HospitalInspections.org

Based on a review of documentation the facility failed to ensure that when restraint or seclusion is used, there must be documentation in the patient's medical record of the following:

The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior.

Findings included:

Facility based policy entitled, "Protective Hold/Seclusion" stated in part, "D. Face to Face Evaluation by the Provider:
1. Within one hour of the initiation of protective hold/seclusion, the patient shall be evaluated in person by a provider or a registered nurse. If a nurse is performing the face to face evaluation it must be a nurse trained to perform the evaluation of the patient and it may not be the nurse who initiated the protective hold. The evaluation will be documented in the medical record to include the following:
a. The date and time of the evaluation
b. An assessment of the patient's immediate situation
c. An evaluation of the patient's reaction to the intervention
d. An assessment of the patient's medical and behavioral condition, to include a complete review of systems assessment, behavioral assessment, as well as a review and assessment of the patient's history, drugs, and medications, most recent lab work, etc.
e. An assessment of the need to continue or terminate the protective hold/seclusion ...

Review of medical records revealed the following issue regarding face to face evaluations:

* Patient #B8 was in seclusion on 11/25/18 from 1510-1710, the one-hour face to face evaluation was not completed until 11/25/18 at 2300.
* Patient #B9 was in a physical hold on 11/15/18 from 2145-2148 the one-hour face to face evaluation was not completed until 11/16/18 at 0653.

The above finding were confirmed in an interview with staff member B12 on 12/12/18.

Based on review of records and interview, it was determined that the facility failed to enforce its own policies and procedures in regard to authentication of medical records.

Findings were:

Facility policy entitled "Physician and Staff Signature Verification Policy" stated in part "To identify all physicians and clinical staff authorized to document in the patients' medical record. All entries in the medical record must be dated, timed and authenticated in writing or facility approved electronic form, by the person responsible for providing or evaluating the service provided."

On 8/18/18, Patient # 6 (Roster C) was physically restrained twice. The orders were received for the restraints taking place at 09:20 and 22:30 were not electronically signed by the ordering doctor until 10/8/18.

In an interview with the Regional Director of Risk Management on 12/12/18, the above findings were confirmed.

Based on a review of facility documentation, observation and staff interviews, the facility failed to develop, implement and maintain an active, hospital-wide program for the prevention, control and investigation of infections and communicable diseases as evidenced by:

a. Not providing and maintaining a clean and sanitary environment in all hospital areas in order to avoid sources and transmission of infections and communicable diseases. Cross refer Infection Control Program A0749.

b. Not mitigating risks contributing to healthcare-associated infections. Cross refer Infection Control Program A0749.

c. Little or no evidence of active surveillance. Cross refer Infection Control Program A0749.

d. Inadequate documented evidence of complying with the reportable disease requirements of the State of Texas. Cross refer Infection Control Program A0749.

e. Hospital administration receiving only scanty infection control reporting with no corrective actions taken. Cross refer Infection Control Leadership Responsibilities A0756.

f. Failure to designate a person or persons responsible for implementing a hospital-wide infection control program. Cross refer to A0748.

These deficient practices had the potential impact of placing all patients and staff at the facility at risk for acquiring a communicable disease or infection.

Based on observation and a review of documentation, the facility failed to designate an infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

Findings were:

During a tour of the dietary department on 12-11-18, the following observations were made:

* Hardened, sticky residue was noted on the underside of the motor mechanism of the stand mixer, in the area suspended over the mixing bowl.

* Sticky residue was noted in the drawer under the overflow preparation area.

* The Cuisinart-brand griddle/sandwich press was coated in a dark, sticky residue.

Facility policy IC 400.12 titled "Infection Prevention for Dietary" stated, in part:
"I. Purpose: To provide infection prevention and control for the dietary department.

II. Responsibilities:
...
C. Assures that the kitchen is cleaned properly..."

A document titled "High Temperature Dishwasher Log" stated parameters for the dishwasher final rinse temperature as between 180 - 190 degrees Fahrenheit. 5 of 11 breakfast-time rinse temperatures and 1 of 11 lunch-time rinse temperatures had been logged as being less than 180 degrees, but the log contained no documentation that any corrective measures had been taken.

Facility policy titled "Dishwasher Compliance Standards" stated, in part:
"1. Temperature standards are as follows:
a. Minimum Standard - wash 150-160 degrees Fahrenheit
b. Final Rinse - 180-190 degrees Fahrenheit
...
3. Any discrepancies from standards are immediately reported to the Food Service Supervisor."

The above was confirmed in an interview with the interim CEO and other administrative staff on the afternoon of 12-12-18.

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure that the person or persons designated as infection control officer(s) developed, implemented and maintained an active, hospital-wide program for the prevention, control and investigation of infections and communicable diseases as evidenced by:
a. Not providing and maintaining a clean and sanitary environment in all hospital areas in order to avoid sources and transmission of infections and communicable diseases.
b. Not mitigating risks contributing to healthcare-associated infections.
c. Little or no evidence of active surveillance.
d. Inadequate documented evidence of complying with the reportable disease requirements of the State of Texas.

