HospitalInspections.org

Based on observation and interview, the facility failed to ensure that 42 of 42 patients received care in a safe setting:

1. A patient room, undergoing remodeling, located on the Psychiatric Intensive Care Unit (PICU) unit was left unlocked and accessible to patients. It contained multiple hazards.

2. An open unattended waiting room located at the end of the Unit 4 hallway contained a biohazard sharps container that contained used syringes and a box containing multiple new packaged syringes...

Findings include:

1.

Observation on 04-16-12 at 3:10 p.m. during initial tour of the facility revealed room 270 unlocked and accessible to patients on the PICU. Interview with Director of Community Education (Staff ID # 7) at this same time, he stated the room was presently being renovated.

Further observation inside the room several pieces of furniture (chairs, nightstand) located on top of 2 twin-sized beds. The furniture on top of the beds was covered with large pieces of loose clear plastic. In addition, there was a plastic shower curtain located on top of the bed. The bathroom contained bags of powered plaster and other construction supplies stored in large plastic bags.

The time of observation, there were currently 24 patients located on the hallway.

After surveyor intervention, Staff ID # 7 stated he would immediately inform the Maintenance Director to secure the room. In addition, he asked a staff member to stand in attendance outside the door until the room was secured.

Observation on 04-16-2 at 4:00 p.m. revealed the room (270) was locked on the lower half of the door with a dead bolt key-entry lock.

2.

Observation on 04-19-12 at 11:02 a.m, during a tour of the facility with the facility Maintenance Director (Staff ID # 8) revealed an unattended waiting room (204) at the end of the hallway on Unit 4, the geriatric psychiatric unit. The door was open to the room.

Further observation revealed a table inside the room. On top of the table was a red biohazard " sharps container " with several used syringes located in it. In addition, there was a grey plastic box that contained approximately 2o new TB syringes.

The room was observed left unattended for approximately 13 minutes. During this time period, 4 patients were observed walking near by in the hallway.

At the time of observation, the patient census on the geriatric psych unit was 18 patients, all of whom had some degree of cognitive impairment.

Observation on 04-16-12 at 11:15 a.m. the VP of Clinical Services (Staff ID # 2) walked through double-doors near the unattended waiting room. Surveyor showed Staff ID #2 the unattended waiting room. The VP of Clinical Services stated at this time, the biohazard container with contaminated syringes and the new syringes were hazards and should not have been left in the room accessible to patients. She removed the biohazard container and the new syringes at this time.

Based on interview and record review, the facility failed to ensure that all departements were efefctively included in the scope of the Quality Assurance program:

Radiology, laboratory, and dietary (contracted) services were not effectively integrated into the facility ' s established Performance Improvement Plan.

Findings include:

Interview on 04-17-12 at 1:00 p.m with the Administrator (Staff ID # 1), he stated that contracted services included: laboratory, radiology, and dietary.

Review of the facility ' s Performance Improvement meeting minutes for December 201l January, 2012; February 2012; and March 2012 failed to reveal any performance improvement data reported or discussed for laboratory, radiology, and dietary services.

Review of the facility ' s " PI Committee-Department Quarterly PI Reporting Schedule-2011-2012 " (presented and approved at the 07-27-11 PI meeting) failed to reveal inclusion of laboratory, radiology, and dietary services on the reporting grid.

Interview on 04-18-12 at 1:00 p.m. with VP of Clinical Services (Staff ID # 2) she stated incident reports were monitored and analyzed for the contracted services.

Interview on 04-17-12 at 9:55 a.m with Director of PI/ Risk management (Staff ID # 4) she stated she was not aware of any specific QA data reported for radiology or for laboratory.

Interview on 04-19-12 at 10:50 a.m.with the Director of Facilities Maintenance and Safety
(Staff ID # 8), he reported that dietary PI data was reported at Safety Committee and then forwarded to the PI Committee, Medical Executive Committee (MEC) and then to the Governing Board for review. Record review during this interview included the review tool utilized by the dietary department titled " Food Safety Audit. " Review of the Safety Committee minutes for 2011 and 2012 (YTD) revealed the dietary data had been reported to this committee. Review of the PI Committee, MEC, and Governing Board Meeting minutes (20111 and 2012 YTD) failed to reveal this same data had been reported.

