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Based on observation, document review, and interview the Governing Body failed to:

A. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

a. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

b. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that the following COP posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychological services at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Refer to tag A0144 for additional information.

B. ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.

Refer to tag A0168 for additional information.


C. ensure sufficient numbers of nursing staff on 3 of 3 units (Step-down unit, Intensive care unit (ICU), and Telemetry/Medical-Surgical unit).

Refer to tag A0392 for additional information.


D. ensure one nurse, who was currently assigned to patient care, had current competencies in 1 of 2 personnel files reviewed for the step down unit (staff #25).

Refer to tag A0397 for additional information.


E. ensure open dates were logged on medications that were currently in use for patients. The medications that were not dated were antibiotics, eye drops, treatment ointment, and nasal sprays.

Refer to tag A0405 for additional information.


F. ensure 1 of 37 sampled patients received blood transfusions as ordered and they failed to ensure there were complete physician orders for blood transfusions (Patient #21). Patient #21 had lab results which revealed his congestive heart failure was severe.

Refer to tag A0409 for additional information.


G. provide a sanitary environment and have an active program for preventing infections. This deficient practice was found in twelve of the hospital departments (Dialysis, Labor and Delivery, Radiology, Laboratory, Outpatient Laboratory, Outpatient Radiology, Step Down Unit, Intensive Care (ICU), Respiratory, Emergency Department (ED), Medical/Telemetry Unit and Dietary.) The facility failed to:


a. ensure the dialysis department maintained infectious free equipment for the R/O machines.

b. ensure the labor and delivery department maintained a sanitary environment for their L&D rooms, equipment, and the operating rooms where C-Sections were performed. Also, the storage areas in the C-Section area were unkept and disorganized.

c. ensure the radiology department stored Transvaginal probes and Transesophogeal probes per the manufacture guidelines.

d. ensure the laboratory department stored equipment, supplies, and specimens in a sanitary manner that prevented potential contamination.

e. ensure the outpatient laboratory maintained a sanitary environment and stored patient consumable items in a manner that prevented potential contamination.

f. ensure the outpatient radiology department Computed Tomography Scan (CT Scan) storage room was maintained in good repair and sanitary. The room was found to have holes in the wall dead bugs in the light fixtures.




g. ensure hinged surgical equipment was sterilized in an open position, peel packets of sterilized equipment was dated, and expired sterilized equipment was discarded in the Stepdown unit, Intensive care unit and Emergency department.

h. ensure proper handwashing was performed before and after direct patient care on the Medical-Surgical unit.

i. ensure respiratory supplies were properly enclosed to prevent contamination, supplies were sanitized prior to usage, storage bins were kept clean, soiled equipment was discarded, and the flooring in the supply room was kept clean in the Respiratory department.

j. ensure proper infection control techniques were used in the kitchen. The facility failed to ensure dishes and pans were stored on clean surfaces, dishes in high traffic areas were covered, dishes and pans were properly cleaned before storage, ovens/fryers and refrigerators were cleaned, food was removed from cardboard boxes prior to entrance into food storage areas and refrigerators, staff handling hazardous food used proper infection control techniques, food transport carts were kept clean and repaired, plastic bags of juice and soda were protected from cross contamination, dented cans of food were discarded properly, and proper handwashing was performed during tray preparation and passing of trays to patients.

Refer to tag A 0749 for additional information.


H. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as weapons and as ligatures for hanging or strangulation.

a. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

b. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that the deficient practice posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychiatric services at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Refer to tag A1101 for additional information.

Based on observation, interview, and record review, the facility failed to :


A. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

Patient #37 took approximately 75 tablets of 325 mg Aspirin trying to kill herself prior to presenting to the Emergency Department (ED). Patient #37 was placed in a room which had ligature hazards.

B. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

C. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that the following COP posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychological services at risk for the likelihood of harm, serious injury, and possibly subsequently death.



Refer to tag A0144 for additional information.



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D. ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.

Refer to tag A0168 for additional information.

Based on observation, interview, and record review, the facility failed to :

A. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

Patient #37 took approximately 75 tablets of 325 mg Aspirin trying to kill herself prior to presenting to the Emergency Department (ED). Patient #37 was placed in a room which had ligature hazards.

B. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

C. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that this deficiency posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychological services at risk for the likelihood of harm, serious injury, and possibly subsequently death.



Findings include:



During an observation of the Emergency department (ED) on 12/07/2017 after 10:00 a.m., the following was found:


Room #3 was identified as the room used for psych patients by Staff #43. The room did not have a hardened ceiling. The ceiling was a drop down ceiling with ceiling tiles within a metal frame. When the ceiling tiles were pulled back there was wiring, metal bars, and flexible metal conduits that could be used as weapons and as ligatures for hanging or strangulation. There was a water sprinkler and an air vent in the ceiling that posed a ligature risk.

Staff #43 confirmed knowing about the hazards.




Review of the ED record on Patient #31 revealed she was a 59 year old female who presented on 12/02/2017 at 7:33 a.m.. Patient #31 presented with suicidal ideation's and was placed in Room #3.

At 7:35 a.m., Patent #31 stated "I am hearing voices and I am suicidal, and I'm having marriage problems,.." Patient #31 was given an acuity level of 2 (meaning urgent).

At 7:40 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Do you feel hopeless or helpless? Yes
Have you had thoughts of suicide in the past? Yes
Are you having thoughts of suicide now? Yes
Have you previously attempted suicide? Yes
Do you have a plan to hurt yourself or someone else? Yes

Patient #31 was assigned a suicide risk level of 2 (meaning high risk). The type of supervision assigned was for continuous visual surveillance. There was documentation that observation should be performed at all times by designated staff with direct line of sight. "..Remove and secure personal items. Patient is placed in a hospital gown."

At 8:20 a.m. there was documentation that the police department was there to see Patient #31.

At 9:00 a.m., there was documentation that the behavioral center was there to evaluate Patient #31.

At 2:18 p.m., (almost 7 hours later) Patient #31 left the ED (transferred out to a higher level of care).

There was no documentation of who was monitoring Patient #31 and how often.

There was also no documentation of a physician's order addressing the level of supervision Patient #31 was to be placed on.

Staff #43 confirmed the problems with the monitoring and there be no documentation of who was monitoring Patient #31. Staff #43 reported the gown placed on Patient #31 would have been a paper gown.



Review of the ED record of Patient #34 revealed he was a 5 year old male who presented on 11/08/2017 at 8:30 p.m., with complaints of suicidal ideation and behavior disorders.

Review of nursing documentation at 8:52 p.m., revealed Patient #34 was assigned an acuity level of 1 (meaning emergent).

At 9:04 p.m., Patient #34 was assigned a suicide risk level of 1 (meaning immediate high risk with continuous visual surveillance (line of sight) and 1:1 observation). There was documentation by nursing that the mother and father was at the bedside.

At 11:12 p.m., discharge orders were given for Patient #34 to be discharged home with his family. Patient #34 was to be seen in the a.m. by the behavioral center.

At 11:13 p.m., Patient #34 left the ED.

Review of the ED record revealed no documentation of the monitoring to indicate the mother and father remained at the bedside.

There was also no documentation of a physician's order addressing the level of supervision Patient #34 was to be placed on.




Review of the ED record on Patient #35 revealed she was a 58 year old female who presented on 11/04/2017 at 2:51 a.m... Patient #35 presented with complaints of suicide ideation's and hallucinations and was placed in Room #3.

At 2:54 a.m., Patient #35 was assessed as having an acuity level of 1 (meaning emergent). There was documentation that Patient #35 was hearing voices and they were telling her to hurt herself and family members.

At 3:00 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Thought of suicide in the past? Yes
Thought of suicide now? Yes
Do you have a plan to hurt yourself or someone else? Yes

At 3:27 a.m., Patient #35 was assigned a suicide risk level of 3 (meaning moderate risk).



According to the facility's policy dated 05/26/2015 and named "ER-Suicide Risk Assessment and Interventions in Acute Care Setting" the following was documented:

"Moderate Risk Patients (Level 3):
Possible danger to self or others. Observed restless or impulsive behavior, intrusive or disordered, confused/withdrawn, dazed or anxious, ambivalent about treatment. Not likely to wait for treatment. History of suicide attempt without current ideation or plan; presence of mood disturbance; symptoms of depression and/or anxiety (socially withdrawn, acute change in previously enjoyed activities), elevated or irritable mood, angry.
o LEVEL OF SUPERVISION: Close observation.
o If patient subsequently elopes from the patient care unit and returns, then increase level of observation."


According to the facility's policy this was the definition for close observation:

"..C. Close observation: Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals of at least every 15 minutes. Supportive family/friend must receive education from staff and agree to communicate with staff and seek staff assistance for any concerns..."


Patient #35 had current suicide ideation and a plan. The facility inaccurately assessed Patient #35's supervision level and plan.

According to the ED record Patient #35 was placed on observations by staff at an every 15 minute interval.

According to the ED notes Patient #35 was discharged to a higher level of care at 8:36 a.m. (over 5 hours after presenting).

There was no documentation of the every 15 minutes observation on the record nor 1:1 observation during this timeframe.

There was also no documentation of a physician's order addressing the level of supervision Patient #35 was to be placed on.

Staff #43 confirmed the problems with the assessment and monitoring.





Review of the ED record of Patient #37 revealed she was a 17 year old female who presented to the ED on 10/30/2017 at 8:58 p.m.. Patient #37 presented for poisoning by aspirin, intentional self-harm and suicidal ideations.

Review of nursing documentation at 8:59 p.m., revealed Patient #37 "took aprox 75 tablets of 325 mg asa at about 1930 to kill herself and the baby she may be carrying." Patient # 37 was accompanied by her mother according to documentation.

Patient #37 was assessed as having an acuity level of 2 (meaning urgent).


At 9:01 p.m., the Suicide Risk Assessment revealed some of the following questions were asked:


Do you feel hopeless or helpless? Yes
Have you had thoughts of suicide in the past? Yes
Are you having thoughts of suicide now? Yes
Have you previously attempted suicide? No
Do you have a plan to hurt yourself or someone else? Yes

Patient #37 was assigned a suicide risk level of 2 (meaning high risk). The type of supervision assigned was for continuous visual surveillance. There was documentation that observation should be performed at all times by designated staff with direct line of sight. Remove and secure personal items. Patient was placed in a hospital gown.

At 10:00 p.m., nursing documented that Patient #37 was "laughing and joking with mom before mom left ..."

At 10:58 p.m., Patient #37 supervision was elevated to a suicide risk level of 1 (meaning immediate high risk with continuous visual surveillance (line of sight) and 1:1 observation).


According to nursing documentation at 10:58 p.m., Patient #37 "belongings collected and placed in blue scrubs, room must keep monitor in place per md orders and poison control recommendation for continuous monitoring, patient within view of desk."

Review of facility's monitoring form revealed Patient #37 was being monitored every 15 minutes from 9:00 p.m. - 11:30 p.m. There was no other documentation of the continuous monitoring from 11:30 p.m. - 3:35 a.m.

Review of nursing documentation at 3:35 a.m., Patient #35 came off the higher level of psych (monitoring) at this time.

Staff #43 confirmed Patient #35 came off of psych monitoring at 3:35 a.m., and he could not find any documentation of monitoring after 11:30 p.m...

During an interview on 12/07/2017 after 12:30 p.m., Staff #47 reported that their protocol for suicidal patients was to strip them of everything and place them in paper scrubs. They would call the behavioral center to evaluate the patient and try to find placement. The 1:1 supervision was supposed to be the nurse or police department. When the patients are on close observation the door to their room is left open where the patient can be seen. Staff #47 reported she would probably have other patients to take care of also. The staff were supposed to document in the chart every 15 minutes on the patients when they were being monitored.






Review of a facility's policy dated 05/26/2015 and named "ER-Suicide Risk Assessment and Interventions in Acute Care Setting" revealed the following:


"All patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will receive an initial assessment to determine suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients from inflicting harm to self or others.

PURPOSE:
To identify patients at risk for suicide and provide safety interventions (applicable to all patients in organizations surveyed under the Behavioral Health Care standards, all patients in psychiatric hospitals, and to any patient in a general hospital with a primary diagnosis or complaint of an emotional or behavioral disorder, including those related to substance abuse) .....


Levels of Supervision

A. Continuous visual surveillance - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately, De-escalation techniques will be used as appropriate.

B. Continuous visual surveillance. Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight to patient. If de-escalation techniques are ineffective, patient will be escalated to Acuity 1.

C. Close observation: Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals of at least every 15 minutes. Supportive family/friend must receive education from staff and agree to communicate with staff and seek staff assistance for any concerns.

D. Intermittent observation: Observation at a minimum of 30-minute intervals by clinical staff.

E. General observation: Routine check by clinical staff at a minimum of one-hour intervals.

PROCEDURE:

A. Trigger Questions:

A licensed healthcare professional will screen for suicide risk by identifying those patients with a primary diagnosis or primary complaint of an emotional or behavioral disorder including substance abuse, or by identifying those patients at risk based on objective or subjective symptoms (even if not a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse).

1) If a licensed healthcare professional suspects a patient presentation may be the result of self harm (i.e., sole victim of unwitnessed trauma, new terminal diagnosis, family report, etc.), the following trigger questions at the top of the Suicide Risk/Behavioral Disorder Assessment will be asked of the patient (if screening all ED patients, may utilize the first three questions):
a. Do you feel hopeless or helpless?
b. Have you had thoughts of suicide?
c. Are you having any now?
d. Have you previously attempted suicide?
e. Do you have a plan to hurt yourself or others?
2) If patient is not presenting with primary complaint of emotional or behavioral disorder or
substance abuse, and answers "NO" to all questions, sign, date and time bottom of form.
3) If patient answers "yes" to any of the initial questions, complete the Suicidal Risk/Behavioral Disorder Assessment.

