed the bathroom vent was not working during the observation.

Based on record review and interview, the hospital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) Failing to maintain a sanitary environment;
2) Failing to disinfect the washing machine per hospital policy and in between patient use;
3) Failing to adhere to the appropriate dwell time of a disinfectant;
4) Failing to appropriately store clean patient care equipment away from soiled linen;
5) Failing to appropriately store clean linen;
6) Failing to clean patient care equipment in between patient use and failing to perform hand hygiene before and after donning and doffing gloves; and
7) Failing to wear gloves when handling a sharps waste container.

Findings:

1) Failing to maintain a sanitary environment.

On 2/12/18 at 10:10 a.m., a physical environment tour was conducted with S2DON. The following observations were made and verified by S2DON:

Room 15
a. Plastic urinal on the bathroom floor that contained 1 ounce of yellow liquid.

Rooms 15, 17, 19 and 21 entrance door contained dingy clear plastic signs with exposed black sticky stained adhesive.

Group Therapy/Dining Room
a. 3 seat sofa cushions contained cracked vinyl material- unable to properly disinfect the furniture unable to properly dinsifect furniture due to torn upholstery.
b. Chair contained cracked vinyl seat cushion- unable to properly disinfect the furniture due to torn upholstery.

On 2/12/18 at 11:00 a.m. the following was noted in the commons area in front of the nurse's station:
a. cobwebs with insects trapped within them were noted on the wall above the water dispenser;
b. the 5-gallon water jug on the water dispenser was dirty.

In an interview on 2/12/18 at 11:40 a.m. S2DON and S12MHT verified the above findings.

2) Failing to disinfect the washing machine in between patient use per hospital policy.

Review of the hospital's policy "Laundering of Patient Clothes" (EOC-24 revised 12/1/2011) revealed in part:
Policy: Patient's clothing shall be laundered according to the procedures listed below. Staff shall be responsible for maintaining washers and dryers. MHT/Housekeeping staff: Staff shall clean the washers by running the empty machine using the hot water cycle and one cup of bleach. Cleaning shall be documented on the on the cleaning log.

Review of the "Nightly Disinfection of Washer" form dated 1/6/18 - 2/14/18 revealed in part:
Daily at 10P (p.m.):
1. Use 1 cup of detergent with bleach and run cycle with hot water
2. Clean lent trap after each use.

Further review of the "Nightly Disinfection of Washer" form revealed no documentation of washer disinfection for 1/7/18, 1/10/18, 1/12/18, 1/14/18, 1/15/18, 1/16/28, 1/18/18, 1/21/18, 1/22/18, 1/23/18, 1/28/18, 1/29/18, 1/30/18, 2/1/18, 2/2/18, 2/3/18, 2/5/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18 and 2/11/18 = 22 days.

On 2/12/18 at 2:07 p.m., an interview was held with S12MHT. She acknowledged the MHTs washed the patient's clothing. When asked, S12MHT stated the policy was to wash the patient's clothes separately and to sanitize in between with bleach pods. She stated the hospital currently did not have any bleach pods. S12MHT stated the bleach supply had been depleted since last Friday. S12MHT stated she was responsible for making the order when she the staff made her aware.

On 2/15/18 at 9:30 a.m., the "Laundering of Patient Clothes" was verbally reviewed with S3COO and she stated the policy should have indicated the washing machine should have been disinfected in between washing patient's clothing.

In an interview on 2/15/18 at 11:13 a.m., with S2DON, she verified the staff should have been sanitizing the washing machine with bleach in between washing the patient's clothing and each night.

3) Failing to adhere to the appropriate dwell time of a disinfectant when cleaning the shower and bathtub rooms.

A review of the NABC Concentrate 1 cleaning solution manufacturer's instructions revealed in part:
One-step Cleaning/Deodorizing/Disinfecting Hard, Non-Porous surfaces: ...Treated surface must remain wet for 10 minutes.

On 2/12/18 at 2:07 p.m., an interview was held with S14MHT. He stated he had been the assigned "shower guy" from 3p.m.-9 p.m. When asked, S14MHT explained he sprayed the shower room and bathtub/bathtub room, the floors, walls, knobs, heads and shower chairs with a blue cleaning solution provided by housekeeping. S14MHT stated the contact time was 1 minute. However, he allowed the "blue solution" to set for 2-3 minutes, then he rinsed it off. After all of the patients have completed their bath or shower, he would conduct a final cleaning using the same solution (blue) and would spray Scrubbing Bubbles cleaning solution for the tile and grout. He stated the protocol was to sanitized in between patients. S14MHT stated he had not received any training on how to appropriately clean the shower and bathtub room.

