HospitalInspections.org

Based on record review and interview, the hospital's Governing Body failed to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate since the hospital did not have have a dedicated Emergency Department.
Findings:


Review of hospital policies and procedures provided by S6DirQA Corp (Corporate Director of Quality Assurance) as current, revealed Policy TX-SPEC-11: Change in Condition/Early Response Intervention to Deteriorating Patient Condition (revision date 7/2014) was a policy pertaining to inpatients. Further review revealed no procedure for appraisal of emergencies, initial treatment, and transfer as appropriate for any emergency in the hospital.

Review of Policy PC-13: Provision of Emergency Services (2013), provided by S6DirQA Corp as current, revealed provisions that inpatients had 24 hour nursing care available. IOP (Intensive Outpatient Program) provided those outpatients were included in the policy. Further review revealed no procedure for appraisal of emergencies, initial treatment, and transfer as appropriate for any emergency in the hospital, including emergencies other than hospital patients.

Review of Policy PC-06: Patient Flow/Triage (2013), provided by S6DirQA Corp as current, revealed the purpose of the policy is to provide safe management of patients in the event of unanticipated increase in volume, and to ensure the needs and safety of patients who are in temporary locations awaiting an admission are addressed or patients that arrive in the event of disaster situations. Further review revealed no procedure for appraisal of emergencies, initial treatment, and transfer as appropriate for any emergency in the hospital, other than hospital patients.

In an interview 06/26/15 at 8:15 a.m., S6DirQA Corp confirmed the hospital did not have a policy for the appraisal for emergencies, initial treatment, and referral, when appropriate, that covered any emergency, including those that did not involve a hospital patient.

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks/points and safety hazards.

Findings:
An observation on 06/23/15 from 1:30 p.m. to 2:30 p.m. of the locked in-patient psychiatric unit with S6DirQA Corp (Corporate Director of Quality Assurance) revealed the following observations:

1) The psychiatric unit had 10 (ten) bedroom units with 2 (two) beds in each unit and each unit had 1 (one) bathroom inside the unit for patient use. The bathroom doors inside each unit were not able to be seen from the main hallway. The doors to all the patient bathrooms were observed to have door hinges set apart widely enough to allow for potential ligature risks.

2) The door handles on all the patient bathroom doors were flanged lever-type handles that could facilitate a ligature risk.

3) The sinks in all the patient bathrooms were observed to have flanged-type handles that could be used as ligature points.

4) The toilets in all the patient bathrooms were observed to have exposed plumbing that could be used as a ligature points.

5) The beds in all the patient rooms had metal slatted frames with removable springs and each bed had 3 non-removable bed cranks at the foot of each bed.

6) The mattresses on all the patient beds were observed to have a full length zippered encasement where the zipper portion ran down the entire length of the mattress which could pose as a safety suffocation hazard and as an opportunity for hiding contraband or unsafe items.

In an interview on 06/23/15 at 2:45 p.m. with S6DirQA Corp, the above observations were reviewed with S6DirQA Corp. S6DirQA Corp indicated that patients were allowed to close the doors to their rooms and that the patient bathroom doors were not visible from the main hallway and were not able to be seen from the main hallway. S6DirQA Corp indicated that the hospital did not have a policy in place that addressed the mitigation for the potential safety/hazard risks in the use of beds with metal slatted bed frames, removable springs, and hand cranks or zippered mattress covers. S6DirQA Corp further indicated that the hospital had potential ligature risks and safety issues that needed to be addressed.

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were administered in accordance with physician orders for 3 (#2, #5, #6) of 5 patient records reviewed for medication administration from a sample of 8 open patient records. Findings:

Review of the hospital policy entitled "TX-MED-01 Medications" contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed, in part, "...5. Transcription of Orders: Physician orders medications to be administered; RN/LPN (Registered Nurse/Licensed Practical Nurse), Reviews the physician's medication order for content and clarity. If the order is not clear, the physician shall be contacted for clarification. Routes a copy of the medication order to pharmacy each time a medication order is written. Nurse, Transcribes the medication order onto the patient's Medication Administration Record (MAR); Records scheduled medications on the patient's MAR from top to bottom; Records PRN (as needed) drug orders, STAT (now), and one-time orders on the patient's MAR. Records the date and his/her initials in the "ORD DATE INIT" column of the MAR. 7. Documentation: All medications shall be documented in the patient's Medication Administration Record (MAR) immediately after administration. RN/LPN: Documents administration of medications by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Draws a single line through the time indicated to signify that the medicine has actually been given, and initials. Signs name, title, and initials at the bottom of the MAR. If a dose of scheduled medication is withheld or not given, circles the hour of administration for the medication dose in question and initials next to circled time. Records a full explanation in the integrated progress notes and/or MAR."

