HospitalInspections.org

Based on observation and interview the facility failed to protect the rights of patients requiring a safe environment resulting in the potential for harm and/or unsatisfactory outcomes for all patients receiving care in the facility. Findings include:

See specific tag:
A-144. (1.) Failed to secure two retractable medication room windows resulting in the potential for unauthorized access into medication rooms and, (2.) failed to remove a length of string attached to a mat inside of quiet room resulting in the potential for ligature risk, both increasing the risk for poor safety outcomes to any of the 129 patients receiving care in the facility.

Based on observation and interview, the facility failed to identify environmental safety risks resulting in the potential for patient harm for all 129 patients receiving care in the facility. Findings include:

During tour of the Adult Male Unit on 10/25/22 at approximately 1130 with the Director of Quality (Staff F) present, the retractable medication room window was not securely latched. This window was easily opened from the patient side of the hallway by simply lifting it from the bottom and rolling it upward. Once opened, the entire contents of the medication room were exposed and could be freely accessed by unauthorized persons, this includes access to numerous prescription and over-the-counter medications, sharps, keys, and other contraband. Note there were no medications being actively administered by nursing staff at the time of the observation.

During an interview with the Licensed Practical Nurse (LPN Y) on 10/25/22 at approximately 1132, LPN Y said she was unaware the window was not securely latched. LPN Y said the window should have been securely latched.

During tour of the Pediatric Boys Unit on 10/26/22 at approximately 1000 with the Director of Compliance and Risk (Staff B) present, the retractable medication room window was not securely latched. This window was easily opened from the patient side of the hallway by simply lifting it from the bottom and rolling it upward. Once opened, the entire contents of the medication room were exposed and could be freely accessed by unauthorized persons, this includes access to numerous prescription and over-the-counter medications, sharps, keys, and other contraband. Note there were no medications being actively administered by nursing staff at the time of the observation.

During an interview with Staff B on 10/26/22 at approximately 1145, Staff B acknowledged the medication room windows should have been securely latched. During this interview Staff B was asked to provide a policy and/or a procedure regarding securing of the medication room windows. As of the survey exit date, no policy or procedure regarding such was provided by the facility.






36887

On 10/25/2022 at 1101, during a tour of the locked restraint/seclusion/quiet room on Peds 1 (an all girls unit), a silky-like string approximately 2 feet in length was observed curled up and sitting on the window sill. This finding was confirmed by Chief Nursing Officer Staff C at the time of discovery who agreed this was a potential ligature risk. Staff C attempted to pick up the string to remove it; however it was still attached to the mat. Staff C was able to remove the attached string from the mat and discard it appropriately on the unit.

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See tag
A-0701 Failure to maintain the physical environment
A-0710 Failure to ensure life safety from fire
A-0724 Failure to maintain equipment

Based on observation, interview, and document review, the facility failed to ensure that the condition of the hospital environment was maintained in a manner to promote the safety and well being of patients, resulting in the potential for harm to all occupants in the event of fire. Findings include:

On10/25/22 at approximately 1100, a tour of the facility was conducted with Director of Risk, Staff B. During tour of the Older Adult (OA) unit, the 'Patient belongings' storage area was examined. The walls of the room were lined with three tiers of shelving on three walls. The top shelves were each clearly marked with a 6-inch by 10-inch sign stating, "do not place anything on this shelf". One upper shelf had a large, clear plastic "trash" bag which contained various articles of clothing. The plastic bag was approximately half-full and was situated beneath the ceiling mounted fire suppression sprinkler, with approximately 12 inches of clearance between the bag and the sprinkler. At the time of observation, Staff B was questioned regarding the signage. Staff B stated the signs were to prevent items from being placed on the shelves which could obstruct the sprinklers. Pointing to the bag, Staff B was queried, "Is that supposed to be there?" Staff B stated, "No, that is not supposed to be there", and Staff B removed the bag from shelf.

On 10/27/22 at 1040, Staff B was requested to provide a policy related to storage of items near a sprinkler head. Staff B returned shortly after with Director of Facilities Staff M. Staff B stated that the facility had no policy related to storing items near fire sprinklers and that the signs were posted to prevent fire code violations. Staff M presented a single page document Titled "Annex A. 13-279 (undated)". Section A.8.6.6 of this document states, "Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 inches (457 millimeters) below the ceiling sprinkler deflectors." Above findings were confirmed by the accompanying Director of Facilities Staff M at the time of document review.

Based upon observation, interview and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually cited K-tags below, dated October 20th, 2022.

K-0353
K-0531
K-0741
K-0781
K-0918
K-0920

Based on observation and interview, the facility failed to properly maintain the facility and equipment to ensure an acceptable level of quality, resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

On 10/25/2022 at around 11:10 AM during a tour of the second floor geriatric (older adult) unit of the hospital, dust accumulation was observed on most of the sloped tops of cabinets throughout the unit (including the ones in the medication room), inside of the corridor cabinets where ice/water machines are placed, and on the floor of the electric room across from the elevators. Findings were confirmed by Director of Facilities Staff M at the time of observation.

On 10/25/2022 at around 11:15 am during a tour of the first and second floor, 4 out of 4 janitor closets were observed to have an add on chemical dispensing unit (without the required Wasting Tee Device) directly connected to the mop sink faucet, resulting in the potential for failure of the vacuum breaker and contamination to the facility's potable water system. Findings were confirmed by Director of Facilities Staff M at the time of observation.