HospitalInspections.org

Based in a review of documentation and policy it was determined the facility failed to ensure that medical records were completed in a timely manner.
Findings were:
Facility based Medical Staff Bylaws- Rules and Regulations of BSSH Medical Staff stated in part,
" H. Medical Records ...
1. The attending physician shall be jointly responsible with the treatment team for the preparation of a complete medical record for the patient ...
5. All medical records must be completed within thirty days following discharge of patients.
According to the Hospital Medical Record Delinquency Rates for 2014 the delinquency rate ranged from 4.08% to 48.84%. The average medical delinquency rate for 2014 was 20.41 %. In 2015, the following delinquency rates were noted: January 30% (15 records out of 50 discharges), February 32.35% (11 records out of 34 discharges), March 14.63% (6 records out of 41 discharges), April (8 records out of 39 discharges), and May (11 records out of 23 discharges).
In an interview on 06/10/15, the Director of Information Management stated that the majority of the deficiencies are "discharge note and summaries. The note is due at discharge and the summary is within 30 days". The staff member stated the facility had been "short on medical staff and the clinical director retired."
The above findings were confirmed in an interview with the Program Manager HIM and the Director of Information Managment on 06/10/15.

Based on review of records and interview, it was determined that the hospital failed to provide diets that met the nutritional needs of its patients.
Findings were:
"Clinical Dietary Manual" stated in part under "Diets for Diabetes," "Use of a standardized meal plan is appropriate until an individualized meal pattern can be developed. Whenever possible, it is best to customize meal plans so that usual patterns of eating are maintained, to promote control of blood glucose after discharge ...Medical nutrition therapy is an essential component of diabetes care and management. A multidisciplinary team approach to diabetes education and management is recommended, including a registered dietician, nurse, physician and the individual with diabetes. Ideally, additional members should include a pharmacist, psychosocial councilor and an exercise specialist. If the team approach cannot be implemented, close communication between the physician, dietician and person with diabetes is needed."
The manual goes on to state "The Regular Diet is designed to maintain or promote optimal nutritional status in persons who do not require a modified or therapeutic diet. The Regular Diet is used to promote health and reduce the risks for developing chronic, nutrition related diseases. This diet is indicated for individuals who do not require dietary restrictions or texture modifications."
2 of 5 diabetic patient charts reviewed found the following:
· Patient # 2, admitted 10/10/13, had a "regular" diet ordered upon admission. The patient had no record of a dietary consultation and her diet order was never reevaluated by the multidisciplinary team.
· Patient # 4, admitted 1/1/11, had a "regular" diet ordered. No dietary consultation was found in the medical record.
This finding was confirmed by the Assistant Chief Nursing Executive on 6/11/15.

Based on observation and interview, it was determined that the physical plant was not maintained to ensure the safety of its staff and patients.
Findings were:
Tour of the facility on 6/9/15 revealed the following deficits:
· The grounds of the hospital had high grass throughout which hid prairie dog holes also found throughout the grounds. These hidden prairie dog holes could cause falls and injury to staff and patients alike.
· The covered walkway leading from patient units to the dining area had many mud swallow nests attached. The birds were flying in and out and bird droppings were noted on the sidewalk. An active wasp nest was also observed dangling from the covered walkway.
· The treatment room in the Oaks Unit had stained and ill-fitting ceiling tiles.
· One of two shower rooms on the Oaks Unit had 2 broken windows.
· In the kitchen, 3 doors leading outside needed weather stripping. These open areas could allow vectors access into the building.
· A broken window was observed in the dish washing room.
· Piping leading to the "de-liming" room in the dishwashing room was broken and corroded. Dead cockroaches were noted along the wall.
In interviews with the Assistant Nurse Executive and the Dietary Manager on 6/9/15, the above findings were confirmed.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

" OSHA/Blood Borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

"Disinfecting Washing Machines/Dryers" Policy IC.5 (IC) stated in part, "D. Unit staff will clean the inside of the washing machine after each patient is through washing clothes ...
2. Any visible dirt will be cleaned with a clean cloth, water and cleanser (i.e., Bippy).
3. The inside of the washer will be disinfected with a hospital-approved disinfectant (i.e. Wex-cide 128 or an approved Eco-Lab product). "

"Dish Room Sanitation" Policy (IC.46 (FS) stated in part, "B. Vents ...
2. Vents are cleaned on a scheduled basis with disinfect-cleaner, rinsed with clear water and air-dried. The outside stainless steel surfaces may be polished with stainless steel,"

"Housekeeping Policy" Policy IC.22 (ES) stated in part, "D. Routine Cleaning: Bathrooms and Restrooms...Toilets, shower, bathtub surfaces, and sink area are disinfected."

