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Based on document review and interview, it was determined that in 2 of 3 (Pt #4 and #5) clinical records of patients on psychotropic medications, the Hospital failed to ensure the patients were informed prior to the administration of the medications.

Findings include:

1. Hospital policy entitled, "Consent for Psychotropic Medication Administration," (revised 3/13) required, "Procedure: 1. The Attending Psychiatrist discusses with the patients the indications, benefits, risks, side effects, alternative treatments to and the patient's right to refuse psychotropic medications prior to giving an order for psychotropic medication. 2. Upon receipt for a psychotropic medication not previously prescribed during the current admission,...3. Attending Psychiatrist completes the Medication Consent Form, signs and dates it and have the patient / guardian sign the form witnessed by two staff..."

2. The clinical record of Pt #4 was reviewed on 10/29/13 at approximately 10:15 AM. Pt #4 was a 41 year old female admitted on 10/16/13 with a diagnosis of Bipolar disorder. Pt #4's clinical record contained a medication administration record that included Pt #4 was taking Thorazine 100 mg 2 times a day, Prolixin Deconate 25 mg intramuscular every 4 weeks, and Zyprexa 10 mg every 8 hours as needed. Pt #4's clinical record contained a Consent for Psychotropic Medication Administration signed and dated by the physician on 10/17/13 that indicated Pt #4 was advised of the risk, benefits and side effects of the medications however, the form failed to list the medications that Pt #4 was given.

3. The clinical record of Pt #5 was reviewed on 10/29/13 at approximately 10:45 AM. Pt #4 was a 60 year old female admitted on 10/24/13 with diagnoses of Paranoid/ Delusional. Pt #5's clinical record contained a medication administration record that included Pt #5 was taking Risperdal 2 mg at bedtime and 1 mg in the morning. Pt #5's clinical record contained a Consent for Psychotropic Medication Administration that was unsigned by the physician but dated 10/25/13 that indicated Pt #5 was advised of the risk, benefits and side effects of the medications however, the form failed to include the medications that Pt #4 was taking.

4. The Manager of the Mental Health Unit (E#2) confirmed during an interview on 10/29/13 at 10:45 AM that the consents for psychotropic medications were incomplete.

Based on document review and observation, it was determined that for 1 of 1 Mental Health Units (3 East), the Hospital failed to ensure staff monitor patients safety by conducting safety checks every 15 minutes in accordance with policy. Thus placing 15 of 17 patients on census on 10/29/13 at risk.

Findings include:

1. Hospital policy entitled, "Adult Mental Health Unit," (reviewed/revised 3/13) required, "Policy: It is the policy of Thorek Memorial Hospital and its Adult Mental Health Unit that safety rounds are done every fifteen minutes, identifying the location of all patients on the unit on a pre-assigned room list... Procedure: complete the rounds by identifying each patient individually every 15 minutes. It is then documented on each patient's individual rounds sheet kept in the rounds book...The Charge RN is responsible for making sure making that the 15 minute rounds are being done by the Mental Health Specialist."

2. On 10/29/13 at approximately 9:40 AM, an observational tour of the 3 East Mental Health Unit was conducted. During the tour, the unit's 15 minute precautions monitoring sheets were reviewed. The following precautions sheets were lacking the 9:15 AM and 9:30 AM safety checks that included location and patient behavior:

Pt #5 admitted on 10/24/13 on fall, assault and close observation precautions.

Pt #11 admitted on 10/22/13 on close observation.

Pt #12 admitted on 10/21/13 close observation and sexually acting out precautions.

Pt #13 admitted on 10/27/13 on suicide homicidal and close observation precautions.

Pt #14 admitted on 10/25/13 on close observation.

Pt #15 admitted on 10/28/13 on close observation.

Pt #16 admitted on 10/18/13 on close observation.

Pt #17 admitted on 10/26/13 on fall, assault, and close observation.