Review of PI Committee meeting minutes for 2011 revealed " nutritional consults within 72 hours " were monitored but there was no evidence of PI monitoring for radiology.

Based on interview and record review, the facility failed to ensure that data was consistently utilized to identify opportunities for improvement:

Aggregate data reported to the Performance Improvement (PI) Committee was not consistently analyzed to identify opportunities for improvement.

Findings include:

Review of the PI Committee Minutes for 2011 and 2012 revealed the following issues with analysis and discussion of reported data:

January 4, 2012 Twenty (20) patient falls were reported. There was no discussion or analysis regarding if this negative pattern or trend. If so, no documentation of actions implemented to improve.

March 2012 (meeting held on April 4, 2012): " treatment plans updated to include changes to interventions, medications, and discharge planning " was reported to be at 55 % compliance. There was no documentation of discussion to indicate if this was an acceptable percentage or if any actions were needed for improvement.

July 27, 2011: PI data on restraints was reported as follows: zero (0) episodes of restraints for April 2011; an increase of 12 episodes of restraints reported for May 2011. The meeting minutes failed to reveal a discussion or analysis of the restraint data (causes for increase, units occurred, times of day, etc...) or actions to improve.

Further review of the July 2011 minutes read: " Laboratory: assessment of antidotal evidence that lab orders not being processed. Lack of incident reports and physician referrals have placed the issue on hold. " There was no discussion of establishing a PI measurement indicator /monitor for laboratory services during this meeting or in any of the PI meetings there after,

June 22, 2011: patient falls were reported as follows: March 2011: seven (7) falls occurred; April 2011: fifteen (15) falls occurred; May 2011: eleven (11) falls. There was no discussion in the meeting minutes regarding an analysis of the pattern of falls or actions taken to improve.

Interview on 04-18-12 at 1:00 p.m. with VP of Clinical Services (Staff ID # 2) she stated incident reports were monitored monthly to identify areas that needed improvement.

Review of the facility ' s " Performance Improvement Plan, " revised March 2012, revealed:

" Organization: Governing Body 5.1: " .... ..The Governing Body... has the ultimate responsibility and authority to establish, maintain, and support effective performance improvement program. The Board assures the necessary structures are established and processes are implemented to assess, and continually improve ...quality ... "

" ...5.7. Organization Departments /Services: All departments, services and programs participate in the Performance Improvement program ...data is collected for measurement, and assessment of processes and outcomes. The findings are analyzed to identify significant variances and or opportunities to improve patient care outcomes. "

Based on observation, record review, and interview the facility (facility #A) failed to ensure therapeutic diets were prescribed by a physician on 2 of 10 patients receiving therapeutic diets, ( #'s 24 and 25).

Findings include:

Meal observation on 4/18/12 at 11:30 am in the dinning area located on unit 4 revealed the following:
Patient #24 was served 1800 calories ADA and low sodium diet. This patient's was given salt packet by the food service staff (contract person).
Patient #25 was served regular diet low salt diet. This patient was given salt packet by the food service staff (contract person.

Review of patient #24's medical record -physician order dated 4/14/12 on 4/18/12 revealed he was admitted to the facility on 4/14/12, there was no physician order for 1800 ADA diet. There was a diet order for regular "low na" (no salt).

Review of #25's medical record-physician order dated 4/17/12 on 4/18/12 at 8:30am revealed no diet order for this patient, this patient was admitted on 4/17/12. There was a physician order for "low salt, low fat, low chol diet added" written on 4/18/12, the nurse signed off this order at 10:40am.

Review of "dietary sheet" for unit 4 with staff # 5 on 4/18/12 in the dinning room revealed low na (sodium) 1800 ADA for patient #24 diet and regular low salt diet for patient #25.
Interview with patient #24 during this time (11:40am) revealed "I am given salt all the time" as he was opening the salt packet and sprinkling it on his food. Interview with patient #25 on 4/18/12 in the dinning room at 11:45 am revealed "they give me salt all the time but I throw it away".