Review of the medication policy entitled "TX-MED-02 Medication Administration/Consent" revealed the following, in part, "The following is a sample schedule of standard times to be used for administering medications. Times may be changed based upon department structure, medical staff, patient needs, and orders. Daily: 9 a.m.; BID: 9 a.m., 9 p.m.; TID 9 a.m., 3 p.m., 5 p.m.; QID: 9 a.m., 1 p.m., 5 p.m., 9 p.m.; every 6 hours: 9 a.m., 3 p.m., 9 p.m., 3 a.m.; every 12 hours, 9 a.m., 9 p.m."

Patient #2
Patient #2 is a 69-year-old female admitted to the hospital on 06/16/15 at 7:19 p.m. with admitting diagnoses of Axis I, Bipolar Disorder, mixed, severe, without psychosis; Severe Anxiety, and Suicidal Ideations.
Review of Patient #2's Medication Order Sheet dated 06/16/15 at 7:15 p.m. (Admission Orders) revealed, in part, the following medications were ordered: "Bentyl, 20 mg (milligrams) po (by mouth) TID (three times per day), scheduled for 9:00 a.m., 1:00 p.m., and 9:00 p.m.; Phenytoin/25 mg/ml (milliliter), 4 ml, TID for 30 days (scheduled for 9:00 a.m., 1:00 p.m., 9:00 p.m.); Probiotic and Acidophilus, po, TID (scheduled for 9:00 a.m., 1:00 p.m., 9:00 p.m.); Simethicone 180 mg, po, QID (scheduled for 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m.); Sodium Bicarbonate, 650 mg QID (scheduled for 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m.); Premarin 0.625 mg, po, BID (scheduled for 9:00 a.m., 9:00 p.m.); Keppra (100 mg/ml), 10 ml, po, BID (scheduled for 9:00 a.m., 9:00 p.m.)."

Review of Patient #2's MAR revealed the above-referenced physician orders were not administered at the 9:00 p.m. scheduled time. Further review of the entire medical record for Patient #2 revealed no documentation that the above ordered medications were documented in the medical record as being administered to Patient #2 for the 9:00 p.m. scheduled dosages.

In an interview on 06/25/15 at 10:00 a.m., S2DON (Director of Nursing) confirmed she reviewed the entire medical record for Patient #2 and there was no documentation that the medications prescribed for 9:00 p.m. were administered to Patient #2.

Patient #5
Review of Patient #5's medical record revealed Patient #5 was an 86-year-old female admitted to the hospital on 6/19/15 at 2:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Alzheimer's Disease.

Review of Patient #5's Medication Order Sheet, dated 06/19/15 at 3:30 p.m., revealed the following medication order: "Increase to Haldol, 0.25 mg, one, po, TID (scheduled for 9:00 a.m., 1:00 p.m., and 9:00 p.m.). Review of the MAR for 06/21/15 revealed the 1:00 p.m. dose was not documented as given to the patient, and the space on the MAR was blank. Further review of the medical record revealed no documentation regarding why the 1:00 p.m. dosage was not documented as given and why the space on the MAR was blank for the 1:00 p.m. dosage.

In an interview on 06/26/15 at 10:30 a.m., S2DON indicated she reviewed Patient #5's entire medical record, and S2DON confirmed there was no documentation in the medical record indicating the 1:00 p.m. dosage of Haldol was administered to the patient as ordered.


Patient #6
Patient #6 was a 78-year-old female admitted to the hospital on 06/18/15 at 6:15 p.m. from a nursing home. Diagnoses included Major Depression, Recurrent, Severe, Without Psychosis.

Review of Patient #6's Medication Order Sheet dated 06/18/15 at 7:15 p.m. (Admission Orders) revealed, in part, the following medications were ordered: "Donepezil, 10 mg, po, every evening (scheduled for 9:00 p.m.); Mirtazapine, 15 mg, po, every hour of sleep (9:00 p.m.); Meloxicam, 7.5 mg, po, BID (scheduled at 9:00 a.m. and 9:00 p.m.); Gabapentin, 800 mg, po, TID (scheduled for 9:00 a.m., 3:00 p.m., and 9:00 p.m.); Omega-3 Acid, 1 Gram, po, TID (scheduled for 9:00 a.m., 3:00 p.m., and 9:00 p.m.)."