These deficient practices had the potential impact of placing all patients and staff at the facility at risk for acquiring a communicable disease or infection.

Findings were:

a. [The facility did not] provide and maintain a clean and sanitary environment in all hospital areas in order to avoid sources and transmission of infections and communicable diseases.

Facility policy SM-18 entitled "Housekeeping Cleaning Procedures," included the following:
" ...The Housekeeping Department shall provide the facility with safe and sanitary cleaning services in the interest of promoting an effective infection prevention program ...
Sanitation within the hospital environment depends upon cleaning thoroughness and frequency ...
PROCEDURE:
4. Medication Rooms ...
d. Dust and wet mop: floor ...
12. Patient Laundry Rooms
a. Empty trash, wipe trash can, replace with paper bag
b. Clean lint filter - after every use
c. Sanitize tables
d. Dust and wet mop: floor ..."

Facility policy SM-19 entitled "Refrigerator Cleaning Policy," included the following:
"PURPOSE:
To ensure hospital refrigerators in the medication and exam rooms, employee lounges, and patient kitchens are cleaned and defrosted on a regular basis ...
It is the policy that all refrigerators are maintained on a daily basis by pharmacy, food services, or clinical staff ...
2. The staff on the night shift will monitor refrigerator temperatures in the patient nourishment refrigerators. A schedule for emptying out, cleaning and defrosting refrigerators will be established for each unit, and will be conducted by staff on the night shift.
3. The Pharmacy Department will monitor all medication refrigerators on the units ...
5. The condition of all refrigerators will undergo surveillance during Plant Operations rounds and Risk Management rounds on a regular basis. Compliance, completion of refrigerator logs will be reported to the Safety/Risk Management/Infection Prevention Committee ..."

Facility policy IC 400.26 entitled "Washers and Dryer in Patient Care Areas," included the following:
"I. PURPOSE: To assure that washers and dryers in patient care areas are clean and maintained on a regular basis.
II. GUIDELINES:
1. Washers and dryers in patient care areas are cleaned daily.
2. Washers are disinfected after each patient use.
III. PROCEDURE:
1. Nursing staff will disinfect interior of washer after each individual patients' [sic] laundry is completed using disinfectant wipe. Additionally, any lint in dryer will be removed at this time ...
3. Night shift to ensure floor and counter top are free of trash and are clean. Floors will be mopped by housekeeping staff as needed/requested per unit staff...
4. Hose connections cleaned and checked ...
4. [sic] Night shift staff to document above actions each night on the Washing Machine and Drier [sic] Cleaning Log ..."

During a tour of the hospital on the morning of 12/10/18, with Staff #D5, Director of Utilization Review, the following issues were noted:
On the Star Unit:
o The patient laundry area included a dryer with a lint filter overflowing with lint. There was also a washing machine which appeared unclean with encrusted soap residue in it. The floor of the laundry room was dirty. The "Clothes Washer and Dryer Cleaning Logs" for the area were reviewed in order to determine when the lint filter was last cleaned. The last entry on the log was 11/28/18 and the categories of "Lint filter cleared" and "Floor clean" were checked. The only cleaning logs the facility could provide for this area were July, October and November 2018.

During a tour of the hospital on the afternoon of 12/11/18 with Staff #D3, Infection Control Officer, the following issues were noted:

On the Mesquite Unit:
o In the medication room, there was an approximate 6" x 6" square of sticky tape on the wall. There was also old sticky tape on a number of the cabinets in the room. Sticky tape and residue make thorough cleaning impossible.
o The patient laundry area included a washing machine which appeared unclean and had encrusted soap residue in it. The area in the wall for the connector hoses had a thick layer of dust.
o Patient room 103 had a large crack with broken sheetrock and plaster around a wall door handle protector and in another location.
o In the patient snack area, the counter laminate was chipped and missing in several spots.

On the Brazos Unit:
o In the medication room, there were two bottles of Ketone strips that expired in August 2018.
o 2 of 3 pillows in an unoccupied room were torn. There was dirty linen on the floor.

On the Longhorn Unit:
o In the medication room, a patient medication refrigerator had hair and debris on the interior bottom of the refrigerator, and what appeared to be a "sludge"-like material around the drain at the interior back. The floor of the room was dirty. Patient supplies were stored under the room's sharps container, risking possible contamination when sharps with blood or other liquid were disposed of. Additional items were stored under the sink cabinet.
o In the patient snack area, the refrigerator containing patient snacks was dirty.

The above findings were confirmed with Staff #D5 and #D3 during the tours. They agreed that each item was problematic.


b. [The facility did not] mitigate risks contributing to healthcare-associated infections.

