HospitalInspections.org

Based on review and interview the facility failed to

A. ensure patients were oriented and coherent before signing a consent for voluntary admission, patient rights, treatment, and financial responsibilities in 2 (7 and 9) of 3 (7, 9, and 11) charts reviewed.

B. have physician orders to change involuntary to voluntary status, no documentation that patient was informed of court decision, nor any consents to sign the patient in voluntary in 2 (9 and 11) of 3 (7, 9, and 11)

Review of the policy and procedure Assessment/Admission Procedure for Acute Services/Voluntary Admissions, Policy Number AS003 stated, "Page 2 The intake specialist verbally reviews and completes all admission documents with the patient or guardian.
The patient or guardian acknowledges voluntary admission by signing the Consent for Treatment and Conditions of Admissions which includes:
Patient Bill of Rights; receipt of patient handbook; Patient Grievance forms and procedure and other admission documents.
Only patient assessed to be competent to sign forms will be allowed to do so.
If consents/acknowledgements are not signed at the time of admission, due to patient being incapacitated or otherwise deemed incapable of understanding informed consent, will be allowed to sign paperwork."

Patient #7

Review of Patient #7's chart revealed he was admitted to the facility on 6/15/20. The Licensed Professional Counselor (LPC) documented on 6/15/20 at 1445 that the patient was having grandiose delusions, and manic behaviors. He presents with flight of ideas ...his speech is tangential (erratic), and he is restless and demanding.
Review of the nurses notes on 6/15/20 the nurse documented the patient was "very delusional." The patient was allowed to sign in as a voluntary patient.

Review of the "Consent for Treatment" revealed the patient had scribbled all over the form. On the "Notice of Privacy Practices" the patient had scribbled all over the page, drew multiple circles with numbers around them and the word "time".

Review of the "Assignment of Insurance Benefits" revealed the patient had written incoherent sentences on the form.

Patient #9

Review of patient #9's chart revealed he was admitted to the facility on 6/15/20. Review of the admission orders from the telemed physician on 6/15/20 stated the patient was admitted as voluntary on one page and involuntary on another. The physician stated the patient was too catatonic to answer questions.

Review of the chart revealed the patient requested to be discharged on 6/16/20. An Order or Protective Custody (OPC) was submitted to the court on the 6/16/20. Further review revealed a "Notice of Rejection of Application" on 6/17/20. The application stated, "there is not enough sufficient cause to support the application presented." On the bottom of the notice stated, " Hunt County likely not appropriate venue if patient resides in PA and transported here from Richardson. Also unclear if patient was is (SIC) or was voluntary as intake stated willingness to voluntarily be treated." There was no documentation that the patient was informed that he was at liberty to leave the facility on 6/17/20 or if he had been explained his rights. There was no documentation that the court had been called to question the comment of the patient's residence, how that would corelate in the decision to decide the patient's mental incapacity and need for mental health care.

The patient was found to have signed a "Request for Voluntary Treatment" on 6/18/20 but there was never a physician order to change the patient from involuntary to voluntary. There were no consents signed for treatment, patient rights, or financial information on the chart.

An interview with Staff #2 on 11-5-20 confirmed the patient did not have an order nor had any consents signed for a voluntary admission. Staff #1 stated due to COVID-19 it had been hard to talk to the judges at the court house due to no in-person visits. Staff #1 did confirm that you could call on the phone or zoom at the courts if needed. Staff #1 and #2 did not have an answer to why this patient was not followed through with a failed OPC, no physician orders to change status, no documentation that patient was informed of court decision, nor any consents to sign the patient in voluntary.

Patient #11

Review of patient #11's chart revealed he was admitted to the facility on 10/15/20. The patient was admitted as involuntary on an Emergency Detention Warrant (EDW).

Review of the chart revealed he signed a consent for treatment and all other consents on 10-15-20. The patients EDW was out on 10/19/20 and was no longer under a warrant for mental health care. There was a "Request for Voluntary Treatment" form signed on 10/20/20. There was no physician order to change the patient from involuntary to voluntary.

An interview with Staff #2 on 11-5-20 confirmed there was no physician order written to change the patient's status.

Based on observation, document review, and interview the facility failed to ensure a clean and sanitary environment on 3 (Restore Unit, Square One Unit, and Changes Unit) of 3 patients care units to prevent the transmission of infectious diseases and hospital acquired infections. The facility also failed to follow their own policy on cleaning patient rooms, reusable patient equipment, and cleaning the washer and dryers in the patient care area.


