HospitalInspections.org

Based on observations, review of hospital policies and procedures, interviews, contracted service agreements, hospital Performance Improvement (PI) Program, Quality/PI data reports, Risk Occurrence Reports, complaint investigation documentation, CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary, Alabama Board of Nursing Administrative Code Standards of Nursing Practice, personnel records, emergency crash cart logs, U.S. (United States) Food and Drug Association (FDA) guidelines for Sharps Disposal Containers in Health Care Facilities, manufacturer's directions for product use, and hospital Antibiotic Stewardship Program documentation, it was determined the Governing Body failed to ensure patients rights were protected, care was provided in a safe and sanitary environment, as ordered by the physician, and delivered by trained and competent staff.

Refer to A 064, A 084, A 116, A 118, A 144, A 166, A 168, A 171, A 174, A 175,
A 273, A 286, A 392, A 396, A 405, A 438, A 491, A 620, A 724, A 749, A 781, A 803, and A 1134 for findings.

Based on medical record (MR) review and staff interviews, it was determined the hospital failed to ensure the medical staff conducted a medical consult as ordered by the admitting psychiatrist. This affected PI (Patient Identifier) # 6, one of one psychiatric records reviewed with a medical consult order and had the potential to negatively affect all patients admitted to the psychiatric care units.

Findings include:

1. PI # 6 was admitted to the Geriatric Behavorial Health Unit on 5/5/23 with diagnoses including Mental Illness.

Review of the MR revealed the initial blood pressure (BP) documented on 5/5/23 at 10:44 AM was 205/129, at 2:06 PM the BP was 165/102, and at 6:50 PM the BP was 176/113.

Review of the physician entered orders dated 5/5/23 at 3:56 PM revealed an order for a medical consult.

Review of the MR dated 5/5/23 to 5/15/23 revealed no documentation that a medical consult was performed per the 5/5/23 orders.

An interview was conducted on 5/18/23 at 4:20 PM with Employee Identifier # 2, Chief Executive Officer, who confirmed a medical consult was ordered and not completed.

Based on review of the facility 2022 Performance Improvement (PI) Program, hospital PI data collection reports, Physical Therapy (PT) service Staffing/Management, Biomedical Maintenance service agreements, and interviews, it was determined the hospital staff failed to ensure all contracted services were included in the hospital PI activities for service evaluation. This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Performance Improvement
Revision Date: 7/13/21

Purpose:

.... of the organizational PI plan...is to ensure...the Governing Body (GB), medical staff...professional services staff...deliver care that is optimal in an environment of minimal risk.
... As patient care is a coordinated...collaborative effort, the approach to improving performance involves multiple departments...

The organizational PI Plan...with support and approval from the GB has the responsibility for monitoring every aspect of patient care...to continuously improve and facilitate positive patient outcomes.

Goals of Performance Improvement:

...Provide for a hospital-wide program that assures the organization designs processed (with special emphasis on design of new or revisions in established services) ...to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach...

Assure that the improvement process is organizational-wide, monitoring, assessing, and evaluating the quality...that will lead to PI and reduce the risk for sentinel events...

Scope of Activities:

...The dimensions of performance of patient care and quality control activities in the following services are monitored, assessed, and evaluated:

...Rehabilitation Services
...Safety/Risk Management
...Care of the Environment...

Management Agreement

...Management Agreement is made and entered into as of March 2022 (no day was documented) by and between Professional Resources Management...Bullock County Hospital and Rehab Associates, LLC ("Manager").

...(m) Manager shall perform the Services in a professional and competent manner, in compliance with all applicable governmental...regulations, all applicable standards of certifying and accrediting bodies...

Precision-Med Biomedical Solutions, LLC

...Precision-Med Biomedical Solutions will be available during state and other regulatory inspections...will uphold all standards, regulations ... practices of the facility the work is performed in...All preventative maintenance will be documented, and a full detailed report will be given to the facility...

Parties in Agreement---signed on 5/25/2020 and on 6/1/2020

1. On 5/18/23 at 1:20 PM during a review of the hospital quality improvement program with EI (Employee Identifier) # 1, Chief Nursing Officer/Quality Manager, the surveyor requested to review the QA (Quality Assessment) service evaluation documentation for contracted services including the Outpatient PT department and Biomedical Department. None was provided.

An interview was conducted on 5/18/23 at 5:00 PM with EI # 1 and EI # 2, Chief Executive Officer, who confirmed there was no documentation of QA participation including review of the two contracted services.

Based on review of medical records (MR), hospital policies and procedures, Risk Occurrence Reports (ROR) for 2022 to 2023, Quality data reports for 2022 to 2023, complaint investigation documentation, CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary dated 12/8/17, and interviews with staff, it was determined the hospital failed to ensure a safe environment was provided for the patients.

This had the potential to affect all patients and did affect four of five MRs reviewed which included Patient Identifier (PI) # 1, PI # 2, PI # 4, and PI # 5.

Refer to A 116, A 118, A 144, A 166, A 168, A 171, A 174, and A 175 for findings.

Based on medical record (MR) review, and interview, it was determined the hospital failed to provide a copy of the Patient's Rights on admission.

This affected one of one observation patients, including Patient Identifier (PI) # 16, and had the potential to affect all patients served by the facility.

Findings include:

1. PI # 16 was admitted to the facility for observation on 7/14/22 with a diagnosis of chemical dependency.

Review of the MR revealed no documentation PI # 16 received information on his/her rights as a patient.

In an interview on 5/18/23 at 3:38 PM Employee Identifier # 2, Chief Executive Officer confirmed there was no documentation PI # 16 was informed of his/her rights as a patient.

Based on hospital policies and procedures, Risk Occurrence Reports (ROR) for 2022 to 2023, Quality Data reports for 2022 to 2023, complaint investigation documentation, and staff interview, it was determined the hospital staff failed to ensure all complaints received were:

1. Documented in the hospital Risk Occurrence Report to be tracked, trended and the analysis reviewed with the quality data.

2. Investigated completely with investigation documentation including all possible witnesses and parties involved.

Hospital Policy and Procedure Title: Patient Complaint and Grievance
Review Date: 4/12/23

Policy:

...This organization shall respond to...concerns in a timely...consistent manner...

Definitions:

...Staff present includes any hospital staff present at the time of the complaint...
A written complaint is always considered a grievance...

Procedure:

All grievances are submitted verbally or in writing...either by the patient...or a staff member whom the grievance was reported.
...The Administrator and/or Chief Nursing Officer (CNO) will interview the patient...also query other members of the healthcare team that have been involved in the care...
After thorough research has been conducted...the CNO will work in tandem with staff identified as key individuals critical to problem resolution...There may be situations...the patient ...remains unsatisfied with the hospital's actions...The hospital must maintain documentation of its efforts and demonstrate compliance with CMS (Centers for Medicare/Medicare Services) requirements...

Hospital Policy: Incident Reports
Revision Date: 4/23

Policy:
...actual or potential incidents and events that could endanger the health and safety of individuals within the facility, shall be routinely monitored and investigated through resolution.

Procedure:
A. Methods to identify situations or conditions that may cause injury, or negative outcome shall include:
...2. Unusual and unexpected events.

B. Reported events and incidents shall:
1. Be investigated
2. Have action taken as appropriate.
3. Have follow up taken to resolution.

...F. Incident Report Completing (QA) Reporting
1. The Incident Report shall be completed and signed...either by the:
a) Person involved in the incident
b) Person who discovered the incident
...2. The Appropriate...Supervisor...shall:
c. Assist the employee...others, involved, with action and resolution...

1. An entrance interview was conducted on 5/16/23 at 9:00 AM with EI (Employee Identifier) # 1, CNO. The surveyor provided EI # 1 with a list of requested survey documents that included the hospital Grievance/Complaint log for the past 12 months.

A review of the hospital documents provided failed to reveal complaint/grievance log documentation.

On 5/17/23 at 4:25 PM, the surveyor requested the hospital Grievance/Complaint log documentation for the past 12 months. EI # 2, Chief Executive Officer, reported the grievance/complaints were documented on the hospital ROR previously provided. The surveyor asked for all complaints/grievances to be identified on the ROR document.

Review of the hospital 2022 Quality Data report revealed one complaint was documented October 2022. The surveyor was not provided with the October 2022 complaint documentation or investigation. The October 2022 complaint/grievance was not documented on the hospital ROR.

There were no complaints documented on the 2023 ROR for January to April 2023.

On 5/18/23 at 9:10 AM, EI # 1 reported to the surveyor the ROR documentation did not include a complaint received on 4/17/23. EI # 1 presented a document dated 4/18/23, investigation of a complaint filed on 4/17/23 for the allegation of a patient sexual assault that occurred on the adult psychiatric unit. The complaint allegation was against an employee, a MHT (Mental Health Technician).

Review of the complaint/grievance investigation revealed four statements dated 4/17/23 completed by the patient, a RN (Registered Nurse) whom the patient reported the sexual assault to (not the RN caring for the patient), the patient's SW (Social Worker), and a Mental Health Technician (MHT) whom the patient reported the allegations to.

There was no interview or statement from the alleged assailant documented as part of the investigation, and no interviews with the RN caring for the patient at the time of the alleged assault. There was no documentation of attempts to identify/locate possible witnesses to the alleged events. There was no documentation law enforcement was notified of the sexual assault allegation.

The hospital failed to ensure a thorough and complete investigation was performed and documented.

An interview was conducted on 5/18/23 at 11:50 AM with EI # 1 who confirmed the 4/17/23 sexual assault allegation was not entered and documented in the hospital ROR. EI # 1 reported the patient was interviewed on two separate days, and video footage of three days was reviewed. EI # 1 reported the MHT who allegedly assaulted the patient was interviewed. However, there was no documented interview or statement of events from the employee who was the alleged assailant. EI # 1 confirmed and documented on 4/18/23 the sexual assault allegation grievance was un-substantiated based on video footage review.

Based on observations, CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary dated 12/8/17, hospital policy, and staff interviews, it was determined the hospital failed to ensure:

1. Patients were cared for in a safe environment.

2. Environmental safety risk assessments were conducted to identify potential safety risks.

3. Nursing staff conducted and documented hourly rounds per the Patient Round Flowsheet-Psych (Psychiatric).

4. Staff performed Q (every) 15 minute observations and documented an accurate account of the psychiatric patient status per hospital policy.

This deficient practice affected PI (Patient Identifier) # 15, in one of twelve behavioral health records reviewed, and had the potential to affect all patients in the Adult and Geriatric Behavioral Health Units (BHU).

Findings include:

CMS S&C Memo 18-06-Hospitals
Date: December 08, 2017
Subject: Clarification of Ligature Risk Policy

...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, handles, hinges and closures...

Hospital Policy and Procedure Title: Close Observation of Patients in Inpatient Psychiatric Services
Revision Date: 4/12/23

Policy:

All patients admitted to inpatient psychiatric services will be monitored under close observation unless the physician orders an enhanced observation frequency.

Procedure:

Close Observation

A close observation requires that the patient's assigned MHT (Mental Health Technician) monitor the patient by direct visual contact every 15 minutes which will be documented on that patient's Observation Log by the MHT...

1. A tour of the Adult BHU was conducted on 5/16/23 at 10:00 AM with Employee Identifier (EI) # 6, Social Worker (SW). The following ligature risks, electrical hazards, and mechanical hazards were observed:

a. Patient room 117, the entry door to the seclusion room, the bathroom outside of the seclusion room, and shower room # 5 each had door handles that were constructed in a manner to allow a ligature to be attached creating a patient safety hazard.

b. Patient room 117, the seclusion room entry door, and shower room # 5 had door hinges that were constructed in a manner to allow a ligature to be attached creating a patient safety hazard.

c. Patient rooms 112, 115, 117, and the bathroom outside of the seclusion room had sink handles that were constructed in a manner to allow a ligature to be attached, creating a patient safety hazard.

d. Patient rooms 115 and 117 had sink faucets that were constructed in a manner to allow a ligature to be attached, creating a patient safety hazard.

e. Patient rooms 113, 114, and 115 had soap dispensers that were manufactured in a manner to allow a ligature to be secured over the top.

f. The hallway grab rails were of the open design that would allow a ligature to be passed through.

g. Patient rooms 111, 113, 115, 116 and 117 had electrical outlets that were uncovered and a potential electrocution hazard.

h. The seclusion room had a wall mounted air conditioning unit without a front cover and electrical wiring exposed. One loose red electrical wire approximately 4.5 feet long was laying on the floor that could be used as a ligature.

i. Shower room # 4 had a one foot by one foot open ceiling access panel with exposed plumbing and wiring that could be used to attach ligature.

j. The physician office/Day Room at the end of the hall had three electrical outlets with exposed wiring and without a receptacle or cover.

2. Review of the Environmental Rounds Ongoing List provided to the surveyor on 4/18/23 revealed the maintenance staff had identified the following items and had not been repaired:

a. On 4/3/23 the air conditioner in room 110 needed parts.

b. On 4/13/23 the Seclusion Room air conditioner needed parts and was taken out of service.

c. On 5/3/23 the door handles in room 117 needed replacing. Follow up on 5/6/23 the door handles had been replaced. Observation of room 117 during the tour conducted on 5/16/23 revealed the door handles had not been replaced with ligature free handles.

d. On 5/10/23 room 117 needed wall plug covers.

An interview was conducted on 5/17/23 at 8:30 AM with EI # 2, Chief Executive Officer, who confirmed the observations of ligature risks and electrical hazards and confirmed all of the risks had not been identified and repaired.


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3. A tour of the geriatric psychiatric unit was conducted on 5/16/23 at 1:32 PM with EI # 6. The following ligature risks, electrical hazards and self-harm risks were observed:

a. Day room and room 201 grab rails were of the open design that would allow a ligature to be passed through.

b. Day room and patient rooms 201, 202, 204, 205, 206 and 207 had electrical outlets that were uncovered and was a potential electrical hazard.

c. Day room and the shower room had large trash cans with plastic bags inside which was a potential self-harm risk.

d. Room 202 had a glass mirror which was a potential self-harm risk.

e. Room 206 had peeling paint on walls at the head of the beds and was a potential self-harm risk.

f. Three cabinets built into the end of the hallway were unlocked and contained patient belongings in woven cloth bags with long handles that could pose a ligature risk.

