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Based on interview, clinical record review and document review, the facility failed to ensure compliance with the following Conditions of Participation: Patient Rights (A 0115 and A 0144) and Infection Prevention and Control and Antibiotic Stewardship Programs (A-0747).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, review of facility documentation, and review of the facility's by-laws, the facility failed to budget for facility improvements related to the replacement of door hinges to maintain a safe environment of care in the facility. The presence of regular hinges on the locked psychiatric units of this facility create multiple ligature risks on all patient units in the facility.

Findings include:

Review of the facility's by-laws, titled, "Nevada Commission on Behavioral Health and Developmental Services By-laws", dated 09/2013, revealed the hospital's Governing Body was responsible to undertake and maintain a lead role in providing strategic planning to the Department of Health and Human Services (DHHS). The by-laws documented, The Commission also promotes and assures the protection of the rights of all clients in this system.

Observations of the six locked psychiatric units of the hospital on 08/17/2020 and 08/18/2020 revealed regular hinges were installed on 121 doors located on all six patient units.

A review of the facility's Environmental Risk Assessment, dated 09/29/2017, revealed the facility identified and outlined a plan for risk mitigation to include, "Changing of Ligature Risk Hardware." The plan documented, change hardware for ligature risk in all patient rooms ...includes door hinges, door handles, enclosures or removal of legs on beds and on desk chairs. The assessment noted the changing of the hardware was completed on 11/20/2017.

On 08/18/2020 at 12:30 PM, the Chief Financial Officer (CFO) acknowledged the facility had identified door hinges as an environmental hazard as a result of an Environmental Risk Assessment. The CFO stated the facility had made improvements in 2018 to remove other identified ligature risks in the facility, such as door handles and removing legs on bed and chairs. The CFO indicated the facility did not budget for expenditures related to changing door hinges in the patient care areas of the facility. The CFO revealed the Governing Body of the hospital had made no efforts to replace the door hinges and there were no provisions in the facility's budget to replace the door hinges.

On 08/18/2020 at 11:00 AM, the Administrator explained the facility's Environmental Risk Assessment was in response to an Accrediting Organization's inspection completed in 2017. The Administrator was not the Administrator at the time of the assessment and could not explain why the door hinges were not replaced. The Administrator acknowledged the facility budgeted and took measures to replace door handles in the facility but failed to replace the hinges.

Based on observation, interview, facility document review, and review of facility policies, the facility did not meet the Condition of Participation for Patient Rights by failing to ensure care was provided in a safe setting by removing high risk environmental hazards, including ligature risks and providing a ligature resistant environment in six locked psychiatric units of the facility. This deficient practice had the potential to affect all patients diagnosed with suicidal ideations in the facility.

Findings include:

Observations, interviews, facility document review, and review of facility policies revealed door hinges and telephone cords were not assessed by the facility as environmental hazards for patients diagnosed with suicidal ideation. The facility failed to arrange and maintain care in a safe setting of six locked psychiatric units. Observations conducted on six locked psychiatric units revealed the facility failed to provide a safe, ligature "resistant" or "free" environment. (Refer to A0144)

The effect of this failure resulted in creating an unsafe clinical setting for psychiatric patients on six locked units of the hospital.

Based on observation, interviews, facility document review, and review of facility policies, the facility failed to ensure care was provided in a safe setting by removing high risk environmental hazards, including ligature risks and providing a ligature resistant environment in six locked psychiatric units of the facility. Door hinges and telephone cords were not assessed by the facility as environmental hazards for patients diagnosed with suicidal ideation. The effect of this failure resulted in creating an unsafe clinical setting for psychiatric patients on six locked units of the hospital.

