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Based on observation, record review, and interview, the facility failed to:

A. Safeguard and uphold the rights of patients in the facility. This failure resulted in 53 patients (Patient #'s 3-55) on suicide precautions being exposed to ligature risks inside their bedrooms.

B. Ensure that a face-to-face evaluation was conducted by a Qualified RN (QRN) within one-hour after the administration of a chemical restraint. This failure resulted in 4 of 4 patients (Patients #48, #51, #58, and #59) receiving a chemical restraint with no face-to-face evaluation being conducted by a QRN within one-hour after the administration of the chemical restraint.

C. Ensure that 1 of 1 patients (Patient #2) received care in a safe setting. This failure resulted in a Psychiatric Care Assistant (PCA) performing a one-man physical hold. Available staff neither assisted the PCA nor called for assistance. The patient sustained red marks during the physical hold.

D. Ensure proper orders for the use of restraint. This failure resulted in 1 of 1 patients (Patient #2) being ordered chemical restraint on an as needed basis (PRN).


Refer to tags A-0144, A-0154, A-0169 and A-0179.

Based on observation, interview, and record review, the facility failed to ensure a safe setting in patients' rooms who were on suicide precautions (Patient #'s 3-55) as evidenced by not recognizing the patient bedrooms' bathroom doors as a ligature risk.


Findings:


Record review of facility policy titled "Suicide Prevention Plan", policy ID: 6447868, effective 06/2019, stated "Environmental Risk Assessment. The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide. All staff are responsible for evaluating the environment for potential ligature risks."

Observation on 9/3/19 at 9:30 AM of facility's Cedar unit, where Patient #1 had successfully committed suicide by using towels tied together, throwing the ends of the towels over the bedroom door, and successfully hung himself with these towels while inside his room with the door shut, revealed the following: The bathroom door inside the room, which had the top cut at an angle in an attempt to make the door ligature resistant, was still able to be used as a tie-off point.

Surveyor asked Staff #A to see if he could use a bedsheet to tie-off on the corner of the door near the hinge side. CEO Staff #A demonstrated placing the sheet in the corner of the door, closing the door, applying forceful downwards pressure, and the sheet held in place.

In an interview with Staff #A at the time of demonstration, he stated that the bathroom door was a ligature risk that it had never been identified before. In addition, Staff #A stated that all the bathroom doors in the facility were the same.

Record review of patient census sheets for 9/3/19 showed there were 16 patients (Patient #'s 26-41) housed on the Cedars unit, all of whom were on Suicide Precautions.

Record review of patient census sheets for 9/3/19 of facility's Meadows unit showed there were 14 patients (Patient #'s 42-55), all of whom were on Suicide precautions.

Record review of patient census sheet for 9/3/19 of facility's Sunrise unit showed there were 23 patients (Patient #'s 3-25), all of whom were on suicide precautions.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 1 patients (Patient #2) received care in a safe setting. This failure resulted in a Psychiatric Care Assistant (PCA) performing a one-man physical hold. Available staff neither assisted the PCA nor called for assistance. The patient sustained red marks during the physical hold.

Findings:

Record review of the Crisis Prevention Institution (CPI) Participant Workbook © 2015 (reprinted 2019) showed:
Page 30 - Physical Interventions - Holding Position

Principles of Holding in a Standing Position:

Lower-Level Holding - One staff member is seen standing off to one side of the patient.

Medium-Level and High Level Holding - Two staff members are utilized, one on each side of the patient.

Page 32 - Physical Interventions - Holding Position

Children's Control Position - Lower Level Holding (one staff member to the side of the child). Medium, and Higher Level Holding (one staff member behind the child). "The Children's Control Position is designed to be used with children. Consider using this position only with individuals considerably smaller than yourself."

" ... Understanding the Risks of Physical Restraints ... When using physical interventions to manage the risks associated with an individual's behavior, staff face the dilemma that the specific intervention used may compromise the welfare and safety of those involved, and as such it is important that physical interventions are applied within a context of best practice in order to minimize harm."


Record review of the video surveillance footage of the physical hold involving Patient #2 on Saturday, 8/10/2019 (2:45 PM - 3:00 PM), showed Staff Q in the day room with Patient #2. Patient #2 turned over tables, threw chairs, and destroyed wall art. Staff RR assisted with moving the chairs. Staff Q moved in behind Patient #2 and put her in a one-man hold. Still utilizing this one-man hold, he single-handedly walked Patient #2 to the seclusion room.

In an interview with Staff Q on 9/3/2019 at 1:00 PM, he stated:

a) He is a CPI trainer;

b) Patient #2 had been intrusive with other patients, turned over tables, threw chairs, and broke two pictures with a chair;

c) Staff RR did not call for assistance or assist in the management of Patient #2;

d) Staff RR should have called for assistance;

e) The one-man hold is used on children according to CPI training;

f) He single-handedly restrained Patient #2; and

g) He should have waited for assistance before physically restraining the patient.


