HospitalInspections.org

Based on observation and interview, 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 acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks and safety hazards. Findings:

Main Campus:
An observation on 06/16/15 from 11:00 a.m. to 12:00 p.m. of the main campus (locked in-patient psychiatric unit) with S2DON revealed the following observations:

1) The psychiatric unit had 4 (four) bedroom units with 4 (four) beds to each unit. There were 2 (two) beds on each side of the unit and the 2 (two) beds on each side were separated by a wall. The main entrance to each unit was through a single door from the main hallway and there was 1 (one) bathroom inside each unit for the 4 beds. The bathroom doors inside each unit were not able to be seen from the main hallway. There were also 2 (two) single occupancy bedrooms each with their own bathroom. The bathroom doors in those rooms were also not able to be seen from the main hallway. (4 units, 18 beds). The doors to all the patients' rooms and all the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature risks,

2) the hinges of the doors to all the patient rooms and bathrooms were observed to be secured to the door and the frame with non-tamper resistant screws,

3) the door handles on all patient room doors and bathroom doors were flanged-type handles that could facilitate a ligature risk,

4) the sinks in 5 of 6 patient bathrooms were observed to have flanged handles that could be used as ligature points,

5) the toilets in all the patient bathrooms were observed to have exposed plumbing that could be used as a ligature point,

6) the drawer pull handles on the patients' nightstands in all the patient rooms had pull handles (non-flush, metal handle, secured with 2 non-tamper resistant screws) and each nightstand had 3 (three) handles and these could facilitate a potential ligature anchor or potential weapon if removed,

7) each unit had an air conditioner unit in the window that was encased by a metal slatted encasement with the electrical encased pole secured up the wall with clips that could be potential ligature points,

8) the psychiatric unit had 6 beds that had side rails on them and 3 cranks located at the foot of the beds, which elevated and lower the beds and the head and foot of the beds, and

9) 2 of the 6 hospital beds with siderails also had removable springs in the bed's frame.


In an interview on 6/16/15 at 12:15 p.m. with S2DON, the above observations were reviewed with S2DON. S2DON indicated that patients were allowed to close the doors to their rooms and further indicated that the hospital had potential ligature risks and safety issues that needed to be addressed. S2DON confirmed that the hospital had no policy in place that addressed the ligature points and safety hazards in the use of beds with bed side rails, metal removable springs, and hand cranks located on the foot of the bed.


Off-Site Campus:
In an observation on 06/17/15 from 9:10 a.m. to 10:20 a.m. of the off-site campus (locked in-patient unit) with S11PM (RN, Program Manager) revealed the doors to the patients' rooms and the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature. S11PM confirmed patients are allowed to close the door to their rooms and confirmed the bathroom doors posed a ligature risk. S11PM stated there were 16 beds (14 rooms) on this unit and confirmed the door hinges were the same in all the patient rooms. S11PM confirmed patients are allowed to close the door the room.

1. The hinges of the doors to the patient rooms and bathrooms were observed to be secured to the door and the frame with non-tamper resistant screws.
2. The door handles on patient room doors and bathroom doors were flanged-type handles that could facilitate a ligature point.
3. The sinks in the bathroom of the patient rooms 201, 203, 205-214 (12 of 14 rooms) were observed to have flanged handles that could be used as ligature points. The toilets in all the patient rooms were observed to have exposed plumbing that could be used as a ligature point. S11PM confirmed the observations.

4. Drawer pulls (non-flush, metal handle, secured with 2 non-tamper resistant screws) on chest of drawers (3 drawers on each chest), facilitating a potential ligature anchor or potential weapon if removed, were observed in all 14 patient rooms. In room 203, the top drawer pull was observed to be broken in the center with rough, exposed edges. S11PM confirmed the observations.

5. The beds in all 14 patient rooms were observed to have 1/4 side rails on both sides of the upper end of the bed (Head of the bed). Plastic covered pillows were observed in all the patient rooms. Patient rooms #204 and 212 were observed to have plastic covered diapers and bed pads stored on the shelf adjacent to the patient


Surveyor: Guardina, Sharon


30172

Based on record review and interview, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of the contracted services of Radiology, Physical, Occupational, and Speech Therapy, Housekeeping Services, and Biohazardous Waste. Findings:
Review of the hospital's Quality Improvement Plan revealed the plan was hospital wide and would include all services.