Findings include:

Observations of the six locked psychiatric units of the hospital on 08/17/2020 and 08/18/2020, revealed regular hinges were installed on doors as listed below:

1. Ten patient bedroom doors (total of 60 doors)
2. Two corridor doors (total of 12 doors)
3. Two patient bathroom doors (total of 12 doors)
4. One housekeeping closet door (total of 12 doors)
5. One "quiet" room door (total of six doors)
6. One laundry room door (total of six doors)
7. One treatment team door (total of six doors)
8. Four seclusion/restraint room doors in the facility and a bathroom door in the seclusion area (total of seven doors)

The presence of regular hinges on the locked psychiatric units of this facility created multiple ligature risks on all patient units in the facility.

On 08/17/2020 at 11:30 AM, the Patient Safety Officer (PSO) stated all patient room doors had 3 hinges with spaces between each hinge (not a piano hinge). The PSO indicated the spaces between, above and below the hinges, were ligature points that presented a risk for hanging/strangulation.

On 08/18/2020 at 9:05 AM, Mental Health Technician (MHT) 5 revealed there had been no training from the hospital related to identifying the presence of open hinges on patient doors as a potential ligature risk.

On 08/18/2020 at 9:15 AM, Registered Nurse (RN) 4 indicated there had been no training by the hospital that identified the hinges on the patient room doors as a ligature risk. RN 4 revealed the hospital talked about "what to do" related to the functioning of the door but nothing related to the hinges being a ligature risk.

On 08/18/2020 at 9:25 AM, MHT 9 indicated the hospital did not provide any training related to identification of open spaces between hinges on the patient room door as a potential ligature point.

On 08/18/2020 at 9:35 AM, RN 5 revealed open hinges had not been identified as a ligature risk by the hospital.

On 08/18/2020 at 9:40 AM, RN 6 stated there was a place on the monitor board (a form used by MHTs to document observations) to initial hourly if an observation was done by the nurse. RN 6 revealed ligature training was part of the nursing skills fair in October 2019. RN 6 explained the training provided included to check patients on suicide risk for hanging on hinges but was not trained about identifying the spaces between hinges as a potential ligature risk.

On 08/18/2020 at 11:25 AM, the Training Officer stated the power point used in training on suicide, identified door hinges as a ligature risk but did not identify the open space between hinges as a ligature risk for hanging/strangulation.

On 08/18/2020 at 11:50 AM, the Chief Nursing Officer (CNO) stated the hospital had ligature risk training years ago. The CNO stated the open space between door hinges was not identified as a ligature risk in training hospital staff.

Observations while accompanied by the CNO and RN 1 of the Rapid Stabilization Unit (Pod H) on 08/17/2020 at 11:00 AM, revealed telephones hanging on the wall in the patient day rooms of both PODs A and B. The telephones were uncovered and had 24-36-inch spiral cords attached to the telephone. The cords could be extended further due to being tight spirals and were able to be detached from the telephone.

Observation of Pods E, G, and H on 08/18/2020 at 12:10 PM, with two patient care units on each POD, revealed a mounted telephone in each of the six dayrooms with a 24-36-inch cord hanging from each telephone in each of the six patient dayrooms.

On 08/17/20 at 11:10 AM, the CNO reported the facility had not thought to do anything about the telephone cords. The CNO and RN 1 reported "staff are always in the dayroom."

A review of the facility's policy, "Health and Safety Inspections," dated 09/2018, revealed "A facility risk assessment shall be conducted at least annually." The policy stated, "A health and safety inspection shall be conducted at least monthly and more frequently if needed or directed."

On 08/18/2020 at 11:00 AM, the Administrator stated the facility's "Environmental Risk Assessment" was in response to an Accrediting Organization inspection completed in 2017. The Administrator was not the Administrator at the time of the assessment and the facility implemented interim mitigation that included increased levels of supervision for patients with a diagnosis of suicidal ideation. The Administrator acknowledged the facility took measures to replace door handles in the facility but failed to replace the hinges. The Administrator did not indicate whether the facility had identified telephone cords as a ligature risk.