An interview was conducted on 5/17/23 at 8:30 AM with EI # 2, who confirmed the observations of ligature risks, electrical hazards and self harm risks.



30952

4. PI # 15 was admitted to the Geriatric BHU 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional. PI # 15 was pronounced dead on 11/9/22 at 6:42 AM.

Review of physician orders dated 11/3/22 at 12:45 AM to 2:45 AM revealed the Level of Observation was 1:1 (1 staff to 1 patient), place patient in seclusion.

Review of the Observation Log dated 11/3/22 from 12:45 AM to 6:15 AM revealed the following Q (every) 15 minute observation documentation: location- bedroom: activity- appears asleep, room door open.

Review of the Restraint/Seclusion Flowsheet documentation revealed PI # 15 was in seclusion at 12:40 AM and was released at 2:45 AM.

Staff failed to ensure an accurate account of PI # 15's location, observation status and activity was conducted and documented.

Review of the 11/6/22 Patient Round Flowsheet-Psych revealed hourly rounding by the nurse was conducted each hour from 12:00 AM to 7:00 AM. There was no documentation hourly nurse rounds were conducted from 8:00 AM to 6:00 PM.

Nursing staff failed to conduct and document hourly rounds for a 10 hour period on 11/6/22.

Review of the Observation Log dated 11/8/22 revealed no identifying documentation of the staff member who conducted Q 15 minute observations from 6:00 AM to 7:30 AM.

MR review revealed no Q 15 minute observations were documented after 11/8/22 at 11:45 AM. PI # 15 was pronounced dead in his/her hospital room at 6:42 AM.

The hospital staff failed to ensure Q 15 minute observation rounds were conducted and documented on PI # 15 per hospital policy.

An interview was conducted on 5/18/23 at 4:40 PM with EI # 2, who confirmed staff failed to document hourly and q 15 minute checks as ordered.

Based on medical record (MR) reviews, hospital policy and procedure and staff interview it was determined the hospital failed to document a written modification to the patient's Plan of Care (POC) with the use of seclusion and/or restraints.

This deficient practice affected three of three MRs reviewed of patients in restraint or seclusion including Patient Identifier (PI) # 13, PI # 12, PI # 15, and had the potential to affect all patients with restraints and/or seclusion in the Behavioral Health Units (BHU).

Findings include:

Hospital Policy: Multidisciplinary Treatment Plan
Policy number: M.4
Reviewed: 4/12/23

Policy Purpose: To provide individualized, age appropriate, comprehensive and coordinated care designed to meet the needs of each patient...

A plan of care will be initiated for each patient within twenty-four hours...of admission...

Procedure:

...E. Additional problems which have been identified since the time of admission will also be addressed. The staff, based on the physician's plan of care, will incorporate interventions ...

Hospital Policy: Use of Seclusion and Violent (Behavioral) Restraints, Emergency Restraint Chair
Policy Number S 2 (two)
Revision Date: 6/18/21

...A physical restraint is any physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body, or head ... Mechanical devices include an emergency restraint chair.

...Seclusion: The placement of a patient in a room or area alone from which a patient cannot leave at will...

1. PI # 13 was admitted to the Geriatric BHU on 4/10/23 at 1:48 PM with diagnoses including Mental Illness, Mild Anemia with Hematuria, and Hypomagnesemia.

Review of the Multidisciplinary Treatment Plan revealed the Treatment Plan was initiated on 4/10/23.

Review of the Problem Activity dated 4/10/23 revealed the identified problem was ineffective coping related to mental illness with goals including for PI # 13 to identify life conflicts from the past or present, state at least two coping mechanisms, and establish a realistic daily coping goal using a scale of one to ten.

Review of the Restraint/Seclusion Episode Assessment revealed PI # 13 was placed in seclusion on 4/12/23 from 8:35 AM until 9:00 AM.

Review of the Reason for Restraint/Seclusion revealed the patient was hitting or trying to hit others, kicking or trying to kick others, and threatening and cursing.

Further review of the Problem Activity notes dated 4/12/23 through discharge on 4/25/23 revealed no changes in the Treatment Plan after the seclusion incident.

An interview was conducted on 5/18/23 at 4:00 PM with EI # 1, Chief Nursing Officer, who stated the plan of care was reviewed the following morning and again the next night but no changes were noted.

2. PI # 12 was admitted to the Adult BHU on 5/4/23 at 11:40 AM with diagnoses including Depression, Suicide Ideation, and Substance Abuse.

Review of the Nursing Problem Activity note dated 5/4/23 revealed the identified problem of ineffective coping related to difficulty concentrating.

Review of the History and Physical dated 5/5/23 at 12:12 PM revealed the Treatment Plan was for PI # 12 to be placed on suicide and homicide precautions, detoxed from THC (Tetrahydrocannabinol), started on Abilify 15 milligrams, oriented to twelve steps, and candidate for long-acting antipsychotic injectable.

Review of the Patient Progress Notes, Nursing Shift Assessment, dated 5/5/23 at 8:00 PM revealed the nurse documented PI # 12 was "... being combative towards staff, kicking, hitting, and trying to bite...placed in seclusion chair (restraint chair)..."

Review of the Physician Order for Restraint/Seclusion dated 5/5/23 at 8:00 PM revealed an unsigned order for PI # 12 to be placed in the Emergency Restraint Chair.

An observation of the Seclusion Room conducted on 5/16/23 revealed a restraint chair with velcro straps capable of restraining the arms and legs located in the middle of the room.

There was no documentation the treatment plan was updated to reflect needed changes in care following the use of the restraint chair.

An interview was conducted on 5/18/23 at 4:15 PM with EI # 1, who confirmed the POC had been reviewed the following morning but no updates to the plan had been implemented.



30952

3. PI # 15 was admitted to the Geriatric BHU on 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional.

Review of the physician orders dated 11/3/22 at 12:45 AM included 1:1 (one staff to one patient) observation...place patient in seclusion.

Review of the Restraint/Seclusion Observation Flowsheet documentation revealed PI # 15 was placed in seclusion for physical aggression on 11/3/22 at 12:45 AM and released at 2:45 AM.

MR documentation revealed one treatment plan problem dated 11/3/22, 11/4/22, 11/6/22, 11/7/22, and 11/8/22 for paranoid thinking interfering with the ability to function. The treatment plan failed to include documentation of the seclusion intervention, and the evaluation of the use of seclusion on 11/3/22.

There was no documentation of modification/updates/revision to the plan of care after seclusion use on 11/3/22.

An interview was conducted on 5/18/23 at 4:20 PM with EI # 1, who confirmed there was no documentation the staff updated/revised the treatment plan following the use of seclusion on 11/3/22.

Based on medical record (MR) review, hospital policy and procedure, and interviews, it was determined the hospital failed to ensure a physician order was obtained and authenticated for all patients who were placed in restraints or seclusion.

This deficient practice affected two of three MR reviews for patients in restraint or seclusion including Patient Identifier (PI) # 13, PI # 12, and had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Use of Seclusion and Violent (Behavioral) Restraints, Emergency Restraint Chair
Policy number: S.2
Reviewed: 4/12/23

... Procedure:

...Orders for Patient Seclusion:

The Unit RN (Registered Nurse) will obtain and document a physician's ... verbal order no later than one (1) hour following initiation of the seclusion/restraints.

... The order will be signed, timed, and dated by the physician or the RN who accepted the prescribing physician's telephone order when the seclusion/restraints was ordered.

The ordering physician will personally sign, date, and time the telephone order within twenty-four (24) hours of the time the order was originally issued...

1. PI # 13 was admitted to the Geriatric Behavioral Health Unit (BHU) on 4/10/23 at 1:48 PM with diagnoses including Mental Illness, Mild Anemia with Hematuria, and Hypomagnesemia.

Review of the Nursing Shift Assessment dated 4/12/23 at 4:30 PM revealed the nurse documented PI # 13 was "...belligerent towards staff with verbal abuse, threatening staff, trying to hit and kick others...MD notified. Order received for seclusion with close observation..."

Review of the Restraint/Seclusion Episode Assessment dated 4/12/23 revealed PI # 13 was placed in seclusion at 8:35 AM and released at 9:00 AM.

Review of the Physician Order for Restraint/Seclusion dated 4/12/23 at 8:35 AM revealed Employee Identifier (EI) # 19, Psychiatrist, had signed the order and there was no date or time the order was signed.

Review of the Nursing Order dated 4/12/23 at 8:35 AM revealed the seclusion phone order was signed by EI # 19 on 4/24/23 at 9:39, which was twelve days after the date of the seclusion.

An interview was conducted on 5/18/23 at 4:00 PM with EI # 1, Chief Nursing Officer, who confirmed the hospital failed to ensure the physician order was authenticated per the hospital policy.

2. PI # 12 was admitted to the Adult BHU on 5/4/23 at 11:40 AM with diagnoses including Depression, Suicide Ideation, and Substance Abuse.

Review of the Nursing Shift Assessment dated 5/5/23 at 8:00 PM revealed the nurse documented PI # 12 was "...combative towards staff, kicking, hitting, and trying to bite...placed in seclusion chair...(EI # 19, Psychiatrist) made aware of patient in seclusion chair (restraint chair)..."

Review of the Restraint/Seclusion Episode Assessment dated 5/5/23 revealed PI # 12 was placed in the restraint chair at 8:00 PM and released at 9:11 PM.

Review of the Physician Order for Restraint/Seclusion revealed an order for PI # 12 to be placed in the Emergency Restraint Chair. There was no documentation EI # 19 had signed or dated the the order for the restraints.

An interview was conducted on 5/18/23 at 4:15 PM with EI # 1, who confirmed the hospital failed to ensure the ordering psychiatrist signed the seclusion order per the hospital policy.

Based on review of the hospital policy, medical record (MR) documentation, and staff interviews, its was determined the hospital staff failed to obtain/document orders which included the maximum length of time for use of the restraint/seclusion intervention, the specific behaviors which constituted the emergency resulting in the need for seclusion, and the specific release criteria that the patient will demonstrate before seclusion will be discontinued.

This affected PI (Patient Identifier) # 15, in one of three records reviewed for the use of restraint/seclusion and this deficient practice had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Use of Seclusion and Violent (Behavioral) Restraints, Emergency Restraint Chair
Policy Number S 2 (two)
Revision Date: 6/18/21

Policy: To define guidelines and procedure for use of Seclusion/Restraints on the Behavioral Health Unit

...Procedure:

...In an emergency situation, seclusion/restraints may be utilized by a Registered Nurse (RN)...A physician's order will be obtained within one hour of application.

...Orders for Patient Seclusion

The...RN will obtain and document a physician's order...The order will be signed, timed, dated...
The original written order for patient seclusion/restraints will accomplish the following:
1) Designate the specific procedure authorized...
2) Specify the date, time of day, and maximum length of time for which the procedure will be used, not to exceed four (4) hours for seclusion and (2) two hours for emergency restraint chair.
3) Describe the specific behaviors which constituted the emergency resulting in the need for seclusion
4) Describe the specific release criteria that the patient will demonstrate before seclusion will be discontinued

1. PI # 15 was admitted to the Geriatric Behavorial Health Unit on 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional.

Review of the physician orders dated 11/3/22 at 12:45 AM included 1:1 (one staff to one patient) observation...place patient in seclusion. The psychiatrist signed the seclusion order on 11/4/22 at 11:11 AM. There was no maximum length of time documented for the seclusion order.

MR review included a document titled, Restraint/Seclusion Observation Flowsheet, that revealed PI # 15 was placed in seclusion on 11/3/22 at 12:45 AM. There was no date and no time out of seclusion documented and no psychiatrist's signature on the document.

An interview was conducted on 5/18/23 at 4:20 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed there was no documentation of the maximum time allowed in seclusion on the 11/3/22 order and no physician/psychiatrist signature was documented.

Based on review of the hospital policy, medical record (MR) documentation, and staff interviews, it was determined staff failed to inform the patient of restraint/seclusion release criteria to ensure the earliest possible release. This affected PI (Patient Identifier) # 15, PI # 12, in two of three restraint/seclusion record reviews, and had the potential to negatively affect all patients in restraint/seclusion.

Findings include:

Hospital Policy: Use of Seclusion and Violent (Behavioral) Restraints, Emergency Restraint Chair
Policy Number S 2 (two)
Revision Date: 6/18/21

Policy: To define guidelines and procedure for use of Seclusion/Restraints on the Behavioral Health Unit

...Procedure:

...In an emergency, seclusion/restraints may be utilized by a Registered Nurse (RN)...A physician's order will be obtained within one hour of application.

...Orders for Patient Seclusion

The...RN will obtain and document a physician's order...The order will be signed, timed, dated...
The original written order for patient seclusion/restraints will accomplish the following:
1) Designate the specific procedure authorized...
2) Specify the date, time of day, and maximum length of time for which the procedure will be used, not to exceed four (4) hours for seclusion and (2) two hours for emergency restraint chair.
3) Describe the specific behaviors which constituted the emergency resulting in the need for seclusion
4) Describe the specific release criteria that the patient will demonstrate before seclusion will be discontinued

New Order Implementation and Rationale

...As soon as is feasible after seclusion/restraints have been implemented, the RN will discuss explanation/education regarding initiation of seclusion/restraints and behavior necessary for discontinuation.

1. PI # 15 was admitted to the Geriatric BHU (Behavioral Health Unit) on 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional.

Review of the physician orders dated 11/3/22 at 12:45 AM included 1:1 (one staff to one patient) observation...place patient in seclusion.

Review of the Restraint/Seclusion Observation Flow Sheet documentation revealed physical aggression was the reason for seclusion.

There was no documentation of PI # 15's initial response to seclusion, and no documentation the criteria for release was explained to PI # 15.

An interview was conducted on 5/18/23 at 4:20 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the staff failed to follow the hospital policy and procedure for the use of seclusion.