4) Failing to appropriately store clean patient care equipment.

On 2/15/18 at 9:45 a.m. the soiled linen cabinet was observed with S2DON. 2 wheel chairs and 1 walker were stored next to the soiled linen bin. During the observation, S2DON verified the patient care items should have been stored separately away from the soiled linen cart.

5) Failing to appropriately store clean linen.

During the physical environment tour on 2/12/18 at 11:15 a.m., with S3COO, the clean linen cart was observed uncovered, exposing clean linen. S3COO verified the clean linen should have been covered.

6) Failing to clean patient care equipment in between patient use and failing to perform hand hygiene when donning and doffing gloves.

Hand washing Policy IC- 22:
Policy: Employees practice good hand hygiene between each patient. Hand hygiene includes wearing gloves when indicated, hand washing when indicated, or decontamination with alcohol-based hand antiseptic before and after each patient contact. Procedure: Hand washing with soap and water is recommended: Immediately after removing gloves.

Alcohol-based hand antiseptics: Decontaminate hands with hand sanitizer: b. When you have touched a patient's intact skin, i.e. after taking a pulse, temperature or blood pressure.e. When you come in contact with inanimate objects, including medical equipment, in a patient's vicinity.

On 2/12/18 at 11:10 a.m., S12MHT was observed pushing the vital signs monitor into the dining/day room. She opened the door with her bare hands, donned a pair of gloves and began obtaining a blood pressure and temperature on Patient #7. Afterwards, S12MHT helped Patient #R1 remove his jacket and placed the blood pressure cuff on the patient's arm to obtain his blood pressure. After taking the patient's blood pressure, S12MHT removed her gloves and donned a clean pair of gloves. At this time, S13MHT had arrived from the nurse's station to replace S12MHT. S12MHT doffed her gloves and returned to the nurse's station to care for a new patient. S13MHT donned a pair of gloves. S13MHT had taken Patient #R1's temperature, returned the vital signs monitor to the nurse's station and cleaned the blood pressure cuff. S13MHT doffed his gloves and walked out of the nurse's station to care for another patient. S12MHT and S13MHT was not observed washing and/or sanitizing her hands before and after caring for Patient R1. Also, S12MHT was not observed sanitizing the blood pressure cuff in between patient use.

On 2/12/18 at 12:10 p.m., during lunch meal, S13MHT was observed pulling the meal cart down the hall. S13MHT was knocking on the several doors of patient's rooms and opening doors with his bare hands checking for patients to announce the arrival of the lunch meal. After arriving to the dining area, S13MHT opened the lunch cart and began passing meal trays. He was not observed performing hand hygiene prior to distributing the first meal tray. Before S13MHT distributed the second meal tray, S12MHT brought S13MHT a pair of gloves. Both donned gloves and continued distributing meal trays. S13MHT had distributed eight meal trays. After completion, S12MHT was observed writing on a sheet of paper while wearing the same gloves as she stood next to the meal cart. S12MHT, then, while wearing the same gloves, distributed a lunch meal tray to Patient #R2. Both S12MHT and S13MHT was not observed washing and/or sanitizing their hands before donning gloves to distribute meal trays.

On 2/12/18 at 2:25 p.m. an interview was held with S12MHT in the day/dining room. When asked, she stated the facility policy was to wash your hands in between patient contact, prior to the start of caring for a patient and when changing gloves anytime any surface was touched. S12MHT verified she should have washed and/or sanitized her hands. During the interview, S12MHT had given S14MHT a pair of gloves to begin taking patient vital signs. S14MHT donned gloves and proceed to take vital signs on Patients #R3, #8, #6, #R4, #7 and #10. S12MHT verified S14MHT did not wash and/or sanitize his hands prior to and in between patient contact.

In an interview on 2/12/18 at 2:55 p.m., with S14MHT, he verified he did not wash his hands prior to obtaining vital signs on Patients #R3, #8, #6, #R4, #7 and #10 and in between patient contact in the day/dining room.

On 2/14/18 at 10:39 a.m., an interview was held with S13MHT. When asked, he stated the facility policy was to sanitize your hands before and after wearing gloves and after patient contact or touching objects. When informed of the observations on 2/12/18, S13MHT verified he did not wash or sanitize his hands before and after lunch meal pass and before and after taking the patient's vital signs.