Review of the Quality Improvement Plan and the Performance Improvement Indicators for 2015 revealed no documented evidence that Radiology, Physical, Occupational, and Speech Therapy, Housekeeping Services, and Biohazardous Waste services were included in the QAPI program.

In an interview on 06/17/15 at 4:30 p.m. S2DON (Director of Nursing) provided an annual evaluation of the hospital's contracted services when quality monitoring of contracted services was requested for review. S2DON indicated the contracted services and the contract are reviewed and evaluated once a year and it was done in July 2014. S2DON confirmed there were no quality indicators/measures currently monitored for the contracted services of Radiology, Physical, Occupational, and Speech Therapy, Housekeeping Services, and Biohazardous Waste.

26351

Based on observations, record review and interview, the hospital failed to ensure medical records were protected from water and fire damage. Findings:
Review of the hospital policy titled HIM-15: Analysis Retention Storage Location of Medical Records, effective date of 07/10/15, revealed all completed (closed) medical records are secured in the medical records permanent file area at a minimum of ten years. The policy revealed no provisions for the storage of records where they are protected from fire and water damage.
In an interview on 06/17/15 at 10:55 a.m. at the off-site campus with S10MR (Medical Records), she stated the closed medical records prior to 2014 were stored in the gymnasium.
On 06/17/15 at 11:15 a.m. an observation of the medical record storage at the off-site campus gymnasium was conducted with S10MR and S1Administrator. 15 cardboard boxes of 2012 and 2013 patient records from the off-site campus were observed to be stacked on the floor in the gymnasium. 14 cardboard boxes of patient records from the main campus were observed to be stacked on the floor in the gymnasium. There was no sprinkler system present in the gymnasium. S1Administrator and S10MR confirmed the closed records from both campuses were stored in this gymnasium for 2012 and 2013 and the records were not protected from fire or water damage in the event of a fire.
An interview was conducted with S7Director of HIM (Health Information Management) on 6/17/15 at 1:30 p.m. She confirmed old medical records are stored at the offsite location in the gymnasium in cardboard boxes. S7Director of HIM further reported there are approximately 2 to 2.5 years of medical records stored in the gym at the offsite location and the records are not protected from fire and water damage.

In an interview on 06/18/15 at 11:55 a.m., S7Director of HIM confirmed the hospital did not have a policy and procedure for the protection of patient records.

Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 2 of 2 (#10, #13) sampled patients with medication variances reviewed with known medication errors out of a total sample of 13. Findings:

Review of the hospital policy titled, Pharm-107: Medication Administration Error, effective date of January 2006, revealed in part the following: When medication is administered improperly or a drug reaction occurs, the following procedure is used: Notify physician, Director of Nursing or Designee. Record incident in nurse's notes and on Incident Report form. (Do not document on nurse's notes that an incident form was completed.)


Patient #10
Review of the medical record for Patient #10 revealed the patient was a 53 year old female admitted to the hospital's main campus on 05/15/15 with a diagnosis of Schizophrenia-Bipolar. The patient's diagnoses also included Possible Diabetes Mellitus.

Review of the Occurrence Report dated 05/18/15 revealed the following: Order 5/18/15 - transcribed on MAR (Medication Administration Record) as Lantus 3 units SQ Q HS (Subcutaneous injection every bedtime), order read Lantus 30 units SQ Q HS per S17MD (physician). On 05/23/15 - got clarification from S17MD, order is Lantus 30 units SQ Q HS.

Review of the physician's orders revealed an order dated 5/18/15 at 7:20 p.m. for Lantus Insulin SQ Q HS. The prescribed number of units was not clearly legible.
Further review of the physician's orders revealed the following:
05/23/15 at 8:30 p.m. Clarification of 05/18/15 order: Lantus 30 units SQ Q HS.
05/23/15 at 8:35 p.m. Give Lantus 15 units SQ Q HS.

Review of the MAR dated 05/18/15 through 05/22/15 revealed Lantus 3 units SQ was administered to Patient #10 at 8:00 p.m. every day.

Review of the nurse's notes revealed no documented evidence that the medication error or physician notification of the error was documented in the patient's record.

