HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1. failure to ensure patients were observed by MHTs in accordance to physician orders and hospital policy for 3 (#1, #2, #3) of 3 (#1, #2, #3) patients reviewed for documented observation levels out of a sample of 5 (#1-#5);
2. failure to ensure patients did not have access to contraband items/items for 2 (#1, #3 ) of 2 (#1,#3) patients reviewed for access to contraband items out of a sample of 5(#1-#5); and
3. failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients requiring acute inpatient psychiatric care, who had been admitted for being a danger to self or others.

Findings:

1. failure to ensure patients were observed by MHTs in accordance with physician orders

Review of the hospital's policy titled, Levels of Observation, revealed in part, to better ensure that the patient is fully observed, named hospital, has installed electronic systems designed to enhance the contact established by the staff member with the patient...In the event that the staff member does not make contact with the patient within 15 minutes or at a close enough proximity, both the staff member and the charge nurse are notified by a visual and audio display...Close observation is the routine Level of Observation applied to patients that are not considered at risk and in need of increase supervision...Line of sight is defined as maintaining visual observation of a patient all times...One-to-One observation is maintained when a patient is considered at high risk and require observation by a staff member dedicated only to that patient.

Patient #1

Review of EMR physician orders (navigated by S2DON) revealed on 02/28/2022 at 10:47 p.m. the patient was on the observation level 2, line of sight. Further review revealed on 03/01/2022 at 12:24 a.m. the patient was on level 3 observation level every 15 minutes check and on 03/08/2022 at 7:00 a.m. the patient was changed to level 1 observation level, which is one-to-one observation.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/04/2022 revealed no documentation Patient #1 was observed from 10:45 a.m. to 1:00 p.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/05/2022 revealed no documentation Patient #1 was observed from 7:45 a.m. to 5:45 p.m. The observation sheet did not indicate which observation level the patient was being monitored.



Patient #2

Review of EMR physician orders (navigated by S2DON) revealed on 03/20/2022 at 3:00 p.m. Patient #2 was on the observation level 2, line of sight. Further review revealed on 03/20/2022 at 3:40 p.m. the patient was on level 3 observation level every 15 minutes check and on 03/23/2022 at 3:53 p.m. the patient was changed to level 1 observation level, which is one-to-one observation.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/20/2022, revealed no documentation Patient #2 was observed from 7:45 p.m. to 11:45 p.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/21/2022, revealed no documentation Patient #2 was observed from 12:00 a.m. to 6:30 a.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/22/2022, revealed no documentation Patient #2 was observed from 3:45 p.m. to 5:00 p.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/25/2022, revealed no documentation Patient #2 was observed from 3:30 p.m. to 11:45 p.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/26/2022, revealed no documentation Patient #2 was observed from 12:00 a.m. to 7:15 a.m. and 6:45 p.m. until 11:45 p.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/27/2022, revealed no documentation Patient #2 was observed from 12:00 a.m. to 7:30 a.m. The observation sheet did not indicate which observation level the patient was being monitored.

Patient #3

Review of EMR physician orders (navigated by S2DON) revealed on 03/18/2022 until 03/22/2022 the patient was on the observation level 2, line of sight. Further review revealed on 03/22/2022 at 3:40 p.m. the patient was changed to level 1 observation level, which is one-to-one observation.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/21/2022, revealed no documentation Patient #3 was observed from 12:00 a.m. until 6:30 a.m. The observation sheet did not indicate which observation level the patient was being monitored.

Review of the Behavioral Health-Patient Observation Sheet, dated 03/26/2022, revealed no documentation Patient #3 was observed from 12:00 a.m. until 7:00 a.m. The observation sheet did not indicate which observation level the patient was being monitored.

An interview was conducted with S2DON on 03/28/2022 at 2:45 p.m. She reported the hospital has an EMR where the MHTs document the patients' observation levels and observations. When the internet and/or iPads go down the MHTs switch to paper documentation. S2DON further reported it has been an issue with the paper documentation being scanned into the EMR.


2. failure to ensure patients did not have access to contraband items/item

Review of the hospital policy, titled Control of Contraband and Dress Code, revealed in part, named Beacon Behavioral Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or counter-therapeutic. At Beacon Behavioral Hospital there are three categories of Contraband: (1) restricted: items that are secured away from the patient with staff supervision and/or at scheduled times; and (2) prohibited: items that are prohibited from the secured unit and or patient access at all times...Prohibited items: This category includes any items that a patient will not be permitted to access at any time while on the unit....vii. lighters and matches.

Patient #1
Review of an incident report dated 03/05/2022 at 8:31 a.m. revealed Patient #1 was caught smoking in his room.


Patient #3
Review of an incident report dated 03/24/2022 at 3:50 p.m. revealed Patient #3 asked if he could make sure his identification was in the safe. The tech started screaming for help. I walked in and the patient was smoking a cigarette.

An interview was conducted with S1Adm on 03/28/2022 at 2:30 p.m. S1Adm reported one incident a patient was picking up old butts off the ground in the patio area and bringing them inside and trying to smoke them. He further reported there was a patient in the hospital that was an electrician and the patient would take out the metal nose piece of his mask and put it in an electrical outlet and attempt to light cigarettes.


3. failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality

The following observations were conducted on 03/28/2022 from 10:00 a.m. to 11:00 a.m.
The toilets observed in all patient rooms were noted to have bases exposed and were not flush to the wall and the toilet seats could be raised providing additional access for potential ligature anchors.

