HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to notify one patient's representative (Patient #1) of changes to the plan of care. A total of 30 medical records were reviewed. The facility's census was 68.

Findings include:

The facility's Absence Without Leave (AWOL) Elopement policy ( PC#112, Effective 07/2015) stated:
Elopement
When a patient is discovered missing, staff members will search for the patient in the hospital and hospital grounds.
If the patient is on an involuntary status or a conservatorship, the local police department and the conservator must be notified immediately.
Staff will notify the following people:
·Physician immediately
·Guardian
·immediate family, as appropriate
·Probation Officer, if applicable
·CEO (Chief Executive Officer)/Administrator
·Local Police Department.
·Provide as much following information to the Police Officer when he/she arrives
Nursing staff will document time, who was notified, efforts made to ensure that the patient is safe, areas searched and the patient's behavior and mental status in the progress notes

Patient #1 eloped from the facility on 11/08/20 around 2:30 AM. Local police were notified by the facility and the local police apprehended Patient #1 and placed Patient #1 in jail. The medical record did not contain evidence of the facility notifying Patient #1's representative of the change.

The complainant was interviewed on 01/06/21 at 4:11 PM. The complainant reported the facility has not notified the family of Patient #1's elopement. The complainant reported the police department notified the family of Patient #1's elopement.

The findings were shared with Staff Z on 01/07/21 at 11:02 AM and confirmed..

Based on observation, interview, and documentation review, the facility failed to ensure the construction type of the building was maintained, ensure a hazardous area was adequately enclosed, ensure the spray pattern of sprinklers was not obstructed (A717), ensure areas open to the corridor were provided with smoke detection, ensure smoke barriers provided at least a one-hour fire resistance rating, ensure electrical equipment was properly installed, ensure fire drills were conducted at unexpected times, prohibit space heaters in patient sleeping areas, provide remote annunciator panels at regular work stations. (A709) This has the potential to affect all patients receiving services from the facility. The facility census was 68.

Findings include:

See A709 and A717

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients receiving services from the facility. The facility census was 68.

Findings include:

1. Please see K161 for findings related to the facility failing to maintain the required 1-hour fire-resistant-rating for the Type V(111) building construction type;

2. Please see K321 for findings related to the facility failing to provide a 1-hour fire-rated barrier and 3/4-hour fire-rated doors to include positive latching door hardware and dual-leaf door system coordinating devices;

3. Please see K361 for findings related to the facility failing to provide smoke detectors in spaces not separated from corridors with smoke tight partitions;

4. Please see K372 for findings related to the facility failing to ensure a smoke barrier provided at least a one-hour fire-resistant-rating;

5. Please see K511 for findings related to the facility failing to ensure all electrical equipment was properly installed;

6. Please see K712 for findings related to the facility failing to conduct fire drills at unexpected times;

7. Please see K781 for findings related to the facility failing to prohibit portable space heaters in patient sleeping areas; and

8. Please see K916 for findings related to the facility failing to provide essential electric system remote annunciator panels at regular work stations.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients receiving services from the facility. The facility census was 68.

Findings include:

Please see K351 for findings related to the facility failing to ensure the spray pattern of sprinklers was not obstructed.

Based on observation, policy review and interview, the facility failed to ensure staff followed policies for preventing and controlling the transmission of infections within the hospital for one of one blood glucose check observed on Patient #30. The facility's census was 68.

Findings include:

The facility's Blood Glucose Monitoring policy (#WT 101, Created 01/16/18) stated:
5. All testing shall be performed in accordance with the Standard Precautions for the handling of blood and body fluids.
- Touch the test end of the test strip to the drop of blood and hold until the meter beeps. (The strip automatically draws the blood).
- Wait for the meter to count down. Read the test result and record it.
Remove the test strip and lancet and place them in bio-hazardous waste and needle containers respectively.

Staff E was observed performing a blood glucose check for Patient #30 on 01/07/21 at 7:10 AM. Staff A brought the glucometer kit into Patient #30's room. Staff A retrieved a new lancet from the glucometer kit, used the lancet on Patient #30, then placed the used lancet into the glucometer kit, which contained additional Band-Aids, lancets and alcohol wipes.

The findings were shared with Staff Z on 01/07/21 at 7:20 AM and confirmed.