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Based on observation, record review, and interview, the hospital failed to establish a process for prompt resolution of patient grievances and failed to inform each patient of whom to contact to file a grievance as evidenced by failing to include a provision in the hospital policy for providing the patient or patient representative with the phone number and address for lodging a grievance with the State agency (that has licensure responsibility) and failing to inform the patient that he/she may lodge a grievance with the State agency regardless of whether he/she has first used the hospital's grievance process.

Findings:

Review of the hospital's policy titled, Client/Consumer Complaint and Grievance Policy and Procedure, number CP-16, provided by S3QAD as current policy, revealed the following: J. If the concerns cannot be resolved through this hospital, the individual is to be encouraged to contact the Joint Commission by calling or emailing (numbers and email address included).
There was no documented evidence in the policy of a provision that the patient could lodge a grievance with the State agency (Health Standards Section), and there was no phone number or address of the State agency included in the policy. Further review of the policy revealed no documented evidence of a provision that the patient could lodge a grievance with the State agency regardless of whether the patient had first used the hospital's grievance process.


Review of the Patient Family Handbook that was provided to patients/families at admission to the hospital revealed the procedure for patients/consumers was included in the handbook. Review of the procedure revealed no documented evidence of the State agency contact number or address for the patient/family to lodge a grievance. There was no documented evidence of a provision that indicated the the patient could lodge a grievance with the State agency regardless of whether the patient had first used the hospital's grievance process.


On 12/15/15 at 10:15 a.m., an observation was made of the posted patient rights and patient complaint procedure in Unit 7B with S14RNM. There was no documented evidence that the complaint procedure included the State agency telephone number and address and the procedure did not include a provision that the patient could lodge a grievance with the State agency regardless of whether the patient had first used the hospital's grievance process. S14RNM confirmed the State agency contact information was not included in the posted complaint procedure or posted patient rights.


On 12/15/15 at 11:45 a.m., an observation was made of the posted patient rights and patient complaint procedure in Unit 7C with S14RNM. There was no documented evidence that the complaint procedure included the State agency telephone number and address and the procedure did not include a provision that the patient could lodge a grievance with the State agency regardless of whether the patient had first used the hospital's grievance process. S14RNM confirmed the State agency contact information was not included in the posted complaint procedure or posted patient rights.


In an interview on 12/16/15 at 9:30 a.m., S3QAD reviewed the hospital policy and Patient Family Handbook and confirmed there were no provisions in either document for the patient/family to lodge a grievance with the State agency. S3QAD confirmed the telephone number and address of the State agency (Health Standards Section) responsible for licensure was not included in the policy or the handbook given to patients or families. She confirmed there was no provision in the policy/procedure that indicated the patient/family could lodge a grievance with the State agency regardless of whether the patient had first used the hospital's grievance process. S3QAD stated she was not aware that the hospital was required to inform patients of the State agency contact information.

Based on record review and interview, the hospital failed to ensure the grievance process specified time frames for review of the grievance and the provision of a response to the patient/family. Findings:

Review of the hospital's policy titled, Client/Consumer Complaint and Grievance Policy and Procedure, number CP-16, provided by S3QAD as current policy, revealed no provisions for a written response to the patient and there was no provision for the time frame of a response to the patient. Further review of the policy revealed the only time frame identified in the policy was 3 days for resolution and investigation of the patient's grievance.

In an interview on 12/16/15 at 9:10 a.m., S6CRO confirmed she was responsible for patient grievances. S6CRO confirmed the hospital's policy did not have a provision for a written response to the patient's grievance and the policy did not include a time frame for a written response. S6CRO stated sometimes they send a letter to the complainant, but not always.

In an interview on 12/16/15 at 9:20 a.m., S3QAD confirmed the hospital's policy for patient grievances did not include a time frame for a response to the patient.

