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Based on interview and record review the facility failed to ensure unit 500 (a locked secure unit patients found to be incompetent to stand trial) had completed contraband searches. This failure had the potential to endanger and physically harm patients and staff on the unit.

Findings:

During a concurrent interview and record review on 7/16/24 at 3:00 p.m. with Director of Quality (DOQ), the facility's "Contraband Search Results (CSR), for unit 500 "dated 7/2/24 and 7/6/24 at 5:30 p.m., and dated 7/10/24 at 5:00 a.m. were reviewed. DOQ stated staff should be completing a contraband search each shift and documenting.

During a concurrent interview and record review on 7/16/24 at 3:08 p.m. with Registered Nurse (RN) 2, facility's CSR, dated 7/2/24, 7/6/24 and 7/10/24 was reviewed. The CSR indicated there were no contraband searches on: 7/2/24 no shift times, 7/6/24 no am night shift documentation, and 7/10/24 no day shift documentation. RN 2 confirmed the missing dates of documentation. RN 2 stated no staff had checked the unit for contraband on the dates reviewed.

During a concurrent interview and record review on 7/16/24 at 3:24 p.m. with RN 1, facility's CSR dated 7/2/24, 7/6/24, and 7/10/24 was reviewed. The CSR indicated there was no completed contraband searches on: 7/2/24 no shift times, 7/6/24 no am night shift documentation, and 7/10/24 no day shift documentation. RN 1 stated the normal process is to do a contraband check every shift. RN 1 stated she could not explain the missing documentation on contraband dates.

During an interview on 7/16/24 at 3:55 p.m. with Chief Nursing Officer (CNO), CNO stated the process for contraband search for every shift was not followed.

During a review of the facility policy and procedure (P&P) titled, "Contraband and Restricted Articles," dated
7/27/22, the P&P indicated, "to ensure a safe environment. To provide a monitoring system for patients who are utilizing sharps or items designated as contraband."

During a review of "2024 Nursing Clinical Indicators (NCI)," dated 2024, the NCI indicated, "Compliance with Contraband Checks, Completed daily/shift."

Based on interview and record review, the facility failed to develop and evaluate a comprehensive care plan for two of 30 sampled patients (Patient 16 and Patient 25). This failure had the potential for unmet patients care needs.

Findings:

During a concurrent interview and record review on 7/16/24 at 1:20 p.m. with Chief Nursing Officer (CNO), the "Master Treatment Plan (MTP)," for Patient 19 dated 7/8/24 was reviewed. Patient 19 was in a manual hold (seclusion) on 7/11/24. The MTP for Patient 19 indicated, a treatment plan dated 7/15/24. CNO stated that MTP should've been reviewed within 24 hours.

During a concurrent interview and record review on 7/16/24 at 2:05 p.m. with CNO, the "MTP," for Patient 25 dated 7/5/24 was reviewed. The chart indicated, Patient 25 was in seclusion on 7/11/24. The MTP was not updated for seclusion. CNO stated that MTP should've been reviewed within 24 hours and documented.

During the review of the facility's policy and procedure (P&P) titled "Multidisciplinary Treatment Planning" dated 3/25/2022, the P&P indicated, "To provide a process and guidelines for implementation of a comprehensive, individualized multidisciplinary treatment plan for every patient. . .The plan shall be revised as soon as possible, but no later than 24 hours, following any major event such as a physical hold, suicide gesture or attempt or any clinical change in the patient's presentation/status."

Based on interview and record review, the facility failed to ensure verbal order were signed by the physician with date and time according to the facility's policy and procedure for one of 30 sampled patients (Patient 30). This failure had the potential for miscommunication that could result in errors and in unmet care needs.

Findings:

During a concurrent interview and record review on 7/16/24 at 3:20 p.m. with Chief Nursing Officer (CNO), Patient 30's "Restraint/Seclusion orders for Violent Behavior (RS)," dated 7/9/24, was reviewed. The RS indicated, "Restraint Manual Hold 2 hours children ages 9-17." The nurse obtained the order by telephone and the order was not signed by the physician. CNO stated the physician did not sign the order.

During a review of the facility's policy and procedure (P&P) titled, "Verbal Orders," dated 10/28/2022, the P&P indicated, "Verbal/telephone orders must be co-signed/verified by a practitioner who is responsible for the care of the patient and is authorized to prescribe in accordance with state law and hospital policy. Verbal orders must be authenticated within the time-frame defined in the medical staff rules and regulations and as required by state law and regulations. (e.g. within 24 hours)."

