HospitalInspections.org

Based on document review and interview, the facility failed to provide a comprehensive delineated list of current contracts for review.

Findings include:
1. On 2/14/2022 at 1025 hours, S1, Director of Accreditation/Quality Improvement, was asked to provide a list of all contracts the facility currently maintained as being active. A partial listing of "memorandum's of understanding" was provided, but did not include all currently active contracts.

2. In interview on 2/16/2022 at 1600 hours, S1, Director of Accreditation/Quality Improvement, confirmed that no comprehensive and delineated listing of all of F1's active contracts was available for review.

Based on document review, observation and interview; nursing failed to follow policy regarding suicide precautions in 1 of 4 (patient 4) medical records reviewed.

Findings include:

1. Review of policy titled: Suicide Assessment and Intervention, Inpatient Unit - Procedure Version # 8, last approved 04/27/2021, indicated - Remove belts, suspenders, shoelaces and any strings in shirts and pants.

2. Review of patient 4's medical record on 02/15/22 at 1015 indicated suicide precaution ordered at suicide precaution (SP) 2 - moderate risk of immediate suicide.

3. During observation of group activity on 02/15/22 at 0930, this writer observed patient 4 with red strings hanging from waist of pants.

4. Interview with S4 (Inpatient Psychiatric Supervisor, Registered Nurse [RN]) on 02/15/22 at 1530 confirmed patient 4 was wearing scrub pants with draw string and nursing did not follow policy leaving patient 4 access to string in pants.

Based on record review and interview, the facility failed to maintain automatic sprinkler systems (see tag K353), failed to conduct fire drills or documented orientation training on each shift for 4 of 4 quarters (see tag K712), failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during 1 of the past 12 months (see tag K918) and failed to ensure a written record of weekly inspections for the generator was maintained for 14 of 52 weeks (see tag K918).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

1. Based on record review and interview, the facility failed to maintain automatic sprinkler systems in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

1. Based on review of "System Inspection Certificate" documentation dated 10/19/21 during record review with the General Services Supervisor from 10:30 a.m. to 1:35 p.m. on 02/15/22, the Fire Hydrant located at Ground Southeast parking was in need of repair. The inpection report stated the fire hydrant failed the annual test with problem listed 'will not self drain'. Based on interview at the time of record review, the General Services Supervisor stated stated he was not aware there was a problem with the fire hydrant and documentation of the repair or replacement of the aforementioned fire hydrant on or after 10/19/21 was not available for review.

2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during 1 of the past 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. Chapter 6-4.4.1.3 of 2012 NFPA 99 requires batteries for on-site generators shall be maintained in accordance with NFPA 110, 2010 Edition, Standard for Emergency and Standby Power Systems. 8.3.7 requires storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 states defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

2. Based on record review on 02/15/2022 between 10:30 a.m. and 1:35 p.m. with the Director of Facilities and General Services Supervisor present, there was no monthly generator load test documentation available for January of 2022. Based on interview at the time of record review, the General Services Supervisor confirmed there was no emergency generator load test documentation for January 2022.

3. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 14 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all residents, staff and visitors.

Findings include:

3. Based on record review with the General Services Supervisor on 02/15/22 from 10:30 a.m. to 1:35 p.m., documentation for the weeks of: January 3rd, 10th, 31st, December 20th & 27th, November 1st, October 11th, August 2nd & 23rd, July 19th, June 14th & 21st, May 24th and April 26th weekly generator testing was not available for review. Based on an interview at the time of record review, the General Services Supervisor confirmed weekly generator testing documentation for the aforementioned weeks was not available for review at the time of the survey.

These findings were reviewed with the Accreditation & Quality Improvement Director, Director of Facilities, and General Services Supervisor during the exit conference.

Based on record review and interview, the facility failed to conduct fire drills or documented orientation training on each shift for 4 of 4 quarters. LSC 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. QSO-20-31 1135 temporary waiver states in lieu of a physical fire drill, a documented orientation training program related to the current fire plan, which considers current facility conditions, is acceptable. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. This deficient practice affects all staff and residents.