Pt #18 admitted on 10/26/13 on fall, close observation and sexually acting out precautions.

Pt #19 admitted on 10/27/13 on suicide and close observation.

Pt #20 admitted on 10/25/13 on homicidal and close observation precautions.

Pt #21 admitted on 10/26/13 on suicide and close observation.

Pt #22 admitted on 10/21/13 on homicidal precautions and close observation.

Pt #23 admitted on 10/24/13 on suicidal and close observation precautions.

Pt #24 admitted on 10/22/13 on suicide and close observation precautions.

3. The Manager of the Mental Health Unit (E#2) stated during an interview on 10/29/13 at approximately 10:45 AM that the precautions sheets should have been completed every 15 minutes.

A. Based on document review and interview it was determined that in 1 of 1 restraint log, the Hospital failed to ensure nursing maintained the log as required.

Findings include:

1. Hospital policy entitled, "Restraint," (reviewed/revised 9/13) required, "G. RN Documentation: 7. Nursing will maintain a restraint log to include the following elements: shift; date, time of the order..."

2. The clinical record of Pt #4 was reviewed on 10/29/13 at approximately 10:15 AM. Pt #4 was a 41 year old female admitted on 10/16/13 with a diagnosis of Bipolar disorder. Pt #4's clinical record contained documentation that Pt #4 was placed in restraints on 10/19, and 10/20/13.

3. The Behavioral Health Unit's restraint log was reviewed on 10/29/13 at approximately 10:45 AM. The log failed to include documentation of Pt #4's restraint usage on 10/19/13 at 7:45 AM and on 10/20/13 at 10:05 PM.

4. The Manager of the Behavioral Health Unit (E#2) stated during an interview on 10/29/13 at approximately 10:45 AM that the restraint log did not include the restraint usage for Pt #4 and should have been complete.

B. Based on document review and interview, it was determined that for 1 of 1 (P#10) clinical record reviewed of a patient requiring subcutaneous heparin administration, the Hospital failed to ensure the injection site was documented as required.

Findings include:

1. Hospital policy entitled, "Medication Administration," (revised 8/13) required, "IV. Guidelines:B. Electronic Medication Administration Records (M.A.R.): 6. The nurse(s) initials, the time the medication is given on the M.A.R. and documents the site of administration on all injectable medications."

2. The clinical record of Pt #10 was reviewed on 10/29/13 at 1:45 PM. Pt #10 was a 47 year old female admitted on 10/23/13 with diagnoses of Dizziness, Diabetes mellitus, Arterial sclerotic heart disease and Hypertension. Pt #10's clinical record contained a physician's order dated 10/23/13 for Heparin 5000 units twice a day. Pt #10's M.A.R. contained documentation administration as ordered, however from 10/23/13 until 10/28/13 at 8:00 PM. The M.A.R. lacked documentation of the administration site.

3. The Manager of the Medical Stabilization Unit (E#2) stated during an interview on 10/29/13 at approximately 1:45 PM that the M.A.R. did not contain documentation of the injection site as it should have.

Based on documentation review and interview, it was determined the Hospital failed to ensure medical records were completed within 30 days following discharge.

1. On 10/29/13 at approximately 2:00PM, the Medical Staff Bylaws were reviewed. The Bylaws included,"If the medical records remains incomplete thirty (30) days after discharge, the President shall notify the Practitioner by mail that his/her Admitting and Surgical Privileges shall be suspended ten(10) days from the dated of notice..."

2. On 10/29/13 at approximately 3:00PM, the Director of Medical Records (E#11) presented a typed attestation dated 10/29/13 stating the Hospital had 59 incomplete medical records.

3. E#11 stated during an interview on 10/29/13 at approximately 3:00 PM that he was not aware of the CMS requirement for completion of medical records.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on October 29 - 31, 2013, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on October 29 - 31, 2013, the surveyor(s) find(s) that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Forms 2567 (two thus; one for Building 01 and one for Building 02), dated October 31, 2013.

