HospitalInspections.org

Based on staff interview and document review, the hospital failed to ensure radiological services were supervised by a radiologist.

The findings include:

On 10/26/2021 at approximately 1:15 PM, an interview was conducted with Staff B, a certified radiological technologist (CRT), during which he stated that to his knowledge, there is no one functioning as a radiology supervisor or consultant.

A review was conducted of the purchase order dated August 26 2021, which outlined a dollar amount and fees per study that would be provided by Radiology Associates of Tallahassee. There was no statement outlining the provision of a radiologist to serve in the role as a supervisor or consultant for the radiology department.

On 10/27/2021 at approximately 1:40 PM, an interview was conducted with the Director for Clinical Services, who stated that the hospital does not have anyone functioning in the role of radiology supervisor or consultant. The Director of Clinical Services further stated they will be developing a Standard Agreement to obtain the services of a radiology provider to serve in the role as a supervisor or consultant for the radiology department and provide for the quality measures and consulting necessary. She stated they currently have no one in the role of a Medical Director for Radiology.

Based on observations, interviews, and review of operating procedures, service requests, and a capital improvements program plan, the facility failed to maintain buildings in a clean and sanitary manner and failed to maintain equipment in clean and working condition throughout the psychiatric hospital, Unit 14, Ward A.

The findings include:

On 10/25/2021 at approximately 2:15 to 2:25 PM, an observation was made of the Examination room on unit 14, ward A. During the observation a window behind the medication cart was noted to have looped fabric affixed to the window which appeared to be curtain tie-backs, but no curtains were present. The fabric was a light tan color and had numerous black spots which appeared to be biological growth. Also observed was a ceiling tile in the room which was stained dark brown and black in one corner near the door to the room. A sharps container (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments) was observed on the floor of the room approximately half full (photographic evidence obtained).

On 10/25/2021 at approximately 2:30 PM, an observation was made of the Women's bathroom on unit 14, ward A which revealed 4 toilet stalls. The first two stalls closest to the door each had a privacy curtain covering the stall entrance. The last two toilet stalls shared a curtain which was hung perpendicular to the wall of the 3rd stall's entrance leaving the front portions of the third and fourth stall open. This privacy curtain was observed to be stained near the top where the plastic portion of the curtain met the mesh top. The floor in the bath and shower area was uneven with several tiles missing. The only bathtub had a sign taped to it which indicated it was broken. On the wall behind the tub, an open panel in the wall revealed a metal pipe with a temperature gauge. Inside the panel box underneath the pipe was a white towel.

On 10/25/2021 at 2:32 PM, an observation was made in conduction with the Executive Nurse Director made of the Refrigerator in nurses' station of unit 14, ward A. A white towel was observed on the floor protruding from under the refrigerator door. The Executive Nurse Director stated the refrigerator was used for patient drinks and supplements. The refrigerator was observed to contain three plastic pitchers filled with liquid, pre-packaged supplement drinks and prepackaged single serve puddings. On the bottom shelf of the refrigerator there was another white towel. The top shelf on the inside of the refrigerator door was covered with what appeared to be spilled liquid. A stain which appeared to be from a dark spilled liquid was observed on the floor in front of the refrigerator.

At the time of the observation an interview was conducted with the Executive Nurse Director, who explained the refrigerator had been leaking and a work order was placed to have it fixed. The Executive Nurse Director also explained the refrigerator needed to be condemned and the facility was unable to order a new refrigerator until the process to condemn the existing refrigerator was completed.

On 10/27/2021 at approximately 10:27 AM, a follow up observation of the refrigerator's freezer contained a can of soda with frozen dark liquid on top of the can which was not present during the observation on 10/25/2021. Also observed was the thermometer in the refrigerator which indicated the temperature was 46 degrees. A temperature log attached to the front of the refrigerator indicated "if the refrigerator temperature is out of range, relocate or properly discard items ... and notify your supervisor immediately so repairs to the refrigerator can be initiated." The form indicated the temperature range was 35 to 41 degrees Fahrenheit for the refrigerator. The documented temperature readings on the log showed the temperature was out of range on 10/19/2021 at 48 degrees and documentation indicated "adjusted." The temperature remained out of range on 10/20/2021 at 46 degrees, on 10/21/2021 at 46 degrees, and on 10/22/2021 at 48 degrees (all temperature recordings are in Fahrenheit).

On 10/27/2021 at approximately 10:27 AM, an interview was conducted with Registered Nurse F, who confirmed the temperature reading for the refrigerator was 46 degrees Fahrenheit at the time of the observation.

On 10/27/2021 at approximately 11:10 AM, an observation of the men's restroom, unit 14, ward A, was conducted which revealed two ceiling tiles near the entrance were stained dark brown and black. Inside the men's bathroom, a towel was observed on the floor under the only urinal in the bathroom. The paint on the concrete block wall surrounding the urinal appeared to be peeling away from the wall from moisture behind the paint. There were two toilet stalls separated by a wooden wall and a square hole was cut into the wall between the two toilets at the level where a toilet paper holder would normally be located. Inside the bathroom over a partial wall separating the toilet area from the bathing area was a white plaster ceiling that was peeling.