B. A Registered Nurse (RN) will assess the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse or displaying symptoms of an emotional or behavioral disorder utilizing the Suicide Risk/Behavioral Disorder Assessment.
1. Ask trigger questions at top of Suicide Risk/Behavioral Disorder Assessment and document patient answers.
2. Complete the Suicide Risk/Behavioral Disorder Assessment even if the patient answers "No" to the trigger questions.
3. Select the indicators in the columns titled "Observed" and/or "Reported" which most closely apply to the patient's situation or behavior.
4. Then identify the appropriate acuity in the first column that correlates with the HIGHEST level of observed or reported factors.
a. From highest acuity (Acuity 1) to lowest-acuity (Acuity 5)
5. Selection of the applicable acuity box identifies the interventions that are being implemented.
6. Substance abuse and/or intoxication can co-exist with other behavioral or emotional disorders. Consider observed and reported factors and assign highest level of acuity. Note: Behavior can change over time as substance/alcohol is metabolized. Be aware of the potential for risk of DTs in the presence of chronic alcohol abuse and respond to change in behavior as appropriate.
7. Physician is to sign Suicide Risk/Behavioral Disorder Assessment, note date and time, and select either reviewed, no added orders, or reviewed, see added orders.
a, Additional orders are to be documented as MD order.
8. Behavioral health clinician, psych evaluator, on-coming nurse during change of shift, etc. will sign as "other", and note date and time of review.
9. The Frequent Observation Flow Sheet is to be utilized for documentation for all patients on whom a Suicide Risk/Behavioral Disorder Assessment is completed.
a. Use form even if observation is less than every 15 minutes.
b. Check box at top of form to indicate level of observation implemented.
C. Physician orders for the level of suicide precautions will be initiated immediately. Suicide precautions can be initiated by nursing staff, in the absence of a physician, with documented reasons based upon the Suicide Risk/Behavioral Disorder Assessment screening tool and nursing assessment. This information shall be recorded in the medical record, and the patient's physician shall be notified as soon as possible to obtain an order for the level of suicide precautions ....
D. Any patient with an identified suicide risk will be referred to a mental health or behavioral health professional for assessment and treatment planning and provided community resources if discharged.
E. The level of suicide risk and need for suicide precautions must be reassessed by the qualified medical provider or Registered Nurse if there is an observed or stated change in behavior, and at least every 24 hours. Notify the physician if the assessment changes the level of precautions indicated. Only the physician can order the discontinuation or change in suicide precautions. The physician must document current clinical status and rationale for continuing, modifying, or discontinuing precautions.
F. General Safety Interventions to keep patient safe from harm to self or others:
o Referral by physician order to obtain psychiatric/behavioral health consult.
o Clinical status and patient safety documented every 15 minutes for acuity 1, 2 and 3 patients.
o Ensure a safe environment:
o Complete Psych-Safe Room Check List
o Remove all needles, sharps and sharps containers from patient's room
o Inventory and secure patient personal items and remove potentially harmful items from the room.
o Diet is ordered with plastic ware and non-breakable dishes. No silverware or
aluminum cans.
o Remove hanging hazards such as rope blinds, call cords, curtains, shower curtains in room and clothing items such as belts, ties, head band or bandanas, shoelaces. May replace patient clothing with paper gown, hospital gown and/or pajamas.
o Search belongings brought in by visitors for any harmful items.
o Staff to stay with patient during medication administration to ensure patient has
taken medication.
o Identify and remove or replace with breakaway hardware in bathing facilities and
observation during shower/bath, if available; otherwise maintain visual surveillance and/or utilize bedside commode. Remove bedside commode from room after each use.
o Every shift, room searches will be conducted for potentially harmful items, utilizing
Psych-Safe Room Check List. Items brought in by visitors will be searched prior to
being given to patient; i.e. Flowers, fruit baskets, books, magazines, clothing, etc ....




G. Interventions Relative to Level of Suicide Risk:

Immediate Risk Patients (Level 1):
Severe behavioral disorder with immediate threat of dangerous violence. As evidenced by observed violent behavior, possession of a weapon, self-destructive acts or behavior that resulted in self-harm; reported verbal commands to do harm to self or others that the person is unable to resist (command hallucinations), recent violent behavior, reported violent/self-destructive behavior or behavior that has resulted in harm to self or others, including actual suicide attempt..
o LEVEL OF SUPERVISION: Continuous visual surveillance (line of sight) with 1:1 observation.
o Continuous 1:1 Direct Observation at all times including when transported from unit for transfers, imaging, and surgery. Observation will be documented including name and title of person observing, time of observation, and name and title of periodic relief person (i.e. attachment B).
o "General Safety Interventions"

High-Risk Patients (Level 2):
Probable risk of danger to self or others. As evidenced by observed extreme agitation/restlessness, physically/verbally aggressive, uncooperative, hallucinations/delusions/paranoia, distorted perception of reality. May or has required restraint/seclusion. Words or behavior reflect high risk of elopement (pacing, hovering near doorway). Signs of depression (activities of daily living impacted). Reported threat to harm self or others, suicidal ideation with or without a plan; acute drug or alcohol intoxication with history of suicide attempt or ideation, psychotic symptoms (hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior, or overwhelming symptoms of depression. If unable to de-escalate may require restraint or seclusion. High risk for eloping and not waiting for treatment.
o LEVEL OF SUPERVISION: Continuous visual surveillance.
o Continuous visual supervision when transported from unit for transfers, imaging, and surgery. Observation will be documented including name and title of person observing, time of observation, and name and title of periodic relief person.
o "General Safety Interventions"

Moderate Risk Patients (Level 3):
Possible danger to self or others. Observed restless or impulsive behavior, intrusive or disordered, confused/withdrawn, dazed or anxious, ambivalent about treatment. Not likely to wait for treatment. History of suicide attempt without current ideation or plan; presence of mood disturbance; symptoms of depression and/or anxiety (socially withdrawn, acute change in previously enjoyed activities), elevated or irritable mood, angry.
o LEVEL OF SUPERVISION: Close observation.
o If patient subsequently elopes from the patient care unit and returns, then increase level of observation.
o "General Safety Interventions"

Low Risk Patients (Level 4 and 5):
Level 4: Mild distress. Irritable, tense and/or sad, but cooperative. Patient in waiting. Reliable historian. Acute drug or alcohol intoxication with no history of suicide attempt or current ideation. Preexisting mental health disorder. Mild anxiety or depression (tense, jumpy, sad or unhappy). Willing to wait.
Known patient with chronic psychosis
o LEVEL OF SUPERVISION: Intermittent observation.
Level 5: No acute distress or behavioral disturbance. Communicative and engaged in developing plan of care. Willing to discuss concerns. Compliant with instructions. Pre-existing mental health disorder. Known patient with chronic unexplained somatic symptoms. Requesting medications. Financial, social, accommodation or relationship problems. History of drug or alcohol abuse.."

Based on review of records and interview, the hospital failed to ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.

Review of Patient #24's chart and restraint log revealed the following:

On 10-31-2017 at 3:25 pm, nursing staff received a telephone order to apply soft wrist restraints, soft ankle restraints, and place all 4 bed side rails in the up position. These were ordered to prevent patient from removing medical devices. No order for a vest restraint was found.

On 11-1-2017, nursing documentation states that the patient was in a vest restraint at 6:00 am and again at 8:00 am. The restraint log for 11-1-2017 was not completed and did not indicate the type of restraint used for the patient.

A telephone interview was conducted with Staff #31 on the afternoon of 12-6-2017. Staff #31 confirmed that a vest restraint was on the patient when she conducted her morning assessment. Staff #31 stated she removed the vest sometime after 9:00 am because it had become soiled. Staff #31 stated the vest was not needed so she did not replace it.


Review of Patient #27's chart revealed the following:

Per the Nursing restraint initiation documentation, restraints were initiated on 7-19-2017 at 2:30 pm to prevent the patient from interfering with medical care, devices, tubes, or drains. The record documents the type of restraint as a vest restraint.

No restraint orders were found.




Review of Patient #29's chart and restraint log revealed the following:

A physician order for a vest restraint was written and signed on 5-14-2017. The physician did not time the order. Nursing staff did not document with signature, date, and time that the order had been noted.

Per nursing notes, soft wrist restraints had been discontinued on 5-14-2017 at 10:00 am.

Patient Assessment Report, Nursing - Restraint Initiation indicated the soft wrist restraints were initiated again on 5-14-2017 at 5:38 pm. No order for the initiation of wrist restraints was found.

Patient Assessment Report, Nursing - Restraint Monitor, Non Violent, indicated the staff were monitoring a restraint vest that had been applied on 5-12-2017 at 11:00. No order for a vest restraint was found for that time.

The restraint log for 5-14-2017 showed the wrist restraints discontinued, but did not show them re-initiated. The log indicated the vest restraint had been initiated at 5:00 pm on 5-14-2017.

Review of the Restraint and Seclusion Policy, PolicyStat ID: 3703693, Last Revised: 11/2016, was as follows:

Page 10 of 18, Item E. iii. "Orders for restraints may never been written as standing orders or PRN orders. Each episode of restraint or seclusion must be initiated in accordance with an order by a physician or other LIP. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required. Staff can not discontinue restraint or seclusion as a trial and then re-start it under the same order." (sic)

Based on document review and interview the facility failed to establish a clear expectation for safety. The facility failed to

A. develop a system that ensured the hospital was a clean and sanitary environment for thirteen of the hospital departments (Dialysis, Labor and Delivery, Radiology, Laboratory, Outpatient Laboratory, Outpatient Radiology, Step Down Unit, Intensive Care (ICU), Respiratory, Emergency Department (ED), Medical/Telemetry Unit and Dietary, Ambulatory Surgery Center.) Also, the facility failed to follow their own policy for cleaning equipment.

B. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

a. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

b. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

C. ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.

Refer to tag A286

Based on document review and interview the facility failed to establish a clear expectation for safety. The facility failed to

A. develop a system that ensured the hospital was a clean and sanitary environment for thirteen of the hospital departments (Dialysis, Labor and Delivery, Radiology, Laboratory, Outpatient Laboratory, Outpatient Radiology, Step Down Unit, Intensive Care (ICU), Respiratory, Emergency Department (ED), Medical/Telemetry Unit and Dietary, Ambulatory Surgery Center.) Also, the facility failed to follow their own policy for cleaning equipment.

B. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

a. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

b. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

C. ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.



Findings include:


A. Dialysis Department:

During a tour on 12/04/17 at 1:00 PM of the Dialysis storage room where the portable R/O (reverse osmosis) machines were stored observed the following infection control issues with Staff #5.

This deficient practice of allowing moisture to remain in the connection tubing for a month had the likelihood to promote microbial growth and mold.

There was a connection tubing coiled and connected end to end hanging on the rail of the R/O machine. Also, observed fluid in the connection tubing. The connection tubing was observed on 2 different R/O machines.

On the back of one of the R/O machine (#81683) observed a wet soaked towel with brown stains that were visible.

An interview with Dialysis Contract Staff #6 revealed that that R/O machine (#81683) had been leaking water and it had not been reported to Bio-medical Technician. Further interview with Staff #6 revealed the connection tubing on the back of the machines was used to drain the machines if the machine tubing could not reach a sink for drainage. Staff #6 was asked when do you change the tubing. Staff #6 stated, "once a month."


An interview with Staff #5 on 12/04/17 at 1:30 PM confirmed the above findings.


Labor and Delivery Department/C-Section Area:

During a tour on 12/05/17 between 9:00 AM and 10:30 AM of the Labor and Delivery area (L&D) observed the following infection control issues with Staff #1 and Staff #11.



During the tour, observed a storage room in #5 labor and delivery room that was cluttered with clean and dirty equipment. The room was in disarray. There was a dirty cloth lying on the floor of the room. Observed vital sign machines, portable light poles, shower chairs, and portable bedside commode chair with a bucket in the seat of the chair. Some of the equipment had plastic bags over them indicating the equipment was clean, but other pieces of equipment had nothing covering the equipment. It was noted that the commode chair had no tape across the lid to indicate it was clean per the facility policy.

During the tour observed a storage room in #6 labor and delivery room, there was a used foam mattress with a sheet covering it on the floor of the storage room. Also there were 2 cardboard boxes of boot covers lying on the floor. There was piece of equipment (portable light Pole) and some type of metal rack leaned against the wall. There was no indication if the equipment was clean or dirty. There were dust and dirt particles observed on the floor.

There was a room off the main hallway of the Labor and Delivery area which had an open ceiling exposing the electrical panel, fire panel, and water piping. That room is where the Ultrasound machine was stored. The room was not designed to store clean equipment for patient care.

Upon entrance to L&D #5 and #7 observed an extra bed in the doorway of each room, the beds were not covered with sheets. There was no indication if the beds were clean or dirty. These beds were sitting in the clean labor and delivery rooms.

In L&D #7 observed a white substance on the front of the cabinet door. Surveyor took a wet paper towel and was able to wipe the white substance off the cabinet. The room was set up and noted clean to receive a patient in labor. The doors were missing on part of the cabinet, and exposed electrical wires and outlets were observed. Also, observed raw exposed wood framing inside the cabinet where the monitor was sitting. Unpainted or unsealed wood cannot be cleaned from contaminated infectious waste.

The cart in the triage room was covered in dust and dirt particles.

A review of the policy titled, "Cleaning of Medical Equipment to prevent the spread of infection" revealed the following:

"References and Citations:
Purpose:
The purpose of this policy is to establish guidelines for relevant cleaning measures for the control and prevention of infection in the hospital.
The physical or chemical method used to remove or reduce the capacity of microorganisms, which produce disease, does not kill spores so it cannot be called sterilization. Patient care items and reusable equipment can be disinfected by chemicals and are safe for reuse. Uses of these chemical processes have limitations and chemicals should be used only as directed.

This policy will discuss the following equipment:
Durable Equipment Cleaning
Laryngoscope handles
Wireless Phones
Workstations On Wheels (WOWS)
Cleaning of Computers
Terminal Cleaning of equipment in Women's Services
Patient-Owned Equipment Policy

Durable Equipment Cleaning

lt is the responsibility of nursing staff to clean the following reusable patient care equipment such as/but not restricted to: blood pressure machines, telemetry boxes, glucometers etc.

All items to be disinfected must he clean. (Organic soil such as blood, feces and tissue must be removed) IV pumps glucometers, telemetry boxes, will be wiped down with the hospital approved disinfectant (i.e. Sani cloth) daily and cleaned every time after each patient use.

After IV pumps are cleaned, a plastic bag will be placed over the pump to indicate that the machine has been cleaned and is ready for patient use. Nursing staff will know that the pump is soiled and not ready for use unless the plastic bag is in place. As a safeguard, the nurse will wipe down any uncovered pump before putting pump into use on patient.

Sani-Cloth Germicidal Disposable Cloths are to be used for disinfecting reusable equipment.

Bedside commodes and IV pumps will be cleaned by housekeeping department. A paper tape will be placed over the commode lid to indicate that the toilet has been cleaned and is ready for patient use. Nursing staff will know that the toilet is soiled and not ready for use unless the paper tape is in place. A plastic garbage bag will be placed over the IV pump after it is cleaned. Staff will use this as an indication the IV pump has been cleaned and is ready for patient use."



C-Section Area: This area had 2 operating rooms for C-sections and this area was labeled "Operating room attire beyond this point."


In the suture room which was located in the C-section area, there were miscellaneous items in the sink. The sink had sterile gloves, parts of suction equipment, suction canister, and piece of metal bar. Observed on the ledge of the sink was a sterile plastic bundle of surgical attire and on the other side of the sink were more sterile supplies.

Under the sink observed brown water stains, dust, dirt, and bugs.

On the floor behind the wire rack of sterile supplies was a pair of sterile gloves lying on the floor.

There were 12 rolls of (6 inch) sterile and unsterile tape on the bottom shelf of the wire rack with no barrier. This type of tape was used to tape across the dressing of the patient's abdomen after a C-section surgery. There was no barrier to prevent dust during sweeping and splashing when mopping the floor.

The suture room appearance was unclean, cluttered, and disorganized.

In operating room #1, the housekeeping staff had just cleaned the room. Observed an open surgical blade package on the shelf in the operating room. Also, when checking the foam mattress padding on the operating bed, it was observed that the padding was still wet under the mattress. The cleaning agent cannot disinfect until the agent is completely dry. The operating bed was already made with sheets and set up for the next surgical procedure.

The yankauer suction handle on the anesthesia machine was open and connected to the suction tubing. There was no way to determine if the yankauer handle had been used in the previous case.

The handwashing sink in the medication room between the 2 operating rooms had a white substance in the sink. The cold water handle did not work. The spout on the water outlet was rusted. There were no paper towels in the holder. A box of shoe covers on the sink was blocking the empty towel rack. Also, beside the sink was a blue plastic container that had a brown dried substance in the bottom of the container.

There was a dirty utility room which was located behind the sterile line that was located near the C-section operating rooms. In this room observed 2 cardboard boxes on the shelf. On the floor beside the hopper was the sink drain cap. The floor had an unclean appearance with dust and dirt particles.

