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Based on review of documentation, it was determined that the facility failed to ensure that the patients' regulated rights for participation in activities and participation in religious activities was ensured. Findings were:

In the Texas Administrative Code, the following regulation is found under a subchapter entitled Rights of Persons Receiving Mental Health Services:
25 TAC 404.155(a)(1)(c): "The right to have an opportunity for physical exercise and for going outdoors, with or without supervision, as clinically indicated, at least daily. A physician's order limiting this right must be reviewed and renewed, if necessary, at intervals no longer than every three days and the findings of the review must be documented in the individual's record".

The facility's Patient Advocate, a social worker, provided the surveyors with a copy of the calls received by the advocate's office for the first three quarters of the Federal fiscal year 2013, beginning October 1, 2012 through September 30, 2013. The results for the month of May 2013 and the last quarter of the fiscal year were not available at the time of the survey. In the listings, the following calls from inpatient were documented:

There were not enough staff to go outside or to attend activities. These calls were received on 10/19/12 (two separate calls),10/23/13. 10/04/12 (four separate calls), 10/16/12, 10/02/12 (two separate calls), 10/12/12, and 10/24/12.

During the second quarter, these same classification of calls were received on 12/5/12, 1/08/13 (two separate calls), 12/20/12(three separate calls, 2/26/13, 12/17/12.

In the third quarter report, calls of this nature were received on 3/22/13, 3/28/13, and 4/11/13. In addition, two separate calls were received at the advocacy offices on 4/23/13 that there were not enough staff for patients to attend church services.

There was no physician's order limiting the patient's right to participate in going outdoors or to participate in activities.

Based upon observation, record review, and interview, the Governing Body failed to



A. Ensure that the hospital's QAPI program assessed the services furnished directly by hospital staff, identify quality and performance problems, or implement appropriate corrective or improvement activities.

Refer to A0283, A0286, A0297, A0308, A0309

B. Ensure nursing provided ongoing assessment of patients that included the assessing of patient care needs, patient's health status, and patient's response to treatment in accordance with accepted standards of nursing practice. Nursing also failed to establish and implement interventions on established care plans.

Refer to Tags A0395, A0396



C. Meet the needs of its patients, in that the facility failed to maintain on-site emergency laboratory services and that all of its laboratory analysis was sent to off site facilities. In addition, the lab failed to maintain appropriate standards for processing specimens in that high school students were observed drawing from lab tubes containing patients' blood prior to being sent for analysis. Also observed were open containers of urine, awaiting packing for analysis, under a blowing fan and cleaning products were being sprayed above the urine samples, thereby increasing the possibility of contamination of the samples.

Refer to Tag A0583

D. Ensure the Infection Control Officer had a working system for reporting, identifying and controlling potential communicable diseases in both patients and staff in 6 of 6 departments and/ or services (Nursing, Kitchen, Laboratory, Radiology, Laundry, Central Supply). The Governing Body also failed to ensure the Director of the Dietary Department functioned in the full capacity as oversight within the department to ensure sanitation, safety practices within the department, training of food service staff, and participate in the Quality Assessment Process Improvement(QAPI) program for the facility.

Refer to Tags A0749, A0620, A0622

E. 1. Maintain the physical environment of the patient care area in a clean and sanitary
manner.
2. Provide a clean and sanitary kitchen for preparing food. The kitchen staff lacked
the knowledge for safe food handling.
3. Remove expired supplies from patient care areas. Expired supplies were made
available for lab testing, patient consumption (eating) and patient use.

Refer to tagA620, A622, A0724, A0749

F. Provide a sanitary envirnoment and the facility failed in its efforts at infection control in 6 of 6 departments and/or services (Nursing, Kitchen, Laboratory, Radiology, Laundry, Central Supply). The facility also failed to ensure the Infection Control Officer had a working system for reporting, identifying and controlling potential communicable diseases in both patients and staff.
Refer to A 0749
G. Have an organized Respiratory Service to meet the needs of patient who require respiratory care. The facility failed to ensure the medical staff identified and approved the scope of diagnostic and/or therapeutic respiratory services provided by the facility. Respiratory Care Services was not integrated into the Quality Assessment Process Improvement (QAPI) program.

Refer to Tag A1152, A1153, A1154, A1160

H. Ensure involvement in the organ procurement process, even though the facility professed to maintain a contract with an organ procurement organization.
I. Develop an organized anesthesia service by not appointing director of anesthesia services, develop policies and procedures that would provide for direction anesthesia services and require the involvement of the service in a hospital wide Quality Assessment and Performance Improvement program (QAPI).

Based on review of documentation and interview, it was determined that the chief executive officer failed in his mission to insure the rights of all patients served by the facility as there were insufficient staff available on numerous days for patients to exercise their rights for going outdoors, to participate in activities, and to participate in worship services of their choosing. Findings were:

In the Texas Administrative Code, the following regulation is found under a subchapter entitled Rights of Persons Receiving Mental Health Services:
25 TAC 404.155(a)(1)(c): " The right to have an opportunity for physical exercise and for going outdoors, with or without supervision, as clinically indicated, at least daily. A physician's order limiting this right must be reviewed and renewed, if necessary, at intervals no longer than every three days and the findings of the review must be documented in the individual's record " .

A patient ' s ability to attend activities is dependent on the availability of staff for escort to and from the activities when held off the patient ' s living unit.

The facility ' s Patient Advocate, a social worker, provided the surveyors with a copy of the calls received by the advocate ' s office for the first three quarters of the Federal fiscal year 2013, beginning October 1, 2012 through September 30, 2013. The results for the month of May 2013 and the last quarter of the fiscal year were not available at the time of the survey. In the listings, the following calls were documented:

Under the heading " There were not enough staff to go outside or to attend activities " . These calls were received on 10/19/12 (two separate calls),10/23/13. 10/04/12 (four separate calls), 10/16/12, 10/02/12 (two separate calls), 10/12/12, and 10/24/12.

During the second quarter, these same classification of calls were received on 12/5/12, 1/08/13 (two separate calls), 12/20/12(three separate calls, 2/26/13, 12/17/12.

In the third quarter report, calls of this nature were received on 3/22/13, 3/28/13, and 4/11/13. In addition, two separate calls were received at the advocacy offices on 4/23/13 that there were not enough staff for patients to attend church services.

There was no physician ' s order limiting the patient ' s right to participate in going outdoors or to participate in activities. There was insufficient staff to insure that this right was guaranteed to patients.

Based on numerous tours throughout the hospital, observation, interviews with staff, and record review, it was determined that the governing body failed to implement and enforce policies and procedures of the facility; nor did the governing body ensure that the hospital's QAPI program assessed the services furnished directly by hospital staff, identify quality and performance problems, or implement appropriate corrective or improvement activities. Findings were:

In response to a complaint investigation, the facility had developed a policy in May of 2013, discontinuing the utilization of nasogastric (NG) tubes. The policy stated, in part, that nasogastric tubes shall not be used at the facility. Prior to the development of this policy, the facility had been using nasogastric tubes on patients who were not eating. Restraints were frequently used in conjunction with the NG tubes to prevent patients from pulling out the tube. The combination of the NG tubes and the concomitant use of restraints were found to be contributing factors in the death of a female patient in February of 2012.

During a tour of the Medical Unit of the facility (Med 2) the afternoon of 6/10/2013, a box contained nasogastric tubes and labeled as such was found in the unit's medication room and available for patient use. The fact that the NG tubes were still present on the medical unit and available for staff to use on patients in indicative of the fact that the governing body had failed to ensure that the staff was aware of the new policy, that the policy had been adequately promulgated to the nursing staff, and that the staff was acting on the policy by eliminating the inventory of NG tubing on the medical unit.

The facility is part of the larger Texas Department of State Health Services State Mental Health Hospital system, and as such, responds to certain critical indicators developed by the Department and the State Hospital Section that meet the needs of the whole. Among these indicators is the cost of outside medical services, the cost of overtime incurred for staff to allow for 1:1 sitters, the ongoing reduction of the use of restraint or seclusion. In review of the Terrel State Hospital's Quality Improvement Plan for FY 2012-2013, there was no deviation from these Statewide indicators found; therefore, no indication that there was any assessment or identification of quality indicators individualized for this particular facility, no performance problems found for this individual facility, and, therefore, no development of appropriate corrective action plans.

The governing body failed to develop and implement policies regarding the use of a contract with an organ procurement organization consistent with the requirements at 42 cfr 482.45. The facility's policy stated, in part, that they will not notify an "Organ Procurement Organization (OPO) of the imminent death of a prospective donor".

The governing body failed provide on-site emergency laboratory services on a 24 hour, seven day a week basis, as stipulated at 42 cfr 482.27(a).

Based on interview and observation, the facility failed to ensure three of three certified units' patient care areas were free of safety risks, in that beds in the patient rooms had exposed metal springs on a steel frame with rough edges that posed the potential to be dismantled for use as a weapon against self or others.

Cross refer to tag A0144.

Based upon interview and observation, it was determined that the facility failed to provide for the patient's right to privacy on two of two certified units.

An interview with Staff #16 revealed that all adult units, including two certified units (7A and 7B) were constructed and equipped the same, and that all rooms on the adult units were equipped with 6 beds and 6 wardrobe cabinets.

A tour to two adult units (5A and 5B) was conducted the afternoon of 6/10/2013, accompanied by staff including nursing administrative staff. When entering the unit, there was a large centrally located activity area with tables and chairs and game tables for both make and female patients. There were 2 patient hallways that extended from the centralized activity area with a glassed in nursing station at the entrance to each hallway. The halls were designated male and female halls. The 5 (five) patient rooms in each hallway had 6 (six) beds each and a wardrobe cabinet for clothing storage for each bed, totally 6 (six) such cabinets in each room. The doors to the rooms had a long, narrow window in them allowing visual access into and out from the room. There was no covering on the windows. The patient rooms had no private areas for dressing, changing, or taking care of personal hygiene needs. The hallway had a single communal restroom for use of 30 patients. Interview with staff #16 revealed that these same observations would be consistent on units 7A and 7B, the certified units, as all adult units were constructed and equipped the same.

An interview with Staff #16 during the tour occurred. When questioned about patient privacy while dressing or undressing, staff #16 confirmed that there was no way for patients to have privacy while dressing due to no private areas and the window in the door remaining uncovered.

Staff # 16 also reported that patients were not able to go to the single communal restroom to change because of the need for the restroom to be readily available to all the patients on the units.

Based on interview and observation, it was determined that the facility failed to insure 3 of 3 certified units (7A, 7B, and Med-2) patient care areas were free of safety risks to patients. Beds in the patient rooms had exposed metal springs on steel frames with rough edges that had to potential to be dismantled for utilization as a weapon against self or others. Wooden wardrobe cabinets on casters, used for clothing storage, had the potential to be used to inflict injury on another patient (by tipping) or had the potential to be used as a barricade to prevent either entrance or egress into or out of the room. Door closures and hinged were a potential ligature risk.

An interview with Staff #16 revealed that all adult units, including two certified units (7A and 7B) were constructed and equipped the same, and that all rooms on the adult units were equipped with 6 beds and 6 wardrobe cabinets.

A tour to two adult units (5A and 5B) was conducted the afternoon of 6/10/2013, accompanied by staff including nursing administrative staff. When entering the unit, there was a large centrally located activity area with tables and chairs and game tables for both male and female patients. There were 2 patient hallways that extended from the centralized activity area with a glassed in nursing station at the entrance to each hallway. The halls were designated male and female halls. The five patient rooms in these hallways each had 6 (six) beds and a wardrobe cabinet for each bed to be used for clothing storage.

Observation of patient rooms on the female hallway revealed beds in the rooms had exposed metal springs on the steel bed frames that allowed for the potential of injury to self and others if dismantled and used as a weapon.

The wardrobe cabinets in the patient rooms were on heavy metal casters that allowed for ease of movement of these large pieces of furniture. The rolling wardrobes had the potential to inflict injury on another patient and also had the potential to be used as barricades to prevent entrance and/or egress to and from the patient rooms

The doors to the patient rooms had door closures and hinges that presented a possible risk if used to tie or anchor a ligature.

Interview with Staff #16 confirmed the potential for harm for the beds, wardrobe, and door closures. Staff #16 further reported that these issues had also been raised during a recent visit to the facility from their accrediting organization. Staff #16 further reported that these potential risks had previously been identified and had been included in the proposed capital budget request for the facility; but that there was no way of knowing or predicting if these funds would be released so that the changes could take place. These changes would include the certified units of 7A, 7B, and Med-2.

Based upon observation, record review, and interviews, the Governing Body failed to

A. Implement and enforce policies and procedures of the facility; nor did the governing body ensure that the hospital's QAPI program assessed the services furnished directly by hospital staff, identify quality and performance problems, or implement appropriate corrective or improvement activities.

Refer to Tag A0283

B. Monitor specific facility performance improvements to monitor the quality of care provided, and ensuring clear expectations for patient and staff safety.

refer to Tag A286, A297

C. Involve all departments of the facility in the Quality Assessment Performance Improvement(QAPI) process.

Refer to tag A0308

D. Ensure that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. The hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. The determination of the number of distinct improvement projects is conducted annually.

Refer to Tag A0309

Based on numerous tours throughout the hospital, observation, interviews with staff, and record review, it was determined that the governing body failed to implement and enforce policies and procedures of the facility; nor did the governing body ensure that the hospital's Quality Assessment Performance Improvement (QAPI) program assessed the services furnished directly by hospital staff, identify quality and performance problems, or implement appropriate corrective or improvement activities.