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2. PI # 12 was admitted to the Adult BHU on 5/4/23 at 11:40 AM with diagnoses including Depression, Suicide Ideation, and Substance Abuse.

Review of the Nursing Shift Assessment dated 5/5/23 at 8:00 PM revealed the nurse documented PI # 12 was "...combative towards staff, kicking, hitting, and trying to bite...placed in seclusion chair (restraint chair)...(EI # 19, Psychiatrist) made aware of patient in seclusion chair..."

An observation of the Seclusion Room conducted on 5/16/23 revealed a restraint chair with velcro straps capable of restraining the arms and legs located in the middle of the room.

Review of the unsigned Physician Order for Restraint/Seclusion dated 5/5/23 at 8:00 PM revealed orders for Emergency Restraint Chair.

Review of the Restraint/Seclusion Episode Assessment dated 5/5/23 revealed PI # 12 was placed in the restraint chair at 8:00 PM and released at 9:11 PM.

Review of the Restraint/Seclusion Observation Flow Sheet dated 5/5/23 revealed no documentation of the initial response of the patient to the intervention.

An interview was conducted on 5/18/23 at 4:15 PM with EI # 1, who confirmed the hospital failed to ensure the staff documented the use of restraint/seclusion per the hospital policy.

Based on review of the hospital policy, medical record (MR) documentation, and staff interviews, it was determined the staff failed to document the results of patient monitoring for a patient in seclusion. This affected PI (Patient Identifier) # 15, in one of three record reviews for seclusion/restraint use and had the potential to negatively affect all patients treated at the facility.

Findings include:

Hospital Policy: Use of Seclusion and Violent (Behavioral) Restraints, Emergency Restraint Chair
Policy Number S 2 (two)
Revision Date: 6/18/21

Policy: To define guidelines and procedure for use of Seclusion/Restraints on the Behavioral Health

...Procedure:

...Seclusion Precautions and Activities by Staff

...Continuous observation will be required when a patient in seclusion has been administered psychoactive medication on an emergency basis...monitoring and care activities documented every fifteen minutes on the Seclusion/Restraint Flowsheet. Adequate respiration and circulation will be ensured at all times...

1. PI # 15 was admitted to the Geriatric Behavioral Health Unit on 11/2/22 with diagnoses including Schizoaffective disorder bipolar type manic and delusional.

Review of the physician orders dated 11/3/22 at 12:45 AM included 1:1 (one staff to one patient) observation...place patient in seclusion. The psychiatrist signed the seclusion order on 11/4/22 at 11:11 AM.

Review of the Restraint/Seclusion Observation Flow Sheet documentation revealed an IM (Intramuscular) prn (as needed) medication was administered at 12:50 AM.

Further review of Restraint/Seclusion Observation Flow Sheet documentation by the RN (Registered Nurse) at 12:40 AM, 12:55 AM, 1:15 AM, 1:35 AM, 2:00 AM, 2:15 AM, and 2:38 AM revealed the following observations were "done", indicated with check marks documented at each of the following: circulation checks, blood pressure, temperature, pulse, respirations, injury, range of motion, bathroom, fluids offered, and behavior.

There were no results of the observations documented in areas documented as 'done". There was no documentation of the presence/absence of injury, no documentation of the results of the circulation checks, no documentation that respirations were labored or unlabored, what the observed patient behavior(s) were, no documentation whether PI # 15 accepted or refused bathroom and fluids, and no documentation that PI # 15 agreed to the release criteria.

An interview was conducted on 5/18/23 at 4:20 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed the staff failed to document the results of patient monitoring while in seclusion.

Based on review of the hospital PI (Performance Improvement) program documentation, and interviews, it was determined the hospital PI program data reports failed to include hospital readmissions. This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

1. On 5/17/23, Employee Identifier (EI) # 1, Chief Nursing Officer, provided the surveyor with the 2022 and 2023 hospital PI Program documentation which included quality indicator data reports..

Review of the 2022 and 2023 PI Program and quality indicator data failed to include documentation that the hospital collected, monitored and analyzed hospital readmissions.

An interview was conducted on 5/18/23 at 1:20 PM with EI # 1 who reported the hospital does monitor hospital readmissions. EI # 1 confirmed there was no documentation the hospital PI program included hospital readmissions in its quality indicator data reports.

Based on review of the hospital Risk Occurrence Report (ROR), policies and procedures, Performance Improvement (PI) program documentation, and staff interviews, it was determined the hospital staff failed to implement a plan of action to address and reduce narcotic wasting medication discrepancies. This had the potential to affect every patient served by the hospital.

Hospital Policy: Incident Reports
Revision Date: 4/23

Policy:

...actual or potential incidents and events that could endanger the health and safety of individuals within the facility, shall be routinely monitored and investigated through resolution.

Procedure:

B. Reported events and incidents shall:
1. Be investigated
2. Have action taken as appropriate.
3. Have follow up taken to resolution.

C...
1. The QA (Quality Assurance) Committee shall collate...monthly incidents for trending and severity.
2. From the trending, the QA Committee shall develop plans for resolution of negative trends...
3. From each department's plan of action and plans for resolution, the QA Committee shall implement those that are appropriate...

Hospital Policy Number: PHARM-05.00
Review Date: 2/22/23

Policy:

The organization has a process to respond to actual or potential medication errors...documented using the hospital discrepancy, waste...med (medication) error form...

Procedure:

When a medication error...occurs, the following should occur...
...Report the error...in detail, to include...dates, times, and signatures, on the Discrepancy, Waste...Med Error Form...The practitioner should forward the Discrepancy, Waste...Med Error Form to the CNO (Chief Nursing Officer)...for investigation...Medication errors will be reported at the monthly medical staff meetings...
Component of the...monitoring and reporting include...education to all appropriate clinical staff... Drugs which are frequently encountered in...med error reporting may be targeted for more intense evaluation and educations...Medication errors will be reported and trended...

Findings include:

1. Review of the hospital ROR for the past 12 months revealed a total of fifty four (54) medication errors. Thirty one (31) of the documented medication errors/discrepancies were identified by the pharmacist as narcotic wasting occurrences.

An interview was conducted on 5/18/23 at 1:21 PM with EI (Employee Identifier) # 1, CNO, who reported the pharmacist monitored and tracked medication errors and medication errors were reported as a part of the hospital-wide QAPI program. The surveyor asked EI # 1 what was the hospital procedure for narcotic wasting? EI # 1 reported two nurses were to witness and document the narcotic wastage. The surveyor asked what actions had been taken to address the 31 narcotic wasting discrepancies identified on the ROR and reduce future medication errors? EI # 1 provided the surveyor with a document titled, "Attention Nursing, for all controlled waste (pills or liquid) the nurse must record waste in Omnicell with another witness and then the nurse and witness must place the pill or liquid waste in the RX (prescription) Destroyer bucket, Thanks Pharmacy. There was a 4/23 (April 23) date handwritten on the document. EI # 1 reported the reminder was posted at the Omnicell.

Review of the hospital 2022 and 2023 PI activity documentation failed to include improvement actions to address and reduce medication discrepancies related to narcotic wasting by nursing staff.

An interview was conducted 5/16/23 at 5:00 PM with EI # 1, and EI # 2, Chief Executive Officer, who confirmed there was no documentation of actions taken to address and reduce the narcotic wasting medication discrepancies.

Based on MR (medical record) reviews, hospital policies and procedure, and staff interviews it was determined the hospital failed to ensure the staff:

1. Followed the physician order for vital sign (VS) assessments in six of twelve inpatient Behavorial Health MR's reviewed including Patient Identifier (PI) # 5, PI # 6, PI # 15, PI # 3, PI # 4and PI # 8.

2. Documented the care provided during CPR (cardiopulmonary resuscitation) Code Blue, per the hospital policy and procedure, in one of one inpatient record reviewed of a Code Blue that included PI # 15.

This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy Physician Order Review-Responsibility of Licensed Nursing Staff
Policy Number: None
Revision Date: 01/2023

Purpose:

...To ensure patient safety and comply with the standards of care.
...To maintain appropriate continuity in patient care.

Policy:

The provider order is required...for all...procedures
...The nurse will specifically check the physicians order prescribed...
...The present nurse and oncoming nurse will review the physician orders to ensure that orders are completely implemented.

Hospital Policy and Procedure: Cardiopulmonary Resuscitation (CPR) Code Blue
Review Date: 4/12/23

...Policy

Code Blue is the signal paged to notify members of the Code Team to the location...
The CPR report (CPR record) must be completed by the nurse and physician following each arrest.

Procedure

When discovering a patient unresponsive;
call a code blue immediately...CPR protocol may be initiated after calling for help.
Roles of the Code Team
Physician: direct the code, give orders
ER (emergency) nurse: apply monitor leads and assess cardiac rhythm...
...Med-Surg (medical surgical) nurse-ER nurse:establish IV (intravenous access)...
CPR trained provider-compressions
...Nursing leader-...assist with CPR record

Charting
Throughout CPR measures, an assigned nurse will document:
Medications being administered...
Defibrillation with the amount of wattage...
Other procedures being performed...
Patient's response
Record on nurse notes
...Patient reaction to all measures given...
heart action, if any, include samples of tracings
Nurse's signature

CPR report
...filled out by the nurse and physician...
Report distribution: patient chart, risk management...

1. PI # 5 was admitted to the hospital on 5/12/23 with a diagnosis of Suicidal Ideation (SI) Without a Plan and Depression.

Review of the nursing order dated 5/12/23, signed by the physician 5/14/23 revealed an order for VS BID (twice daily) and PRN (as needed).

Review of the Patient Progress Notes (PPN) VS revealed VS were obtained once on 5/13/23 at 7:34 AM, and once on 5/16/23 at 7:24 AM.

The nursing staff failed to follow the physician order to obtain VS BID.

An interview was conducted on 5/18/23 at 3:20 PM with Employee Identifier (EI) # 2, Chief Executive Officer (CEO), who confirmed VS were not monitored according to the physician order.



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2. PI # 6 was admitted to the Geriatric BHU (Behavioral Health Unit) on 5/5/23 with diagnoses including Mental Illness.

Record review revealed the initial blood pressure (BP) documented on 5/5/23 at 10:44 AM was 205/129, at 2:06 PM BP 165/102, and at 6:50 PM BP 176/113.

Review of the nursing order dated 5/5/23 at 3:58 PM, and signed by the physician included vital signs BID/PRN.

Review of the PPN's dated 5/12/23, 5/13/23, and 5/14/23 revealed VS were documented at 7:42 AM on 5/12/23, documented next on 5/13/23 at 7:49 AM, and documented next on 5/14/23 at 8:06 AM.

Staff failed to perform and document VS monitoring BID from 5/12/23 to 5/14/23.

An interview was conducted on 5/18/23 at 4:20 PM with EI # 2, who confirmed VS were not documented BID as ordered.

3. PI # 15 was admitted to the Geriatric BHU on 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional. PI # 15 was pronounced dead on 11/9/22 at 6:42 AM.

MR review revealed history and physical documentation that included a past medical history of metastatic hepatic and pancreatic cancer. The record of admission documentation revealed PI # 15 did not have an advance directive.

Review of the nursing order dated 11/2/22 at 11:13 AM, signed by the physician, included VS q (every) 1 hours, which was changed to BID/PRN on 11/2/23 at 2:19 PM.

Review of the PPN dated 11/2/22 revealed staff documented VS at 10:13 AM, and again at 2:07 PM. There were no VS documented for 3 hours between 10:13 AM and 2:07 PM.

Review of the PPN dated 11/6/22 revealed VS were documented one time at 7:41 PM, and not BID as ordered.

Staff failed to perform and document VS monitoring as ordered by the physician on 11/2/22 and 11/6/22.

Review of the Nursing Shift Assessment documentation dated 11/9/22 at 7:46 AM revealed during morning rounding PI # 6 was noted to have passed away quietly in his/her sleep. CPR initiated; Code blue was called. ER MD (emergency medical doctor) pronounced patient death at 6:42 AM.

There was no documentation of the time hospital staff initiated CPR, the staff members involved in the Code Blue, and what resuscitative efforts were performed. There was no documentation the CPR report was completed by the nurse and physician per hospital policy.

An interview was conducted on 5/18/23 at 4:20 PM with EI # 2, who confirmed VS were not documented as ordered. During the 5/18/23 interview, the surveyor requested the CPR record documentation for PI # 15. None was provided. The staff failed to document care provided during resuscitative efforts per the hospital policy and procedure.


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4. PI # 3 was admitted to the Geriatric BHU on 5/9/23 with diagnoses including Suicidal Ideations without a Plan and Substance Abuse.

Review of the nursing order dated 5/9/23 at 1:53 AM and signed by the physician 5/10/23 at 11:04 AM revealed an order for VS BID/PRN.

Review of the PPN's revealed VS were obtained once on 5/12/23 at 7:53 AM and once on 5/13/23 at 7:37 AM.

The nursing staff failed to follow the physician's order to obtain VS assessments BID.

An interview was conducted on 5/18/23 at 3:48 PM with EI # 2, who confirmed the physician's order was not followed.

5. PI # 4 was admitted to the Geriatric BHU on 5/9/23 with diagnoses including Schizophrenia and Diabetes Mellitus Type Two.

Review of the nursing order dated 5/10/23 at 12:07 PM and signed by the physician 5/10/23 at 11:04 AM revealed an order for VS BID/PRN.

Review of the PPN's revealed VS were obtained once on 5/12/23 at 7:30 AM and once on 5/13/23 at 7:32 AM.

The nursing staff failed to follow the physician's order to obtain VS assessments BID.

An interview was conducted on 5/18/23 at 3:53 PM with EI # 2, who confirmed the physician's order was not followed.

6. PI # 8 was admitted to the Geriatric BHU on 5/8/23 at 8:27 PM with diagnoses including Schizophrenia and Suicidal Ideation.

Review of the nursing order dated 5/8/23 at 8:31 PM and signed by the physician 5/10/23 at 11:04 revealed an order for VS BID/PRN.