In an interview with Staff B and C on 9/3/2019 at 2:00 PM, they stated that the RN did not call for assistance to manage the behavior of Patient #2 and that the Staff Q needed assistance.


Record review of an interview with Staff RR dated 8/16/2019 at 3:00 PM showed: Repeated interventions with Patient #2 did not decrease her behavior. Physician had decreased Patient #2's narcotic medication. The patient was not happy with this. The restraint and seclusion was appropriate and was "handled appropriately." Patient #2 threatened to throw a drink machine. She did not think a "code" needed to be called. The patient stated she had red marks after she was removed room seclusion. This was accurate and had been noted on the "one-hour debriefing."


Record review of the Seclusion/Restraint Order/Progress Note, dated 8/10/2019, 3:00 PM - 4:40 PM, for Patient #2, showed:
Seclusion 2:58 PM - 4:00 PM

"One-Hour Face-to-Face Evaluation ... Assessment of Immediate Situation ... Patient making threats; punching walls; property damage; threatening; aggressive behavior; throwing tables and chairs ...

"Patient's Response to Intervention ... verbally aggressive; trying to get away; kick; screaming; cursing; yelling; threatening to hurt staff and others ...
"Skin Assessment ... reddened ... discomfort back arms. Reason: restraint. Pain 8 out of 10 back arms. Cause: restraint ..."

Based on record review and interview, the facility failed to ensure proper orders for the use of restraint. This failure resulted in 1 of 1 patients (Patient #2) being ordered chemical restraint on an as needed basis (PRN).

Findings:

Record review of Physician's Orders for Patient #2, dated 8/10/2019 at 3:45 PM, showed a telephone order from Staff E for Haldol 10 mg intramuscular (IM) for psychosis, Ativan 4 mg IM for agitation, and Benadryl 50 mg IM for extrapyramidal symptoms (EPS) PRN times one.


In an interview with Staff C on 9/3/2019 at 2:00 PM, she stated that an order for an emergency medication should not be written as a PRN.


Record review of policy 6516123, "Seclusion and Restraint," effective 07/2019, showed:

"Seclusion/restraint procedures are considered to be unusual, high-risk events that warrant timely assessment ...

"Definitions ...

"Chemical Restraint - A drug or medication that is not being used as a standard treatment for the patient's medical or psychiatric condition and that results in restriction of the patient's freedom of movement ...

"[R]estraint orders are NOT written as standing or PRN orders ..."

Based on record review and interview, the facility failed to ensure that a face-to-face evaluation was conducted by a Qualified RN (QRN within one-hour after the administration of a chemical restraint. This failure resulted in 4 of 4 patients (Patients #48, #51, #58, and #59) receiving a chemical restraint with no face-to-face evaluation being conducted by a QRN within one-hour after the administration of the chemical restraint.


Findings:

Patient #48.

Record review of Physician Orders for Patient #48 showed:
8/28/2019 at 7:05 PM - Haldol 10 mg IM for agitation, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Medication Administration Record (MAR) for Patient #48 showed the following medications were administered:
8/28/2019 at 7:00 PM - Haldol 10 mg IM for agitation, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS was administered as a now dose.

Further review showed that there was no face-to-face evaluation conducted by a QRN within one-hour after the administration of the chemical restraint.


Patient #51.

Record review of Physician Orders for Patient #51 showed:
8/23/2019 at 12:39 AM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Physician Orders for Patient #51 showed:
8/23/2019 at 11:40 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Medication Administration Record (MAR) for Patient #51 showed the following medications were administered:
8/23/2019 at 12:50 AM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.
8/23/2019 at 11:40 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

Further review showed that there was no face-to-face evaluation conducted by a QRN within one-hour after the administration of these chemical restraints.



Patient #58.
Record review of Physician Orders for Patient #58 showed:
3/28/2019 at 7:17 AM - Thorazine 100 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS STAT (immediately) one time was ordered by Staff E.

Record review of Physician Orders for Patient #58 showed:
3/28/2019 at 6:00 PM - Thorazine 100 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS STAT (immediately) one time was ordered by Staff E.

Record review of Physician Orders for Patient #58 showed:
3/31/2019 at 8:10 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg PO (orally) for EPS one time now was ordered by Staff E.

4/3/2019 at 1:00 PM - Zyprexa Zydis 20 mg PO for psychosis, Ativan 4 mg PO for anxiety, and Benadryl 50 mg PO for EPS one time now was ordered by Staff E.

4/4/2019 at 9:05 AM - Haldol 10 mg PO for psychosis and Ativan 1 mg PO for anxiety one time now was ordered by Staff E.

