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Based on observation, interview and record review the facility failed to ensure patients received care in a safe setting. Hospital has a current census of 92 patients.

1. Failed to follow their policy and procedures for contraband items found in 4 of 10 rooms observed in Unit 4. Unit 4 had a patient census of 16 patients. (Room #s 404, 405, 406 & 409).

2. Failed to accurately measure the temperature of medication refrigerator in Unit 9.

3. Failed to ensure that electrical equipment entering the facility was properly inspected.

4. Failed to ensure patient bedroom doors were closed and unlocked when there were no patients in the room in 4 of 12 Patient rooms. Also, 1 of 12 bedroom doors was closed when a patient was inside.

Findings included:

Policy and Procedure Reviewed:

Review on 10/16/2019 of the current facility Policy and Procedure titled, "Contraband Items (Unapproved Items)", Date issued 11/19/2010, Last Revised 12/17/2018, Reads in part: "We strive to keep our hospital free of potentially hazardous items. As a result, we have determined what items are considered contraband are not approved for patients admitted to BHB (Behavioral Hospital of Bellaire). Items brought in that are deemed as contraband will be sent home or stored in a safe area off the treatment unit for pick up at time of discharge. The list includes, but is not limited to:

Belts, cords, straps, ties, shoe laces, scarves, bandanas or sashes
Any clothing with drawstrings including: hoodies, jackets, sweatshirts, sweat pants, pajamas, shorts or pants with draw strings. Food of any kid (No food of any kind is permitted to be delivered and/or to be stored for patients on any unit unless ordered by Physician)".

Review on 10/15/2019 of the "Lead Tech Daily Environmental Rounds" last revised 8/2/2019 reads; Each shift is responsible for completing environmental rounds. By signing this, you are accepting this unit's appearance and will be held accountable if rounds are not complete. Box #7 Read; Patient Rooms- No soiled linen plastic bags, hygiene products or contraband.

Policy and Procedure:

Review of the facility's current Policy and Procedure on 10/17/2019 at 10:00 a.m. titled "Temperature Monitoring of Medication Refrigerators", Date issued 07/15/2019 reads: Policy: This is the policy of Behavioral Hospital of Bellaire that electrical thermometers will be used to monitor the temperatures of the Pharmacy and Medication room refrigerators ..... Procedure: 1. Will ensure there are working thermometers in each Unit Medication Room by routinely and frequently checking the temperature at all times. 3.Ensure the temperature range of the refrigerated medications is stored between 36-46 degrees F. 4. Assigned nursing staff will complete daily rounds/checks to ensure functioning of thermometers - both electronic and/or manual.

Policy and Procedure Reviewed:

On 10/18/2019 at 8:40 a.m. review of the facility's current policy titled "Non-Clinical Electrical Equipment Safety Policy", Last Review Date: 12/17/18 read, Policy: In order to prevent the use of faulty or incorrect electrical equipment by staff and patients, all electrical equipment in patient areas will be tested by maintenance prior to initial use and at an interval justified by previous experience. Procedure: Any electric equipment entering the facility must first be visually inspected by the Plant Operations Department to ensure electrical safety prior to its use or bear a current inspection sticker or tag from the providing vendor.

Observation:

Observation of Unit 4 on 10/15/2019 at 10:30 a.m. along with the Chief Nursing Officer, Employee ID #52 and Unit 4 Registered Nurse, Employee ID #61 the following items were identified:

Room 404 B
Patient ID #10 occupied room 404B. Review of medical records document patient was currently on suicide precautions.

Surveyor observed 1 pair of black shorts that contained drawstrings in the bottom hem of each leg of the shorts. Also found was a unopened package of a fig bar.

Room 405 A
Patient ID #9 occupied room 405A. Review of medical records document patient was currently on assault precautions and elopement precautions.

Surveyor observed 1 burgundy zippered front opened sweatshirt that containing a drawstring in the hoodie portion of the sweatshirt.

Room 406 B
Patient ID #11 occupied room 406B. Review of medical records document patient to currently be on fall precautions.

Surveyor observed a paper bag identified with patient ID #11's name containing morning hygiene products including 4 ounces of mouthwash, 4 ounces of liquid body lotion, deodorant, hard plastic toothbrush and tooth paste. Each bottle and tooth paste contained caps that could easily be removed.

Room 409 B
Patient ID #8 occupied room 409B. Review of medical records documents patient under Assault precautions, elopement precautions and sexual assault observation precautions.

