HospitalInspections.org

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of grievance documentation for 7 of 8 patients (Patients 18, 20, 23, 24, 26, 27, and 28), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the governing body failed to fully implement its POC effective 07/07/2022 to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to the findings cited at Tag A-263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement.

3. Refer to the findings cited at Tag A-385 under CFR 482.23 - CoP: Nursing Services.

4. Refer to the findings cited at Tag A-700 under CFR 482.41 - CoP: Physical Environment.

5. Refer to the findings cited at Tag A-750 under CFR 482.42(a)(3) - Standard: Infection Prevention Clean and Sanitary EOC.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of grievance documentation for 7 of 8 patients (Patients 18, 20, 23, 24, 26, 27, and 28), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure each patient's right to provision of care in a safe setting. Those failures resulted in actual and potential physical and psychological harm to patients.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tags A-144 and A-145 under CFR 482.13(c) - Standard: Privacy and Safety.

2. Refer to the findings cited at Tags A-118, A-122, and A-123 under CFR 482.13(a)(2) - Standard: Patient Grievances

29708


Based on interview, review of grievance documentation for 7 of 8 patients who submitted grievances (Patients 18, 20, 23, 24, 26, 27, and 28) regarding 8 of 9 grievances, review of P&Ps, and review of the hospital's POC, it was determined the hospital failed to fully implement its POC related to grievance processes as investigations of patient grievances were not complete and written responses were not provided to patients.

Findings include:

1.a. Review of the hospital's POC reflected "The OSH Grievance Policy (7.006) will be updated to provide that a Grievance Committee shall review and respond to all grievances, as delegated by OSH's Governing Body, and will require a Grievance Committee to provide written grievance responses to the grievant within 7 days of the hospital receiving the grievance. The Grievance Committee may issue a written response outside of the 7 days, for good cause, including but not limited in circumstances where additional investigation is required to address complex grievances or to accommodate isolation/quarantine on the complainant's unit. In which case, the patient will be provided with a written estimation of anticipated response. The policy will also be updated to explain expectations for the Grievance Committee to provide thorough grievance responses and expectations for grievance form completion."

1.b. Review of the P&P titled "Patient Grievances" dated 07/17/2022 reflected that it included the following language: "OSH responds to ineligible grievances per Procedures A. The following issues or statements are ineligible for the grievance process ..." Review of "Procedure A" titled "Policy Attachment ... Grievance Process" and dated 07/17/2022 reflected that in those cases there was a process by which the grievance committee would review those "ineligible grievances" and issue a written response to the patient within seven days.

2.a. Review of the complaint and grievance log for Patient 18 reflected that the "Concern Type" for two grievances dated 07/11/2022 were recorded as "Non-Grievable."

2.b. A "Patient Grievance" form regarding Patient 18 documented as received on 07/11/2022 with blank "Patient Signature:" and "Date" sections reflected "11:45pm 6/9/22 Nurse on B2 refuses to take my heart problems seriously! My heart feels very much in pain [illegible entry] Hurts too! I just had a heart attack just now! Nurse refused to call Dr. so I can go to Salem ER for heart attack. I need to be sent to ER in Salem Hospital ... I've just had another heart attack so need to be sent to ER to have blood work done, EKG, etc.! Nurse doesn't take my life seriously enough to be send to E/R (sic) in Salem Hospital because of heart attack ... I'm blind in my R eye, left eye just fine. Need to go to E/R (sic) ..."

A "Patient Grievance Response" form regarding Patient 18 with "Date Unit Received: 7/11/22" was reviewed. The only information on the form was the patient's name, unit, unit received date, an "Avatar" number, and a grievance number. Sections on the form that were not completed included:
- "Date Sent"
- "Date Ruled Out"
- "Investigating Yes or No"
- Box next to "Patient met"
- Box next to "Patient declined to meet"
- "Date of review"
- "The following staff contributed to this response"
- "Information and unit response (attach additional pages, if needed."
- "Patient Signature"-* Box next to "Declined to sign" -* "Completion Date:"
- "Staff Completing grievance:"

A 2-page document titled "Determination of an Ineligible Issue" dated 07/12/2022 regarding Patient 18 was provided with the other grievance documents. Page 1 reflected:
"There are some issues that Oregon State Hospital (OSH) does not have the authority or ability to address. These issues are ineligible for the grievance process. Ineligible issues include but are not limited to those listed below. Your concern is ineligible for the grievance process because it is about:" The following items were listed on the form with boxes next to them:
* "Legal status and court orders" followed by
- "Informed consent (medication)"
- "Psychiatric Security Review Board (PSRB)"
- "Commitment types"
- "Discharge requests"
* "Medical diagnosis"
* "Grieving on behalf of a peer"
* "Issues already resolved by the grievance process and have not occurred again."
* "Other:"
The box next to "Issues already resolved by the grievance process and have not occurred again." was checked.

The form further reflected "Patients will not receive a written response when their concern is identified as ineligible. The IDT will receive a copy and may decide to discuss a patient's grievance with them, outside of the grievance process. Patients may not appeal ineligible issues."

Page 2 reflected "Your concern is still important. Below is a list of resources that may help you address your concern. You are also encouraged to talk to your IDT about any problem or concern ..."
- "If your grievance stated or implied that it was an emergency issue or a civil rights violation, Ombuds and Family Services has screened it - and ruled it out prior to this notification."
- The "For concerns about your legal status or discharge" section was followed by information about a law library; and various boards, organizations, and contact information.
- "For concerns about medications: Talk to your doctor or the nurse manager on your unit."
- "For information about the informed consent (medication) process, including your rights: Contact OSH Informed Consent at [phone number]."
- "For concerns about a peer/another patient: Talk to a trusted staff person or a Peer Recovery Specialist."
- "For concerns about actions or decisions by other local, state or federal agencies you will need to contact those agencies directly."
- "General Resource: OSH Ombuds & Family Services Salem: [phone number] Junction City: [phone number]."

Although the 2-page document had the patient's name on it, it was not clear if it was provided to the patient. It was not clear what specific issues in the complaint were "already resolved by the grievance process," how they were resolved, and when. In addition, the document was inconsistent with the hospital's POC. For example, the document deemed certain grievances "ineligible" and the patient would not receive a written response to those. However, the hospital's POC reflected "a Grievance Committee shall review and respond to all grievances ... and will require a Grievance Committee to provide written grievance responses to the grievant within 7 days of the hospital receiving the grievance."

No other grievance documentation was provided for the patient. There was no documentation of an investigation of the patient's complaint. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she stated, "There is no written response." The OMB stated there should be additional documentation that refers to a prior grievance submitted by the patient that was already reviewed and addressed. However, he/she stated that was not done.

