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Based on record review and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by failure to have documented evidence of a check/review of the Louisiana Department of Health's "Louisiana Adverse Action Website" before hire and every 6 months after for 3 (S16MHT, S17MHT, S18RecT) of 3 unlicensed personnel files reviewed .
Findings:

Review of the Louisiana Department of Health's "Louisiana Adverse Action Website" revealed, in part that all licensed and/or certified providers that employ unlicensed direct care staff that meet the provisions of LAC 48:1, Chapter 92 related to Direct Service Workers are required to check the Adverse Actions Website prior to hire and every six months thereafter to assure that a finding of abuse, neglect or misappropriation of property has not been placed against a prospective hire or a currently employed or contracted DSW.

Review of the personnel file for S16MHT revealed hire on 03/02/2022 and Louisiana Adverse Action Website was checked prior to hire but not every 6 months..

Review of the personnel file for S17MHT revealed hire in April 2021 and the Louisiana Adverse Action Website was never checked.

Review of the personnel file for S18RecT revealed hire 03/03/2017 and the Louisiana Adverse Action Website was never checked.

In interview on 09/28/2022 at 8:15 a.m., S1Adm verified the Louisiana Adverse Action Website is not routinely checked.

Based on observation and interview the facility failed to ensure patients received care in a setting free from objects that could be used for self-harm.
Findings:

Tour of the facility on 09/26/2022 between 9:27 a.m. and 10:40 a.m. accompanied by S2DON revealed the following:
1) Room c- Air conditioner with an open panel and a zippered mattress on the bed
2) Room d- Zippered mattress on the bed
3) Room f- Zippered mattress on the bed
4) Room G3- Hygiene cart unattended with soap, shampoo, conditioner, toothbrushes, toothpaste, and combs. Cups in plastic sleeve on nourishment table.
5) Room a- toothbrush, comb and toothpaste on sink ledge.

During the tour between 9:27 and 10:40 S2DON verified the above findings.

Based on record review and interview, the hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report allegations of abuse to the Department of Health and Hospitals or law enforcement for 3(R1, R2, R3) of 5 (R1, R2, R3, R4, R5) occurrences reviewed involving possible patient abuse.

Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.


Patient R1
Review of the occurrence report from 08/15/2022 at 3:50 p.m. revealed Patient R1 exhibited "Inappropriate behavior towards females ...Inappropriately touching female patient and ejaculating standing in hid doorway." The report indicates the R1 was uncontrollable and broke out of seclusion. The local police department was called to assist in the situation but there is no documentation the police were notified of the sexual assault. The document also indicates the physician was not notified. There is no documentation Louisiana Department of Health was notified.

Patient R2
Review of the occurrence report from 05/13/2022 at 5:31 p.m. in the day room revealed Patient R2 "walked past Patient R6 and grabbed her breast and butt." The document does indicate the physician and Patient R6's mother were notified. There is no documentation Louisiana Department of Health was notified.

Patient R3
Review of the occurrence report from 05/09/2022 at 8:00 p.m. revealed Patient R3 complained a MHT "inappropriately touched her in her inner right thigh and crotch area." The document indicates neither the doctor nor the patient's family were notified. There is no indication an investigation was performed. There is no documentation Louisiana Department of Health was notified.

In interview on 09/27/2022 between 2:30 and 2:45 p.m., S1Adm verified the above occurrences were not thoroughly investigated and they were not reported to Louisiana Department of Health.

Based on record review and interview the hospital failed to perform a face to face evaluation within one hour of initiation of seclusion for 3(#4, #5, and #8) of 4(#4, #5, #6, and #8) reviewed records of patients placed in seclusion.
Findings:

Review of hospital policy Restraint or Seclusion, revised 03/21/2018, revealed in part, "A face to face assessment of any patient subjected to Restraint or Seclusion (regardless of the duration) will occur within one hour by a qualified practitioner, as indicated in federal regulations. . . . If the one hour assessment is conducted by a registered nurse or physician assistant it is not considered complete until the assessing practitioner has consulted with a physician or advanced practice registered nurse as soon as possible thereafter."

Patient #4
Review of the medical record for Patient #4 revealed admission on 07/25/2022 with a diagnosis of Bipolar Disorder with suicidal ideation and was discharged on 08/03/2022.