Based on document review and interview, it was determined for 1 (10/18/13) of 23 days in October 2013, the Hospital failed to ensure documentation of biological testing results.

Findings include:

1. On 10/30/13 at approximately 1:00 PM, Hospital policy titled," Flash/Steam Sterilizer Protocol" revised 09/2013 included,"Biological and chemical testing is completed at the beginning of each day in the OR prior to running any sterilization cycles. The biological indicator is sent to Central Sterile for rapid read out. Central is responsible for notifying the OR control desk of failed results. Document on the flash sterilization log."

2. On 10/30/13 at approximately 9:30 AM, the flash sterilization log for October 2013 was reviewed. The log dated 10/18/13 contained a section for documenting biological test results. The section titled,"parameters met? Yes or No " was incomplete.

3. The Director of Surgical Services ((E#13) was interviewed on 10?30/13 at approximately 9:40 AM. The Director stated the log for 10/18/13 was incomplete.

3. During observational tour of the 3 East Behavioral Unit on 10/29/13 at approximately 10:00 AM, Pt. #5 and #30 were identified as isolation patients with contact isolation signs on their doors.

4. Pt #5 was a 60 year old female was admitted on 10/24/13 with diagnoses of Paranoid and Delusional. Pt #5's clinical record contained a wound culture of her right heel dated 10/25/13 that indicated, Staphylococcus Coag Negative. Pt #5's clinical record indicated that she was placed into contact precautions on 10/25/13, as required.

5. Pt #30 was a 53 year old male admitted on 10/28/13 with a diagnosis of Aggressive behavior. Pt #30's clinical record contained a wound culture dated 10/26/13 from Pt #30's left leg that indicated, Acinetobacter Baumanii Complex and Diptheroids. Documentation indicated, "Unusual resistance pattern detected...patient requires contact isolation."

6. The Consulting Infection Preventionist (E #4) was interviewed on 10/29/13 at approximately 11:50 AM. E#4 stated that the isolation list is updated daily and the infection control officer reviews and follows up to ensure all patients on the list are isolated appropriately. E#4 further stated Pt. #5 and #30, should be on the daily list of isolation patients.












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Based on document reviews and interview, it was determined that for 2 of 7 (Pt. #5, & #30) patients on isolation, the Hospital failed to ensure all patients on isolation were included in the Hospital"s "Isolation Patient list for Infection control."

Findings include:

1. Hospital policy titled "Surveillance" (reviewed 4/11) required, "The Infection Preventionist systematically collects, tabulates and analyzes with the objective of prevention and/or reducing the rates of hospital acquired infection... Information of individual infection reports is entered into computer database. Reports are produced listing infections by nursing unit, organism and site...."

2. The list of all patients currently on isolation was requested on 10/29/31 at approximately 11:50 AM. The Consulting Infection Control Preventionist provided a list containing 5 names of patients currently on isolation. However the list did not include Pt. #5 and #30 identified during an observational tour on 10/29/13 and record review as isolation patients.

A. Based on document review, observation, and interview, it was determined that in 1 of 2 (room 4) operating rooms toured, the Hospital failed to ensure operating rooms were cleaned in a manner to prevent contamination.

Findings include:

1. Hospital policy entitled, "Cleaning and Sanitation in the Operating Room," (R/R 6/13) required, "III Guidelines: Daily preparation: 1. Daily, prior to the start of the first schedule cases, all horizontal, flat, and catching surfaces in each OR suite will be damp dusted...The surfaces include, but not limited to the following: overhead surgical lights and tracts, vents, gauges..."

2. On 10/30/13 at approximately 7:15 AM a surgical technician (E #8) entered OR #4, which included a surgical table that had been previously disinfected and covered with clean linen for the first case. E #8 entered OR #4 and proceeded to disinfect surrounding tables, male stands, light switches and finished by cleaning the overhead surgical lights located above the clean linen on the surgical table. Thus potentially contaminating the clean surgical table.