Surveyor observed 1 pair of tan ladies pants that contained draw strings in the hem of each leg of the pants. Also, was observed 1-unopened bottle of a Nutrition Drink, 2-unopened packages of oatmeal raisin bars, 1-unopened packaged of a large chocolate chip cookie, 1-unopened snack pack of cheese crackers, 1-unopened peanut butter and jelly sandwich and 2-unopened 8-ounce cartons of milk.

Interview on 10/15/2019 at 11:30 with the Chief Nursing Officer, Employee ID #52 confirmed the contraband items identified should not have been in the patient's room.

Interview with Mental Health Technician Employee ID #75 at 11:30 a.m. on 10/17/2019 stated the patient's clothes are checked when they come in through intake and should be checked each shift by the technicians and any time family or friends bring clothing into the hospital for the patients it should be checked. She further stated there was no reason for contraband items to be in patient's rooms.

Observation on 10/16/2019 at 10:30 a.m. of Unit #9 along with the Chief Nursing Officer, Employee ID #52 and Registered Nurse, Employee ID #61 and Assistant Chief Nursing Officer, Employee ID #59 the following items were identified:
Medication Room Unit #9

Based on observation, record review and interview the facility failed to adhere to their policy for temperature measurement of medication refrigerators by documentation of inaccurate measurement of temperatures.

Record Reviewed:

Medication Refrigerator/Freezer Log, Unit #9, October 2019. Documents Unit closed October 1-7, 2019. October 8 - 15, 2019 documented by the initials "PB" with entries 2 times per day with a refrigerator temperature of 39 degrees on each day.

Interview on 10/16/2019 at 11:45 a.m. with the Nursing Manager #59 stated the nursing supervisor is responsible for documentation of medication refrigerator temperatures on units that are closed. Nurse Manager stated the supervisors work 12 hours shifts and the temperature should be recorded each shift.

Interview on 10/16/2019 at 12:00 p.m. with Nursing Supervisor, Employee ID #67 confirmed that the "PB" initials were his and he had documented on the dates October 8th through October 15th, 2019 on the refrigerator log with the temperature of 39 degrees on each day. Employee ID #67 stated he did not work each day that he had documented on the temperature log. Employee ID #67 stated he was told the log need to be completed each day and it had always showed a 39-degree temperature, so he documented that.

Review of Staff scheduling on 10/17/2019 at 10:15 a.m. documents Employee ID #67's work schedule from October 8, 2019 to October 15, 2019.
Employee ID #67 work schedule documents Employee ID #67 off work on 3 of the days he documented the temperatures on the medication refrigerator log:

10/8/19 OFF 39 degrees documented by Employee ID #67
10/9/19 OFF 39 degrees documented by Employee ID #67
10/10/19 OFF 39 degrees documented by Employee ID #67
10/11/19 06:45-19:30 39 degrees documented by Employee ID #67
10/12/19 06:45-19:15 39 degrees documented by Employee ID #67
10/13/19 0:645-19:15 39 degrees documented by Employee ID #67
10/15/19 10:30-19:15 39 degrees documented by Employee ID #67

Based on observation, interview and record review the facility failed to follow their policy and procedure for electrical equipment safety checks found in 1 of 10 patient rooms observed. (Room # 401).

Observation of Unit 4 on 10/15/2019 at 10:30 a.m. along with the Chief Nursing Officer, Employee ID #52 and Unit 4 Registered Nurse, Employee ID #61 the following items were identified:

Room 401 B: One Portable EverFlo oxygen concentrator was identified in use by Patient ID #33. Oxygen concentrator did not have an electrical safety sticker.

Interview with Employee ID #52 confirmed there was no electrical safety sticker on the oxygen concentrator. Employee ID #2 stated Patient ID #33 had brought the oxygen concentrator into the hospital with him from the group home and confirmed the concentrator should have had an electrical safety check prior to letting the patient use it in the hospital.

Observation on 10/15/19 at 10:00-10:30 AM of facility's Unit 8 revealed the following:

Room 808 door closed, unlocked (no patients in room).
Room 811 door closed, unlocked (no patients in room).
Room 812 door closed, unlocked (no patients in room).
Room 813 door closed, unlocked (no patients in room).
Room 803 door closed, unlocked (a patient was inside room).

Record review of facility policy titled "Patient Room Doors" dated 1/11/16 stated that vacant patient [room] doors will be locked and patient room doors are to remain open when occupied.

Interview with Staff #79 at time of findings confirmed that the doors should have been locked if no patients were inside the rooms, and the doors should have been opened up if patients were inside the rooms.