Based on record review and interview, the hosptial failed to ensure a written notice of the hospital's response to the patient's grievance was provided to the patient for 3 of 3 (#7, #13, #R1) patient grievances reviewed. Findings:

Review of the hospital's policy titled, Client/Consumer Complaint and Grievance Policy and Procedure, number CP-16, provided by S3QAD as current policy, revealed no provisions for a written response to the patient and there was no provision for the time frame of a response to the patient.

Patient #7
Review of the hospital's Tracking Complaint/Requests log dated July 2015 - present revealed on 09/07/15 the sister of Patient #7 reported to the RN that the PA was very rude and mean to her and her brother. Review of the related documents and the the log revealed an investigation was conducted and staff written statements were obtained. There was no documented evidence of a written response to the patient or the patient's sister. Further review of the log revealed the grievance was not resolved until 09/21/15, 14 days after the grievance was reported.


Patient #13
Review of the hospital's Tracking Complaint/Requests log dated July 2015 - present revealed on 08/06/15 Patient #13 filed a written complaint regarding one RN for the fourth time gave the patient the wrong medication dose. Review of the Patient-Consumer Complaint form and the log revealed an investigation was conducted and the RN was counseled related to the patient's grievance. There was no documented evidence of a written response to the patient. Further review of the log revealed the grievance was not resolved until 09/22/15, 47 days after the grievance was filed.


Patient #R1
Review of the hospital's Tracking Complaint/Requests log dated July 2015 - present revealed on 08/01/15 Patient #R1 filed a written complaint regarding being kept out of his room on weekends to get him to go to the cafeteria. Review of the Patient-Consumer Complaint form and the log revealed an investigation was conducted and a new process implemented related to the patient's grievance. There was no documented evidence of a written response to the patient. Further review of the log revealed the grievance was not resolved until 08/28/15, 27 days after the grievance was filed.


In an interview on 12/16/15 at 9:30 a.m., S6CRO confirmed the above patient grievances did not have written responses sent to the patient. S6CRO stated she did a verbal resolution with Patient #R1, but there was no letter sent. S6CRO confirmed she was not aware a written response to the patient was required.

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks/points and safety hazards.
Findings:
On 12/14/15 from 12:10 p.m. through 1:30 p.m., the following observations were made with
S5QAM (Quality Assurance Manager) and S7Nurse Manager on Unit17 (female). There were 8 bedrooms (4 beds/room) and 2 community bathrooms (3 shower stalls, 3 sinks & 3 toilets).
The following ligature risk and safety risk were noted:
All of the doors were noted to have round door knobs that could facilitate a ligature risk. All doors were noted to have door hinges set apart widely enough to allow for potential ligature risks. Screws on door handles and door hinges were not of the non-tamper type. In the patient bathrooms, (located on Hall "A"), the toilets were observed the have water pipes and turn off handles exposed on one side of the toilet. Observations in room 116 revealed a pair of shoes with the shoe strings in them.
In an interview on 12/14/15 at 1:30 p.m., S5QAM & S7Nurse Manager confirmed the findings.
On 12/14/15 from 4:00 p.m. through 5:15 p.m., the following observations were made with S5QAM (Quality Assurance Manager), S7Nurse Manager, and S9PAS (Psychiatric Aide Supervisor) of Unit 11 (female). There were 8 bedrooms (4 beds/room & 1 room with 2 beds) and 2 community bathrooms (3 shower stalls, 3 sinks & 3 toilets).
The following ligature risk and safety risk were noted:
All of the doors were noted to have round door knobs that could facilitate a ligature risk. All doors were noted to have door hinges set apart widely enough to allow for potential ligature risks. Screws on door handles and door hinges were not of the non-tamper type. Eleven of the 32 beds on the unit were noted to have metal slatted frames with removable springs. Observations in room 116 revealed a pair of tennis shoes with long shoe laces on the open shelf in the room.
The above findings were confirmed by S5QAM, S7NurseManager, and S9PAS (Psychiatric Aide Supervisor).