4/4/2019 at 11:16 AM - Thorazine 50 mg PO for psychosis, Ativan 1 mg PO for anxiety, and Benadryl 50 mg PO for EPS one time now was ordered by Staff Y.

4/5/2019 at 2:30 AM - Thorazine 50 mg IM for aggression, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time now was ordered by Staff E.


Record review of Medication Administration Record (MAR) for Patient #58 showed the following medications were administered:

3/28/2019 at 7:30 AM - Thorazine 100 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS STAT one time.

3/28/2019 at 6:25 PM - Thorazine 100 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

3/31/2019 at 8:15 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg PO (orally) for EPS one time now.

4/3/2019 at 1:00 PM - Zyprexa Zydis 20 mg PO for psychosis, Ativan 4 mg PO for anxiety, and Benadryl 50 mg PO for EPS one time now.

4/4/2019 at 9:49 AM - Haldol 10 mg PO for psychosis and Ativan 1 mg PO for anxiety one time now.

4/4/2019 at 11:25 AM - Thorazine 50 mg PO for psychosis, Ativan 1 mg PO for anxiety, and Benadryl 50 mg PO for EPS one time now.

4/5/2019 at 3:56 AM - Thorazine 50 mg IM for aggression, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time now.


Further review showed that there was no face-to-face evaluation conducted by a QRN within one-hour after the administration of these chemical restraints.


Patient #59.
Record review of Physician Orders for Patient #59 showed:
8/12/2019 at 1:44 PM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Physician Orders for Patient #59 showed:
8/14/2019 at 10:10 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Physician Orders for Patient #59 showed:
8/17/2019 at 7:00 PM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Physician Orders for Patient #59 showed:
8/18/2019 at 8:00 AM - Haldol 5 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time was ordered by Staff E.

Record review of Medication Administration Record (MAR) for Patient #59 showed the following medications were administered:

8/12/2019 at 2:15 PM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

8/14/2019 at 10:22 AM - Haldol 10 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

8/17/2019 at 7:20 PM - Haldol 10 mg IM for psychosis, Ativan 4 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

8/18/2019 at 8:30 AM - Haldol 5 mg IM for psychosis, Ativan 2 mg IM for anxiety, and Benadryl 50 mg IM for EPS one time.

Further review showed that there was no face-to-face evaluation conducted by a QRN within one-hour after the administration of these chemical restraints.


In an interview with Staff C on 9/3/2019 at 2:00 PM, she stated she did not know that there needed to be a face-to-face evaluation conducted by a QRN within one-hour after the administration of the chemical restraint.


Record review of policy 6516123, "Seclusion and Restraint," approved 7/2019, showed:
" ... Seclusion/restraint procedures are considered to be unusual, high-risk events that warrant timely assessment ...
"Chemical Restraint - a drug or medication that is not being used as a standard treatment for the patient's medical or psychiatric condition and that results in restriction of the patient's freedom of movement ...
QRN - Qualified Trained RN ... Determines if seclusion/restraint is appropriate ... Performs comprehensive, individualized assessment ..."

Based on observation, interview with the dietary manager, and record review, the facility failed to ensure that the dietary personnel were competent in their assigned duties. This failure was evidenced by:

a) The dishwasher temperature log was missing the quality check for 3 of 3 days; and

b) Sandwiches in 3 of 3 patient refrigerators were not labeled with the date the sandwiches were prepared.


Findings:

a) Dishwasher Temperature Log.

In an interview with Staff U and Staff W on 9/4/2019 at 10:35 AM, they stated that a daily quality check of the temperature of the dishwasher is to be documented daily on the dishwasher log using a disposable ECOlab T-Stick Temperature Sensor. Staff U stated the temperature sensor is to turn black when a safe temperature has been reached.

Record review of the ECOlab T-Stick Temperature Sensors instructions showed that the tip of the T-Stick changes from white to black, thus indicating a safe temperature has been reached.

The surveyor observed Staff U on 9/4/2019 at 10:35 AM demonstrate the use of the ECOlab T-Stick Temperature Sensor. She inserted the temperature sensor into the prongs of a plastic fork and stabilized it in the dishwasher. She then ran the dishwasher through a wash and rinse cycle. The temperature sensor did not turn black. Staff U stated that the temperature sensor may not turn black if the dishwasher has cooled down. She ran the dishwasher through the wash and rinse cycle again. The temperature sensor had turned black. She explained that the dishwasher should be ran through the wash and rinse cycle one time before the quality check is done.

Record review of the dishwasher log on 9/4/2019 showed no documentation for a quality check for 9/1, 9/2, and 9/3. Some of the ECOlab T-Stick Temperature Sensors for August were not black.

In an interview with Staff U (Dietary Manager) on 9/4/2019 at 10:35 AM, she stated the rotation of a lot staff through the kitchen over a holiday weekend is how the quality checks for 9/1, 9/2, and 9/3 happened.