Inteerview with facility staff #26 on 4/18/12 at 11:55am in the dinning room revealed "we usually will call out the names of those patients who are on special diets to the dietary staff who serves the meals".

Review of facility policy titled "Dietary Services" dated 11/19/10 on 4/18/12 revealed:

POLICY: "All patients must have a diet ordered by a physician and communicated to the Dietary Department in writing by nursing staff. This is to ensure that all patients are served meals accordance with their diet order". 1. "All diet orders are to be recorded in the patient's Medical Record as prescribed by the physician". 2. "Physician orders modified /therapeutic diet upon admission of patient to the hospital". "Nursing service to communicate the diet order ot the dietary Department.

Interview with staff #23, (RD) on 4/18/12 at 1:30pm in the conference room revealed she comes to the facility three times a week and that the nurses will refer any patient with special nutritional need to her. This staff person confirmed she had not assessed patient #24. Patient #24 was admitted on 4/14/12.

Based on observation, record review and interview the facility (facility #B) failed to ensure (1). patients' nutrional needs are met in accordance with with pysician's oreder, and (2) also receive regular review and update on 6 of 10 patients on therapeutic diets, patients #s 3, 4, 6, 7, 11, and 12.

Findings include:

During lunch observation on 4/20/12 at 12:00pm in the dinning room revealed the following:

All the 42 patients present in the dinning room during lunch were served the regular tray (same portion sizes and same menu). There were no separate meals for either low salt or caloric controlled diets observed. Review of diet list provided by the facility for the 24 patients on " special diets " on 4/20/12 revealed that all the patients listed were either on "NAS diet"-no added salt or "NAS, "NCS"-no added salt/no concentrated sweets. There was no 1800 ADA diet listed for the above patient #s 3, 4, 5, 6, 11, and 12. Patient #4 had no added salt diet on the special diet list, review of this patient physician order-History and Physica (H & P) dated 4/4/12 on 4/20/12 revealed he had order for 1800 ADA and no added salt as well.

Review of physician orders-H & P for patient # 3 dated 2/1/12 on 4/20/12 revealed order for "1800 cal., no added salt" diet. Staff 23 documented on nutrirional assessment dated 3/1/12 revealed "offer double portion".

Review of physician orders-H & P for patient #6 dated 4/2/12 on 4/20/12 revealed order for "1800 cal., no added salt" diet. Staff 23 documented on nutrirional assessment dated 4/19/12 revealed "wt loss is expected if diet is followed".

Review of physician orders-H & P for patient # 7 dated 3/20/12 on 4/20/12 revealed order for "1800 cal. ADA, heart healthy" diet. Staff 23 documented on nutrirional assessment dated 3/29/12 revealed "monitor snacks & frequency, monitor weight".

Review of physician orders-H & P for patient #11 dated 3/20/12 on 4/20/12 revealed order for "1800 cal., heart healthy" diet. Staff 23 documented on nutrirional assessment dated 3/29/12 revealed "average weight gain:".

Review of physician orders-H & P for patient #12 dated 3/20/12 on 4/20/12 revealed order for "1800 cal., heart healthy" diet. Staff 23 documented on nutrirional assessment dated 3/29/12 revealed "wt is expected if diet & exercise is followed".

There was no documentation of staff diet teaching for all the patients mentioned above and no documentation of no concentrated sweets diet in all the patients (3, 4, 6, 7, 11, and 12) nutritional assessment records. Patient #s' 3 , 4, 6, 7, 11, and 12 received the same diets like the patients who were not on special diet.

Review of facility # B policy (no date) titled "FOOD SERVICE" ON 4/20/12 revealed "Nutritional assessments, consultations and special diets must be ordered by the physicians".
"A special diet consultation must be completed and given to the Registered Dietitian".

Interview with facility staff # on 4/20/12 revealed all the meals were prepared by their contracted food service and trays were set up by their staff before delivery, " we give them patient count every morning and we (facility staff) serve the trays to the patients upon delivery here" .

Intakes: TX00156087, TX00156774, TX00159878

Based on observation and interview, the facility's infection control officer failed to to implement polcies that ensured a sanitary environment to prevent the spread of infection:

1. Clean linen was not properly stored.

2. Colostomy bags belonging to a discharged patient were stored in the supply room. The colostomy bags were not in original packaging.