In an interview on 06/17/15 at 3:30 p.m., S2DON reviewed the occurrence report regarding the Lantus Insulin and the patient's medical record. S2DON confirmed the medication error and the nurse did not document the error in the patient's medical record. S2DON confirmed the nurse should have documented the physician notification and the medication error in the nurse's notes.


Patient #13
Review of the medical record for Patient #13 revealed the patient was a 79 year old female admitted to the hospital's off-site campus on 05/15/15 with a diagnosis of Dementia of the Alzheimer's Type with Early Onset, with Delusions.

Review of the Occurrence Report dated 05/17/15 revealed Patient #13 was administered only 1 - 0.5 mg. Xanax on the evening of 05/16/15 instead of 2 - 0.5 mg tablets of Xanax that were ordered. The occurrence report revealed the error was discovered as a discrepancy in the medication count in the automated medication dispensing machine.
Review of the Occurrence Report dated 05/22/15 revealed Patient #13 was again only administered 1 - 0.5 mg. Xanax instead of 2 - 0.5 mg Xanax on 05/19/15 at 2:00 p.m. The occurrence report revealed the error was discovered as a discrepancy in the medication count in the automated medication dispensing machine.


Review of the physician's orders revealed an order dated 5/15/15 at 12:45 p.m. for Xanax (Alprazolam) 0.5 mg. give 2 tablets (1 mg.) by mouth 3 times a day.

Review of the MARs dated 05/17/15 and 05/19/15 revealed the nurse documented the medication was administered as ordered.

Review of the nurse's notes revealed no documented evidence that the medication errors or physician notification of the errors was documented in the patient's record.

In an interview on 06/18/15 at 10:40 a.m., S1Administrator confirmed the above medication errors were discovered the next day when the count was not correct in the automated medication dispensing machine. She confirmed the medication errors were not documented in the patient's medical record.

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:
Failing to ensure there was a radiologist who supervised the radiology services of the hospital (see findings in tag A-0546);

Based on record review and interview, the hospital failed to have a qualified full-time, part-time or consulting radiologist who supervised the radiology services provided to patients who received treatment at the hospital. Findings:
Review of a list of credentialed physicians and providers provided by hospital revealed no credentialed radiologist.
Review of the governing body meeting minutes revealed no documentation of the appointment of a radiologist who supervised the radiology services of the hospital.
Review of the hospital's organizational chart revealed no documentation of a radiologist who supervised the radiology services of the hospital.
In an interview 06/17/15 at 3:00 p.m., S1Administrator reported the hospital had no radiologist overseeing radiological services. S1Administrator reported that radiological services were provided to hospital patients, in part, by a mobile X-ray service that performed mobile X-rays in the hospital.

Based on observations, interviews, and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by: failing to ensure environmental cleaning of patient rooms followed hospital policy and acceptable infection control practices, failing to have policies in place for glucometer disinfecting, failing to ensure equipment/supplies for patient use was disinfected according to acceptable infection practices, and failing to ensure that staff donned fresh gloves when staff went from dirty to clean tasks.