Record review of policy 6835529, "Kitchen Sanitation and Foods Handling," approved 9/2019 showed: "All equipment is cleaned and sanitized according to procedure use."


b) Sandwiches:

Observation of sandwiches in the patient refrigerators on 3 of 3 units (Meadows, Cedar, and Sunrise) on 9/3/2019 from 9:00 AM - 11:00 AM showed the sandwiches had no dates on them that indicated when they had been prepared.

In an interview with Staff F on 9/3/2019 at 9:20 AM, she stated, she was unsure when the dietary staff had placed the sandwiches in the refrigerator, adding, "It was probably later in the evening." She also stated, there was once a schedule "but the kitchen took it down."

In an interview with Staff U on 9/4/2019 at 10:35 AM, she stated, the sandwiches are supposed to be labeled to indicate the date they were prepared.

Record review of policy 6835529, "Kitchen Sanitation and Foods Handling," approved 9/2019 showed: "Foods shall be prepared in a clean functional environment and served in such a manner as to prevent food-borne illness and contamination."

Record review of Job Description for the Dietary Manager (no date) showed:
"Job Responsibilities ...
"Ensures food is properly labeled and dated per established guidelines for food safety."

Based on interview and record review, the facility failed to ensure an acceptable level of safety and quality in the use of glucometers. This failure resulted in the lot numbers for control solutions (levels 1, 2, and 3) and glucose test strips not being recorded on 2 of 2 Glucometer Control Logs.

Findings:

Observation of the glucometer equipment on the Meadows and Sunrise units on 9/5/2019 at 9:30 AM revealed the Henry Schein True Metrix Self-Monitoring Blood Glucose System. There was a glucometer in the in the medication room on the Sunrise unit and on the crash cart on the Meadows unit.

Record review of the policy 5258819, "Glucometer/Blood Sampling - Capillary (Finger Stick)," effective 10/2018, showed:

"General Guidelines.

"1. Assess blood glucose meter, and use if in good repair, supplies are adequate, and the control test is accurate ...

"2. Review the manufacturer's instructions related to the use of the blood glucose monitor ...

"5. When in use, ... the True Metrix machine, quality tests will be monitored nightly based on ... level 1, ... level 2, ...level 3 ... "


Record review of the True Metrix Self-Monitoring Blood Glucose System owner's booklet (no date) showed the lot number for the test strips and control solutions is to be "used for identification ..."

Record review of the Glucometer Control Log on the crash cart on the Meadows unit showed the lot number for the control solutions had not documented. Record review of the glucometer control log in the medication room on the Sunrise unit showed the lot number for the control strips had not been documented.

In an interview with Staff CC on 9/5/2019 at 9:35 AM, she stated the Glucometer Control Log is to include the lot numbers for the test strips and the control solutions.

Based on observation, interview, and record review, the facility failed to ensure the maintenance of a sanitary hospital environment. This failure was evidenced by:

a) 1 of 3 clean linen rooms having an opened bucket of dry wall compound stored in the room; and

b) 1 of 1 biohazard containers was not labeled as "biohazard" and did not have a red bag in it.

Findings:

a) Clean Linen Room

Observation of the clean linen room on the Meadows Unit on 9/3/2019 at 9:00 AM revealed an open bucket of dry wall compound stored in the room.

Record review of policy 5669495, "Linen Management," approved 1/2019 does not address storing soiled items in the clean linen room. It does outline procedures for making sure the linen is covered and stored in the clean linen room. It also outlines procedures for keeping soiled linen from contaminating the clean linen.

In an interview with Staff A on 9/3/2019 at 9:00 AM, he stated the dry wall compound should not have been stored in the room with the clean linen. He also stated he would have it removed immediately.


b) Biohazard Container.

Observation of the exam room on the Sunrise Unit on 9/5/2019 at 9:35 AM showed no container labeled as a biohazard container. There were supplies for drawing blood in the cabinets.

In an interview with Staff CC on 9/5/2019 at 9:35 AM, she stated that procedures performed in the exam room could generate contaminated material, such as gauze or gloves soiled with blood.

In an interview with Staff W on 9/5/2019 at 9:35 AM, he stated that supplies soiled with blood could be taken from the exam room on the Sunrise Unit to a biohazard container in another area of the Sunrise Unit.

Upon exiting the room, the surveyor noted a red container with a black plastic bag in it.


In an interview with Staff CC on 9/5/2019 at 9:35 AM, she stated that the red container was the biohazard container. She also stated the container should be labeled as "biohazard" and should have a red biohazard bag in it.


Record review of policy 6515889, "Managing Risk - Hazardous Materials," approved 7/2019, showed:
"Hazardous materials are labeled throughout their use, handling, and disposal ... Labeling is evaluated during environmental tours ... [W]here collection cans or containers are used, the container is labeled ..."