The facility is part of the larger Texas Department of State Health Services State Mental Health Hospital system, and as such, responds to certain critical indicators developed by the Department and the State Hospital Section that meet the needs of the whole. Among these indicators is the cost of outside medical services, the cost of overtime incurred for staff to allow for 1:1 sitters, the ongoing reduction of the use of restraint or seclusion. In review of the facility's Quality Improvement Plan for FY 2012-2013, there was no deviation from these Statewide indicators found; therefore, no indication that there was any assessment or identification of quality indicators individualized for this particular facility, no performance problems found for this individual facility, and, therefore, no development of appropriate corrective action plans.


32143

Review of the Quality Assessment Performance Improvement (QAPI) program materials on 6/11/2013 revealed that the information gathered was data driven only. There were no performance improvement activities present, completed or ongoing. there was nothing identified to improve or make changes based on committee, performance improvement teams, or action team recommendations.

Interview with staff #41 on 6/13/2013 confirmed that nursing and social work report data to Quality. When questioned on what type of data staff #41 stated, "I have numbers I report like patient incident reports, med errors, restraints that kind of stuff but as far as getting information back I'm not sure we do." Staff #41 confirmed that there are committee's that meet to discuss identified problems but that's taken to nurse executive meetings and reported to staff #8. Staff #41 was not sure where that information went from there.

An interview with staff #6 was initiated on 6/13/2013 concerning data, restraints , and performance improvement. Surveyor requested to see the QAPI data for the last year. Staff #6 delivered his information with data driven information only. Staff #6 confirmed he pulled data as instructed from his superiors. Multiple times staff #6 confirmed that this is how it is done state wide and how the facility was above national standards. Staff #6 was questioned on how they could define issues, educate , and correlate with staff and Staff #6 responded, "Only way to get consensus is to get examples, look at them and say what do you think this is. Everyone has an opinion. Got consensus and send to NRI. Examples of behavioral and medical. They've evolved, we've evolved, and ya'll evolved."

Based on document review and interviews the Governing Body(GB) failed to monitor specific facility performance improvements to monitor the quality of care provided, and ensuring clear expectations for patient and staff safety.

Review of the Quality Assessment Performance Improvement (QAPI) data on 6/13/2013 revealed data collection and analysis of data. No implementation of actions, feedback, training or implementations for Performance Improvement (PI) activities were documented.

No evidence was provided of the facility's QAPI program recommending quality indicators or of Medical Staff and the Governing Body's involvement in approving quality indicators for the ECT procedure area or anesthesia service.

Interview with staff #41 confirmed that information is collected and discussed in mid level management and sent to nurse executive level. No information is coming back to staff level for education or feedback.


22003

The facility is part of the larger Texas Department of State Health Services State Mental Health Hospital system, and as such, responds to certain critical indicators developed by the Department and the State Hospital Section that meet the needs of the whole. Among these indicators is the cost of outside medical services, the cost of overtime incurred for staff to allow for 1:1 sitters, the ongoing reduction of the use of restraint or seclusion. In review of the facility's Quality Improvement Plan for FY 2012-2013, there was no deviation from these Statewide indicators found; therefore, no indication that there was any assessment or identification of quality indicators individualized for this particular facility, no performance problems found for this individual facility, and, therefore, no development of appropriate corrective action plans.

Based on review of Quality Assessment and Performance Improvement (QAPI) information, and interviews,the facility failed to have performance improvement projects designed to address facility specific issues to improve the quality of patient care.

A handout was given to the Survey team when we arrived to the facility. Staff #6 reported that it was a handout to give a description of the organization and general information.

A review of the Introduction handout under "Primary Hospital and State Wide Committees it listed 21 different committee's and 11 state wide committee's. The committee's listed are as follows;
1. Hospital Governing Body
2. Medical Executive
3. Medical Staff
4. Health safety and Infection Control
5. Information Management
6. Pharmacy and Therapeutics
7. Medical Peer review
8. Surgery, Anesthesia and Tissue.
9. Patient Education
10. Ethics
11. Behavior Therapy
12. Nurse Executive
13. Nurse Staffing
14. Hospital Executive Committee
15. Respect and Dignity
16. Building
17. Joint Commission Readiness
18. Food Service
19. Employee Recognition and Reward
20. Facility Performance Improvement Priorities
21. Selected department and QIT Reports.

The facility has 21 different committee's to assist in performance improvement. Data collection and analysis from data was present. Upon surveyor request, no information was given on any tailored performance improvements in place and on-going from any of the above committee's.

Interview with staff #41 confirmed that information is collected and discussed in mid level management and sent to nurse executive level. No information is coming back to staff level for education or feedback.



22003

The facility is part of the larger Texas Department of State Health Services State Mental Health Hospital system, and as such, responds to certain critical indicators developed by the Department and the State Hospital Section that meet the needs of the whole. Among these indicators is the cost of outside medical services, the cost of overtime incurred for staff to allow for 1:1 sitters, the ongoing reduction of the use of restraint or seclusion. In review of the facility's Quality Improvement Plan for FY 2012-2013, there was no deviation from these Statewide indicators found; therefore, no indication that there was any assessment or identification of quality indicators individualized for this particular facility, no performance problems found for this individual facility, and, therefore, no development of appropriate corrective action plans.






28043

Interview with staff #6 on 6/11/2013 reported that he follows the guidelines that have been set by the state for the state facility's in what data is collected and how.

Surveyor asked staff #6, " how are nurse managers involved in the QI process?"

Staff #6 responded, "In previous survey, not adequate nursing survey notes. The process for looking for nursing survey notes. Nursing assessment time frames is one of the indicators. Staff #8 sits with us in MEC (medical executive committee), and nurse manager director of admissions. Lot of documentation requirements in that committee."

Surveyor asked," nurse managers that actually manage these units, how are they involved? Are they the people that implement?"

Staff #6 stated,"Many sit on a committee. Nurse executive committee - aggregate reports - chain is through MEC. They have department head meetings with each nurse manager; talks about their department."

Surveyor asked,"Talking to the managers, they aren't involved, they pull some data out of the computer, that they've been asked to accumulate. They send the data. They are not getting feedback as far as implementing. That's what they say. How are you getting that information back to nurse managers to implement QAPI? If you can't communicate back to them what's the purpose? Do you do that or does staff #8 take that back to the nurse managers?"

Staff #6 replied," Staff #8 does that - takes it to nurse managers, nurses meet every Thursday. There are indicators tracked hospital wide. Plethora of things in management. They are tracked within nursing. Decided to be facility-wide indicators, timeliness and presence of nursing summary notes. Indicators that are tracked, though long ago met our MOS from TJC."

Surveyor asked,"All those would be in last QAPI report?"

Staff #6 relied," If identified in nursing, would be in nursing report for last quarter. If hospital wide, would be in other reports. There is nursing report that goes to governing body. There are statewide, facility and department indicators. A plethora of things. Staff #59, sits on that as well as safety officer, all part of quality management. My committee membership is in statewide medical records committee, refining that. We also have an ad hoc committee of our leadership that meets every week to deal with emerging things. We also have hospital-wide priorities, mostly programmatic. One is to address patient wait times and patient flow."

Surveyor asked," Do you have a list of the teams that are addressing these quality indicators?"

Staff #6 replied," It ' s in the handout- committee structure in handout. All restraints from May 1 to present. FYI, ya'll came and you know the story, how we got that lady from Tyler and the findings. We had 122 medical restraints in April, 22/23 in May.
The last 2 weeks have had none."

The surveyor commented," In the May 15th 2013 governing body minutes, reduction of restraint seclusion was the goal of this facility. This has been in the attention of the governing body for some time as well."

Staff #6 replied,"This was prepared before the actual meeting, it takes several weeks to prepare."

Surveyor asked," was the governing body made aware?"

Staff #6 stated, "They participated actively with recommendations for our Plan of Correction. Their intent was to use the experience here to create a common policy for the entire system. Actively involved in discussions with that. As a matter of fact, have to do am action memo, whether complaint of abuse or UD. Have to send action memo and send to them. Any incident that's reportable goes to central office."

Surveyor asked,"Do you maintain a log of the action memos?"

Staff #6 replied," I don't know - the risk manager does that. Seclusion date should say at bottom 6/13. New statement under non-violent restraint. This does not apply to routine procedures such as blood draws, and routine in clinic."

Based on document review and interviews, the Governing Body (GB) failed to involve all departments of the facility in the Quality Assessment Performance Improvement(QAPI) process.

Review of the QAPI data revealed that the Laboratory, Anesthesia, and Respiratory departments were not being monitored in the QAPI process.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have an organized Respiratory Department. Staff #6 confirmed Laboratory, Respiratory, and Anesthesia were not being monitored in the QAPI program.

Committees it listed 21 different committee's and 11 state wide committee's. The committee's listed are as follows;
1. Hospital Governing Body
2. Medical Executive
3. Medical Staff
4. Health safety and Infection Control
5. Information Management
6. Pharmacy and Therapeutics
7. Medical Peer review
8. Surgery, Anesthesia and Tissue.
9. Patient Education
10. Ethics
11. Behavior Therapy
12. Nurse Executive
13. Nurse Staffing
14. Hospital Executive Committee
15. Respect and Dignity
16. Building
17. Joint Commission Readiness
18. Food Service
19. Employee Recognition and Reward
20. Facility Performance Improvement Priorities
21. Selected department and QIT Reports.

The facility has 21 different committee's to assist in performance improvement. Data collection and analysis from data was present. Upon surveyor request no information was given on any tailored performance improvements in place and on-going from any of the above committee's.

Interview with staff #41 confirmed that information is collected and discussed in mid level management and sent to nurse executive level. No information is coming back to staff level for education or feedback.Based on document review and interview's the Governing Body (GB) failed to ensure an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. The Governing Body also failed to address priorities for improved quality of care and patient safety and that all improvement actions were evaluated.

Review of Quality Assessment and Performance Improvement (QAPI) information, and interviews, the facility did not present any projects designed to monitor facility specific issues to improve the quality of patient care.

A handout was given to the Survey team when we arrived to the facility. Staff #6 reported that it was a handout to give a description of the organization and general information.

A review of the Introduction handout under "Primary Hospital and State Wide

Based on observations, interviews, and record reviews, the facility failed to follow its own policy and procedures to provide patient assessment in 9 (#18, 8, 3, 5, 7, 13,17, 21, and 23) out of 9(#18, 8, 3, 5, 7, 13,17, 21, and 23) charts reviewed. The facility failed to provide ongoing assessment that included the assessing of patient care needs, patient's health status, and patient's response to treatment in accordance with accepted standards of nursing practice. Nursing also failed to notify physicians when patients experienced a change in condition. Nursing failed to document and follow physician orders for vital signs, weights, intake, and outputs in 3 (#18, 8, and 3) out of 4 (#18, 8, 3 and 5) patients reviewed. The facility failed to ensure the nursing department established appropriate care plans and failed to act on interventions of the established care plans.
Refer to Tag A0395, A0396

Based on observations, interviews, and record reviews, the facility failed to follow its own policy and procedures to provide patient assessment in 9 (#18, 8, 3, 5, 7, 13,17, 21, and 23) out of 9 (#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) charts reviewed. The facility failed to provide ongoing assessment that included the assessing of patient care needs, patient's health status, and patient's response to treatment in accordance with accepted standards of nursing practice. The facility failed to document and follow physician orders for vital signs, weights, intake, and outputs in 3 (#18, 8, and 3) out of 4 (#18, 8, 3 and 5) patients reviewed.
Review of nursing progress notes for patient's (#18, 8, 3, 5, 7, 13,17, 21, and 23) revealed during the first three days patient assessments are incomplete. No assessments for fall status, pain, level of consciousness, risk assessments, physical assessments that include Neurological, Cardiovascular, Respiratory, Gastrointestinal, GU/Renal, Musculoskeletal, or Integumentary were found in the progress notes. The progress note was a short summarized shift note titled "1st Day Note", "1st Night Note", and did not give a complete picture of the patient's condition.

Interview with staff #8 on 6/12/13 confirmed that the nurses are to document in the progress notes every shift for the first three days. Staff #8 confirmed that the only other place in the Electronic Medical Record (EMR) an assessment is completed is in the initial nursing assessment performed on admission.

Interview with staff #41 on 6/12/13 confirmed that the patients nursing notes are charted on everyday the first week. If there is something wrong with the patient then they are charted on more frequently depending on what's going on with the patient.

Review of "Provision of Care, Treatment, and Services Section 7-4" on 6/13/13 revealed the policy "Documentation" was revised in February 2013. The policy states:

"It is the policy of Nursing Services to provide prompt, valid and useful documentation on each patient in the patient's medical record.

C.) Electronic Documentation for Inpatient Nursing Care Documentation:

1.) Each inpatient will receive 24-hour nursing care supervised by an RN (Registered Nurse). Following admission, an RN will document a reassessment of each inpatient, at a minimum of each shift x three days, utilizing the Progress Note Billing TX type in the EMR (Electronic Medical record). Additionally, any patient that is on special precaution that requires a reassessment every shift, said reassessment shall also be documented in this section.

2.) The reassessment note shall then be documented by an RN as the patient's condition warrants following patient's admission. NOTE: Exception to this standard will be patients admitted to Medical II unit. Each Medical II patient will have a minimum of one RN daily reassessment and note (one per 24 hour period) for the extent of their stay on this unit.