2.c. Another "Patient Grievance" form regarding Patient 18 was reviewed. The form was documented as received on 07/11/2022 and signed by the patient and dated 07/09/2022. It reflected "I was forced a needle in my left backside cheek. Dr. orders ..."

A "Patient Grievance Response" form regarding Patient 18 with "Date Unit Received: 7/12/22" was reviewed.
The only information on the form was the patient's name, unit, unit received date, an "Avatar" number, and a grievance number. Sections on the form that were not completed were the same as those identified in Finding 2.b. above.

A 2-page document titled "Determination of an Ineligible Issue" dated 07/13/2022 regarding Patient 18 was provided with the other grievance documents. The document included the same information as the "Determination of an Ineligible Issue" document in Finding 2.b. above with the exception that "Your concern is not eligible for the grievance process because it is about:" was followed by a checked box next to "Legal status and court orders."

No other grievance documentation was provided for the patient. There was no documentation of an investigation of the patient's complaint. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she stated there was no written response except the document saying the patient was "ineligible" for a written response, and "We don't know for sure if that was given to the patient." The OMB confirmed there was no other documentation related to the grievance.

3. A "Patient Grievance" form regarding Patient 20 documented as received on 07/09/2022 reflected "Why was the MP3 player that was sent in denied? How can we make it qualified?" The "Patient Signature:" and "Date:" sections were blank. There was no other documentation regarding the patient's complaint.

An undated "Patient Grievance Response" form regarding Patient 20 was reviewed. The only information on the form was the patient's name, unit, and a grievance number. Sections on the form that were not completed included:
- "Date Sent"
- "Date Ruled Out"
- "Investigating Yes or No"
- Box next to "Patient met"
- Box next to "Patient declined to meet"
- "Date of review"
- "The following staff contributed to this response"
- "Information and unit response (attach additional pages, if needed)."
- "Patient Signature"-* Box next to "Declined to sign"
- "Completion Date:"
- "Staff Completing grievance:"

No other grievance documentation was provided for the patient. There was no documentation of an investigation of the patient's complaint. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

4. A "Patient Grievance" form documented as received on 07/13/2022 was signed and dated by Patient 23 on 07/12/2022. It reflected "Staff went through my personal belongings without my permission ... without me being present and some items are missing ... 3 pens 1 jewelry box [illegible entries]"

A "Patient Grievance Response" form regarding Patient 23 reflected "Patient met" and "Date of review: 7/19/22." Under "Information and unit response (attach additional pages, if needed," it reflected "[Patient 23] took my original response and declined to return it to me. [He/she] does not agree with the response I provided ... Patients were provided the opportunity to be present for this room and personal item check ... no client pre-notification is required to remove contraband or unapproved items from client property ... new protocol allows security staff to remove items from patient belongings without prior notice ... staff will work with clients on options for storing removed items." The patient signature line was blank and the box next to "Declined to sign" was also blank. The form was signed by a staff and "Completed Date" reflected 07/27/2022.

It was not clear what the outcome of the meeting with the patient was. The form indicated the patient took the "original response" and refused to return it, but it was not clear what was written on the "original response." There was no investigation regarding whether items were removed from the patient's room including the items the patient reported were missing. No other grievance documentation was provided for the patient.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she acknowledged the documentation regarding a written response was unclear and it could not be determined what the patient was provided. The OMB stated, "The updated grievance process didn't go into effect until July 18th."

5. A "Patient Grievance" form documented as received on 07/13/2022, and signed by Patient 24 and dated 07/11/2022 reflected, "I'm feeling threatened by others, And I'm not recieving (sic) the correct food, I'm not feeling the correct sufficiency in meals. And I'd like to recieve (sic) the proper care & information for health care and hospital stay. I'm feeling neglected, and rushed daily to neglect my needs. And I didn't get proper intake."

The response to the question, "How have you tried to resolve this issue?" reflected "Yes I have consistently asked for religious service and have tried to remain resting in my room, but feel to (sic) much dis-comfort (sic). I've also tried to ask for more sufficient items on food, and I've also asked for hospital admission packet form and papers and information not received ..."

A "Patient Grievance Response" form regarding Patient 24 with "Date Unit Received: 7/8/22" was reviewed. Under "Information and unit response (attach additional pages, if needed," it reflected "feeling threatened by others, and I'm not recieving (sic) the correct food, not feeling sufficiency in meals and I'd like to receive the proper care & information for health care and hospital stay. I'm feeling neglected." The form was signed by the patient. All of the handwritten entries on the form appeared to be the same handwriting as on "Patient Grievance" form written by the patient above. The "Completion Date:" and "Staff Completing grievance:" sections were blank.

An undated, typed document with no information regarding the author of the document was attached to the "Patient Grievance Response" form. It reflected "Information and unit response ... On 7/14/2022 the IDT from AN3 met with [Patient 24] for about 20 minutes ... [Patient 24] states in [his/her] grievance 'I feel threatened by others.' The PMHNP recommends medication to assist [Patient 24] in having reduced mental illness symptoms to which [Patient 24] declines at this time ... 'I'm not receiving the correct food.' [Patient 24] met with OSH dietician on 7/8/2022 and Ensure was ordered. Dietician states in [his/her] notes [he/she] will meet follow up with [Patient 24] by 7/25/2022 ... 'I'd like to receive the proper care and information' [Patient 24] received admission paperwork on 7/8/2022 ..."

The documentation lacked a complete and timely investigation of the patient's complaints. For example, it was not clear when the attached document was completed. There was no investigation related to the patient's complaint of feeling threatened by others. The documentation reflected only that he/she was recommended medications to assist in reduced mental illness symptoms. There was no investigation related to the patient's statement "I'd like to receive the proper care."

No other grievance documentation was provided for the patient. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she stated the patient wrote in the "staff sections" on the grievance response form and "We don't know if the patient received a written response."

6. A "Patient Grievance" form documented as received on 07/19/2022 and signed by Patient 26 and dated 07/17/2022 reflected "[Name] the evening nurse has harassed me on 2 occans (sic) about being at the end of my hall with with (sic) [name]. Both times we were abaying (sic) all rules and policies of OSH. This kind of behavior stress (sic) me out and makes it harder to work with staff as a team. Stop this [person] from projecting [his/her] own fears onto me ..."

A "Patient Grievance Response" form regarding Patient 26 with "Date Unit Received: 7/19" was reviewed. The only information on the form was the patient's name, unit, unit received date, and a grievance number. The form was otherwise incomplete.

No other grievance documentation was provided for the patient. There was no investigation of the patient's complaint, including of being "harassed" by a nurse. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

7. A "Patient Grievance" form documented as received on 07/19/2022 and signed by Patient 27 and dated 07/15/2022 reflected "I would like a formal and accurate explanation for why patients (including myself) do not have acess (sic) to computers through computer lab and supported education ..."