Based on record review and interview, the facility failed to ensure that the required one-hour face-to-face post restraint assessment was performed for 5 of 5 sampled patients (Patient #'s 1, 35, 32, 34 and #21) who had received emergency medications to control violent and/or aggressive behaviors.

Findings included:

Record review of the US Code of Federal Regulations, 42 CFR 482.13, under conditions of participation for Patient Rights, in part, currently defines the term 'Restraint', as;

"B) A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition" (please also refer to Tag A0160).

Review of facility policy titled "Use of Restraint", dated 1/11/16, only addressed the use of physical/personal restraint and failed to address the use of emergency medications as a restraint. It also stated, in part " ...4. The use of restraint is prohibited except as defined in this document".

Record review of Patient #35's Emergency Psychotropic Medication Order Forms showed the following:

-On 9/7/19 at 22:09, there was an Emergency Medication order given because the patient had been going into other peer's room and was verbally aggressive towards them and as a result, "was going to hurt other patients". There was an order from Dr. Staff #55 to give Emergency Psychotropic Medications; Thorazine 50 mg (milligrams) IM (intramuscularly) and Ativan 1 mg IM. Reason for administering: "To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually commits." There was no one-hour post-restraint face-to-face assessment done.

-On 9/9/19 at 07:30 AM, the patient was attacked by another patient due to being intrusive, confused, and psychotic, having poor boundaries, taking her clothes off. There was an Emergency Psychotropic Medication order from Dr. Staff #55 for Zyprexa 10 mg IM and Benadryl 25 mg IM which were given. The reason was for poor boundaries and severe psychosis. There was no one-hour post-restraint face-to-face assessment done.

-On 9/9/19 at 23:30 (11:30 PM), there was an Emergency Psychotropic Medication order for Zyprexa 10 mg IM and Benadryl 50 mg IM from Dr. Staff#77 because patient was aggressive, confused, and very psychotic. The reason for administration was for severe psychosis. There was no one-hour post-restraint face-to-face assessment done.

-On 9/10/19 at 23:30 (11:30 PM), there was an Emergency Medication order for Ativan 2 mg IM and Zyprexa 10 mg IM from Dr. Staff #76. The patient was aggressive towards staff and roommate, spitting and throwing water at staff. Reason for administration was Severe Psychosis. There was no one-hour post-restraint face-to-face assessment done.

-On 9/13/19 at 03:45 AM, there was an order for the Emergency Psychotropic Medications Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 25 mg IM from Dr. Staff#55 because patient was trying to hit staff and was banging on objects. There was no one-hour post-restraint face-to-face assessment done.

-On 9/21/19 at 22:30 (10:30 PM), there was an order for Emergency Psychotropic Medications Thorazine 50 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM from Dr. Staff #76. The patient had been aggressive towards staff, was hitting the wall, was spitting at nurse, and had spit-out all her medications. Reason for giving the meds was Severe Psychosis. There was no one-hour post-restraint face-to-face assessment done.

Record review of Patient #34's Emergency Psychotropic Medication order forms showed the following:

-On 9/5/19 at 1314 (1:14 PM) there was an order (ordering doctor name not printed or signed to order) for Ativan 1 mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM. The patient was irritable, agitated, threatening another patient, increased psychosis, screaming loud and hitting walls. The reason for administration was to prevent imminent probable, or substantial, bodily harm to the patient because the patient was overtly or continually threatening or attempting to commit suicide or serious bodily harm. Also, to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts. There was no one-hour post-restraint face-to-face assessment done.

-On 9/17/19 at 10:50 AM, there was an order for Emergency Psychotropic Medications from Dr. Staff #78 for Zyprexa 10 mg IM, and Benadryl 50 mg IM. The patient was loud, making verbal and physical threats, agitated, and psychotic. The reason for administration was to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits, poor boundaries, and severe psychosis. There was no one-hour post-restraint face-to-face assessment done.

-On 9/24/19 at 14:50 (2:50 PM), there was an order for Emergency Psychotropic Medications from unknown doctor (illegible signature, name not printed) to administer Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 1 mg IM. The patient had been cursing at staff and throwing chair in hallway. The reason for administration was to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits. There was no one-hour post-restraint face-to-face assessment done.

-On 9/26/19 at 8:00 PM, there was an order for Emergency Psychotropic Medications for Zyprexa 10 mg [IM], Ativan 2 mg [IM] and Benadryl 50 mg [IM] (ordering doctor name not printed). The patient was very aggressive, yelling, cursing, hitting wall, and spitting at staff. Reason for administration was to prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious body harm. Also, to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits, and Severe Psychosis. There was no one-hour post-restraint face-to-face assessment done.