3.) Once the patient has been in the hospital a minimum of seven days, the weekly progress note detailing the patient's progress toward treatment goals will be established. NOTE: Medical II patients are expected to have a weekly progress note as well, detailing the progress toward the goals and objectives of their recovery plan, for both physical and psychiatric health.

4.) Reassessment documentation by the RN will include a description of patient behavior, a summary of fall observations, summary of psychiatric and medical conditions including pain, falls, staff intervention, and treatment. Documentation will be descriptive, utilizing behavioral examples when indicated.

5). The reassessment of the patient and the documentation of such shall be made by an RN as often as the patient's condition warrants. The procedural elements as described above represent the minimums as required by this hospital for RN reassessment and subsequent documentation.

Review of the "Client Recovery Plan-Full Report" revealed the patient #18 was a 70 year old, white female, admitted to the facility on 3/7/2013 with a diagnosis of Psychosis, Mood Disorder, rule out Alzheimer's Dementia, and rule out Behavioral Problems. Patient #18 also had multiple co-morbidities such as Diabetes Type 2, Gastrointestinal Esophageal Reflux Disorder (GERD), Degenerative Joint Disease (DJD), Hypothyroidism, Hypokalemia, Dyslipidemia, and Constipation. This was patient #18's first visit to this facility and was admitted with an Order of Protective Custody (OPC)Warrant.
Review of RN admission note dated 3/7/2013 at 9:16 PM stated: "Patient also states, 'I'm pregnant.' When asked how she knew she stated, 'cause they talk to me.' She told the nursing home staff that someone was trying to kill the snakes in her belly." Patient #18 was cooperative and non-aggressive during admission process. Patient #18 denied suicidal or homicidal gestures. Physician Admission Orders dated 3/7/2013 stated, "Weekly weight. Notify physician of weight gain 10lbs or 5% of baseline. 1 weight every 7 days. Reason: medication monitoring. "The following weights were documented in patient #18's Medical Observation Notes:
1.) 3/7/2013 at 8:30 PM, revealed the patient's weight was 220lbs and a body mass index (BMI) of 33.4 on admission.
2.) On the Physician Physical Exam note 3/8/2013 at 11:15AM, revealed the patient's weight was 217lbs. A 3lb loss in 14.5 hours.
3.) 3/9/2013 at 1:58 AM, revealed the patient's weight was 260lbs. A 43lb weight gain in 14.5 hours.
4.) The next weight should have been on 3/14/2013. There was no medical observation note for that day.
5.) 3/16/2013 at 1:22 AM, revealed the patient refused to weigh. There was no nursing documentation for 3/16/2013.
6.) 3/22/2013 at 5:59 AM, revealed a weight of 205.2lbs. (A 55lb loss in 13 days) No documentation in the nursing progress notes of significant weight loss or physician notification.
Nursing progress note documentation for 3/25/2013 at 3:27 PM, revealed patient #18 was vomiting and physician #49 was notified and ordered the patient to go to the clinic. Patient #18 went to the clinic at 3:05 PM. Physician's note dated 3/25/2013 at 3:48 PM revealed patient #18 was seen in the clinic but no weight was recorded or discussed. Physician # 47's clinical impression stated," 1.) History of vomiting. Questionable upper Gastrointestinal Bleed. 2.) Clinically, she appears dehydrated. 3.) Diabetes Mellitus. 4.) Hypothyroidism. 5.) GERD. Plan: Obtain stat CBC (complete blood count), CMP (complete metabolic panel), urinalysis, chest X-ray, and electrocardiogram. Admit to medical ward. Start her IV (intravenous fluids) normal saline. Place her on sliding scale insulin coverage. Further recommendations will be made after reviewing lab."
On the medical observation note for 3/25/2013 at 6:04 PM, revealed a weight of 194lbs. No nursing progress note documentation on weight loss or physician notification. Patient #18 had an 11.2lb weight loss in 3 days.
Review of patient #18's medical record revealed that patient #18 had a change in condition. The nursing progress note dated 3/26/2013 at 10:42 AM, revealed that the patient had an elevated blood pressure of 183/96. Patient was alert and talking to staff. Patient told the nurse she was hurting but could not tell her where. The patient had been vomiting all through the night. The nurse contacted physician #47 and an order was given to start a Catapress patch for elevated blood pressure on 3/26/2013 at 8:19AM. The patient was ordered Intravenous fluids(IV) with potassium (IV), a Foley Catheter, IV Levofloxacin 500 mg once for infection, strict intake and output, and a nasogastric tube insertion (NGT). The nurse was unable to place the NGT due to a nose bleed so the NGT was discontinued.
Review of patient #18's medical record revealed that the intake and output was not consistently documented in the EMR. There was no documentation for intake or output on 3/30 and 3/31/2013 except for day shift. There also was no documentation for 4/1/2013. Orders for intake and output were discontinued on 4/2/2013.
On the medical observation note for 4/12/2013 at 4:08 PM, revealed patient #18's weight is 213.6lbs a 19.6 weight gain in 18 days. No weights documented for 4/1/2013 or 4/8/2013. No nursing documentation concerning weight or physician notification.
On the medical observation note for 5/3/2013 at 6:49 AM, revealed patient #18's weight is 200.4lbs a 13.2 weight loss in 21 days. No documented weights obtained in 20 days. No nursing documentation of patient weight loss or physician notification.
Review of a physician order dated 3/25/2013 at 4:12 PM stated, " Blood Sugar Checks QID 1 EA four times a day." Numerous blanks were found on the EMR as follows:
1.) 4/15/2013 revealed no BS for 4:30 PM.
2.) 4/16/2013 revealed no BS reading for 4:30 PM.
3.) 4/20/2013 revealed no BS readings for 8:00 PM.
4.) 4/21/2013 revealed no BS reading for 4:30 PM.
5.) 4/23/2013 revealed no BS readings for 4:30 PM.
6.) 4/29/2013 revealed no BS readings for 4:30 PM and 8:00 PM. There was a documented 4 units given but no documentation on what, when, or where.
7.) 4/30/2013 revealed no BS readings for 11:30 AM, 4:30 PM and 8:00 PM.
8.) 4/26/2013 revealed no BS readings for 4:30 PM and 8:00 PM.
9.) 4/29-5/1/2013 revealed no BS readings for 4:30 PM and 8:00 PM.
10.) 5/3-5/5/2013 revealed no BS readings for 4:30 PM and 8:00 PM.
11.) 5/7-5/8/2013 revealed no BS readings for 4:30 PM and 8:00 PM.
12.) 5/10/2013 revealed no BS readings for 6:30 AM, 4:30 PM, and 8:00 PM.
13.) 5/13/2013 revealed no BS readings for 6:30 AM.
14.) 5/14/2013 revealed no BS readings for 4:30 PM, and 8:00 PM.
15.) 5/19/2013 revealed no BS readings for 11:30 AM.
16.) 5/20/2013 revealed no BS readings for 6:30 AM.
17.) 5/24, 5/27, 6/10/2013 revealed no BS readings for 4:30 PM and 8:00 PM.
18.) 6/06/2013 revealed no BS readings for 11:30 AM and 4:30 PM.
Review of the Vital Sign report revealed that patient #18 had 96 documented, "Refused Vitals" from 3/7/2013 to 6/11/2013. No comments were noted on the Medication Observation Sheets of RN or physician notification concerning refusal of vital signs or weights. Review of the Nursing Progress Reports revealed only 11 nurse entries of patient refusal.
No other documentation of patient's vital signs were found up to 6/11/2013. No medical observation sheet documentation for vital signs were found for the following dates; 3/10, 3/14, 3/18, 3/19, 3/21, 3/26, 3/27, 3/28, 3/29, 3/30, 4/1, 4/2, 4/4, 4/7, 4/9, 4/11, 4/14, 4/16, 4/21, 4/22, 5/18, 5/29, 5/31, 6/1, 6/4, 6/5, 6/8, 6/9.


28043

Review of the medical record of Patient #3 revealed a "Client Recovery Plan" [treatment plan] with a problem of "Alteration in Cardiac Function/Circulation." One of the objectives for this identified problem was "He will identify diagnosis, name(s) of medication(s) possible: possible side effects, warning signs, and importance of taking medications and communicating with physician after discharge." The intervention was "Nursing staff will monitor and record vital signs: breath sounds, weight, peripheral edema, and activity tolerance at least once per shift." There was no documented evidence in the medical record of nursing staff assessing or recording breath sounds, weight, peripheral edema and activity tolerance at least once per shift between the dates of 5/3/13 and 6/13/13.


28659


Review of Pt. #5's medical record revealed patient was a 62 year old female with a diagnosis of Bipolar Disorder, Diabetes Mellitus, Type II, Chronic Obstructive Pulmonary Disease, Hypertension, and Morbid Obesity. On 1/31/2012, Pt #5 V/S were recorded as 93/66, 101, 16. The nursing documentation records the following:

Pt #5 stated "it hurts to try to hold her head up", she is drooling...Pt is unable to assist staff with any of her care. She is spoon fed, only ate 5%...There was no documentation of nursing assessment, nursing intervention or that the physician was notified of the patient's condition. On 2/1/2012 at 5:20 PM Pt #5's V/S were as follows; 93/59, 99.1, 84,20. There was no nursing documentation of further assessment or intervention Pt #5. Nursing documentation records Pt #5 was in bed with TED (Anti-embolism hose), her FC has dark urine with sediment. The physician was not notified per nursing documentation. On 2/4/2012 at 7:29 PM Pt #5's V/S were recorded as 80/59, 96.6 67,18. Pt #5's B/P was rechecked by the staff and was recorded as 102/62, however her pulse was recorded as 105 beats per minute (BPM).There was no nursing documentation the nurse assessed Pt #5 further or attempted any nursing intervention. There was no nursing documentation the physician was notified of Pt #5's elevated pulse.

On 2/30/2012 at 8:14 AM the nurses notes reflected Pt #5 V/S were 81/53, 96.0, 73, 20. There was no documentation that Pt #5's blood pressure (B/P) had been rechecked, as 81/53 was well below the parameters set in the care plan for safe blood pressure. There was no documentation the physician had been notified or that any nursing assessment or intervention had been attempted.

On 5/25/2013 at 11:09 AM Pt #5's V/S were recorded as 84/55, 96.9,64,16. Here BP was rechecked at 100/63. On 5/26/2013 at 5:04 PM Pt #5's V/S were recorded as 89/55, 96.9, 67, 20. There was no nursing assessment or interventions documented and there was no documentation the physician was notified of Pt #5's low B/P.

An interview with staff #8 was conducted on 6/13/2013 at 2:00 PM. Staff #8 was questioned concerning intake and outputs. Staff #8 had a copy of the policy in hand and was shown examples of incomplete intake and output records. Staff #8 reported that if the patient did not have a Foley catheter it was just a "guesstimation" on the patient's output. Staff #8 reported that the facility did have urine hats to collect the urine in bathrooms but some patients have on diapers. Staff #8 was unable to describe how output could be collected and documented if the patient was in a diaper. Staff #8 was asked if at any time diapers were weighed and documented. Staff #8 stated, "No, we just have not done that. "Staff #8 was questioned about the high parameters for vital signs. Staff #8 had brought the policy for vital signs and displayed the vital sign parameter chart. Staff #8 reported that she was on the State Committee that discussed this issue. Staff #8 reported that the committee could not decide on parameters so they left it up to each hospital to allow the Medical Executive Committee (MEC) to decide and implement.
Review of "Provision of Care, Treatment, and Services Section 7-13" on 6/13/13, revealed the policy "Performing Routine Vital Signs" was revised in February 2013. The policy states:
" PURPOSE: Vital signs are defined as the patient's temperature, pulse, respiration, and blood pressure.
A.) This policy does not take the place of specific physician's orders nor the vital signs requirement for patients placed on such medications as anti-hypertensive medications.
D.) Patients on antibiotics will have temperature taken every four hours till afebrile.
PROCEDURES AND KEY POINTS: RESPONSIBLE PERSON:
Licensed staff to ensure that vital signs are taken accurately and recorded in the patient's electronic medical record. Vital signs are recorded in the electronic medical record (EMR) under the Medical Observation section. Routine vital signs are to be taken on a weekly basis. Vital sign parameters are as follows: Pulse < 45 >125, Systolic Blood Pressure < 85 >170, Diastolic Blood Pressure <45 >120, Respiration <10 >32 per minute, Temperature <96.0 >103.0, Pain < N/A > 'severe', Blood Glucose <50 mg/dl >350 mg/dl, Pulse Oximeter reading < 88%." The policy did not indicate approved vital sign parameters for children.
An interview with staff #8 was conducted on 6/13/2013 at 2:00 PM. Staff #8 stated, "These are the vital sign parameters for the all the patients in the facility." Staff #8 was holding the policy for vital signs as referenced above.