Tour of the facility on 6/9/15 revealed the following deficits:

· The nutrition area on the Oaks unit had two dead houseflies observed in the windowsill.
· A "clean" patient washing machine on the Oaks Unit had debris inside, indicating it had not been sanitized after use.
· The floor of a shower room on the Oaks unit had chipped and missing tiles and the bathtub had a red substance (jelly?) spilled inside.
· The treatment room on the Oaks unit had a ceiling tile with water damage present. The water damage presents the risk of contamination with bacteria and/or mold.
· The "thawing" refrigerator had two large, thawing loaves of meat. These loaves were unlabeled as to content or date purchased. The same refrigerator had a large unlabeled pan of what the kitchen manager claimed was chicken.
· In the kitchen area 14 external shipping boxes (containing cups, lids, bowls, plates) were observed on shelves. External shipping boxes presents a risk of introducing outside contaminates such as dirt, debris, and pests.
· Debris and food crumbs were found behind banks of ovens and cook tops in the kitchen.
· The air-conditioning vent over the oven was dusty as was the AC vent leading into the dining room.
· The hallway rug that spanned the length of the entire unit in the Mesquite Unit was malodorous. The seclusion room in that same hallway smelled strongly of urine.
· The treatment room in the Mesquite Hallway had an exam table with a torn vinyl covering. A weight machine in the gym also had a torn covering. These torn coverings made cleaning impossible and cross contamination likely.

In interviews with the Assistant Nurse Executive and the Dietary Manager on 6/9/15, the above findings were confirmed.

Based on record review and interview, the facility failed to ensure that the Master Treatment plans (MTPs) for 10 of 10 active sample patients (A1, A2, A3, A4, A5, B1, B13, B23, B26 and B27) included interventions by the physicians. This failure results in MTPs that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment which can impact on patients' ability to improve.

Findings include:

A. Medical Records

1. The facility did not have a Master Treatment Plan policy. However, the "Person Centered Recovery Plan (PCRR)," their name for the Master Treatment plans (no date), did state the following about the MTPs: "Who Records: the medical staff, registered nurses, clinical social workers, case workers, psychologists, dietary, and ATD (Activity Therapy Department) treatment team." Under the section for "Interventions", the following was stated - "The interventions are the actions that staff will take to actively assist the patient in achieving the objective. Interventions must be discipline specific."

2. None of the Master Treatment Plans of the 10 active sample patients (dates of the MTPs in parenthesis) had interventions by the physicians: A1 (2/20/15), A2 (5/13/15), A3 (4/30/15), A4 (6/3/15), A5 (6/8/15), B1 (5/14/15), B13 (6/8/15), B23 (5/28/15) B26 (6/3/15), B27 (4/10/15).

B. Interviews

1. In an interview on 6/10/15 at 10:50 a.m., the absence of physician interventions on the Master Treatment Plans was discussed with Nursing Director. She stated, "Physician interventions have not ever been included on the patients' treatment plans. Physicians include the treatment to be provided for patients in their Psychiatric Evaluations and on a Treatment Plan Review Progress Note."

2. In an interview on 6/10/15 at 2:15 p.m., the absence of physician interventions on the Master Treatment Plans of active sample patients A1, A2 and A3 was discussed with the Medical Director. He agreed with the findings.

Based on record review and interview, the facility failed to ensure that discharge summaries were completed in a timely fashion defined by hospital requirements for two (2) of six (6) discharged patients (D2 and E5) and that a discharge summary included a recapitulation of all the treatment received during the hospital stay for one (1) of six (6) discharged patients, all of whose records were reviewed for facility compliance. These failures compromised the effective transfer for those patients being transferred to other care providers by not providing information that identified either effective of ineffective treatment strategies for each individual patient.

Findings include:

A. Medical Records

1. The facility did not have a Discharge Planning policy. The information on discharges was included in the "Person Centered Recovery Plan", (no date), section 4, titled "Discharge/Furlough Summary." It stated: "Purpose: to provide a chronological summary of all important aspects of hospitalization; to be used as a reference for both providers of follow up care and as a source document for readmission"---"When recorded: within 30 calendar days of the patient's departure by discharge or furlough with intent to discharge"---"This addendum to the discharge order note includes the reason for admission, significant physician findings, and course of treatment in the hospital."

2. Patient D2, who died 4/26/15, had a Discharge Summary completed 6/8/15, almost 2 months after the patient was deceased.

3. Patient E2 was admitted on 11/12/07 and discharged on 4/7/15. The Discharge Summary stated: "Stabilized on medication. Still has occasional problems with inappropriate sexual activity." These 2 sentences served as a recapitulation of the patient's 8 year treatment in the facility.

4. Patient E5, who was discharged on 4/17/15, did not have a Discharge Summary completed in the medical records as of 6/10/15-about 2 months after leaving the facility.


B. Interview

In an interview on 6/10/15 at 2:15 p.m., the lack of timeliness for D2 and recapitulation of hospital stay for E2's discharge records were discussed with the Medical Director. For the timeliness, the Medical Director's comment was - "This is bad and delinquent." For the recapitulation information, the Medical Director stated "It's almost nothing."