The sealant around the sink had come loose, leaving a crack in the Formica allowing water and infectious waste to enter the crack.

In the cabinet shelves observed multiple labels labeled, "Treated Solid Medical Waste" which were scattered all over the shelf. There was a gray plastic bin that contained bottles of surface cleaners, but the bin was rusted and dirty in appearance. The shelf was cluttered with plastic bags and empty plastic bottles in a disorganized matter.


"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Card board boxes harbor parasites, insects, and microorganisms.

Temperature and Humidity logs:

During the tour of the C-section operating rooms and the surgical area the temperature and humidity logs were reviewed. The following issues were found:

A review of the log for operating room #3 noted that there was a temperature out of range on 10/15/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in the operating room #3.

A review of the log for operating room #3 noted that there was a temperature out of range on 11/05/17 and 11/14/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in the operating room #3.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 10/26/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 11/15/17, 11/22/17, and 11/29/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 12/05/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #2 noted that there was a temperature out of range on 10/12/17, 10/26/17, and 10/30/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #2.

A review of the log for L&D operating room #2 noted that there was a temperature out of range on 11/28/17 and 11/29/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #2.


Review of the AORN Perioperative Standards and Recommended Practices, "Temperature should be maintained between 68 degrees F to 73 degrees F (20 degrees to 23 C) within the operating room suite and general work areas in sterile processing.

"Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.

Low humidity increases the risk of electro static charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed. Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."


Radiology:


During a tour of the ultrasound room in the radiology department on 12/05/17 at 4:00 PM observed storage issues with the Transvaginal probe and transesophageal (TEE) probes.

This deficient practice had the likelihood to cross-contaminate the Transvaginal probe and Transesophageal (TEE) probes.

If there is any moisture on the probes, condensation can occur inside the plastic bags and microbial growth could occur. A porous surface, like wood, holds moisture and dirt and would promote microbial growth and mold. The probe holder system was located in a high traffic area, exposing probes to potential damage or cross-contamination.

The transvaginal probes were stored on a wooden rack with plastic bags covering the probes. The wooden rack was in the main ultrasound room where procedures were being performed on patients.

The Transesophageal TEE probes (2) were coiled up in a white plastic bag inside a plastic drawer near the floor in the main ultrasound room where procedures were being performed on patients.


A review of the manufacture's guidelines revealed the following:
"Store the device in a manner that will protect them from damage or contamination. The manufacture's recommendations are to hang the probes vertically in a cabinet and store in a clean environment."

An interview with Staff #29 on 12/05/17 at 4:30 PM confirmed the above findings.

Laboratory:

On 12-5-2017 the following conditions were observed in the laboratory:

Cardboard shipping boxes were being used in the laboratory on top of counters, under counters, and in cabinets to collect papers for shredding and store parts for lab equipment. Shipping boxes can harbor pests and bring contaminants into the hospital and laboratory setting.

Uncovered pipettes for drawing up solutions to be used in lab testing were left exposed in a drawer with markers, pencils, and miscellaneous supplies. A piece of wire identified for use to dislodge "hung-up curettes" was stored in a biohazard waste bag in the same drawer.

A sterile swab with the expiration date of 08/2000 was found in a drawer.

Spare parts for lab analyzing equipment were stored in a drawer with hand lotion.

Lab equipment control solution and primer solution stored in drawer with caulking and electrical tape.

The specimen freezer was visible soiled with dust, dirt, and rust. The seal at the bottom of the door had been repaired with gaps in the seal that allowed dirt and bacteria to collect.

A drawer front was missing, exposing the unfinished porous material. This would allow spills with contaminants to be absorbed into the material.

Printer ink cartridges, lab equipment liquid agents, and patient lab supplies were being stored together.

A cushioned floor mat was cracked and had a corner missing, exposing the foam cushion to contaminated spills. The bottom of the mat was caked with dust and dirt.


Outpatient Laboratory:

On 12-6-2017 a tour of the outpatient laboratory was made.

A lower cabinet door front had evidence of a spill. The laminate at the bottom of the door was lifted away from the door material, allowing spills to collect and harbor bacterial growth.

Glucose solution intended for patients to ingest for blood glucose testing was being stored in a refrigerator with a biohazard label and signage that read, "No Food Consumption". Laboratory equipment control solutions were stored in the refrigerator.



Outpatient Radiology:

On 12-6-2017 a tour of the outpatient radiology was made.

The Computed Tomography Scan (CT Scan) storage room had holes in the wall. Overhead light fixtures had dead bugs in them.

Step Down Unit:

On 12/5/2017 at 2:20 p.m., a pair of forceps was found in the emergency airway cart in the step down unit. The instrument was enclosed in the sterilization pack and there was no date of sterilization on the peel pack. Staff #23 confirmed the observation.

ICU:

On 12/6/2017 at 5:35 p.m., two pacemaker cords were found in the ICU supply cabinet in sterilization packs. There was no sterilization date on one of the peel packs and the other peel pack was dated 2013. Staff #22 confirmed the observation.

On 12/6/2017 at 5:45 p.m., peel packs were found hanging in the ICU supply room which included forceps and hemostats that were dated 2006, 2012. 2013. There was a sterilized linen set that was dated 2006.

ED:

On 12/7/2017 at 916 a.m., a hemostat in the ED was found in a sterilization peel pack and stored in a supply cart. The hemostats had been sterilized closed and was not dated. Staff # 43 confirmed the observation.



According to the Centers for Disease Control and Prevention (CDC) article, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at
:http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, documented on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.


Review of the manufacturer insert named "STERILIZATION PACKAGING: SHELF-LIFE STUDY" revealed the following information about the sterilization packs the facility were using:

"The 100% success in maintaining sterility over a 52 week period demonstrates that, with the proper use of Vital Care Reps., Inc. and Vital Care Industries, Inc.* packaging, all of the various formats i.e. tubing, heat-seal and self-seal pouches are effective means of storing sterile supplies for a minimum of 52 weeks."

During an interview on 12/11/2017 after 4:29 p.m., customer service representative #74 reported that they only validated sterilization for one year.


MedTele/Medical Surgical Department:

During an observation on 12/6/2017 after 10:34 a.m., Staff #38 went into a patient's room and took vital signs. Staff #38 did not sanitize her hands prior to entering or exiting the patient's room.



Respiratory department:


During an observation on 12/4/2017 after 1:25 p.m., the following was found:

Respiratory supplies being used were found in a drawer unbagged.
Inside the airway lockbox was a syringe/needle kit which was soiled with dried blood.
Oxygen supplies used for respiratory treatments were stored in soiled plastic bins.
The tile flooring underneath the respiratory supply shelf had a build-up dust and dirt.
A pulse oximeter probe was found soiled with dried blood.

Oxygen flowmeters were stored in a drawer and they were not bagged to indicate they were clean. An unidentified respiratory staff member was observed to get a flowmeter out of the drawer and left the respiratory department with the flowmeter. The flowmeter was not cleaned during the observation.

Staff # 8 confirmed the observation.

Review of the facility's policy named "Disposable Equipment Change Out "dated 1/20/2017 revealed:
"All reusable equipment will have surfaces wiped with hospital approved disinfectant and then bagged with equipment cover, indicating clean and ready for use."



Kitchen:

During an observation of the kitchen on 12/5/2017 after 8:30 a.m., the following was found:


Dish storage/drying rack near the dishwashing room were found with clean dishes stored on them. The racks were soiled with a build-up of debris and one rack had sections of the protective coating missing. The rack could not be properly sanitized.

Dish and pan storage racks near the three compartment sink had clean dishes stacked on them. When pans were pulled off the shelf they were found to be soiled with dried food and dried water marks.

The dish and pan shelves had no covering over them and they were next to a high traffic area and the dishwashing area.

Clean pans were stored on the counter of the three compartment sink. Staff failed to store the pans on a drying rack. A rolling cart was sitting outside of the three compartment sink area. On top of the cart was a tray which had bloody water in it.

Adjacent to the cart near the three compartment sink were shelves of clean pans, holding racks and pots which were stored on a shelf that was soiled with dried food and spills.

The can opener had a build- up of debris and was rusted. With the rust on the can opener there was no way it could be sanitized.

Inside the dish room there was a foul odor which could be smelled next to the sink. Staff #76 took the top off the trash can and it was found to have standing water. Staff #76 reported that someone had put fish in the trashcan and she had put the water in the trash can the night before.

The two stand up refrigerators between the main kitchen and the serving prep area for the public were found to be soiled with dried food and spills. The rubber sealant around the doors of the refrigerator was soiled with a build of dried spills. Food was stored in these refrigerators that had soiled dried food in them.

The Hot food storage unit in the same area was soiled with food spills and a build build-up of grease.

Six large plastic bags of juice and soda for the beverage dispenser machine were found stored in open pans underneath the food prep area. The bags nor there spouts were covered. Staff #75 was prepping fish and chicken on the counter above the bags.

Breakfast food was still stored on the steam table. The crevices around the steam table were soiled with a build-up of dried food.

The toaster was found to have a build-up of food debris inside the bottom panel.

The Seran wrap holders were found to have a build-up of food spills in the bottom panel and food debris in the crevices. The white grout in between the tiles next to the Seran wrap area had a build-up of black substance.

The inside walls and the top of the microwave were soiled with a build-up of dried food.

The outside doors and the inside of the Confection Ovens were soiled with dried food and a build-up of grease. One of the ovens had chicken cooking in it.

The bottom inside panels and flooring of the deep fryer had a build-up of grease and black particles.

There were cardboard boxes with food items being unloaded in the dried food area, refrigerator, and freezer area.

Two of the food transport carts had plastic mesh coverings that was soiled. One of the coverings had a broken zipper and would not close up.

There was a shelf in the kitchen that had expired and dented cans of food stored on it. The sign indicating what was on the shelf was not visible.

Staff #'s 13, 14, 15, & and 16 confirmed the observations.


During the meal prep Staff #75 was observed prepping chicken. Staff #75 was observed to leave the meat prepping area and go to the heating box. Staff #75 opened the heating box without removing his soiled gloves.

During tray preparation Staff #20 was observed to drop a food item off a tray. Staff #20 picked the item up and placed it back on the tray. Staff #20 failed to remove her gloves and sanitize her hands prior to placing the item back on the tray.


While passing meal trays on the Step down unit, Staff #24 was observed assisting with passing trays. Staff #24 removed a tray from a patient's room and returned it to the tray cart in the hallway. Staff #24 removed another tray off the meal cart and failed to sanitize her hands first.


Review of the "INFECTION CONTROL ROUNDS" sheets for October and November 2017 revealed staff #13 (infection control nurse) documented some of the same problems identified during the survey which were not corrected.


A review of a facility's policy named "FOOD AND SUPPLY STORAGE" and dated 1/2017 revealed the following:

All food, nonfood and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Date and rotate items; first in, first out (FIFO) discard food past the use-by or expiration date.

Maintain designated area for items that are damaged (such as dented cans that are to be returned for credit. Post sign, "Return to Supplier" (MQAS-2)

.
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Card board boxes harbor parasites, insects, and microorganisms.

Ambulatory Surgery Center

During a tour of the Ambulatory Surgery Center Department on 12-5-2017 at approximately 9:35am with staff #1 and #10, wheelchairs and a dirty linen cart were observed being stored in an inset in the hallway where patients were being made ready for surgery. When asked if the wheelchairs were dirty and place there for cleaning.
Staff #1 and #10's response was the wheelchairs are clean. We will remove the dirty linen.

An interview on 12-5-2017 at approximately 10:30am with staff #1 and #10 confirmed the above findings.




B. During an observation of the Emergency department (ED) on 12/07/2017 after 10:00 a.m., the following was found:

Room #3 was identified as the room used for psych patients by Staff #43. The room did not have a hardened ceiling. The ceiling was a drop down ceiling with ceiling tiles within a metal frame. When the ceiling tiles were pulled back there was wiring, metal bars, and flexible metal conduits that could be used as weapons and as ligatures for hanging or strangulation. There was a water sprinkler and an air vent in the ceiling that posed a ligature risk.

Staff #43 confirmed knowing about the hazards.

Review of the ED record on Patient #31 revealed she was a 59 year old female who presented on 12/02/2017 at 7:33 a.m.. Patient #31 presented with suicidal ideation's and was placed in Room #3.

At 7:35 a.m., Patent #31 stated "I am hearing voices and I am suicidal, and I'm having marriage problems,.." Patient #31 was given an acuity level of 2 (meaning urgent).

At 7:40 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Do you feel hopeless or helpless? Yes
Have you had thoughts of suicide in the past? Yes
Are you having thoughts of suicide now? Yes
Have you previously attempted suicide? Yes
Do you have a plan to hurt yourself or someone else? Yes

Patient #31 was assigned a suicide risk level of 2 (meaning high risk). The type of supervision assigned was for continuous visual surveillance. There was documentation that observation should be performed at all times by designated staff with direct line of sight. "..Remove and secure personal items. Patient is placed in a hospital gown."

At 8:20 a.m. there was documentation that the police department was there to see Patient #31.

At 9:00 a.m., there was documentation that the behavioral center was there to evaluate Patient #31.

At 2:18 p.m., (almost 7 hours later) Patient #31 left the ED (transferred out to a higher level of care).

There was no documentation of who was monitoring Patient #31 and how often.

There was also no documentation of a physician's order addressing the level of supervision Patient #31 was to be placed on.

Staff #43 confirmed the problems with the monitoring and there be no documentation of who was monitoring Patient #31. Staff #43 reported the gown placed on Patient #31 would have been a paper gown.

Review of the ED record of Patient #34 revealed he was a 5 year old male who presented on 11/08/2017 at 8:30 p.m., with complaints of suicidal ideation and behavior disorders.

Review of nursing documentation at 8:52 p.m., revealed Patient #34 was assigned an acuity level of 1 (meaning emergent).

At 9:04 p.m., Patient #34 was assigned a suicide risk level of 1 (meaning immediate high risk with continuous visual surveillance (line of sight) and 1:1 observation). There was documentation by nursing that the mother and father was at the bedside.

At 11:12 p.m., discharge orders were given for Patient #34 to be discharged home with his family. Patient #34 was to be seen in the a.m. by the behavioral center.

At 11:13 p.m., Patient #34 left the ED.

Review of the ED record revealed no documentation of the monitoring to indicate the mother and father remained at the bedside.

There was also no documentation of a physician's order addressing the level of supervision Patient #34 was to be placed on.

Review of the ED record on Patient #35 revealed she was a 58 year old female who presented on 11/04/2017 at 2:51 a.m... Patient #35 presented with complaints of suicide ideation's and hallucinations and was placed in Room #3.

At 2:54 a.m., Patient #35 was assessed as having an acuity level of 1 (meaning emergent). There was documentation that Patient #35 was hearing voices and they were telling her to hurt herself and family members.

At 3:00 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Thought of suicide in the past? Yes
Thought of suicide now? Yes
Do you have a plan to hurt yourself or someone else? Yes

At 3:27 a.m., Patient #35 was assigned a suicide risk level of 3 (meaning moderate risk).

According to the facility's policy dated 05/26/2015 and named "ER-Suicide Risk Assessment and Interventions in Acute Care Setting" the following was documented:

"Moderate Risk Patients (Level 3):
Possible danger to self or others. Observed restless or impulsive behavior, intrusive or disordered, confused/withdrawn, dazed or anxious, ambivalent about treatment. Not likely to wait for treatment. History of suicide attempt without current ideation or plan; presence of mood disturbance; symptoms of depression and/or anxiety (socially withdrawn, acute change in previously enjoyed activities), elevated or irritable mood, angry.
o LEVEL OF SUPERVISION: Close observation.
o If patient subsequently elopes from the patient care unit and returns, then increase level of observation."


