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Based on review of facility documents, observation and staff interviews (EMP), it was determined that Wernersville State Hospital failed to ensure that all drugs and biologicals were secured and/or locked.

Findings include:

Review of Wernersville State Hospital Pharmacy procedure entitled, Medication Safety revealed, "... promote the safe administration, dispensing, storage and use of medication ... ."

Review of Wernersville State Hospital Dental and Podiatry Departments Policy entitled Storage, Control and Disposal of Medications, revealed, "... Medications must be stored behind locked cabinets and kept safely out of the reach of consumers ... ."

A tour on June 12, 2012, at 10:20 AM, of the Physical Therapy Gym in Building 34, revealed that eight tubes of Triamcinolone cream were stored in a cabinet that was not able to be secured.

An interview with EMP3 on June 12, 2012, at 10:30 AM confirmed that the tubes of Triamcinolone cream were not secured.

Based on observation, review of facility documents, and staff interviews (EMP), it was determined that Wernersville State Hospital failed to ensure the environment was maintained to assure that safety and well-being of patients.

Findings include:

A review on June 15, 2012, of the Wernersville State Hospital Physical Therapy Policy revealed, " ... A temperature of 150-170 degrees F. shall be maintained and checked daily as logged as such. ... Cleaning of the Unit-every three months ... ."

1) A tour on June 12, 2012, at 10:20 AM, of the Physical Therapy Gym in Building 34, revealed that the Hydrocollator had a brown colored build-up inside the equipment. There were no temperature or cleaning logs available for review.

Interview with EMP4 on June 12, 2012, at 10:30 AM confirmed that no cleaning or temperature logs had been maintained.

2) A tour on June 12, 2012, at 10:40 AM of the medication room in Building 35, Unit 3, revealed a 3" X 4' gouge into the plaster of the wall behind the medication cart.

Interview with on June 12, 2012, at 10:40 AM with EMP5 confirmed that the area would not able to be cleaned.

3) A tour on June 12, 2012, at 2:00 PM of the treatment room in Building 35, Unit 2, revealed seven catheterization trays and 5 Foley catheters that were expired.

Interview on June 12, 2012, at 2:00 PM with EMP5 confirmed that the equipment was expired.

A tour on June 13, 2012, at 11:15 AM of the treatment room in Building 37, Unit 2, revealed one catheterization tray and 1 Foley catheter that were expired.

Interview on June 13, 2012, at 11:15 AM with EMP6 confirmed that the equipment was expired

A review on June 15, 2012, of facility policy entitled Dating of multiple use vials and acceptable periods of use, "... Purpose: USP(Chapter 797) standards allow for the use of multiple use vials for 28 days after initial entry ... B. The nurse withdrawing medication from a multiple use vital for the first time will annotate the date of entry into the product label or the auxiliary label affixed by the pharmacist ... ."

4) A tour on June 12, 2012, at 10:00 AM, of the Treatment Room in Building 35, Unit 3, revealed a 250 ml vial of normal saline that was open and undated, and a 250 ml vial of normal saline that was open and dated November 2011.

Interview on June 12, 2012, at 10:00 AM, with EMP5 confirmed that the bottles were opened and not discarded according to policy.

A review on June 13, 2012, of facility policy entitled Crash and Treatment Carts, revealed "... 5. The licensed nurse (assigned by the Charge Nurses) will check the crash cart ... and document these checks were performed by placing initials on the Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check. This check shall be performed each shift ... ."

5) During a tour on June 13, 2012 of Building 35 , Floor 1, a review of of the crash cart in the activity/program area revealed the "Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check" sheet was not initialed by the day shift staff on February 1-29, 2012; March 23, 24, 29, 2012; April 7, 8, 13, 16, 17, 26, and 30, 2012; May 3, 7, 12, 13, 17, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. and 31. 2012; June 2, 3, 6, 7, and 12, 2012. Further review revealed the "Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check" sheet was not initialed for evening and night shift for the months of January, February, March, April, May, and June 2012.

An interview conducted on June 13, 2012 at 10:45 AM, with EMP5 confirmed the the "Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check" sheet was not initialed by staff.

6) A review of the facility's "Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check" sheets revealed:

The sheet was not initialed on day shift on January 27, 2012, March 13, and 29, 2012, and on evening shift June 6, and 11, 2012 for Building 34, Unit 2.

The sheet was not initialed on evening shift on January 24, and 25, nightshift on February 23, and 28, evening shift on April 17, and on day shift on May 8, 21, 28, 29 and 30, 2012 for Building 34, Unit 3 .

The sheet was not initialed on day shift on May 20, 22.23,24,25,26, 27, 28, and 31, 2012, and on evening shift June 8, and 10, 2012, and on night shift on June 5 and 6, 2012, for Building 34, Unit 4.

An interview conducted on June 13, 2012 at 2:50 PM confirmed that the "Crash Cart Seal/ Window Keys-Crank/Bandage Scissors /AED Check" sheet was not initialed by staff.

Based on a review of policy, medical records (MR) and interview with staff (EMP) it was determined that Wernersville State Hospital failed to implement their policy to refer a patient death to the Organ Procurement Organization for one patient of four patients (MR26) reviewed.