Facility policy #IC 400.08 entitled "Hand Hygiene," effective date 7/7/14, included the following:
" ...All inpatient and outpatient personnel will comply with hand hygiene practices to reduce transmission of pathogenic microorganisms to patients and other personnel within the healthcare setting ...Hand hygiene is absolutely essential for prevention and control of healthcare-acquired infections (HAIs), and should be practiced faithfully by all healthcare personnel without exception in order to remove foreign matter, colonized and transient microorganisms. It represents the most effective method for preventing transfer of infection to the patient, from one patient to another, from a patient or patient equipment to healthcare personnel, and from one part of the patient's body to another.

Plain liquid soap and alcohol-based hand antiseptics are provided for routine hand antisepsis ...

A. When to Perform Hand Hygiene
1. Decontaminate hands after contact with a patient's intact skin (as in taking a pulse or blood pressure, or lifting a patient).
2. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, as long as hands are not visibly soiled.
3. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care.
4. Decontaminate hands after contact with inanimate objects (including medical equipment) in immediate vicinity of the patient ...
6. Decontaminate hands before donning personal protective equipment.
7. Decontaminate hands before preparing/serving medication.
8. Decontaminate hands after removing personal protective equipment ...
11. Before coming on duty.
12. When hands are soiled.
13. Before and after each patient encounter.
14. After toileting.
15. After blowing or wiping the nose.
16. Before and after eating ...

V. Monitoring
Performance Improvement activities will be conducted to monitor organizational goals for compliance with hand hygiene guidelines. Processes will be improved as need [sic] to facilitate compliance ..."

During a tour of the hospital on the afternoon of 12/11/18 with Staff #D3, Infection Control Officer, it was noted by surveyors that there appeared to be no soap available for patients to wash their hands. Specifically, this was noted on the Mesquite unit for geriatric psychiatric patients and on the Brazos unit for adolescents.

In an interview with Staff #D3 during the tour of the Mesquite unit, she stated, "We have some soap over by a sink in the day room of the unit so patients can go out there and wash their hands. And they get soap for bathing ... We've been looking into getting the breakaway soap dispensers, but we haven't been able to do that yet ..." The patient snack area did have a sink with a small soap dispenser next to patient beverage cups. Staff #D3 was asked if facility staff were in the hallway or a patient room and needed to wash their hands, whether they would have to wash them behind the nursing station or in the dayroom area, or if there were any other handwashing facilities available for staff on another part of the unit. She stated, "They'd probably have to go to the nurses station."

While touring the Brazos unit for adolescent patients, again it was noted there was no soap in patient rooms. Staff #D3 stated, "They get soap for bathing here too." When asked if there was soap in the dayroom of the unit for the patients to wash their hands, she stated, "Not on this unit, no."

In an interview with Staff #D3 on the afternoon of 12/11/18 in the facility conference room after the tour, referring to the lack of patient access to soap for handwashing, she stated, "It's that way throughout the hospital."

In an interview with Staff #D1, Interim CEO, on the afternoon of 12/12/18 in the facility conference room, she was asked if there was soap available in patient rooms for handwashing on any of the hospital units. She stated, "They took all the soap dispensers down at some point because they were ligature risks ..."

According the CDC "Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force" found at https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf stated in part,
"Recommendations
1. Indications for handwashing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74)."

According to the CDC "Clean Hands Count for Safe Healthcare" found at https://www.cdc.gov/features/handhygiene/index.html stated in part,
"Most germs that cause serious infections in healthcare are spread by people's actions. Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 25 hospital patients on any given day. Every patient is at risk of getting an infection while they are being treated for something else. Even healthcare providers are at risk of getting an infection while they are treating patients. Preventing the spread of germs is especially important in hospitals and other facilities such as dialysis centers and nursing homes."

Per the CDC, "Show Me the Science - When & How to Use Hand Sanitizer" found at https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html
Stated in part,
"Washing hands with soap and water is the best way to reduce the number of microbes on them in most situations. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol ...
Many studies have found that sanitizers with an alcohol concentration between 60-95% are more effective at killing germs than those with a lower alcohol concentration or non-alcohol-based hand sanitizers 1,2. Non-alcohol-based hand sanitizers may 1) not work equally well for all classes of germs (for example, Gram-positive vs. Gram-negative bacteria, Cryptosporidium, norovirus); 2) cause germs to develop resistance to the sanitizing agent; 3) merely reduce the growth of germs rather than kill them outright, or 4) be more likely to irritate skin than alcohol-based hand sanitizers 1,2...
Although alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly 1-10, people may not use a large enough volume of the sanitizers or may wipe it off before it has dried 10. Furthermore, soap and water are more effective than hand sanitizers at removing or inactivating certain kinds of germs, like Cryptosporidium, norovirus, and Clostridium difficile 11-15 ...
Many studies show that hand sanitizers work well in clinical settings like hospitals, where hands come into contact with germs but generally are not heavily soiled or greasy 1. Some data also show that hand sanitizers may work well against certain types of germs on slightly soiled hands 2,3. However, hands may become very greasy or soiled in community settings, such as after people handle food, play sports, work in the garden, or go camping or fishing. When hands are heavily soiled or greasy, hand sanitizers may not work well 1,4,5Handwashing with soap and water is recommended in such circumstances."