3. The Director of Surgical Services (E#13) stated during an interview on 10/30/13 at 11:50 AM that the overhead light should not have been cleaned over the clean table.

B. Based on document review, observation, and interview it was determined that in 1 of 2 (OR #4) operating rooms, the Hospital failed to ensure opened sterile surgical supplies were not left unattended.

Findings include:

1. Hospital policy entitled, "Asepsis and Aseptic Technique in the Operating Room," (R/R 6/13) required, "III. Guidelines: 4. Surgical Set-up: The opening of sterile supplies and preparation...should be done as close as possible to the time of use. Once opened, one member of the surgical team must constantly monitor the sterile field."

2. On 10/30/13 at approximately 7:20 AM the surgical technician (E #8) proceeded to open sterile equipment in preparation for the upcoming surgical case. Between 7:21 AM and 7:25 AM: At 7:21 AM E#8 left the room; 7:22 AM (one minute later) E#8 entered and then immediately left the room; At 7:23 AM E#8 entered and immediately left the room leaving the packs unattended for 2 minutes until 7:25 AM when the circulating nurse (E#14) entered the room. E #8 left and entered and left the room 3 times leaving the sterile supplies unmonitored.


3. The Director of Surgical Services (E#13) stated during an interview on 10/30/13 at 11:50 AM stated the surgical packs should not be left unattended when opened.



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C. Based on document review, observation and staff interview, it was determined that for 2 of 7 (E #5 & #6) employees, the Hospital failed to ensure staff adherence to Hospital policy on surgical attire.

Findings include:

1. Hospital policy entitled, "Surgical Attire," (R/R 3/13), required, "III. Guidelines:7. All persons entering restricted areas of the surgery department will wear head covers/surgical hats....Head covers/surgical hats must cover all exposed head hair...8. All persons in the restricted areas of the surgery department will wear masks when entering sterile environments. Persons who enter the semi-restricted and restricted areas of the OR will wear surgical attire intended for use within the department... 10. Jewelry, other than watches, should not be worn in the restricted areas of the department."

2. On 10/30/13 at 7:35 AM, a surgical technician ( E #5) was in OR 3 cleaning and setting up a case while wearing earrings. At 8:40 AM a surgeon (MD #1) entered OR #3 wearing earrings.

3. The above findings were confirmed with the circulating nurse (E #14) on 10/30/13 at 8:40 AM, who stated that staff should not wear jewelry in the OR.

4. On 10/30/13 at approximately 7:15 AM, the Operating Room Tech (E #8) entered room OR #4 with approximately 1 inch of hair exposed from around her temple.

5. On 10/30/13 at approximately 8:00 AM, a surgeon (MD #3) and the surgical assistant (MD #4) entered OR #4 with their masks untied at the bottom.

6. The above findings were discussed with the Director of Surgical Services Director during interview on 10/30/13 at approximately 8:30 AM who stated staff should adhere to the Hospital's surgical attire.
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D. Based on document review, observation and interview, it was determined that for 5 of 5 sutures the Hospital failed to ensure expired supplies were not available for patient use.

Findings include:

1. The Hospital policy titled, "Afternoon Staff Assignments" (reviewed/revised 4/13) required, "1. Supplies: Stock and Special Orders...c. Check expiration dates (specific dates or expiring at end of month.) Stock supply outdates are removed and given to the OR control desk for disposition...."

2. During observational tour of the OR on 10/30/13 at 7:10 AM, the following expired sutures were found in the central core supply racks:

(1) 3-0 Monocryl suture expired on 7/2012.
(4) 6-0 Vicryl suture, expired on 1/2013.

3. The above findings were confirmed with the Director of Surgical Services (E #13) during an interview on 10/30/13 at approximately 7:20 AM, who stated that supplies are checked monthly and dispose all expired supplies.