HospitalInspections.org

Based on record review and interview the facility failed to measure, analyze and update quality data in 1 of 5 (Dietary) direct and indirect patient care areas. This deficiency has the potential to affect all patients receiving care at this facility.

Findings include:

Per review on 7/30/14 at 10:30 AM of facility policy titled "Quality Assurance and Performance Improvement Plan" dated 2/1/10 it states " The Acute Psychiatric Hospital Quality Assurance and Performance Improvement Plan is a collaborative effort that applies to all departments, services and individuals whose activities within the Acute unit have either a direct or indirect influence on patient care." It also states under goals of the Quality program "Focus studies on high risk, high volume and problem prone areas, correct deficiencies and ensure quality care to all patients....to measure the success of implemented changes and track performance to ensure that it is maintained. Re-assess the program effectiveness annually."


20878


Per interview with Food Service Director E on 07/28/14 at 2:30 PM no data is collected for the hospital, instead data from the nursing home (attached to the hospital) is submitted as hospital data.

Per interview with DON/QA director A on 07/28/14 at 3:00 PM each department is responsible for devising their own quality initiatives with little direction from the QA director or committee.

Based on observation, record review and interview, the hospital failed to ensure the physical plant provides a safe environment for all patients, staff and visitors. This has the potential to affect all inpatients.

Findings include:
The hospital failed to maintain a safe environment as described in the following life safety deficiencies. See Ktags for details.
K-011, Separation walls
K-022, Exit sign
K-029, Hazardous spaces
K-038, Egress pathway
K-052, Fire alarm system monitoring
K-056, Sprinkler system installation
K-062, Sprinkler system maintenance
K-074, Cubicle curtains
K-147, Electrical wiring

Based on observation, record review and interview, the hospital failed to ensure the physical plant provides a safe environment for all patients, staff and visitors. This has the potential to affect all inpatients.

Findings include:
The hospital failed to maintain a safe environment as described in the following life safety deficiencies. See Ktags for details.
K-011, Separation walls
K-022, Exit sign
K-029, Hazardous spaces
K-038, Egress pathway
K-052, Fire alarm system monitoring
K-056, Sprinkler system installation
K-062, Sprinkler system maintenance
K-074, Cubicle curtains
K-147, Electrical wiring

Based on observation , record review and interview, this facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection in 4 of 7(clean linen room, soiled linen room, group room, medication room) areas observed. This deficiency potentially affects all 13 patients currently admitted during this survey.

Findings include:

Per review on 7/29/14 at 12:45 PM, of facilities policy titled "Patient Personal Laundry" dated 8/1/11, it states "patients are expected to wear clean clothes. Laundry facilities are provided within the building for that purpose. Patient personal clothing is washed every night after 11:00 PM by unit staff."

Per CDC guidelines for Environmental Infection Control in Health Care Facilities "all washing machines and dryers in a health care setting must be properly maintained according to the manufactures instructions..... proper laundry procedures are followed; these procedures involve a) a physical removal of bulk solids (e.g. feces) before the wash/dry cycle and b) proper use of temperature, detergent and laundry additives."

On 7/29/14 at 8:30 AM noted washer and dryer in the utility room on the acute unit. Per interview with DON A on 7/30/14 at 10:00 AM, staff wash the patients personal clothing on the unit. They do not wash each patients clothing separate. They do not monitor water or drying temperatures and they do not use commercial grade detergents. Per DON A, the infection control committee has not been involved in the approval of the detergents used.

Per interview on 7/30/14 at 10:00 AM, DON A stated, this facility uses CDC guidelines.


20878


Observations were made during a tour of the acute care unit with Deputy Director B on 07/28/14 at 10:00 AM.

- In the soiled linen room it was observed that vases and a laundry basket containing a blanket were stored under the sink.

-In the clean linen room clean towels were stored, uncovered, on shelves.

-In the "group room" (#8), magazines, slide carousels, a basketball, and a water pitcher were stored in a cabinet under the sink.

- In the medication room cigarettes were stored in a cabinet under a sink by the refrigerator.

During interview with DON A on 7/29/14 at 10:15 AM, DON A stated patient care items should not be stored under sinks and the facility does not currently have a policy that speaks to under sink storage.