Per the Texas Department of State Health Services information regarding Influenza found at http://dshs.texas.gov/idcu/disease/influenza/ which stated in part,
"Transmission
Human to Human
Influenza viruses are spread from person to person by respiratory droplets generated when an infected person coughs, sneezes, or talks in close proximity to an uninfected person. Sometimes, influenza viruses are spread when a person touches a surface with influenza viruses on it (e.g., a doorknob), and then touches his or her own nose or mouth ...
Treatment & Prevention
o Hand washing and using alcohol-based hand sanitizers ..."
Hand hygiene is important to reduce the potential transmission of illness including the influenza virus. Effective hand hygiene, including routine access to hand soap and hand sanitizer, is essential to minimize the potential spread of influenza. The removal of soap dispensers, with inconsistent provision of soap and hand sanitizer to patients and possibly to staff, could potentially increase the transmission of germs and increased the risk of influenza transmission the unit. This placed patients and staff at increased risk of illness.


c. [The facility did not] provide evidence of current active surveillance.

Facility policy IC 400.00 entitled "Infection Control Program," effective date 7/7/14, included the following:
" ...It is the belief that Georgetown Behavioral Health Institute, to include all Inpatient and Outpatient Programs, shall fulfill its responsibilities in the areas of prevention, care and control of actual and/or potential infections through continuous surveillance and activities of combined staff support of all departments and programs ...
II. Goals and Objectives:
A. To assure there is an effective organization-wide program for surveillance, reporting, management and prevention of infections and communicable disease.
B. Function as part of the overall organization performance improvement program. The plan shall be based on accepted epidemiological methods for surveillance and prevention of adverse outcomes related to infections ...
D. Active infection control to restrict and/or minimize the spread of existing diseases or infections to the fullest extent possible.
E. Adherence to internal and external standards and requirements as set forth by accreditation and licensure agencies, laws/statutes, professional bylaws and rules and regulations.
F. Assure implementation of appropriate measures to correct problems identified or to improve the quality of patient care at any level of the infection control process.
G. Hand hygiene compliance and other goals as indicated on each year's Infection Control Plan.

III. Procedures:
A. The Infection Control Team:
1. The Infection Control Preventionist (ICP) and the Chief Nursing Officer (CNO) -
a. Shall coordinate the Infection Control Program ...
c. Shall evaluate data and make recommendations for the implementation of the Infection Control Program.
d. Shall act as an agent in notifying the Texas Department of State Health Services of all patients presenting with a communicable disease as per policy ...
e. Performs and directs total-house surveillance and related activities, including the investigation of clusters of infections above expected levels and single cases of unusual hospital associated infections, on-going collection and review of data, as well as any required follow-up.
f. Reports monthly surveillance data to the Committee of the Whole (COW) and to the Medical Executive Committee (MEC) as needed.
g. Shall have access to microbiological and serological laboratory services through the contractual laboratory.
h. Shall identify, recommend and coordinate educational and training needs related to Infection Control ...
5. The Committee of the Whole shall be responsible and accountable for an active facility wide infection control program. The Committee of the Whole shall receive and review a report of the activities and findings of the infection control function ...
C. Scope of Care
1. Scope of Care: Patient care services are provided in a manner to prevent and control infection. This includes setting standards, policies and procedures for infection surveillance for all inpatient and outpatient services affecting patients as well as all organization personnel ..."
Review of facility policy #IC 400.13 entitled "Infection Prevention Surveillance," last revised 3/2/17, included the following:
" ...PURPOSE:
To have knowledge of patient infections to guide prevention activities so appropriate actions/follow-up may be done ...
Surveillance at Georgetown Behavioral Health Institute is performed in all patient care areas, including inpatient and outpatient areas ...
c. Surveillance may also include the following:
i. Review of culture reports and other pertinent lab data
ii. Review of antibiotic(s) given
iii. Nurse consultation
iv. Medical record review
v. Follow-up on communicable disease exposure
vi. Physician consultation ...
3. Process measures:
a. Involves monitoring of practices that directly or indirectly contribute to a health outcome.
b. Focuses on observations and analysis of practices and environmental conditions ..."

Review of the facility "2018 Georgetown Behavioral Health Institute Infection Prevention and Control Plan/Program and Risk Assessment," included the following:

" ...The Safety/EOC (Environment of Care)/Infection Control Committee will: (meets monthly) ...
Evaluate at least quarterly, Infection Control indicators of performance as compared to thresholds set by the Committee, looking specifically for
o Unusual epidemics.
o Clusters of infections.
o Infections due to unusual or resistant pathogens ...
...The Governing Board will: (meets quarterly)
o Fulfill the responsibility for assuring the effective implementation of the Infection Control Program.
o Review the findings, actions, and recommendations of the hospital-wide Infection Control Program.
o Receive reports quarterly on the findings and actions taken in the Infection Control Program ...