-On 9/27/19 at 2:40 PM, an order for Zyprexa 10 mg IM and Benadryl 50 mg IM was ordered by a doctor (no printed name on order). The patient was aggressive, impulsive, trying to hit staff, yelling and psychotic. Reason for administration was to prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm. Also, to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits. Also for Severe Psychosis. There was no one-hour post-restraint face-to-face assessment done.

Record review of Patient #32's Emergency Psychotropic Medication order form showed the following:

-On 8/12/19 at 0400 (4:00 AM), an order for Haldol 10 mg IM, Ativan 1 mg IM, and Benadryl 50 mg IM was ordered by Dr. Staff #78. The patient was verbally aggressive, was undressing on hallway, slamming the door, and refusing PO (by mouth) medication. Reason for administration was to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits. There was no one-hour post-restraint face-to-face assessment done.

Record review of Patient #34's Emergency Psychotropic Medication order form showed the following:

-On 9/5/19 at 1314 (1:14 pm), an order for Ativan 1 mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM was made by an unknown doctor (no signature or printed name of doctor on order). The patient was irritable, agitated, not responding to verbal de-escalation, threatening another patient, increased psychosis, screaming loud and hitting walls. The reason for administering the medication was to prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or bodily harm. Also, to prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits, and also for Severe Psychosis. There was no one-hour post-restraint face-to-face assessment done.

Record review on 10/17/2019 of Emergency Psychotropic Medications orders for Patient ID #1 revealed the following:

-On 07/10/2019 at 1430 Patient ID #1 record review documented patient's behavior as "Patient is agitated, aggressive, loud, yelling and cursing. Patient was threatening and spitting at staff. Patient is not following verbal redirections." Emergency Medication orders from staff doctor ID #76 showed to give Thorazine 50 mg (milligram) IM (intramuscular), Benadryl 50mg and Ativan 2 mg IM. No documentation was found for the one-hour post restraint face-to-face assessment.

- On 07/08/2019 at 1500 Patient ID #1's documented patient's behavior as, "Aggressive, agitated, walking around the unit naked". Emergency Medication orders from staff doctor ID #55 showed to give Zyprexa 10 mg, Benadryl 50 mg IM. Reason for administering medications documented as "severe psychosis". No documentation was found for the one-hour post restraint face to face assessment.

-On 06/30/2019 at 1624 patient #1's behavior was documented as "manic and psychomotor agitation". Emergency Medication orders from staff doctor ID #55 showed to give Thorazine 50mg IM and Benadryl 50 mg IM. Reason for administering the medications documented as: "To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts and severe psychosis. Patient exhibiting uncontrollable anger outburst and manic episode". No documentation was found for the one-hour post restraint face-to-face assessment.

-On 06/25/2019 there was an order for emergency medications at 1248. Patient ID#1's behavior was documented as "Psychotic, exhibiting manic behavior". The medications were administrated at 1300; Emergency Medication orders from staff doctor ID #55 showed to give, Lorazepam 2 mg, IM, Benadryl 50 mg [IM], Haldol 10 mg [IM]. Reason for administering the medications documented as, "To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits and severe psychosis". No documentation was found for the one-hour post restraint face-to-face assessment.

-On 06/25/2019 an order was received for emergency medications at 1405. Patient #1's behavior was documented as "Physically aggressive and property destruction." Emergency Medication orders from staff doctor ID #55 showed to give Thorazine 50 mg IM. Reason for administering the medications documented as, "To prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm. To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits. Severe Psychosis". There was no one-hour post-restraint face-to-face assessment done.

In an interview on 10/17/19 at approximately 1:00 PM, Dr. Staff #55 stated that if an emergency medication is given IM and the patient is not forced to take the medication, then there would be no one-hour post restraint face-to-face exam performed; it would only be performed if the patient was forced to take the emergency medication.



Record review on 10/17/2019 of Emergency Psychotropic Medications orders for Patient ID #21 revealed the following:

-On 09/27/19 at 03:30, there was an Emergency Medication order given to patient
#21 because the patient had been going into other peer's room, psychotic, disruptive and disorganized, and extremely paranoid and refused regular medications. There was an order from Dr. Staff #55 to give Emergency Psychotropic Medications; Thorazine 50 mg (milligrams) IM (intramuscular) and Ativan 2 mg IM. Reason for administering: 1) "To prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm. 2) To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually commits. 3) Severe Psychosis" There was no one-hour post-restraint face-to-face assessment done.

