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Based on observation, interview, record review, and policy review, the facility failed;
-To ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to provide an environment aimed at preventing looping and/or hanging hazards.
-Ensure plastic/vinyl shower curtains, which could be suffocation hazards, were removed from three of four patient bathrooms and four of four common bathrooms; and
-Ensure puncture hazards in eighteen of eighteen patient rooms were altered or removed.

Twelve of the 29 currently admitted patients were on suicide precaution observation.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

Based on observation, interview, record review and recognized standards of practice, the facility failed to ensure patients were provided care in a safe setting by failing to:
-Ensure patients were provided care in a safe environment free of looping hazards and ligature points in 14 of 18 patient rooms and four of four common bathrooms;
-Ensure plastic/vinyl shower curtains, which could be suffocation hazards in three of four patient bathrooms and four of four common bathrooms were removed; and
-Ensure puncture hazards in eighteen of eighteen patient rooms were altered or removed.

At the time of the survey 12 of 29 patients were on suicide precautions. The facility census was 29.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:
The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
- Plumbing enclosed in a tamper-resistant enclosure to prevent access by patients. Plumbing fixtures should be enclosed to minimize risks. All supply and waste plumbing should be concealed and inaccessible with tamper resistant fasteners;

2. Record review of the facility policy titled, Section 2 "Provision of Care", "Client Protective Levels," Page 34.1, implemented 07/04, last review 06/23/11, directed the following: Protective levels will be ordered by the primary physician or physician on call. In the absence of a physician, protective levels may be initiated by the unit charge nurse. Once a level has been initiated, a physician order is to be obtained within two hours. Protective levels include:
-Every 15 minutes checks: Based on patient's assessed needs, observation may be done more often than 15 minutes, but no longer than 15 minutes;
-Line of Sight While Awake (LOS w/a): Client is within staff line of sight while awake. While sleeping, the client is placed on every 15 minute watches;
-Line of Sight (LOS): Client is within staff line of sight. Location and activity is documented every fifteen minutes. While sleeping, client remains on line of sight;
-One-to-One (1:1): One-on-One staffs are assigned to one patient. Based upon the client's activity, staff may remain at the patient's door while the client is in the room alone. If a patient is bathing or toileting, the staff member is to remain at the door, with the door ajar to maintain privacy. Location and activity is documented every fifteen minutes. While sleeping, client is placed on line of sight;
-Suicide (SP): Patients at risk for self-inflicted, life-threatening injury;

Record review of the facility policy titled, Section 2 "Provision of Care", "Client Protective Levels" Page 34.3, implemented 07/04, last review 06/23/11, directed the following:
-Reassess precautions and protective levels each shift, make changes and recommendations as needed.
-When assessment findings indicate no further need for precautions and/or protective levels, the doctor should be informed within the next 24 hours.
-Remove articles which the patient is not permitted [to have].
-Perform precautions as ordered.
-Remove shoelaces, belts and jewelry for the following precautions levels:
-Every 15 minute watch;
-Line of Site while awake;
-Line of Site;
-One-to-One;
-Suicide Precautions;

3. Observation of the Pre-Adolescent unit on 05/14/12 at 1:00 PM showed a common shower/toilet room for boys, and a common tub, shower and toilet room for girls. Both the boy's and girl's bathrooms were equipped with single toilets. The flush valve and plumbing behind each toilet was covered with a metal box, but the box stopped short; approximately 12 inches above the base of the toilet and protruded three inches from the wall. This potentially exposed multiple attachment points and looping hazards for a device to be looped around/over the exposed pipe or enclosed valve and still have more than 12 inches of free-fall or distance between the choke point and the floor.

Both of the showers were equipped with plastic/vinyl shower curtains, which were easily detached. These plastic/vinyl curtains presented a potential suffocation hazard.

Observation of the four Pre-Adolescent rooms numbered 300, 301, 302, and 303 showed an uncapped one quarter inch wide shaft for a window control knob that was approximately one inch long and protruded out from the base of each window frame. This presented a potential hazard for self harm of patients with suicidal ideations to cut/puncture themselves.