Review of the PPN'S revealed VS were obtained once on 5/9/23 at 7:59 PM, once on 5/12/23 at 9:13 AM, once on 5/13/23 at 9:31 AM, once on 5/14/23 at 8:58 AM and once on 5/17/23 at 7:33 AM.

The nursing staff failed to follow the physician's order to obtain VS assessments BID.

An interview was conducted on 5/18/23 at 3:19 PM with EI # 2, who confirmed the physician's order for VS BID was not followed.

Based on hospital policies and procedure, medical record (MR) review and interview, it was determined the hospital failed to ensure:

1. A Multidisciplinary Treatment Plan (MDTP) was developed for each patient to include identified problems, goals and interventions.

2. The MDTP was implemented and ordered therapies were documented for each patient.

3. The MDTP included realistic target dates for patient's accomplishment of each goal established.

This affected six of twelve behavioral health unit (BHU) record reviews including Patient Identifier (PI) # 15, PI # 6, PI # 13, PI # 12, PI # 10, PI # 7, PI # 3 and had the potential to affect all patients admitted to the adult and geriatric BHU.

Hospital Policy and Procedure: Multidisciplinary Treatment Plan (MDTP)
Policy number: M.4 (four)
Review Date 4/12/23

Policy Purpose: To provide individualized, age appropriate, comprehensive, and coordinated care designed to meet the needs of each patient...

A plan of care (POC) will be initiated for each patient within twenty-four hours...of admission....participating in the MDTP include:
1. Nursing staff
2. Case Management staff
4. Activities Staff and
5. Counseling staff.

...The POC...a multidisciplinary approach....integrate assessments based on...needs, strengths, limitations, and goals of the...patient.
...The MDTP will include:
1. Pre-screening Assessment
2. Psychiatric evaluation...emphasis on the physician's initial treatment plan.
4. Nursing Admission Assessment
...8. Activity Recreation Therapy Assessment...

The MDTP will be completed no later than three...days following the date of admission...signed by the...physician, each member of the treatment team, and the patient.
The treatment plan will be a multidisciplinary effort based of (on) the Treatment Team's Assessment...Each discipline is responsible for documenting his/her role and intervention...The RN (Registered Nurse) will incorporate the role of the physician in the plan, based on the physician's...psychiatric assessment.
...The MDTP must address the patient's primary problems...educational needs, medical problems...Discharge Planning, patient strengths, and weaknesses. Short and long term goals for the problems identified will be formulated...
Interventions must describe how they will assist...in meeting the objectives. The frequency of performance and length of the interventions must be documented. The person responsible, with...title for performing each intervention, must be documented...
The MDTP included realistic target dates for patient's accomplishment of each goal established...
If the objective/interventions require revision, documentation of a revision date must be included, and the plan revised accordingly...

Procedure:

A. The RN responsible...will initiate the Multidisciplinary Problem List...Medical problems requiring active treatment during the admission will be identified...
B. Discharge treatment planning will be at...admission...
C. Problems identified following admission...not addressed during the admission will be listed on the Multidisciplinary Problem List...
D. Within twenty-four...hours of admission...staff assigned to the MDT Team will initiate the MDTP, formulate short and long term objectives and interventions for the problems identified on admission.
E....The staff, based on the physician's POC, will incorporate interventions related to the physician's role in the treatment of the patient.
F. Obtains the patient's signature on the Treatment Plan...

Hospital Policy: Psychosocial Assessment
Policy Number P .12
Review Date: 4/12/23

Policy:

...Psychosocial Assessment Objectives and Goals

Initial treatment objective and interventions will be developed ...documented on the assessment. These will be transferred to the Master Treatment Plan of Care (POC) for implementation....

1. PI # 15 was admitted to the Geriatric BHU on 11/2/22 with diagnoses including Schizoaffective Disorder Bipolar Type Manic and Delusional.

MR review revealed the following multi-discipline documentation:

1. Nurse Admission Assessment-Psy (psychiatric) dated 11/2/22 at 2:11 AM, upon patient's (pt's) arrival to the unit revealed no SI/HI (suicidal ideation/homicidal ideation) /w/in (within)last 6 month. The patient reported chief complaint, "I have CA (Cancer) stage 4 (spread to other parts of the body)", no pt. (patient) limitations.

2. The Psychosocial/Social Work (SW) assessment dated 11/2/22 at 3:45 PM revealed Initial Treatment Plan documentation that PI # 15 had poor insight; poor judgement, paranoia, and delusional thoughts. Goal One, medication management, the patient will learn and identify two reasons to take medications to be measured by attending a minimum of three group sessions and two individual session per week.

The interventions failed to describe how they assist in meeting the objectives (goals). The frequency of performance and the length the interventions to be performed was not documented. There were no short term and long term goals/objectives per the hospital policy.

3. The RN Problem Activity dated 11/2/22 at 2:41 PM revealed one problem, Paranoid thinking interfering with ability to function. The three goals for the one problem were-Patient will describe reason for hospitalization; Patient will take medication as prescribed; Patient will report any signs/symptoms of mental illness to staff.

There were no interventions documented to meet the three goals. The three goals were not identified as short term or long term. The goals failed to include realistic target dates for patient's accomplishment of each goal established. There was no problem documented for the medical problem of advanced cancer.

4. SW documentation dated 11/2/22 at 3:45 PM revealed the initial treatment plan for the patient experiencing poor insight and judgement, paranoia, and delusional thoughts; Goal one; Medication management-The patient will learn and identify two important reasons why he/she needs to take his/her medication as prescribed. This will be measured by attending a minimum of three groups sessions and two individual sessions per week as needed.

There was no documentation describing how group and individual sessions would assist in meeting the objectives/goals. The frequency of performance was documented, but there was no documentation for length of the time to complete the intervention per the hospital policy.

5. The RN multi-disciplinary assessment documentation dated 11/3/22 at 11:51 AM revealed a request for MR's from a cancer center, follow up appointment date documented. There was no documentation the MDTP was updated with the medical problem, cancer.

6. The RN Case Management (CM) documentation dated 11/3/22 at 12:07 PM revealed Treatment Plan problem being addressed, Medication treatment, Individual and Group therapy, Psycho-education.

There were no MR documentation including interventions for the psycho-education plan, no frequency of performance, and no long and short term goals for the psycho-education.

7. On 11/4/23 at 11:40 AM, 48 hours after admission, the psychiatric history/physical was completed which revealed bizarre behavior poor insight, delusional judgement limitations. The MD (medical doctor) treatment plan documentation included: Identify need for a Power of attorney for healthcare decisions, need for biopsy of liver/pancreas, psycho-education provided, ensure plus bid (twice daily), inpatient stay five to seven days, iron started for anemia.

MR review revealed the MDTP was completed/signed by the patient, the psychiatrist, SW and RN on 11/7/22, five days after admission. Staff failed to ensure the MDTP was completed in three days, per the hospital policy.

There was no medical record documentation the Problem Activity, and Goals initiated on 11/2/22 were updated/revised to incorporate the physician's treatment plan interventions including the need for POA identification and management of symptoms associated with the medical conditions, cancer, and anemia.

There was no documentation an Activity Recreation Therapy Assessment was performed, and that Activity staff participated in the POC development.

MR review failed to include the Master Treatment POC documentation.

MR review revealed documentation one individual therapy session was conducted the week of 11/2/22 on 11/4/22 and not two days per the SW Initial Treatment Plan assessment/goal.

An interview was conducted on 5/18/23 at 4:20 PM with EI (Employee Identifier) # 1, Chief Nursing Officer (CNO), who confirmed the MDTP documentation failed to include all problems identified, interventions were not discipline specific and lacked the length of time to complete, goals were not identified as long and short term, and therapy was not provided per the treatment plan.

2. PI # 6 was admitted to the Geriatric BHU on 5/5/23 with diagnoses including Unspecified Bipolar Mood Disorder Manic with Mixed Features.

MR review revealed the following multi-discipline documentation:

The RN initial Assessment documentation completed on 5/5/23 at 10:44 AM revealed the BP 205/129 (an elevated BP), No SI. The Nurse Problem Activity documentation dated 5/5/23 at 11:00 PM revealed, Problems-Alteration in Psychosocial Function related to (R/T) SI; evaluation was blank. The Goals: Pt will regain coping mechanism and behaviors; Pt will remain free from self-induced injury; Pt will display a non-violent manner.

There was no documentation that on 5/5/23 and 5/6/23 the SW, CM, and Activity Recreation Therapy initiated a POC. The staff failed to follow the hospital policy for POC initiation for disciplines participating in the Multidisciplinary treatment plan.

On 5/7/23 at 10:55 AM, 48 hours after admission, the psychiatric history/physical diagnostic impression was unspecified bipolar mood disorder manic with mixed features. The psychiatrist documented problems included Hypertension and Chronic PTSD (post-traumatic stress disorder). The physician's treatment plan for PI # 6 was SI/HI precautions, low salt diet, cognitive behavior therapy, new medication regimen, and expected inpatient stay five to seven days.

SW documentation dated 5/7/23 at 3:27 PM, a therapy assessment progress note, revealed no aggressiveness/ HI ; The modality documented was supportive, cognitive behavior, the "plan," was attend groups daily, comply with medication regimen. Free of harm, to self and others, adherence to discharge plan.

Further review of the 5/7/23 3:27 PM documentation titled, SW Psychosocial Assessment, revealed an initial treatment plan to address the court ordered admit for HI: Goal one: medication management-The patient will learn and identify two important reasons why he/she needs to take medication as prescribed. This will be measured by attending a minimum of two groups and three individual sessions per week.

The medication management intervention failed to include documentation to describe how it would assist in meeting the objectives per the facility policy. There was no documentation of length of the medication management intervention.

The psychiatrist progress note dated 5/11/12 at 11:04 AM revealed continue psychoeducation and groups.

There was no documentation group therapy was conducted from 5/7/23 to 5/12/23 per the SW 5/7/23 treatment plan. There was no documentation individual therapy was conducted the week of 5/7/23 to 5/13/23.

There were MDTP meetings dated 5/8/23 and 5/15/23 signed by the MDT and PI # 6. There was documentation the nurse reviewed the MDTP problem, Alteration in Psychosocial Function R/T SI, daily 5/6/23 to 5/16/23 with no MDTP revisions/updates and progress documented.

MR review failed to include the Master Treatment POC documentation.

There were no interventions documented to achieve the three goals documented on the 5/5/23 initial admission. The MDTP failed to included realistic target dates for patient's accomplishment of each goal per facility policy. There was no problem, intervention/goal documented for the hypertension.

An interview was conducted on 5/18/23 at 4:20 PM with EI # 2, Chief Executive Officer (CEO), who confirmed the MR documentation failed to reveal staff followed the hospital MDTP policy and conducted group therapy as ordered in the patient treatment plan.


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3. PI # 13 was admitted to the Geriatric BHU on 4/10/23 at 1:48 PM with diagnoses including Mental Illness, Mild Anemia with Hematuria, and Hypomagnesemia.

Review of the MDTP revealed the Treatment Plan was initiated on 4/10/23.

Review of the Problem Activity dated 4/10/23 revealed the identified problem was ineffective coping related to mental illness with goals including for PI # 13 to identify life conflicts from the past or present, state at least two coping mechanisms, and establish a realistic daily coping goal using a scale of one to ten.

Review of the Patient Progress Notes, Phychosocial section, revealed the SW documented the patient was experiencing some psychiatric issues and established a goal of medication management.

There was no documentation to identify which goals were short term or long term.

An interview was conducted on 5/18/23 at 4:00 PM with EI # 1, who confirmed the hospital failed to ensure the the plan of care was developed and updated per the hospital policy.

4. PI # 12 was admitted to the Adult BHU on 5/4/23 at 11:40 AM with diagnoses including Depression, Suicide Ideation, and Substance Abuse.

Review of the Nursing Problem Activity note dated 5/4/23 revealed the identified problem of ineffective coping related to difficulty concentrating. The goals included for PI # 12 to identify life conflicts from past or present, state at least two coping mechanisms, and establish a realistic daily coping goal using a scale of zero to ten.

There was no documentation of which goals were short term and long term.

Review of the Patient Progress Notes, Psychosocial section, revealed the SW documented the psychosocial assessment and developed an initial treatment plan on 5/7/23 at 3:02 PM, which was three days after admission.

An interview was conducted on 5/18/23 at 4:15 PM with EI # 1, who confirmed the hospital failed to ensure the plan of care was developed and updated per the hospital policy.


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5. PI # 10 was admitted to the adult psychiatric unit by court order on 5/11/23 at 3:38 PM with admission diagnosis of Aggression.

Review of the admission nursing assessment dated 5/11/23 at 6:09 AM revealed PI # 10 arrived to the unit ambulatory, Affect blunted & hostile, Mood irritable & angry, Behaviors manic, withdrawn & bizarre, Thought Processes disorganized, Delusions mixed, Paranoia present, Homicide Ideations denies, Eye Contact poor and refused to answer questions.
Admission vital signs obtained at 10:32 AM were BP 225/95, pulse 78, respirations 18 and temp 98.5 oral.

Review of the Therapy Progress note by the SW dated 5/11/23 at 5:00 PM revealed PI # 10 did not attend therapy, individual therapy revealed no interaction, behavior resistant, hostile, disorganized and disruptive with a Plan: Attend groups daily, comply with medication regimen.

Review of the physician's progress notes dated 5/15/23 and 5/16/23 revealed a plan for medications and psychoeducation. There was no documentation the RN incorporated the physician's assessment for psychoeducation in the MDTP as directed in the hospital policy.

Review of the MR revealed the following Problems/Goals dated 5/11/23, 5/12/23, 5/13/23, 5/14/23, 5/15/23, 5/16/23 and 5/17/23:
Paranoid thinking interfering with ability to function.
Treatment noncompliance interfering with ability to function.
There were no short and long term goals documented with target dates, and no interventions to attain the goals were documented.

Review of the psychosocial note dated 5/14/23 at 11:56 AM by the SW revealed Initial Treatment Plan: Goal 1 - medication management - Patient will learn to identify 2 important reasons to take medications as prescribed to improve overall daily functioning / mood. This will be measured by attending a minimum of 2 Group Therapy Sessions and 3 Individual Therapy Sessions per week.