Further review revealed Patient #4 was placed in seclusion on 07/30/2022 at 8:00p.m. She was released from seclusion on 07/30/2022 at 9:00 p.m. The one hour face to face occurred on 07/30/2022 at 9:36 p.m. The physician was notified of the one hour face to face on 07/30/2022 at 10:00 p.m.

Patient #5
Review of the medical record for Patient #5 revealed admission on 07/18/2022 with a diagnosis of paranoid schizophrenia and was discharged on 07/28/2022.

Further review of the medical record revealed Patient #5 was placed in seclusion on 07/19/2022 at 2:35 p.m. and released on 07/19/2022 at 4:18 p.m. The one hour face to face occurred on 07/19/2022 at 1:35 p.m. The physician was notified of the one hour face to face on 07/19/2022 at 1:35 p.m.

Patient #8
Review of the medical record for Patient #8 revealed admission on 07/21/2022 with a diagnosis of bipolar disorder and was discharged on 08/01/2022.

Further review of the medical record revealed Patient #8 was placed in seclusion on 07/22/2022 at 9:05 a.m. and released on 07/22/2022 at 12:52 p.m. The one hour face to face occurred on 07/22/2022 at 12:45 p.m. The physician was notified of the one hour face to face on 07/22/2022 at 12:45 p.m.

In interview on 09/28/2022 at 4:30 p.m. S1Adm verified the one hour face to face for Patients #4 and #5 were not documented within one hour of initiation of seclusion.

In interview on 09/28/2022 at 2:43 p.m. S2DON verified the one hour face to face for Patient #8 was not documented within one hour of initiation of seclusion.


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Based on record review and interview the registered nurse failed to immediately notify the attending physician of the results of the one hour face to face for 3(#4, #5, and # 6) of 4(#4, #5, #6, and #8 ) reviewed records of patients placed in seclusion.
Findings:

Review of hospital policy Restraint or Seclusion, revised 03/21/2018, revealed in part, "A face to face assessment of any patient subjected ot Restraint or Seclusion (regardless of the duration) will occur within one hour by a qualified practitioner, as indicated in federal regulations. . . . If the one hour assessment is conducted by a registered nurse or physician assistant it is not considered complete until the assessing practitioner has consulted with a physician or advanced practice registered nurse as soon as possible thereafter."

Patient #4
Review of the medical record for Patient #4 revealed admission on 07/25/2022 with a diagnosis of bipolar disorder with suicidal ideation and was discharged on 08/03/2022.

Further review revealed Patient #4 was placed in seclusion on 07/30/2022 at 8:00 p.m. She was released from seclusion on 07/30/2022 at 9:00 p.m. The one hour face to face occurred on 07/30/2022 at 9:36 p.m. The physician was notified of the one hour face to face on 07/30/2022 at 10:00 p.m.

Patient #5
Review of the medical record for Patient #5 revealed admission on 07/18/2022 with a diagnosis of paranoid schizophrenia and was discharged on 07/28/2022.

Further review of the medical record revealed Patient #5 was placed in seclusion on 07/19/2022 at 2:35 p.m. and released on 07/19/2022 at 4:18 p.m. The one hour face to face occurred on 07/19/2022 at 1:35 p.m. The physician was notified of the one hour face to face on 07/19/2022 at 1:35 p.m.

Patient #6
Review of the medical record for Patient #6 revealed admission on 07/23/2022 with a diagnosis of major depression and was discharged on 08/01/2022.

Further review of the medical record revealed Patient #6 was placed in seclusion on 07/30/2022 at 12:15 a.m. and released on 07/30/2022 at 1:20 a.m. The one hour face to face occurred on 07/30/2022 at 1:15 a.m. The physician was notified of the one hour face to face on 07/30/2022 at 12:20 a.m.

In interview on 09/28/2022 at 4:30 p.m. S1Adm the notification of the physician was not correctly documented.

Based on record review and interview the psychiatric hospital failed to ensure all staff were trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion as part of orientation. This deficiency is evidenced by failure to provide training on the use of restraint or seclusion to 3(S12RN, S14RN, S15LPN) of 8 (S2DON, S4LPN, S12RN, S13RN, S14RN, S15LPN, S16MHT, S17MHT) reviewed nursing staff personnel records.
Findings:

Review of the orientation training for Beacon Behavioral Hospital, LLC revealed education and demonstration of competency in the use of restraint and seclusion were included in the schedule.