A "Patient Grievance Response" form regarding Patient 27 with "Date Unit Received: 7/19" was reviewed. The only information on the form was the patient's name, unit, unit received date, and a grievance number. The form was otherwise incomplete.

No other grievance documentation was provided for the patient. There was no documentation of an investigation of the patient's complaint. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she confirmed there was no documentation that reflected a written response was provided to the patient.

8. A "Patient Grievance" form documented as received on 07/19/2022 and signed by Patient 28 and dated 07/18/2022 reflected "[Name] is targeting me. [He/she] is using a previous sexual encounter that was on the unit, and trying to make it look like I am like [him/her]." In response to the question "How have you tried to resolve this issue?" it reflected "I'm not, [he/she] is an animal and is dangerous."

A "Patient Grievance Response" form regarding Patient 28 with "Date Unit Received: 7/19" was reviewed. The only information on the form was the patient's name, unit, unit received date, and a grievance number. The form was otherwise incomplete.

No other grievance documentation was provided for the patient. There was no documentation of an investigation of the patient's complaint. There was no documentation of a written response provided to the patient. There was no documentation that reflected a written estimation was provided to the patient indicating additional time was needed to investigate the grievance or for another "good cause" in accordance with the hospital's POC.

During an interview with an OMB on 07/28/2022 at the time of the grievance review, he/she confirmed there was no documentation that reflected a written response was provided to the patient. In response to whether there was any further investigation or other documentation, the OMB stated "No."

Based on interview, review of grievance documentation for 7 of 8 patients who submitted grievances (Patients 18, 20, 23, 24, 26, 27, and 28) regarding 8 of 9 grievances, and review of the hospital's POC, it was determined the hospital failed to fully implement its POC related to grievance processes as investigations of patient grievances were not complete and written responses were not provided to patients.

Findings include:

1. Refer to the findings cited under Tag A-118, CFR 482.13(a)(2) - Standard: Grievances.


29708

Based on interview, review of grievance documentation for 7 of 8 patients who submitted grievances (Patients 18, 20, 23, 24, 26, 27, and 28) regarding 8 of 9 grievances, and review of the hospital's POC, it was determined the hospital failed to fully implement its POC related to grievance processes as investigations of patient grievances were not complete and written responses were not provided to patients.

Findings include:

1. Refer to the findings cited under Tag A-118, CFR 482.13(a)(2) - Standard: Grievances.


29708

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure each patient's right to receive care in a safe setting in the following areas.
* Patient supervision and prevention of patient elopement during off-campus activities.
* Patient supervision and prevention of patient elopement and entry into unauthorized areas during on-campus activities.
* Patient supervision and prevention of patient access to contraband, unsafe and prohibited items that can be used for SAs, SH or harm to others. At least one patient reviewed experienced actual harm as result of failure to prevent those items in the EOC and failure to observe the patient as ordered by the physician.
* Supervision and prevention of other unsafe conditions in the indoor and outdoor EOC.
* Investigation of incidents to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patient and other patients.
* Hospital leadership monitoring of the EOC, and of staff practices to ensure a safe EOC.

Tours of patient care areas were conducted on both OSH-Salem and OSH-JC campuses. Those areas included but were not limited to 24 patient rooms and two seclusion rooms on eight HLOC units. The majority of those patient rooms were observed to be disorganized, cluttered and littered with piles of unfolded clothing and linens, numerous papers and documents, numerous food and beverage items, numerous containers of personal care products and other various types of items. Those conditions were observed on floors, beds, under mattresses on beds, shelves, desktops, bedside stands and in bathrooms and provided numerous opportunities for concealment of unsafe and prohibited items and rendered floors and other surfaces to be not readily cleanable.

Findings include:

A. Following are findings regarding POC implementation related to supervision of patients to prevent elopement during off-campus activities, to maintain accountability for patients during on-campus activities off the secure unit, and to prevent patient entry into unauthorized areas:

1.a. The POC to prevent patient elopement during off-campus outings was not fully implemented. The POC included the following actions that the hospital attested it would implement:
"Issue administrative directive to modify policy 6.006, 'On-Grounds and * (sic) Off-Grounds Outings' to: Update timeline for nursing assessment prior to outing (2 hours or less). Update timeline for managers to approve trip slips (must be approved 24 hours prior at minimum, except in cases of urgent medical/legal/discharge trip slip generation) ... Update contents of pre-trip meeting to be reviewed by staff with patients prior to every outing before leaving the secure perimeter ... Add requirement that a personal search of patient (including confirmation of amount of money patient is carrying) is conducted prior to departure for approved on-grounds and off-grounds trips ... Monitoring: Chief Treatment Fidelity Analyst will coordinate monthly with Discipline Chiefs and Treatment Mall Managers to accompany outings for direct observation of staff compliance with policy requirements for outings on an ongoing basis ... Date of completion for correcting deficiency cited: July 6, 2022."

1.b. Review of Trip Slip and medical record documentation for Patient 1 reflected that he/she went on a recreational off-campus outing on 07/22/2022 scheduled to begin at 0900. The documentation was not complete in accordance with the POC as follows:
- The manager's approval for the outing was documented as obtained on 07/22/2022 at 0712, approximately two hours prior to the outing instead of at least 24 hours prior to the outing as indicated in the POC.
- There was no documentation of the "pre-trip meeting" indicated in the POC, including on the medical record outing "Group Note" completed by the staff who conducted the outing.

1.c. Review of Trip Slip and medical record documentation for Patient 2, Patient 3, Patient 4 and Patient 5 reflected that they went on a recreational off-campus outing on 07/27/2022 scheduled to begin at 1100. The documentation was not complete in accordance with the POC as follows:
- The managers's approval for the outing was documented as obtained on 07/27/2022 at 1046, approximately 15 minutes prior to the outing instead of at least 24 hours prior to the outing as indicated in the POC.
- There was no documentation of the "pre-trip meeting" indicated in the POC and there were no medical record outing "Group Notes" documented for any of the patients as of the date of this review on 07/29/2022.
- The "Personal Search" and "Money Confirmation" fields required for security staff to complete at the time of patients' departure were blank for all four of the patients.

1.d. During interview with the DOTS, the TM, the TCPS and other staff at the time of the review on 07/29/2022 beginning at 1145 they confirmed the findings and indicated that it was not clear who was responsible for the "pre-trip meeting" and how and where that was to be documented.

1.e. The POC for "Monitoring" off-campus outings had not been implemented. A document titled "Patient Trip Visual Observation Assignment Tracker" was provided at the time of the review of off-campus outings. The tracker documentation reflected that the POC off-campus outings "direct observation" process was not scheduled to begin until the "Week of Aug 1-7" and had not been implemented at the time of this survey.