Review of "Provision of Care, Treatment, and Services Section 7-21" on 6/13/13, revealed the policy "Weight and Nutritional Intake" was revised 2013. The policy states: "Considerations and related issues:
A.) BMI (body mass index) protocol will be implemented upon initiation of atypical antipsychotic medications.
Procedures and Key Points:
A.) all new admissions will be weighed upon admission and weekly, or as often as deemed necessary per medical doctor or attending physician. Weights are also to be taken during admission physicals. Weights are to be documented in the EMR under the Medical Observation tab, other chart entry -Medical Observation. B.) Weight loss or gain of five pounds or more in one month's time will be verbally reported to the RN on duty." C.) A significant weight loss or gain will be reported to the physician, Nurse Manager, and Clinical Nutritionist."
Review of "Medical Services Manual Section 1-22" on 6/13/13, revealed the policy "Intake and Output Records" was revised on January 2013. The policy states,
"Accurate intake and output records will be maintained for all patients having an order for one and all patients receiving IV Therapy (excluding saline locks and IV placed solely for Electroconvulsive Therapy (ECT.) Nursing staff is responsible for maintaining intake and output records.
Procedure: 1. The intake and output record shall include the following:
INTAKE:
A.) All liquids by mouth.
B.) Amount of solution used in irrigating Levin tubes.
C.) Fluids taken by mouth.
D.) All IV's or clysis.
OUTPUT:
A.) all urinary drainage.
B.) Drainage from T-tubes.
C.) Contents from suction pump.
D.) All emesis.
2.) Documentation shall be found in the Medical Observation Intake/Output section of CWS.
A.) Documentation shall occur near the end of the shift.
B.) Documentation of intake shall be entered by licensed staff.
C.) Documentation of output shall be entered by PNA (psychiatric nurse assistant) staff.

Review of patient #8's medical record on 6/12/13 revealed the patient was admitted to the facility with a diagnosis of Schizophrenia, Urinary Tract Infection, and Pregnant. Patient's pregnancy was confirmed with a serum pregnancy test on 4/10/2013. A physician order was written on 4/15/2013 for patient to see "OB/GYN." Review of Nursing Progress Note dated 4/24/2013 at 1:11 PM, revealed Patient #8 was taken to a local Hospital for a Sonogram and physician visit. There was no documentation of importance of prenatal care, dietary changes, common discomforts of pregnancy, exercise abilities and limitations or sexual activity during pregnancy in the nursing progress notes or nursing care plan. There was no order for fetal heart tones. Patient #8 discharged from the facility on 6/13/2013.

Review of "Provision of Care, Treatment, and Services Section 7-22" on 6/13/13, revealed the policy and procedure for "Care of the Pregnant Patient." The purpose of the policy states: "To ensure the safety and well-being of the patient and the unborn child, to the extent possible.
Procedures and Key Points:
A. For all pregnant patients. The RN will initiate a referral to the clinic upon admission for the clients to be seen by the consulting OB-GYN. based on physician order.
B. Nursing staff will assure that the patient is aware of all appointments, both at this hospital and an outside appointment.
C. Nursing staff will notify Medical Nutrition Therapy of the admission of the pregnant client, and the estimated due date.
D. Nursing staff will assist client in meeting her nutritional, medical, emotional, and physical needs during pregnancy.
E. Nursing staff will teach the patient about pregnancy and the teaching plan will include:
1. The importance of prenatal care.
2. Dietary changes.
3. Warning signs to report to the physician (and staff while in TSR).
4. Common discomforts of pregnancy.
5. Exercise abilities and limitations.
6. Fetal activity and movement.
7. Sexual activity during pregnancy.
F. The RN will consider the age and developmental status of the patient for all educational needs.
G. The RN will consult with the attending physician regarding need for fetal heart monitoring while in this facility."

Based on document review and interview the facility failed to ensure the nursing department established appropriate care plans and failed to act on interventions of the established care plans for 2 of 30 (#5, #3) patients reviewed.

On 6/12/2013, during the afternoon, a review of patient (pt/Pt) #5's Medical/Psychiatric Care Plan from the her Medical Record (MR) revealed Pt #5 was a long term stay pt. who was admitted on 12/9/2011. Her medical care plan revealed the following:

Problem: Alteration is urinary elimination/incontinence. Pt. had documented problems related to stress incontinence and had a Foley Catheter (FC).
Goal: Pt will achieve and maintain adequate urinary elimination.
Objectives: At least every 8 hours, Pt will urinate independently in toilet (sic).
Pt would not develop skin break down as a results of incontinence.
Pt #5 will not develop complications related to the FC.
Interventions: Nursing staff will perform incontinent care as needed.
Nursing staff will perform FC care.

Pt #5 had a documented indwelling FC, therefore independent urination could not occur, incontinence should not occur with a properly functioning FC, and incontinent care should not be needed.

Problem: Alteration is cardiac functioning/circulation.
Goal: Pt will achieve and maintain stable cardiac and circulatory function such that she can tolerate mild to moderate physical activity.
Objectives: Pt. will evidence vital signs (V/S) within normal limits: heart rate 60-100, blood pressure greater than 100/60 and less than 140/90.
Intervention: Physician will evaluate need for medication and/or non-pharmacological treatment.
There was no nursing intervention on the care plan for this problem.

On 1/31/2012, Pt #5 V/S were recorded as 93/66, 101, 16. The nursing documentation records the following:

Pt #5 stated "it hurts to try to hold her head up", she is drooling...Pt is unable to assist staff with any of her care. She is spoon fed, only ate 5%...There was no documentation of nursing assessment, nursing intervention or that the physician was notified of the patient's condition. On 2/1/2012 at 5:20 PM Pt #5's V/S were as follows; 93/59, 99.1, 84,20. There was no nursing documentation of further assessment or intervention Pt #5. Nursing documentation records Pt #5 was in bed with TED (Anti-embolism hose), her FC has dark urine with sediment. The physician was not notified per nursing documentation. On 2/4/2012 at 7:29 PM Pt #5's V/S were recorded as 80/59, 96.6 67,18. Pt #5's B/P was rechecked by the staff and was recorded as 102/62, however her pulse was recorded as 105 beats per minute (BPM).There was no nursing documentation the nurse assessed Pt #5 further or attempted any nursing intervention. There was no nursing documentation the physician was notified of Pt #5's elevated pulse. On 2/30/2012 at 8:14 AM the nurses notes reflected Pt #5 V/S were 81/53, 96.0, 73, 20. There was no documentation that Pt #5's blood pressure (B/P) had been rechecked, as 81/53 was well below the parameters set in the care plan for safe blood pressure. There was no documentation the physician had been notified or that any nursing assessment or intervention had been attempted. On 5/25/2013 at 11:09 AM Pt #5's V/S were recorded as 84/55, 96.9,64,16. Here BP was rechecked at 100/63. On 5/26/2013 at 5:04 PM Pt #5's V/S were recorded as 89/55, 96.9, 67, 20. There was no nursing assessment or interventions documented and there was no documentation the physician was notified of Pt #5's low B/P.

Problem: Alteration in mobility/strength and/or potential for falls. Pt had a documented unsteady gait and a fall risk score of 49.
Goal: Pt will achieve and maintain adequate physical mobility; such that she does not develop complications from immobility and is able to function optimally to achieve her personal goals in the community.
Interventions: Physician and Registered Nurse will assess strength,mobility, range of motion, and functional ability to bear weight, transfer herself, assist with transfer herself or assist with transfer and follow instructions.

On 12/24/2011 a Psychiatric Nursing Assistant (PNA) documented the following: "Client (pt) notified the Staff that a client was on the floor. I immediately went to the room to the scene were (sic) client (Pt #5) was on the floor. I notified RN (nurse) that the client was on the floor. He sent two staff members from the men (sic) unit. RN (nurse) did not arrive to the scene. Staff and I was (sic) able to help client up from the floor, onto her wheelchair. Staff wheeled client to lobby". There was no nursing documentation that Pt #5 was ever assessed by the RN for injury. There was no documentation family or physician was notified of the patient's fall and there was no changes noted to Pt #5's care plan.

On 6/12/2013 in the 4th floor conference room in the morning the Facility titled "Provision of Care, Treatment and Services section 7-13" "Performing Routine Vital Signs"
Purpose: Vital Signs are defined as the patient's temperature, pulse, respiration and blood pressure.

Parameters:
Pulse; less than 45 BPM or greater than 125 BPM
Blood Pressure Systolic; less than 85 or greater than 170 (sic)
Blood pressure Diastolic; less than 54 greater than 120 (sic)
Respirations; less than 10 per minute or greater than 32 per minute
Temperature; less than 96.0 or greater than 103.

The facility policy for Vital Sign parameters was not followed when Pt #5's medical care plan (MCP) was created. The nursing staff failed to follow the parameters set by the facility and/or the MCP.

The above findings were confirmed by staff #58.



28043

Review of the medical record of Patient #3 revealed a "Client Recovery Plan" [treatment plan] with a problem of "Alteration in Cardiac Function/Circulation." One of the objectives for this identified problem was "He will identify diagnosis, name(s) of medication(s) possible: possible side effects, warning signs, and importance of taking medications and communicating with physician after discharge." The intervention was "Nursing staff will monitor and record vital signs: breath sounds, weight, peripheral edema, and activity tolerance at least once per shift." There was no documented evidence in the medical record of nursing staff assessing or recording breath sounds, weight, peripheral edema and activity tolerance at least once per shift between the dates of 5/3/13 and 6/13/13.

Based on review of documentation, interviews, and observation, it was determined that the facility's laboratory failed to meet the needs of its patients, in that the facility failed to maintain on-site emergency laboratory services and that all of its laboratory analysis was sent to off site facilities. In addition, the lab failed to maintain appropriate standards for processing specimens in that high school students were observed drawing from lab tubes containing patients' blood prior to being sent for analysis. Also observed were open containers of urine, awaiting packing for analysis, under a blowing fan and cleaning products were being sprayed above the urine samples, thereby increasing the possibility of contamination of the samples and decreasing the potential for accuracy in the final analysis.

Refer to Tag A0583

Based on observation, interviews and record review, it was determined that the facility did not have on-site emergency laboratory services available to meet the emergency needs of their patients. The laboratory did not perform any of the patients' lab analysis on-site. Findings were:

The facility has a certificate of waiver for laboratory services, mainly for glucometer testing.

An interview with the lab manager who also serves as the facility's infection preventionist was conducted on the morning of 6/11/2013 in a conference room in the administrative area of the facility. The lab manager reported that the only labs that the facility conducts themselves are strep A and influenza. She reported that there are phlebotomists to draw blood and obtain urine samples on the patients of the facility; but they prepare the specimens to be couriered to the main lab at the Austin State Hospital. She reported that any "stat" labs are sent to a hospital in the near-by town of Kaufman for analysis with an approximate 1 ½ hour turnaround from the time the specimens arrive at the hospital in Kaufman until the results are called into the Terrell State Hospital.

During an interview with physician #1, conducted during a tour of the clinic area on 6/10/2013 in the afternoon of 6/10/2013, the physician stated that the doctors at the facility conduct their own hemoccult tests and analysis at the facility.

During a tour of the laboratory the morning of 6/11/2013, a senior phlebotomist was interviewed, she reported that there is no lab testing available at the facility with the exception of the glucometer testings, that all specimens for analysis are collected in the early morning, prepared for shipment to Austin for analysis, are picked up by courier between the hours of 3:30 PM and 5:00 PM. It was her understanding, she related, that the specimens were delivered to the Austin State Hospital (a CLIA certified laboratory) at 7:00 AM the next morning for analysis. The specimens were packed in ice, had been centrifuged if that was appropriate for a particular physician ' s order, or packed in dry ice if needed. These specimens were then taken to the receptionist's desk at the front doors of the administration building to be picked up by the courrier service. This phlebotomist was not able to describe the courier service utilized nor what condition the specimens were maintained at during the night. She did relate that it was her understanding that the courier had numerous stops along the way from Terrell to Austin. There was no one in the facility's laboratory area when the phlebotomy staff left at the end of their shift.

A search of Google Maps revealed that the driving time from the Terrell State Hospital to the Austin State Hospital was three hours and 45 minutes without any other stops.

While the lab was being toured, ten high school students were noted to be participating in a "summer camp" experience for various activities in the healthcare field. These students were observed drawing blood from patient specimens, and preparing slides with the blood obtained from the tubes. The students were under the direct supervision of the phlebotomists and their adult leader. These tubes of blood were later processed for shipment to Austin

Based on observation and interview, the facility failed to

A. Ensure the Infection Control Officer had a working system for reporting, identifying and controlling potential communicable diseases in both patients and staff in 6 of 6 departments and/ or services (Nursing, Kitchen, Laboratory, Radiology, Laundry, Central Supply)
Refer to A 0749

B. Ensure the Director of the Dietary Department functioned in the full capacity as oversight within the department to ensure sanitation, safety practices within the department, and participate in the Quality Assessment Process Improvement(QAPI) program for the facility.

Refer to A0620

C. Ensure shift supervisors in the kitchen were adequately trained to meet safe food handling requirements in 1 of 1shift supervisor.

Refer to A0622

Based on observation, interview and document review, the facility failed to ensure the Director of the Dietary Department functioned in the full capacity of oversight within the department to ensure sanitation, safety practices within the department, and participate in the Quality Assessment Process Improvement(QAPI) program for the facility.


On 6/11/2013 at 3:00 PM in the main kitchen of the facility, accompanied by Staff #1 the CEO, Dietary supervisor, Staff #24 and dietary shift manager, and Staff #14 the following observation were made:

· Dead flies were immediately spotted on the window sill. In this same area was a Hobart slicer found on a counter under the windows.

· The Hobart slicer was observed uncovered and dusty. Staff member #14 indicated the machine was currently broken and was awaiting a part for repair.

· The area, where pots and pans were kept following washing, was a drying rack. This rack was observed with pots stacked wet one inside the other, contaminating both the top and bottom pots and making for an area where bacteria could readily occur.

· A long handled strainer was noted to have a great deal of rust, making the implement difficult to clean and to insure that there were no food particles within the rusted area.