On 12/15/15 from 10:10 a.m. through 12:00 p.m., the following observations were made with S14RNM of Unit 7B (male):

The patient restroom located in the hallway adjacent to the nutrition room was observed to have a round door knob and flanged type handles on the sink that could be used as possible ligature points. S14RNM stated if patients are 1:1, the staff stands at the door with the door open. S14RNM confirmed patients not on 1:1 precautions could close the door.

The day room was observed to have an open barrel for trash with a plastic liner noted in the barrel.

The nutrition room (next to the day room where patients were observed to walk in and out of the day room) was observed to be unlocked. 3 large metal tongs were observed in one of the unlocked drawers, a plastic trash can liner was observed in a large barrel type trash can, and a broom type handle was observed in the corner. S14RNM confirmed the observations and stated the door to the nutrition room should be locked.

The "Sensory Room" was observed to have 3 electrical cords plugged into non-GFI outlets. A total of 4 non-GFI outlets were observed in the room. S14RNM confirmed the observations, but stated she did not know if the outlets were GFI. She confirmed there was no reset button on the outlets. S14RNM stated the room was used by patients to allow for a quiet calming place for the patient. She confirmed staff do not have to be in the room with the patient.

Observation of patient rooms 112, 115, 116, 117, 118, and 119 all of the doors were noted to have round door knobs that could facilitate a ligature risk. All doors were noted to have door hinges set apart widely enough to allow for potential ligature risks. Screws on door handles and door hinges were not of the non-tamper type. Observation of room 112 revealed an uncovered electrical outlet on the right side of the room that was not GFI. At 10:40 a.m. S10Maintenance arrived and confirmed the electrical outlet was not GFI and should not be uncovered in the patient room. Further observation of these rooms revealed unlocked wooden cabinets with open handles and cabinet hinges that presented potential ligature points. The cabinet in room 117 had a metal rod bolted inside the cabinet that presented potential ligature point. Observation of the rooms revealed 4 platform type beds in each room. The air conditioner units in rooms 115, 116, 117, 118, 119, and 120 had a padlock on front panel that presented a ligature risk. The above observations were confirmed by S14RNM.

Further observation of the patient rooms revealed the following hazards: the arm of a pair of glasses was found in the cabinet in room 119, strings in pants and jacket in room 117. S14RNM removed the glasses arm and stated patients were allowed to have strings in their clothing and shoes. She stated shoestrings and clothing strings were removed if the patient was on 1:1 precautions.
Observation of the common bathroom on Unit 7B with S14RNM revealed the following ligature points and safety hazards:
All 3 sinks were observed to have a faucet extending over the sink and 2 flanged handles that could be used as ligature points.
The walls around the toilet to the left of the sinks was observed to have hinges set apart widely enough to provide a potential ligature point.
The locked cabinet that contained the water control valves was observed to have a piece of metal extending upward from the hinge approximately 3-4 inches. The metal piece was observed to have a sharp edge.
The bench adjacent to the tub was observed to be attached to the wall with space between the brackets that could provide a low ligature point.
The above observations were confirmed by S14RNM. S14RNM confirmed patients are allowed to use the bathroom without staff present, but staff was present when patients showered. S14RNM reported environmental Suicide Risk rounds were done 4 times an hour. S15RNS was also present for the observations in the bathroom and confirmed a patient could harm themselves in less than 15 minutes.

On 12/15/15 from 12:05 p.m. to 12:30 p.m. the following observations were made with S14RNM of Unit 7C (male):
The patient restroom located in the hallway adjacent to the nutrition room was observed to have a round door know and flanged type handles on the sink that could be used as possible ligature points. S14RNM confirmed the observations.