The corner of a wall in the hallway across from the nurses' station was damaged and a chair rail on the lower portion of the wall outside the nurses' station was broken.

A review of the Service Request Policy, operating procedure #70-3, dated September 1, 2021, paragraph 4a indicated "daily service provides routine repairs to correct minor wear and tear to the building or its systems. Daily service work orders will receive a scheduled completion date and be assigned to a repair shop immediately."

A review of service requests regarding the Ward A refrigerator demonstrated on-going, unresolved concerns for this refrigerator dating back to June, 2020:

An email dated 6/15/2020 indicated work order #7088520 generated on 6/15/2020 at 8:43 AM, for "fridge on dorm A in room 238 needs to be checked by HVAC (Heating, ventilation, and air conditioning) it is leaking water on the floor." An email dated 7/8/2020 indicated work order 7088520 for water leaking on the floor was completed.

An email dated 10/22/2021 confirms a work order numbered #8609422 for "fridge is leaking needs to be checked and condemned if not repairable." An email dated 10/26/2021 indicated work order #8609422 had been completed and noted "settings on fridge was turned down and freezer setting was all the way up readjusting and cleaned up the water."

An email dated 10/27/2021 indicated work order #8622143 was generated for "fridge was checked yesterday now it is not keeping cold. Needs to be checked."

On 10/28/2021 at approximately 12:30 PM, an interview was conducted with the Maintenance Director, who was shown pictures of the stained ceiling tiles on ward A and agreed that those need to be addressed. He said those tiles occasionally have leaks from the HVAC systems that cause those issues with the drop ceiling tiles.

The Maintenance Director was shown the photographs of the hole in the wall of the men's bathroom stall on unit A. The Maintenance Director said, "I don't understand why that's like that." He viewed the photo of the plaster ceiling in the men's bathroom and stated that is peeling as a result of moisture from the HVAC system. He observed the photo of the broken chair rail on the wall near the nurses' station and said that does not require a capital expenditure and can be repaired. The dent on the corner of the wall and the broken chair rail, he explained were both from being hit by wheelchairs and can be repaired. The maintenance director explained there is a maintenance tech assigned to each building that is a contracted employee who should make periodic walk-through inspections as part of the daily routine. The documentation of the walk-throughs is found in work orders and employees are expected to submit those as they see them.

The Maintenance Director went on to say that there is a process for submitting a maintenance ticket either through email or phone call to the contracted company and that would be assigned to a repair person in that department. The severity of the problem determines how quickly the request is taken care of and an email is sent when the repair is made. He also stated that the bathrooms in unit A are in bad shape and have been on our FCO (fixed capital outlay) for four years at least; that's how we address major repairs. The catalog with photos of our FCO (fixed capital outlay) request is done annually. The Maintenance Director explained how the process worked. The repair requests made on the FCO are combined with requests from other state facilities (a total of three facilities in the state). They all get thrown in one pile and submitted to the secretary then on to the legislature for funding. Its' about 24 million dollars a year which gets pared down from 24 million to about 1 million for a year to cover all (psychiatric forensic) buildings in the state of Florida. A single elevator can cost up to 250 thousand dollars and we have 24 elevators just here. Once the allocation is given, they have to sit on that money until something breaks and they can whittle the small money off as the year goes on. I have been informed the American relief plan that just came out within the last 6 months has some money and the bathrooms in (unit 14) are on the list to be addressed, but we don't know if that money will be given at the end of session or end of fiscal year. The bathrooms, from our guessing and getting people in for estimates, is going to cost about 300 thousand dollars to fix and make it all anti-ligature.

On 10/28/2021 at approximately 11:50 AM, an interview was conducted with the Administrator who confirmed the facility leadership made rounds of the facility to inspect its condition and has requested for money for bathroom repairs. The administrator explained there are numerous areas in need of repair, and this is documented in a bound catalog with pictures and descriptions.

Based on observation, staff interview and review of facility protocol, the facility failed to ensure staff adhere to infection control standards as prescribed within facility policy affecting at least 2 of 16 patients (patients #19 and #20).

The findings include:

During an observation of group activities in the activity room on ward A, Unit 14 on 10/27/2021 at approximately 10:16 AM, Direct Care Staff E was observed to enter the activities room wearing blue disposable gloves on both hands. At the time of the observation, 11 patients were present in the activities room, sitting at tables, engaged in activities such as coloring and bingo. The bingo activity was led by the rehabilitation director and 2 other staff members were present in the room. Direct Care Staff E entered the room wearing gloves and sat down between two patients and assisted them in coloring activities, touching the crayons and paper they were using for the activities while still wearing the same gloves she had on when she entered the room. No staff member redirected staff E to change or remove gloves prior to engaging in activities with patients.

In an interview on 10/27/2021 at approximately 10:25 AM, Direct Care Staff E explained that she was still wearing the gloves because she had been serving beverages to patients prior to entering the room and forgot to take them off. Direct Care Staff E was then observed to remove the gloves and continue assisting patients #19 and #20 in activities without performing hand hygiene.

A review of protocol G-143 dated July 1, 2021 under paragraph 3.b. indicated, "gloves will be changed after contact with each resident. Hands should be washed immediately after gloves are removed."