On 6/11/2013 at 3:15 PM, the kitchen's walk in refrigerator was toured with the above mentioned staff. The following observations were made:

· The emergency light and battery above the door inside the refrigerator was covered with grease and dust.

· On an upper shelf in the refrigerator was a partially wrapped pound of butter with approximately a quarter to a third of the wrapper missing. No staff was able to tell how long the butter had been unwrapped open to the air in the refrigerator. The butter was available to be utilized in cooking for the patients of the facility.

· Also in the walk in refrigerator were three deep pans of eggs already cook for the next morning's breakfast. The eggs were covered with foil that did not fit tightly around the pans. The egg content had spilled over the side of the pans. The pans were placed in the refrigerator, with the spillage readily visible. The staff intended to serve this egg product to patients some 12 hours after being only partially covered and spilled on the cart.

· There was a white substance stuck to the floor, underneath the stainless steel storage rack, as you entered the refrigerator, to the right of the entrance.

On 6/11/2013 at 3:20 PM in the main food preparation area of the kitchen, with the above mentioned staff present, the following observations were made:

· In the food preparation area, a long stainless steel table had a lower shelf. The shelf was observed with food particles and grease and dust stuck on it. On this shelf were three boxes of bananas ready to be dispensed to patients as well as a large bottle of cooking oil used in patient food preparation.

· Another stainless steel table was positioned at the end of the first preparation table forming an "L" shape. The lower shelf of this table was likewise found oily and sticky with oil/grease and dried drip marks.

· Two very large high volume mixers were against a wall near these tables, next to the door to the walk-in refrigerator. Observed on the lever that lifted the beater out of the bowel, was grease or oil oozing out, to the point that is was pooling on the floor beneath the mixer.

On 6/11/2013 at 3:25 with the above mentioned staff present the following observations were made:

· Oven #1 was found to have a build-up of grease, food particles and dirt on top.

· Oven #5 had burnt residue on top of it.

· Behind oven #5 was a leak from the plumbing, water was pooling beneath this oven, again providing a medium for bacterial growth, mold and mildew.

· The grill was found to be sticky with grease and there were food particles found on the grill itself as well as the collecting tray at the front of the grill.

On 6/11/2013 at 3:30 in an anteroom of the kitchen noted to be the prep area for special diets, accompanied by the above staff, the following observations were made:

· A refrigerator/freezer was found with two large aluminum pans containing frozen lasagna. The containers were ripped and the food product was exposed to air inside the freezer.

· The above mentioned lasagna pans had no date of them. None of the above mentioned staff were able to state how long the lasagna had been in the refrigerator/freezer or how long the pans had been torn.

· On a window sill in this same area were two small stainless steel containers that were sealed with aluminum foil. Foil was removed by staff #1, the Superintendent, to reveal three to four eggs in each container. The eggs were not dated and no staff present was able to tell neither the surveyor nor the Superintendent how long they had been sitting in the window sill.

· Next to the containers of eggs, were two small Styrofoam bowls with lids that maintained a closed environment for the products within the bowls, however, the bowls were not labeled with the food product within, or the date that the lids had been placed on the bowls. The Superintendent took the lid off one of the bowls and the bowl contained what appeared to be cooked rice.

· The second container on the window sill, held what appeared to be dried powder, that once reconstituted, would be used to make chicken broth. There was no date or labeling on either of these food products.

During this tour of the kitchen, the Director of the Dietary Department, Staff #24 indicated the findings in the Kitchen were not her fault, the kitchen supervisor had been out for a week.

During this tour of the kitchen, the shift supervisor, Staff #14 confirmed she had received very little training, on what her job would be when she moved into the shift supervisors position. She also confirmed she had received very little help from the upper staff. She just tried to put out the best food she could.

During an interview with Staff #24, the Director of the Dietary Department on 6/10/2013 in the afternoon, confirmed the Dietary Department did not participate in Process Improvement. She indicated she turned in numbers to the Quality Assessment committee but her department did not formally collect data for the purpose of making quality improvements and the QA committee had never requested she do so. She also confirmed she was not made aware of any Quality decisions for the facility.

Based on observation and interview the facility failed to ensure shift supervisors in the kitchen were adequately trained to meet safe food handling requirement in 1 of 1 shift supervisors.


On 6/11/2013 at 3:00 PM in the main kitchen for the facility, accompanied by Staff #1 the CEO, Dietary supervisor, Staff #24 and dietary shift manager, Staff #14 the following observation were made:

· Dead flies were immediately spotted on the window sill. In this same area was a Hobart slicer found on a counter under the windows.

· The Hobart slicer was observed uncovered and dusty. Staff member #14 indicated the machine was currently broken and was awaiting a part for repair.

· The area, where pots and pans were kept following washing, was a drying rack. This rack was observed with pots stacked wet one inside the other, contaminating both the top and bottom pots and making for an area where bacteria could readily occur.

· A long handled strainer was noted to have a great deal of rust, making the implement difficult to clean and to insure that there were no food particles within the rusted area.

On 6/11/2013 at 3:15 PM, the kitchen' s walk in refrigerator was toured with the above mentioned staff. The following observations were made:

· The emergency light and battery above the door inside the refrigerator was covered with grease and dust.

· On an upper shelf in the refrigerator was a partially wrapped pound of butter with approximately a quarter to a third of the wrapper missing. No staff was able to tell how long the butter had been unwrapped open to the air in the refrigerator. The butter was available to be utilized in cooking for the patients of the facility.

· Also in the walk in refrigerator were three deep pans of eggs already cook for the next morning's breakfast. The eggs were covered with foil that did not fit tightly around the pans. The egg content had spilled over the side of the pans. The pans were placed in the refrigerator, with the spillage readily visible. The staff intended to serve this egg product to patient some 12 hours after being only partially covered and spilled on the cart.

· There was a white substance stuck to the floor, underneath the stainless steel storage rack, as you entered the refrigerator, to the right of the entrance.

On 6/11/2013 at 3:20 PM in the main food preparation area of the kitchen, with the above mentioned staff present, the following observations were made:

· In the food preparation area, a long stainless steel table had a lower shelf. The shelf was observed with food particles and grease and dust on stuck on it. On this shelf were three boxes of bananas ready to be dispensed to patients as well as a large bottle of cooking oil used in patient food preparation.

· Another stainless steel table was positioned at the end of the first preparation table forming an "L" shape. The lower shelf of this table was likewise found oily and sticky with oil/grease and dried drip marks.

· Two very large high volume mixers were against a wall near these tables, next to the door to the walk-in refrigerator. Observed on the lever that lifted the beater out of the bowel, was grease or oil oozing out, to the point that is was pooling on the floor beneath the mixer.

On 6/11/2013 at 3:25 with the above mentioned staff present the following observations were made:

· Oven #1 was found to have a build-up of grease, food particles and dirt on top.

· Oven #5 had burnt residue on top of it.

· Behind oven #5 was a leak from the plumbing, water was pooling beneath this oven, again providing a medium for bacterial growth, mold and mildew.

· The grill was found to be sticky with grease and there were food particles found on the grill itself as well as the collecting tray at the front of the grill.

On 6/11/2013 at 3:30 in an anteroom of the kitchen noted to be the preparation area for special diets, accompanied by the above staff, the following observations were made:

· A refrigerator/freezer was found with two large aluminum pans containing frozen lasagna. The containers were ripped and the food product was exposed to air inside the freezer.

· The above mentioned lasagna pans had no date of them. None of the above mentioned staff were able to state, how long the lasagna had been in the refrigerator/freezer or how long the pans had been torn.

· On a window sill in this same area were two small stainless steel containers that were sealed with aluminum foil. The foil was removed by staff #1, the Superintendent, to reveal three to four eggs in each container. The eggs were not dated and no staff present was able to tell neither the surveyor nor the Superintendent how long they had been sitting in the window sill.

· Next to the containers of eggs, were two small Styrofoam bowls with lids that maintained a closed environment for the products within the bowls. However, the bowls were not labeled with the food product within, or the date that the lids had been placed on the bowls. The Superintendent took the lid off one of the bowls and the bowl contained what appeared to be cooked rice.

· The second container, on the window sill, held what appeared to be dried powder, that once reconstituted, would be used to make chicken broth. There was no date or labeling on either of these food products.

On 6/11/2013 in the afternoon, during this tour of the kitchen, the shift supervisor, Staff #14 confirmed that she had received very little training on what her job would be when she moved into the shift supervisors position. She also confirmed she had received very little help from the Dieticians, Department Director or other knowledgeable staff. She just tried to put out the best food she could.

Based on document review and interview the facility failed to:
A. Maintain the physical environment of the patient care area in a clean and sanitary manner.
Refer to tag A0749
B. Provide a clean and sanitary kitchen for preparing food. The kitchen staff lacked the knowledge for safe food handling.
Refer to tags A0620, A0622
C. Remove expired supplies from patient care areas. Expired supplies were made
available for lab testing, patient consumption (eating) and patient use.

Refer to tag A0724

Based on tour, observation, and interviews, it was determined that the facility failed to remove expired supplies from patient care areas. Expired supplies were made available for lab testing, patient consumption (eating) and patient use.


28043

During a tour of the area that the facility refers to as the Clinic, on 6/10/2013 at 3 PM, the following expired drugs or biologicals were found:
In a cabinet in the first cubicle, a bottle of Betadine had an expiration date of July, 2012, and a tag on the bottle indicated that it had been opened in July of 2012. This bottle was present and still available for patient use.

A box of suture strips (Steristrips) was found with an expiration date of 2/2011. There were 18 of these expired strips available for patient use.

In the second cubicle, in the drawer of the bedside table, there was found numerous (too numerous to count) longhandled swabs. These swabs were outside of any packaging, and also found in this drawer was a large number of tongue depressors. When asked what the swabs were used for, physician #55 reported that the swabs were used for taking cultures. When asked further if these contaminated swabs could be used for cultures, the physician responded affirmatively.

In the eye examination area (cubicle 4) on a shelf was a box of " Splash Shields " sitting on a shelf. It was noted on the box that the entire box was purchased for $36.00 or $1.35 per shield. The box was stuck to the shelf and covered with dust. Physician #1 reported that these shields were no longer in use. The hospital superintendent had joined the surveyor and the physician at that point and informed the physician to dispose of the box and contents. On 6/11/2013 at 10:00 am, the clinic was again toured and the box and its contents remained on the shelf and remained covered with a coating of dust.

When asked who was to do the cleaning of the Clinic area and the drawers and cabinets, survey staff was informed by the Hospital Superintendent that the nursing staff that works in the area is responsible for this, while housekeeping staff was responsible for surface cleaning only.

In an interview with the Infection Preventionist on 6/11/13 in the 4th floor conference room of the administrative area at 9 AM, she stated that the facility does not perform hemocults, and that these tests are sent out for analysis. She reported that the facility only performs Strep A and flu tests.

In the clinic is a surgery room which was toured on 6/11/13 at 9:15 AM, the high horizontal surfaces were covered with dust.

Based on tour observation, interview and documentation review, the faclity failed to provide a sanitary envirnoment and the facility failed in its efforts at infection control in 6 of 6 departments and/or services (Nursing, Kitchen, Laboratory, Radiology, Laundry, Central Supply). The facility also failed to ensure the Infection Control Officer had a working system for reporting, identifying and controlling potential communicable diseases in both patients and staff.
Refer to A 0749

28659



Based on observation and interview, the facility failed to ensure that the Infection Control Officer had a system for reporting, identifying and controlling sources for potential communicable diseases in both patients and staff in 6 of 6 departments and/or services (Nursing, Kitchen, Laboratory, Radiology, Laundry, Central Supply)

Nursing:

On 6/10/2013 at 3:00 PM, during a tour of the area identified by the facility as the "Clinic", accompanied by Staff #1, the Chief Executive Officer (CEO), and Staff #8, the Director of Nurses(DON), and the Staff LVN (Licensed Vocational Nurse) the following was observed:

· In patient examination bay #2, there was a ¼ inch round hole in the examination chair in the middle of the vinyl seat, which could not be properly disinfected.

· There was a dead bug in the podiatry cart, which was in need of cleaning.

· There was a pair of scissors in a pouch which had been sterilized, in the closed position, preventing exposure of all surfaces to the sterilizing agent and presenting a risk of cross contamination. The Centers for Disease Control and Prevention (CDC) article, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, by William A Rutala, PhD., M.P.H., David J. Weber M.D., M.P.H. and the Health care Infection Control Practices Advisory Committee (HICPAC), found at:

, states on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.


· There was a greasy dirty surface, contaminated with dust and lint in the drawer of the gynecologic examination table containing 3 vaginal speculums which were available for patient examination.

· In the cabinet under the sink, there was black dirt and a layer of dust. Stored under the sink was a cardboard case of suture removal kits, Betadine scrub sponges, and cardboard boxes.

· In the ophthalmology room there was 2.5% Phenylephrine Hydrochloride Ophthalmic solution, expired 4/2013, and Optifree Replenish Eye Solution 2 fluid ounces, expired 3/2012, quantity of 3. The sterility of these medications were compromised. Both of these ophthalmic solutions were available for patient use.

There were dead bugs and what appeared to be insect droppings and dust and debris in the floor of the cabinet and drawers. There was a thick layer of dust on the cabinet where urinary catheters were stored.

· In a cabinet in the first cubicle, a bottle of Betadine had an expiration date of July 2012, and a tag on the bottle indicated that it had been opened July 2012. This bottle was still available for patient use.