A review of the facility's "Environmental Risk Assessment," dated 09/29/2017, revealed the facility identified and outlined a plan for risk mitigation to include, "Changing of Ligature Risk Hardware". The plan stated, "Change hardware for ligature risk in all patient rooms ...includes door hinges, door handles, enclosures or removal of legs on beds and on desk chairs." The assessment noted the changing of the hardware was "Completed" on 11/20/17. The review revealed the facility did not complete the required annual facility risk assessment and the annual assessment did not include the identification of ligature risks in the facility.

A review of monthly health and safety inspections for 05/2020 to 08/2020 revealed the monthly health and safety inspections did not address ligature risks in any patient care areas of the facility. The facility had provided no additional evidence related to maintaining a ligature resistant environment in the facility.

Review of personnel files on 08/18/2020 from 11:10 AM to 11:50 AM with the Training Officer assisting, revealed no documented evidence of specific training and competency assessment related to ligature risks and designation of separated door hinges as a ligature risk for MHTs 1, 5, 8, and 9 and RNs 4, 5, and 6.

Based on observation, interview, and review of facility policies and procedures, the facility did not meet the Condition of Participation for Infection Prevention and Control by failing to ensure proper disinfecting methods were used for multi-patient use glucometers used in the facility. The facility's failure to ensure proper disinfecting methods were used for a multi-patient use glucometer during a blood glucose check, placed four patients requiring blood glucose monitoring, as well as any newly admitted patients requiring blood glucose monitoring, in a situation that was likely to cause serious harm, injury, impairment, or death.

Findings include:

Observation on 08/19/20 at 10:53 AM, revealed Registered Nurse (RN) 2 washed her hands and donned gloves. RN 2 removed the ACCU-CHECK Inform II glucometer from the docking/charging station, located on the counter in the nursing station and placed the device on the nursing station counter. RN 2 wiped the front of the glucometer screen with an alcohol wipe. After performing P9's fingerstick and checking the blood glucose level, with the glucometer, RN 2 removed the gloves and wiped the front of the glucometer screen with an alcohol wipe. RN 2 did not clean any other part of the glucometer. The glucometer was placed back in the docking/charging station on the nursing station counter. RN 2 failed to disinfect the entire glucometer as required by hospital policy.
(Refer to A 0749).

Based on observations, interviews, and review of facility policies and procedures, the facility failed to ensure:
1) proper disinfecting methods were used for a multi-patient use glucometer during a blood glucose check of one of four patients (Patient 9), to prevent the transmission of infections within the hospital, and 2) hand hygiene was performed.

Findings include:

1) Glucometer:

On 08/19/2020 at 10:53 AM, observations conducted on the Rapid Stabilization Unit (RSU) revealed Registered Nurse (RN) 1 performed a blood sugar check on Patient 9 (P9). Prior to performing the blood glucose check on P9, RN 1 was observed cleaning the screen of the multi-patient use glucometer with an alcohol wipe. After performing the blood glucose check of P9, RN 1 cleaned the glucometer screen with another alcohol wipe. The multi-patient use glucometer observed in use during the check was an "ACCU-CHEK Inform II Blood Glucose Monitoring System". The observation revealed RN 1 only cleaned the screen of the multi-patient use glucometer.

A review of the facility's policy, "ACCU-CHEK Inform Blood Glucose Monitoring System", dated 11/2019, revealed the section titled, "Infection Control" documented, "The ACCU-CHEK Advantage meter MUST be disinfected after each use with an alcohol wipe."

A review of the manufacturer's guidelines titled, "ACCU-CHEK Inform II Blood Glucose Monitoring System Operator's Manual" (Version 3.0, dated 03/2013) documented, "Acceptable active ingredients and products for cleaning and disinfecting are: Clorox Germicidal Wipes" and "Super Sani-Cloth Germicidal Disposable Wipes."