Review of the personnel records for S12RN, S14RN, and S15LPN revealed no orientation training and no evidence of education and competency for the use of restraint or seclusion.

In interview on 09/28/2022 at 11:58 a.m. verified S12RN and S15RN were agency nurses and did not have orientation training. At that time, S2DON was notified of the missing documents from the personnel file of S14RN. Documentation of participation in orientation for S14RN was not provided at the time of exit at 5:05 p.m.

Based on observation and interview the psychiatric hospital failed to ensure all direct care staff had education, training, and demonstrated knowledge in the use of nonphysical intervention skills. This deficiency is evidenced by failure to document training in nonphysical interventions skills for 2 (S12RN, S15LPN) of 10 (S2DON, S4LPN, S12RN, S13RN, S14RN, S15LPN, S16MHT, S17MHT, S18RecT, S20SW) direct care staff personnel files reviewed.
Findings:

Review of the personnel files for S12RN, and S15LPN failed to reveal training in nonphysical intervention skills.

In interview on 09/28/2022 at 11:58 a.m. S2DON was notified of the missing documents from the personnel files of S12RN, and S15LPN. The information was not provided to the surveyor at the time of exit at 5:05 p.m.

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. The deficient practice was evidenced by suspending Quality Assurance/Performance Improvement audits for 2022 due to EMR (electronic medical record) implementation (See Findings A-0273).

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. The deficient practice was evidenced by suspending Quality Assurance/Performance Improvement audits for 2022 due to EMR (electronic medical record) implementation.

Findings:

Review of the hospital's governing body meeting minutes dated 01/10/2022 revealed 2022 QAPI plan and indicators reviewed. Further review revealed discussed and approved suspending PI audits until Q3 (third quarter) due to EMR implementation.

Review of the hospital's policy titled "Hospital QAPI Plan 2022" revealed in part, note all measures monitored that are marked as CEA (Clinical Education/Auditing Team) are suspended for 2022 until all facilities fully implement Wellsky EMR. Monthly: all performance measure data is collected, reviewed, and submitted to facility leadership and clinical educators for inclusion in COW (Committee of the Whole). Further review revealed the service areas that include performance measures/outcomes that are to be evaluated by CEA are restraint and seclusion, social services, nursing/RN, nursing/LPN, and psychiatry.

Review of the hospital's committee of the whole meeting minutes and agenda that were conducted in the months of February, March, May, June, July, and August of 2022 revealed no documented evidence of performance improvement activities.

In an interview on 09/27/2022 at 1:40 p.m. S1Adm verified QAPI audits were suspended for 2022 due to the PI team implementing a new EMR system.

Based on record review and interview the hospital failed to analyze and initiate preventative measures after adverse patient occurrences. This deficiency is evidenced by failure of the hospital to thoroughly investigate occurrences involving 2 patients (R4, R5) of 5 (R1, R2, R3, R4, and R5) patients listed in adverse occurrences.
Findings:

Review of the policy "PR- Control of Contraband and Dress Code," revised 03/21/2018 revealed in part, " Beacon Behavioral Hospital utilizes a number of methods for controlling the existence of Contraband, including, but not limited to:

· Checking inventorying patient belongings on admission and when brought in during hospitalization.
· Prohibiting visitors from bringing in bags, purses, packages, and backpacks.
· Requiring that items never be given directly to a patient by a visitor without ensuring that the items were inspected by staff.
· Maintaining specific written rules
· Ensuring that patients do not have access to high-risk items
· Limiting windows at ground level from being opened to a point where contraband can be passes into the unit
· Checking patient rooms daily
· Obtaining orders to search a patient's room if there is reason to believe that a high-risk item may be present

. . . 4. Illegal items, such as illegal fire arms and illicit drugs, will be given to law enforcement for disposal: 5. Contraband consisting of prescription medications will be given to the pharmacy for disposal."

Patient R4
Review of the occurrence dated 08/15/2022 at 9:00 a.m. revealed R4 was witnessed coming out of another patient's room. The report also documents, "in report this morning, it was reported that he had a piece of foil with heroin." The report indicates the physician was not notified and there is no indication administration or local police were notified. There is no documentation of what was done with the suspected heroin.

Patient R5
Review of the occurrence dated 08/08/2022 at 8:30 a.m. revealed R5 was in his room and "gave nurses a pill in a plastic bag." "The patient said it was his Seroquel." The report does not indicate the physician was notified and there is no indication administration was notified. There is no documentation an investigation was performed to find out why the medication was not found at admission.