· A box of suture strips (Steri-strips) was found with an expiration date of 2/2011. There were 18 expired strips available for patient use.

· In the second cubicle, in the drawer of the bedside table, there was numerous (too numerous to count, TNTC) long handled swabs. These swabs were outside of any packaging, and also found in this drawer was a large number of (TNTC) tongue depressors. When asked what the swabs were used for, Physician #10, the clinic physician reported that the swabs were used for taking cultures. When asked further, if these contaminated swabs could be used for cultures, the clinic physician responded affirmatively.

· In the eye examination area, (cubicle #4), was a box of "Splash Shields" sitting on a shelf. The box was stuck to the shelf and covered with dust. Physician #1 reported that these shields were no longer in use. The physician was instructed at that time, by the facility superintendent, to dispose of the box. However, on 6/11/2013 at 1:30 PM, during a revisit to the Clinic the box and its content remained on the shelf covered with dust.

The above was confirmed in an interview the afternoon of 6/10/2013 during a tour in the clinic with the Clinic LVN and the CEO.

On 6/10/2013 at 3:30 PM, during a tour of Med-2 (medical unit), accompanied by the CEO, staff #1, and the DON, Staff #8, the following observations were made:

· There were 14 dead bugs and spider webs in the window sill of the medication room. In the medication room, there was a 1 pound container of Hydrocerin Cream for Dry Skin with "8-10-12. Exp.(expired) 9-8-12" hand written on the container. Contamination could not be ruled out. The Hydrocerin Cream was available for patient use.

· The refrigerator in the medication room was in need of cleaning with 4 drips in the freezer; the floor of the freezer was dirty. There was a thick layer of dust and lint on the top of the refrigerator.

· The medication cart in the medication room was in need of cleaning. There was a sticky substance on the front of and inside of 3 of 5 drawers and there was dust and lint in 4 of 6 drawers.

The above findings were confirmed during a tour of Med-2 the afternoon of 6/10/13 with Staff #1 and Staff #8.

During a tour of the Med-2 (Medical Unit) unit at 4:00 PM on 6/10/2013, accompanied by Staff #8 the CNO, the following was observed:

· In the patient activity room, a cloth chair had a paper attached to the chair with the handwritten words, "Patient wet in chair". The chair was turned toward the wall, but was in the room and available for patient use. In an interview during the tour with the Staff #8, CNO, she stated that the chair should have been removed from the room and taken for cleaning and not left in the patient activity room. This presents a risk for cross contamination.

· In the patient supply room, there were 3 external cardboard shipping cartons on the shelving stored above patient supplies available for use, including bariatric briefs, exam gloves, laundry detergent and patient bed pans. "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items)."

· In the patient shower room, over half of the surface of the shower bench legs were rusted, which prevents disinfection as rust cannot be disinfected. There was peeling paint and the floor tiling was cracked, which renders the area difficult to get it properly disinfected.

· In the patient whirlpool room, there was a dirty, sticky substance adhered to the supply cart in the room, presenting a risk for cross contamination. There were 7 holes in the wall, which prevents effective cleaning and provides an entry for dirt particles or pests.

· During a tour of a patient bedroom, rust was observed on the patient lockers which prevents effective cleaning and disinfection between patients. In the Visitors Room, there were stains on 2 red cloth chairs and a hole in the vinyl of another chair, which prevents effective cleaning.

· In the Patient Isolation Room, on the patient supply cart were IV (Intravenous) bags, 1000 ml 0.45% Sodium Chloride which expired 2/2013, quantity 2. Also on the supply cart, which contained IV solution and IV supplies, was a black canvas cloth duffle bag, containing a CPAP (Controlled Positive Air Pressure) machine. The black canvas bag was covered in dust and was dirty. The CPAP machine inside the bag was in need of cleaning, with sticky tape residue, which could not be sanitized. The CPAP machine was available for patient use.

· The patient bathroom in the Isolation Room had rust on the sink, preventing effective disinfecting in an area for patients with infectious disease.

· In the nurse's station, on a shelving unit with patient supplies, there was a sticky grayish-black residue and rust from an old spill covering a 12 x 12 inch area on one shelf where cardboard patient tissue boxes were stored, available for patient use. Several of the patient tissue boxes had absorbed some of the grayish black substance, presenting a risk for cross contamination.

· In the nurse's station, on a shelving unit with patient supplies, there was an external cardboard shipping carton containing patient supplies stored next to a box labeled "Culteretts (sic) and oxygen mask". "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust " . (AAMI ST46-Section 5.2 Receiving items)

· In a drawer in the nurse's station containing patient blood pressure cuffs were also an old telephone, rosary beads, and other miscellaneous contents. The drawer was in need of cleaning of dust and dirt; there were drips on the side of the drawer.

· There was a rusted metal cabinet in the nurse's station which contained a thick layer of dust, lint, debris and was in need of cleaning. The cabinet contained old, broken down, water stained cardboard boxes and dirty paper binders. There was a thick layer of dirt and debris and there were drips on the metal door and inside the door of the cabinet. The patient blood pressure cuffs were stored next to this metal cabinet, creating a risk of cross contamination.

The above findings were confirmed by Staff #8, the CNO, during a tour of the Med-2 unit on the afternoon of 6/10/2013.

During a tour of the Geriatric unit the afternoon of 6/10/2013, accompanied by Staff #8, the CNO, and Staff #1, the CEO, the following was observed:

· In the food storage area, there were cases of Gatorade and patient disposable drinking cups stored on the floor. There was a sticky substance on the wrapper of a package of paper plates on the shelves.

· In the hallway leading to the food storage area and visiting room, there were 15 water damaged and discolored ceiling tiles. In the Patient Activity Room, there were 5 water damaged ceiling tiles. In the Patient Day Room, there were 12 water damaged and discolored ceiling tiles. The above increased the risk of contamination in a moist environment.

· In the Kitchen Receiving area, the weather stripping was torn and deteriorated around the main external door as sunlight from the outside was visible from the inside of the building on the left and right sides of the door and the bottom of the door. This increased the risk of dust and pests, creating a risk for cross contamination of serving utensils, food, and the kitchen environment.

· In the kitchen dishwashing area, there was standing water near the ice machine. There was also standing water in the dishwashing machine. In an interview with Staff #1, he stated that the dishwashing machine was not being used. Standing water presents a safety hazard and a risk for the growth and cross contamination of water borne bacteria in the kitchen area.

· In the medication room, there was a woman's brown purse sitting is a patient supply cabinet, on top of an open box of sterile abdominal pads packets which were available for patient use. This presents a risk of cross contamination as the bottom of the purse was in direct contact with the abdominal pad packets.

The above findings were confirmed in an interview with Staff #8, the CNO and Staff #1, the CEO during the tour of the Geriatric Unit on the afternoon of 6/10/2013.

During a tour of the Procedure Room in the clinic the morning of 6/11/2013 at 9:00 AM, accompanied by Staff #11, the Clinic Nurse (LVN, Licensed Vocational Nurse), the following was observed:

· There was a layer of greasy and sticky dust on the surface of the OR (Operating Room) ceiling lamp, above the treatment area.

· There was dust and debris in the drawers containing gloves.

There was a container of Tincture of Benzoin compound that had dirty tape adhered to the container on which was handwritten "9-25-09". Contamination could not be ruled out. This tincture of Benzoin was available for immediate use on a patient.

· There was a tube of surgical lubricant which was opened and not labeled with a date opened. Contamination could not be ruled out.

· There was a layer of dust on high horizontal surfaces.

The above findings were confirmed in an interview with Staff #11, the clinic LVN, during the tour of the Procedure Room in the clinic on the morning of 6/11/13.

Central Supply

During a tour of the Central Supply and Instrument Processing area the morning of 6/11/2013 at 9:30 AM, accompanied by Staff #8, the CNO, the following observation were made:

· There was no door or physical separation between the dirty room for instrument processing and the sterilization and the clean supply room. This presents a risk for cross contamination of patient supplies, including IV solutions and IV start kits.

· In the clean supply room there were corrugated external shipping containers on the shelves with IV solution bags, IV start kits, and other supplies. " External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated materials serve as generators of and reservoirs for dust". (AAMI ST46-Section 5.2 receiving items)

· In the Housekeeping room, there was a mop bucket containing dirty water. There were water damaged cardboard boxes in the housekeeping room, and the wooden cabinet shelves, containing clean mop heads and other supplies, were stained and had a layer of dust and dirt.

· Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, CDC stated, in part, "The basic principle of steam sterilization, as accomplished in an autoclave, is to expose each item to direct steam contact at the required temperature and pressure for the specified time. Thus, there are four parameters of steam sterilization: steam, pressure, temperature, and time ...the steam cycle us monitored by mechanical, chemical, and biological indicator ...The ability of the sterilizer to reach physical parameters necessary to achieve sterilization should be monitored by mechanical , chemical, and biological indicators ...Periodic infection control rounds to areas using sterilizers to standardize the sterilizer's use may identify correctable variances in operator competence; documentation of sterilization records, including chemical and biological indicators test results; sterilizer maintenance and wrapping; and load numbering of packs. These rounds also may identify improvement activities to ensure that operations area adhering to established standards."

· In an interview on 6/11/2013 in the sterilization room with Staff #13, responsible for sterilizing surgical instruments, she stated that there was no log book for documenting sterilization activities, including chemical and biological indicators test results, and load numbering of instrument packs. When asked, Staff #13 stated she had never been trained or told about a log book or monitoring of the above, stating "we just learned by doing".

· Staff #13 stated that the autoclave machine did not have a printer to record the above. Based on the lack of documented evidence that the time, temperature and pressure requirements were met, there was no way to ensure that the surgical instruments used were sterilized. Without a log to track surgical instrument loads, in the event of a positive biological indicator result (indicating that surgical instruments were not sterile), the facility would have no ability to recall surgical instruments that were not sterilized. The facility would not be able to track the patients and procedures that involved the unsterilized surgical instruments. This increased the risk for transmission of infection and cross contamination.

· In supply room 4, there were external corrugated shipping boxes stored on the shelves with patient supplies, including IV injection caps and IV blunt cannulas, syringes, IV arm boards, Anti Embolism stockings, abdominal pad dressings, adhesive bandages and other patient supplies, available for patient use.

· In supply room 2, there were corrugated external shipping boxes stored on the shelves with patient supplies that included breast pumps and other supplies.

The above findings were confirmed in an interview with staff #8, the CNO, during the tour of the Central Supply and Instruments processing area the morning of 6/11/2013.

On 6/11/2013 at 9:15 AM during a tour of a surgery suite used for ECT (Electroconvulsive Therapy), accompanied by staff #8, the Director of Nursing, and staff nurse #13 the following observation were made:

· The high horizontal surfaces were observed covered with dust.

· There was a layer of dust in the undercarriage of a gurney in the hallway and on the gurney in the OR (Operating room)/ECT room; there was also tape on the gurney frame. This presents a risk of cross contamination.

· There was tape on the drawers of the ECT cart in the OR/ECT room; there was a sticky substance on the front of one of the drawers in the ECT cart.

· There was tape on the handle of the oxygen cylinder cart; tape cannot be disinfected and presents a risk for cross contamination.

· In the first drawer of the instrument table, sterile instruments were observed in their autoclave pill packages.

· A Laryngoscope was observed in an opened autoclave package and the hand held light was affixed to the blade.

· Staff #21 explained she opened the sterile package before each ECT procedure to insure the light on the laryngoscope blade worked. When asked when the next ECT was scheduled she explained they were scheduled Monday, Wednesday and Friday. The next opportunity for use was 24 hours.

· In the sterile instrument drawer was an endotracheal tube in a sterile package that was opened with a 10 centimeter syringe attached to the inflatable bulb. Staff #21 explained she did this to insure the bulb would inflate before it was inserted into a patient's trachea.

· Both sterile instruments were opened 24 hour in advance of the procedure. Sterility had been compromised for both of these instruments used for invasive procedure.

· In the patient bathroom there was no emergency calling system.

The above findings were confirmed by Staff #8, the CNO, during a tour of the Electroconvulsive Therapy (ECT) area the morning of 6/11/2013.

On 6/12/2013 during the morning observation of the ECT services provided in the OR/ECT suite the following observation were made:

· During the ECT treatment for Patient #2, Staff #7, the CRNA (Certified Registered Nurse Anesthetist) attempted to retrieve an item dropped on the floor. And with both gloved hands, touched and moved the contaminated biohazard container, including touching the contaminated red biohazard bag with her gloved hands. Without changing gloves, sanitizing or washing her hands after touching the biohazard bag, Staff #7 returned to caring for the patient and touched the patient's face with her contaminated gloved hands. Staff #7 did not clean or sanitize her hands until the end of the procedure. Staff #7 was also observed chewing gum with her mouth open while leaning over Patient 2's face, approximately 6 inches above the patient's face. After the ECT treatment, Staff #7 dropped a rubber tourniquet on the floor, reached down and picked up the contaminated tourniquet off the floor, and placed it on the anesthesia cart into a tray containing the opened vials of succinylcholine and labetalol and other opened medications. This presented a risk of cross contamination.

· During observation of ECT treatment for 3 out of 3 patients, the technician took off the patient's shoes and placed the sole of the shoes directly on the sheet in between the patient's legs. This presented a risk of cross contamination.

Kitchen:

On 6/11/2013 at 3:00 PM in the main kitchen for the facility, accompanied by the CEO, Dietary supervisor and dietary shift supervisor the following observation were made:

· Dead flies were immediately spotted on the window sill. In this same area was a Hobart slicer found on a counter under the windows.