Findings:
A review of the hospital's policy titled, "Cleaning and Disinfection Patient Rooms" provided by S2DON as the most current, revealed in part: Use separate cloth to clean toilet bowl. Damp wipe with a clean cloth all horizontal surfaces with hospital approved disinfectant. Mop water and mop heads should be cleaned/changed after every third room or more if needed.
On 6/16/15 at 10:00 a.m. an observation was made of S9Housekeeper cleaning patient rooms. Observations revealed the following: dirty mop water, same mop head used to mop multiple patient rooms, same toilet brush used to clean multiple patient bathroom toilets, and 2 (two) frayed non-disposable white cleaning rags that were used to clean multiple patient rooms.
In an interview on 6/16/15 at 10:30 a.m. with S9Housekeeper she was asked about the cleaning practices in cleaning patient rooms. S9Housekeeper indicated that she was responsible for the daily cleaning of patient rooms. S9Housekeeper indicated that she changed the mop water and used a new mop head when it got dirty usually after she cleaned 4 patient rooms which included 2 patient bathrooms. She indicated she used the same toilet cleaning brush for all the patient bathrooms and changed the toilet brush to a fresh one usually once a week. S9Housekeeper indicated the same 2 (two) non-disposable white cleaning rags were used for dusting, cleaning windows, and cleaning baseboards in all the patient rooms each day.
In an interview on 6/16/15 at 12:30 p.m. with S2DON, she indicated that she was the Infection Control Officer for the hospital. S2DON was made aware of the observed infection control breaches in environmental cleaning. S2DON indicated that the observed infection control breaches in environmental cleaning did not follow hospital policy or acceptable infection control practices.
A review of the hospital policy titled, "Cleaning, Disinfection, and Sterilization", provided by S2DON as the most current, revealed in part: Accu-Check and Glucometer -Clean according to instructions in equipment/manufacturer manual. Use EPA/Hospital approved disinfectant where disinfectant solution is called for. Clean nightly and as needed.
A review of the manufacturer's manual for the hospital's glucometer revealed in part: Cleaning the Meter- Clean the outside of the meter with a damp cloth and mild soap/detergent. Store the meter in the carrying case when not in use. There was no documentation from the manufacturer on how to disinfect the glucometer between patient use.
A review of the hospital policy titled, "Glucose Testing by Finger Stick", provided by S2DON as the most current revealed no documentation of the care and cleaning/disinfecting of the multiple-use hand held glucometer used for patient's accu-checks.
On 6/16/15 at 10:45 a.m. an observation (Main Campus) was made of S8LPN performing an accu-check with a multiple patient use hand held glucometer on Patient #2 and an observation was made of S8LPN preparing an insulin injection for Patient #2. Observations revealed: S8LPN did not change her soiled gloves (after performing the accu-check) and don clean gloves before returning all the clean glucometer supplies back into the accu-check supply cart. S8LPN did not disinfect the glucometer after use on Patient #2 before returning it to the accu-check supply cart. S8LPN placed the glucometer device directly back into the accu-check supply cart and S8LPN did not place the glucometer into its designated carrying case. S8LPN did not sanitize or wash her hands after removing her gloves. S8LPN did not don gloves prior to preparing the insulin injection for Patient #2. S8LPN did not wipe the multiple-use insulin bottle with an alcohol wipe before withdrawing the insulin medication. S8LPN did not sanitize or wash her hands immediately after removing gloves after the insulin injection was given to Patient #2.
On 6/17/15 at 11:00 a.m. an observation (Off-site Campus) was made of S12LPN performing an accu-check with a multiple patient use hand held glucometer on Patient #12. Observations revealed: S12LPN did not change his soiled gloves (after performing the accu-check) and don clean gloves before returning all the clean glucometer supplies back into the accu-check supply cart. S12LPN did not disinfect the glucometer after use on Patient #12 before returning it to the accu-check supply cart. S12LPN placed the glucometer device directly back into the accu-check supply cart and S12LPN did not place the glucometer into its designated carrying case.
In an interview on 6/17/15 at 2:00 p.m. with S2DON, the hospital's policies and manuals on the glucometer care and use was reviewed with the S2DON. She indicated that the hospital did not have a specific policy in place for the disinfecting/cleaning of the glucometer after each patient use. She further indicated that the glucometer should be disinfected after each patient use according to acceptable infection control practices.
An observation on 6/15/15 at 1:45 p.m. was made of the blood pressure machine (Main Campus) in the nurse's Patient Assessment Room used by the RNs when they perform initial patient assessments. There were 2 (two) non-disposable blood pressure cuffs stored in the blood pressure machine tray that were worn and frayed with tears in them.
In an interview on 6/15/15 at 1:50 p.m. with S2DON, she was made aware of the blood pressure cuffs used in patient care by the RNs. She was asked how the staff disinfected the blood pressure cuffs that were frayed and torn. She indicated that the blood pressure cuffs that were used by the RNs when they performed initial patient assessments should be replaced.
An observation on 6/17/15 at 10:00 a.m. (Off-site Campus) of the intravenous pumps stored in the Clean Supply Room. There were 2 (two) intravenous pumps noted to have old tape on the top of the pumps.
In an interview on 6/17/15 at 10:15 a.m. with S11PM, she was asked about the old tape noted on the 2 (two) intravenous pumps stored in the Clean Supply Room. S11PM indicated that the 2 (two) intravenous pumps in the Clean Supply Room were cleaned patient equipment and that the 2 (two) intravenous pumps should have had the old tape removed prior to disinfecting the pumps by staff.