Bringing transparency to federal inspections
Tag No.: A0115
The Condition of Participation for Patient Rights has not been met.
Based on a tour of the hospital and review of hospital documents the hospital failed to ensure that patient's on the Behavioral Health Unit were cared for in a safe setting that was free from ligature points and other safety hazards which had been previously identified by the hospital.
Please see A144
Tag No.: A0144
Based on a tour of the hospital and review of hospital documents the hospital failed to ensure that patient's on the Behavioral Health Unit were cared for in a safe setting that was free from ligature points and other safety hazards which had been previously identified by the hospital. The findings include:
On 12/11/18 at 10:00 AM, during a tour of the Behavioral Health Unit, while accompanied by the Behavioral Health Unit Director and the Director of Engineering the following was observed:
1. The electrical receptacles throughout the Behavioral Health Unit (Pond 4) to include resident rooms were not designed to a psychiatric institutional standard i.e. not tamper resistant and/or not controlled by staff.
2. The doors to rooms throughout the Behavioral Health Unit (Pond 4) had hinges and door handles that posed a potential hanging hazard and were not designed to a psychiatric institutional standard.
3. There were open wall HVAC registers & grilles on the unit that posed a potential hanging hazard and were not designed to a psychiatric institutional standard.
4. The bathroom 7-908 had a lock & hasp on the box that covered the handicap shower that is not designated for use by behavioral patients and posed a potential hanging hazard. The nurse call box for this room and room 7-924 could be pulled away from the wall posing a potential hanging hazard and not designed to a psychiatric institutional standard.
5. The observation room had a plate glass window for staff to observe patients that is easily breakable and not designed to a psychiatric institutional standard posing a hazard to staff and patients.
6. That the patient bathrooms and shower rooms throughout the unit were not provided with soap dispensers that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used.
7. The patient bathrooms and shower rooms throughout the unit had grab rails the were not tight to the wall and had gaps that posed a potential hanging hazard.
The hospital conducted an environmental risk assessment in 9/2018 which identified the above noted ligature points. The hospital identified that many items needed to reduce ligature risks such as door hinges were on back order. Prior to this inspection, the hospital had no date for abatement of these hazards.
In addition, although the hospital identified that environmental hazards existed on the Behavioral Health Unit, no additional safety measures were implemented to ensure patient safety while awaiting abatement of the environmental hazards.
An immediate action plan was requested and included current patient risk assessments and the addition of environmental safety rounds.
The patient census was 15. There were no patients with current suicidal or self-harm tendencies.
Tag No.: A0489
The Condition of Participation for Pharmaceutical Services has not been met.
Based on documentation review, tour of the hospital pharmacy and compounding areas and staff interviews, the hospital failed to ensure that the hospital pharmacy was in compliance with the USP 797 standard for compounding of medication to ensure the safety and well-being of patients.
Please see A501
Tag No.: A0501
Based on documentation review, tour of the hospital pharmacy and compounding areas and staff interviews, the hospital failed to ensure that the hospital pharmacy was in compliance with the USP 797 standard for compounding of medication to ensure the safety and well-being of patients. The following was observed:
1. On 12/11/18 at approximately 11:12 AM, the ceiling tile in the Biological Safety Cabinet Room (Chemo Prep and Compounding Room) was lifted away from the ceiling grid due caulking that separated from the ceiling grid and tile, failing to maintain the separation from the ceiling cavity above.
2. Caulking was separating from the ceiling grid in multiple areas, however the ceiling envelope was secure in the in the laminar air flow workbench area and anti-room. Interview of the Lead IV room tech indicated the rooms had just been recertified for use and she didn't know when engineering had last conducted ongoing maintenance inspections to identify areas or equipment in need of repair.
Subsequent to these observations, the hospital developed an action plan that included recommendations from consultation with the Department of Consumer Protection Drug Control Section. Aspects of the plan included reducing the IV compounding production to only low risk medications with a 12 hour Beyond Use Date (BUD), moving medium risk compounding to an off-site facility, repair of caulking, terminal cleaning and recertification.
Tag No.: A0700
The Condition of Participatient for Environmental Services has not been met.
Based on a tour of the hospital, the facility failed to ensure that the Behavioral Health Unit was designed and maintained in such a manner as to promote the safety and wellbeing of patients.
Please see A701
Tag No.: A0701
Based on a tour of the hospital, the facility failed to ensure that the Behavioral Health Unit was designed and maintained in such a manner as to promote the safety and wellbeing of patients. On 12/11/18 at 10:00 AM, during a tour of the Behavioral Health Unit, while accompanied by the Behavioral Health Unit Director and the Director of Engineering the following was observed:
1. The electrical receptacles throughout the Behavioral Health Unit (Pond 4) to include resident rooms were not designed to a psychiatric institutional standard i.e. not tamper resistant and/or not controlled by staff.
2. The doors to rooms throughout the Behavioral Health Unit (Pond 4) had hinges and door handles that posed a potential hanging hazard and were not designed to a psychiatric institutional standard.
3. There were open wall HVAC registers & grilles on the unit that posed a potential hanging hazard and were not designed to a psychiatric institutional standard.
4. The bathroom 7-908 had a lock & hasp on the box that covered the handicap shower that is not designated for use by behavioral patients and posed a potential hanging hazard. The nurse call box for this room and room 7-924 could be pulled away from the wall posing a potential hanging hazard and not designed to a psychiatric institutional standard.
5. The observation room had a plate glass window for staff to observe patients that is easily breakable and not designed to a psychiatric institutional standard posing a hazard to staff and patients.
6. That the patient bathrooms and shower rooms throughout the unit were not provided with soap dispensers that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used.
7. The patient bathrooms and shower rooms throughout the unit had grab rails the were not tight to the wall and had gaps that posed a potential hanging hazard.
The hospital conducted an environmental risk assessment in 9/2018 which identified the above noted ligature points. The hospital identified that many items needed to reduce ligature risks such as door hinges were on back order. Prior to this inspection, the hospital had no date for abatement of these hazards.
An immediate action plan was requested and included the addition of environmental safety rounds.