· The Hobart slicer was observed uncovered and dusty. Staff member #14 indicated the machine was currently broken and was awaiting a part for repair.

· The area, where pots and pans were kept following washing, was a drying rack. This rack was observed with pots stacked wet one inside the other, contaminating both the top and bottom pots and making for an area where bacteria could readily occur.

· A long handled strainer was noted to have a great deal of rust, making the implement difficult to clean and to insure that there were no food particles within the rusted area.

On 6/11/2013 at 3:15 PM, the kitchen's walk in refrigerator was toured with the above mentioned staff. The following observations were made:

· The emergency light and battery above the door inside the refrigerator was covered with grease and dust.

· On an upper shelf in the refrigerator was a partially wrapped pound of butter with approximately a quarter to a third of the wrapper missing. No staff was able to tell how long the butter had been unwrapped open to the air in the refrigerator. The butter was available to be utilized in cooking for the patients of the facility.

· Also in the walk in refrigerator were three deep pans of eggs already cook for the next morning's breakfast. The eggs were covered with foil that did not fit tightly around the pans. The egg content had spilled over the side of the pans. The pans were placed into the refrigerator, with the spillage readily visible. The staff intended to serve this egg product to patient some 12 hours after being only partially covered and spilled on the cart.

· There was a white substance stuck to the floor, underneath the stainless steel storage rack as you walked in the refrigerator to the right of the entrance.

On 6/11/2013 at 3:20 PM in the main food preparation area of the kitchen, with the above mentioned staff present, the following observations were made:

· In the food preparation area, a long stainless steel table had a lower shelf. The shelf was observed with food particles and grease and dust on stuck on it.

· On this shelf were three boxes of bananas ready to be dispensed to patients as well as a large bottle of cooking oil used in patient food preparation.

· Another stainless steel table was positioned at the end of the firsts preparation table forming an "L" shape. The lower shelf of this table was likewise found oily and sticky with oil/grease and dried drip marks.

· Two very large high volume mixers were against a wall near these tables, next to the door to the walk-in refrigerator. Observed on the lever that lifted the beater out of the bowel, was grease or oil oozing out, to the point that is was pooling on the floor beneath the mixer.

On 6/11/2013 at 3:25 with the above mentioned staff present the following observations were made:

· Oven #1 was found to have a build-up of grease, food particles and dirt on top.

· Oven #5 had burnt residue on top of it.

· Behind oven #5 was a leak from the plumbing, water was pooling beneath this oven, again providing a medium for bacterial growth, mold and mildew.

· The grill was found to be sticky with grease and there were food particles found on the grill itself as well as the collecting tray at the front of the grill.

On 6/11/2013 at 3:30 in an anteroom of the kitchen noted to be the preparation area for special diets, accompanied by the above staff, the following observations were made:

· A refrigerator/freezer was found with two large aluminum pans containing frozen lasagna. The containers were ripped and the food product was exposed to air inside the freezer.

· The above mentioned lasagna pans had no date of them. None of the above mentioned staff were able to state how long the lasagna had been in the refrigerator/freezer or how long the pans had been torn.

· On a window sill in this same area were two small stainless steel containers that were sealed with aluminum foil. Foil was removed by staff #1, the Superintendent, to reveal three to four eggs in each container. The eggs were not dated and no staff present was able to tell neither the surveyor nor the Superintendent how long they had been sitting in the window sill.

· Next to the containers of eggs, were two small Styrofoam bowls with lids that maintained a closed environment for the products within the bowls, however, the bowls were not labeled with the food product within, or the date that the lids had been placed on the bowls. The Superintendent took the lid off one of the bowls and the bowl contained what appeared to be cooked rice.

· The second container, on the window sill, held what appeared to be dried powder, that once reconstituted, would be used to make chicken broth. There was no date or labeling on either of these food products.

During this tour of the kitchen, the Director of the Dietary Department, Staff #24 indicated the findings in the Kitchen were not her fault, the kitchen supervisor had been out for a week.

During this tour of the kitchen, the shift supervisor, Staff #14 confirmed she had received very little training, on what her job would be when she moved into the shift supervisors position. She also confirmed she had received very little help from the upper staff. She just tried to put out the best food she could.

Laboratory:

On 6/11/2013 at 10:00 AM, during a tour of the laboratory (Lab), with the lead laboratory technician present. The following observations were made:

· There was a 12-inch oscillating fan on a shelf above a large, opened red biohazard container, the lid was loosely positioned on top. The oscillating fan was powered on and blowing directly over the, opened biohazard container. The biohazard container contained contaminated needles, drips of blood along the sides, and other biohazard materials.

· Another fan was powered on and positioned very near a staff member preparing open urine specimens for shipment to the contracting laboratory for analysis. Also a housekeeper was spraying a surface cleaner very near the opened urine samples. The spray cleaner was picked up by the oscillating fan and dispersed over the staff member and the urine samples.

· The spread of dust, bacteria, and other microorganisms, from the fan blowing across the opened biohazard container and the opened urine specimen containers creates an unsafe environment and a risk for cross contamination in the laboratory.

· On the blood draw station table, there were observed two dirty tourniquets.

· There was a towel that was in need of cleaning on top of the specimen draw station table and there was dirty tape and sticky residue on the table, indicating a lack of sanitation.

· In a metal drawer containing phlebotomy blood draw supplies, there was a used, dirty tourniquet on top of the blood draw needles and paper tape, creating a risk of cross contamination.

· 5 portable blood draw boxes, used to obtain blood specimens from patients on the units, were positioned on a cabinet. Once opened, all five boxes contained supplies used to draw patient blood samples. A small biohazard sharps container was observed in each box. The lid of each sharps container was removed exposing the content to the air and across contaminating all supplies contained in the portable box. Observed positioned in the corner of the portable box was the lid of the sharps container, positioned upside down and containing unopened vacutainer needles (a needle designed to have a sharp lumen at both ends that is secured into a plastic sleeve to draw blood). The inside of the sharps containers were visibly soiled with what appeared to be dried blood. The portable boxes also contained rubber tourniquets, which although designed, for single use, appeared to have been used more than once.

· All five boxes had loose particles of debris in the bottom of the boxes. One of the five boxes had many (12) non sterile syringes, with no tip covers, the tips were exposed to air and in contact with other items within the box. This practice cross contaminated syringes intended for sterile blood draws.

· In each of the 5 phlebotomy boxes, when the laboratory draw supplies were removed, the boxes contained dust, lint, debris, dirt, paper clips, old needles, dirty paper tape, opened dried alcohol prep pads, ointment packets, opened empty needle packets and did not appear to have been cleaned or disinfected in a long time. 1 box was observed with loose gauze having a reddish-brown dried substance, which appeared to be dried blood.

· Staff #9, while viewing the portable phlebotomy boxes, stated that the biohazard containers were used without the safety lids .Staff #9 explained the lab staff would place their discarded blood draw needles, gauze, syringes and other supplies in the small sharps container, without the lid. The portable supply box would be carried back to the laboratory and the laboratory staff would remove the portable sharps container, with the lid removed and carry the content to the larger biohazard sharps container, that was observed, with the fan blowing over it, and empty the content of the small sharps container into the large biohazard sharps container. The laboratory staff would return the small sharps container to the portable box to be reused. The lids were not attached because the small sharps would hot fit into the portable box with the lid on. Staff #9 did not appear to recognize the risk to either the patient's or the staff with this unsafe practice. The above presents a risk of cross contamination for patients of the facility and staff involved in drawing blood.

· In the supply area , there was a drawer containing individual syringe packets, needles, opened paper tape and a box of microscope glass cover slides, along with a box of staples, an opened band-aide , a spool of thread, a container of hand lotion, a calculator, safety pin, high school graduation announcement and envelope. As well as other miscellaneous items. There was dust, lint and debris in the bottom, of the drawer. The above presents a risk of cross contamination wit lab supplies available for patient use.

· In a cabinet underneath a sink, there was an opened gallon of germicidal cleaner which was not labeled with the date opened. There was, a torn, water stained cloth covering the base of the cabinet. When the cloth was pulled back, there were larger areas of rust, approximately 12 x 8 inches, 2 x 1 inches, ½ x ½ inches and spills on the base of the cabinet. There were broken areas around the pipes, providing an opening for dust and insect penetration. The above presents a risk for cross contamination.

Radiology:

On 6/10/2013 at 11:00 AM with staff #11 present, a tour of the radiology department revealed the following:

· 1 of 2 x-ray rooms was observed decorated for the use of younger patients. This room contained a stationary radiology unit used for (PA) Chest x-ray. The chin rest used to stabilize a person's head during the chest x-ray was observed heavily soiled.

· Room #1 was decorated with wall decorations of plastic balloons which had a large accumulation of dust on them.

· A side table in Room #1 held plush stuffed animals to comfort and/or distract younger patient during the x-ray. However, the plush stuffed animals could not be cleaned between patients, lend themselves to the possibility of cross-contamination between the younger patients.

· During this tour, staff #11 indicated he had no process for disinfecting the plush stuffed animals after patient handling. This presented a cross contamination risk.

· In the EKG room, there was a layer of dirt and black fuzz in the two drawers in the examination table. 4 holes were observed in the vinyl cover of the examination table, which prevents proper disinfection between patients and 3 pieces of tape adhered to the side of the table with a sticky residue. The sticky surface of tape could not be properly disinfected. The pillow on the table was old and worn with small tears in the covering; all the above presented a risk for cross contamination.

· There was no emergency call system in the patient bathroom in the x-ray room.

· In the x-ray processing room, the floor was wet and there was an industrial rug on the floor that was saturated with dark stained moisture and discoloration which appeared to be mold. There was a bucket of liquid containing a dirty rag observed next to equipment in the x-ray processing room. In an interview with staff #11, the x-ray technician, he stated that the bucket with liquid was left by the contractor who services the machine once a month and the contractor "just leaves it sitting there". Staff #11 stated it had been several days since the contractor had been there. The standing liquid with a dirty rag presents a risk f

Based on interviews and a review of facility policies and procedures, it was determined that the facility failed to have an involvement in the organ procurement process, even though the facility professed to maintain a contract with an organ procurement organization. Findings were:

The facility has a policy entitled Organ Procurement/Donation, numbered Medical/Clinical 4-81 and last revised in July of 2012, which stated the "Terrell State Hospital complies with the Conditions of Participation of the Health Care Financing Authority (HCFA), Joint Commission Standards", and, under a subheading entitled Organ Tissue Donation, the facility states: "Terrell State Hospital does not procure organs and/or tissue for transplantation".

Under the procedures section of this policy, the facility states:
"1. Terrell State Hospital is an acute psychiatric hospital. All patients in need of acute medical services are transferred to a local acute care facility for immediate care. Thus all potential anatomical donors are referred in the same manner " .

Under procedure #4 "Terrell State Hospital is not responsible for notifying the OPO (Organ Procurement Organization) of the imminent death of a prospective donor".

The facility also had a policy entitled "Procedures in the Event of Death", numbered Medical/Clinical 4-39 and last revised in March of 2013. This policy's stated purpose is "To provide procedures and assign areas of responsibility to be followed in the event if a death." Although this policy sets for specific actions to be taken and assigns specific personnel to complete these actions, the policy failed to include the notification of an Organ Procurement Organization, nor does it include a step to ascertain the patient's or family's wishes as to organ or eye donation.

Based on observation and interview the facility failed to develop an organized anesthesia service by not appointing director of anesthesia services, develop policies and procedures that would provide for direction of anesthesia services and require the involvement of the service in a hospital wide Quality Assessment and Performance Improvement program (QAPI).
On 06/12/2013 beginning at approximately 9:00 AM the surveyors observed three patients (#1, #2, #30) receiving electroconvulsive therapy (ECT, a treatment in which seizures are electrically induced in anesthetized patients) while being administered general anesthesia (A variety of medications may be administered, with the overall aim of ensuring sleep relaxation of skeletal muscles, and loss of control of reflexes of the autonomic nervous system ) by CRNA #7.

An interview on 06/12/2013 in the patient recovery area at approximately 10:30 AM with CRNA #7 confirmed general anesthesia was being administered to patient receiving ECTs.
Multiple requests were made to review anesthesia service's policies and procedures. No policies and procedures were provided for review.

An interview with staff #12, who was reported by physician #3 to be the person in charge of the ECT procedure area, was asked how the department and anesthesia was involved in the facility's QAPI program. Staff #3 was not able to provide evidence of involvement in the QAPI program.

An interview on 06/13/2013 at approximately 1:30 PM with physician #3 in the administrative conference room revealed the Medical Staff and the Governing Body had not appointed a director of anesthesia services. The interview confirmed there were no anesthesia policies and procedures available for review by the surveyor. When asked if the ECT procedures be performed in the facility were being monitored for quality and reported to the QAPI program. Physician #3 referred to a document titled, "ECT Treatment Anesthesia Review," as the way ECT quality was being monitored. Physician #3 was asked if the results gathered from this document was reported to QAPI. Physician #3 revealed only if there was a bad outcome and we have had no bad outcomes.

No evidence was provided of the facility's QAPI program recommending quality indicators or of Medical Staff and the Governing Body's involvement in approving quality indicators for the ECT procedure area or anesthesia service.