Review of Patient #6's MAR revealed the above-referenced physician orders were not administered at the 9:00 p.m. scheduled time. Further review of the entire medical record for Patient #6 revealed no documentation that the above ordered medications were documented in the medical record as being administered to Patient #6 for the 9:00 p.m. scheduled dosages.

In an interview on 06/26/15 at 10:30 a.m., S2DON indicated she reviewed Patient #6's entire medical record, and S2DON confirmed there was no documentation in the medical record indicating the 9:00 p.m. dosages of the medications ordered were administered to the patient as ordered.

Based on interviews and record reviews the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) The hospital failed to develop policies and procedures that addressed safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital. (see A-0535)

2) The hospital failed to ensure that there was a radiologist who was a member of the medical staff who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital. (see A-0546)

Based on interview and record reviews, the hospital failed to develop policies and procedures that addressed safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:
A review of the contracts provided by S6DirQA Corp (Corporate Director of Quality Assurance) revealed the hospital had a contract with a mobile medical service to provide mobile radiology services for in-patients.

A review of the hospital's Policy and Procedure Manual provided by S6DirQA Corp, as the most current manual, revealed no documented evidence of any policies and procedures related to radiology services that addressed safety precautions against radiation hazards for the safety of staff and patients during radiological procedures performed in the hospital.

In an interview on 06/25/15 at 4:00 p.m. with S6DirQA Corp, she was asked if the hospital had any policies and procedures for safety precautions against radiation hazards for staff and patients when radiologic services were performed on in-patients in the hospital setting. S6DirQA Corp indicated that the hospital's Radiation policies included a policy for the medical protocols to be followed for radiology diagnostics studies when ordered by physicians and a policy that radiology services were provided as needed through a contractual agreement with a mobile radiology service. S6DirQA Corp indicated that the hospital had no other policies and procedures in place that related to radiology services or to the safety precautions against radiation hazards for staff and personnel during radiology procedures.

Based on interview and record reviews the hospital failed to ensure that there was a radiologist who was a member of the medical staff and who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.

Findings:
A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S6DirQA Corp, (Corporate Director of Quality Assurance) as a current list, revealed no documented evidence that a radiologist was identified as the Director of Radiology or the Supervising Radiologist.

A review of the Governing Body meeting minutes revealed no documentation of the appointment of a radiologist as the Director of Radiology or the Supervising Radiologist for the hospital.
A review of the hospital's organizational chart revealed no documentation of a radiologist as the Director of Radiology or the Supervising Radiologist for the hospital.
A review of the contracts provided by S6DirQA Corp revealed the hospital had a contract with a mobile medical company to provide radiology services.

In an interview on 06/25/15 at 4:00 p.m. with S6DirQA Corp, she was asked for documentation of the appointment of a Director of Radiology for the hospital. S6DirQA Corp indicated that the hospital had a contract with a mobile medical company to provide radiology services and that the mobile medical company had radiologists on staff. S6DirQA Corp indicated that the hospital did not have an appointed Director of Radiology services who was a member of the medical staff and who supervised the radiology services for the hospital.

Based on observation and interview, the hospital failed to ensure the dietary manager implemented, maintained, and monitored safe practices for the handling of food for patients.
Findings:
An observation on 06/23/15 at 1:28 p.m. revealed the following contents stored in the patient's refrigerator in the patients' dining room: two plastic gallon jars with a purple-colored liquid; the 2 jars had a hand-written date of 06/20/15. The 2 jars with the purple-colored liquid did not contain a food label on the jars indicating what the liquid was, where it came from, the ingredients contained in the liquid, the nutritional value of the liquid, the name of the vendor and/or supplier of the liquid. Further observation revealed 3 plastic gallon jars with an orange-colored liquid. One of the jars had a hand-written date on them of 06/20/15, and the other two jars containing the orange-colored liquid had no dates written on the containers. The 3 jars of orange-colored liquid did not contain a food label on the jars indicating what the liquid was, where it came from, the ingredients contained in the liquid, the nutritional value of the liquid, the name of the vendor and/or supplier of the liquid.