2.a. The POC related to door security to prevent patient elopement from secure areas and patient entry into unauthorized areas was not fully implemented. The POC reflected the "Date of completion for correcting deficiency cited: July 6, 2022" and included the following actions that the hospital attested it would implement:
"Through training, ensure staff are knowledgeable about transport process, including a specific emphasis on:
o handoff communication - notification to lead nurse when taking patients off the unit and returning them, including any behavioral concerns during time off unit
o transport ratios - per existing policy
o physical supervision - per existing policy (monitor location of patients to account for all patients at all times, verify all patients are with the group before moving to another area and remain together during transport, etc.)
o door closing - per existing policy (verify that all doors are closed and secure after going through them, redirect patients away from doors if they are not meant to go through them; escorting staff positioned at rear of group to ensure doors are closed and secure)."

Regarding "Monitoring" the POC reflected:
"The Clinical Nurse Advisor will complete rounds on a weekly basis for 4 months to directly observe staff completing the following tasks:
o on the unit RCM
o verify unit doors are being checked
o transport to and from units
o Dining room staffing and monitoring of patients
o Staff ratios for off-unit activities."

2.b. Door security practices observed were unclear and inconsistent. It was not clear how staff were to identify whether patients were in vicinity of doors when they were passing through secure doors and it was not clear how staff were to "verify" and "ensure" doors were closed and secure before leaving secure doors unattended. For example:
During tour of MN2U on 07/26/2022 at 1520 with the DCNO, OSH-JC DON, and DSW observations from outside the locked Mountain South entry door to MN2U revealed the following:
* Directly outside the entry door, a short cement corridor and cement stair landing were observed. From the landing, ten cement stairs leading upward and ten cement stairs leading downward were observed.
* The door opened and five people exited the door one at a time, walked single-file through the corridor and landing, and walked more quickly or jogged down the stairs. The sound of footsteps was loud and echoed as the persons went down the stairs.
* None of the people stopped after exiting the door.
* None of the persons made physical contact with the door after exiting the door.
* None of the persons were observed visually or otherwise checking the door to verify it closed.

2.c. During an interview on 07/26/2022 with the OSH-JC DCNO and other staff present at the time of the observation, he/she revealed:
* Staff escorting patients from the unit would not know if unauthorized patients from the unit followed them out the door until they got to the bottom of the stairs and did a "head count."
* In response to what the hospital's P&P were with regard to how staff ensured the door closed after they exited the door, he/she stated there were a "variety of ways" and staff could "see" the door close, "listen for the click of the door," or physically check the door. He/she stated the hospital's protocol did not specify.

2.d. Review of video recording without audio from a camera view of the outside of Mountain South door on 07/27/2022 at approximately 1140 with a DOS, OSH-JC DON, OSH-Salem DCNO and other staff present revealed:
* The camera view included the outside of Mountain South door, corridor outside Mountain South door, full view of the stairs leading upward, partial view of the stair landing and first five stairs leading down the stairs, and full view of the last five stairs leading downward.
* The door opened and five people were observed exiting the door and walking quickly or jogging down the stairs as described in the observation above.
* The door did not fully close until after the last person stepped onto the first stair leading downward.
* No person was observed stopping at the door and making physical contact with the door, or otherwise verifying it was closed.
* No person was observed looking at the door at any time after exiting, while walking through the corridor, or before reaching the end of the landing at the top of the stairs.
* The video view did not fully show the last person's head or face when he/she reached the end of the landing at the top of the stairs or when going down the stairs.

2.e. During an interview with a DOS, OSH-JC DON, OSH-Salem DCNO and other staff present on 07/27/2022 at the time of the video review the following information was provided:
- Five people exited the door.
- The first person who exited the door was a staff. The next three people were patients, and the last person was a staff.
- The door was not within view of the first staff person when it closed.
- Staff present during the video review could not confirm that the last staff person exiting the door verified it was closed. The OSH-Salem DCNO stated, "I don't know if there's a way to tell if they checked the door closure." The DOS stated, "It could go either way."

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B. Following are findings regarding POC implementation related to patient access to contraband, unsafe and prohibited items, and to investigation and response to incidents to prevent recurrence:

3.a. The POC to prevent patient access to contraband, unsafe and prohibited items that could be used for SAs and SH and could result in harm to patients and others was not fully implemented, and investigations and response to such incidents were not clear or complete. The POC actions that the hospital attested it would implement included, but were not limited to:
* "Since the date of survey, OSH has instituted a new standard prohibited items list that applies across all hospital units, which identifies items a patient may have access to and the degree of supervision necessary when an item is in use. This list is applied when patients are admitted and their belongings are inventoried/screened. Unauthorized items are placed in off-unit storage or disposed of per existing policy, and limited-access items are placed into on-unit storage which requires staff to obtain the item for a patient's temporary use ..."
* "Develop Unit and Mall protocol (see next bullet) to monitor patient safety, infection control measures, and environment of care checklist on a weekly basis. This protocol is referred to as the Patient Environment Safety Surveillance (PESS). The checklist requires staff to verify environmental safety items such as: o Environment in good repair (including signs, badge readers, etc.) o Unobstructed pathways o Patient rooms free of garbage, food, fluids, dirty laundry visible o Environment free of ligatures and contraband/prohibited items (including items which have been modified in such a way that they become potential weapons/ligatures) o Furniture and shower curtain in good repair ..."
* "[PESS] process to assess the physical environment on patient care units and in Treatment Mall spaces on a weekly basis. o Direct that unit and Treatment Mall supervisors locating hazards found in the physical environment must document findings, and o Complete any work order to fix broken items, and o Ensure Incident Reports are completed for any physical damage within the environment from a critical incident or upon discovery during inspections within the patient unit or treatment mall area, and o Report any safety concerns to the OSH Safety Team and Facilities ..."
* "Issue administrative directive to modify policy 2.001 'Infection Prevention Program' to allow staff to perform infection prevention measures such as removal of garbage, spoiled food, dirty linen, and dirty clothing from rooms ... o Upon completion of the PESS checklist, supervisors must retain copies of the form for audit purposes from hospital leadership and Safety Team ..."
* Implement PESS process. o Use prohibited items data to prioritize patient units to perform comprehensive unit searches and patient property inventory. Remove any prohibited items or excess property from units and verify that items in use are allowable per the "Risk Level" of the room. o Develop PESS checklist for units and treatment malls. o Train direct care Nursing and Treatment Services staff on the PESS process and checklist. o Direct care staff will read and acknowledge Administrative Directive modifying policy 8.009 "OSH Safety Program" which establishes the Patient Environment Safety Surveillance Process. o Implement Unit & Mall PESS protocol/audit; take corrective action in the moment ..."
* "Monitoring: The Clinical Nurse Advisor will round on a weekly basis on the units for 4 months to directly observe staff completing RCM and interview them on their understanding of their role ..."
* "Date of completion for correcting deficiency cited: July 6, 2022."