Findings include:

Based on record review on 02/15/22 with the General Services Supervisor at 1:10 p.m., the only completed fire drill within the last twelve months was conducted 04/20/2021 at 9:52 a.m. There were no other fire drills or documented orientation training related to the current fire plan to review for the past twelve month period. Based on interview at the time of record review, the General Services Supervisor stated the facility decided not to conduct fire drills due to the COVID19 Public Health Emergency, and the facility has discussed resuming fire drills in the near future. The General Services Supervisor confirmed there were no fire drill documentation or orientation training to review at the time of the survey.

This finding was reviewed with the Accreditation & Quality Improvement Director, Director of Facilities and General Services Supervisor at the exit conference.

Based on document review and interview, the facility failed to ensure the Infection Preventionist was qualified through education, training, experience or certification and appointed by the governing body (S5).

Findings Include:

1. Interview on 02/16/22 at 10:30 am with S1 (Director of Accreditation/Quality Improvement [QI]) confirmed that S5 (Chief Nursing Officer) was the Infection Preventionist for the inpatient unit.

2. Review of S5's personnel file lacked documentation of infection control education.

3. Interview with S1 on 02/16/22 at 1:40 pm confirmed that S5's personnel file lacked documentation of infection control education, training, experience or certification.

4. It could not be determined if S5 was appointed by the Governing Board as the Infection Preventionist. Requested Board minutes from S1 where S5 was appointed to be the Infection Preventionist at 10:30 am and 1:40 pm on 02/15/22.

Based on observation, document review and interview, the facility failed to keep a sanitary environment in 6 of 6 (E-206, E-207, E-208, E-209, E-210 and E-211) restrooms observed.

Findings Include:

1. Tour of facility on 02/14/22 at 2:20 pm with S3 (Service Director-Acute Intensive Services) and S4 (Inpatient Psychiatric Supervisor), this surveyor observed wipeable, copious amounts of dust on top of lights, dark colored build-up on shower seams and around the cover over the hot and cold knobs in each shower in 6 bathrooms (E-206, E-207, E-208, E-209, E-210 and E-211).

2. Review of the Housekeeping Procedures indicated cleaning of the inpatient restrooms daily.

3. Interview with S3 and S4 on 02/14/22 at approximately 2:30, confirmed copious amounts of dust on top of lights, dark colored build-up on shower seams and around the cover over the hot and cold knobs in each shower in 6 bathrooms (E-206, E-207, E-208, E-209, E-210 and E-211).

Based on document review and interview, the facility failed to provide tuberculin testing per policy in 3 of 3 new hires, since 01/01/21 (P3, P5 and P11).

Findings Include:

1. Review of policy titled: Infection Control-Program Policy (Version #4) last approved 07/16/2021 indicated staff should follow all Infection Control policies and procedures (adhering to State Board of Health, CDC and OSHA guidelines).

2. Review of the CDC guidelines, TB Screening and Testing of Health Care Personnel (updated March 8, 2021) indicated if the Mantoux tuberculin skin test is used to test health care personnel upon hire, two-step testing should be used.

3. Review of P3 and P5 (each a Registered Nurse) and P11's (Mental Health Technician) personnel files had documentation of 1 tuberculin test, but lacked documentation of a second tuberculin test; each hired in 2021/2022.

4. Interview on 02/16/22 at 12:25 pm with S8 (Director of Human Resources) confirmed P3, P5 and P11 lacked documentation of a 2nd tuberculin test needed to complete the 2-step tuberculin testing.

Based on document review and interview, the facility failed to include all disciplines in reviewing the treatment plan for 1 of 4 (Patient 2) treatment plans reviewed.

Findings Include:

1. Review of policy titled: Treatment Plan Policy (Version #4) last approved 04/28/2021, indicated that the plan is to be reviewed by all persons involved.

2. Review of Patient 3's Treatment Plan, created on 02/13/22 (date of admission) at 6:54 pm completed and signed only by Registered Nurse and Patient.

3. Review of Treatment Plan Meeting on 02/14/22 indicated a list of multi-disciplinary names with hand written check marks by the names (virtual meeting). Lack of documentation of which Patient/s were discussed or notes stating such in the medical record.

4. Interview on 02/15/22 at 10:00 am with S4 (Inpatient Psychiatric Supervisor) confirmed that since Patient 3 was admitted over the weekend, they would have been discussed at the Treatment Plan Meeting on 02/14/22.