This deficient practice had the likelihood to cause harm to all patients by placing them at risk for contracting an infectious disease or hospital acquired infection.


Findings include:


An observation tour was conducted with Staff #1 on 11/4/2020 at 10:50 AM. The following was observed.



Restore Unit

Dayroom

Upon entering this unit is a large day area with multiple tables and chairs for patients to gather. A large window that lines the wall faces the outside courtyard/smoking area. A cigarette butt is noted lying on the inside of the window sill. There is a cup noted on the floor. Two chairs pushed together are noted with multiple used blankets piled on the tops of the chairs. The chairs are noted to have black dirt, dust and debris between the seat cushions and the hard-plastic base. There is trash, and heavy dust on the floor. The floor is sticky to the soles of this surveyor's shoes. Looking through he large window onto the courtyard multiple cigarette butts and trash are noted on the ground. 3 (unlocked cabinets in the day rooms) of 3 unlocked cabinets that was being used to store patient personal hygiene products was noted to have dirt, dust, and debris on the bottom shelf.


Laundry Room

In the laundry room there are two washing machines and two dryers used for patients clothing. On the lid of the washing machine a brown particle is noted. Inside the washing machine is patient clothing. The bleach compartment is noted to be soiled with dirt and dust. On top of the dryer are clothes belonging to a patient that are not labeled for a specific patient. The floor has chipped tiles and noted to be exposing the concrete surface beneath the tile. The floor is heavily soiled with dirt, dust, and debris throughout the laundry room. Staff #1 stated she received approval for new flooring this morning.

Staff #1 was asked to present the information for the approval of the floor repair or replacement for review. No documentation was presented or perceived for review.


Staff #5 confirmed the inside of the washers and dryers is not always cleaned by housekeeping staff on a daily basis."


Room #116

The vinyl baseboard on the wall coming out of the bathroom was noted to be separating from the wall. This created an opening for rodents and insects. Surrounding the vinyl baseboard was dirt and dust and paint was missing from the metal door frame. The metal surface cannot be cleaned to prevent the spread of infectious disease. A multi-tiered wooden cabinet was against the wall for patient belongings. On the top self was an unopened milk carton readily available for a patient to drink. Staff #1 could not confirm how long the milk had been exposed to room temperature.


Room #118

On a shelf of the multi-tiered, open faced wooden cabinet, used for patient storage was personal hygiene products. Shampoo, Conditioner, deodorant, toothpaste, and non-skid socks. These items were readily available for use with no patient identifier for the items. This is a double occupancy room. Staff #1 could not confirm or deny when "Bed A" was discharged or to whom the products belonged to. Inside the bathroom was a dirty rag lying in the floor of the shower. The metal handrails in the shower were noted to have dirt and a rust color where the rail attaches to the shower wall. Also, there are open personal hygiene supplies, hair conditioner, body wash, and lotion noted on the handrail inside the shower. Staff #4 was asked if the patient in "Bed A" was discharged and who the hygiene products belonged to. Staff #4 replied, "I think the patient was discharged but I am not sure who the products in the shower or the cabinet belong to. They should be for the patient that is still in this room." More hygiene products, lotion, was noted on the sink. Inside the sink, located at the drain, was noted a dark, almost black colored that surrounded the drain. The drain covering was noted with a white and black color around the drain. Porcelain was missing inside the toilet bowl. At the base of the toilet dirt, dust, and debris was noted along with a white stain on the floor. On the surface behind the seat of the toilet a rust color around the hinges an on the surface was noted. Directly behind the seat, the caulk was missing that sealed the tank to the base leaving a separation between the two. The seat was soiled with a brown color


Patient Exam Room between Units Square One and Restore

Inside a closed cabinet that stored patient care supplies was multiple plastic bins. Xeroform (a dressing gauze for wounds) was noted expired. Five packages of this dressing were noted to expire 10/31/2020. One package was noted to be opened and readily available for patient use. An exam table in the room was noted to have dirt, dust, and debris on the back of the exam table. A rolling three-tiered cart storing blood tubes and lab draw supplies was so heavily covered with dust, this surveyor could draw a line with a fingertip. At the base of the wall the vinyl baseboard was peeling away from the wall exposing the sheetrock. Missing and chipped paint was noted. The porous surface could not be sanitized to ensure patient safety and prevent cross contamination of infectious diseases.