On 08/19/2020 at 12:50 PM, the Infection Control Officer (ICO) reviewed the hospital policy titled, "ACCU-CHEK Inform Blood Glucose Monitoring System" and acknowledged the policy did not meet the manufacturer's guidelines for the ACCU-CHEK Inform Blood Glucose System. The ICO was not aware the hospital policy did not meet the manufacturer's guidelines for cleaning and disinfecting the glucometer device.

On 08/19/2020 at 2:10 PM, RN 3 explained the entire glucometer should be cleaned with an Oxivir wipe per the glucometer manual. When RN 3 was informed the manual directed to use Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes to clean the glucometer, RN 3 stated "that's like Oxivir."

On 08/19/2020 at 2:15 PM, RN 2 stated the ACCU-CHEK Inform Blood Glucose System manufacturer's guidelines required the glucometer to be cleaned after each patient use by using an alcohol wipe or an Oxivir wipe.

On 08/19/2020 at 2:50 PM, a Unit Manager (UM) reviewed the difference in the content of Oxivir wipes and Super Sani-Cloth and stated the Oxivir wipes contain hydrogen peroxide and not isopropanol which was contained in Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes.

The facility's failure to ensure proper disinfecting methods were used for a multi-patient use glucometer during a blood glucose check, placed four patients requiring blood glucose monitoring, as well as any newly admitted patients requiring blood glucose monitoring, in a situation that was likely to cause serious harm, injury, impairment, or death.

An Immediate Jeopardy (IJ) was identified on 08/19/2020 at 4:20 PM and the IJ was removed on 08/20/20 at 4:30 PM.

2) Hand Hygiene:

Observation on 08/17/20 at 11:53 AM in POD G, a mental health technician failed to remove gloves after opening the door to a patient's room and perform hand hygiene.

Observation on 08/17/2020 at 2:17 PM on the RSU, a mental health technician failed to remove gloves after discarding a contaminated tissue and perform hand hygiene.

Observation on 08/17/2020 at 3:20 PM in POD G, a mental health technician failed to remove gloves after closing the laundry door and perform hand hygiene.

Observation on 08/17/2020 at 3:35 PM in POD E, a mental health technician failed to remove gloves after checking a patient's blood pressure and perform hand hygiene.

Observation in the hospital lobby entrance used for screening staff and visitors on 08/19/2020 at 8:00 AM, a registered nurse failed to remove gloves and perform hand hygiene after taking a visitor's temperature during the screening process. The RN explained the gloves were changed if the patient had a temperature greater than 100.4 degrees Fahrenheit or if the patient was touched.

Review of the hospital policy titled, "Hand Hygiene Policy" effective February 2019, revealed routine hand washing should always occur before and after touching a patient, before and after a clean or aseptic procedure, after a body fluid exposure, before and after handling patient food and food tray, before and after staff breaks, before and after eating, before and after caring for a patient, after handling patient personal belongings, after going to the restroom, and after glove removal. If hands are not visibly soiled, rubbing them with an alcohol-based formulation was acceptable.

Based on interview, record review, and policy review, the hospital failed to ensure the Infection Control Officer (ICO) was responsible for the surveillance and reporting of staff members with suspected or confirmed cases of COVID-19. This deficient practice had the potential to risk transmission of COVID-19 to all patients and staff members. The hospital employs 280 staff who could be affected by this deficient practice.

Findings include:

Review of the hospital policy titled, "COVID-19 Safety Protocol," effective July 2020, documented the hospital ". . . is committed to the health and well-being of our staff, patients, and visitors including the provision of a safe environment, minimizing exposure and risk of transmission to respiratory pathogens, and adhering to federal and state guidelines on COVID-19 prevention measures. . . Staff who have been confirmed or had possible exposure with a close contact with confirmed COVID-19 infection and are exhibiting symptoms, will be required to stay home for at least 10-14 days since the date of first exposure. Prior to returning to work, staff will be advised to contact HR [human resources] to coordinate their return to work date. Staff may not return to work until cleared by HR. . . . The Infection Prevention Coordinator will be responsible for notifying the Hospital Administrator, Medical Director, Director of Nursing, Director of Laboratory Services, and the Southern Nevada Health District of all patients or staff presenting with symptoms consistent with COVID-19 infection within 24 hours of discovery. . ."