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.41 Physical Environment as evidenced by:

1. Based on observation, interview, and record review, the facility failed to maintain 1 of 3 portable air units (on unit 400) in proper working condition. (Refer to A 701, item 1).

2. Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature for patient rooms when the temperatures reached higher then acceptable ranges.
(Refer to A 701, item 2).

These failures resulted in placing patients at risk for heat related illnesses and mental distress.

3. Based on observation, interview, and record review, the facility failed to maintain a safe environment for two of seven units (unit 200 and unit 600) in the facility when walls had cracked and missing wall boards and loose ceiling tiles. This failure resulted in placing patients at risk for injury to self and others. (Refer to A 722).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure quality health care in a safe and comfortable physical environment, in compliance with Conditions of Participation for Physical Environment.

Based on observation, interview, and record review, the facility failed to:

1. Maintain 1 of 3 portable air units (on unit 400) in proper working condition.

2. Maintain a safe and comfortable temperature for patient rooms when the temperatures reached higher then acceptable ranges.

These failures resulted in placing patients at risk for heat related illnesses and mental distress.

Findings:

1. During a concurrent observation and interview on 7/12/24 at 11:59 a.m. with Director of Quality (DOQ) in unit 400, portable air unit Air Rex Model # AHSE 14 temperature read "80.4 Fahrenheit (F) EK" on display screen. The unit was blowing warm air. DOQ stated water needs to be removed from the unit and then it will run cool air. DOQ stated no one dumped the water from the machine.

During a concurrent observation and interview on 7/12/24 at 5:07 p.m. with Director of Plant Operation (DPO) on unit 400 was outside room 409, the portable air unit was off, no air blowing from unit. DPO stated," the breaker is tripping and we can not get the air unit back up."

During a review of the facility's policy and procedure (P&P) titled "Emergency Management & Disaster Plan," dated 2024. The P & P indicated, "The hospital maintains a plan of care for patient's during disruption of services to efficiently respond to a disaster that would require displacement of all or most patients at the hospital,"

2. During a concurrent observation and interview on 7/12/24 at 2:24 p.m. with DOQ in unit 300, with temperature infrared (thermometer which measures the temperature by radiation emitted) gun (model number 4th century), the following temperatures were reflected:

Middle of hallway 84.7 F on unit 300.

Back of hallway 85.6 F on unit 300.

The DOQ made no statement.

During an interview on 7/12/24 at 2:26 p.m. with Patient 16 in room 314, Patient 16 stated, "it's hot."

During an interview on 7/12/24 at 2:27 p.m. with Patient 19 in room 315, Patient 19 stated, "It's hot. I'm dying."

During a concurrent observation and interview on 7/12/24 at 2:28 p.m. with DOQ in unit 400 with temperature infrared gun, the following temperatures were reflected:

Middle of hallway 80.0 F on unit 400.

Back of hallway 86.7 F on unit 400.

During a concurrent observation and interview on 7/12/24 at 2:45 p.m. with DOQ and Chief Nursing Officer (CNO) in unit 300, with temperature infrared gun, the following temperatures were reflected:

Room 307, 86.3 F.

Room 309, 86.1 F.

Room 310, 86.0 F.

Room 311, 86.5 F.

Room 312, 87.0 F.

Room 313, 89.0 F.

Room 314, 89.0 F.

Room 316, 94.0 F.

Room 315, 88.0 F.

During a concurrent observation and interview on 7/12/24 at 3:01 p.m. with DOQ and CNO in unit 400, with temperature infrared gun, the following temperatures were reflected:

Room 407, 87.0 F.

Room 408, 82.0 F.

Room 409, 87.0 F.

Room 410, 83.0 F.

Room 411, 88.0 F.

Room 412, 88.0 F.

Room 413, 89.0 F.

Room 414, 87.0 F.

Room 415, 90.0 F.

Room 416, 88.0 F.

During an interview on 7/12/24 at 3:55 p.m. with Patient 9, Patient 9 stated it is very hot in here and being on the unit, makes me confused.

During an interview on 7/12/24 at 3:56 p.m. with Patient 31, Patient 31 stated the heat on unit 300 makes me feel sleepy.