In an interview on 06/23/15 at 1:28 p.m., S2DON (Director of Nursing) indicated the refrigerator was for patients' food items only. S2DON indicated she believed the liquid in the gallon jars was Kool-Aid which was sent to the hospital from the contracted facility that provided the patients' dietary needs. S2DON confirmed the gallon jars contained no label, and the hand-written date on the jars did not indicate what the date meant. S2DON further confirmed the containers of liquid should have contained the proper labels and dates.

Based on observations, interviews and record reviews the hospital failed to ensure that the dietary service department's staff had demonstrated competencies in their assigned dietary duties. This failed practice was evidenced by no documentation in the employee files for 4 out of 4 MHTs (Mental Health Technician) employee files (S10MHT, S11MHT, S28MHT, S32MHT) reviewed for dietary skills competency. The hospital had a census of 18 patients at the hospital with a total capacity for 20 patients.

Findings:
An observation on 06/23/15 at 4:15 p.m. of S11MHT revealed S11MHT in the hospital's dietary area preparing patient's dinner meal trays. S11MHT was observed monitoring the food temperatures and setting up the warming table for the patient meals.
In an interview on 06/23/15 at 4:15 p.m. with S11MHT, she indicated that a contract service brought the patient food to the hospital for each meal. S11MHT indicated that she was a MHT (mental health technician) and that she was mostly assigned dietary duties. She indicated that she was responsible for monitoring food temperatures, preparing the patient meal trays according to their dietary cards and setting up the warming table for the patient's 3 meals that day. S11MHT indicated that she also worked with the patients as a MHT when she was not performing dietary duties. S11MHT further indicated that all MHTs can be assigned dietary duties.
An observation on 06/24/15 at 11:00 a.m. of S32MHT revealed S32MHT in the hospital's dietary area preparing patient's lunch meal trays. S32MHT was observed monitoring the food temperatures and setting up the warming table for the patient meals.
In an interview on 6/24/15 at 11:00 a.m. with S32MHT, she indicated that a contract service brought the patient food to the hospital for each meal. S32MHT indicated that she was a MHT (mental health technician) and that she was assigned dietary duties when S11MHT was not working or was assigned other MHT duties. She indicated that her dietary duties included: monitoring food temperatures, preparing the patient meal trays according to their dietary cards and setting up the warming table for the patient's 3 meals that day. S32MHT indicated that she worked with the patients as a MHT when she was not performing dietary duties. S32MHT further indicated that all MHTs can be assigned dietary duties.
A review of the employee files on 06/26/15 for 4 out of 4 MHT employee's (S10MHT, S11MHT, S28MHT, S32MHT) files reviewed for a dietary skills competency check list, revealed no documented evidence that they had a skills competency check list for dietary assigned duties in the hospital's dietary department.
In an interview on 06/26/15 at 11:30 a.m. with S5IC/DM/QA (Infection Control Nurse/Dietary Manager/Quality Assurance) she indicated that she was also the Dietary Manager for the hospital. S5IC/DM/QA was asked about the dietary competency skills checklists for the MHTs who were also assigned dietary duties. S5IC/DM/QA indicated that all the MHT were able to be assigned dietary duties and that she checked off all the MHTs for dietary duties; but, she did not document it. S5IC/DM/QA was unable to provide any dietary skills competency documentation for any MHTs

Based on observations, interviews, and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by: 1) failing to have policies in place for glucometer disinfecting; 2) failing to ensure equipment (floor buffer) was cleaned according to acceptable infection control practices; 3) failing to ensure the patients' refrigerator was maintained in a clean manner; and 4) failing to ensure patient care areas (male shower room) was maintained and cleaned according to acceptable infection control practices.