Based on interviews and record reviews, the facility failed to have an organized Respiratory Service to meet the needs of patient who require respiratory care. The facility failed to ensure the medical staff identified and approved the scope of diagnostic and/or therapeutic respiratory services provided by the facility. Respiratory Care Services was not integrated into the Quality Assessment Process Improvement (QAPI) program.

Refer to Tags A1152, A1153, A1154, A1160, A1163

Based on interviews and record reviews, the facility failed to have an organized Respiratory Service to meet the needs of patient who require respiratory care. The facility failed to ensure the medical staff identified and approved the scope of diagnostic and/or therapeutic respiratory services provided by the facility.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have an organized Respiratory Department.

An interview was conducted with Staff #8, the Chief Nursing Executive, on 6/13/2013. Staff #8 reported that the nursing staff provided oxygen administration, hand held nebulizers, inhalers, pulse oximeter monitoring, and suction as ordered by the physician. Staff #8 reported there were no policies and procedures for respiratory services and no training or competencies was conducted for nursing staff.

An interview was conducted with Staff #3, Medical Director, on 6/13/2013. Staff #3 reported the medical staff has not identified or approved in writing the scope of diagnostic and/or therapeutic respiratory services to be provided by the facility.

Based on interviews, the facility failed to have an organize Respiratory Department or a Director of Respiratory Services.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have an organized Respiratory Department or Director of Respiratory Services.

Based on interviews and record reviews, the facility failed to have an organized Respiratory Services or a Director of Respiratory Services. The facility also failed to ensure training and competencies were provided to 16 of 16 (# 8, 16, 25, 26, 28, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 57) nursing personnel to qualify them to provide respiratory services.

Review of 16 of 16 nursing personnel records revealed no staff education or competencies to provide respiratory care. The facility failed to have staff education or training to meet the qualifications of Respiratory Services.


Interview with staff #8 on 6/12/2013 confirmed that nurses were responsible for providing respiratory services as follows: administer O2, hand held nebulizers, inhalers, pulse oximeters, and suction when ordered.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have an organized Respiratory Service.

Based on Interviews and policy/ procedure reviews the facility failed to have a Respiratory Department. The facility failed to have a scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff.

On 06/12/2013 beginning at approximately 9:00 AM the surveyors observed three patients (#1, #2, #30) receiving electroconvulsive therapy (ECT, a psychiatric treatment in which seizures are electrically induced in anesthetized patients) while being administered general anesthesia (A variety of medications may be administered, with the overall aim of ensuring sleep, amnesia, analgesia, relaxation of skeletal muscles, and loss of control of reflexes of the autonomic nervous system) by Certified Registered Nurse Anesthetists (CRNA #7).

An interview on 06/12/2013 in the patient recovery area at approximately 10:30 AM with CRNA #7 confirmed general anesthesia was being administered to patient receiving ECTs.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have a Respiratory Department or designated staff to be available if mechanical ventilation, or Oxygen support was needed during an emergent condition if general anesthesia was being administered.

Based on Interviews and policy/ procedure reviews the facility failed to have a Respiratory Department. The facility failed to have a scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff.

Interview with staff #1, 3, 6, and 8 on 6/13/2013 confirmed the facility did not have a Respiratory Department.

Based on Client Recovery Plan (treatment plan) review the facility failed to sufficiently update the treatment plan goals when a patient needs a new goal, is regressing, progressing, or when the patient goal is not theraputic to the patient's issues in 10(#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) out of 10(#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) patient charts reviewed.

Review of "MEDICAL/CLINICAL Section 4-86" on 6/13/13 revealed the policy "Assessment Timeframes" was revised in June 2013.

The policy states," Recovery plan for direct admissions: 1st 14 day review-due within 14 days of Master or by 21st day of hospitalization. 2nd 14 day review- due within 14 days of 1st 14 day review or the 35th day of hospitalization. Restraint/Seclusion Review: Treatment team to review when patient is restrained / secluded more than 2 times in a 30 day period." There was no specific policy or guidelines for Client Recovery Plans.

Review of Client Recovery Plan (treatment plan) for patient #12 states, " Obj: patient #12 will exibit clear lung fields and clear breath sounds. Opened: 5/20/13 Review date: 6/12/13 Progress Towards Goals: Stable. Review Comments: He has gained 3 pounds this review period."Patient #12 interventions, objectives, and goals did not reveal a regression for this patient. The plan was not updated or altered to assist the staff and patient in an obtainable goal.

Review of patient #8's medical record on 6/12/2013 revealed the patient was diagnosed with a Urinary Tract Infection(UTI) on admission and started on Macobid 100mg(antibiotic) to treat the UTI. The treatment plan reveals a problem for the UTI but does not address the antibiotics.

Review of patient #8's physician orders revealed patient was ordered an "Adult Mechanical Restraint Chair" on 4/21/2013 and a "Personal Restraint Horizontal Restraint" not to exceed 15 min for violent behavior. Patient #8 was ordered "Adult Mechanical Restraint Chair" on 4/22/2013 for violent behavior. The treatment team had not addressed this issue on patient #8's treatment plan. The treatment team failed to follow the facility's policy for Restraint and Seclusion Review.

Interview with staff #56 stated, " we have treatment team each week and update the treatment plans if needed."

Review of the medical record of Patient #3 revealed a "Client Recovery Plan" [treatment plan] with a problem of "Alteration in Cardiac Function/Circulation." One of the objectives for this identified problem was "He will identify diagnosis, name(s) of medication(s) possible: possible side effects, warning signs, and importance of taking medications and communicating with physician after discharge." The intervention was "Nursing staff will monitor and record vital signs: breath sounds, weight, peripheral edema, and activity tolerance at least once per shift." There was no documented evidence in the medical record of nursing staff assessing or recording breath sounds, weight, peripheral edema and activity tolerance at least once per shift between the dates of 5/3/13 and 6/13/13.


28659

On 6/12/2013, during the afternoon, a review of patient (pt/Pt) #5's Medical/Psychiatric Care Plan from the her Medical Record (MR) revealed Pt #5 was a long term stay pt. who was admitted on 12/9/2011. Her medical care plan revealed the following:

Problem: Alteration is urinary elimination/incontinence. Pt. had documented problems related to stress incontinence and had a Foley Catheter (FC).
Goal: Pt will achieve and maintain adequate urinary elimination.
Objectives: At least every 8 hours, Pt will urinate independently in toilet (sic).
Pt would not develop skin break down as a results of incontinence.
Pt #5 will not develop complications related to the FC.
Interventions: Nursing staff will perform incontinent care as needed.
Nursing staff will perform FC care.

Pt #5 had a documented indwelling FC, therefore independent urination could not occur, incontinence should not occur with a properly functioning FC, and incontinent care should not be needed.

Problem: Alteration is cardiac functioning/circulation.
Goal: Pt will achieve and maintain stable cardiac and circulatory function such that she can tolerate mild to moderate physical activity.
Objectives: Pt. will evidence vital signs (V/S) within normal limits: heart rate 60-100, blood pressure greater than 100/60 and less than 140/90.
Intervention: Physician will evaluate need for medication and/or non-pharmacological treatment.
There was no nursing intervention on the care plan for this problem.

On 1/31/2012, Pt #5 V/S were recorded as 93/66, 101, 16. The nursing documentation records the following:

Pt #5 stated "it hurts to try to hold her head up", she is drooling...Pt is unable to assist staff with any of her care. She is spoon fed, only ate 5%...There was no documentation of nursing assessment, nursing intervention or that the physician was notified of the patient's condition. On 2/1/2012 at 5:20 PM Pt #5's V/S were as follows; 93/59, 99.1, 84,20. There was no nursing documentation of further assessment or intervention Pt #5. Nursing documentation records Pt #5 was in bed with TED (Anti-embolism hose), her FC has dark urine with sediment. The physician was not notified per nursing documentation. On 2/4/2012 at 7:29 PM Pt #5's V/S were recorded as 80/59, 96.6 67,18. Pt #5's B/P was rechecked by the staff and was recorded as 102/62, however her pulse was recorded as 105 beats per minute (BPM).There was no nursing documentation the nurse assessed Pt #5 further or attempted any nursing intervention. There was no nursing documentation the physician was notified of Pt #5's elevated pulse. On 2/30/2012 at 8:14 AM the nurses notes reflected Pt #5 V/S were 81/53, 96.0, 73, 20. There was no documentation that Pt #5's blood pressure (B/P) had been rechecked, as 81/53 was well below the parameters set in the care plan for safe blood pressure. There was no documentation the physician had been notified or that any nursing assessment or intervention had been attempted. On 5/25/2013 at 11:09 AM Pt #5's V/S were recorded as 84/55, 96.9,64,16. Here BP was rechecked at 100/63. On 5/26/2013 at 5:04 PM Pt #5's V/S were recorded as 89/55, 96.9, 67, 20. There was no nursing assessment or interventions documented and there was no documentation the physician was notified of Pt #5's low B/P.

Problem: Alteration in mobility/strength and/or potential for falls. Pt had a documented unsteady gait and a fall risk score of 49.
Goal: Pt will achieve and maintain adequate physical mobility; such that she does not develop complications from immobility and is able to function optimally to achieve her personal goals in the community.
Interventions: Physician and Registered Nurse will assess strength,mobility, range of motion, and functional ability to bear weight, transfer herself, assist with transfer herself or assist with transfer and follow instructions.

On 12/24/2011 a Psychiatric Nursing Assistant (PNA) documented the following: "Client (pt) notified the Staff that a client was on the floor. I immediately went to the room to the scene were (sic) client (Pt #5) was on the floor. I notified RN (nurse) that the client was on the floor. He sent two staff members from the men (sic) unit. RN (nurse) did not arrive to the scene. Staff and I was (sic) able to help client up from the floor, onto her wheelchair. Staff wheeled client to lobby". There was no nursing documentation that Pt #5 was ever assessed by the RN for injury. There was no documentation family or physician was notified of the patient's fall and there was no changes noted to Pt #5's care plan.

On 6/12/2013 in the 4th floor conference room in the morning the Facility titled "Provision of Care, Treatment and Services section 7-13" "Performing Routine Vital Signs"
Purpose: Vital Signs are defined as the patient's temperature, pulse, respiration and blood pressure.

Parameters:
Pulse; less than 45 BPM or greater than 125 BPM
Blood Pressure Systolic; less than 85 or greater than 170 (sic)
Blood pressure Diastolic; less than 54 greater than 120 (sic)
Respirations; less than 10 per minute or greater than 32 per minute
Temperature; less than 96.0 or greater than 103.

The facility policy for Vital Sign parameters was not followed when Pt #5's medical care plan (MCP) was created. The nursing staff failed to follow the parameters set by the facility and/or the MCP.

The above findings were confirmed by staff #58.



32143

Based on Client Recovery Plan (treatment plan) review, the facility failed to identify problems requiring treatment and defining outcome goals to be achieved in 2 (#8 and 18) out of 10(#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) charts reviewed. .

Review of "MEDICAL/CLINICAL Section 4-86" on 6/13/13 revealed the policy "Assessment Timeframe" was revised in June 2013.

The policy stated:
"Recovery plan for direct admissions:
1st 14 day review-due within 14 days of Master or by 21st day of hospitalization.
2nd 14 day review- due within 14 days of 1st 14 day review or the 35th day of hospitalization.
Restraint/Seclusion Review: Treatment team to review when patient is restrained/secluded more than 2 times in a 30 day period."

There was no specific policy or guidelines for Client Recovery Plans.

Review of patient #8's medical record on 6/12/2013 revealed the patient was diagnosed with a Urinary Tract Infection (UTI) on 4/8/2013 and started on Macrobid 100 mg(antibiotic) to treat the UTI. The treatment plan reveals a problem for the UTI but does not address the antibiotics as a treatment intervention.

Review of patient #8's physician orders revealed patient was ordered an "Adult Mechanical Restraint Chair" on 4/21/2013 and a "Personal Restraint Horizontal Restraint" not to exceed 15 min for violent behavior. Patient #8 was ordered "Adult Mechanical Restraint Chair" on 4/22/2013 for violent behavior. The treatment team had not addressed this issue on patient
#8's treatment plan. The treatment team failed to follow the facility's policy for Restraint and Seclusion Review.

Review of patient #18's treatment plan revealed the patient had a problem addressed for behaviors and restraints. The objective was written on 3/29/13 and stated," Patient #18 will be free of aggressive and/or destructive behavior for at least 7 days before discharge." On 5/28/13 the status towards achieving the objective was marked,"progressing." The reviewer's comments stated, " Patient #18 has been doing much better in general, but did have an incident this last week where she bit a staff member on the arm and was held." The patient's treatment plan did not have a regression or change documented to provide theraputic interventions or goals.

Review of patient #18's physician orders on 3/26/2013 revealed the patient was ordered a Foley catheter, patient was placed on Levaquin (antibiotic) for an infection on 4/1/2013, and placed on regular insulin following a sliding scale. There is no documentation noted in the treatment plan for above interventions.

Interview with staff #56 stated, "we have treatment team each week and update the treatment plans if needed."

Based on review of the Client Recovery Plan ( treatment plan), individuals writing problems, objectives, interventions, and goals are considered the responsible parties. The facility failed to list these individuals as treatment team members and identify the credentials of the responsible parties listed in 10 (#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) out of 10 (#18, 12, 8, 3, 5, 7, 13,17, 21, and 23) treatment plans reviewed.

Interview with staff # 56 on 6/12/2013 confirmed that the responsible parties are not always included on the treatment team with the patients. Staff #56 stated, "They try to communicate that information in report and usually somebody knows what's going on."