The POC included a full definition of PESS that reflected "PESS" is a process where Unit Administrators and Unit Safety Specialists use a checklist to monitor environmental safety items such as:
· Environment in good repair (including signs, badge readers, etc.)
· Unobstructed pathways
· Patient rooms free of garbage, food, fluids, dirty laundry visible
· Environment free of ligatures and contraband/prohibited items (including items which have been modified in such a way that they become potential weapons/ligatures)
· Furniture and shower curtain in good repair"

3.b. A document titled "[OSH] Patient Property/Item Access List" dated 07/06/2022 was reviewed. It contained sections for "Contraband ... Prohibited Items: No Access Allowed ... Tier 1: Checkout For Off-Unit Use, Specified Locations Only ... Tier 2: Checkout For On-Unit Use, Supervised ... Tier 3: Checkout For On-Unit Use, Unsupervised." A list of items followed under each section, some which were not clear, and some which were observed during tours of patient units. For example:

* Under "Prohibited Items: No Access Allowed" the list included "All Jewelry, with exceptions for the following: ... Bracelets or Anklets that are easy breakaway, no metal, AND no clasp ... Rings that are not significantly raised." It was not clear what the criteria was for "easy breakaway" and "significantly raised" as different individuals may assess those differently. Further, it was not clear whether there was a limit on the number of bracelets or anklets a patient was permitted to possess. There was a risk that the string or elastic from multiple bracelets could be tied together, combined, twisted or braided to form a longer, non-breakaway ligature. Such a case was identified in the original SA SOD report dated 01/17/2022 for Patient 3 who was reviewed during that survey.

* Under "Prohibited Items: No Access Allowed" the list also included "Any item with ethyl, methyl, or isopropyl alcohol as the first or second ingredient ... Glass, mirror, or ceramic items ... Non-OSH issued pens/pencils/markers (must be 'mini' length) ... Plastic bags or plastic wrap ... Prescription or over-the-counter drugs ... Wire, cables, cords, or rope longer than 9 inches." Such items were observed on patient care units as reflected in the findings that follow in this deficiency.

* Under "Tier 2: Checkout For On-Unit Use, Supervised" the list included "Scissors, including safety scissors" and "String, twine, thread, or yarn (no longer than 9 inches)." Such items were accessible to patients, or observed to be on patient care units and unsupervised as reflected in the findings that follow in this deficiency.

3.c. The P&P titled "Handling Patient Food on Units," dated 02/01/2022 reflected "Cleanliness and Food Safety ... When patients are allowed to eat in their rooms because they are unwilling or unable to travel to the dining area, staff assigned to RCM duties must check for, and assist patients in the removal of, all food waste and uneaten foods and fluids (excluding water) after each meal or snack, including meals and snacks, eaten outside routinely scheduled times ..."

4. During tour of MN2U on 07/26/2022 beginning at 1500 with the DCNO, OSH-JC DON, and DSW the following observations were made:

* In PtRm-CC a small plastic unmarked/unlabeled medication cup containing an unknown thick, white substance was observed on a shelf. Also on the shelf was deodorant, body wash, a tub of Light Moisturizer, toothpaste, toothbrush, and a white bin containing numerous other toiletry items. A toothbrush, toothpaste, deodorant and other toiletry items were observed on a desk. There was no information on the toiletry items distinguishing who they belonged to in the double occupancy room. A shoebox size plastic bin with a lid on it was observed. A Jolly Rancher candy was on top of the lid. Inside the bin multiple packaged snack items including KitKat bars, small containers of Trix and Lucky Charms cereal, Rice Krispies Treats, and other food items were observed. During an interview with the OSH-JC DON at the time of the observation, he/she stated the bin containing snacks should be in the unit "kitchenette" and should not be in the patient's room.

* In PtRm-AA a desk was observed cluttered and disorganized with various items including an apple, hairbrush, two chapsticks, Dove deodorant, large lotion bottle, an individually wrapped Jolly Rancher and Life Savers-shaped candies, a tall solid white plastic coffee cup with lid, a water bottle with three thin bracelet-appearing items draped around the bottle, another water bottle, six disposable surgical masks, two small trinket boxes with lids, loose papers and envelopes, notebooks, and other items. Two paper cups containing individual mustard packets and two puzzle boxes were observed on a shelf. On the same shelf, a crumpled lunch size brown paper bag was observed tucked towards the back of the shelf with the top folded over and appeared to have an item or items inside it. During an interview with the OSH-JC DON at the time of the observation, he/she stated the apple, mustard packets and candy should not be in the patient's room.

* On 07/26/2022 at approximately 1700, observations from inside the medication room revealed:
- Two medication pass windows between the medication room and a corridor open to the milieu. Each window had a counter just below the window.
- An RN was observed standing at one of the windows. The RN was positioned with the window to the left and a computer keyboard, monitor and other items in front of the RN to the right of the window.
- The window was open several inches, enough for the RN to easily move his/her hands in and out of the window to administer medications to patients outside the window.
- Patient 28 was observed leaning against the wall directly outside the open window. The RN put a pair of bandage scissors on the counter inside the open window within reach of the patient. The RN was observed turned to the right at an angle from the window towards the computer with his/her hands near the computer keyboard.
- Thereafter, the RN used the bandage scissors to cut open a capsule and administer the contents to the patient.

The RN did not maintain control of the scissors when he/she put the scissors on the counter within reach of the patient. This created the opportunity for the patient to access the scissors and inflict self-harm or harm to others.

Review of video recording without audio from a camera view inside the medication room on 07/27/2022 at approximately 1140 with the a DOS, OSH-JC DON, OSH-Salem DCNO and other staff present confirmed the observation on 07/26/2022 above related to the failure to maintain control of scissors at the medication window. During an interview with the OSH-Salem DCNO on 07/27/2022 at the time of the video recording review, he/she confirmed the RN put the scissors on the counter at the medication window within reach of a patient and did not maintain control of the scissors.

5.a. During tour of MN3U with the TMM, the PD, a CS and other unit staff on 07/26/2022 beginning at 1515 observations included, but were not limited to, the following items and conditions:

In double-occupancy PtRm-DD:
* Piles of unfolded clothing, papers and documents, numerous personal care and other items strewn on beds, floors, and surfaces in a cluttered and disorganized manner.
* A green plastic basket with personal care items including a hairbrush full of hair, uncovered long-handled toothbrush, toothpaste, open Kleenex, three containers of deodorant, bar soap.
* Three uncovered and unlabeled containers of white creme-type substances of various sizes and with various amounts, one of which was full and had a plastic spoon sticking into the substance.
* On the bathroom shelf an uncovered, used long-handled toothbrush, toothpaste, and barsoap in a dirty container.
* In a brown paper bag an open box of "Jelly Beans" and a clear plastic bulk-food-type container labeled as "Sesame Sticks." However, the contents of the plastic container were a trail mix concoction that included dried banana chips, coconut shavings, dried pineapple and papaya, dates, and raisins.
* Multiple plastic and rigid beverage containers, including paper cups with various types and amounts of unidentified liquids.