Square One Unit

Dayroom

The dayroom floor is noted to be heavily covered with dirt and dust. A window looking into the courtyard was along the wall. The window sill was heavily soiled with dirt, dust, and debris. A large brown colored, dried liquid is visible on the window sill. Along the base of the window sill connected to the floor, is a large amount of dirt and debris. Multiple chairs are in the dayroom for patient use. The chairs were noted to have dirt and dust in between the cushion and the plastic base.

Room 123

The base of the shower had a brown colored stain. There was missing paint from the external metal shower frame exposing the metal surface beneath. This surface could not be sanitized for patient safety. The toilet seat was missing porcelain. Around the base of the toilet, next to the floor, was a brown color at the base near the caulking. There was dirt and dust visible at the wall. The vinyl base board was peeling away from the wall and peeling paint was noted on the wall next to the tank. This provided and opening for insects.

The mattress on the patient bed was turned over and noted to be cracked and torn in several places. This material cannot be sanitized and disinfected in between patients to prevent the spread of infectious diseases. The inside of a ball point pen and trash was found in between the mattress and the wooden base of the bed.

The multi-tiered, wooden open-faced cabinet, used for patient storage was heavily covered in dust.



Changes Unit

Room 107

Two multi-tiered opened faced wooden storage cabinets for patient belongings was noted to have dust and debris. Behind the room door, the floor was heavily covered with dust, dirt, and debris. The door stop for the door was heavily covered with dirt and dust.


Medication Room

The top of the sink had a dried liquid that was pink in color. In the cabinets under the counter there was dirt, dust, and debris noted. The cabinets stored patient supplies for medications. The cabinet under the sink was unlocked and stored an empty corrugated box. On the floor of the cabinet was a large black colored, dried liquid that covered almost half of the surface. On the inside of the doors, brown color covered the bottom portion of the door on both sides. On the inside framing of the doors was a black/gray colored area that resembled mold. Staff #6 was asked what the discoloration on the cabinet doors, the floor of the cabinets, and the framing was. Staff 6 stated, "I'm not sure, but I think we had a water leak at some time in there." Staff #4 confirmed the findings.


Nurses Station

A portable vital sign machine was heavily soiled with dirt, dust, and debris. The face plate was held in place by scotch tape. The basket on the back of the portable vital sign machine was noted to have dirt and debris on the inside. Staff #6 was asked who was responsible for the cleaning of the vital sign machine. Staff #6 stated, "We wipe it down in between patients and return it to the nurses station."


Staff #1 and Staff #8 Confirmed the findings.


Clean Storage Room

Inside the clean storage room was reusable patient equipment being stored. Plastic bags were used to cover the clean equipment readily available for patient use. The plastic bag was removed covering the wheel chair. The wheel chair was noted to be heavily soiled in dirt and dust. The vinyl was torn on the arm of the chair exposing the cloth material beneath. This material could not be disinfected or sanitized to prevent the spread of infectious diseases. The wheels of the wheel chair were noted to be heavily soiled with dirt and debris. The plastic cover was removed from the bed side toilet. One of the legs on the toilet was rusted at the base of the leg. Under the seat rust was noted where the base and the seat were connected.

Gym

Inside the gym it is noted that the floor has multiple bees/wasps. Some are dead, and some are alive. Along the wall is a line of chairs for patient use. The chairs are noted to have trash, dirt, and dust. A dried white liquid is noted on the back of one of the chairs. A used cup was let in the water fountain. On the wall is a large vent noted to be heavily covered with dirt and dust.

Staff #1 and Staff #4 confirmed the findings.


An interview was conducted on 11/5/2020 after 10"00 AM with Staff #5. Staff #5 was asked how often the unit was cleaned. Staff #5 replied, "We clean the unit 3 times in a day. We mop the floors after breakfast and lunch. We just have two housekeepers right now, so we stay very busy cleaning all the time. The nurses are supposed to clean the patient equipment."



An interview was conducted with Staff #8 on 11/5/2020 at 2:25 PM. Staff #8 was asked if the housekeepers had a cleaning schedule for the units. Staff #8 said, "We don't really have a cleaning schedule. It is supposed to be cleaned three times a day, but we just recently hired a second housekeeper and she spent two weeks in orientation." Staff #8 was asked to confirm the facility only had one housekeeper. Staff #8 replied, "We had only one housekeeper for about 2 months and myself. I did help with the cleaning when I could and when I was available. We used to have five housekeepers here. We had one FTE (Full Time Employee) taken away from the department and two others quit. I have brought it to the attention of the leadership team that the department was understaffed, and we were able to hire someone else. I take a lot of pride in this job, but we just do not have the man power to complete it." Staff #8 was asked if the cleaning was completed to protocol. Staff #8 replied, "We are at least wiping down all flat surfaces and cleaning the patient rooms but there is just not enough of people to deep clean." Staff #8 was asked how long bees had been a problem in the gym. Staff #8 stated, "I have noticed them more just recently. I swept the gym floor before I left last night, and it had multiple bees on it. When I returned this morning the gym floor had more bees, some alive and some dead so I had to sweep it again. We have pest control come every week and it was reported to me that the bees may be in the ducts."