On 08/19/2020 at 12:50 PM, the ICO, who was also the employee health nurse, revealed when the COVID policies and training were done, she was not involved in the process. The ICO was responsible for patient reporting related to COVID-19, but employee reporting of positive COVID-19 was handled by human resources and the department supervisor. The ICO stated that human resources were responsible for employee COVID-19 testing and the time frame for any quarantine if necessary. The ICO did not know if any employee had tested positive for COVID-19.

On 08/20/2020 at 11:35 AM, the hospital Administrator stated the Chief Nursing Officer (CNO) was responsible to develop the COVID -19 Infection Control policies. The Administrator did not provide an explanation as to why the ICO was not the person responsible for the surveillance and reporting of employee positive COVID-19 results as required by hospital policy and the division of responsibility between ICO and human resources.

Based on interview, record review and review of hospital policy, the hospital failed to develop treatment plans that clearly delineated interventions to address the specific treatment needs for ten of ten (Patients (P) P1, P2, P9, P10, P11, P12, P13, P14, P15, and P16) reviewed in the sample.

Findings include:

1. Review of P1's electronic medical record (EMR) revealed a treatment plan dated 07/23/2020 that indicated "delusional thought processes". The treatment plan for nursing interventions documented, "Nurse will administer medication as ordered and monitor and record compliance, symptoms side effects and response to treatment daily," Nursing will engage in friendly conversation and encourage socialization with other patients and in activities daily." There were no nursing interventions directed at the care and safety of the patient in the clinical area. The risk assessment dated 07/23/2020 documented that P1 was a moderate risk for suicide and had "cut wrists/arms and throat in the past ...", "runs into traffic, swallows plastic objects, and cleaning solutions." The treatment plan did not include safety interventions to address potential violence/injury to self.

2. Review of P2's EMR revealed a treatment plan dated 07/22/2020, indicated rapid, tangential thought processes. The nursing interventions documented, Nursing staff will engage in conversation and encourage verbalization of feelings, Nursing staff to encourage and support attendance at all meals, and Nursing will engage in friendly conversation and encourage socialization with other patients and in activities. There were no nursing interventions directed at the care and safety of this patient in the clinical area. The Suicide Risk Assessment dated 07/23/2020), documented "Moderate Risk for Suicide," the treatment plan did not include staff interventions to address this safety issue.

3. Review of P9's EMR revealed a treatment plan dated 08/13/2020 which indicated, Endorses SI [Suicide Ideation]. The treatment plan did not include interventions other than to provide 1:1 monitoring for falls. The patient's suicide ideation was not addressed except for "Nursing staff will observe, record, and report any changes in the client's mood elation, withdrawal, sudden resignation." The treatment plan did not include additional nursing safety interventions. The treatment plan revealed diagnoses of coronary artery disease, hyperlipidemia, and dementia. Generic nursing interventions included "Nursing staff will monitor [Patient]daily and follow up on any signs and symptoms of illness "and "Nursing staff will administer all prescribed medications and treatments as ordered and will document [Patient's] compliance."

4. Review of P10's EMR revealed a treatment plan dated 08/13/2020, indicated "hearing voices all the time." A generic nursing intervention documented, "Nursing staff will administer medications indicated for psychotic symptoms, and monitor the medications effectiveness, side effects, or adverse reactions daily. "There were no nursing interventions to direct nursing personnel in how to care for this patient if hallucinations were present. The treatment plan indicated to provide every 5-minute safety monitoring for aggression and the Suicide Risk Assessment data base (undated) documented P10 experienced several suicide attempts, including a hanging attempt within the last 2 weeks. There were no interventions in the treatment plan to address safety issues.