Further observation of the patient rooms revealed the following hazards: Strings in pants were found in room 119. Shoes with shoe strings were found in rooms 114, 115, and 117. S14RNM confirmed the observations of clothing and shoe strings in the patients' rooms and stated shoestrings and clothing strings were removed if the patient was on 1:1 precautions.
Observation of the common bathroom on Unit 7C with S14RNM revealed the following ligature points and safety hazards:
All 3 sinks were observed to have a faucet extending over the sink and 2 flanged handles that could be used as ligature points.
The walls around all 6 toilet stalls were observed to have hinges set apart widely enough to provide a potential ligature point.
3 out of 4 shower stalls were observed to have 1 round knob that could be used as a ligature point.
The bench adjacent to the tub was observed to be attached to the wall with space between the boards of the seat that could provide a low ligature point.
The above observations were confirmed by S14RNM. S14RNM confirmed patients are allowed to use the bathroom without the staff present, but staff was present when patients showered.





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Based on record review and interview, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program included an ongoing program that shows measurable improvement in indicators that improve health outcomes as evidenced by failing to have the frequency and detail of data collection specified by the hospital's governing body.

Findings:

Review of the hospital "Performance Improvement Plan" for fiscal year 2015-2016 and presented as the current plan by S3QAD revealed the following: The hospital will systematically aggregate and analyze data in such a way that current performance levels, patterns, and/or trends can be identified.
The hospital compiles data in usable formats and the hospital identifies the frequency for data analysis. Further review of the plan revealed the hospital collects data on behavior management and treatment.

Review of the Quality Improvement Meeting minutes dated 12/03/14, 01/28/15 and 11/05/15 revealed data was collected and reported for Behavioral Interventions for the previous quarters and a percentage of documentation compliance was indicated.

Review of the data collected for the hospital's performance improvement project for treatment plans revealed the monitoring of the indicators would be done randomly on a weekly basis. The project also revealed a compliance goal of 96%.

In an interview on 12/16/15 at 10:50 a.m., S3QAD was asked to provide the methodology for the above 2 quality indicators. S3QAD was unable to provide documentation of the methodology for the data collection for the monitoring of the the behavioral interventions.
At 11:45 a.m. S3QAD contacted S18PI Coordinator by telephone. S18PI Coordinator indicated the scope and frequency of data collection was indicated on the data collected and was, "Random weekly chart audits." S18PI Coordinator confirmed there was no specific number of chart audits identified and there was no explanation of how the compliance percentage would be calculated.

In an interview on 12/16/15 at 12:30 p.m., S5QAM stated the psychologist did the audit for the behavioral interventions. She 100% of the behavior plans were reviewed by S20Psychologist. S5QAM confirmed she was unable to provide documentation of the methodology for the data collection including how the percentage of compliance was calculated.

In a telephone interview on 12/16/15 at 12:35 p.m. S19 Psychologist confirmed she did the chart audits for the behavioral plans. She stated the percentage indicated on the data was an average of the incomplete documentation of the behavior plan interventions and not an indication of compliance with all the indicators.

In an interview on 12/16/15 at 1:00 p.m. S3QAD confirmed they did not have documentation of the methodology for these indicators that included the frequency and detail of the data collection.

Based on observation, record review and interviews, the hospital failed to ensure confidentiality of patient information and protection of medical records from loss and/or destruction.

Findings:

Observation of a room located on Unit 17 at 1:00 p.m. revealed a locked room with medical records on the desk (5), locked filing cabinets (2) and 2 laboratory chairs. Laboratory items (vacutainers & syringes packages, and 2x2s) used for vein puncture was noted in the trash can.

In an interview on 12/14/15 at 1:40 p.m., S7Nurse Manager indicated that the room was a storage room for overflow (thinned) medical records (current patients). She confirmed that the items were used for vein puncture and that staff was using the room as a laboratory and patients who had lab work would enter the room. She indicated that the facility has an assigned room (V/S) for laboratory performance on each unit. She indicated that due to the large amount of content in the medical records, it is difficult for storage of the medical records in the locked file cabinets. She indicated that medical records stored in the room was accessible to patients and the patients' Health Information was not protected against unauthorized access by patients.