Findings include:

A review on June 15, 2012, of the Wernersville State Hospital Policy/ Procedure entitled RI 700 Body, Organ and Tissue Donation, revealed, "... physicians will contact the Gift of Life Donor Program at the time of death, when a death occurs on State Hospital Grounds ... ."

A review on June 14, 2012, of MR26 revealed the patient expired on October 9, 2012, at 15:55 PM. There was no documentation of notification to the Organ Procurement Organization that the patient had expired.

Interview with EMP2 on June 13, 2012, at 14:06 PM confirmed that MR26 had not been referred to the Organ Procurement Organization at the time of death.

Based on record review, policy review and interview, the hospital failed to assure that social workers wrote progress notes that contained information which specifically addressed patient progress towards treatment goals and discharge planning. Nine out of 12 sample patients (A1, A2, A5, A6, A8, A9, A10, A11, and A12) had missing weekly and/or monthly social work progress notes. Lack of social work documentation of patient progress impedes the treatment team's ability to evaluate the patient's response to treatment.

Findings include:

A. Record Review

1. Patient A1 was admitted on 11/07/06. Since review beginning with August 2012, there was one missing social work monthly progress note for October 2012.

2. Patient A2 was admitted on12/5/11. Since review beginning with August 2012, there were two missing social work monthly progress notes for October and November 2012.

3. Patient A5 was admitted on 9/10/12. There were no social work weekly progress notes from 9/10/12 to 10/25/12.

4. Patient A6 was admitted on 3/20/12. There were four missing social work weekly progress notes from 3/20/12 to 6/22/12 and there was one missing social work monthly note for October 2012.

5. Patient A8 was admitted on 5/1/12. There were seven missing weekly social work progress notes from 5/1/2 to 6/26/12. Additionally, there were no social work monthly progress notes since 7/26/12.

6. Patient A9 was admitted on 1/25/12. There were no social work monthly progress notes from 4/6/12 to 10/10/12.

7. Patient A10 was admitted on 9/27/12. There were five missing social work weekly progress notes from 9/27/12 to 11/29/12. There were weekly notes on 10/16/12 and 10/24/12 in the chart.

8. Patient A11 was admitted on 1/21/09. Since review beginning with 5/31/12, there were four missing social work monthly progress notes, beginning after 7/26/12.


9. Patient A12 was admitted on 6/18/98. Since review beginning with 5/22/12, there were three missing social work monthly progress notes after 6/18/12.

B. Policy Review

The Social Work Policy on Progress Notes dated 1/25/1980 and revised 10/24/12, states social work progress notes are required "Weekly for the first eight (8) weeks after admission and monthly thereafter."

C. Staff Interview

In an interview on 12/4/12 at 1:50 pm , the CSRE (Chief of Social Work/Rehab Executive) and the Director of Social Work confirmed that there were missing weekly and/or monthly progress for sample patients A1, A2, A 5, A6, A8 , A 9, A10, A11, and A12. The Director of Social Work said "I am new since February 2012 and I see that I did not follow our policy."

Based on record review, interview and policy review, the Director of Social Work failed to ensure that Social Work Progress Notes met professional social work standards for 9 out of 12 sample patients (A1, A2, A5, A6, A8, A9, A10, A11, and A12). Notes were not written with a minimum frequency which would delineate social work involvement in patient care. This failure can result in a lack of professional social work treatment services and hampers the treatment team's ability to identify and address important treatment issues for patient care.

Findings include:

A. Record Review

1. Patient A1 was admitted on 11/07/06. Since review beginning with August 2012, there was one missing social work monthly progress note for October 2012.

2. Patient A2 was admitted on12/5/11. Since review beginning with August 2012, there were two missing social work monthly progress notes for October and November 2012.

3. Patient A5 was admitted on 9/10/12. There were no social work weekly progress notes from 9/10/12 to 10/25/12.

4. Patient A6 was admitted on 3/20/12. There were four missing social work weekly progress notes from 3/20/12 to 6/22/12 and there was no social work monthly note for October 2012.

5. Patient A8 was admitted on 5/1/12. There were no weekly social work progress notes from 5/1/2 to 6/26/12 and there were no social work monthly progress notes since 7/26/12.

6. Patient A9 was admitted on 1/25/12. There were no social work monthly progress notes from 4/6/12 to 10/10/12.

7. Patient A10 was admitted on 9/27/12. There were five missing social work weekly progress notes from 9/27/12 to 11/29/12.

8. Patient A11 was admitted on 1/21/09. Since review beginning with 5/31/12, there were four missing social work monthly progress notes, beginning after 7/26/12.


9. Patient A12 was admitted on 6/18/98. Since review beginning with 5/22/12, there were three missing social work monthly notes after 6/18/12.

B. Policy Review

The Social Work Policy on Progress Notes dated1/25/80 and revised 10/24/12, states social work progress notes are required "Weekly for the first eight (8) weeks after admission and monthly thereafter."

C. Staff Interview

In an interview on 12/4/12 at 1:50 PM the CSRE (Chief of Social Work/Rehab Executive) and the Director of Social Work confirmed that there were missing weekly and /or monthly progress for sample patients A1, A2, A 5, A6, A8 , A 9, A10, A11, and A12. The Director of Social Work said "I am new since February 2012 and I see that I did not follow our policy."