During an interview on 05/16/12 at 10:30 AM, Staff I, Pre-Adolescent Unit Manager, and Staff K, Director of Facilities stated that they had not considered the control shaft as a potential hazard.

Staff I stated that the doors to both bathrooms and the patient's rooms are locked when the room is not occupied. She stated that patients receive line-of-sight supervision when they are in the bathrooms but are permitted privacy to close the door when using the toilet.

4. Record review of the Pre-Adolescent Unit Hourly Check Sheet dated 05/14/12 showed Patient #17 and Patient #26 were on suicide precautions with every 15 minute observation.

During an interview on 05/14/12 at 1:35 PM, Staff H, Continuous Quality Improvement Director, stated that staff do not observe patients in the Pre-Adolescent Unit's hall bathrooms unless the patient is on a LOS or 1:1 precaution level. Every 15-minute suicide precaution patients are not observed while in the hall bathrooms. This confirmed suicidal patients are left unsupervised in common bathrooms with access to potential looping and hanging hazards.

During an interview on 05/14/12 at 1:40 PM, Staff I, Pre-Adolescent Nursing Director, stated that staff do not observe patients in the Pre-Adolescent Unit's hall bathrooms unless the patient is on a LOS or 1:1 precaution level. Every 15-minute suicide precaution patients are not observed while in the hall bathrooms.

5. Observation on the Adolescent unit on 05/15/12 at 9:30 AM and on 05/16/12 at 4:30 PM showed ten patient rooms numbered 205, 207, 208, 209, 210, 211, 212, 213, 214, 215 with the following:
-Room 205 was equipped with a private shower. Room 205 had an exposed toilet flush valve with 35 inches of exposed water supply pipe. There was three inches of clearance between the wall and the toilet, which created a looping hazard for any unsupervised patient with suicidal ideations.
-Observation in the other nine rooms showed each had a private toilet. The toilet flush valve was covered by a metal valve cover box with a sloped front and squared edges. The box only covered the top 14 inches of plumbing and ended approximately five feet above the floor, which exposed plumbing below the bottom of the metal box. This created several potential attachment points for material to be looped over the valve cover.

Both of the common showers were equipped with plastic/vinyl shower curtains. These plastic/vinyl curtains presented a potential suffocation hazard for any patients with suicidal ideations.

Observation in the ten rooms showed an uncapped one quarter inch wide shaft for a window control knob that was approximately one inch long and protruded out from the base of each window frame. This presented a potential hazard for self harm of patients with suicidal ideations to cut/puncture themselves.

Record review of the Adolescent Unit census sheet dated 05/13/12 showed ten of the fifteen patients were on suicide precautions with every 15 minute observation checks.

6. Observation on the Adult unit on 05/15/12 at 10:00 AM and on 05/16/12 at 4:30 PM showed the following:
-Rooms 101, 102, 103, and 104 each were equipped with a private toilet. The flush valve was covered by a metal box with sloped front and squared edges. The box only covered the top 14 inches of plumbing and ended approximately five feet above the floor. This exposed a 30 inch portion of the water supply pipe above each toilet, which created several potential attachment points for material to be looped over the valve cover.

The private showers in Rooms 101, 102 and 103 had plastic/vinyl shower curtains. These plastic/vinyl curtains presented a potential suffocation hazard.

Observation showed each of the four rooms had an uncapped one quarter inch wide shaft for a window control knob that was approximately one inch long and protruded out from the base of each window frame. This presented a potential hazard for self harm of patients with suicidal ideations to cut/puncture themselves.

During an interview on 05/15/12 at 9:35 AM, Staff K (Director of Facilities) and Staff AA (Maintenance Technician) stated that no staff had ever considered or reported the uncapped window control knobs as a hazard to patients.