Review of the Hospital's Policy #24.1 titled "Administrative, Technical, and Physical Safeguards" presented by S11HIM (Health Information Manager) as being current read in part: DHH (Department of Health & Hospitals) must take reasonable steps to safeguard information from any intentional or unintentional use or disclosure ......... Each DHH workplace will store files and documents containing confidential information in locked rooms or storage systems when available.


In an interview on 12/16/15 at 11:00 a.m., S2COO (Chief Operating Officer) indicated that laboratory procedures should not be performed in the medical records storage room.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) Failing to ensure the glucometer was cleaned per manufacturers recommendations for 2 of 2 blood glucose fingersticks observed;

2) Failing to ensure Biohazard containers were stored separate from the patient's laundry room;

3) Failing to maintain a sanitary physical environment, and;

4) Failing to ensure furniture and patient bedding's were maintained in good condition.

Findings:

1) Failing to ensure the glucometer was cleaned per manufacturers recommendations for 2 of 2 blood glucose fingersticks observed:

Review of the hospital policy for cleaning glucometers after use on patients revealed to follow the manufactures recommendations for cleaning the glucometer. Review of the manufacturers recommendations for the glucometer revealed that a commercially available EPA-registered disinfectant detergent or germicide wipe was to be used to clean and disinfect the glucometer.

On 12/15/15 at 11:05 a.m., observation revealed S13LPN performed a fingerstick blood glucose check using the glucometer on patient #R4. Further observations at that time revealed that S13LPN wiped the glucometer with a 70% isopropyl alcohol swab after using it. Interview with S13LPN at that time revealed that the glucometer was clean and ready to be used on the next patient.

On 12/16/15 at 11:20 a.m., observation revealed S12RN performed a fingerstick blood sugar check using the glucometer on patient #R5. Further observations at that time revealed that after using the glucometer on the patient, S12RN did not clean and disinfect the glucometer. S12RN was observed to place the unclean glucometer back into the plastic box that contained clean blood glucose testing supplies. S5QA Manager was present during the above observation. On 12/16/15 at 11:35 a.m., interview with S5QA Manager confirmed that S12RN did not clean the glucometer after using it on the patient and placed it back in storage with clean supplies.

On 12/16/15 at 2:00 p.m., interview with S3QA Director confirmed that staff should be cleaning and disinfecting the glucometer with Caviwipes after use on each patient. S3QA Director further revealed that Caviwipes are recommended by the manufacturer of the glucometer for cleaning.


2) Failing to ensure Biohazard containers were stored separate from the patient's laundry room:

During an observation of Unit 7C with S14RNM on 12/15/15 at 12:05 p.m., an observation was made of the patients' laundry room. The door to the room was observed to have a red/orange biohazardous sign affixed to the door. Upon entering the room a plastic barrel with a red garbage bag was observed in the room next to the washing machine. S12RNM confirmed the biohazardous waste was stored in this container in this room where the washing machines and clothes dryers were located. S14RNM confirmed the biohazardous waste should not be stored where patients clothes were laundered, dried, folded and stored until taken to their rooms. S14RNM also confirmed the biohazardous waste on Unit 7B was also stored in the patients' laundry room.


3) Failing to maintain a sanitary physical environment:

Observations on 12/14/15 at 12:20 p.m. of Unit 17 revealed:
Day room/Activity room, hallway, showers, and floors were noted to be visibly soiled floors The tables located in the Day/Activity rooms were noted to have food particles on the top on them.
The windows/screen (13) (outer) in the Day/Activity rooms were noted to have heavy amount of dirt, spider webs and thick layer of mud splatter on them, making visibility poor. The curtains were noted to have spider webs along the top edges and in the corner of the windows.
The Day/Activity Room was noted to have a sign which stated "Caution Possible Flooding!!! Do Not Open This Door!!. A floor mat (5 ft. x 3 ft.) located in front of the door was noted to have caked on dark particles and a build-up of dirt & grime. There was an approximately 1-2 inches of opening at the bottom of the door. There were approximately 13 sand bags outside the door, located approximately 6 feet from the door.
The water fountains (2) were noted to have red residue caked around the drinking sprout and base with red dusty powder on the top of the units.
The in-flow and out-flow vents (air conditioners/heater) on were noted to have a large amount of visible build-up of grayish matter. The sprinkler units located throughout the units were noted to have a large amount of visible build-up of grayish matter.
The laundry room was noted to have large amount of dust/lint behind the washer (2) and dryers (2).

Observations on 12/14/15 at 4:15 p.m. of Unit 11 revealed:
Day room/Activity room, hallway, showers, and floors were noted to have visibly soiled floors.
The in-flow and out-flow vents (air conditioners/heater) on were noted to have a large amount of visible build-up of grayish matter. The sprinkler units located throughout the units were noted to have a large amount of visible build-up of grayish matter.
The shower mats were noted to have water underneath them and the shower stalls were dry. The faucet on the tub "Hall A" was noted to be leaking with water seeping around the tub, causing a wet area around the tub (area rusty and wet) dripping around the tub and onto the floor.
All of the above findings were confirmed by S5QAM and S7NurseManager at the time the observations were made.

On 12/15/15 at 11:45 a.m., an observation was made of the Exam/Treatment room on Unit 7C with S14RNM. A large accumulation of dust was noted on top of the window unit air condition. A large accumulation of dust, debris, and brown substance was observed on the floor under the air condition unit. Also observed in the room were 2 wheelchairs, a patient scale, a lab chair, and a rolling blood pressure machine. S14RNM confirmed the dust and debris was present on top of, and on the floor below, the air condition window unit. S14RNM confirmed the room contained patient care equipment and the room was used for patient examinations or treatments.

4) Failing to ensure furniture and patient bedding were in good condition
Observations of Unit 17 on 12/14/15 at 12:20 p.m. revealed two chairs located in the day/activity room was noted to have multiple tears on the seat cushions.
Observations on Unit 11 on 12/14/15 at 4:15 p.m. revealed one comforter on a patient's bed was noted to have a large tear along the seam with the white fiber stuffing exposed.
The above findings were confirmed at the time of the observations by S5QAM and S7NurseManager.
The knobs (temperature selection) on the dryers (2) in the laundry room were noted to be missing.
In an interview on 12/15/15 at 5:00 p.m., S9PAS(Psychiatric Aide Supervisor) indicated that the knobs had been broken for a couple of months and they were on order. She indicated with the knobs missing there was no way to indicate the heating setting. She indicated the knobs were on order and she was not certain when they would arrive.
In an interview on 12/16/15 at 11:00 a.m., S2COO(Chief Operating Officer) indicated she was not aware of the housekeeping issues on the units and work orders should have been placed for any repairs needed. She indicated that housekeepers are assigned to each units and the patients are responsible for some of the housekeeping.

On 12/15/15 at 10:30 a.m. an observation was made of a chair positioned in the hallway outside the medication room on Unit 7B with S14RNM. The vinyl covering of the seat of the chair was observed to be ripped/torn with the fabric stuffing exposed. S14RNM confirmed the vinyl covering of the chair was ripped/torn and the surface of the chair could not be properly disinfected.

On 12/15/15 at 11:45 a.m. an observation was made in the Day Area of Unit 7C with S14RNM. One chair was observed to have vinyl covering that was split/cracked in multiple areas of the chair with the underlying fabric exposed. Also observed in the same room was a 3 seat sofa with 2 large slits in the plastic covering on the seat of the sofa. S14RNM confirmed the observations and the chair/sofa could not be properly disinfected with the openings in the vinyl/plastic coverings of both the chair and the sofa.


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