3. Paper bags used to contain dirty laundry were placed directly on the floors of patient rooms.

4. Patient supplies were contained in original shipping boxes in the supply room. Several empty boxes were located on the floor near the supply room.

Findings include:

1.

Observation on 04-19-12 at 11:25 a.m, during a tour of the facility with the Maintenance Director (Staff ID # 8) revealed the facility laundry room located though double-doors at the end of Unit 7.

Interview with Staff ID # 8 at this same time, he reported this area was used as a maintenance work area and equipment storage area. In addition, the contaminated and clean laundry was stored and transported into this area.

The door to the clean linen room was directly open to the maintenance work area. Observation inside the clean linen storage room revealed two (2) large plastic linen transport carts with zippered plastic covers. One (1) of the 2 plastic covers was left unzipped.

Further observation revealed a large cart inside the room that contained two (2) bundles of " clean " blankets and six (6) bundles of " clean " bed pads. This laundry was not covered in plastic or any type of covering. In the corner of the clean linen storage room was a " soiled utility bin " that had 6 (six) bundles of bed pads stored on the top of it. The bed pads were not covered in plastic or any type of covering.

Interview at this same time with the Maintenance Director (Staff ID # 8) he stated the linen contract service person delivered the clean linen and placed it in the clean linen room. The laundry service staff removed the plastic and zipped the plastic covers shut. He went on to say there must have been extra linen and the delivery person set it on the cart and the utility bin.

Interview on 04-19-12 at 3:30 p.m. with VP of Clinical Services (Staff ID # 2) she stated the clean linen cart covers should always be zipped shut. She went on to say that clean linen should not be stored uncovered.

Review of the facility policy titled "Receiving Clean Linen," revised 11-18-2010, read"...The Plant Maintenance / Housekeeping Staff: "1. Reports to the dock to check clean linen for proper handling and covering of carts...2. Transports linen cart to clean linen room. 3. Removes all protective plastic covering before entering the clean linen room...4. Pushes carts into the cleean linen room." The facility clean lienen policy failed to address the storage of extra linen and also keeping the clean linen room door closed when not in use.

2.

Observation on 04-16-12 at 2:50 p.m. during initial tour of the facility revealed a supply room located at the end of the hallway on Unit 7. Further observation inside the supply room revealed a brown paper bag located on a shelving unit. The paper bag had a white label on it with patients name and an admission date of 10-18-11. Inside the bag was a plastic grocery store bag with approximately 25 loose colostomy bags. The bags were not in the original packaging.

Interview at this same time with the VP of Clinical Services (Staff ID # 2) she stated the colostomy bags had been ordered for that patient and then she was discharged.

Additional observation of the supply room on 0-4-19-12 at 11:30 a.m. revealed several issues in the supply room had been corrected. The paper bag of colostomy bags was observed on the top shelf of a supply rack.

3.

Observation on 04-16-12 at 3:10 p.m. during initial tour of the facility revealed paper bags located directly on the floor in several patient several rooms on Unit 4 (Geri-psych unit). There rooms were: 224, 228, and 253.

Interview at the same time of observation with RN Staff (ID # 13) she said the bags were used for dirty laundry. She went on to say the laundry was picked up and washed every day.

Interview on 04-19-12 at 19:50 a.m with the facility Maintenance Director, he stated all of the paper bags had been replaced with small plastic trash cans on 04-16-12 , he went on to say the facility had taken plastic trash cans away because a patient tried to hit another patient with one in the past.

4.

Observation on 04-16-12 at 2:50 p.m. during initial tour of the facility revealed a supply room located at the end of the hallway on Unit 7. Further observation inside the supply room revealed several boxes of supplies that were contained in the original shipping boxes. In addition, 8 empty boxes were located in the hallway outside the supply room; 4 of them directly on the floor.

Based on interview and record review, the facility failed to ensure that all departements were efefctively included in the scope of the Quality Assurance program:

Radiology, laboratory, and dietary (contracted) services were not effectively integrated into the facility ' s established Performance Improvement Plan.