ICRN will: ...
o Monitor and perform analysis of infection rates ...
o Investigate significant clusters of infection or those resulting from an unusual or resistant organism.
o Carry out in-service education and orientation of new employees as directed by the Safety/EOC/Infection o Control Committee, as well as conducting in-service programs as needed ...

All staff are required to:
o Participate in house-wide and department specific orientation relative to Infection Prevention and Control.
o Perform department specific Infection Prevention and Control monitoring for compliance and report to the ICRN.
o Participate in the hand washing monitoring program...

PERFORMANCE IMPROVEMENT
The ICRN will perform monthly quality monitors to comply with Infection Prevention and Control Policies and Objectives ...According to the results of these monitors and observations, the ICRN, in conjunction with the Safety/EOC/Infection Control Committee and Performance Improvement Committee, will augment monitors as needed.
2018 PERFORMANCE IMPROVEMENT MONITORS INCLUDE:
1. Healthcare Associated Infections (HAI) per 1000 patient days
2. Compliance with Tuberculosis (TB) testing of all employees
3. All patients will have Infection Screening completed prior to admission
4. Report of Infection completed for all antibiotics ordered
5. Handwashing compliance
6. All infections with antimicrobials ordered to be added to patient treatment plan ...

III. ACTION PLAN ...
Goals
Improve compliance with hand hygiene guidelines ...
Measurable Objective
o Observe a least 12 opportunities for appropriate hand hygiene per month from all departments including dietary, clinical staff, medical staff, housekeeping, and nursing staff.
o Reach and maintain 90% compliance for all employees in all departments every month ...
Timeframe
o Monthly data collected is reported in the Safety/EOC/Infection Control Committee Meeting and Performance Improvement Committee Meeting where all Directors are present ...
Healthcare Associated Infections (HAI) ...
o Monthly reports to reflect fewer healthcare associated infections for patients, visitors and staff.
o If a patient has an infection or potential for infection, the unit nurse fills out a Report of Infection that is given to the ICRN. It is then logged onto a tracker and patient's recent labs are attached ...
Urinary Tract Infections ...
o If a patient has an infection or potential for infection, the unit nurse fills out a Report of Suspected Infection that is given to the ICRN. It is then logged onto a tracker and patient's recent labs are attached ..."
Skin Related Infections ...
o If a patient has an infection or potential for infection, the unit nurse fills out a Report of Suspected Infection that is given to the ICRN. It is then logged onto a tracker and patient's recent labs are attached ...
Tuberculosis - Staff and patients ...
o All employees will have a TB skin test upon hire and annually thereafter. If unable to have TB test, the employee will complete a chest x-ray or present results of current chest x-ray ..."

Review of facility infection control surveillance for 2018 revealed a single notebook which included a listing of patients with a suspected infection who had been prescribed antibiotics at the facility. Specific organisms involved had not been identified. No pertinent patient labs or cultures were included. The notebook appeared to include no follow-up regarding the listed infections. There was no evidence that the facility was analyzing the patient infection information.

A review of the governing board meeting minutes for 2018 revealed only two meetings: on 4/27/18 and on 11/15/18. The meeting on 4/27/18 included a 1st quarter infection control report that included minimal information on healthcare associated infection rates without any detail. It did include a note saying, "See attached log." No log was attached to the set of minutes. The minutes did not include any information related to facility handwashing compliance. A very brief blurb in the minutes of the 11/15/18 meeting mentioned only the numbers of patients with infections for the 2nd and 3rd quarters. This did not include any type of analysis regarding these infections; no other specific information was provided. No other infection control information was included in the governing board minutes.

A review of minutes for the facility Environment of Care/Safety/Infection Control meetings for 2018 included only two meetings: 6/28/18 and 11/28/18. Under the Infection Prevention and Control top for the meeting on 6/28/18, the following items were discussed, as examples:
"1. Hospital Acquired Infections - rate. One episode of medication resistant lice ...Action/Follow-up: [Blank].
2. Issues: dirty & clean supplies being stored in the same areas since the storage room was turned into an office on Brazos ...Action/Follow-up: ... A large storage shelving container to be ordered to store the dirty hygiene bins in to keep away from the clean supplies and linens ...
4. Hand hygiene form needs to be revamped and re-implemented for ongoing monitoring ...Action/Follow-up: ... Form to be changed and given to Lead MHTs for implementation ...
A. Unit and Dept. inspection findings reviewed ...
- Back Facilities [sic] hallways to be cleared of "all" stored Items/junk.
- Continue to log all items and equipment that are removed from facilities or discarded in Asset Form.
- Continue to train all direct care staff on the importance of radios and how to properly use them.
- The Director of PI/Risk to take over IC and maintain all IC records and how to properly use them.
- Insure plenty of snack are being delivered daily to Units and Out Patient Services with Dietary ..."

