HospitalInspections.org

Based on indicator review and interview the facility failed to alter, over time, the interventions for one (1) of three (3) indicators elected for review.

Findings include:

Review of raw data and percentages of indicator #1 "Clinical: Patients admitted to Intensive Outpatient will still be active in treatment after 90 days; showing success in Long Term Care." The percentages 90 day retention were, over a 10 month period, were essentially stable in the low 70 to mid 80 percentiles. However, the interventions never changed and were essentially to involve staff in discussions of what might improve retention and to continue to monitor retention rates at 90 days.

Interview on exit with the CEO and Director of QAPI / Medical Records, confirmed that indicator interventions should be changed when the outcomes are below those desired. In this case the facility wanted 100% retention at 90 days in their Intensive Outpatient program.

Based on review of facility policies and procedures and staff interview, the facility lacked a Utilization Review (UR) Committee consisting of two or more doctors of medicine or osteopathy to carry out the UR function.

Findings include:

Review of facility's policies and procedures revealed policy entitled 'Performance Improvement Plan', dated 01/2014 which provides that the Utilization Management process is 'designed to assure effective utilization of services for all patients while maintaining an optimal level of care'. but fails to address the composition of the UR committee.

Interview on 11/5/14 at 12:35 p.m., with the UR coordinator (Employee # 18) in his/her office revealed that the UR coordinator performed all UR functions solely and communicated with the Governing Body via email as needed.

Based on observation, interview, and policy search the facility failed to provide a safe environment for their locked unit patients with regard to the possibility of harm with electricity.

Findings include:

Observation on 11/5/14 at 9:30 a.m of the locked mental health unit revealed eight (8) rooms and a maximum of sixteen (16) patients was found as follows:

Rooms 1, 3, 5, and 7 had multiple unprotected electrical sockets in that metal ojbects could be inserted in the sockets producing electrical shock(s). The Clinical Director (employee #9) and the floor nurse showed us that these could indeed be turned off at a control panel. The panel had rooms 1, 3, 5, and 7 clearly marked in the circuit switch boxes. However, 7 was in the "ON" position.

Interview with employee #9 confirmed that there was no need for any of the patients on the unit to have electricity live in the outlets available to them. They were commonly turned on when medical equipment was needed for care of the patient. So a maximum of two (2) of sixteen (16) patients were at risk of self-harm. The switch was turned off to room #7. They further confirmed that there was no routine check currently being done to ascertain if the switches were in the correct position for patient needs.

Observation at 10:00 a.m. revealed the locked Trauma unit to have five (5) rooms with a maximum of ten (10) patients was found as follows:

Rooms 1, 2, 3, 4, and 5 all had electrical outlets with the potential of self harm. The floor nurse showed us to the circuit switches for this converted locked unit. These were locked but located in a room outside of the building. These switches were not marked in such a way that they could easily be identified with rooms 1-5 and most of the circuits were in the "ON" position. This potentially places at risk ten (10) of ten (10) patients on this floor.

Interview with employee #16, in charge of plant operations confirmed the above findings and added that the Trauma unit was just recently (this year) converted to a locked unit and that the circuit switches were not marked as in the other unit. Further, employee #9 confirmed that patients were housed in the Mental Health and Trauma units who were a clear and present danger to themselves and others as needed.

A policy could not be found on the monitoring of electrical circuits. At 10:45 a.m. on 11/6/14 employee #16 confirmed that there was currently no such policy
about the monitoring of proper empowering of correct circuits for patient's needs.