In double-occupancy PtRm-EE:
* Piles of unfolded clothing, papers and documents, personal care and other items strewn on beds, floors, and surfaces in a cluttered and disorganized manner.
* Uncovered and unlabeled containers of white powder.
* Desktops cluttered with items that included: personal care items, a long-handled toothbrush, toothpaste, and an open bottle of flavored water.
* At least three corded earbuds and a beaded bracelet were found.
* There was used bar soap on the bathroom sink

In double-occupancy PtRm-FF:
* Piles of unfolded clothing, papers and documents, personal care and other items strewn on beds, floors, and surfaces in a cluttered and disorganized manner.
* Piles of unfolded clothing items in uncovered, household-type laundry baskets and overflowing from shelves.
* Papers and documents under a bed mattress.
* Floor, desktops, windowsill, bathroom shelves and the surface of a bed underneath the mattress covered with dirt, dust, debris, and grime.
* At least three corded earbuds tangled up together on a bedside stand along with a beaded necklace of greater than 12 inches and a beaded bracelet.
* Numerous plastic and rigid beverage containers, and paper cups, of various sizes full of clear, and darkly colored cold liquids. Staff present identified some of those as old coffee and tea.
* The bottoms of a red plastic basket and a blue plastic basket in which personal care items were stored covered with a build-up of dirt, hair, and debris.
* A one serving applesauce container with dried out applesauce remnants.
* Condiment packets in various places - ketchup, parmesan cheese, packages of cheddar cheese.
* A large ring with a large face, alcohol prep pads, and hard candies.
* Numerous bottles and containers of personal care products on the floor, on desktops, on the bathroom shelf, on the windowsill, on bedside stands and in plastic baskets.
* An uncovered and unlabeled container of a thick green crème-like substance.
* In the bottom of a plastic household-type laundry basket underneath a large pile of clothing, and in a brown paper bag numerous food items found included:
- Pieces of candy
- A container of scrambled eggs
- Three unopened, individual size cartons of milk
- A bottle of red beverage
- Four containers of individual size cereal
- Ketchup, mayonnaise, and mustard condiment packets
- Packages of individual string cheese and individual cheddar cheese
- A container of green grapes
- An unlabeled container of light green-colored liquid that staff present identified as "pickle juice"
- Three medium-size bags of potato chips
The laundry basket was sitting on a folded paper bag on the floor that was wet with an unknown liquid.

In hallways:
* Signs affixed to room doors that identified the room use were observed to be designed with raised, individual letters constructed from a thick, rigid plastic material. Numerous letters from signs were observed to be broken or missing. Those letters had the potential to be used for self-harm or harm to others. For example:
- A "STORAGE" room sign was missing the letters S, T, O, and half of the G.
- A "CLIENT RESTROOM SHOWER" room sign was missing the letters C, L, an S, half of an R, and half of the H.
- A "CLEAN UTILITY" room sign was missing the letters N, U, T and Y.

5.b. Observations made on MN2U and MN3U were reviewed with staff that included the JCA, the APD, the CNO, the OSH-Salem DCNO and other staff on 07/27/2022 beginning at 1040. During that review the following information was provided or confirmed:
* Although items that contained isopropyl alcohol were on the prohibited items list, staff were unsure whether that included alcohol prep pads that had been found in a patient room. Alcohol prep pads contain isopropyl alcohol.
* The necklace found in a room, and anything over 9", that was not a religious item for which there is a mitigation plan, was not allowed.
* Although metal and clasps on bracelets were not allowed, metal badge clips on patient identification badges were allowed.
* Although string, cords, yarn and other such items over 9" were not allowed, the numerous corded earbuds found in patient rooms were OSH issued and approved, and were allowed. However, it was not clear whether there was a limit on the number of corded earbuds a patient may possess or that were allowed in a patient room. There was a risk that those cords from multiple earbuds could be tied together, combined, twisted or braided to form a longer and stronger ligature. Staff confirmed that the corded earbuds were stocked on the unit, given to patients upon their request for use without supervision, and that there was no tracking of those to account for all that a patient may have.

6. During tour of L2U with the APD, the OSH-Salem DCNO, and a CS on 07/27/2022 beginning at 1625 observations included, but were not limited to, the following items and conditions:

In the entry to the unit:
* The POC "[OSH] Patient/Property/Item Access List" posted on the wall inside the unit was dated 02/10/2022 and was not the current 07/06/2022 version.

In the seclusion room:
* A bottle of shampoo and unidentified liquid in a paper cup on the observation windowsill inside the seclusion room bathroom.

In double-occupancy PtRm-HH:
* Piles of unfolded clothing, papers and documents, personal care and other items strewn on beds, floors, and surfaces in a cluttered and disorganized manner.
* Unfolded clothing items in an uncovered, household type laundry basket.
* Documents and papers, an uncovered toothbrush and other items on desktop and other surfaces.
* Condiment packets of hot sauce and pieces of candy.
* An uncovered and unlabeled container of a clear gel-like substance.
* A container that included at least two full-size ballpoint pens and various markers.
* Four containers labeled with "Aromatherapy" lotion dated with incomplete "Use by" dates of "02/23" and "03/23." It was not clear if "23" was the day or the year.
* An uncovered and unlabeled container found in a box that held approximately eight uncovered, barely distinguishable candies or cough drops that had begun to melt together to form one mass.
* A used bar soap on the bathroom sink and another used bar soap in a soap container on the bathroom shelf.

In double-occupancy PtRm-GG:
* Piles of unfolded clothing, papers and documents, personal care and other items strewn on beds, floors, and surfaces in a cluttered and disorganized manner.
* Some of the clothing/linen items in the piles were visibly soiled with areas of tan colored dried liquid spills.
* In the bathroom five tubes of toothpaste, some uncapped, an uncovered long-handled toothbrush, used bars of soaps.
* Surface of the bed under the mattress was covered with build-up of dirt and debris and areas of rust-colored dried liquid.
* A lidded, blue plastic container had an unidentifiable residue of clear to white substance in it.
* At least five beaded bracelets and a ballpoint pen.
* The floor covered with dirt and debris.

