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Based on observation, interview, record review and policy review, the facility failed to:
- Identify patient safety risk for unattended scissors hanging from a chain.
- Secure the crash cart (mobile cart which contains emergency medical supplies and medications) of one observed.
- Secure the emergency cart (mobile cart which contains emergency medical equipment) of one observed.
- Ensure the quality control monitoring system for seven blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) monitoring systems of 15 observed for expiration dates.
The lack of adequate evaluation and supervision of patient safety needs had the potential to affect all patients at the facility. The facility census was 99.

Findings included:

1. Review of the facility's document titled, "Memo for Unit Safety - Nursing Stations," dated 01/16/19, showed that as part of an ongoing safety risk assessment, nursing was directed to not leave items such as scissors, staplers, or other sharp objects out on counters - keep them put away in drawers and only get them out when in use.

Review of the facility's document titled, "Leadership Rounding," dated 04/27/19, showed that the rounding for high-risk issues, precautions, medication side effects, contraband (items secretly brought into the facility that could be detrimental to the patient's health) cleanliness and maintenance were performed on Unit 5 and 6.

Observation on 04/30/19 at 9:00 AM, of Unit 5 and 6 nurse's station, showed an emergency cart with a pair of scissors hanging from an approximately two foot long chain on the outside of the cart. The nurse's station was accessible to patients and visitors.

During an interview on 05/01/19 at 10:45 AM, Staff L, Director of Nursing (DON), stated that the scissors opened the emergency cart. She was unaware of the safety risk.

2. Review of the facility's policy titled, "Electroconvulsive Therapy (ECT, an alternative treatment, also known as shock therapy, for individuals with major depression not helped by medication therapy or when medication therapy is contraindicated) crash cart dated 04/2012, showed direction for pharmacy to place a new numbered lock (pull-away locks that allows the facility to identify if cart security was breached based on recorded lock numbers) on the cart and record the lock number on the crash cart checklist.

Observation on 04/29/19 at 4:25 PM, in the ECT procedure room, showed that the ECT Crash cart had two large bags of yellow disposable numbered plastic locks in the bottom drawer.

During an interview on 04/29/19 at 4:25 PM, Staff H, Mental Health Technician/Office Manager of ECT, stated that the Registered Nurses (RNs) were responsible for checking the crash cart and securing the cart with the yellow numbered locks.

During an interview on 04/29/19 at 4:25 PM, Staff G, Pharmacy Director, stated that the pharmacy did not keep a master log of the plastic locks and that nurses were responsible for logging the numbered locks. She also stated that the lock numbers were not in any numerical order.

3. Review of the facility's document titled, "Emergency Cart Lock, Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary), Check and Oxygen Checklist," showed that the locks used to secure the integrity of the emergency cart were documented on the checklist, and were random numbers in no numerical order.

Observation on 04/30/19 at 9:00 AM, of Unit 5 and 6 Nurse's station, showed one large bag of red plastic locks in the bottom drawer of the emergency cart. The emergency cart was located in an unsecured nurse's station.

During an interview on 04/30/19 at 9:10 AM, Staff J, House Supervisor, stated that the facility had no process for the plastic locks.

During an interview on 05/01/19 at 10:45 AM, Staff L, DON, stated that she was unaware the plastic locks were not appropriately logged.

The unauthorized access into both the crash cart and the emergency cart was a safety concern for all of the patients and staff who could retrieve sharp objects, scissors, ligature items or medications. The mental health units had patients with histories of attempted suicide (to cause one's own death), homicidal thoughts (thoughts or attempts to cause another's death) and depression.

4. Review of the facility's policy titled, "Use of the Blood Glucose Monitoring System (quality controls)," showed:
- The control solutions confirm the meter and test strips are working together properly.
- The control solutions are provided to check the system.
- The control solutions have three levels of testing (Level 1, Level 2 and Level 3).
- The purpose of the control solutions check is to validate quality and performance.
- The control solutions must be marked with the date to be discarded and is to be discarded after three months of opening.
- Do not use the control solution if the expiration date printed on the bottle label has passed or it has been three months since first opening the bottle.

Observations made on 04/30/19 and 05/01/19 between 9:00 AM and 12:00 PM showed the following control solutions:
- Unit 5 and 6 emergency cart, one Level 2 solution and one Level 3 solution opened with an expiration date of 04/14/19.
- Unit 5 and 6 medication room, one Level 1 solution and one Level 3 solution both opened with no date.
- Unit 4 medication room, one Level 1 solution, Level 2 solution and Level 3 solution opened with no dates.

During an interview on 05/01/19 at 10:45 AM, Staff L, DON, stated that the night shift nurses were to check for expired solutions and was unaware these weren't being checked.

Based on observation, interview and policy review, the facility failed to ensure that staff documented the open date on two open multi-dose insulin (medication that regulates the amount of sugar in the blood) vials, of eight open insulin vials observed. These failures had the potential to damage the quality and integrity of the medication, and could be life-threatening for all patients who required insulin. The facility census was 99.

Findings included:

1. Review of the facility's policy titled, "Multi-Dose Injectables and Liquids," dated 06/01/16, showed that multi-dose vials of medication, must be dated, timed and initialed upon opening to maintain the product integrity.

Observation on 04/30/19 at 10:00 AM, on the Acute Adult Unit, showed one opened, used and undated Lantus (long acting blood-glucose-lowering medication) multi-dose insulin vial in the medication refrigerator.

Observation on 04/30/19 at 10:13 AM, on the Detox Unit, showed one opened, used and undated Humalog (a rapid-acting blood-glucose-lowering medication) multi-dose insulin vial in the medication refrigerator.

During an interview on 05/01/19 at 10:45 AM, Staff L, DON, stated that she expected all of the nurses to label the multi-dose insulin vials with a date when it was opened.