According to the facility's policy this was the definition for close observation:

"..C. Close observation: Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals of at least every 15 minutes. Supportive family/friend must receive education from staff and agree to communicate with staff and seek staff assistance for any concerns..."

Patient #35 had current suicide ideation and a plan.

Based on interview and record review the facility failed to:

A. ensure sufficient numbers of nursing staff on 3 of 3 units (Step-down unit, Intensive care unit (ICU), and Telemetry/Medical-Surgical unit).

The facility failed to have sufficient numbers of Registered nurse to serve as charge nurse and provide patient care. The charge nurses were attempting to be charge nurse over Step down and the Intensive care unit. They would go back and forth between the units during their shift. The facility failed to designate allotted hours for a charge nurse for the Step down unit on their staffing matrix. The facility failed to have sufficient numbers of licensed nurses on the Telemetry/Medical-surgical unit. The nurses were spending long hours after their shifts were over catching up on charting.

The facility failed to have sufficient numbers of Registered nurses to recover patients after bedside procedures which required administration of anesthesia. Patient #21 had a bedside procedure and a nurse on the unit had to recover the patient. There was documentation in the nurses notes that respiratory staff had to be called after the procedure to assist with getting Patient #21's oxygen saturation up to a safe level. The staffing was not adjusted considering the condition of the patient.

The facility failed to have sufficient numbers of certified nurses aide to provide activities of daily living care.

Refer to tag A0392 for additional information.


B. ensure one nurse, who was currently assigned to patient care, had current competencies in 1 of 2 personnel files reviewed for the step down unit (staff #25).

Staff #25 started his competencies 4/14/ 2017 and as of 12/6/2017 (over 7 months) had not completed it.

Refer to tag A0397 for additional information.


C. ensure open dates were logged on medications that were currently in use for patients. The medications that were not dated were antibiotics, eye drops, treatment ointment, and nasal sprays.

The facility failed to ensure preparation dates and expiration dates were placed on Intravenous (IV) medications that were prepared by pharmacy prior to administration. There was no way for nursing to determine when the IV medications expired.

The facility failed to ensure internal and external medications were separated. Oral medications, nasal spray, and ointment normally used externally.

The facility failed to ensure medications that were taken from the Pyxis (Medication Storage Unit) were either administered timely or returned back to the unit. Oral medications were stored in a medication cart in the supply room and staff could not explain how they got there.

The facility failed to ensure patients home medications were accurately assessed, physician ordered and reconciled. The facility failed to ensure timely administration of seizure medications and monitoring prior to administration in 2 of 2 patients reviewed for usage of the seizure medication Dilantin (Patient #'s 5 and 6).

These deficient practices were found on 3 of 3 units (Step-down, Intensive care unit,and Telemetry/Medical-surgical unit )

Refer to tag A0405 for additional information.


D. ensure 1 of 37 sampled patients received blood transfusions as ordered and they failed to ensure there were complete physician orders for blood transfusions (Patient #21). Patient #21 had lab results which revealed his congestive heart failure was severe.

Refer to tag A0409 for additional information.

Based on interview and record review, the facility failed to ensure sufficient numbers of nursing staff on 3 of 3 units (Step-down unit, Intensive care unit (ICU), and Telemetry/Medical-Surgical unit).

The facility failed to have sufficient numbers of Registered nurse to serve as charge nurse and provide patient care. The charge nurses were attempting to be charge nurse over Step down and the Intensive care unit. They would go back and forth between the units during their shift. The facility failed to designate allotted hours for a charge nurse for the Step down unit on their staffing matrix. The facility failed to have sufficient numbers of licensed nurses on the Telemetry/Medical-surgical unit. The nurses were spending long hours after their shifts were over catching up on charting.

The facility failed to have sufficient numbers of Registered nurses to recover patients after bedside procedures which required administration of anesthesia. Patient #21 had a bedside procedure and a nurse on the unit had to recover the patient. There was documentation in the nurses notes that respiratory staff had to be called after the procedure to assist with getting Patient #21's oxygen saturation up to a safe level. The staffing was not adjusted considering the condition of the patient.

The facility failed to have sufficient numbers of certified nurses aide to provide activities of daily living care.

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


STEP DOWN UNIT


Review of the facility staffing matrix dated 10/24/2017 revealed no designated allotted hours listed for a charge nurse.

For a patient census of 10 and above the staffing matrix called for 4 RN's on the 7:00 a.m. -7:00 p.m. shift (day shift) and 4 RN's on the 7:00 p.m. -7:00 a.m. shift (night shift).


Review of nursing staffing numbers for the timeframe of 11/28-12/04/2017 revealed the following:

On 11/28/2017 the patient census was 11 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/02/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/03/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/04/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.



During an interview on 12/06/2017 after 9:30 a.m., Staff #37 confirmed having to work as the charge nurse between the Stepdown unit and ICU during the shift. Staff #37 reported their unit is busy, stressful and they have high acuity patients. Staff #37 reported they used to have 5 RN's now they have 4 RN's without any unit secretary. The charge nurse is the go to person for everything. Some of their duties include caring for the patients after bedside procedures, monitoring patients, educate staff, and monitor blood administration. Sometimes it is so busy they cannot do vital signs. People are staying after the end of their shift to do their charting up until 8:00 p.m.

During an interview on 12/05/2017 after 11:45 a.m., Staff #21 reported the patient to nurse ratio was 3:1 and the nurses provided total patient care. Staff #21 reported that the charge nurse had to do everything. They were charge nurse for the Step-down unit and also the 15 bed Intensive care unit (ICU).They had to go back and forth between the units during their shift. Staff #21 reported that on 12/01/2017 they had 2 patients who were on 1:1 care and no changes had been made in the staffing. The nurses kept the same number of patients. The nurses had to recover a patient who had a bedside procedure (EGD/colonoscopy) and a heart cath patient.

Review of the staffing sheet for 12/01/2017 revealed the patient census was 8 and there was 4 RN's on day and 3 RN's on nights. There was no documentation of change in staffing to accommodate the 1:1 patients. There was no allotted time for the charge
nurse.


Review of a chart of one of the 1:1 patients from 12/01/2017 revealed the following:


Review of nurses notes on Patient #21 revealed on 12/01/17 the endoscopy team and the physician were in the patient's room to do an EGD and Colonoscopy.

According to the operative notes the following was done:

The type of anesthesia listed was general and it was started at 11:14 a.m.. An esophagogastroduodenoscopy (EGD) was started at 11:17 a.m. and it was over at 11:22 a.m.. A colonoscopy with polypectomy was started at 11:25 a.m. and over at 11:47 a.m.. At 11:54 a.m. the anesthesia was stopped. There was documentation that the nurse circulator (on the Endo team) gave report to the (floor) nurse. Patient #21 remained on the Step down unit.

According to nurses notes at 12:30 p.m., the physician was talking to the family about the scope finding. At 1:27 p.m., the patient was desaturating to 72 % while on oxygen at 2 liters via nasal cannula. Patient #21 was placed on oxygen at 6 liters via facemask. Still desaturating at 84 %. Respiratory was called to put the patient back on Bipap. Placed on Bipap at 60 %. Saturation picked up to 94%.. The next documentation from nursing was at 3:00 p.m. and then at 5:33 p.m. when the saturation level was at 98 % on Bipap.

During an interview on 12/05/2017 after 11:45 a.m., Staff #21 confirmed that they have to recover patients after bedside procedures. Staff #21 reported they had to recover patients who had received sedation.


Review of the facility's policy named "Moderate Sedation" dated 07/2016 revealed the following:
" ...In addition to the Licensed Independent Practitioner (LIP) performing the procedure, there are sufficient numbers of qualified staff present during the procedure to provide the sedation, monitor and recover the patient, and assist the LIP ...."

Review of the 2014 Edition of the Perioperative Standards and Recommended Practices, For Inpatient and Ambulatory Settings, pages 607 and 608 revealed the following:

"Postoperative
Phase 1 level of care ...

Class 1:1 -One nurse to one patient
*At the time of admission until the critical elements**are met.
*Unstable airway.***
*Any unconscious patient 8 years of age and under.
*A second nurse must be available to assist as necessary."

"**Critical elements can be defined as:
-Report has been received from the anesthesia care provider, questions answered, and the transfer of care has taken place.
-Patient has a secure airway.
-Initial assessment is complete.
-Patient is hemodynamically stable."



ICU UNIT


Review of nursing staffing numbers for the timeframe of 11/26-12/04/2017 revealed the following:

On 11/26/2017 the day shift was short 1RN's and the night shift was short 3 RN's.

On 11/27/2017 the day shift was short 2 RN's and the night shift was short 3 RN's.

On 11/28/2017 the day shift was short 2 RN's and the night shift was short 2 RN's.

On 11/29/2017 the day shift was short 1RN's and the night shift was short 2 RN's.

On 11/30/2017 the day shift was short 1RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/01/2017 the night shift was short 1 RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/02/2017 the night shift was short 2 RN's.

On 12/03/2017 the day shift was short 1RN and night shift was short 2 RN's.

On 12/04/2017 the night shift was short 1 RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/05/2017 the day shift was short 2RN's.


Review of the facility staffing matrix dated 10/24/2017 revealed 12 designated hours listed for a charge nurses for 6:00 a.m.-6:00 p.m. day shift and 6:00 p.m. -6:00 a.m. night shift.

During an interview on 12/06/2017 after 6:11 p.m., Staff #22 confirmed the staffing numbers. Staff #22 reported not having a criteria for what ICU patients met the 1:1 status. The charge nurse was being shared with the Step down unit. Staff #22 reported they may spend a total of 6 hours on each unit.



MEDICAL/SURGICAL UNIT


Review of nursing staffing numbers for the timeframe of 11/26-12/04/2017 revealed the following:

On 11/26/2017 the night shift (7p-7a) was short by two Certified nurses aides (CNA) and short 10 hours for a unit secretary.

On 11/27/2017 the day shift (7a-7p) was short by two nurses and one CNA. The night shift (7p-7a) was short by two nurses and short two CNAs.

On 11/28/2017 the day shift (7a-7p) was short by one nurse and one CNA. The night shift (7p-7a) was short by one nurse and short two CNAs.

On 11/29/2017 the day shift (7a-7p) was short by two nurses and one CNA. The night shift (7p-7a) was short by two nurses and short three CNAs.

On 11/30/2017 the day shift (7a-7p) was short by one nurse.

On 12/01/2017 the day shift (7a-7p) was short by one nurse.

On 12/02/2017 they were short a unit secretary by two hours on the 3p-11p shift.

On 12/03/2017 they were short a unit secretary by two hours on the 3p-11p shift.

On 12/04/2017 the day shift (7a-7p) was short by one nurse.The night shift (7p-7a) was short by one nurse and short one and a half CNAs.

On 12/05/2017 the day shift (7a-7p) was short by one CNA. The night shift (7p-7a) was short by one nurse and short three CNAs.

During an interview on 12/06/2017 after 4:00 p.m., Staff #5 confirmed the staffing numbers.

During confidential interview with staff on the unit the following was reported about staffing:

One staff member reported that staffing is rough. Four to five patients per nurse would be ideal, but that's not what always occurring. The staff member reported one nurse having up to 7 patients and that meant going home in tears. Sometimes the charge nurse had to take patients when they were short staffed. The charge was over the entire floor which was over 30 beds. The staff member reported working a weekend recently and having to take 6 patients. The CNAs who worked that weekend had 15 patients a piece and they are only supposed to have 10 patients a piece. Some of the nurses are getting exhausted.


One staff member reported sometimes the three CNAs have to take care of 40 patients. They each have 13 -14 patients. The family members get upset because they cannot make it to the patient's rooms timely. The CNAs are responsible for vital signs, activities of daily living, transfers and feeding patients. Sometimes if baths cannot be given on their shift they have to be passed to the night shift. If night shift cannot get the baths done they are pushed to the next day. It is hard for staff to get their charting done.


One staff member reported that here lately the staffing has been bad. The nurses are averaging 5-6 patients each, but the ideal number would be 1 nurse to 5 patients. The day shift CNAs are taking 15-16 patients sometimes and night shift CNAs are taking 15-16 patients always. The charge nurse also had to take patients when the unit was understaffed. A couple of days the charge nurse took 5-6 patients and took care of the charge nurse duties also. Day shift nurses normally get off at 6:00 p.m., but they are staying over sometimes until 10:00 p.m. charting.


During an interview on 12/07/2017 after 8:30 a.m., Staff #1 (CNO) reported corporate was getting onto her about the nursing staff overtime hours. Staff #1 reported not knowing the reason the nurses were getting so much overtime.

Based on interview and record review, the facility failed to ensure one nurse who was currently assigned to patient care had current competencies in 1 of 2 personnel files reviewed for the step down unit (staff #25).

Staff #25 started his competencies 4/14/ 2017 and as of 12/6/2017 (over 7 months) had not completed it.

This deficient practice had the likelihood to cause harm to all patients in ICU and Step down unit.

Findings include:


Review of the "ICU & SDU RN/LVN Orientation Competency" sheet on Staff #25 revealed his 2017 competencies were started 04/14/2017. Review of the form revealed the following areas had not been completed as of 12/06/2017 (over 7 months):

Intravenous lines and medications
Pulmonary system care
Weaning from ventilators
Assisting with extubations
Assisting with insertion of chest tubes
Assisting with removal of chest tubes
Auto transfusions
Insertion of NG (nasogastric) or feeding tube orally and nasally
Insertion of Dobhoff tube
Genitourinary System Care
Cardiovascular System Care
Integumentary System Care
Neuro System Care

During an interview on 12/06/2017 after 11:01 a.m., Staff #5 confirmed Staff #25 had not completed the competencies. Staff #5 reported it should have been completed by mid August 2017.

Based on observation, interview, and record review, the facility failed to:

A. ensure open dates were logged on medications that were currently in use for patients. The medications that were not dated were antibiotics, eye drops, treatment ointment, and nasal sprays.

B. ensure preparation dates and expiration dates were placed on Intravenous (IV) medications that were prepared by pharmacy prior to administration. There was no way for nursing to determine when the IV medications expired.

C. ensure internal and external medications were separated. Oral medications, nasal spray, and ointment normally used externally.

D. ensure medications that were taken from the Pyxis (Medication Storage Unit) were either administered timely or returned back to the unit. Oral medications were stored in a medication cart in the supply room and staff could not explain how they got there.

E. ensure patients home medications were accurately assessed, physician ordered, and reconciled. The facility failed to ensure timely administration of seizure medications and monitoring prior to administration in 2 of 2 patients reviewed for usage of the seizure medication Dilantin (Patient #'s 5 and 6).

These deficient practices were found on 3 of 3 units (Step-down, Intensive care unit,and Telemetry/Medical-surgical unit )


This deficient practice had the likelihood to cause harm to all patients.


Findings include:



During an observation on 12/5/2017 after 2:15 PM, the following was found on the Step down unit:

One syringe of Chlorhexadine Gluconate solution, germicidal mouthwash, had no preparation or expiration date.
Three bags of 105 milliliter (ml) Keppra, anticonvulsant, had no preparation or expiration date.
One 110 ml bag of Depacon, anticonvulsant, had no preparation or expiration date.
One bottle of Nystatin topical,antifungal antibiotic, powder had no expiration date.
One bottle of the glaucoma agent Timolol eye drop, had no open date logged on it.
One bottle of the glaucoma agent Dorzolamide eye drops had no open date logged on it.