In an interview on 2/15/18 at 11:13 a.m., with S2DON, she stated hand hygiene should be performed before and after wearing gloves and after patient contact. S2DON also stated patient care equipment should be sanitized in between patient use. After being made aware, S2DON verified S12MHT and S13MHT should have washed and/or sanitized their hands prior to patient contact, donning and doffing gloves and before distributing meals trays. S2DON also verified the blood pressure cuff should have been cleaned in between patient use.

7) Failing to wear gloves when handling a sharps waste container.

On 2/12/18 at 10:45 a.m. S11LPN was observed transporting a full sharps waste container into the biohazard room without wearing gloves. When asked, the S11LPN stated she was instructed not to wear gloves while in the hall.

In an interview on 2/15/18 at 11:13 a.m., with S2DON, she verified S11LPN should have worn gloves while transporting the sharps waste to the biohazard room.





38777

Based on record reviews and interview, the hospital failed to ensure each patient receive a psychiatric evaluation that contained an estimate of memory functioning. This deficient practice was evidenced by failing to have documented evidence of the means used by the examiner to determine the patient's memory functioning for 8 (#1, #2, #3, #6, #7, #8, #9, #10) of 10 sampled patients' psychiatric evaluations reviewed that had been completed by S6NP from a total patient sample of 18.

Findings:

Review of the Psychiatric Evaluation conducted for Patients #1, #2, #3, #6, #7, #8, #9, and #10 revealed the evaluations were conducted by S6NP. Review of all of the referenced patients' Psychiatric Evaluations revealed the patients' memory function was documented as follows: immediate, recent, and remote memory is intact. Further review revealed no documented evidence of the means used by the examiner to determine the above referenced patients' memory functioning.

In an interview on 2/14/18 at 10:30 a.m., S3COO reviewed the above-listed psychiatric evaluations and confirmed the evaluations did not include a description of how memory had been determined.





34161




38777

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in descriptive, not interpretive fashion. This deficient practice was evidenced by failing to have documented evidence of an inventory of the patients' assets, other than being listed as limited assets, for 8 (#1, #2, #3, #6, #7, #8, #9, #10) of 10 sampled patients' psychiatric evaluations reviewed that had been completed by S6NP from a total patient sample of 18.

Findings:

Review of the Psychiatric Evaluation conducted for Patients #1, #2, #3,#6, #7, #8, #9, and #10 revealed the evaluations were conducted by S6NP. Review of all of the referenced patients' Psychiatric Evaluations revealed the patients' assets were documented as " limited assets at this time. " Further review revealed no documented evidence of a list or description of the referenced patients' assets other than being documented as limited.

In an interview on 2/14/18 at 10:30 a.m., S3COO reviewed the above-listed psychiatric evaluations and confirmed the evaluations of the referenced patients needed to be more descriptive than limited at this time. S3COO agreed the assets should have been listed and described.



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Based on record reviews and interview, the hospital failed to ensure each patient's Initial Treatment Plan included the types of group therapies, specific treatment modalities utilized, responsible staff, and duration of therapies for 7 (#1, #2, #3, #6, #8, #9, #10 ) of 7 sampled patients reviewed for treatment plans from a total patient sample of 18.

Findings:

Review of the Initial Treatment Plans for Patients #1, #2, #3, #6, #8, #9, and #10 revealed the interventions for the Initial Treatment Plan for all referenced patients was documented as, "attend group therapy daily." Further review revealed no documented evidence of a description of the types of group therapy, the modality of each group therapy, the staff members (with their credentials) who were responsible for conducting the group therapies, and the duration of the group therapies with the exception of the nursing related therapies/interventions.

In an interview on 2/12/18 at 2:32 p.m. with S3COO, she indicated the type and frequency of therapy groups was directed by the patient's plan of care and the Psychiatric Evaluation. S3COO reported the Nurse Practitioner and/or Psychiatrist made recommendations for types of patient therapies upon completion of the Psychiatric Evaluation.

In an interview on 2/14/18 at 10:10 a.m. with S3COO, she indicated the Psychosocial and Activities Assessments were required to be completed within 72 hours of patient admission and the Psychiatric Evaluation was to be completed within 60 hours of patient admission. She indicated the Initial Plan of Care was the patients' treatment plan, perhaps for as long as 72 hours after patient admission, until the multidisciplinary team assessments had been completed and the plan had been formulated. She reported currently all inpatients' Initial Treatment Plan interventions related to group therapies, except for nursing related interventions, were for the patients to attend all groups daily until the master treatment plan had been formulated. She acknowledged the current patient Initial Treatment Plans referenced above had not specified the types of groups, the staff members (with their credentials) responsible for the groups, the modalities used, and the duration of the groups. S3COO agreed the plans lacked individualization.





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