The minutes of the 11/28/18 meeting included no infection control items of significance.

In an interview with staff member #D3, current Infection Control Nurse, on the afternoon of 4/11/18, in the facility conference room, she stated that she had recently joined APIC (Association for Professionals in Infection Control and Epidemiology) and was to imminently receive instruction from a corporate sister facility infection control director in Houston. She stated, "I'm feeling overwhelmed. Our last infection control person just quit on this past Friday. I'm also Interim Director of Nursing." She added, "We've had a lot of people cycle through in the past year as the infection control person." When asked if there was any training provided for hospital staff on infection control topics, she stated, "No so much - maybe bloodborne pathogens. New employees get some training at orientation." When asked if she or anyone at the facility was monitoring handwashing practices, she said they were not. When asked about monitoring of tuberculosis, she stated, "It's getting done. We're at about 65%." When this surveyor stated it seemed the facility had no active infection control program, Staff #D3 nodded and stated, "We don't really have a program right now and probably haven't for a while." When asked about infection follow-up and analysis, she stated, "Most of our infections are just UTIs (urinary tract infections)."

A review of the personnel file for Staff #D4, former Infection Control Nurse of the facility and the individual who had quit her position the previous Friday, revealed she had been in the position from 9/18/18 through 12/7/18. Her file included no job description related to the duties of the Infection Control Nurse, nor any specialized infection control training which might have qualified her for the position.

In an interview with Staff #D1, hospital Interim CEO, on the morning of 12/12/18, she stated, Staff #D4, previous Infection Control Nurse, had repeatedly refused training and this was part of her decision to leave the facility. She also provided a listing of 5 different individuals who had filled the position of Infection Control Nurse during 2018.

According to CMS Interpretive Guidelines: The hospital must designate in writing an individual or group of individuals as its infection control officer or officers. In designating infection control officers hospitals should assure that the individuals so designated are qualified through education, training, experience, or certification (such as that offered by the Certification Board of Infection Control and Epidemiology Inc. (CBIC), or by the specialty boards in adult or pediatric infectious diseases offered for physicians by the American Board of Internal Medicine (for internists) and the American Board of Pediatrics (for pediatricians)). Infection control officers should maintain their qualifications through ongoing education and training, which can be demonstrated by participation in infection control courses, or in local and national meetings organized by recognized professional societies, such as APIC and SHEA."


d. [The facility did not] provide adequate documented evidence of complying with the reportable disease requirements of the State of Texas.

Review of facility policy #IC 400.02 entitled "Communicable Disease Reporting," last revised 8/4/16, included the following:
" ...Reporting of a suspected or confirmed communicable disease is mandated under Texas State Law. The primary responsibility for reporting rests with the provider and infection Control Nurse of a Health Care Institution.
The list of reportable diseases is attach to this policy as 400.02a ...
III. PROCEDURE: ...
3. Infection Control:
a. Obtain the laboratory results as applicable from the medical record ...
d. Record the report on the infection control monthly log...
f. Review late lab reports from Medical Records with Chief Nursing Officer and or Medical Director to make decision regarding reporting ..."

The facility provided no communicable disease log for surveyor review though it was requested at the start of survey. The list of reportable diseases referenced in the above policy was only for the hospital county and was from 2016. There was no current state listing of reportable conditions attached to the policy.

In an interview with Staff #D3 on the afternoon of 12/11/18 in the hospital conference room, she was asked about the current listing of state reportable conditions. She stated, "I have a current listing in my office." It was not clarified whether the listing was available to hospital staff.

Based on a review of facility documentation, observation and staff interview, the facility leadership failed to ensure the hospital quality assessment and performance improvement (QAPI) program and training programs addressed infection control issues and implemented corrective actions plans to address them.

Findings were:

Review of document entitled "The Governing Board of Georgetown Behavioral Hospital Health Institute, LLC" revealed the following:
"Section 7.3 - Management of the Environment of Care
7.3.1 The Board shall oversee the planning and implementation of methods for providing for the safety, protection and care of Hospital patients and others, and ensure allocation of appropriate resources to maintain a safe, secure care environment ...
Section 7.4 - Planning
7.4.1 The institutional planning process shall include the following minimum features: ...
7.4.1(c) establishment of a collaborative planning process within the Hospital, to address:
7.4.1(c)(iii) planning that addresses all of the important patient care and organizational functions identified by JCAHO ...
Section 7.6 - Performance Improvement ...
7.6.2 The performance improvement plan shall require participants to implement and report on the activities and mechanism for planning, designing, measuring, assessing and improving the processes related to important patient care and organizational functions. All organized services, including services furnished by a contractor, shall be evaluated. The scope of performance improvement activities being done at any given time shall include all specifically required activities ...
Section 8.2 - Authority and Duties ...
8.2.1(l) to present to the Board or its authorized committee, periodic reports reflecting the professional service of the Hospital ...
8.2.1(o) to review and respond to all inspection reports of any authorized inspecting agency, and to insure that the Hospital meets the standards of JCAHO and any other appropriate accreditation requirements ..."