Review of the MR revealed no documentation of 2 Group Therapy Sessions and 3 Individual Therapy Sessions per week as documented by the SW treatment plan and no documentation psychoeducation was provided. The hospital failed to ensure an individualized treatment plan was developed and implemented for PI # 10.

An interview conducted 5/18/23 at 3:35 with EI # 1 confirmed the treatment plan was not developed and documented as directed in the hospital policy.

6. PI # 7 was admitted to the adult psychiatric unit on 5/9/23 at 12:29 AM with admission diagnosis of Schizophrenic, Bipolar.

Review of the admission nursing assessment dated 5/9/23 at 1:56 AM revealed PI # 7 required a wheelchair for mobility, assistance with transfers and toileting, no cardiovascular abnormalities with 2+ non-pitting edema to ankles and feet, Mood euthymic, Behaviors manic, Thought Processes disorganized and Loose Associations, Hallucinations auditory, Delusions mixed, Impulse Control and Comprehension impaired. There was no discharge plan or education documented.

Review of the MR revealed a note by the SW dated 5/11/23 "attempted to complete psychosocial several times today but pt refused". There was no documentation the SW completed the psychosocial assessment or contributed to development of the MDTP.

Review of the MR revealed the following Problem/Goals dated 5/9/23:
Ineffective coping R/T (related to) mental illness;
Goal: Patient will identify life conflicts from the past or present.
Patient will state at least 2 coping mechanisms.
Patient will establish a realistic daily coping goal using a scale of 0-10.
There were no short and long term goals documented with target dates and no interventions to accomplish the stated goals. There were no medical problems/goals/interventions on the treatment plan to address the patients physical and medical needs.

Review of the MR revealed no documentation of group therapy, psychoeducation or individual therapy.

There was no documentation a multiple disciplinary treatment plan was developed and implemented within 3 days of admission as required.

An interview conducted 5/18/23 at 3:25 with EI # 1 confirmed the treatment plan was not developed and documented as directed in the hospital policy.


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7. PI # 3 was admitted to the Geriatric BHU on 5/9/23 at 00:10 AM with diagnoses including Suicidal Ideation without a Plan and Substance abuse.

MR review revealed the following multi-discipline documentation:

1. The Psychosocial Assessment/SW dated 5/9/23 at 11:28 AM revealed Initial Treatment Plan documentation that PI # 3, is "experiencing some psychiatric issues as evidenced per documentation provided to our facility." Goal One : Medication management- the patient will learn and identify two important reasons why he/she needs to take his/her medications as prescribed. This will be measured by attending a minimum of three groups and two individual sessions per week, as needed.

The Treatment Plan failed to include short term and long term goals with target dates for attaining the goals.

2. The RN Problem Activity Note dated 5/9/23 at 1:27 AM revealed two problems:
A. Problem-Ineffective coping related to substance abuse usage. The three goals for the first problem were:
a. Patient will identify life conflicts from the past or present.
b. Patient will state at least two coping mechanisms.
c. Patient will establish a realistic daily coping goal using a scale of 0-10.

Further review of the RN Problem Activity Note dated 5/9/23 at 1:27 AM revealed the second problem:
B. Problem- Ineffective Coping related to acute situational stress. The three goals for the second problem were:
a. Patient will identify life conflicts from the past or present.
b. Patient will state at least two coping mechanisms.
c. Patient will establish a realistic daily coping goal using a scale of 0-10.

There were no interventions documented to meet the three goals of each problem. The three goals were not identified as short term or long term goals and failed to include realistic target dates for the patient's accomplishments of each goal.

3. SW documentation dated 5/9/23 at 11:28 AM Therapy Progress Note Plan:
Attend groups daily, Comply with medication regimen, Voices understanding of Plan of Care, Free of harm to self, Free of harm to others, Adherence to Discharge Plan.

Modality: Cognitive Behavior, Problem Solving, Dialectic Behavior.

This documentation revealed the patient attended an individual session on 5/9/23. There is no documentation what individual session the patient attended. No documentation how group and individual sessions would assist in meeting the goals listed above. There was no documentation for length of time to complete the intervention per facility policy.

4. The RN CM documentation dated 5/11/23 at 1:30 PM revealed Treatment Plan Problems being addressed:
Medication Therapy, Individual Therapy, Group Therapy, Psycho-Education, Relapse Prevention

Review of the MR documentation revealed no interventions for the psycho-education plan, no frequency of performance, and no long and short term goals for the psycho-education.

5. The Psychiatric History and Physical (H/P) was completed 5/10/23 at 10:56 AM revealed Chief Complaint: Suicidal Ideation.
The patient reported being down and depressed for six months, voiced homicidal thoughts, suicidal thoughts, history of cocaine abuse, drinking alcohol, 12 cans of beer per day, feels hopeless, helpless and worthless, has mood swings, history of Post Traumatic Stress Disorder (PTSD) and major depressive disorder.

Further review of the H/P dated 5/10/23 at 10:56 AM, Mental Status Exam revealed- PI # 3 unkempt, has increased psychomotor activity, angry demeanor, anxious and depressed mood, with congruent affect...voiced suicidal and homicidal thoughts ..., insight and judgement poor.

Diagnostic Impression: Major Depressive Disorder, recurrent, severe, History of Polysubstance Dependence, Rule Out Antisocial Personality Disorder.

Treatment Plan: Patient is placed on Suicidal and Homicidal Precautions,..., will be provided cognitive behavior therapy, will be detoxed and oriented to 12 steps, expect stay 5-7 days, candidate for inpatient rehabilitation program.

6. MR review revealed the MDTP was completed/signed by the patient, psychiatrist, SW, RN on 5/10/23. There was no MR documentation the Problem Activity, Goals initiated on 5/9/23 were updated/revised to include the psychiatrists treatment plan interventions including the need for identification and management of symptoms associated with the treatment for Anger Management, Depression, detox and PTSD.

7. There was no documentation an Activity Recreation Therapy Assessment was performed and that activity staff participated in the POC development.

8. The MR failed to include the Master Treatment POC documentation.

MR review revealed one individual therapy session was conducted the week of 5/9/23 on 5/9/23 and not the two days per week as documented in the Psychosocial/SW Initial Treatment Plan Assessment/Goal. There is no documentation what group therapies were attended, how many, and how often.

An interview was conducted on 5/18/23 with EI # 2 at 3:48 PM who confirmed the MDTP documentation failed to include all problems identified, interventions were not discipline specific and lacked the length of time to complete, goals were not identified as long or short term, and therapy was not provided per the treatment plan.

Based on medical record (MR) review, Alabama Board of Nursing Administrative Code Standards of Nursing Practice, and staff interviews, it was determined the nursing staff failed to document patient complaint and/or result of as needed (PRN) medication(s).

This deficient practice affected four of fifteen inpatient MR reviewed, including Patient Identifier (PI) # 5, PI # 13, PI 10, PI 7, and had the potential to affect all patients served by the hospital.

Findings Include:

Alabama Board of Nursing
Administrative Code Chapter 610-X-6
Standards of Nursing Practice

610-X-6-.07 Standards for Medication Administration And Safety:

...2) The licensed nurse shall exercise decision-making skills when administering medications, to include but not limited to:

(a) Whether medications should be administered.

(b) Assessment of patient's health status and complaint prior to and after administering medications, including as needed (PRN) medications...


1. PI # 5 was admitted to the hospital on 5/12/23 with a diagnosis of Suicidal Ideation (SI) Without a Plan and Depression.

Review of physician orders dated 5/12/23 revealed orders for:

a. Diphenhydramine (Benadryl) 50 mg (milligrams) every 6 hours PRN for allergic reaction, itching, help with sleep, or agitation. Give PO/IM (by mouth/intramuscular) per patient status.

b. Hydroxyzine (Atarax) HCL (Hydrochloric acid) 25 mg tablet every 6 hours PRN anxiety.

c. Promethazine (Phenergan) 25 mg tablet every 6 hours PRN nausea/vomiting.

Review of the Medication Administration Report revealed:

1. Phenergan 25 mg oral was administered on 5/13/23 at 7:56 PM, reason documented was nausea.

2. Benadryl 50 mg oral was administered on 5/13/23 at 7:59 PM, reason documented was sleep.

3. Atarax 25 mg oral was administered on 5/13/23 at 7:59 PM, reason documented was anxiety.

Review of the Nursing Shift Assessment Nurses Note dated 5/13/23 at 8:00 PM revealed PI # 5 had no distress, no complaints of pain, no needs voiced, and denied anxiety.

The RN (Registered Nurse) administered PRN medications for sleep, nausea, and anxiety one minute prior to documenting PI # 5 had no needs voiced and denied anxiety.

An interview was conducted on 5/18/23 at 3:20 PM with Employee Identifier (EI) # 2, Chief Executive Officer, who confirmed there was no documentation to support the reason PRN medications were given.


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2. PI # 13 was admitted to the adult psychiatric unit on 4/10/23 at 1:48 PM with diagnoses including Mental Illness, Mild Anemia with Hematuria, and Hypomagnesemia.

Review of the medication orders dated 4/10/23 revealed orders for haloperidol (Haldol) 5 mg IM every six hours PRN for psychosis and diphenhydramine 50 mg IM every six hours as PRN for agitation.

Review of the Patient Progress Notes, Medications, dated 4/13/23 revealed Haldol 5 mg was given IM at 7:11 AM PRN for psychosis and Benadryl 50 mg was given IM at 7:11 AM PRN for agitation.

Review of the Patient Rounding Flowsheet dated 4/13/23 revealed the nurse documented at 7:00 AM and at 8:00 AM the patient was in the Day Room alert and oriented.

There was no documentation of the need for the PRNs for psychosis or agitation.

Further review of the Patient Progress Notes, Medication, dated 4/13/23 at 9:32 PM revealed Haldol 5 mg was given IM prn for psychosis and Benadryl 50 mg was given IM prn for agitation

Review of the Patient Rounding Flowsheet dated 4/13/23 revealed the nurse documented at 9:00 PM the patient was in the hallway alert and oriented and at 10:00 PM the patient was in the bedroom alert and oriented.

There was no documentation of the need for the PRNs for psychosis or agitation.

Review of the Patient Progress Notes, Medication, dated 4/21/23 at 3:49 PM revealed Haldol 5 mg was given IM PRN for psychosis and Benadryl 50 mg was given PRN for agitation.

Review of the Patient Rounding Flowsheet dated 4/21/23 revealed 3:00 PM the nurse documented the patient was in the Day Room alert and oriented. At 4:00 PM the nurse documented the patient was in the bedroom alert and oriented.

There was no documentation of the need for the PRNs for psychosis and agitation.

Review of the Patient Progress Notes, Medications, dated 4/23/23 at 5:00 PM Haldol 5 mg was given IM PRN for psychosis and Benadryl 50 mg was given IM PRN for agitation.

Review of the Patient Rounding Flowsheet dated 4/23/23 revealed the nurse documented at 5:00 PM the patient was in the hallway alert and oriented.

There was no documentation of the need for the PRNs for psychosis and agitation.

An interview was conducted on 4/18/23 at 4:00 PM with EI # 2 who confirmed there was no documentation of the need for PRNs for psychosis and agitation.



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3. PI # 10 was admitted to the adult psychiatric unit by court order on 5/11/23 at 3:38 PM with admission diagnosis of Aggression.

Review of the physician's orders revealed:

a. Ativan 2 mg po BID (twice a day)
b. Ativan 1 mg po every 6 hours prn agitation
c. Haldol 5 mg po BID
d. Haldol 5 mg po every 6 hours prn for psychosis
e. Benadryl 25 mg po BID
f. Benadryl 50 mg po every 6 hours for allergic reaction, itching, sleep , or agitation
g. Atarax 25 mg po every 6 hours prn for anxiety

Review of the medical record revealed on 5/14/23 at 8:00 PM revealed the patient was sitting in the dayroom, no complaints or needs voiced and denies anxiety...at 8:15 PM PI # 10 was administered:
Haldol 5 mg oral BID dose, Benadryl 25 mg BID dose,
Ativan 1 mg oral prn for agitation, Atarax 25 mg oral prn for agitation.

There was no documentation PI # 10 was experiencing agitation requiring prn medications.

Further review of the MR revealed on 5/15/23 at 8:00 PM, PI # 10 was alert and oriented...no acute distress noted...denies all...anxiety: low, denies episodes of intense anxiety...At 8:15 PM PI # 10 was administered:
Haldol 5 mg oral BID dose, Benadryl 25 mg BID dose,
Ativan 1 mg oral prn for agitation, Atarax 25 mg oral prn for agitation.

There was no documentation PI # 10 was experiencing agitation requiring prn medications.

An interview conducted 5/18/23 at 3:35 PM with EI # 1, Chief Nursing Officer, confirmed there was no documentation PI # 10 was experiencing agitation requiring the prn medications administered.

4. PI # 7 was admitted to the adult psychiatric unit on 5/9/23 at 12:29 AM with admission diagnosis of Schizophrenic, Bipolar.

Review of the physician's orders revealed:

a. Trazodone 50 mg po at HS (hour of sleep)
b. Ativan 1 mg po every 6 hours prn agitation
c. Haldol 5 mg po BID
d. Haldol 5 mg po every 6 hours prn for psychosis
e. Benadryl 50 mg po every 6 hours for allergic reaction, itching, sleep, or agitation
f. Atarax 25 mg po every 6 hours prn for anxiety

Review of the medical record revealed on 5/11/23 at 8:00 PM the patient was sitting in the dayroom...no needs voiced...denies anxiety...at 9:00 PM PI # 7 was administered:
Haldol 5 mg oral BID dose, Trazodone 50 mg BID dose, Ativan 1 mg oral prn for agitation, Atarax 25 mg oral prn for agitation and Benadryl 50 mg prn for sleep.

There was no documentation PI # 7 was experiencing agitation or sleeplessness requiring prn medications.

