HospitalInspections.org

Based on a review of records for 12 patients, it was determined that 10 patients, #1-7, #9, #11, and #12 had orders for locked bedroom doors resulting in the hospital failure to allow bedroom access and rest during daytime non-treatment hours.

Review of records for patients #1-7, #9, #11 and #12 revealed that each patient had an order for a locked bedroom door between variously documented hours. For instance, patient #1's bedroom was to be locked from 0800 to 1500, whereas, patient #4's bedroom was to be locked from 0730-1300. Multiple rationales were given for these orders inclusive of participation in treatment, normalizing circadian rhythm, and in the prevention of contraband. Consequent to these orders was the fact that during daytime non-treatment hours, patients were not allowed to rest in their rooms as could other patients without such orders.

Therefore, following group and activity times or after lunch when other patients without locked door orders could rest in their rooms, patients with locked door orders could not. For instance, due to a locked bedroom door, patient #1 was compelled to be out on the unit for at least 7 hours without a break.

Interdisciplinary Treatment Plans revealed an incorporated out-of-bed element. Additionally, patient #2 had a Behavioral Plan which incorporated a locked bedroom door until 1430.

In summary, while the hospital had the authority to lock bedroom doors during treatment hours, the hospital failed to provide a rest period for at least 10 patients during non-treatment hours. This policy failed to support the patients' rights to particpate in, or refuse to participate in treatment.

Based on a review of restraints for patient #2, it was determined that staff applied an intellectual criterion to a behavioral goal for termination of seclusion.

Patient #2 was an adult, admitted to the psychiatric hospital via court order. In June 2018, patient #2 became aggressive and threatening towards staff and peers. Patient #2 was placed into seclusion with a criteria of "Commit to safety" for release from seclusion. Based on this, the hospital applied an intellectual criterion to a behavioral goal which required more from patient #2 than the discontinuance of the combative, threatening behaviors. While discussion with patient #2 could include a commitment to safety, termination of the intervention was dependent only upon the criterion of ceasing the violent threatening behaviors.

Based on interviews and a review of staff restraint training, it was revealed that restraint training included a manual hold ending in prone positioning which was known to have a high risk of injury including positional asphyxia.

Review of hospital restraint training revealed multiple methods of manual restraint inclusive of a provision for intentionally placing a patient in a prone position. Review of training revealed illustrations of the "Forward Lowering Technique" demonstrated staff lowering a patient to the floor in a prone position. Interview with training staff on 6/27/2018 at approximately 1000 revealed that if a patient was placed in a prone position, staff were taught to immediately roll a patient into a supine position.

Prone positioning had been demonstrated to be an inherently dangerous restraint practice with a high incidence of asphyxia, injury, and death. While struggles with patients in a health care setting may unintentionally result in prone positioning, instruction to intentionally place a patient in prone positioning is an unsafe, non-standard form of manual restraint.

In summary, hospital staff failed to demonstrate safe restraint training when it trained staff in prone positioning.

Based on findings under Life Safety Code survey ID 61BF21, it was determined that the hospital is out of compliance with the condition of physical environment. See tag A-701 and attached LSC survey.

Based on observations, 1) florescent light fixtures throughout the hospital unit bedrooms and bathrooms were accessible to patients, and represented a sharps and ligature risk 2) while conducting food service tour, it was determined that the facility failed to ensure that the kitchen area was constructed and maintained in a manner that ensures a sanitary environment.

Upon unit tours of June 26, 2018, it was noted that each bedroom had square florescent lighting fixtures which extended below the ceiling level, and which could be easily accessed, and damaged to allow further access to glass for harm to self or other. One example was of patient #1 who had recently broken the light in patient #1's bedroom and was suspected of wanting to create an improvised weapon from the broken parts.

Further, each bathroom had florescent tube lighting, also within easy access to patients. It is not known if the florescent light fixtures could have held the weight of a patient, but could have been used as a point by which to attach a ligature, further increasing potential risks to patients.

On June 26, 2018, the surveyors, accompanied by the COO (Chief Operating Officer), toured the facility main kitchen at 10:15 AM. The following observations were made:

1) The steamer was installed so that it extended past the edge of the hood. Cooking equipment must be installed under the hood with sufficient over overhang to ensure that steam and grease laden vapors are captured and not allowed to disperse through the kitchen.
2) The ceiling tiles in the kitchen were unsmooth and unable to be cleaned. Interview of the COO revealed that the tiles were periodically replaced.
3) Holes were observed in the walls where plumbing waste pipes were installed for the hand sink by the slicer and the garbage disposal. The escutcheon plate for the garbage disposal waste pipe was not flush with the wall or adequately attached. Perforations in walls must be sealed to ensure ease of cleaning and to prevent pests from entering the wall for nesting.
4) The gasket of the walk-in freezer did not fit properly, allowing warm air from the kitchen to enter the freezer. There was an ice buildup on the door jam and floor of the entrance to the walk-in freezer.
5) The pressure gauge for the dishwasher read five (5) PSI (pounds per square inch) and did not move during operation of the dishwasher. The pressure required for adequate sanitization of dishes is 15 to 15 PSI for the final sanitizing rinse.
6) In the walk-in freezer, meats that were cooked and cooled were observed in the walk-in freezer, including seven meat loaves, one turkey breast and one roast pork. These items were greater than three inches thick and wrapped in aluminum foil. When the surveyor inquired about cooling methods, the HACCP (food safety) plan was reviewed with the dietary manager. The HACCP plan did not have a description of approved cooling methods. Generally, leftover foods should be cooled uncovered at a depth or thickness of three inches or less.
7) In cottage 2, adjacent to the food dry storage area, the gasket that sealed the bottom of the loading dock door was pulled loose. When the dietary manager put it back on the door, there was still a four inch gap at the bottom of the door. This door must be sealed to prevent pests from entering the building.