5. Review of P11's treatment plan dated 08/11/2020 revealed a "Fall Risk due to seizure hx [history] ..." The treatment plan documented, "Responding to internal stimuli & yelling incoherent phrases." The treatment plan did not include any social work or activity therapy interventions. The "Anger/Aggression Risk Assessment" dated 8/11/2020 assessed the patient was a "High Risk of Anger/Aggression. The treatment plan did not include any specific interventions documented to address this problem.

6. Review of P12's treatment plan dated 07/22/2020 revealed, disorganized thought processes. The nursing interventions were generic and documented, "Nurse to administer medication as ordered and monitor and record compliance, symptoms, side effects and response to treatment." "Nurse to dispense medication, monitor and record compliance, side effects and response to treatment." "Nursing will engage in friendly conversation and encourage socialization with other patients and in activities." There were no nursing interventions directed at the care and safety of the patient in the clinical area. There were no social work interventions for this problem.

7. Review of P13's EMR revealed a treatment plan dated 08/6/2020 documented,
"disorganized thought process ...verbally aggressive and threatens staff, presenting significant danger to self & others ..." Generic nursing interventions were listed as "Nurse will administer medication as ordered and monitor and record compliance, symptoms, side effects and response to treatment" and "nursing staff will provide medication management group once a week to help [Patient] acquire enough information and skills necessary to manage [his/her] medications in order to get maximum benefits from them." There were no specific nursing interventions to provide safety for the patient and others in the clinical area. On 08/10/2020 the treatment plan revealed, "anger/agitation and aggressive behaviors," was added after the patient "grabbed a peer by the neck and sucker punched another peer." The treatment plan did not include additional interventions focused on the patient's aggressive behavior.

8. Review of P14's treatment plan dated 06/28/2020 documented, "alteration of thought process ...Suicidal thought couple of days ago." The nursing intervention related to the potential for suicide listed in the problem documented, "Nursing staff will engage [Patient] in simple activities or tasks that will help [Patient] distract [himself/herself] from voices and other altered thoughts and decrease the possibility of acting on the voices and harmful thoughts." The treatment plan did not include specific interventions to guide nursing personnel in the safety of this patient who was potentially suicidal and experiencing hallucinations.

9. Review of P15's treatment plan dated 08/4/2020 revealed, "Unable to care for [himself/herself] due to inability to remain grounded and oriented to time and situation." Generic nursing interventions were documented as "Nursing staff will engage in conversation and encourage verbalization of feelings and nursing staff will engage in friendly conversation and encourage socialization with other patients and in activities" and "nurse to dispense medication, monitor and record compliance, side effects and response to treatment." There were no nursing interventions to address the patient's lack of orientation and psychotic symptoms. The treatment plan revealed, "Potential danger to others as evidenced by tried [sic] to hit and spit on staff and peers."

10. Review of P16's treatment plan dated 07/29/2020 revealed, "Rapid, tangential thought processes." Nursing interventions were generic and listed as "Nurse will administer medication as ordered and monitor and record compliance, symptoms, side effects and response to treatment, nursing staff will engage in friendly conversation and encourage socialization with other patients and in activities, and nursing staff will engage in conversation and encourage verbalization of feelings." The treatment plan revealed, "refused to take the medications to be administered, became agitated, angry, threatening and verbally abusive."

In an interview on 08/18/2020 at 9:45 AM, the patient's treatment plans were discussed with Licensed Clinical Social Worker, Unit Manager and the Director of Social Work. The Licensed Clinical Social Worker, Unit Manager and the Director of Social Work indicated the treatment plans for nursing interventions were not patient specific to address the patient concerns.

Review of hospital policy, "Inpatient Treatment Plan, Number: PF-CC-20, Effective Date: 01/19, revealed most directions/guidelines for the staff to follow when developing staff interventions for the plans related to group/small assignments. A statement regarding interventions documented under "IV. Procedures: Section G. b" which documented, ... Each discipline can add goals/objectives and associated interventions for their discipline to help the patient reach desired reduction in symptoms."


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