Staff # 21, 22, and 23 confirmed the observation. Staff # 22 reported that the premixed IV bags expire in fourteen days according to pharmacy.



During an observation on 12/6/2017 after 1140 AM the following was found on the Med/Surg Tele unit:

There were internal and external medications stored in a bag together such as Desitin cream, Flonase nasal spray, and a container of docusate sodium. The tube of Desitin cream and the Flonase nasal spray did not have open dates logged on them.

One tube of Santyl treatment ointment did not have an open date logged on it.
One bottle of the glaucoma agent Timoptic eye drops did not have an open date logged on it.
One bottle of combination eye drop Brimonidon plus Timolol (glaucoma agent) did not have an open date logged on it.
One tube of Garamycin sulfate, antibiotic ointment, did not have a preparation or expiration date and it was inappropriately stored.
One 250 ml bag of Vancomycin, antibiotic, one 100 ml bag of Protonix, Gastrointestinal medication, one 200 ml bag of Cipro, and two 100 ml bag of Flagyl, antibiotic, which did not have a preparation or expiration date.

Staff #5 confirmed the observation.



During an observation on 12/6/2017 after 530 PM, the following was found on Intensive care unit (ICU):

One 100 ml bag of Flagyl, antibiotic, had no preparation or expiration date.
One 50 ml bag of Merrem, antibiotic, had no preparation or expiration date.
One 250 ml bag of 400 milligram (mg) Inotropin in D5W IV solution, cardiac drug, had no preparation or expiration date.
One bottle of the glaucoma agent Xalantan eye drops did not have an open date logged on it.


A medication cart was stored in the supply room. When opened, two of the drawers contained medications in cup. There was no identification on the cups as to who the medication belonged to or when they were pulled. One cup contained seven tablets of Hydralazine. One cup contained one tablet of Potassium chloride.

Staff #22 confirmed the observation and reported not knowing how the medications got there.


According to the United States Pharmacopia<797> Resource Guide, dated 2013 revealed the following:

Page 22
"Multiple-dose vials are designed for use beyond a single dose. Unless other wise specified by the manufacturer, the maximum beyond-use date after initial puncture is 28 days."

Page 19
Since compounding sterile preparations requires manipulation of the manufacturer's product, the date beyond which the CSP(Compounded Sterile preparation) can be used is different from the expiration date. CSPs must be labeled with a beyond-use date, which is determined by the compound being prepared and the temperature at which it will be stored.



Review of the clinical record of Patient #6 was a 69 year old male who presented to the ED on 11/29/2017 at 5:54 p.m. for complaints of falling and hitting the back of his head.

Patient #6 was given a diagnosis of failure to thrive in the ED. There was no documentation of an assessment of Patient #6's home medications in the ED records by nursing.

A physician's history and physical dated 11/29/2017 at 8:50 p.m., revealed Patient #6 home medications were addressed then. Patient #6 was on the medications Phenytoin Sodium Extended 200 milligrams orally, two times a day and Clonazepam 0.5 milligrams orally two times a day for seizures.

Review of the physician's plan was to start the clonazepam and phenytoin. There was documentation of Patient #6 having a diagnosis of failure to thrive, depressive behavior, anorexia, frequent falls, dysphagia and weakness.

Patient #6 left the ED at 9:15 p.m. and was admitted to the Medical/surgical unit at 9:57 p.m.


Review of physician orders dated 11/29/2017 at 11:03 p.m., revealed an order was written for Phenytoin sodium extended 100 milligrams, administer 200 milligrams two times a day (for seizures).

Review of the medication administration record revealed Patient #6 received the following doses of the anti-convulsant Phenytoin:

11/30/2017 at 8:38 a.m. and 9:06 p.m.;
12/01/2019 at 9:20 a.m. and 9:26 p.m.

According to lab results dated 12/02/2017 at 9:52 a.m., Patient #6 had a Phenytoin level of 16.0 (reference range being 10-20). This lab was drawn 3 days after being in the hospital.


Review of the medication administration record revealed Patient #6 received the following doses of the anti-convulsant Phenytoin:

12/02/2017 at 8:53 a.m. and 8:46 p.m.:
12/03 at 9:42 a.m and 9:48 p.m.;
and 12/04 at 12:42 p.m.

According to the clinical notes Patient #6 was discharged to a rehabilitation center on 12/04/2017 at 4:30 p.m.

Patient #6 was admitted back into the facility on 12/06/2017 with a diagnosis of falls (2 days after being discharged).

There was no Dilantin level ordered, but Patient #6 was placed back on Dilantin 200 milligrams twice a day again.




Review of the ED record on Patient #5 revealed she was a 75 year old female who presented on 12/03/2017 at 8:38 p.m. for complaints of chest pain and headache.

According to the home medication list, Patient #5 was on the anti-convulsant "Phenytoin 50 mg
Chew 3 tabs Daily."

A physician's history and physical dated 12/03/2017 at 10:52 p.m., revealed Patient #5 was on Phenytoin sodium extended, 50 mg orally once a day at home.

Review of the admission order set dated 12/03/2017 at 11:00 p.m., revealed a physician's order to "continue home meds."

Patient #5 left the ED at 12:46 a.m. midnight( going to the Medical/Surgical unit).

Review of an order dated 12/04/2017 at 6:43 a.m., revealed a physician's order for Phenytoin sodium extended, 30 mg caps. Give 50 mg orally once a day. The order was discontinued on 12/04/2017 at 12:04 p.m.. There was documentation that the order was "wrongly entered upon admn"

An order was written on 12/04/2017 at 12:05 p.m. for Phenytoin sodium extended 300 milligrams caps. Give 300 milligrams once a day.

According to the medication administration record the first dose of Phenytoin 300 milligrams was administered on 12/04/2016 at 1:00 p.m.

The order was corrected and medication administration started on this seizure medication 12 hours after the initial order was written for the medication.

During an interview on 12/06/2017 after 2:00 p.m., Staff #41 confirmed the discrepancy and reported not know what happened. Staff #5 and #41 revealed not knowing of an incident report being completed on the order being put in incorrectly.

Based on interview and record review the facility failed to ensure 1 of 37 sampled patients received blood transfusions as ordered and they failed to ensure there were complete physician orders for blood transfusions (Patient #21). Patient #21 had lab results which revealed his congestive heart failure was severe.


This deficient practice had the likelihood to cause harm in all patients who received blood transfusions in the facility.

Findings include:


Review of the Emergency department (ED) record of Patient #21 revealed he was a 73 year old male who presented on 11/28/2017 at 1:20 p.m., with complaints of chest pain and shortness of breath.

Review of lab reports on Patient #21 revealed on 11/28/2017 at 1:54 p.m., he had a low hemoglobin of 7.4 (reference ranges being 13.5-17.5) and a low hematocrit at 28.3 (reference ranges being 36.0-46). Patient #21 had an elevated BNP- B-Type Natriuretic Peptide of 4043 with reference ranges being 0-125 (The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable).

Patient #21 left the ED at 7:18 p.m. and was transferred to the Step-down unit.
According to physician orders into the Step-down unit Patient #21 was given diagnoses of congestive heart failure and hypoxemia.

Review of lab reports dated 11/28/2017 at 10:05 p.m., revealed Patient #21 had a critically low hemoglobin of 6.6 (reference ranges being 13.5-17.5) and the hematocrit had decreased further to 23.1 (reference ranges being 36.0-46).
Review of physician orders revealed on 11/28/2017 at 11:41 p.m., there were two orders written to "TRANSFUSE PACKED RBCS".."ASAP" and "ONCE". There was no documentation on how fast to infuse the blood. The physician's order was incomplete and did not include the rate.

Review of physician's orders dated 11/29/2017 at 12:07 midnight, revealed an order to administer the diuretic "FUROSEMIDE INJ 40 MG/4ML SOLN" ...Dose: "40 MG" Route: "INTRAVENOUS PUSH" and Frequency :"ONE TIME ORDER UNSCHEDULED." There were instructions on the physician's order to "Give after first unit of blood."

Review of blood administration records revealed the first unit of blood was started on 11/29/2017 at 1:00 a.m. and stopped at 4:15 a.m.

Review of blood administration records revealed the second unit of blood was started on 11/29/2017 at 4:15 a.m. and stopped at 7:30 a.m.

According to the blood administration record on the first unit of blood, Staff nurse #25 was documented as the nurse administering and monitoring Patient #21 during the first unit.

Review of the blood administration record on the second unit of blood revealed Staff nurse #25 documented and signed as the nurse who obtained the blood from the lab at 04:07 a.m. This would have been during the time Staff nurse #25 documented that the blood infusion was still going on Patient #21. There was no documentation of another nurse monitoring Patient #21 while Staff nurse #25 went to the lab to get the second unit of blood.

Review of the medication administration record revealed documentation that Staff nurse #25 administered the Furosemide on 11/29/2017 at 3:24 a.m. ... The medication was administered prior to completion of the first unit of blood. The physician's order was not followed.

Review of the facility's policy named "Blood and Blood Product Administration" dated 10/2017 revealed the following:

" ...A physician order is required for administration for all blood products."

During an interview on 12/05/2017 after 3:00 p.m., Staff 24 confirmed the incomplete physician's order, time the Furosemide was administered and not knowing who was monitoring Patient #21 while the nurse went to the lab for more blood.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services involving compounding, packaging, or dispensing of drugs and biologicals were performed consistently with state and federal laws. The facility failed to:

A. ensure open dates were logged on medications that were currently in use for patients. The medications that were not dated were antibiotics, germicidal mouthwash preparation and a cardiac intravenous preparation.

B. ensure preparation dates and expiration dates were placed on Intravenous (IV) medications that were prepared by pharmacy prior to administration. There was no way for nursing to determine when the IV medications expired.


These deficient practices were found on 3 of 3 units (Step-down, Intensive care unit,and Telemetry/Medical-surgical unit ) and had the likelihood to cause harm to all patients.


Findings include:



During an observation on 12/5/2017 after 2:15 PM, the following was found on the Step down unit:

One syringe of Chlorhexadine Gluconate solution, germicidal mouthwash, had no preparation or expiration date.
Three bags of 105 milliliter (ml) Keppra, anticonvulsant, had no preparation or expiration date.
One 110 ml bag of Depacon, anticonvulsant, had no preparation or expiration date.

Staff # 21, 22, and 23 confirmed the observation. Staff # 22 reported that the premixed IV bags expire in fourteen days according to pharmacy.



During an observation on 12/6/2017 after 11:40 AM, the following was found on the Med/Surg Telemetry unit:


One tube of Garamycin sulfate, antibiotic ointment, did not have a preparation or expiration date and it was inappropriately stored.
One 250 ml bag of Vancomycin, antibiotic, one 100 ml bag of Protonix, Gastrointestinal medication, one 200 ml bag of Cipro, and two 100 ml bag of Flagyl, antibiotic, which did not have a preparation or expiration date.

Staff #5 confirmed the observation.



During an observation on 12/6/2017 after 530 PM, the following was found on Intensive care unit (ICU):

One 100 ml bag of Flagyl, antibiotic, had no preparation or expiration date.
One 50 ml bag of Merrem, antibiotic, had no preparation or expiration date.
One 250 ml bag of 400 milligram (mg) Inotropin in D5W IV solution, cardiac drug, had no preparation or expiration date.

Staff #22 confirmed the observation.


According to the United States Pharmacopia<797> Resource Guide, dated 2013 revealed the following:

Page 22
"Multiple-dose vials are designed for use beyond a single dose. Unless other wise specified by the manufacturer, the maximum beyond-use date after initial puncture is 28 days."

Page 19
Since compounding sterile preparations requires manipulation of the manufacturer's producet, the date beyond which the CSP(Compounded Sterile preparation) can be used is different from the expiration date. CSPs must be labeled with a beyond-use date, which determined by the compound being prepared and the temperature at which it will be stored.

Based on interview and review of records, the facility failed to ensure radiology staff had documented initial competencies or annual competencies for 15 technicians (Staff #30, 48, 49, 50, 51, 52, 53, 54, 56, 57, 58, 59, 60, 62, and 63) of 15 technicians reviewed for the procedure of starting intravenous (IV) access (placing a catheter into the vein of a patient) on patients requiring IV injections necessary for radiologic studies.

Interview was conducted with Staff #29 and Staff #30 on 12-5-2017. Staff #29 confirmed that technicians within the radiology department routinely performed the procedure of starting IV access on patients who presented to the department for radiologic studies requiring IV injections. When asked how the competencies were assessed for starting IV access, Staff #29 responded, "It's within their scope of practice." When asked again about competencies, Staff #29 stated that Staff #30 monitored the competencies. Staff #30 stated that technicians had initial and annual competencies for starting IV access and for use of existing IV access.

Review of competencies was made. It was found that that there was no initial or annual competency for the procedure of starting IV access.

Based on observation, interview, and record review the facility failed to provide a sanitary environment and have an active program for preventing infections. This deficient practice was found in twelve of the hospital departments (Dialysis, Labor and Delivery, Radiology, Laboratory, Outpatient Laboratory, Outpatient Radiology, Step Down Unit, Intensive Care (ICU), Respiratory, Emergency Department (ED), Medical/Telemetry Unit and Dietary.) The facility failed to:


A. ensure the dialysis department maintained infectious free equipment for the R/O machines.

B. ensure the labor and delivery department maintained a sanitary environment for their L&D rooms, equipment, and the operating rooms where C-Sections were performed. Also, the storage areas in the C-Section area were unkept and disorganized.

C. ensure the radiology department stored Transvaginal probes and Transesophogeal probes per the manufacture guidelines.

D. ensure the laboratory department stored equipment, supplies, and specimens in a sanitary manner that prevented potential contamination.

E. ensure the outpatient laboratoy maintained a sanitary environment and stored patient consumable items in a manner that prevented potential contamination.

F. ensure that outpatient radiology department Computed Tomography Scan (CT Scan) storage room was maintained in good repair and sanitary. The room was found to have holes in the wall dead bugs in the light fixtures.


G. ensure hinged surgical equipment was sterilized in an open position, peel packets of sterilized equipment was dated, and expired sterilized equipment was discarded in the Stepdown unit, Intensive care unit and Emergency department.

H. ensure proper handwashing was performed before and after direct patient care on the Medical-Surgical unit.

I. ensure respiratory supplies were properly enclosed to prevent contamination, supplies were sanitized prior to usage, storage bins were kept clean, soiled equipment was discarded, and the flooring in the supply room was kept clean in the Respiratory department.

J. ensure proper infection control techniques were used in the kitchen. The facility failed to ensure dishes and pans were stored on clean surfaces, dishes in high traffic areas were covered, dishes and pans were properly cleaned before storage, ovens/fryers and refrigerators were cleaned, food was removed from cardboard boxes prior to entrance into food storage areas and refrigerators, staff handling hazardous food used proper infection control techniques, food transport carts were kept clean and repaired, plastic bags of juice and soda were protected from cross contamination, dented cans of food were discarded properly, and proper handwashing was performed during tray preparation and passing of trays to patients.

Refer to tag A 0749 for additional information.