Review of the medical record revealed on 5/13/23 at 8:00 PM the patient was sitting in the hallway in a w/c (wheelchair)...no needs voiced...denies anxiety...at 8:08 PM PI # 7 was administered:
Haldol 5 mg oral BID dose, Trazodone 50 mg BID dose, Ativan 1 mg oral prn for agitation, Atarax 25 mg oral prn for agitation and Benadryl 50 mg prn for sleep.

There was no documentation PI # 7 was experiencing agitation or sleeplessness requiring prn medications.

An interview conducted 5/18/23 at 3:25 PM with EI # 1 confirmed there was no documentation PI # 7 was experiencing agitation or sleeplessness requiring the prn medications administered.

Based on observations, review of hospital policy and procedure, and interviews, it was determined the hospital failed to ensure medical records (MRs) were protected from access by persons other than HIM (health information management) staff and the Plant Operations Manager and stored to protect from fire and water damage.

This deficient practice did affect five boxes of MRs stored in the laundry room on the Adult Behavorial Health Unit (BHU) and MR stored in the MR/File room and had the potential to affect all MR's stored in this hospital

Findings include:

Hospital Policy: Medical Record Storage
Policy Number: None
Revised Date: 3/2023

Policy: It is the policy of Bullock County Hospital that all records are stored (climate controlled environment) on campus.

Procedure: All current patient records are electronic. MR maintains a file room for old patient paper charts. The file room shall be kept locked when not in use. The area is equipped with shelving and or cabinets and is climate controlled. The area is kept under lock and key and accessible by HIM staff and the the Plant Operations Manager.

1. A tour was conducted on 5/16/23 at 9:55 AM of the Adult BHU with Employee Identifier # 6, Social Worker. During the tour, a locked laundry room was accessed by the badge of EI # 6. When asked who else could access the locked laundry room, EI # 6 stated, "All Gateway employees with a badge could acess the locked laundry room. The surveyor observed five cardboard boxes of MR stored in cardboard "printer paper" boxes. Three boxes were stacked on top of each other with two more boxes stacked on top each other. The bottom boxes were directly on the floor. Inside the boxes were records with patient names, vital sign logs, shower schedules, etc.

An interview was conducted on 5/16/23 at 9:59 AM during the tour and the surveyor asked EI # 6 if the boxes were supposed to be in the laundry room? EI # 6 reported, "No, I am sure they are here waiting to be transported to the MR department." The boxes containing patient MRs were unprotected from fire or water damage and were accessible by persons other than HIM staff and/or the Plant Manager.

2. A tour of the MR/File Room located in the hospital annex was conducted on 5/18/23 at 12:40 PM with EI # 2, Chief Executive Officer. The surveyor observed numerous cardboard "printer boxes" filled with MRs stacked on top of each other and many of the MR boxes were placed directly on the floor. The MRs were not protected from fire or water damage.

An interview was conducted on 5/18/23 with EI # 2, at 3:15 PM, who confirmed the MRs were sitting directly on the floor, not on shelves and in cabinets as per the hospital policy, were not protected from fire or water damage, and were accessible by persons other than HIM staff and/or Plant Manager.

Based on review of personnel records and interview with staff it was determined the hospital failed to ensure all pharmacy staff hospital received hospital orientation and a competency skills evaluation.

This deficient practice affected two of two contracted staff personnel records including Employee Identifier (EI) # 18, Pharmacy Technician, and had the potential to affect patients.

Findings include:

1. A review of the personnel files conducted on 5/18/23 revealed EI # 18 was hired on 8/29/22.

There was no documentation EI # 18 received orientation and no documentation of a competency skill evaluation.

An interview was conducted on 5/18/23 at 2:00 PM with EI # 7, Human Resources Director-Corporate, who confirmed the hospital failed to ensure all pharmacy staff received an orientation and a competency skills evaluation.

Based on observations, review of hospital policies and procedure, personnel records, and interview, it was determined the hospital failed to ensure the dietary department provided a safe and sanitary enviroment for meal preparation and food storage.

Findings Include:

Refer to A 620 for findings.

Based on observations, review of hospital policies and procedures, personnel records, and interviews with staff, it was determined the hospital failed to ensure:

1. Safe storage of food items in the dietary department.

2. Foods were labeled with the open date and discard or expired date.

3. Expired foods were not available for use.

4. Prepared foods were labeled with the date prepared, discard date and discarded when expired.

5. Sanitizing solutions were mixed appropriately, tested for proper concentration of chlorine and results documented.

6. Freezer temperatures were monitored and action taken when above zero degrees.

7. Dietary services equipment and work areas were clean and kept free of encrusted grease deposits and/or accumulated soil.

8. There was a qualified dietary manager to oversee the daily management of dietary services.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Receiving, Inventory, Storage: Food Storage Guidelines
Revision Date: 1/2023

Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice...

Procedure: All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers according to the timetable in the Dry, Refrigerated and Freezer Storage Chart...

Frozen Meat/Poultry and Foods

Storage: Store items promptly at 0 degrees F (Fahrenheit) or below...Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil...label and date all food items.

Thawing:...Thaw meat by placing in deep pans and setting on lowest shelf in refrigerator...

Dry Storage:

Any opened products shall be placed in seamless plastic or glass containers with tight fitting lids or Ziploc bags.

Label and date all storage containers as follows:
1. The received date should already be on it
2. Date opened.
3. Date the item expires.

Recommended Shelf Life for Food Storage - Dry Storage Items

Cake mixes - 1 year

Refrigerator Items

Cheese, Processed open - 1 month...Shredded cheese tends to mold and dehydrate quicker than block cheese.
Meat, Processed, luncheon meat slices - 5 days...unopened vacuum packs keep about 2 weeks.

Hospital Policy: Food Safety and Sanitation: Tray Line Leftover Storage
Revision Date: 1/2023

Policy: Leftover foods will not be saved and re-used for human consumption if there is any doubt of wholesome quality...

Procedure:
Not To Be Saved
...Mayonnaise-based Entrees, Salads
Meats - Precooked or cooked the day before and chilled

Hospital Policy: Food Safety and Sanitation: Sanitizing Equipment/Work Area
Revision Date: 1/2023

Policy: Nutrition Services equipment and work areas will be cleaned and sanitized according to the Georgia Food Code.

Procedure:

Food contact surfaces shall be washed, rinsed, and sanitized after each use.

The food contact surfaces of grills, griddles, and similar cooking equipment shall be cleaned at least once per day. The surface shall be kept free of encrusted grease deposits and/or accumulated soil.

Non-food surfaces shall be cleaned as often as necessary to prevent accumulation of dust, dirt, or food particles.

Hospital Policy: Food Safety and Sanitation: Sanitizer Use Concentrations for Food Service
Revision Date: 1/2023

Policy: All surfaces and equipment shall be washed with a sanitizing solution.

Procedure:

Sanitation buckets...must be established with appropriate sanitizing solution each morning...The solution must be tested with the appropriate test strip and recorded.

The container MUST be labeled with the proper name of the sanitizing solution.

Nutrition staff shall change these buckets at least three (3) times a day and test with appropriate litmus strips each time the solution is changed to assure accurate levels of sanitizer.

Chemical - Chlorine
Concentration - 50-99 ppm (parts per million) in water between 75 - 100 degrees F.

Hospital Policy: Food Safety and Sanitation: How to Clean in a Three Compartment Sink
Revision Date: 1/2023

Procedure:
...Clean items in the first sink in a detergent solution...
Rinse items in the second sink. Spray or dip them in water that is at least 110 degrees F...
Sanitize items in the third sink. Water should be at a temperature of 170 degrees or more...

Hospital Policy: Food Safety and Sanitation: Record of Refrigeration Temperatures
Revision Date: 1/2023

Policy: A daily temperature record is to be kept of refrigerated items.

Procedure:

The Nutrition Manager is to assign an employee to daily record all refrigerator and freezer temperatures on...Temperature Log.

The freezer temperature must be 0 degrees or below.

The refrigerator temperatures must be 41 degrees or below.

Temperatures above these areas are to be reported to the Manager immediately.

Note on the temperature forms the plan of action taken when the temperatures are not in acceptable range.

Have work orders in writing as proof of requested work. Enter request for repair into the Resource Center online ticket system.

Hospital Policy: Kitchen Equipment
Effective Date: 1/2023

Procedure: Kitchen equipment will be checked...for electrical safety at least annually. Kitchen equipment will be tagged with the date of the inspection and the next inspection due date...

Job Description: Dietary Supervisor

Job Requirements:
Knowledge of basic food quantity, food preparation, food service and sanitation principles as it applies to hospital food service...

Qualifications:
High School Diploma with at least five (5) years of progressive food service experience.
ServSafe Certified

1. A tour of the dietary department was conducted on 5/16/23 at 10:20 AM with Employee Identifier (EI) # 13, Kitchen Supervisor. The following deficient practices were observed:

a. Chest Deep Freezer- a single can of Coke (identified as belonging to an employee) was sitting on top of a container of ice cream. There was a buildup of ice on all sides and up to the rim of the freezer. EI #13 was asked when was the last time the freezer was defrosted. EI # 13 stated, "not too long ago". The was no documentation of a routine or defrosting schedule. The staff failed to ensure employee foods were not stored in patient food areas and the deep freezer was free from ice buildup.

b. Review of the Chest Deep Freezer temperature (temp) logs dated March 1, 2023 to May 15, 2023 revealed a temperature above zero degrees F each day with no corrective action plan documented. EI # 13 confirmed the out of range temperatures had not been reported to anyone. The staff failed to ensure freezer temperatures were maintained at zero degrees or below.

c. Observation of the three (3) door refrigerator revealed standing water, 1/4 to 1/2 inch deep, in the bottom right side of the refrigerator, in the water was a large plastic container with two packs of ham and two packs of cheese; the middle compartment contained, on the top shelf, a thawing sheet pan of sausage located under a dripping drain pipe; on the shelf directly under the sausage was a sheet pan of biscuits defrosting. The staff failed to defrost meat in a manner to prevent contamination with dripping water, protect foods stored under defrosting meat and failed to ensure equipment was in proper working order.

d. Observation of the cooking area revealed a six (6) burner gas stovetop with a missing knob for one (1) of three (3) front burners. The griddle plate to the right side of the stovetop was not in working order due to the drip pan having holes. Grease was observed on the floor under the griddle. There was no out of order sign and no documentation it had been reported for repair or replacement.

The gas oven was dirty with grease build up and rust observed. EI # 13 stated it had been cleaned "not too long ago."

There were dust particles clinging to the suppression nozzles under the stove hood, which could potentially contaminate cooking foods.

The tilted skillet and the two (2) door convection over had dirt and grease build up. EI # 13 stated they had been cleaned "not too long ago."

There was no documentation of a routine nor a deep cleaning schedule for the kitchen appliances.

e. In the cleaning area was a three compartment sink with a large roasting pan positioned under the first sink. EI # 13 stated the first sink was not working properly and a part had been ordered. The second sink contained soapy water. The third sink was the sanitizing sink and was filled with water and had a heater attachment underneath. EI # 3 stated the water had to be 180 degrees to sanitize and was recorded on a log.

Review of the Three Compartment Sink Log for the month of May 2023 revealed an area to record Breakfast, Lunch and Dinner and document Time, Wash temp F, PPM (parts per million), and Initials. In the column "PPM" was recorded "180" for each entry.

There was a small red bucket sitting on the counter beside the sink containing a liquid with a towel submerged. EI # 13 stated that was the sanitizing solution for cleaning. There was a bottle of chlorine test strips on the counter with an expiration date of 4/2023. EI # 13 tested the sanitizing solution with a test strip which did not register any chlorine. EI # 13 stated, "it should read at 100 ppm." The surveyor requested the log and EI # 13 stated, "they did not keep a log of the results." The staff failed to ensure kitchen work surfaces and pots/pans were sanitized to prevent potential infections.

The following kitchen equipment had no preventative maintenance (PM) documentation:
chest freezer;
three door refrigerator;
electric grater;
toaster;
convection oven;
industrial mixer;
three household type refrigerators with PM sticker indicating a due date of 2020.
The staff failed to ensure kitchen equipment was checked for electrical safety.

f. Observation of the kitchen food storage area revealed three household type refrigerator/freezers. There was ice cream and food kept in the freezer. There was no log for monitoring the freezer temperatures. One refrigerator contained two white containers labeled "stew 5/5/23" with no indication if this was the prepared date or discard date. There were packs of lunch meat, bologna and country cured ham opened with no label. EI #13 stated," those belong to the employees." The staff failed to ensure food storage freezer temperatures were monitored, food was labeled with the open/discard dates and failed to ensure employee food items were not stored with hospital/patient foods.

g. Observation of the walk in freezer revealed a box of corn on the cobb, okra, squash and french fries, opened with no open date.

h. Observation of the walk in refrigerator revealed:
a large plastic container tabled "uncooked peas" with no open or discard date;
a gallon size container of opened Ranch Salad Dressing dated 5/2/22;
an open gallon size mayonnaise dated "5/11/23" with no indication if this was the open date or discard date;
a 9 (nine) ounce size container of yellow mustard with a Best By date of 6/4/2020;
a gallon size mayonnaise container, half-full with a red sauce with no identification and no open or discard date;
a stainless steel bowl covered loosely with plastic wrap and labeled "chicken salad 5/10/23" with no indication is this was the preparation date or discard date;
two (2) large bags of opened shredded cheese with no open or discard date;
a 32 ounce pack of smoked ham slices opened and not labeled;
a gallon size ziploc bag containing unidentified diced meat with no label or dates;
one bottle of Italian dressing expired on 3/28/23;
one bottle of chicken flavored based paste expired on 12/28/2020;

The staff failed to ensure frozen and refrigerated foods were stored and labeled for safety.

i. Observation of the dry storage area revealed the following:
three (3) containers of yellow mustard with Best By date of 6/4/2020;
two (2) bottles of Heinz 57 sauce with Best By date of 11/12/2021;
two (2) bottles of A-1 sauce with Best By date of 9/18/2021;
seven (7) boxes of Argo cornstarch with Best by date of 6/20/2021;
five (5) packs dry ranch mix packets expired on 1/7/21;
twelve (12) 9 inch pie shells expired on 3/17/21;
one (1) bottle of hamburger seasoning with no open date;
one (1) bottle of greens seasoning with no open date;
one (1) bag of confectioners sugar with no open date.