During an interview on 05/15/12 at 2:54 PM, Staff DD, Adult Unit Nursing Manager, confirmed there are currently no suicidal patients on the adult unit, but the unit does and has admitted suicidal patients. Staff DD, also confirmed that the suicidal patients routinely have access to the bathroom in their rooms when on 15 minute checks.




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19957

Based on interviews, record reviews and review of Medical Staff Rules and Regulations, the facility failed to ensure medical record entries had dated and timed signatures for six patients (#1, #4, #7, #8, #9, and #17) ) of sixteen current patients' and four (#18, #19, #20 and #21) of nine discharged medical records reviewed for complete medical records entries. The facility census was 29.

Findings included:

1. Review of the Medical Staff Rules and Regulations, approved 09/2011 showed the following:
-All entries in the patient's medical record shall be authenticated/dated/timed.

2. Record review Patient #1's medical record showed staff failed to time the following reports:
-Psychosocial Admissions Assessment dated 05/05/12. The author signed the report, but failed to date and time the signature.
-Educational assessment dated 05/09/12.
-Nutritional assessment dated 05/10/12.

Record review Patient #4's medical record showed staff failed to time the following reports:
-Psychosocial Admissions Assessment dated 05/05/12. The author signed the report, but failed to date and time the signature.
-Educational assessment dated 05/11/12.
-Nutritional assessment dated 05/10/12.


Record review Patient #7's medical record showed staff failed to time the following reports:
-Consent report admit and treatment dated 05/08/12
-Medication notice dated 05/08/12
-Consent for the use or disclosure of patient health information for treatment, payment or health care operations dated 05/08/12.
-Certification of need for psychiatric services dated 05/08/12.
-Confidential information consent dated 05/08/12.
-Consult report dated 05/14/12.
-Psychosocial Assessment Admissions dated 05/08/12.
-Case Manager's assessment dated 05/10/12.
-Educational assessment dated 05/11/12.
-Nutritional assessment dated 05/10/12.

Record review Patient #8's medical record showed staff failed to time the following reports:
-Nursing Summary of assessment dated 05/10/12.
-Pain assessment report dated 05/10/12.
-Psychosocial Assessment Admissions dated 05/10/12.
-Educational assessment dated 05/14/12.
-Nutritional assessment dated 05/10/12.

Record review Patient #9's medical record showed staff failed to time the following reports:
-Psychosocial Assessment dated 05/11/12.
-Psychosocial Admissions Assessment dated 05/14/12.
-Educational assessment dated 05/15/12.

Record review Patient #17's medical record showed staff failed to time the following report:
-Nutrition assessment dated 05/10/12.

Record review Patient #18's medical record showed staff failed to time the following reports:
-Psychosocial Assessment dated 04/20/12.
-Nutrition Assessment dated 04/23/12.
-Summary of nursing assessment dated 04/20/12.
-Case manager's assessment dated 04/23/12.

Record review Patient #19's medical record showed staff failed to time the following reports:
-Psychosocial Assessment dated 02/20/12.
-Nutrition Assessment dated 02/25/12.
-Summary of nursing assessment dated 02/20/12.
-Case manager's assessment dated 02/27/12.
-Discharge summary dictated 02/29/12.

Record review Patient #20's medical record showed staff failed to time the following reports:
-Consent report dated 04/05/12. Signed by Psychiatrist, but failed to time and date signature.
-Psychosocial Assessment dated 04/02/12.
-Psychosocial summary dated 04/03/12.
-Nutrition Assessment dated 04/05/12.
-Summary of nursing assessment dated 04/02/12.
-Case manager's assessment dated 04/05/12.
-Education assessment dated 04/05/12.

Record review Patient #21's medical record showed staff failed to time the following reports:
-Pain assessment dated 04/21/12.
-Nursing admission assessment summary report dated 04/21/12.
-Psychosocial Assessment admissions report dated 04/21/12.
-Psychosocial summary dated 04/03/12.
-Nutrition Assessment dated 04/05/12.
-Summary of nursing assessment dated 04/02/12.
-Education assessment dated 04/25/12.