Based on observation, record review, and interview, the infection control officer failed to develop a system that ensured the hospital was a clean and sanitary environment for thirteen of the hospital departments (Dialysis, Labor and Delivery, Radiology, Laboratory, Outpatient Laboratory, Outpatient Radiology, Step Down Unit, Intensive Care (ICU), Respiratory, Emergency Department (ED), Medical/Telemetry Unit and Dietary, Ambulatory Surgery Center.) Also, the facility failed to follow their own policy for cleaning equipment.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:


Dialysis Department:

During a tour on 12/04/17 at 1:00 PM of the Dialysis storage room where the portable R/O (reverse osmosis) machines were stored observed the following infection control issues with Staff #5.

This deficient practice of allowing moisture to remain in the connection tubing for a month had the likelihood to promote microbial growth and mold.

There was a connection tubing coiled and connected end to end hanging on the rail of the R/O machine. Also, observed fluid in the connection tubing. The connection tubing was observed on 2 different R/O machines.

On the back of one of the R/O machine (#81683) observed a wet soaked towel with brown stains that were visible.

An interview with Dialysis Contract Staff #6 revealed that that R/O machine (#81683) had been leaking water and it had not been reported to Bio-medical Technician. Further interview with Staff #6 revealed the connection tubing on the back of the machines was used to drain the machines if the machine tubing could not reach a sink for drainage. Staff #6 was asked when do you change the tubing. Staff #6 stated, "once a month."


An interview with Staff #5 on 12/04/17 at 1:30 PM confirmed the above findings.


Labor and Delivery Department/C-Section Area:

During a tour on 12/05/17 between 9:00 AM and 10:30 AM of the Labor and Delivery area (L&D) observed the following infection control issues with Staff #1 and Staff #11.



During the tour, observed a storage room in #5 labor and delivery room that was cluttered with clean and dirty equipment. The room was in disarray. There was a dirty cloth lying on the floor of the room. Observed vital sign machines, portable light poles, shower chairs, and portable bedside commode chair with a bucket in the seat of the chair. Some of the equipment had plastic bags over them indicating the equipment was clean, but other pieces of equipment had nothing covering the equipment. It was noted that the commode chair had no tape across the lid to indicate it was clean per the facility policy.

During the tour observed a storage room in #6 labor and delivery room, there was a used foam mattress with a sheet covering it on the floor of the storage room. Also there were 2 cardboard boxes of boot covers lying on the floor. There was piece of equipment (portable light Pole) and some type of metal rack leaned against the wall. There was no indication if the equipment was clean or dirty. There were dust and dirt particles observed on the floor.

There was a room off the main hallway of the Labor and Delivery area which had an open ceiling exposing the electrical panel, fire panel, and water piping. That room is where the Ultrasound machine was stored. The room was not designed to store clean equipment for patient care.

Upon entrance to L&D #5 and #7 observed an extra bed in the doorway of each room, the beds were not covered with sheets. There was no indication if the beds were clean or dirty. These beds were sitting in the clean labor and delivery rooms.

In L&D #7 observed a white substance on the front of the cabinet door. Surveyor took a wet paper towel and was able to wipe the white substance off the cabinet. The room was set up and noted clean to receive a patient in labor. The doors were missing on part of the cabinet, and exposed electrical wires and outlets were observed. Also, observed raw exposed wood framing inside the cabinet where the monitor was sitting. Unpainted or unsealed wood cannot be cleaned from contaminated infectious waste.

The cart in the triage room was covered in dust and dirt particles.

A review of the policy titled, "Cleaning of Medical Equipment to prevent the spread of infection" revealed the following:

"References and Citations:
Purpose:
The purpose of this policy is to establish guidelines for relevant cleaning measures for the control and prevention of infection in the hospital.
The physical or chemical method used to remove or reduce the capacity of microorganisms, which produce disease, does not kill spores so it cannot be called sterilization. Patient care items and reusable equipment can be disinfected by chemicals and are safe for reuse. Uses of these chemical processes have limitations and chemicals should be used only as directed.

This policy will discuss the following equipment:
Durable Equipment Cleaning
Laryngoscope handles
Wireless Phones
Workstations On Wheels (WOWS)
Cleaning of Computers
Terminal Cleaning of equipment in Women's Services
Patient-Owned Equipment Policy

Durable Equipment Cleaning

lt is the responsibility of nursing staff to clean the following reusable patient care equipment such as/but not restricted to: blood pressure machines, telemetry boxes, glucometers etc.

All items to be disinfected must he clean. (Organic soil such as blood, feces and tissue must be removed) IV pumps glucometers, telemetry boxes, will be wiped down with the hospital approved disinfectant (i.e. Sani cloth) daily and cleaned every time after each patient use.

After IV pumps are cleaned, a plastic bag will be placed over the pump to indicate that the machine has been cleaned and is ready for patient use. Nursing staff will know that the pump is soiled and not ready for use unless the plastic bag is in place. As a safeguard, the nurse will wipe down any uncovered pump before putting pump into use on patient.

Sani-Cloth Germicidal Disposable Cloths are to be used for disinfecting reusable equipment.

Bedside commodes and IV pumps will be cleaned by housekeeping department. A paper tape will be placed over the commode lid to indicate that the toilet has been cleaned and is ready for patient use. Nursing staff will know that the toilet is soiled and not ready for use unless the paper tape is in place. A plastic garbage bag will be placed over the IV pump after it is cleaned. Staff will use this as an indication the IV pump has been cleaned and is ready for patient use."



C-Section Area: This area had 2 operating rooms for C-sections and this area was labeled "Operating room attire beyond this point."


In the suture room which was located in the C-section area, there were miscellaneous items in the sink. The sink had sterile gloves, parts of suction equipment, suction canister, and piece of metal bar. Observed on the ledge of the sink was a sterile plastic bundle of surgical attire and on the other side of the sink were more sterile supplies.

Under the sink observed brown water stains, dust, dirt, and bugs.

On the floor behind the wire rack of sterile supplies was a pair of sterile gloves lying on the floor.

There were 12 rolls of (6 inch) sterile and unsterile tape on the bottom shelf of the wire rack with no barrier. This type of tape was used to tape across the dressing of the patient's abdomen after a C-section surgery. There was no barrier to prevent dust during sweeping and splashing when mopping the floor.

The suture room appearance was unclean, cluttered, and disorganized.

In operating room #1, the housekeeping staff had just cleaned the room. Observed an open surgical blade package on the shelf in the operating room. Also, when checking the foam mattress padding on the operating bed, it was observed that the padding was still wet under the mattress. The cleaning agent cannot disinfect until the agent is completely dry. The operating bed was already made with sheets and set up for the next surgical procedure.

The yankauer suction handle on the anesthesia machine was open and connected to the suction tubing. There was no way to determine if the yankauer handle had been used in the previous case.

The handwashing sink in the medication room between the 2 operating rooms had a white substance in the sink. The cold water handle did not work. The spout on the water outlet was rusted. There were no paper towels in the holder. A box of shoe covers on the sink was blocking the empty towel rack. Also, beside the sink was a blue plastic container that had a brown dried substance in the bottom of the container.

There was a dirty utility room which was located behind the sterile line that was located near the C-section operating rooms. In this room observed 2 cardboard boxes on the shelf. On the floor beside the hopper was the sink drain cap. The floor had an unclean appearance with dust and dirt particles.

The sealant around the sink had come loose, leaving a crack in the Formica allowing water and infectious waste to enter the crack.

In the cabinet shelves observed multiple labels labeled, "Treated Solid Medical Waste" which were scattered all over the shelf. There was a gray plastic bin that contained bottles of surface cleaners, but the bin was rusted and dirty in appearance. The shelf was cluttered with plastic bags and empty plastic bottles in a disorganized matter.


"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Card board boxes harbor parasites, insects, and microorganisms.

Temperature and Humidity logs:

During the tour of the C-section operating rooms and the surgical area the temperature and humidity logs were reviewed. The following issues were found:

A review of the log for operating room #3 noted that there was a temperature out of range on 10/15/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in the operating room #3.

A review of the log for operating room #3 noted that there was a temperature out of range on 11/05/17 and 11/14/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in the operating room #3.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 10/26/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 11/15/17, 11/22/17, and 11/29/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #1 noted that there was a temperature out of range on 12/05/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #1.

A review of the log for L&D operating room #2 noted that there was a temperature out of range on 10/12/17, 10/26/17, and 10/30/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #2.

A review of the log for L&D operating room #2 noted that there was a temperature out of range on 11/28/17 and 11/29/17; which was noted on the log and the temperature was adjusted on the thermostat. There was no follow-up to acknowledge if the adjustment corrected the temperature in L&D operating room #2.


Review of the AORN Perioperative Standards and Recommended Practices, "Temperature should be maintained between 68 degrees F to 73 degrees F (20 degrees to 23 C) within the operating room suite and general work areas in sterile processing.

"Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.

Low humidity increases the risk of electro static charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed. Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."


Radiology:


During a tour of the ultrasound room in the radiology department on 12/05/17 at 4:00 PM observed storage issues with the Transvaginal probe and transesophageal (TEE) probes.

This deficient practice had the likelihood to cross-contaminate the Transvaginal probe and Transesophageal (TEE) probes.

If there is any moisture on the probes, condensation can occur inside the plastic bags and microbial growth could occur. A porous surface, like wood, holds moisture and dirt and would promote microbial growth and mold. The probe holder system was located in a high traffic area, exposing probes to potential damage or cross-contamination.

The transvaginal probes were stored on a wooden rack with plastic bags covering the probes. The wooden rack was in the main ultrasound room where procedures were being performed on patients.

The Transesophageal TEE probes (2) were coiled up in a white plastic bag inside a plastic drawer near the floor in the main ultrasound room where procedures were being performed on patients.


A review of the manufacture's guidelines revealed the following:
"Store the device in a manner that will protect them from damage or contamination. The manufacture's recommendations are to hang the probes vertically in a cabinet and store in a clean environment."

An interview with Staff #29 on 12/05/17 at 4:30 PM confirmed the above findings.




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Laboratory:

On 12-5-2017 the following conditions were observed in the laboratory:

Cardboard shipping boxes were being used in the laboratory on top of counters, under counters, and in cabinets to collect papers for shredding and store parts for lab equipment. Shipping boxes can harbor pests and bring contaminants into the hospital and laboratory setting.

Uncovered pipettes for drawing up solutions to be used in lab testing were left exposed in a drawer with markers, pencils, and miscellaneous supplies. A piece of wire identified for use to dislodge "hung-up curettes" was stored in a biohazard waste bag in the same drawer.

A sterile swab with the expiration date of 08/2000 was found in a drawer.

Spare parts for lab analyzing equipment were stored in a drawer with hand lotion.

Lab equipment control solution and primer solution stored in drawer with caulking and electrical tape.

The specimen freezer was visible soiled with dust, dirt, and rust. The seal at the bottom of the door had been repaired with gaps in the seal that allowed dirt and bacteria to collect.

A drawer front was missing, exposing the unfinished porous material. This would allow spills with contaminants to be absorbed into the material.

Printer ink cartridges, lab equipment liquid agents, and patient lab supplies were being stored together.

A cushioned floor mat was cracked and had a corner missing, exposing the foam cushion to contaminated spills. The bottom of the mat was caked with dust and dirt.


Outpatient Laboratory:

On 12-6-2017 a tour of the outpatient laboratory was made.

A lower cabinet door front had evidence of a spill. The laminate at the bottom of the door was lifted away from the door material, allowing spills to collect and harbor bacterial growth.

Glucose solution intended for patients to ingest for blood glucose testing was being stored in a refrigerator with a biohazard label and signage that read, "No Food Consumption". Laboratory equipment control solutions were stored in the refrigerator.



Outpatient Radiology:

On 12-6-2017 a tour of the outpatient radiology was made.

The Computed Tomography Scan (CT Scan) storage room had holes in the wall. Overhead light fixtures had dead bugs in them.




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During observations the following was found:


Step Down Unit:

On 12/5/2017 at 2:20 p.m., a pair of forceps was found in the emergency airway cart in the step down unit. The instrument was enclosed in the sterilization pack and there was no date of sterilization on the peel pack. Staff #23 confirmed the observation.

ICU:

On 12/6/2017 at 5:35 p.m., two pacemaker cords were found in the ICU supply cabinet in sterilization packs. There was no sterilization date on one of the peel packs and the other peel pack was dated 2013. Staff #22 confirmed the observation.

On 12/6/2017 at 5:45 p.m., peel packs were found hanging in the ICU supply room which included forceps and hemostats that were dated 2006, 2012. 2013. There was a sterilized linen set that was dated 2006.

ED:

On 12/7/2017 at 916 a.m., a hemostat in the ED was found in a sterilization peel pack and stored in a supply cart. The hemostats had been sterilized closed and was not dated. Staff # 43 confirmed the observation.



According to the Centers for Disease Control and Prevention (CDC) article, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at
:http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, documented on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.


Review of the manufacturer insert named "STERILIZATION PACKAGING: SHELF-LIFE STUDY" revealed the following information about the sterilization packs the facility were using:

"The 100% success in maintaining sterility over a 52 week period demonstrates that, with the proper use of Vital Care Reps., Inc. and Vital Care Industries, Inc.* packaging, all of the various formats i.e. tubing, heat-seal and self-seal pouches are effective means of storing sterile supplies for a minimum of 52 weeks."

During an interview on 12/11/2017 after 4:29 p.m., customer service representative #74 reported that they only validated sterilization for one year.


MedTele/Medical Surgical Department:

During an observation on 12/6/2017 after 10:34 a.m., Staff #38 went into a patient's room and took vital signs. Staff #38 did not sanitize her hands prior to entering or exiting the patient's room.



Respiratory department:


During an observation on 12/4/2017 after 1:25 p.m., the following was found:

Respiratory supplies being used were found in a drawer unbagged.
Inside the airway lockbox was a syringe/needle kit which was soiled with dried blood.
Oxygen supplies used for respiratory treatments were stored in soiled plastic bins.
The tile flooring underneath the respiratory supply shelf had a build-up dust and dirt.
A pulse oximeter probe was found soiled with dried blood.

Oxygen flowmeters were stored in a drawer and they were not bagged to indicate they were clean. An unidentified respiratory staff member was observed to get a flowmeter out of the drawer and left the respiratory department with the flowmeter. The flowmeter was not cleaned during the observation.

Staff # 8 confirmed the observation.

Review of the facility's policy named "Disposable Equipment Change Out "dated 1/20/2017 revealed:
"All reusable equipment will have surfaces wiped with hospital approved disinfectant and then bagged with equipment cover, indicating clean and ready for use."



Kitchen:

During an observation of the kitchen on 12/5/2017 after 8:30 a.m., the following was found:


Dish storage/drying rack near the dishwashing room were found with clean dishes stored on them. The racks were soiled with a build-up of debris and one rack had sections of the protective coating missing. The rack could not be properly sanitized.

Dish and pan storage racks near the three compartment sink had clean dishes stacked on them. When pans were pulled off the shelf they were found to be soiled with dried food and dried water marks.

The dish and pan shelves had no covering over them and they were next to a high traffic area and the dishwashing area.

Clean pans were stored on the counter of the three compartment sink. Staff failed to store the pans on a drying rack. A rolling cart was sitting outside of the three compartment sink area. On top of the cart was a tray which had bloody water in it.

Adjacent to the cart near the three compartment sink were shelves of clean pans, holding racks and pots which were stored on a shelf that was soiled with dried food and spills.

The can opener had a build- up of debris and was rusted. With the rust on the can opener there was no way it could be sanitized.