The staff failed to ensure foods were labeled appropriately, stored and discarded when expired or out of date.

The surveyor asked to review the therapeutic diet manual and EI # 13 stated "they took that away about a year ago". The hospital failed to ensure a therapeutic diet manual was approved and available for dietary staff.

An interview conducted on 5/16/23 at 2:15 PM with EI # 23, Registered Dietitian, confirmed there was no therapeutic diet manual available, and confirmed foods were not stored and labeled appropriately, refrigerator and freezer temperatures are to be monitored and action taken if out of range, kitchen equipment and food preparation areas were to be clean and free of grease and dirt buildup, and sanitizing solutions were to be mixed at the correct concentration to ensure surface were cleaned properly. EI # 23 was asked if he/she conducted inspections of the kitchen and food storage areas and confirmed he/she did conduct inspections quarterly and would provide the documentation. No documentation was provided.

An interview conducted 5/17/23 at 9:00 AM with EI # 11, Dietary Manager, confirmed the listed observations were deficient practices and not in accordance with hospital policies. EI # 11 further stated he/she had no knowledge of the freezer temps above zero and that no corrective actions had been taken.

2. Review of the personnel record for EI # 11, Dietary Manager, revealed a hire date of 6/21/21 and a job description for Dietary Supervisor signed on 6/21/21. Review of the job description
requirements revealed: Knowledge of basic food quantity, food preparation, food service and sanitation principles as it applies to hospital food service...and Qualifications: High School Diploma with at least five (5) years of progressive food service experience. ServSafe Certified.

Review of EI # 11's resume revealed no work history or experience in food service.

Further review of the personnel file revealed a ServSafe Certification dated 12/4/21, six (6) months after the hire date.

The hospital failed to ensure a qualified person was employed to provide oversight and management of the dietary services.

3. Review of the Quality Assessment Performance Improvement monitoring data for the freezer temps daily logs revealed 100% for the months of January to April 2023.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations, and A 724 for findings.

Based on observations, review of hospital policy and procedures, hospital crash cart log documentation, and interviews, it was determined the staff failed to:

1. Check, test, and document the defibrillator and crash carts were ready to use daily as directed per the hospital policy, which affected one of one defibrillators, and two of two emergency crash carts.

2. Ensure supplies available for patient use were not expired.

3. Ensure patient care areas and equipment were maintained in a clean and working order.

This had the potential to negatively affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Emergency Crash Cart and Defibrillator Daily Check
Policy Number: None
Effective Date: July 2021

Policy:

Crash carts will be checked every shift if located in the emergency department...

Procedure:

Adult Crash Cart: Check defibrillator, Check at 30 joules, Check while unplugged from wall unit, Document on adult crash cart log, Check if cart is locked...

Pediatric Crash Cart: ...Check if cart is locked

Hospital Policy: Material Management
Policy Number: MM-08
Effective Date: 8/23/21

Procedure:

The Materials Management Department will check all supplies for expiration dates in each area they are responsible for...all departments will be responsible...in other areas of their departments that hold supplies. This will include cabinets, drawers...any other specialty boxes. Any place a supply may be pulled to use on patient care.

Hospital Policy: Reporting Equipment, Maintenance, Cleaning, IT Issues.
Policy Number: None
Effective Date: April 2023

Policy: All Bullock County Hospital staff are responsible to assist with providing a safe, clean environment for patients. The hospital has a resource Center Ticket System which allows employees to enter a ticket (work order) for any issue that an employee observes for equipment, maintenance, cleaning or IT issues.

Procedure:
1. Any staff member who identifies broken or inoperable equipment, maintenance issues, cleaning issues...should enter a ticket into the Resource Center on the BCH home page...
5. If an issue poses an immediate safety risk to patients, visitors or other employees, a phone call should also be made to the department immediately to address the situation.
6. An employee should also notify their supervisor of any issues for which they complete a ticket in the online system.

1. A tour of the Adult Behavioral Health Unit (BHU) was conducted on 5/16/23 at 9:55 AM with EI # 6, Social Worker (SW). The following patient care areas were not maintained in a clean and working order:

The Seclusion Room (Room 118) was observed to have an odor coming from the bathroom, toilet bowl was discolored, floor tiles around the toilet were cracked and discolored.

The laundry room dryer was observed to have an overflowing lint filter, filled with lint.

Pt Rooms 101, 102, 110, 115, were observed to have peeling paint on the walls.

An interview was conducted on 5/16/23 at 1:54 PM with EI # 6, who confirmed all patient care areas in the unit were not maintained in a clean and working order.

2. Tours of the outpatient lab (laboratory) collection area and main lab were conducted on 5/16/23 from 10:00 AM to 10:45 AM with EI (Employee Identifier) # 4, Medical Technologist present.

The surveyor observed five gray top specimen collection tubes which expired 12/11/22, and four blue top collection specimen tubes which expired 12/12/22 in the outpatient lab collection area.

There were two lab collection boxes observed in the main lab. Box one had one gray top collection tube and one blue top collection tube which expired 12/11/22. Collection box two had four gray top collection tubes, one blue top collection tube which on expired 12/11/22, and three Povidone Iodine swabs sticks which expired on 11/5/22.

An interview was conducted on 5/16/23 at 10:45 AM with EI # 4 who confirmed the supplies were expired and available for use.

3. A tour of the radiology department was conducted on 5/16/23 from 12:45 PM to 1:10 PM with EI # 16, Radiology Technician. The tour included inspection of the emergency drug box located in the CT (computed tomography) room. The following supplies were expired:

a. two 5(five) cc (cubic centimeter) syringes, expired 10/2/21

b. two 3(three) cc syringes, expired 5/2/22

c. one 7 (seven) inch intravenous (IV) extension set, expired 3/1/23

d. one Dial-a-Flow regular IV extension set, expired 9/1/21

An interview was conducted on 5/16/23 at 1:10 PM with EI # 16 who confirmed the supplies were expired and available for patient use.

4. A tour was conducted of the Geriatric BHU on 5/16/23 at 1:32 with EI # 6. The following patient care areas were not maintained in a clean and working order:

The Seclusion and Day Room was observed to have cracked, dusty plaster on the walls.

The Day Room and Pt Rooms 201, 202, 204-207 were observed to have dirty, blackened and cracked grout around the sinks.

Laundry room revealed the hopper was dirty, rusty and clogged. EI # 8 Mental Health Technician (MHT) reported the hopper was clogged and not flushing and hadn't been working for several weeks and that it has been reported to maintenance but had not been repaired. EI # 8 also reported the washing machine was not working and had been broken for several weeks and that it had been reported to maintenance and not been repaired.

The surveyor requested the maintenance request report for the hopper and the washing machine and none was provided.

An interview was conducted on 5/16/23 at 1:54 PM with EI # 6, who confirmed all patient care areas in the unit were not maintained in a clean and working order.

An interview was conducted on 5/17/23 at 8:30 AM with EI # 2, Chief Executive Officer (CEO), who confirmed the washing machine and the hopper repaired.

5. A tour of the Emergency Department (ED) was conducted on 5/17/23 from 9:00 AM until 10:20 AM with EI # 17, Registered Nurse, ED. The ED tour included review of the Daily Crash Cart Log beginning 2/1/23 to 5/16/23 for Cart one which included assessment that the defibrillator was fully charged, defibrillator pads were available, testing of the defibrillator, wall oxygen and suction were working properly, and the cart lock and number. Cart two check included the cart lock and number.

There was no documentation the ED staff checked Cart One and Cart Two on the following dates and shifts:

7PM to 7AM shift 2/8/23 to 2/15/23

7AM to 7PM shift 2/16/23 to 2/22/23

7PM to 7AM shift 2/23/23 to 2/28/23

7PM to 7AM shift 3/1/23

7AM to 7PM shift 3/2/23, 3/7/23

7PM to 7AM shift 3/8/23 to 3/14/23, and 3/22/23 to 3/29/23

7PM to 7AM shift 4/5/23

7AM to 7PM shift and 7PM to 7AM shift 4/6/23

7PM to 7AM shift 4/7/23 to 4/11/23

7AM shift to 7PM shift and 7PM to 7AM shift 4/12/23

7PM to 7AM shift 4/21/23 to 4/26/23

7AM to 7PM shift 5/2/23

7AM shift to 7PM shift and 7PM to 7AM shift 5/3/23

7PM to 7AM shift 5/4/23 to 5/10/23

An interview was conducted on 5/17/23 at 10:20 AM with EI # 17 who confirmed the ED staff failed to check, test and document defibrillator and crash carts checks per facility policy.


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Based on observations, U.S. (United States) Food and Drug Association (FDA) guidelines for Sharps Disposal Containers in Health Care Facilities, hospital policies, manufacturer's directions for product use, hospital electronic maintenance request log and interviews, it was determined the staff failed to ensure:

1. A clean and sanitary environment was maintained throughout the hospital.

2. All Equipment utilized in patient care and service provision was maintained in a sanitary manner.

3. All sharp containers and hazardous/medical waste containers were emptied when needed and were covered with a tight fitting lid.

4. Disinfectant products were used according to manufacturer's directions for use.

5. All hand soap and hand sanitizer dispensers were functional, dispensing soap and sanitizing hand rub to staff, patients, and visitors.

6. Hand hygiene was performed according to hospital policy.

This deficient practice had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

U.S. FDA Sharps Disposal Containers in Health Care Facilities
Date: 4/29/21

...Sharps disposal containers are made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter. "Sharps" is a term for objects with sharp points or edges that can puncture or cut skin, such as needles, syringes, lancets, auto injectors, infusion sets, and connection needles. Generally, sharps disposal containers are regulated by the FDA...

Disposal of Sharps Disposal Containers
Sharps disposal containers are marked with a line to indicate when the container is about three-fourths (3/4) full. Following the manufacturer's instructions, close and seal sharps disposal containers when about three-fourths (3/4) full...medical waste disposal vendor instructions, and local medical waste disposal guidelines...prevent injury to health care personnel...

Hospital Policy: Cleaning and Disinfecting
Policy Number: None
Revision Date: 1/23

Policy:

The cleanliness of any healthcare environment is important for infection prevention and control and patient well-being. Environmental Services staff (EVS), along with other healthcare professionals...pays (plays) an important role in quality improvement...and in reducing infection related risks. The EVS Manager is a member of the Infection Control Committee.

...Cleaning...is the removal or (of) organic and inorganic material from objects and surfaces...accomplished by using detergents or enzymatic products. Thorough cleaning is necessary...

Hospital Policy Title: Hand Hygiene
Policy number: None
Revision Date: 4/10/23

Policy:
...Hand washing breaks the chain of infection transmission and reduces person-to-person transmission.
Wash or decontaminate hands:
Upon entering and exiting a patient room
-after handling...contaminated items;
-between contact with different patients;
-between tasks and procedures on the same patient...between different body sites;
-immediately after removing gloves; and
-using a plain soap, antimicrobial agent, such as an alcoholic (alcohol-based) hand rub or waterless antiseptic agent.

The hospital setting is a good setting for communication about personal hygiene...such as informing visitors and the...public about...washing hands...

CDC (clinging disinfectant cleaner) -10 Cleaning and Disinfection

A Quaternary Disinfectant Cleaner compound featuring a clinging foam. Straight or Dilution ... Kills HBV (Hepatitis B Virus), HIV-1 (AIDS Virus), Herpes simplex Type 2 and Influenza A3/Hong Kong viruses on hard nonporous inanimate surfaces. Ready to use, destroys germs faster than most competitive products ... requires five-minute contact time.

NABC (non-acid disinfectant bathroom cleaner) Concentrate

NABC Concentrate is a non-acid formulation designed to disinfect, sanitize, clean and deodorize toilet bowls, urinals, vanity tops, tubs and other hard nonporous bathroom surfaces ...Directions for toilet bowls and urinals use: ...Liberally apply NABC Concentrate ...to the exposed surfaces. Swab the exposed surfaces including under the rim. Allow Concentrate to remain on surfaces for 10 minutes. Flush toilet or urinal.

1. A tour of the Adult Behavioral Health Unit (BHU) was conducted on 5/16/23 at 9:55 AM with EI (Employee Identifier) # 6, Social Worker (SW). The following rooms were not clean and sanitary, and included the Seclusion Room, Laundry Room, Patient (Pt) Rooms-116, 117, 110, 115, 111, 114, 113, 112, 101, 102, 107, 106, and the Day Room.

The Seclusion Room, Laundry Room, twelve of twelve Patient Rooms, and the Day Room were observed to have dirt, grime, and dust along the perimeter of the floor, baseboard molding, and under the air conditioner units. The air conditioner and wall vents were observed to have dirt and dust caked on the vents.

An interview was conducted on 5/16/23 at 1:54 PM with EI # 6 who confirmed the rooms were not clean and sanitary.

2. A tour of the facility's outpatient rehabilitation (rehab) department was conducted on 5/16/23 at 10:00 AM with EI # 20, Licensed Physical Therapy Assistant (LPTA).

During the tour the following therapy equipment was observed as unclean:

a. SciFit upper extremity arm bike had visible dust, small crumbs/debris inside the base tracks, and white spots all over the base of the bike.
b. Sports Art C520R reciprocating bike had visible dust and white spots all over the base of the bike.

Observation of the rehab department itself revealed the floor was dirty around the hydrocollator and Triton traction table, dust along baseboards, and debris was in windowsills.

EI # 20 confirmed the observations of uncleanliness on 5/16/23 at 10:30 AM. EI # 20 reported therapy staff were responsible for cleaning equipment between patients, and hospital staff was responsible for cleaning the rehab department and had not performed cleaning in about four weeks.