During an interview on 05/16/12 at 9:30 AM, both, Staff BB, Director of Health Information Management (HIM) and Staff S, Assistant Director of HIM stated that they just missed checking all entries in the medical records and ensuring that all entries were timed as well as dated. They stated that their audits focused mainly on the medical staff and ensuring that they timed each entry in the medical records.

Staff BB and Staff S stated that they reviewed the regulation and concurred that all entries in the medical records by all disciplines should be timed as well as dated and that they would ensure compliance.

Based on observation and interview, the facility failed to maintain carpet on floors in a clean and serviceable condition that promotes and sustains a safe, clean environment to assure a high level of quality patient care services in four of four patient rooms and corridors of the Pre-Adolescent unit, ten of ten patient rooms and common area in the Adolescent unit and four of four patient rooms and common areas in the Adult unit. The facility census was 29.

Findings included:

1. Observation on 05/14/12 at 1:00 PM through 05/16/12 at 4:30 PM showed the following:
-Carpeted floors in four patient rooms (Rooms 300, 301, 302, 303) in the Pre-Adolescent unit with frayed seams at junctions, in corridors and across thresholds in each patient room doorway.
- Carpeted floors in ten patient rooms (Rooms 205, 207, 208, 209, 210, 211, 212, 213, 214, and 215) of the Adolescent unit with frayed seams at junctions, in corridors and across thresholds in each patient room doorway.
-Carpeted floors in four patient rooms (Rooms 101, 102, 103, 104) and group room of the Adult unit with frayed seams at junctions, in corridors and across thresholds in each patient room doorways.

During an interview on 05/2/11 at 10:50 AM, Staff K stated the carpet was last replaced five years ago. He stated that it is cleaned at least annually, but there is no record kept. He stated that they have made repairs on frayed/worn areas. He stated there are no plans at this time to replace the carpet with new carpet.

Based on observations, interview and record review, the facility failed to prepare and serve foods in a sanitary manner. The facility census was 29.

Findings included:

1. Record review of the Food and Drug Administration (FDA) 2005 Food Code, Chapter 2-4, Hygiene Practices, Subpart 2-402.11 (A) gave the following direction:
- Hair Restraints Effectiveness showed the following:
-(A) Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

The Food Code is considered a nationally-accepted standard of practice for the food industry.

2. Record review of the facility's policy title "Nutrition Services Department Safety Practices," dated 02/23/12. Showed the following:
-Employees must wear effective hair restraints that cover all the hair to prevent the contamination of food or food-contact surfaces.

3. Observation on 05/14/12 between 1:15 PM and 3:45 PM and on 05/15/12 between 12:23 PM and 3:00 PM showed Nutrition Care Staff failed to prepare and serve patients and staff's foods in a sanitary manner, to include the following:
Staff R (Cook) served foods on the patients' and staff serving line with facial hair that was not covered.
-He had facial hair on his cheeks and a beard on his chin.
-The hair on his cheeks measured approximately one-fourth inch and his beard measured approximately one to one and one-fourth inch long.
-Staff R also prepared drinking water and ice in 5 gallon coolers and took to the patient care areas for patients to drink.

Staff Q (Cook) served foods on the patients' and staff serving line.
-He prepared food items for patients and staff.
-Staff Q had facial hair on his chin and he did not wear a facial hair restraint over it.
-The hair on his chin measured approximately one-fourth inch long.

During an interview on 05/15/12 at 12:23 PM, Staff O, Director of Nutrition Care/Certified Dietary Manager (CDM), stated that she did not have a policy that dealt with facial hair specifically; she only had the above policy that dealt with covering of hair in general.

Staff O stated that she did not have a staff who wore facial hair until she hired Staff R the week prior to the survey, at which time she ordered beard restraint but they had not been delivered as of survey date. She stated that Staff Q had not worn facial hair until she hired the new staff. She agreed that she should not have allowed the workers to handle food without facial hair restraints.