Review of facility infection control surveillance for 2018 revealed a single notebook which included a listing of patients with a suspected infection who had been prescribed antibiotics at the facility. Specific organisms involved had not been identified. No pertinent patient labs or cultures were included. The notebook appeared to include no follow-up regarding the listed infections. There was no evidence the facility was analyzing patient infection information with the one exception of a somewhat meaningless infection rate.

A review of the governing board meeting minutes for 2018 revealed only two meetings: on 4/27/18 and on 11/15/18. The meeting on 4/27/18 included a 1st quarter infection control report that included minimal information on healthcare associated infection rates without any detail. It did include a note saying, "See attached log." No log was attached to the set of minutes. The minutes did not include any information related to facility handwashing compliance. A very brief blurb in the minutes of the 11/15/18 meeting mentioned only the numbers of patients with infections for the 2nd and 3rd quarters. This did not include any type of analysis regarding these infections; no other specific information was provided. No handwashing surveillance data was included. No other infection control information was included in the governing board minutes.

A review of minutes for the facility Environment of Care/Safety/Infection Control meetings for 2018 included only two meetings: 6/28/18 and 11/28/18. Under the Infection Prevention and Control top for the meeting on 6/28/18, the following items were discussed, as examples:
"1. Hospital Acquired Infections - rate. One episode of medication resistant lice ...Action/Follow-up: [Blank].
2. Issues: dirty & clean supplies being stored in the same areas since the storage room was turned into an office on Brazos ...Action/Follow-up: ... A large storage shelving container to be ordered to store the dirty hygiene bins in to keep away from the clean supplies and linens ...
4. Hand hygiene form needs to be revamped and re-implemented for ongoing monitoring ...Action/Follow-up: ... Form to be changed and given to Lead MHTs for implementation ...
A. Unit and Dept. inspection findings reviewed ...
- Back Facilities [sic] hallways to be cleared of "all" stored Items/junk.
- Continue to log all items and equipment that are removed from facilities or discarded in Asset Form.
- Continue to train all direct care staff on the importance of radios and how to properly use them.
- The Director of PI/Risk to take over IC and maintain all IC records and how to properly use them.
- Insure plenty of snack are being delivered daily to Units and Out Patient Services with Dietary ..."

The minutes of the 11/28/18 meeting included no infection control items of significance.

In an interview with staff member #D3, current Infection Control Nurse, on the afternoon of 4/11/18, in the facility conference room, she stated that she had recently joined APIC (Association for Professionals in Infection Control and Epidemiology) and was also imminently to receive instruction from a corporate sister facility infection control director in Houston. She stated, "I'm feeling overwhelmed. Our last infection control person just quit on this past Friday. I'm also Interim Director of Nursing." She added, "We've had a lot of people cycle through in the past year as the infection control person." When asked if there was any training provided for hospital staff on infection control topics, she stated, "No so much - maybe bloodborne pathogens. New employees get some training at orientation." When asked if she or anyone at the facility was monitoring handwashing practices, she said they were not. When asked about monitoring of tuberculosis, she stated, "It's getting done. We're at about 65%." When this surveyor stated it seemed the facility had no active infection control program, Staff #D3 nodded and stated, "We don't really have a program right now and probably haven't for a while." When asked about infection follow-up and analysis, she stated, "Most of our infections are just UTIs."

A review of the personnel file for Staff #D4, former Infection Control Nurse of the facility and the individual who had quit her position the previous Friday, revealed she had been in the position from 9/18/18 through 12/7/18. Her file included no job description related to the duties of the Infection Control Nurse, nor any specialized infection control training which might have qualified her for the position.

In an interview with Staff #D1, hospital Interim CEO, on the morning of 12/12/18, she stated, Staff #D4, previous Infection Control Nurse, had repeatedly refused training and this was part of her decision to leave the facility. She also provided a listing of 5 different individuals who had filled the position of Infection Control Nurse during 2018.

According to CMS Interpretive Guidelines: The hospital must designate in writing an individual or group of individuals as its infection control officer or officers. In designating infection control officers hospitals should assure that the individuals so designated are qualified through education, training, experience, or certification (such as that offered by the Certification Board of Infection Control and Epidemiology Inc. (CBIC), or by the specialty boards in adult or pediatric infectious diseases offered for physicians by the American Board of Internal Medicine (for internists) and the American Board of Pediatrics (for pediatricians)). Infection control officers should maintain their qualifications through ongoing education and training, which can be demonstrated by participation in infection control courses, or in local and national meetings organized by recognized professional societies, such as APIC and SHEA."

Based on review of documentation and interview, it was determined that all members of the interdisciplinary team did not always participate in plans of care.

Findings were:

Facility policy entitled "Master Treatment Plan" stated in part "Care and treatment decisions are made on a collaborative basis, with input from all disciplines providing care and services to the patient, to allow for the development of a Master Treatment Plan that is interdisciplinary in nature."