3. A tour of the hospital lab (laboratory) and outpatient lab collection area was conducted on 5/16/23 at 10:02 AM with EI # 4, Medical Technologist. The surveyor observed one biohazard sharps container box overflowing, filled above the empty line in the outpatient lab collection area. In the main lab were two lab collection boxes, both with biohazard sharps containers which did not have a top on the container and were not covered. There was lab tubing containing blood and needles visible in the two biohazard sharps containers.

An interview was conducted on 5/16/23 at 10:45 AM with EI # 4 who confirmed the sharps container was filled above the empty line and the sharps containers were not covered.

4. An observation of therapy treatment by EI # 15, LPTA was conducted on 5/16/23 at 11:00 AM. During the treatment the upper extremity arm bike, resistance bands, two sets of hand weights, small ball, two pillows, and a therapy table were utilized.

The following observations were made:

- no hand hygiene was performed by EI # 15 prior to starting treatment.
- the hand weights and small ball utilized with treatment were cleaned with a multi-purpose spray cleanser and bath cloth. EI # 15 failed to perform hand hygiene prior to cleaning or after cleaning.
- EI # 15 obtained a TENS (transcutaneous electrical nerve stimulation) unit without performing hand hygiene and attached the electrodes to the patient. An ice pack was obtained from the freezer without performing hand hygiene, placed inside a pillowcase, and placed on the patient.
- Once all treatment was completed, without performing hand hygiene, EI # 15 cleaned the handles on the arm bike, removed the freezer pack from the pillowcase and returned it immediately into the freezer, removed the pillowcases from the pillows and placed new ones on the pillows, sprayed and wiped down the therapy table, and cleansed the TENS unit with a Lysol sanitizing wipe. After performing these tasks, EI # 15 washed his/her hands with soap and water. This was the only observation of hand hygiene being performed by EI # 15.

In an interview on 5/18/23 at 10:50 AM with EI # 1, Infection Control Director/Chief Nursing Officer, EI # 1 confirmed hand hygiene was not performed per policy.

5. A tour of the Emergency Department (ED) was conducted 5/16/23 at 11:01 AM with EI # 1 and EI # 14, ED RN (Registered Nurse), House Supervisor.

The ED consisted of 3 rooms, 2 hallway chairs and 2 hallway stretchers to accommodate 8 patients. The stretcher at Hall 4 was observed ready for patients. The rails were rusty, and the base of the stretcher was dirty. The ice machine was dirty with dirt buildup observed in the drain tray.

An interview was conducted 5/17/23 at 11:10 AM with EI # 5, ED RN. EI # 5 was asked how often housekeeping came to clean the ED. EI # 5 stated "there have been issues with that - we have to ask them to come, and I have even asked them to bring clean mop water and not use dirty water in the ED." EI # 5 further stated the ED staff clean the rooms between patients.

6. A tour of the pharmacy department was conducted on 5/16/23 at 11:02 AM. The surveyor observed the double sink in the pharmacy had a black ring around one drain and a white film in the other sink. The hazard waste container was overfilled with materials coming out of the container opening.

An interview was conducted on 5/16/23 at 11:40 AM with EI # 18, Pharmacy Technician, who reported it had been a while since housekeeping cleaned the pharmacy sinks. EI # 18 confirmed the Hazardous/Medical Waste container was overfilled and should have been emptied.

7. A tour was conducted of the Geriatric BHU on 5/16/23 at 1:32 PM with EI # 6. The following rooms were not clean and sanitary, and included the Day Room, Laundry Room, Seclusion Room 200, Pt Rooms 201, 202, 204, 205, 206, 207.

The Day Room, Laundry Room, Seclusion Room, and six (6) of 6 Pt Rooms were observed to have dirt, grime, and dust along the perimeter of the floor, baseboard molding and under the air conditioning units. The air conditioner and wall vents were observed to have dirt and dust caked on the vents. Grout around the sinks were observed to be black and cracked.

An interview was conducted on 5/16/23 at 1:54 PM with EI # 6 who confirmed the rooms were not clean and sanitary.

8. An observation was conducted on 5/16/23 at 3:14 PM with EI # 12, Housekeeping Supervisor, to observe terminal cleaning after patient discharge.

During the observation, EI # 12 failed to clean the patient's bedframe and bed panels, doorknobs, and light switches per hospital policy.

EI # 12 sprayed mattress and top of bed with CDC-10 and wiped immediately with a rag. EI # 12 failed to follow disinfecting manufacture cleaning directions to allow the five-minute wait time for the cleaning product to be effective.

EI # 12 sprayed NABC cleaner in the toilet, brushed inside the toilet bowl and under the rim immediately. EI # 12 failed to allow the ten-minute wait time for the cleaning product to be effective.

In an interview on 5/18/23 at 4:30 PM, EI # 2 verified the findings were not in compliance with hospital policy.

9. An observation of care was conducted on 5/17/23 at 1:24 PM with EI # 5, ED RN. EI # 5 entered ED 2 treatment room and attempted to perform hand hygiene at the sink. There were two hand soap dispensers and one hand rub dispenser in the ED two. After multiple attempts to obtain a hand cleaning product, EI # 5 exited the ED two to the nurse station and performed hand hygiene.

EI # 5 returned to the ED room, dispensed the medication to an unsampled ED patient, removed gloves and exited the ED room. EI # 5 failed to perform hand hygiene after removing gloves, and exiting the treatment room, and before touching objects in the nurse station.

After the observation was complete, the surveyor asked EI # 5 to verify hand soap and hand sanitizers were operating in the other ED treatment rooms. EI # 5 attempted unsuccessfully to have soap dispensed in Trauma One, and in ED Treatment Room three, bay one.

An interview was conducted at 1:30 PM with EI # 5, who confirmed the hospital had failed to ensure the hand soap and hand rub dispensers were operating in all ED treatment rooms.

Upon exiting the ED on 5/17/23 at 1:45 PM, the surveyor attempted to obtain hand rub/sanitizer from the dispenser at the ambulance entrance. There was no hand rub/sanitizer dispensed.

On 5/17/23 at 1:48 PM, the surveyor attempted to obtain hand soap from the soap dispenser at the outpatient lab. No soap was dispensed.

Review of the Resource Center electronic maintenance request log provided to the survey team on 5/18/23 revealed hand sanitizers were reported not working on 1/5/23, 1/17/23, and 1/24/23.

An interview was conducted on 5/18/23 at 10:50 AM with EI # 1, the Infection Control Director/Chief Nursing Officer who confirmed the hospital had failed to ensure hand hygiene products were available to all staff, patients, and visitors and staff failed to follow the hospital hand hygiene policy.



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46293

Based on review of the hospital Antibiotic Stewardship Program (ASP) policy and procedure, program documentation, and staff interviews, it was determined the facility failed to ensure all hospital personnel and medical staff completed competency-based training and education for the hospital ASP. This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy: Antimicrobial Stewardship
Policy Number: PHARM-38.07
Review Date: 02/22/23

Policy:

The Pharmacy Department will help monitor the appropriate use of antibiotics for patients ...focus on the current use of antibiotics...and monitor for resistance patterns in the area.

Procedure:

Pharmacy will present at Medical Staff Meeting monthly the number of antimicrobial recommendations that were accepted by Medical Staff for the prior month...Every two years the Pharmacy Department will publish an antimicrobial susceptibility report or antibiogram...to help practitioners identify local trends in antibiotic effectiveness...

1. Review of the hospital Antimicrobial Stewardship Policy and Procedure on 5/17/23 failed to include documentation that hospital personnel and medical staff would receive education and training for the Antibiotic Stewardship Program.

A review of the hospital Antibiotic Stewardship program and staff interviews were conducted on 5/18/22 at 2:19 PM with Employee Identifier (EI) # 3, Pharmacist and EI # 1, Infection Control Director/Chief Nursing Officer. EI # 3 reported the pharmacy reviews inpatient antibiotic orders and reports monthly the number of antimicrobial recommendations accepted by the medical staff for the prior month. The surveyor asked what was the medical staff acceptance rate for a change in antimicrobial therapy? EI # 3 reported less than 50%.

The surveyor asked EI # 3 and EI # 1 how hospital personnel, including medical staff were trained on the hospital ASP and if there were documentation hospital personnel completed competency-based training and education on the practical applications of antibiotic stewardship guidelines, policies, and procedures? EI # 3 reported policy updates were presented at department head and Medical Staff meetings.

In an interview conducted on 5/18/23 at 2:15 PM, EI # 3 and EI # 1 confirmed there was no documentation hospital staff developed and implemented an ASP education and competency based hospital personnel training program for the hospital ASP.

Based on review of the hospital policy and staff interview, it was determined hospital staff failed to conduct and document a review of the discharge assessment and plans for patients re-admitted within 30 days. This had the potential to negatively affect all hospital in-patient admissions.

Findings include:

Hospital Policy: Discharge Planning
Policy Number D.4 (four)
Review date: 4/12/23

Policy: To establish a written policy and procedure to ensure each patient has an effective and timely assessment for discharge planning needs that maintains continuity and quality of care.
...Discharge planning is part of the continuum of care and is initiated at the earliest point of contact after admission and also utilizes the admission history...discharge criteria and hospital adopted quidelines as cited in the Utlization Review Plan...

All patients must have a discharge plan documented in the medical record.

1. On 5/18/23, the surveyor requested documentation of reviews of 30 day re-admits, assessment of discharge plans and patient needs. No documentation was provided.

An interview was conducted on 5/18/23 at 9:24 AM with EI (Employee Identifier) # 6, Social Worker, who confirmed there was no documentation of reviews of 30 day re-admits or assessments of dishcharge plans and patient needs. EI # 6 stated, "we are a small facility and the Intake Coordinator will see them and notify staff verbally of patient re-admits during huddle or at start and end of day meetings."

Based on review of personnel records and interview, it was determined the facility failed to ensure all staff had documentation of a job specific hospital orientation or competency skills.

This deficient practice affected two of two contracted staff personnel record reviews including Employee Identifier (EI) # 15, Licensed Physical Therapy Assistant, and had the potential to affect all patients receiving rehabilitation services.

Findings include:

Review of the personnel files was conducted on 5/18/23 which revealed EI # 15 was hired on 6/27/22.

There was no documentation EI # 15 had completed a job specific orientation program and no documentation of a competency skills assessment.

An interview was conducted on 5/18/23 at 2:00 PM with EI # 7, Human Resources Director-Corporate, who verified the hospital failed to ensure the contracted employee received orientation and a competency skills assessment.

Based on review of the hospital Emergency Preparedness Program documentation and interview, it was determined the hospital staff failed to complete a facility-based and community-based all hazards risk assessment every two years. This had the potential to affect all patients served by this hospital, staff, and visitors.

Findings include:

Review of the Emergency Preparedness Manual revealed no documentation of a facility-based and community-based risk assessment for the years 2019, 2020, 2021, or 2022.

An interview was conducted 5/18/23 at 3:54 PM with Employee Identifier # 2, Chief Executive Officer, who confirmed the hospital staff had failed to conduct and document a facility-based or community-based all hazards risk assessment.

Based on review of personnel records, CMS (Centers for Medicare and Medicaid Services) Quality, Safety, and Oversight Group Memo, and interview, it was determined the hospital staff failed to ensure all staff, including contracted staff, received emergency preparedness training and education.

This deficient practice affected two of two personnel records of contracted employees reviewed including Employee Identifier (EI) # 15, Licensed Physical Therapy Assistant, and EI # 18, Pharmacy Technician, and had the potential to affect all patients, staff, and visitors.

Findings include:

CMS Quality, Safety, and Oversight Group Memo
Subject: Guidance related to the EP Testing Exercise Requirements-Coronavirus Disease 2019 (COVID-19)
Dated: September 28, 2020

...CMS revised training program requirements, specifically, that facilities develop and maintain a training program based on the facility ' s emergency plan annually by requiring facilities to provide training biennially (every 2 years) after facilities conduct initial training for their emergency program...

A review of personnel records conducted on 5/18/23 revealed EI # 15 was hired on 6/27/22 and EI # 18 was hired on 8/29/22.

There was no documentation EI # 15 and EI # 18 had received initial training in emergency preparedness.

An interview was conducted on 5/18/23 at 2:00 PM with EI # 7, Human Resources Director-Corporate, who confirmed all employees had not received emergency preparedness training.

Based on review of the hospital Emergency Preparedness (EP) documentation, Centers for Medicare, and Medicaid Services (CMS) EP Testing Exemption and Guidance for Inpatient Providers, and staff interview, it was determined the hospital staff failed to ensure annual testing of the EP program had been completed and documented.

This deficient practice had the potential to affect all patients served by this facility, staff, and visitors.

Findings include:

CMS Quality, Safety, and Oversight Group Memo
Subject: Guidance related to the EP Testing Exercise Requirements-Coronavirus Disease 2019 (COVID-19)
Dated: September 28, 2020

Emergency Preparedness Testing Exemption and Guidance:

CMS regulations for EP require specific testing exercises be conducted to validate the facility's emergency program. During or after an actual emergency, the regulations allow for an exemption to the testing requirements based on real world actions taken by providers and suppliers.

Changes specific to Testing Exercise Requirements:

For providers of inpatient services: The testing exercises were expanded to include workshops as an exercise of choice. However, these providers are still required to conduct two EP testing exercises annually.

Inpatient providers and suppliers include: ...hospitals....

Exemption Based on Actual or Man-made Emergency:

...Facilities that activate their emergency plans are exempt from the next required full-scale community based or individual facility based functional exercise...CMS requires facilities to conduct an exercise of choice annually for inpatient providers...
Facilities may need to conduct an exercise of choice following the current Public Health Emergency if they were required to conduct an exercise this year (2020) and did not already do so.

Review of the hospital Emergency Preparedness Manual and program documentation revealed the facility activated their EP plan for COVID-19 (coronavirus disease of 2019) on March 12, 2020.

There was no documentation an exercise of choice was completed in 2021, or a full-scale community or individual facility-based exercise was conducted in 2022.

An interview was conducted 5/18/23 at 3:54 PM with Employee Identifier # 2, Chief Executive Officer, who confirmed the facility had no documentation an exercise of choice was conducted in 2021, or a full-scale community or individual facility- based exercise was conducted in 2022.