In the secure storage room where a number of types of items were stored, such as bins of patients' personal belongings, personal care products, razors and other items that had restrictions for patient use:
* A "Sharps sign-out sheet" reflected a patient had checked out a razor on 07/27/2022 at 1058 and it had not been signed back in at the time of this observation at 1725.
* In a multi-shelf cabinet, numerous types of items and products, new and used, were co-mingled and included, but were not limited to:
- A gallon size container of "Tearless Shampoos and Body Wash" that was close to empty with a purple liquid in it. There were purple-colored spills on shelf surface next to the container.
- A container of "Compressed Gas Duster."
- A plastic tub of a variety of more than eight bottles of partially full personal care products, some upside down and some with patient names on them written with a black marker.
- A cardboard box contained a variety of several partially full personal care products, some upside down and some with patient names written on the bottle. Those included "dark tanning sunscreen oil."
- Containers of "Diversity Oxivir Tb" chemical used for disinfection of surfaces.
* Several products and items were placed on terry cloth washcloths on one of the shelves of the cabinet. The washcloth had multiple-colored spills on it. The items included:
- An open and unlidded container of a beige colored "hair food" that had a wooden tongue depressor sticking out of it.
- An unlabeled bottle of a blue liquid.
- A bottle of "Dandruff Shampoo."
- A partially used bottle of a mouthwash.
- A stack of paper drinking cups place upside down over one of the spill areas on the cloth.
- Three stacks of paper and plastic medicine cups.
- A ballpoint pen.
* Two untitled and undated signs were posted on the cabinet door and contained unclear information about patient access to personal care products. The author or source of the signs was not evident:
- The first sign read: "Mouthwash, lotion, baby powder, and hair conditioning products that should be given in small amounts for patient use, are stored on the top shelf of this cabinet."
- The second sign read: "Please note: mouthwash and baby powder do not need MD orders for the patients to have them. They can be distributed by MHTs. Mouth wash (sic), baby powder, patient lotion, & hair conditioning items are in the patient belonging (sic) area on the first shelf of th

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure each patient's right to be free from all forms of abuse and neglect.

Identification of, investigations of, and response to incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

The CMS Interpretive Guidelines for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guidelines reflect those components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. Refer to the incident/event findings cited under Tag A-144, CFR 482.13(c)(2), CoP Patient's Rights - Standard: Right to safe care. Those findings reflect the hospital's failure to fully implement its POC to ensure investigations of incidents/events that reflected actual and potential neglect were clear, complete, and accurate to prevent recurrence for those patients who experienced actual and potential harm, and for other patients.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of grievance documentation for 7 of 8 patients (Patients 18, 20, 23, 24, 26, 27, and 28), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety.

2. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

3. Refer to the findings cited at Tag A-385 under CFR 482.23 - CoP: Nursing Services.

4. Refer to the findings cited at Tag A-700 under CFR 482.41 - CoP: Physical Environment.

5. Refer to the findings cited at Tag A-750 under CFR 482.42(a)(3) - Standard: Infection Prevention Clean and Sanitary EOC.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that incidents and adverse patient events were fully analyzed to determine causes, and that corrective actions were implemented to prevent recurrence, to promote learning throughout the hospital, and to establish clear expectations for patient safety.

Findings include:

1. Refer to the findings cited at Tags A-144 and A-145 under CFR 482.13(c) - Standard: Privacy and Safety.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that nursing services were organized and managed to ensure the provision of safe and appropriate care to each patient in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-395 under CFR 482.23(b)(3) - Standard: RN Supervision of Nursing Care.

2. Refer to the findings cited at Tag A-405 under CFR 482.23(c) - Standard: Preparation and Administration of Drugs.

3. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that an RN was responsible to ensure the provision of safe and appropriate care for each patient.

Findings include:

1. Refer to the findings cited at Tags A-144 and A-145 under CFR 482.13(c) - Standard: Privacy and Safety

Based on observations, interviews, review of medical record and incident documentation for Patients 9 and 28, review of P&Ps, and review of the hospital's POC it was determined that the hospital failed to ensure that medications were administered and managed in accordance with P&Ps.

Findings include:


29708


1.a. On 07/26/2022 at approximately 1700 on MN2U, an RN was observed to administer a medication to a patient. The RN used bandage scissors to cut a capsule and administer the contents to the patient.

1.b. Documentation of the physician order for the medication administered to Patient 28 on 07/26/2022 was reviewed and reflected the medication was ordered on 06/07/2022 at 1528, and was Diphenhydramine (Benadryl)/Active 50 mg Capsule oral every 6 hours, as needed for agitation, not to exceed 2 doses per day. The order included direction to "***OPEN CAPSULE***" however it did not specify to cut the capsule with bandage scissors.

1.c. The P&P titled "Medication Administration" dated 02/01/2022 reflected under the "Crushing medications" section "When not prohibited by policy, medication type, or provider order, nurses may crush medications in response to patient requests and when, in the nurse's judgement, doing so would be beneficial to the patient. If it is anticipated that the request or situation will continue or recur, the nurse should consult the provider regarding additional orders ... Only devices approved and provided by OSH may be used to crush medications ... Where used in this protocol and as appropriate to the medication involved, the term 'crush' also means to open a capsule and empty out the contents."

The P&P did not include the observed medication preparation practice of cutting a capsule with bandage scissors prior to administration of the medication within the capsule. In addition, the P&P was not fully developed as it referred to "approved and provided devices" that may be used to open a capsule and crush medications but did not include what the approved devices were; and did not include processes for cleaning the devices, and ensuring the complete dose of medication was administered when using the devices.

2.a. Refer to Tag A-144, Finding 7, regarding a suppository found in a patient bathroom, and Finding 13.a. regarding medication for Patient 9.

2.b. The P&P titled "Medication Storage and Security," dated 11/15/2021 reflected "Medications must never be left unattended ... This precludes the nurse from ... providing a patient with a dose of medication (including items such as a medicated cream or suppository) and allowing the patient to self-administer the medication without being under the direct supervision of the nurse at all times."

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that the EOC was maintained in a manner that ensured the provision of safe and appropriate care to all patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-701 under CFR 482.41(a) - Standard: Maintenance of Physical Plant.

2. Refer to the findings cited at Tag A-115 under CFR 482.13 - CoP: Patient's Rights.

3. Refer to the findings cited at Tag A-750 under CFR 482.42(a)(3) - Standard: Infection Prevention Clean and Sanitary EOC.

Based on observations, interviews, review of medical record and incident documentation for at least 11 of 16 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14), review of incident documentation for 3 of 3 EOC incidents (EOC incidents 11, 15 and 17), review of P&Ps, review of PERA/ERSA documentation and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that all hazards and risks were identified and mitigated, and that the EOC was maintained in a manner to ensure the safety and well-being of all patients as follows:
* Floors, walls, and other surfaces in patient rooms, patient bathrooms and other areas were observed in disrepair.
* Floors and other surfaces in patient rooms, patient bathrooms and other areas were observed with excessive build-up of dirt, debris, grime and mold/mildew.
* The PERA/ERSA did not address all hazards and risks in the EOC.