In interview on 09/28/2022 at 8:23 a.m., S1Adm verified the above occurrences were not thoroughly investigated and they were not reported per hospital policy.

Based on record review and interview the medical executive committee is not comprised of a majority of doctors of medicine or osteopathy. This deficiency is evidenced by no doctors in attendance at a documented medical executive committee emergency meeting.
Findings:

Review of the Medical and Professional Staff Organizational Bylaws reveals in part, "Medical Executive Committee (MEC): Those Staff Members of the Committee of the Whole who are entitled to vote on all Staff matters by virtue of the perogative granted to Active Staff Member."

On 09/26/2022 at 9:37 a.m. S1Adm stated the Medical Director was S3MD.

Review of the Medical Executive Committee Meeting Minutes from an emergency meeting on August 12, 2022 held at Beacon Behavioral Hospital/ Remotely reveals S1ADm, S2DON, and S7NP met for "credentialing and appointment of new Medical Director, S3MD." and "Appointment and Approved for the following effective 08/16/2022: S3MD." "Minutes recorded and typed by: S1Adm, RN."

In interview on 09/27/2022 at 2:20 p.m. S1Adm verified the meeting of the medical executive committee and the people present. S1Adm verified the committee was comprised of 2 registered nurses and a nurse practitioner. She verified there were no doctors present. She stated they did not appoint S3MD to the medical staff but only recommended to the governing body he should be appointed.

Based on record review and interview the hospital failed to have a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the qualifications of the nursing staff.
Findings:

Review of the policy titled "Nurisng Service- Nursing Service," revised 03/21/2018 revealed in part, "The registered nurse assigns patient care to nursing staff members based on the individual needs of the patient; the training and skills of the staff member; the scope of practice of the staff member; other issues as applicable."

Review of the Nursing Daily Assignment sheets revealed the nursing staff are assigned duties such as rounding MHT, room searches, washing clothes, trash, coffee, and discharge belongings. There are no patients assigned to any of the nursing staff.

In interview on 09/27/2022 at 10:47 a.m., S2DON verified that the staff were not assigned to specific patients. They were assigned unit duties.

Based on observation and interview, the hospital failed to properly file and store patient records in a manner to protect them from fire or water damage as evidenced by storing paper medical records on open shelving.

Findings:

In an observation on 09/26/2022 at 1:00 p.m. with S5HIM of the medical records storage room, there were 8 rolling units with open shelving that contained paper medical records. Further observation revealed the room contained sprinklers in the ceiling.

In an interview on 09/26/2022 at 1:05 p.m. S5HIM verified the paper medical records were not protected from water damage if the sprinkler system was activated.

Based on observation and interview the hospital failed to maintain accurate records for the receipt and distribution of scheduled drugs.
Findings:

During tour of the facility on 09/26/2022 at 10:19 a.m. the medication room was inspected with assistance from S2DON and S6LPN. The narcotics box was noted to be unlocked.

Inspection of the contents of the narcotics box revealed 2 prescription bottles and a prescription pad. One bottle was noted to contain Alprazolam 1mg and 3 pills were visible which matched the count on the Patient Specific Narcotic Record. The second bottle was noted to contain Tramadol HCL 50 mg and the contents could not be inspected.

S2DON then opened the bottle. The bottle contained a brown paper towel with quarters on top of the medication. The medication was then counted twice by S2DON in the presence of the surveyor. S2DON counted 34 tablets. The count did not match the Patient Specific Narcotics Sheet count of 36.

At the time of discovery, S2DON verified the count on the sheet was not correct. S2DON verified the quarters should not be stored in the medication bottle.

Based on observation and interview the hospital failed to store controlled substances locked within a secure area.
Findings:

Review of the policy "Nursing Service- Home Medication" revealed in part, "Any home medication that is not ordered and cannot be sent out of the hospital will be logged in the patient's inventory and kept in the locked cabinet in the medication room until the patient is discharged."

During tour of the facility on 09/26/2022 at 10:19 a.m. the medication room was inspected with assistance from S6LPN. The narcotics box was noted to be unlocked.

Inspection of the contents of the narcotics box revealed 2 prescription bottles and a prescription pad. One bottle was noted to contain Alprazolam 1mg. The second bottle was noted to contain Tramadol HCL 50 mg.