An interview conducted with Staff #1 and Staff #2 confirmed the Housekeeping Department was understaffed and Staff #1 had recently asked for the approval to hire more housekeepers. Staff #1 was then asked about the bee infestation in the gym. Staff #1 said she had gotten a contract for another pest control service to come out and do an inspection. No documentation was provided for review.


An interview was conducted on 11/4/2020 with Staff #2. Staff #2 was asked how often surveillance rounds were made through the facility. Staff #2 stated, "We report quarterly but I make rounds with the EOC staff monthly." Staff #2 was asked if there were any concerns from the last surveillance rounds completed. Staff #2 stated, "Not at this time. We have been very diligent about COVID-19 and this years Flu season."


A review of the document title, "MONTHLY IC SURVEILLANCE ROUNDS" dated 9/15/2020 by Staff #2 was as follows:

" ...AREA AUDITED, DATE, YES, NO, AND COMMENTS;

PATIENT COMMON AREA/DAY ROOMS:
Showed documented evidence of unattended food/drinks, evidence of pests, dusty vents, and sticky floor.

PATIENT ROOMS:
Showed documented evidence of food and drinks in room, linen on floors, personal hygiene items, soiled towels and washcloths.

MEDICATION ROOMS:
Showed documented evidence of food and drink present, dirty floors, air vents dirty.

NURSES STATION:
Showed documented evidence of dirty air vents and evidence of pests.

UNIT LAUNDRY ROOMS:
Showed documented evidence of cleaning log for washer and dryer not up to date and hand sanitizer dispensers empty.

CLEAN LINEN ROOMS:
Showed documented evidence of refrigerator temps not up to date and within range, refrigerator clean, and sharps containers were greater than 2/3 full.

FRONT ENTRANCE/LOBBY:
Showed documented evidences floors were dirty, furniture was dirty, and evidence of pests.

GROUP ROOMS:
Shows documented evidence of dirty furniture and odors, dirty floors, and unattended food and drinks.

PATIENT SUPPLY AREAS:
Shows documented evidence of corrugated shipping boxes and dust in high areas.

SOILED LINEN ROOMS:
Shows documented evidence of empty hand sanitizer and uncovered soiled linens.

OUTSIDE:
Shows documented evidence of standing water outside, open dumpster lid, and unused or broken items not disposed of ..."

Staff #2 confirmed there was no documentation of a plan to correct the deficiencies found on the surveillance rounds dated 9/15/2020.



A review of the policy titled, "Washers and Dryers in Patient Care Areas," Policy No. IP817 Revised 2/2019 was as follows:

" ...PROCEDURE:
...The washing machine and the dryer surface will be wiped with disinfectant between patient usage.
Housekeeping staff will clean the interior and exterior of washers and dryers daily with a hospital approved disinfectant. Filters will also be checked and cleaned at this time ..."




A review of the facility policy titled, "Cleaning of Reusable Portable Equipment," Policy No. IP802 with a revised date of 2/2019 was as follows:

" ...PROCEDURE:

Items will be cleaned based on the schedule by using hospital approved disinfectant wipes and or alcohol wipes.

Items awaiting cleaning will be kept separate from clean items until cleaned and disinfected.
...
Medication nurse 7 pm-7 am shift is responsible for completion and will initial when done ..."



A review of the CLEANING/DISINFECTING SCHEDULE BY DEVICE revealed the blood pressure machine and cuff would be cleaned and disinfecting wipes after each use by Nursing.




A review of the facility policy titled, "Cleaning Patient Rooms" Policy No. IP812 with a review/revised date of 2/2019 was as follows:

" ...PROCEDURE:

Environmental services staff are responsible for the following:

Damp wipes furniture in patient rooms with clean cloth, using germicidal detergent solution ..."

Staff #1 and Staff #4 confirmed not all furniture had been cleaned according to facility policy in patient rooms observed during tour on 11/4/2020.



Staff #1, #2 and #4, and #8 confirmed the above findings.