Inside the dish room there was a foul odor which could be smelled next to the sink. Staff #76 took the top off the trash can and it was found to have standing water. Staff #76 reported that someone had put fish in the trashcan and she had put the water in the trash can the night before.

The two stand up refrigerators between the main kitchen and the serving prep area for the public were found to be soiled with dried food and spills. The rubber sealant around the doors of the refrigerator was soiled with a build of dried spills. Food was stored in these refrigerators that had soiled dried food in them.

The Hot food storage unit in the same area was soiled with food spills and a build build-up of grease.

Six large plastic bags of juice and soda for the beverage dispenser machine were found stored in open pans underneath the food prep area. The bags nor there spouts were covered. Staff #75 was prepping fish and chicken on the counter above the bags.

Breakfast food was still stored on the steam table. The crevices around the steam table were soiled with a build-up of dried food.

The toaster was found to have a build-up of food debris inside the bottom panel.

The Seran wrap holders were found to have a build-up of food spills in the bottom panel and food debris in the crevices. The white grout in between the tiles next to the Seran wrap area had a build-up of black substance.

The inside walls and the top of the microwave were soiled with a build-up of dried food.

The outside doors and the inside of the Confection Ovens were soiled with dried food and a build-up of grease. One of the ovens had chicken cooking in it.

The bottom inside panels and flooring of the deep fryer had a build-up of grease and black particles.

There were cardboard boxes with food items being unloaded in the dried food area, refrigerator, and freezer area.

Two of the food transport carts had plastic mesh coverings that was soiled. One of the coverings had a broken zipper and would not close up.

There was a shelf in the kitchen that had expired and dented cans of food stored on it. The sign indicating what was on the shelf was not visible.

Staff #'s 13, 14, 15, & and 16 confirmed the observations.


During the meal prep Staff #75 was observed prepping chicken. Staff #75 was observed to leave the meat prepping area and go to the heating box. Staff #75 opened the heating box without removing his soiled gloves.

During tray preparation Staff #20 was observed to drop a food item off a tray. Staff #20 picked the item up and placed it back on the tray. Staff #20 failed to remove her gloves and sanitize her hands prior to placing the item back on the tray.


While passing meal trays on the Step down unit, Staff #24 was observed assisting with passing trays. Staff #24 removed a tray from a patient's room and returned it to the tray cart in the hallway. Staff #24 removed another tray off the meal cart and failed to sanitize her hands first.


Review of the "INFECTION CONTROL ROUNDS" sheets for October and November 2017 revealed staff #13 (infection control nurse) documented some of the same problems identified during the survey which were not corrected.


A review of a facility's policy named "FOOD AND SUPPLY STORAGE" and dated 1/2017 revealed the following:

All food, nonfood and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Date and rotate items; first in, first out (FIFO) discard food past the use-by or expiration date.

Maintain designated area for items that are damaged (such as dented cans that are to be returned for credit. Post sign, "Return to Supplier" (MQAS-2)

.
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Card board boxes harbor parasites, insects, and microorganisms.



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Ambulatory Surgery Center

During a tour of the Ambulatory Surgery Center Department on 12-5-2017 at approximately 9:35am with staff #1 and #10, wheelchairs and a dirty linen cart were observed being stored in an inset in the hallway where patients were being made ready for surgery. When asked if the wheelchairs were dirty and place there for cleaning.
Staff #1 and #10's response was the wheelchairs are clean. We will remove the dirty linen.

An interview on 12-5-2017 at approximately 10:30am with staff #1 and #10 confirmed the above findings.

Based on record review and interview, the surgeon failed to complete a History and Physical prior to the surgical procedure on 1 (#13) of 10 surgical records reviewed. The surgeon failed to follow the Medical staff "Rules and Regulations per Article II, Medical Records". Also, the facility failed to follow their own policies on "History and Physical Content Management" and "Content of the Medical Record".


A review of Patient #13's record revealed there was no History and Physical form from the surgeon prior to the patient having a surgical procedure on 09/16/2017. A review of the progress notes by the surgeon did not indicate a medical emergency.

A review of the medical staff rules and regulations "Article II Medical Records, 2.3 Scheduled Operations/Diagnostic Procedures" revealed the following:

"A history and physical exam must be recorded before all surgical procedures and invasive diagnostic procedures, whether inpatient or outpatient. When a history and physical examination, pertinent laboratory, x-ray, and EKG reports are not recorded before a scheduled operation or any potentially hazardous diagnostic procedure, the procedure shall be canceled unless the attending Physician documents that such delay would be a threat to the patient's health."


A review of the facility's policy titled, "History and Physical Content Management" revealed the following:

"PURPOSE: To outline the required content and process for completing the history and physical for patients treated at the .

II. POLICY:
1. A medical history and physical examination (H&P) must be completed and documented within 24 hours following admission or prior to surgery, whichever comes first.
2. An H&P performed prior to admission (within 30 days of admission) may be accepted, but must be accompanied by durable, legible practitioner documentation indicating the H&P was reviewed, the patient examined and noting changes or the lack of changes in the patient's condition. An update to the H&P must be completed and documented within 24 hours after admission or prior to surgery/procedure when utilizing such an H&P.
3. The H&P must be performed and authenticated by a practitioner who is authorized to do so by the Medical Staff.
4. The medical history and physical examination must be completed and documented by a physician, surgeon, or other qualified licensed individual in accordance with state law and facility policy.
More than one qualified practitioner can participate in performing, documenting and authenticating an H&P for a single patient.
When performance, documentation and authentication are split among qualified practitioners, the practitioner who authenticates the H&P is responsible for the content."

A review of the facility's policy titled, "Content of the Medical Record" revealed the following:


"PURPOSE:
To define the contents of patient medical record, whether in paper or electronic format, promotes efficiency and effectiveness of treatment.

DEFINITIONS:
A. Medical Record- The collection of information concerning a patient and his or her health care that is created and maintained in the regular course of business made by a person who has knowledge of the acts, events or diagnoses relating to the patient.
The medical record may include records maintained in an electronic health record system, e.g. an electronic system framework that integrates data from multiple sources, captures data at the point of care.
B. EMR/EHR- Electronic Medical/Health Record
C. Authentication- To establish authorship by written or electronic signature
D. Physician/Practitioner- For the purpose of the policy, physician/practitioner includes physicians, dentists, podiatrists, advanced practice nurses, physician assistants, and other credentialed practitioners who give orders.

III. PROCEDURE:
A. All medical record entries, including handwritten and electronic, must be legible, complete, true and accurate, dated, timed and authenticated by the person responsible for providing or evaluating the services provided, consistent with hospital policies."

An interview with Staff #11 on 12/5/2017 at 3:00 PM confirmed the above findings.

Based on record review and interview, the surgeon and anesthesia provider failed to sign, date, and time the Disclosure and Consent form on 2 (#11, and #17) of 10 surgical records reviewed. Also, the facility failed to follow their own policy on Informed Consent.

A review of Patient #17's record revealed the Disclosure and Consent form was not timed by the surgeon. There was no way to determine if the patient was seen by the surgeon prior to surgery.

A review of Patient #11's record revealed the Disclosure and Consent form was not signed, dated, or timed by the anesthesia provider.

A review of the facility's policy titled, "Informed Consent" revealed the following:

"To insure that proper consent is obtained prior to the designated procedure. To insure that permits are accurately completed.

POLICY AND GENERAL INFORMATION:
1. All patients admitted to our hospital must have an authorization for treatment sheet on their chart signed by the proper person, dated and witnessed prior to a designated procedure.

2. Informed written consent for all procedures must be obtained prior to any invasive procedure. Physician will inform patient of risks, benefits, hazards, and alternatives, and sign consent form or document in progress notes and on history and physical. The purpose of a written consent form is to provide proof that there was a valid consent. The consent itself is not a substitute for the role of the physician in the informed consent process. A signed entry in the physician's progress notes should be made documenting that informed consent was obtained and that the patient was made aware of and understands the risks and possible complications and agrees to the planned procedure, if the informed consent is not signed by the physician."

INFORMED CONSENT FOR PATIENTS RECEIVING ANESTHESIA:

It is the policy of the facility that the patient must be given the opportunity to give an "informed consent" prior to the administration of anesthesia by an anesthesiologist and prior to the performance of operative and/or invasive procedures, diagnostic or therapeutic procedures, or situations when it is deemed advisable to have formal documentation of the patient's consent for treatment. Written verification of the informed consent must be on the patient's chart prior to initiation of anesthesia or any of the above stated procedures.

Informed written consent for all procedures must be obtained prior to any invasive procedure. Physician/staff will inform patient of risks, benefits, hazards, and alternatives, and sign consent form or document in progress notes and on history and physical. The purpose of a written consent form is to provide proof that there was a valid consent. The consent itself is not a substitute for the role of the physician in the informed consent process. A signed entry in the physician's progress notes should be made documenting that informed consent was obtained and that the patient was made aware of and understands the risks and possible complications and agrees to the planned procedure, if the informed consent is not signed by the physician.

Concept of Informed Consent must consist of:

*The risks, drawbacks, complications and expected benefits or effects of anesthesia
*Alternate choices of and to anesthesia
*The nature of the treatment
*The risks, drawbacks, complications and expected benefits or effects of such treatment
*Potential problems related to recuperation
*Any alternatives to the procedure and their risks and benefits
*The likelihood of success
*Possible result of non-treatment
*Verification that the patient understands the information
*Confirmation that the patient has been verbally informed about the anesthesia or procedure
*An opportunity for the patient to ask questions
*If any limitations in the confidentiality of patient information is discovered from or about the patient, the information will be documented in the progress notes
*Is needed for complex procedures, not for simple and common procedures (i.e., blood counts) and is needed for any procedure where anesthesia is planned.

Obtaining Informed Consent:

*It is the anesthesiologist and/or treating physician's responsibility to obtain the informed consent.
*Facility personnel cannot be involved in providing information that is necessary for informed consent-only the physician and/or anesthesiologist can provide the information.

The informed consent form is prepared by the attending physician or operating physician and is discussed with the patient by the physician:

*Supplemented with verbal discussion, and/or Supplemented through written additions that give further information relevant to the patient's condition.
*Medical information set forth needs to be written in clear, simple and easily understood terms.
*Documentation must clearly indicate that the patient has had the opportunity to ask any and all questions he/she may have about the proposed anesthesia and/or procedure."

An interview with Staff #11 on 12/05/2017 at 3:00 PM confirmed the above findings.

Based on observation, interview and record review the facility failed to :


A. ensure 4 of 37 sampled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as weapons and as ligatures for hanging or strangulation.

Patient #37 took approximately 75 tablets of 325 mg Aspirin trying to kill herself prior to presenting to the Emergency Department (ED). Patient #37 was placed in a room which had ligature hazards.

B. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

C. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that the deficient practice posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychiatric services at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Refer to tag A1101 for additional information.

Based on observation, interview and record review the facility failed to :

A. ensure 4 of 37 sanpled patients who were at risk for suicide were placed in a safe setting and their rights were protected (Patient #'s 31, 34, 35 and 37). Patients were placed in rooms that were unsafe and were with ligature hazards. When the ceiling tiles were pulled back in the room there was wiring, metal bars, and flexible metal conduits that could be used as knives and as ligatures for hanging or strangulation.

Patient #37 took approximately 75 tablets of 325 mg Aspirin trying to kill herself prior to presenting to the Emergency Department (ED). Patient #37 was placed in a room which had ligature hazards.

B. ensure patients who were at risk for suicide were assessed accurately and placed on the appropriate monitoring. There was no documentation to show patients at risk for suicide were being monitored.

C. ensure patients who were at risk for suicide received continuous supervision. There was no documentation that patients who were assessed as requiring 1:1 supervision received that type of monitoring. Physician's orders were not received for the level of supervision the patients were assigned.

It was determined that this deficiency posed an Immediate Jeopardy to patient health and safety, and placed all patients receiving psychological services at risk for the likelihood of harm, serious injury, and possibly subsequently death.



Findings include:



During an observation of the Emergency department (ED) on 12/07/2017 after 10:00 a.m., the following was found:


Room #3 was identified as the room used for psych patients by Staff #43. The room did not have a hardened ceiling. The ceiling was a drop down ceiling with ceiling tiles within a metal frame. When the ceiling tiles were pulled back there was wiring, metal bars, and flexible metal conduits that could be used as weapons and as ligatures for hanging or strangulation. There was a water sprinkler and an air vent in the ceiling that posed a ligature risk.

Staff #43 confirmed knowing about the hazards.




Review of the ED record on Patient #31 revealed she was a 59 year old female who presented on 12/02/2017 at 7:33 a.m.. Patient #31 presented with suicidal ideation's and was placed in Room #3.

At 7:35 a.m., Patent #31 stated "I am hearing voices and I am suicidal, and I'm having marriage problems,.." Patient #31 was given an acuity level of 2 (meaning urgent).

At 7:40 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Do you feel hopeless or helpless? Yes
Have you had thoughts of suicide in the past? Yes
Are you having thoughts of suicide now? Yes
Have you previously attempted suicide? Yes
Do you have a plan to hurt yourself or someone else? Yes

Patient #31 was assigned a suicide risk level of 2 (meaning high risk). The type of supervision assigned was for continuous visual surveillance. There was documentation that observation should be performed at all times by designated staff with direct line of sight. "..Remove and secure personal items. Patient is placed in a hospital gown."

At 8:20 a.m. there was documentation that the police department was there to see Patient #31.

At 9:00 a.m., there was documentation that the behavioral center was there to evaluate Patient #31.

At 2:18 p.m., (almost 7 hours later) Patient #31 left the ED (transferred out to a higher level of care).

There was no documentation of who was monitoring Patient #31 and how often.

There was also no documentation of a physician's order addressing the level of supervision Patient #31 was to be placed on.

Staff #43 confirmed the problems with the monitoring and there be no documentation of who was monitoring Patient #31. Staff #43 reported the gown placed on Patient #31 would have been a paper gown.






Review of the ED record of Patient #34 revealed he was a 5 year old male who presented on 11/08/2017 at 8:30 p.m., with complaints of suicidal ideation and behavior disorders.

Review of nursing documentation at 8:52 p.m., revealed Patient #34 was assigned an acuity level of 1 (meaning emergent).

At 9:04 p.m., Patient #34 was assigned a suicide risk level of 1 (meaning immediate high risk with continuous visual surveillance (line of sight) and 1:1 observation). There was documentation by nursing that the mother and father was at the bedside.

At 11:12 p.m., discharge orders were given for Patient #34 to be discharged home with his family. Patient #34 was to be seen in the a.m. by the behavioral center.

At 11:13 p.m., Patient #34 left the ED.

Review of the ED record revealed no documentation of the monitoring to indicate the mother and father remained at the bedside.

There was also no documentation of a physician's order addressing the level of supervision Patient #34 was to be placed on.




Review of the ED record on Patient #35 revealed she was a 58 year old female who presented on 11/04/2017 at 2:51 a.m... Patient #35 presented with complaints of suicide ideation's and hallucinations and was placed in Room #3.

At 2:54 a.m., Patient #35 was assessed as having an acuity level of 1 (meaning emergent). There was documentation that Patient #35 was hearing voices and they were telling her to hurt herself and family members.

At 3:00 a.m., the Suicide Risk Assessment revealed some of the following questions were asked:

Thought of suicide in the past? Yes
Thought of suicide now? Yes
Do you have a plan to hurt yourself or someone else? Yes

At 3:27 a.m., Patient #35 was assigned a suicide risk level of 3 (meaning moderate risk).