Findings include:

Interview on 04-17-12 at 1:00 p.m with the Administrator (Staff ID # 1), he stated that contracted services included: laboratory, radiology, and dietary.

Review of the facility ' s Performance Improvement meeting minutes for December 201l January, 2012; February 2012; and March 2012 failed to reveal any performance improvement data reported or discussed for laboratory, radiology, and dietary services.

Review of the facility ' s " PI Committee-Department Quarterly PI Reporting Schedule-2011-2012 " (presented and approved at the 07-27-11 PI meeting) failed to reveal inclusion of laboratory, radiology, and dietary services on the reporting grid.

Interview on 04-18-12 at 1:00 p.m. with VP of Clinical Services (Staff ID # 2) she stated incident reports were monitored and analyzed for the contracted services.

Interview on 04-17-12 at 9:55 a.m with Director of PI/ Risk management (Staff ID # 4) she stated she was not aware of any specific QA data reported for radiology or for laboratory.

Interview on 04-19-12 at 10:50 a.m.with the Director of Facilities Maintenance and Safety
(Staff ID # 8), he reported that dietary PI data was reported at Safety Committee and then forwarded to the PI Committee, Medical Executive Committee (MEC) and then to the Governing Board for review. Record review during this interview included the review tool utilized by the dietary department titled " Food Safety Audit. " Review of the Safety Committee minutes for 2011 and 2012 (YTD) revealed the dietary data had been reported to this committee. Review of the PI Committee, MEC, and Governing Board Meeting minutes (20111 and 2012 YTD) failed to reveal this same data had been reported.

Review of PI Committee meeting minutes for 2011 revealed " nutritional consults within 72 hours " were monitored but there was no evidence of PI monitoring for radiology.

Based on interview and record review, the facility failed to ensure that data was consistently utilized to identify opportunities for improvement:

Aggregate data reported to the Performance Improvement (PI) Committee was not consistently analyzed to identify opportunities for improvement.

Findings include:

Review of the PI Committee Minutes for 2011 and 2012 revealed the following issues with analysis and discussion of reported data:

January 4, 2012 Twenty (20) patient falls were reported. There was no discussion or analysis regarding if this negative pattern or trend. If so, no documentation of actions implemented to improve.

March 2012 (meeting held on April 4, 2012): " treatment plans updated to include changes to interventions, medications, and discharge planning " was reported to be at 55 % compliance. There was no documentation of discussion to indicate if this was an acceptable percentage or if any actions were needed for improvement.

July 27, 2011: PI data on restraints was reported as follows: zero (0) episodes of restraints for April 2011; an increase of 12 episodes of restraints reported for May 2011. The meeting minutes failed to reveal a discussion or analysis of the restraint data (causes for increase, units occurred, times of day, etc...) or actions to improve.

Further review of the July 2011 minutes read: " Laboratory: assessment of antidotal evidence that lab orders not being processed. Lack of incident reports and physician referrals have placed the issue on hold. " There was no discussion of establishing a PI measurement indicator /monitor for laboratory services during this meeting or in any of the PI meetings there after,

June 22, 2011: patient falls were reported as follows: March 2011: seven (7) falls occurred; April 2011: fifteen (15) falls occurred; May 2011: eleven (11) falls. There was no discussion in the meeting minutes regarding an analysis of the pattern of falls or actions taken to improve.

Interview on 04-18-12 at 1:00 p.m. with VP of Clinical Services (Staff ID # 2) she stated incident reports were monitored monthly to identify areas that needed improvement.

Review of the facility ' s " Performance Improvement Plan, " revised March 2012, revealed:

" Organization: Governing Body 5.1: " .... ..The Governing Body... has the ultimate responsibility and authority to establish, maintain, and support effective performance improvement program. The Board assures the necessary structures are established and processes are implemented to assess, and continually improve ...quality ... "

" ...5.7. Organization Departments /Services: All departments, services and programs participate in the Performance Improvement program ...data is collected for measurement, and assessment of processes and outcomes. The findings are analyzed to identify significant variances and or opportunities to improve patient care outcomes. "