During an interview on 7/12/24 at 3:58 p.m. with Patient 15, Patient 15 stated, "It's so hot I could die."

During an interview on 7/12/24 at 3:59 p.m. with Patient 13, Patient 13 stated,"I can't sleep on the unit."

During an interview on 7/12/24 at 4:00 p.m. with Patient 32, Patient 32 stated "It's hot."

During an interview on 7/12/24 at 4:02 p.m. with Patient 19, Patient 19 stated "It's hot," on the unit.

During an interview on 7/12/24 at 4:07 p.m. with Patient 33, Patient 33 stated she has depression and the heat could make me overdose.

During an interview on 7/12/24 at 4:09 p.m. with Patient 16, Patient 16 stated, "It's hot," on the unit and it's hard to sleep.


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During an interview on 7/12/24 at 4:10 p.m. with Patient 4, Patient 4 stated it is very hot here.

During an interview on 7/12/24 at 4:35 p.m. with Patient 34, Patient 34 stated it is hot here the heat is making me mad, and I can't sleep at night.

During an interview on 7/12/24 at 4:55 p.m. with Patient 35, Patient 35 stated the heat is making me frustrated and making me dehydrated.

During a concurrent observation and interview on 7/12/24 at 5:05 p.m. with DPO in unit 400, with temperature infrared gun the following temperatures were reflected:

Hallway on unit 400 temperature was 86.1 F.

Room 407, 86.5 F.

Room 408, 82.5 F.

Room 409, 87.0 F.

Room 410, 83.0 F.

Room 412, 86.0 F.

Room 411, 88.0 F.

Room 414, 87.0 F.

Room 413, 88.0 F.

Room 415, 91.0 F.

Room 416, 85.0 F.

End of the hallway on unit 400 90.0 F.

Seclusion room on unit 300 86.0 F with door open.

Seclusion room on unit 400 86.0 F with door open.

During a concurrent observation and interview on 7/12/24 at 5:20 p.m. with DPO in unit 300, with temperature infrared gun, the following temperatures were reflected:

Room 307, 85.0 F.

Room 310, 87.0 F.

Room 309, 85.0 F.

Room 312, 85.0 F.

Room 307, 85.0 F.

Room 311, 85.0 F.

Room 314, 85.0 F.

Room 316, 89.0 F.

Room 313, 86.0 F.

Room 315, 84.0 F.

During a review of the facility's policy and procedure (P&P) titled, "Temperature and Humidity Monitoring," dated 5/2021, the P&P indicated, "The purpose of this policy is to provide guidelines for an optimal environment for patient care areas. 2. Any variances in temperatures and/or humidity trends that fall outside the accepted range requires prompt action."

During a review of the facility's P &P titled, "Indoor Air Quality," dated 4/28/23, the P& P indicated, [facility] has a preferred range from 68 to 78 degrees."

Based on observation, interview, and record review the facility failed to maintain a safe environment in the facility when walls had cracked and missing wall boards, and loose ceiling tiles. This failure resulted in placing patients and staff at risk for injury to self and others.

Findings:

During a concurrent observation and interview on 7/15/24 at 8:56 a.m. with Plant Operations (PO) 1 in unit 200, the wall baseboard had a 1 inch by 2 ¼ inch crack. PO 1 stated it was a hazard, and patients and can stick their fingers in it.

During a concurrent observation and interview on 7/15/24 at 9:04 a.m. with PO 1 in unit 600 (a locked secure unit for patients found incompetent to stand trial ), ceiling tile lifted out of place to the left of the wall. There was a cracked ceiling tile above patient door entry. PO 1 stated the younger patients tend to jump and knock the ceiling tile out of place. PO 1 stated it was a safety issue.

During an interview on 7/15/24 at 9:06 a.m. with Registered Nurse (RN) 1, RN 1 stated no one reported the cracked ceiling tiles on the unit.

During a record review of the facility's policy and procedure (P &P) titled, "Plant Operations (Wall Penetrations)," dated 10/29/15, the P&P indicated, "Plant Operation craft workers are to repair penetrations they may find in the immediate area where they may be working."

During a record review of the facility's policy and procedure (P&P) titled, "Plant Operations," dated 10/29/15, the P&P indicated, "The plant operations department shall maintain all equipment in a safe condition so that it will minimize all health hazards in the hospital for the protection of patients, visitors, and employees."