Facility policy entitled "Multidisciplinary Treatment Planning Meeting" stated in part "The multidisciplinary treatment team may include:
1. Provider
2. Therapist
3. Utilization Reviewer
4. Nurse
5. MHT

The Master Treatment Plan is initiated with and signed by the patient and treatment team within 3 program days after admission to the program."

Facility policy entitled "Provider's Role in Treatment Team," last revised 3/3/18, included the following:
" ...The treatment team is led by the patient's attending provider. He/she facilitates a collaborative effort to ensure and effective plan of care, which promotes safe and appropriate patient care ...
A. The care of each patient is directed by an attending provider.
B. The provider works with the entire treatment team to develop and carry out an individualized plan of care for the patient.
C. The provider completes a psychiatric evaluation ...
E. The provider directs and participates in treatment team meetings.
F. He/she assists the team in prioritizing problems, refining interventions and evaluating outcomes ...
H. He/she must indicate approval to validate the written Master Treatment Plan ..."

Facility policy entitled "Documentation Overview" stated in part "Psychiatric Evaluation-The psychiatric evaluation must be completed within 24 hours of the patient's admission ...
Plan of Treatment:
" The comprehensive treatment plan will be initiated by the RN within 8 hours of admission.
" The comprehensive interdisciplinary treatment is completed within 72 hours. The various evaluations and integrated assessment culminate in a comprehensive, patient specific plan of care.
" Treatment plan reviews are conducted at least weekly or when any major change in patient condition occurs.
" A new treatment plan is done for re-admissions."

Patient # 13 (Roster C) was admitted 12/06/2018. On the dates of the survey she was still a patient at the hospital. The Master Treatment Plan was started by Nursing Services on 12/6/18. Review of the patient record revealed no documented patient, doctor, Social Services or Activity Therapy involvement in the patient Treatment Plan.

Patient # 14 (Roster C) was admitted 12/5/18. On the dates of the survey he was still a patient at the hospital. The Master Treatment Plan was started by Nursing Services on 12/6/18. Review of the patient record revealed no documented patient, doctor, Social Services or Activity Therapy involvement in the patient Treatment Plan.

Patient # 15 (Roster C) was admitted on 10/29/18. The Master Treatment Plan Review was dated 11/5/18. The treatment review was signed by the patient (age 16-family involvement?), Nursing Services, Social Services and Activity Therapy on 11/5/18. The physician did not sign the review until 11/6/18 which indicated that he did not attend the Care Plan meeting which he/she was required to lead.

Patient # 15 (Roster C) had a Master Treatment Plan Review that was initiated 11/9/18. Patient signed the plan on 11/9/18, Nursing Services, Social Services and Activity Therapy signed on 11/12/18. The MD signed the document on 11/17/18 again indicating the meeting was held without the lead of the MD.

Patient # 15 (Roster C) had another Master Treatment Plan initiated on 11/26/18. This document was signed by the patient, Nursing Services, Social Services and Activity Therapy staff on 11/26/18. The MD did not sign until 11/27/18 which indicated he did not attend the meeting.

Patient # 15 (Roster C) had a Master Treatment Plan Review initiated on 12/3/18. This document was signed by the patient, Social Services and the Activity Therapy staff on that date. No physician or nursing signatures appeared on the document.

Patient # 16 (Roster C) was admitted 8/4/18. The Master Treatment Plan was initiated 8/4/18 by Nursing Services. The Physician signed the plan on 8/6/18. No patient, Social Services, Activity Therapy or CD Counselor signatures were found on the record.

Patient # 17 (Roster C) was admitted 10/12/18. The Master Treatment Plan Review was signed by the patient (age 13-family involvement?), Physician, Social Services and Activity Therapy staff on 10/18/18. There is no documented evidence that Nursing Services was involved in the Treatment Team meeting.

Patient # 18 (Roster C) was admitted 11/5/18. The Master Treatment Plan was initiated by Nursing Services on 11/5/18. The document was signed by Social Services on 11/8/18 and by Activity Therapy on 11/7/18. The MD signed the plan on 12/6/18. Although the patient (aged 13) signed the plan on 11/5/18, there was no indication of family involvement in the meeting. The signatures and dates indicate that the entire Treatment Team did not meet together to review the plan.

Patient # 18 (Roster C) had a Master Treatment Plan Review that was initiated 11/9/18. The plan was not signed by the patient (sedated by emergency medication) or Nursing Services. Social Services signed the document 11/9/18, Activity Therapy signed the document on 11/12/18 and the physician signed on 11/14/18. The dates next to the signatures indicated that the Treatment Team did not meet together to review the plan.

In an interview with the Regional Director of Risk Management on 12/12/18, it was acknowledged that the Treatment Team did not always meet as a group to discuss patient Plans of Care. It was also confirmed that there was no documented involvement of family/guardians in the Treatment plans of the aforementioned children.