-On 09/27/19 at 06:00, Emergency Medication given to patient #21 because the patient had been going into other peer's room, psychotic, disruptive and disorganized, and extremely paranoid and refused regular medications. according to the nursing note. Thorazine 50 mg IM, Ativan 2 mg IM, and Benadryl unknown amount (amount not written) was given. There was no one-hour post-restraint face-to face assessment done.

-On 09/27/19 at 23:30, there was an Emergency Medication order given to Patient #21 because the patient had been going into other peer's room, psychotic, disruptive and disorganized, and extremely paranoid and refused regular medications. There was an order from Dr. Staff #55 to give Emergency Psychotropic Medications; Thorazine 50 mg IM and Ativan 1 mg IM. Reason for administering:1) "To prevent imminent probable, or substantial, bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm. 2) To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually commits. 3) Servere Psychosis" There was no one-hour post-restraint face-to-face assessment done.


-On 09/28/19 at 06:00, there was an order for Emergency Medication for Patient #21 because the patient had been going into other peer's room, psychotic, disruptive and disorganized, and extremely paranoid and refused regular medications. There was nursing note that Emergency Psychotropic Medications were given; Thorazine 50 mg IM and Ativan 1 mg IM. Reason for administering: "To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually commits." There was no one-hour post-restraint face-to-face assessment done, nor was there a doctors order written.

-On 09/29/19 at 01:15, there was an Emergency Medication order given to patient #21 because the patient had been going into other peer's room, psychotic, disruptive and disorganized, and extremely paranoid and refused regular medications. There was an order from Dr. Staff #76 to give Emergency Psychotropic Medications; Zyprexia 10 mg IM and Ativan 2 mg IM. Reason for administering: 1) "To prevent imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually commits. 2) Poor boundaries" There was no one-hour post-restraint face-to-face assessment done.

Based on observation and interview, the dietary service director failed to ensure safety practices in the kitchen were fully met.

Findings included:

Observation on 10/15/19 at 11:15 AM of the facility's kitchen showed there was a "Champions" brand Dish Machine used to clean and sanitize dishes. The machine had two types of working temperature reading but also had a pressure gage that was inoperable. The 'needle' on the pressure gage was pointing to the far right side indicating the pressure was high, past the upper ranges. DDS Staff #66 was informed and attempted to tap on the gage but it would not move and appeared stuck. In an interview with Staff #66 at the time of findings, he stated the pressure gage was broken and needed to be fixed.

Further observation of kitchen revealed a three compartment sink used to clean and sanitize pots and pans. Record review of the sanitation log for 10/15/19 revealed there were two missing entries; one prior to breakfast and one prior to lunch. In an interview with Staff #66 at the time of findings, he stated that the two entries for the sanitation log should have been recorded but were not.

Continued observation of the kitchen area showed there was a steamer in use. The steamer was rectangular shaped made with stainless steel. Inside the steamer was a tray of carrots and a tray of ready-made meatballs, steaming. There was mineral scaling noticed on the inside walls of the steamer as well as food particles. In an interview on 10/15/19 at the time of findings with Staff #66, he stated that once per month, the entire inside of the steamer was cleared of lime scale with a special 'lime-away' type of solution. However, he stated that the insides were cleaned of scale and food debris daily, using vinegar. When asked to demonstrate, Staff #66 was unable to locate the spray bottle of vinegar used to clean the steamer, or, a container of vinegar.

Based on observation and interview, the facility staff failed to identify and mitigate risks for infections as evidenced by not maintaining a sanitary environment.

Findings included:

1. Observation on 10/15/19 from 10:00 AM-10:30 AM showed there was 1 out of 9 chairs in Unit 8's dayroom with torn-off vinyl on the armrests, exposing soft spongy foam. The foam had the potential to harbor infectious organisms, as it was not possible to sanitize properly. Staff #79 confirmed the findings.

2. Observation on 10/15/19 from 10:00 AM-10:30 AM of Unit 8's exam room had a phlebotomy chair inside. Attached to the chair's right armrest was a roll of paper tape (used for bandaging post blood draws), which appeared to have been previously used and was ready for the next patient use. There was no way to determine how many times, if any, it had been used on other patients, contributing to possible cross contamination. Staff #79 confirmed the findings and removed the paper tape from the chair.

3. Observation on 10/15/19 from 10:00 AM-10:30 AM inside Unit 8's laundry room, inside the clothes washing machine, there were approximately 2 inches of standing water, which had the potential to harbor infectious microorganisms. Staff #53 confirmed these findings as an infection control issue and stated it would be repaired prior to any further use.