S6LPN verified the narcotics box was not locked and contained narcotics at the time of discovery.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

A policy that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital was requested on 09/26/2022 at 3:00 p.m. and on 09/28/2022 at 9:15 a.m. The hospital failed to provide this policy by the survey exit on 09/28/2022.

In an interview on 09/28/2022 at 2:52 p.m. S1Adm verified the hospital does not have a policy that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital. S1Adm stated the hospital uses the contracted servicer's policy.

On 09/28/2022 at 4:45 p.m. S1Adm presented a copy of the contracted servicer's Safety Manual. This copy ended with page 11 and did not include a policy to address proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Based on observation and interview the hospital failed to provide for the nutritional needs of the individual patient in accordance with recognized dietary practices. This deficiency is evidenced by the failure of the hospital to provide a special diet for 1 (#1) of 1 patient with orders for special diet.
Findings:

Review of the hospital policy "AS- Food and Dietetic Services," revised 03/21/2018, revealed in part, "Patients' nutritional needs will be met based on orders issued by authorized licensed prescribers and will consider any allergies noted."

Review of the medical record for Patient #1 revealed admission on 09/26/2022 with a diagnosis of depression. Review of the psychiatric assessment also revealed the patient had a history of diabetes mellitus.

Review of the orders for Patient #1 revealed order #17 placed 09/26/2022 at 9:00 a.m., "Diet: Low/ No Concentrated Sweets."

Direct observation on 09/27/2022 revealed Patient #1 was given the same diet as everyone else which included Salisbury steak, mashed potatoes, mixed vegetables and cake.

In interview on 09/27/2022 at 12:04 p.m. S16MHT verified special diets were identified by writing on the stryofoam container and there were no special diets delivered for that meal.

In interview on 09/27/2022 at 12:07 p.m. S6LPN verified Patient #1 had received the wrong diet.

Based on observation and interview the hospital failed to have a therapeutic diet manual readily available to nursing staff.
Findings:

Review of hospital policy "AS-Food and Dietetic Service," revised 03/21/2018, reveals in part, "Beacon Behavioral Hospital maintains a manual reflecting Therapeutic Diets and Policies and Procedures of the Dietary Services vendor in each nurses' station."

Review of the orders for Patient #1 revealed order #17 placed 09/26/2022 at 9:00 a.m., "Diet: Low/ No Concentrated Sweets."

Direct observation on 09/26/2022 at 10:32 p.m. of snacks being distributed revealed Patient #1 received a Nutragrain bar from S7LPN while the other patients were given a choice of chocolate snack cakes or powdered donuts.

In interview on 09/26/2022 at 10:32 S7LPN was asked about the snack and if she could locate the policy that stated a Nutragrain bar was an acceptable snack for a diabetic. She said she did not know of a policy but they tried to give snacks with a low carbohydrate count. She agreed to try to find a policy.

In interview on 09/26/2022 at 1:25 p.m. S7LPN verified she could not find a policy.

During observation of the unit on 9/27/2022 at 12:07 p.m. S7LPN and S11RN verified they did not know where the therapeutic diet manual was located.

Based on policy review, observation and interview the hospital failed to maintain the facility in such a manner that the safety and well-being of patients are assured. This deficiency is evidenced by failure of the staff to ensure the security of the building after discovering the entrance door was not working properly.
Findings:

1) Failure of the staff to ensure the security of the building after discovering the entrance door was not working properly.

Review of the policy titled, "Environment of Care - Maintaining Environmental Safety" revealed, in part," facilities, supplies and equipment are maintained to ensure safety and quality."

Review of the policy titled "Environment of Care - Managing Safety and Security Risks" revealed, in part," The hospital identifies safety and security risks associated with the environment of care that could affect patient, staff, and other people coming to the hospital's facilities. This is accomplished through routine rounds. The Safety Officer conducts monthly safety and security rounds. . . . The hospital controls access to and from areas it identifies as security sensitive."

An observation on 09/26/2022 at 8:30 a.m. revealed the front door of the facility was unlocked.

An observation on 09/26/2022 at 8:37 a.m. revealed S2DON walk into the facility through the door that was not locked.

An interview on 09/26/2022 at 8:40 a.m. with S9UR indicated the door sometimes stays open after the stretchers go through the door.

An observation on 09/26/2022 at 9:14 a.m. revealed the front door of the facility unlocked with no one present in the lobby. Further observation revealed a sign on the front door indicating the facility was a locked, restricted unit with directions to use the buzzer for entry.