The wall air condition control panels were opened in the patients' rooms. The locks on the panel are a safety issue by providing a potential ligature anchor.

The psychiatric beds in the patient's room are bolted to the floor with 1 ½ inch bolts. The bolts protrude from the floor and are considered a safety hazard.

An interview was conducted with S2DON during the observation and confirmed the ligature and safety hazards in the patients' rooms.

Based on record review, and interview, the hospital failed to ensure clear expectations for patient safety and quality of care were established and addressed through the hospital's QAPI program. This deficient practice was evidenced by failure of the hospital to address in QAPI two patients found with contraband in the facility.

Findings:

Review of hospital's policy titled, Quality Assurance and Performance Improvement Measures, revealed in part, hospital leadership, under the supervision of the QAPI Coordinator, determines how the data are used identify, prioritize and monitor Quality Assurance and Performance Improvement (QAPI) activities...Additionally the QAPI Coordinator collects and maintains written reports...

Patient #1
Review of an incident report dated 03/05/2022 at 8:31 a.m. revealed Patient #1 was caught smoking in his room.

Patient #3
Review of an incident report dated 03/24/2022 at 3:50 p.m. revealed Patient #3 asked if he could make sure his identification was in the safe. The tech started screaming for help. I walked in and the patient was smoking a cigarette.

An interview was conducted with S1Adm on 03/28/2022 at 2:30 p.m. S1Adm reported one incident a patient was picking up old butts off the ground in the patio area and bringing them inside and trying to smoke them. He further reported there was a patient in the hospital that was an electrician and he took out the metal nose piece of his mask and was putting it in an electrical outlet and attempting to light cigarettes.

An interview was conducted with S2DON on 03/29/2022 at 9:30 a.m. She reported she did not do the QAPI for the hospital. She further reported at the end of the month the hospital reported their data at the Committee of the Whole.

An interview was conducted with S5CLEd on 03/29/2022 at 11:30 a.m. She reported all QAPI is done by the individual hospitals. All incident and accident are reviewed in the Committee of the Whole meeting.

No documentation was provided by the hospital to the surveyor indicating the incidents of patients' smoking in the facility had been addressed in the hospital 's QAPI program.

Based on observation, record review, and interview, the hospital failed to ensure facilities and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by failure of the hospital to maintain the facilities in good repair.
Findings:

Review of the hospital policy titled, Managing Safety and Security Risk, revealed in part, the hospital identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities...the hospital maintains all grounds and equipment.

Observations were made on 03/28/2022 from 10:00 a.m. to 11:00 a.m.

An observation was conducted of bathroom in room "a" The bathroom did not have a grab rail. Holes in the wall were present where the grab rail had been secured into the wall.

An observation was conducted of room "b". A hole was observed in the sheetrock behind the head of the bed.

An observation was conducted of shower room on hallway c. The first shower stall had a hole in the insert of the shower stall.

An observation was conducted of the shower room on hallway b. There were multiply missing tiles in the shower room's floor.

An observation was conducted of room "c". The baseboards in room "c" had been removed.

An observation was conducted of room "d" The screws of the light fixture had been removed and tissue stuck under the edges of the light fixture.

These observations were confirmed by S1Adm and S2DON.

Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established. This deficient practice was evidenced by the hospital's failure to maintain a sanitary environment. Findings:

Review of the hospital's policy titled Infection Control, Proper cleaning of patient rooms -inpatient revealed in part, it is the policy of the hospital to have environmental service department (EVS) to clean each occupied patient room daily, considered "routine cleaning" and after a patient is discharged (prior to a new patient admission to the room), which is referred to terminal cleaning.

Observations were conducted on 03/28/2022 between 10:00 a.m. to 11:00 a.m.

An observation was conducted of all the patients' bathrooms. In all the bathrooms there was a metal cap secured to the wall. The metal cap was rusted and unable to be disinfected properly.

An observation was conducted of the women's shower room on hallway B. There was duct tape partially attached to the bottom of the shower stall with debris attached to the partially pulled up duct tape. The shower stall had a black substance in the corner of the stall that partially traveled along the edges of the stall. There was a black substance/stain running down the wall of the shower stall that originated from the call light on wall of the shower stall. There was also a rusted vent cover in the ceiling of the bathroom.

An observation was conducted of the shower room on hallway C. The toilet in the shower room was dirty and the wall air condition unit was caked with gray debris.

An observation was conducted of patient room "e". The patient's floor was covered with multiply areas of stains of dried liquid spills and trash.

The above observations were confirmed by S2DON.

Based on record review and interview, the hospital failed to have 100% of their staff vaccinated for Covid-19. The deficient practice is evidenced by only 89.7% of staff being fully vaccinated, which resulted in a 10.3% unvaccinated rate.

Findings:

Review of the hospital policy titled, Covid-19 Vaccination Policy, revealed in part, All employees must be fully vaccinated by March 15, 2022

Review of the staff vaccination rate spreadsheet with S1Adm and S3SrVice revealed a staff Covid vaccination rate of 89.7% (exemptions are included).

An interview was conducted with S1Adm and S3Sr.Vice on 03/30/2022 at 9:00 a.m. They reported with the updated information added to the hospital vaccination rate spreadsheet, the hospital has 89.7% of their staff fully vaccinated. The hospital's rate of unvaccinated staff is 10.3 %.