Findings:
1) failing to have policies in place for glucometer disinfecting
A review of the hospital policy titled, "Glucometer Method for Obtaining: Care of Meter and Strips," provided by S5IC/DM/QA (Infection Control Nurse/Dietary Manager/Quality Assurance) as the most current, revealed no documented evidence of instructions for the disinfecting of the multiple-use hand held glucometer after each patient use when the glucometer was used for patient's accu-checks.
A review of the manufacturer's manual for the hospital's glucometer revealed in part: Care for the Meter: Cleaning the Meter- Clean the outside of the meter with a damp cloth and mild soap/detergent. Store the meter in the carrying case when not in use. There was no documentation from the manufacturer on how to disinfect the glucometer between patient use.
On 06/23/15 at 4:00 p.m., an observation was made of S7LPN (Licensed Practical Nurse)performing an accu-check with a multiple patient use hand held glucometer on Patient #7. S7LPN did not disinfect the glucometer after use on Patient #7 before returning the multiple-use hand held glucometer back into its case.
In an interview on 06/24/15 at 2:20 p.m. with S5IC/DM/QA (Infection Control/Dietary Manager/Quality Assurance), she indicated that she was the Infection Control Officer for the hospital. The hospital's policies and procedures on the glucometer care and use was reviewed with S5IC/DM/QA. She indicated that the hospital did not have a specific policy in place for the disinfecting of the glucometer after each patient use. S5IC/DM/QA further indicated that the glucometer should be disinfected after each patient use according to acceptable infection control practices.
2) failing to ensure equipment (floor buffer) was cleaned according to acceptable infection control practices
An observation on 06/23/15 at 2:45 p.m. of S8Hskpr (Housekeeper) buffing the hall floors of the hospital with an electric buffer machine. The buffer machine was observed to be "caked" with dirt and dust over the entire outside of the machine that included the buffer's wheels.
In an interview on 06/23/15 at 3:00 p.m. with S8Hskpr, she indicated that she was hired as a housekeeper whose main job was to buff the floors in the hospital. S8Hskpr was asked about the cleaning of the floor buffer machine when it got dirty. S8Hskpr indicated that she did not know who was supposed to clean the floor buffer machine. S8Hskpr further indicated that she was not oriented on the cleaning of the buffer machine.
In an interview on 06/26/15 at 11:30 a.m. with S5IC/DM/QA, she was made aware of the hospital's floor buffer that was observed to be "caked" with dirt and dust over the entire outside of the machine that included the buffer's wheels. S5IC/DM/QA was asked for the cleaning schedule of the hospital's floor buffer machine. S5IC/DM/QA indicated that she was not aware of a cleaning schedule for the hospital's floor buffer and to talk to S16EOC (Environment of Care) Director.
In an interview on 06/26/15 at 12:50 p.m. with S16EOC, he indicated that he was the Director of Environmental Services. S16EOC was made aware of the hospital's floor buffer machine that was observed to be "caked" with dirt and dust over the entire outside of the machine that included the buffer's wheels. S16EOC indicated that the hospital's floor buffer machine did not have a cleaning schedule in place and that the hospital's floor buffer should be routinely cleaned on a regular schedule to prevent it from getting "caked" with dirt and dust.
3) failing to ensure the patients' refrigerator was maintained in a clean manner
An observation on 06/23/15 at 1:15 p.m. in the patients' dining room revealed a refrigerator which was designated as the patients' refrigerator by S2DON (Director of Nursing). The patients' refrigerator was observed to contain dried food and drink residue on the outer surface of the refrigerator door and inside the refrigerator on the shelves.
In an interview on 06/23/15 at 1:28 p.m., S2DON indicated the refrigerator was for patients' food items only. S2DON confirmed the outer surface of the refrigerator door and the shelves on the inside were dirty and contained dried food and liquid residue and should not have been dirty.
4) failing to ensure patient care areas (male shower room) were maintained and cleaned according to acceptable infection control practices
An observation in the male shower room on 06/23/15 at 1:45 p.m. revealed the following:
a) surfaces of the patient belongings metal locker-type cabinets contained a thick brownish-black, sticky substance; b) a laundry bag stand that was soiled on top with a dried light yellow-colored substance; c) the surface of a small cabinet (which held clean patient towels on top of the cabinet) contained dried stains of various colors; d) a folding chair that was soiled.

In an interview on 06/23/15 at 2:00 p.m., S2DON confirmed the patients' belongings lockers, the laundry bag stand, the small cabinet surface, and the folding chair were dirty and soiled, and should not have been dirty and soiled.





31048

Based on record review and interview, the hospital failed to ensure the appointed recreational therapist was qualified by certification and/or licensure as a recreational/activity therapist.

Review of the comprehensive employee list, presented as current, revealed no identified recreational therapist.

In an interview on 06/26/15 at 11:00 a.m., S6Dir QA Corp (Corporate Director of Quality Assurance) indicated S10MHT (Mental Health Technician) was the appointed recreational therapist for the hospital.

A review of the employee file for S10MHT revealed a bachelor's degree in art, and a bachelor's degree in psychology, but did not contain certification and/or licensure as a recreational/activity therapist.

In an interview on 06/26/15 at 1:30 p.m., S6Dir QA indicated S10MHT (Mental Health Technician) was waiting to take the certification course for recreational/activities therapist in July, but S10MHT had not yet completed the certification course.