According to the facility's policy dated 05/26/2015 and named "ER-Suicide Risk Assessment and Interventions in Acute Care Setting" the following was documented:

"Moderate Risk Patients (Level 3):
Possible danger to self or others. Observed restless or impulsive behavior, intrusive or disordered, confused/withdrawn, dazed or anxious, ambivalent about treatment. Not likely to wait for treatment. History of suicide attempt without current ideation or plan; presence of mood disturbance; symptoms of depression and/or anxiety (socially withdrawn, acute change in previously enjoyed activities), elevated or irritable mood, angry.
o LEVEL OF SUPERVISION: Close observation.
o If patient subsequently elopes from the patient care unit and returns, then increase level of observation."


According to the facility's policy this was the definition for close observation:

"..C. Close observation: Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals of at least every 15 minutes. Supportive family/friend must receive education from staff and agree to communicate with staff and seek staff assistance for any concerns..."


Patient #35 had current suicide ideation and a plan. The facility inaccurately assessed Patient #35's supervision level and plan.

According to the ED record Patient #35 was placed on observations by staff at an every 15 minute interval.

According to the ED notes Patient #35 was discharged to a higher level of care at 8:36 a.m. (over 5 hours after presenting).

There was no documentation of the every 15 minutes observation on the record nor 1:1 observation during this timeframe.

There was also no documentation of a physician's order addressing the level of supervision Patient #35 was to be placed on.

Staff #43 confirmed the problems with the assessment and monitoring.





Review of the ED record of Patient #37 revealed she was a 17 year old female who presented to the ED on 10/30/2017 at 8:58 p.m.. Patient #37 presented for poisoning by aspirin, intentional self-harm and suicidal ideation's.

Review of nursing documentation at 8:59 p.m., revealed Patient #37 "took aprox 75 tablets of 325 mg asa at about 1930 to kill herself and the baby she may be carrying." Patient # 37 was accompanied by her mother according to documentation.

Patient #37 was assessed as having an acuity level of 2 (meaning urgent).


At 9:01 p.m., the Suicide Risk Assessment revealed some of the following questions were asked:


Do you feel hopeless or helpless? Yes
Have you had thoughts of suicide in the past? Yes
Are you having thoughts of suicide now? Yes
Have you previously attempted suicide? No
Do you have a plan to hurt yourself or someone else? Yes

Patient #37 was assigned a suicide risk level of 2 (meaning high risk). The type of supervision assigned was for continuous visual surveillance. There was documentation that observation should be performed at all times by designated staff with direct line of sight. Remove and secure personal items. Patient was placed in a hospital gown.

At 10:00 p.m., nursing documented that Patient #37 was "laughing and joking with mom before mom left ..."

At 10:58 p.m., Patient #37 supervision was elevated to a suicide risk level of 1 (meaning immediate high risk with continuous visual surveillance (line of sight) and 1:1 observation).


According to nursing documentation at 10:58 p.m., Patient #37 "belongings collected and placed in blue scrubs, room must keep monitor in place per md orders and poison control recommendation for continuous monitoring, patient within view of desk."

Review of facility's monitoring form revealed Patient #37 was being monitored every 15 minutes from 9:00 p.m. - 11:30 p.m. There was no other documentation of the continuous monitoring from 11:30 p.m. - 3:35 a.m.

Review of nursing documentation at 3:35 a.m., Patient #35 came off the higher level of psych (monitoring) at this time.

Staff #43 confirmed Patient #35 came off of psych monitoring at 3:35 a.m., and he could not find any documentation of monitoring after 11:30 p.m...

During an interview on 12/07/2017 after 12:30 p.m., Staff #47 reported that their protocol for suicidal patients was to strip them of everything and place them in paper scrubs. They would call the behavioral center to evaluate the patient and try to find placement. The 1:1 supervision was supposed to be the nurse or police department. When the patients are on close observation the door to their room is left open where the patient can be seen. Staff #47 reported she would probably have other patients to take care of also. The staff were supposed to document in the chart every 15 minutes on the patients when they were being monitored.










Review of a facility's policy dated 05/26/2015 and named "ER-Suicide Risk Assessment and Interventions in Acute Care Setting" revealed the following:


"All patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will receive an initial assessment to determine suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients from inflicting harm to self or others.

PURPOSE:
To identify patients at risk for suicide and provide safety interventions (applicable to all patients in organizations surveyed under the Behavioral Health Care standards, all patients in psychiatric hospitals, and to any patient in a general hospital with a primary diagnosis or complaint of an emotional or behavioral disorder, including those related to substance abuse) .....


Levels of Supervision

A. Continuous visual surveillance - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately, De-escalation techniques will be used as appropriate.

B. Continuous visual surveillance. Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight to patient. If de-escalation techniques are ineffective, patient will be escalated to Acuity 1.

C. Close observation: Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals of at least every 15 minutes. Supportive family/friend must receive education from staff and agree to communicate with staff and seek staff assistance for any concerns.

D. Intermittent observation: Observation at a minimum of 30-minute intervals by clinical staff.

E. General observation: Routine check by clinical staff at a minimum of one-hour intervals.

PROCEDURE:

A. Trigger Questions:

A licensed healthcare professional will screen for suicide risk by identifying those patients with a primary diagnosis or primary complaint of an emotional or behavioral disorder including substance abuse, or by identifying those patients at risk based on objective or subjective symptoms (even if not a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse).

1) If a licensed healthcare professional suspects a patient presentation may be the result of self harm (i.e., sole victim of unwitnessed trauma, new terminal diagnosis, family report, etc.), the following trigger questions at the top of the Suicide Risk/Behavioral Disorder Assessment will be asked of the patient (if screening all ED patients, may utilize the first three questions):
a. Do you feel hopeless or helpless?
b. Have you had thoughts of suicide?
c. Are you having any now?
d. Have you previously attempted suicide?
e. Do you have a plan to hurt yourself or others?
2) If patient is not presenting with primary complaint of emotional or behavioral disorder or
substance abuse, and answers "NO" to all questions, sign, date and time bottom of form.
3) If patient answers "yes" to any of the initial questions, complete the Suicidal Risk/Behavioral Disorder Assessment.

B. A Registered Nurse (RN) will assess the patient presenting with primary complaint of emotional or behavioral disorder or substance abuse or displaying symptoms of an emotional or behavioral disorder utilizing the Suicide Risk/Behavioral Disorder Assessment.
1. Ask trigger questions at top of Suicide Risk/Behavioral Disorder Assessment and document patient answers.
2. Complete the Suicide Risk/Behavioral Disorder Assessment even if the patient answers "No" to the trigger questions.
3. Select the indicators in the columns titled "Observed" and/or "Reported" which most closely apply to the patient's situation or behavior.
4. Then identify the appropriate acuity in the first column that correlates with the HIGHEST level of observed or reported factors.
a. From highest acuity (Acuity 1) to lowest-acuity (Acuity 5)
5. Selection of the applicable acuity box identifies the interventions that are being implemented.
6. Substance abuse and/or intoxication can co-exist with other behavioral or emotional disorders. Consider observed and reported factors and assign highest level of acuity. Note: Behavior can change over time as substance/alcohol is metabolized. Be aware of the potential for risk of DTs in the presence of chronic alcohol abuse and respond to change in behavior as appropriate.
7. Physician is to sign Suicide Risk/Behavioral Disorder Assessment, note date and time, and select either reviewed, no added orders, or reviewed, see added orders.
a, Additional orders are to be documented as MD order.
8. Behavioral health clinician, psych evaluator, on-coming nurse during change of shift, etc. will sign as "other", and note date and time of review.
9. The Frequent Observation Flow Sheet is to be utilized for documentation for all patients on whom a Suicide Risk/Behavioral Disorder Assessment is completed.
a. Use form even if observation is less than every 15 minutes.
b. Check box at top of form to indicate level of observation implemented.
C. Physician orders for the level of suicide precautions will be initiated immediately. Suicide precautions can be initiated by nursing staff, in the absence of a physician, with documented reasons based upon the Suicide Risk/Behavioral Disorder Assessment screening tool and nursing assessment. This information shall be recorded in the medical record, and the patient's physician shall be notified as soon as possible to obtain an order for the level of suicide precautions ....
D. Any patient with an identified suicide risk will be referred to a mental health or behavioral health professional for assessment and treatment planning and provided community resources if discharged.
E. The level of suicide risk and need for suicide precautions must be reassessed by the qualified medical provider or Registered Nurse if there is an observed or stated change in behavior, and at least every 24 hours. Notify the physician if the assessment changes the level of precautions indicated. Only the physician can order the discontinuation or change in suicide precautions. The physician must document current clinical status and rationale for continuing, modifying, or discontinuing precautions.
F. General Safety Interventions to keep patient safe from harm to self or others:
o Referral by physician order to obtain psychiatric/behavioral health consult.
o Clinical status and patient safety documented every 15 minutes for acuity 1, 2 and 3 patients.
o Ensure a safe environment:
o Complete Psych-Safe Room Check List
o Remove all needles, sharps and sharps containers from patient's room
o Inventory and secure patient personal items and remove potentially harmful items from the room.
o Diet is ordered with plastic ware and non-breakable dishes. No silverware or
aluminum cans.
o Remove hanging hazards such as rope blinds, call cords, curtains, shower curtains in room and clothing items such as belts, ties, head band or bandanas, shoelaces. May replace patient clothing with paper gown, hospital gown and/or pajamas.
o Search belongings brought in by visitors for any harmful items.
o Staff to stay with patient during medication administration to ensure patient has
taken medication.
o Identify and remove or replace with breakaway hardware in bathing facilities and
observation during shower/bath, if available; otherwise maintain visual surveillance and/or utilize bedside commode. Remove bedside commode from room after each use.
o Every shift, room searches will be conducted for potentially harmful items, utilizing
Psych-Safe Room Check List. Items brought in by visitors will be searched prior to
being given to patient; i.e. Flowers, fruit baskets, books, magazines, clothing, etc ....




G. Interventions Relative to Level of Suicide Risk:

Immediate Risk Patients (Level 1):
Severe behavioral disorder with immediate threat of dangerous violence. As evidenced by observed violent behavior, possession of a weapon, self-destructive acts or behavior that resulted in self-harm; reported verbal commands to do harm to self or others that the person is unable to resist (command hallucinations), recent violent behavior, reported violent/self-destructive behavior or behavior that has resulted in harm to self or others, including actual suicide attempt..
o LEVEL OF SUPERVISION: Continuous visual surveillance (line of sight) with 1:1 observation.
o Continuous 1:1 Direct Observation at all times including when transported from unit for transfers, imaging, and surgery. Observation will be documented including name and title of person observing, time of observation, and name and title of periodic relief person (i.e. attachment B).
o "General Safety Interventions"

High-Risk Patients (Level 2):
Probable risk of danger to self or others. As evidenced by observed extreme agitation/restlessness, physically/verbally aggressive, uncooperative, hallucinations/delusions/paranoia, distorted perception of reality. May or has required restraint/seclusion. Words or behavior reflect high risk of elopement (pacing, hovering near doorway). Signs of depression (activities of daily living impacted). Reported threat to harm self or others, suicidal ideation with or without a plan; acute drug or alcohol intoxication with history of suicide attempt or ideation, psychotic symptoms (hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior, or overwhelming symptoms of depression. If unable to de-escalate may require restraint or seclusion. High risk for eloping and not waiting for treatment.
o LEVEL OF SUPERVISION: Continuous visual surveillance.
o Continuous visual supervision when transported from unit for transfers, imaging, and surgery. Observation will be documented including name and title of person observing, time of observation, and name and title of periodic relief person.
o "General Safety Interventions"

Moderate Risk Patients (Level 3):
Possible danger to self or others. Observed restless or impulsive behavior, intrusive or disordered, confused/withdrawn, dazed or anxious, ambivalent about treatment. Not likely to wait for treatment. History of suicide attempt without current ideation or plan; presence of mood disturbance; symptoms of depression and/or anxiety (socially withdrawn, acute change in previously enjoyed activities), elevated or irritable mood, angry.
o LEVEL OF SUPERVISION: Close observation.
o If patient subsequently elopes from the patient care unit and returns, then increase level of observation.
o "General Safety Interventions"

Low Risk Patients (Level 4 and 5):
Level 4: Mild distress. Irritable, tense and/or sad, but cooperative. Patient in waiting. Reliable historian. Acute drug or alcohol intoxication with no history of suicide attempt or current ideation. Preexisting mental health disorder. Mild anxiety or depression (tense, jumpy, sad or unhappy). Willing to wait.
Known patient with chronic psychosis
o LEVEL OF SUPERVISION: Intermittent observation.
Level 5: No acute distress or behavioral disturbance. Communicative and engaged in developing plan of care. Willing to discuss concerns. Compliant with instructions. Pre-existing mental health disorder. Known patient with chronic unexplained somatic symptoms. Requesting medications. Financial, social, accommodation or relationship problems. History of drug or alcohol abuse.."

Based on observation, interview, and record review, the facility failed to ensure the respiratory department developed and had policies approved by the medical staff to address services delivered. The facility failed to:

A. provide an accurate inventory for emergency airway carts on 8 of 8 inventory forms that were reviewed. The inventory sheets did not include accurate information on when and who replaced supplies in the boxes.

B. keep the inventory sheets with the emergency Airway Lock Boxes on the units so an accurate account of the supplies were immediately available for emergencies.

C. ensure 12 of 19 Respiratory policies and procedures were reviewed and approved timely. The facility failed to develop a policy which addressed care of the emergency Airway Locked boxes.

This deficient practice had the likelihood to cause harm to all patients needing emergency airway intervention.

Finding include:

Review of the emergency airway cart inventory sheets revealed the following:

During an observation on 12/4/2017 after 1:25 p.m., the airway locked box in the respiratory department revealed a syringe/needle packet was found with soiled blood. Staff #8 confirmed the observation.

During an observation on the step down unit on 12/05/2017 at 2:20 p.m., the supplies were checked in the airway locked box. There was no inventory sheet with the box. There was a hemostat found in the cart that had been sterilized in a closed position and the packet was not dated to indicate when it was sterilized. Staff #23 confirmed the observation.


Review of the Neonatal Airway lockbox inventory sheet revealed a mark out in date field two times with no initials or date it was changed. The Lock box number had been marked out in lock box field four times with no date or time in it. The expiration field had one mark out with no date or initial. The date shows it to be checked on 9/9/2018, 9/18/2018, and 11/24/2018. There was no October or December inventory check date.

Seven Airway lock box inventory sheets out of eight had changes made to the date, expiration date, therapist name, and lock box number with no date or initials on the change.

Review of the Policy & Procedure list for Respiratory department showed no policy on management/inventory of the Airway boxes. Nine of Nineteen policies were last reviewed on 04/2016 (over 1 ½ year ago). One of the policies were last reviewed 6/2016. Two of the policies were last reviewed 07/2016.


Review of the facility's policy named"ADMIN-Policy Management Policy" dated 07/17/2017 revealed the following:
"C. Periodic Review and Revision of Existing Policies and Procedures

1. Policy review and revisions should be completed in a timely manner upon the anniversary date of the policy effective date, or more frequently if applicable regulatory changes affect policy content."

Review of facility policy named "Code Blue policy" dated 01/2016 revealed:
"Respiratory Therapist: Management of ventilation of the patient; manages and maintains the intubation box."
The respiratory staff failed to follow this policy.