In interview on 09/26/2022 at 9:27 a.m. S2DON verified the entrance door should be locked at all times.S2DON said she thought the door was locked after she reset the locks after entering that morning.

Based on observation, record review, and interview the hospital failed to maintain hospital equipment to ensure an acceptable level of safety and quality. This deficiency is evidenced by 1) failure of the nurisng staff to perform daily glucometer quality controls; 2) failure of the nursing staff to perform daily checks of the emergency cart and automated external defibrillator; and 3) failure to keep maintenance and transport logs on the patient transport van and ensure it was equiped with a fire extinguisher and first aid kit.
Findings:

1) Failure of the nurising staff to perform daily glucometer quality controls.

Review of the policy "NS- Capillary Blood Glucose Monitering," revised 03/21/2018, revealed in part, " Quality control assessment with control solutions shall be completed at least daily on Capillary Blood Glucose Meters."

Review of the Blood Glucose Daily Quality Control Log for the month of September 2022 was performed on 09/26/2022 at 10:32 a.m and revealed the glucometer controls were not done on 09/05/2022, 09/14/2022, 09/23/2022, 09/24/2022, and 09/25/2022.

In interview on 09/26/2022 at 10:32 a.m. S6LPN verifed the dates the glucometer was not checked and verifed it should be checked daily.

2) Failure of the nursing staff to perform daily checks of the emergency cart and automated external defibrillator.

Review of the policy "NS- Emergency Carts," revised 03/21/2018, revealed in part, "Emergency equipment and supplies are checked at least daily and when used."

Review of the Monthly Crash Cart Checklist for the month of May revealed the cart was not checked on May 2, 9, 12, 16, 17, 19, 21, 22, 25, 27, and 30 of the year 2022.

Review of the Monthly Crash Cart Checklist for the month of April revealed the cart was not checked April 1, 4, 5, 8, 9, 10, 13, 14, 15, 17, 18. 19, 22, 23, 24, 26, 27, 28, and 29 of the year 2022.

During the tour of the facility on 09/26/2022 at 10:13 a.m. S2DON verified the emergency cart was not checked daily per hospital policy.

3) Failure to keep maintenance and transport logs on the patient transport van and ensure it was equiped with a fire extinguisher and first aid kit.

Review of the policy titled, "Environment of Care - Maintaining Environmental Safety" revealed, in part, "The hospital keeps furnishings and equipment safe and in good repair. Furnishings and equipment are maintained as to not present any danger to persons within the hospital."

Direct observation on 09/28/2022 at 1:46 p.m. revealed the van used to transport both patients and food did not contain logs of the routine maintenance or transport logs. It also did not have a fire extinguisher or first aid kit.

At the time of observation S2DON verified they were no longer keeping the maintenance logs and there were no patient transport logs. S2DON verified the fire extinguisher and first aid kit were missing from the van.

44763


Based on observation and interview the hospital failed to maintain a clean and sanitary environment to avoid transmission of infection in other areas of the hospital. This deficiency is evidenced by 1) live roaches in the medical records storage room; 2) torn upholstry on chairs throughout hte hospital; and 3) toilet paper rolls on dirty surfaces in several patient rooms with no toilet paper or paper towel holders in the rooms.
Findings:

1) Live roaches in the medical records storage room
In an observation on 09/26/2022 at 1:00 p.m. with S5HIM of the medical records storage room revealed multiple live roaches crawling on the floor.

In an interview during this observation, S5HIM verified there were multiple live roaches crawling on the floor in the medical record storage room.

2) Torn upholstry on 13 of 15 chairs in G3, 7 of 15 chairs in room G1, and 2 of 2 chairs in the nursing station;

Review of the policy and procedure titled, "Infection Control - General Equipment and Textiles - Cleaning and Disinfecting" revealed, in part," the hospital recognizes that infectious agents may be transmitted via fomites such as equipment and/or laundry that is not visibly contaminated. To control the spread of pathogens, the hospital provides guidelines to reduce risk when cleaning and/or disinfecting these items. Surfaces that are likely to be contaminated with pathogens including those that are in close proximity to the patient and frequently touched surfaces in the patient care environment are cleaned and disinfected on a more frequent schedule, no less than every 24 hours, compared to that for other surfaces."

Tour of the facility on 09/26/2022 between 9:27 a.m. and 10:45 a.m. revealed 13 of 15 chairs in room G3 had torn upholstry and 7 of 15 chairs in room G1 had torn upholstry.

During the tour S2DON verified the above findings.

On 09/27/2022 at 12:20 p.m. the two chairs in the nursing station were noted to be completely missing the vinyl covering of the arm rests on the 2 chairs. The armrests were only covered with the backing material from the base of the vinyl fabric.

S11RN and S6LPN verified the armrests of the chairs could not be properly disinfected.

3) Toilet paper rolls on dirty surfaces in several patient rooms with no toilet paper or paper towel holders in the rooms.

Direct observation on 09/26/2022 at 9:50 a.m. revealed the following:

Room 127 with the toilet paper roll balanced on the handrail attached to the wall and no paper towels available for patient use:
Room 128 with the toilet paper roll on the sink and no paper towels available for patient use:;
Room 129 with the toilet paper roll on the back of the toilet and no paper towels available for patient use:;
Room 130 with the toilet paper roll on the back of the toilet and no paper towels available for patient use:

In interview on 09/26/2022 at 9:55 a.m., S2DON verified there were not toilet paper holders in the aforementioned rooms because it depended on when those rooms were renovated.

Based on record review and interview the hospital failed to appoint a qualified individual as leader of the antibiotic stewardship program for the hospital.
Findings:

In interview on 09/28/2022 at 11:20 a.m. S2DON verified she was in charge of the antibiotic stewardship program. She verified she did not have specialized education in infectious disease or antibiotic stewardship. She did not know if she was appointed by the governing body.

Based on record review and interview the hospital failed to document improvements related to proper antibiotic use. This deficiency is evidenced by failure of the hospital to analyze the antibiotic use and recommend improvements to insure compliance with nationally recognized guidelines.
Findings:

Review of the Committee of the Whole minutes from 08/27/2022 revealed they are tracking the number of patients on antibiotics at admission and those started on antibiotics greater than 72 hours after admission.

In interview on 09/29/2022 at 11:20 a.m. S2DON verified their antibiotic stewardship program was only tracking the number of patients on antibiotics greater than 72 hours after admission. S2DON verified there were no set goals for the program. S2DON verified there was no analysis related to the types of infections or if the antibiotics prescribed were in compliance with nationally recognized standards for treatment related to the antibiotic choice and length of treatment.

Based on record review and interview the psychiatric hospital failed to provide adequate numbers of nursing staff to provide the nursing care necessary under each patient's active treatment plan. This deficiency is evidenced by failure of the facility to have adequate staffing of mental health technicians (MHT) per the facility staffing matrix for 5 of 6 evening (7p.m. to 7 a.m.) shifts reviewed.
Findings:

In interview on 09/27/2022 at 1:45 p.m., S2DON stated shortages on the day shift (7 a.m. - 7p.m.) were covered by S2DON and S18RecT, therefore only the evening shifts (7 p.m. - 7 a.m.) were reviewed.

On 09/27/2022 at 3:40 p.m. S2DON also stated the contracted agency nurses would not be on the timesheet, therefore staffing analysis of registered nurses (RN) and licensed practical nurses (LPN) was not performed.

Review of the staffing for MHTs was performed by the surveyor comparing the Nursing Daily Assignment, the daily staffing schedule provided by S2DON and the timesheet showing actual workers for the day.

Review of the Adult Staffing Matrix revealed adequate staffing for 15 to 20 patients would be 2 nurses and 3 MHTs.

Review of the three provided documents revealed on 09/14/2022 the beginning evening shift census was 20 and there were 2 MHTs present.

Review of the three provided documents revealed on 09/ 16/ 2022 the beginning evening shift census was 17 and there were 2 MHTs present.

Review of the three provided documents revealed on 09/18/2022 the beginning evening shift census was 19 and there were 2 MHTs present.

Review of the three provided documents revealed on 09/21/2022 the beginning evening shift census was 20 and there were 2 MHTs present.

Review of the three provided documents revealed on 09/22/2022 the beginning evening shift census was 20 and there were 2 MHTs present.

In interview on 09/28/2022 at 8:20 a.m. S1Adm verified there are only 2 nurses (RN/ LPN or RN/ RN) staffed for each shift and there would not be an extra nurse onsite during the evening shift to perform MHT duties. S1Adm verified there were MHT shortages on the evening shift.