Findings include:

1. During tour of MN2U on 07/26/2022 beginning at 1500 with the DCNO, OSH-JC DON, and DSW the following observations were made:
* In a corridor alcove a handwashing sink with a wall mounted metal soap dispenser above it was observed. The soap dispenser was loosely attached to the wall with a gap between the top and side edges of the dispenser and the wall. This was confirmed with staff present at the time of the observation.

2. During tour of MN3U on 07/26/2022 beginning at 1515 observations of the physical environment in disrepair included, but were not limited to:
* In the hallway corridors signs affixed to room doors that identified the room use were observed to be designed with raised, individual letters constructed from a thick, rigid plastic material. Numerous letters from signs were observed to be broken or missing. Those letters had the potential to be used for self-harm or harm to others. For example:
- A "STORAGE" room sign was missing the letters S, T, O, and half of the G.
- A "CLIENT RESTROOM SHOWER" room sign was missing the letters C, L, an S, half of an R, and half of the H.
- A "CLEAN UTILITY" room sign was missing the letters N, U, T and Y.

3. During tour of L2U on 07/27/2022 beginning at 1625 observations of the physical environment in disrepair included, but were not limited to:
* In PtRm-HH there were deep and wide gouges inches through the dry-wall and into the interior space of the wall along the horizontal length under the bathroom window and the vertical length of the right side of that window. Exposing layers of construction, including a mesh and plaster and other construction materials. The entire window and the surrounding wall were covered with a piece of clear Plexiglas that was screwed into place and through which the damage could be clearly seen. During interview at the time of the observation staff stated that the damage occurred approximately six months ago.
* In PtRm-GG there were areas on the wall near the head of a bed where paint had been removed down to the drywall.

4. During tour of B3U on 07/27/2022 beginning at 1640 with the BPPD, a DOS, and other staff present the following observations were made:
* In PtRm-JJ a large metal plate was observed attached to the wall in the bathroom. The metal plate was bent and damaged with gaps between the wall and the metal plate. At the time of the observation the BPPD stated the plate was probably damaged from a patient hitting the wall.
* In the nurse's station the water in the handwashing sink did not drain effectively and created a situation where the sink filled with soapy water during handwashing to the point where hands could not be rinsed without touching the water that had accumulated inside the sink.
* In the medication room a large section of floor moulding was observed missing revealing a brown wood-like surface near the medication pass windows.
* In the medication room numerous areas of irregular-shaped blue and reddish scrape-looking marks were observed on lower wall sections near the medication pass windows.
* In the medication room it took more than 30 seconds for the hot water at the hand-washing sink to reach a warm temperature necessary for appropriate handwashing.

5. During tour of F1U on 07/28/2022 beginning at 1015 observations of the physical environment in disrepair included, but were not limited to:
* In the hallway corridors signs affixed to room doors that identified the room use were observed to be designed with raised, individual letters constructed from a thick, rigid plastic material. Numerous letters from signs were observed to be broken or missing. Those letters had the potential to be used for self-harm or harm to others. For example:
- A "F02 109" room sign was missing the numbers 9 and part of the 2.
- An "EXAM" room sign was missing the letters E and half of the M.

* In Nourishment Rm 1:
- The inside bottom and side surfaces in both the refrigerator and freezer sections of a refrigerator/freezer were covered with a build-up of debris and spills, and a container of ice cream was stored in the freezer. The refrigerator section of the unit was locked (and unlocked for this observation) and an undated sign on the unit read "Do not put anything in this refrigerator. It no (sic) longer to be used for anything." However, it was not clear when that sign had been placed and the freezer was still available for use.
- At least five areas on the walls had orange-sized areas where painted surfaces were peeled away down to a brown layer of wall construction.
- A long electrical cord of which approximately 18 inches was exposed was plugged into the wall underneath the counter in the room and was accessible to patients should they be in the room.

* In Nourishment Rm 2:
- Areas of caulking around the perimeter of back and side of the sink were covered with beige to brown colored mold/mildew-like matter.
- The linoleum surface under the sink cabinet had a large area of whitish and dark brown to rust discolorations in shapes of water leak stains. One of the large squares of linoleum on which most of the damage was present had separated from the floor and the surface underneath the linoleum had build-up of dirt and debris.

* In PtRm-RR:
- In the caulked and separation areas between the bathroom floor and the shower stall floor there was a build of the dark brown to black mold/mildew-like matter.
- The paint had peeled away from the wall adjacent to the shower stall above one section of the mold/mildew-like matter.
- The bottom section of the shower curtain, particularly along the very bottom edge for the width of the curtain had a significant build-up of approximately one to two inches from the bottom of dark brown, mold/mildew-like matter with black spots. An approximately three-to-four-inch vertical section of that had a thick, black mold/mildew-matter. There were splatter spots evident on the curtain several inches from the bottom that were gray and mold/mildew-like.
- The caulking around the fixtures on the bathroom sink had a build of dark brown, mold/mildew-like matter.

* In PtRm-LL and PtRm-MM there was a build up of brown, mold/mildew-like substance around sink fixtures and bathroom and shower stall caulking and floor tiles

6.a. The PERA/ERSA had not been developed to include all areas in the EOC that created potential risk for patients. For example:

6.b. Refer to Tag A-144 Finding B.4. regarding observations of medication pass windows.

During an interview with the SM on 07/29/2022 at 1630, regarding MN2U and T2U medication pass windows, he/she revealed:
- Regarding T2U, it was his/her understanding the same window design was in all 21 units at OSH-Salem.
- Regarding a physical environment risk assessment for the windows at MN2U and T2U, he/she stated there was no specific risk assessment.

6.c. Refer to Tag A-144 Finding B.9. regarding medical bed observations and review of the clinical mitigation plan.

A document titled "[ERSA] Summary 2021-22" for "Tree 1-3 Units OSHSC" was reviewed. Regarding the medical bed, the ERSA reflected:
- Under the column for "Mitigated Risks" it reflected "Medical Bed."
- Under the column for "Mitigation," it reflected "Clinical Mitigation Plan."
- Under the column for "Remarks" it reflected "Update Risk Assessment."

There was no further information about the risk assessment including specifying what was meant by "Update risk assessment" and when the update was due. In an email received on 08/11/2022 at 0956 from the CMSPD in response to what was meant under the remarks for the medical bed "Update Risk Assessment," he/she reported that "'Update Risk Assessment' notates that the risk assessment is due for review. After confirming with our Safety Manager, the medical bed risk assessments are scheduled to be completed by the end of August 2022."

6.d. Refer to Tag A-144 Finding C.15. regarding observations of bushes and shrubs in the outdoor courtyard "plaza."

During interview with the SM and other staff at the time of the PERA/ERSA review on 07/29/2022 at approximately 1615 the SM stated that the outdoor courtyard/"plaza" area and mitigation plans related to the bushes and plants had not been included in the PERA/ERSA to date as there had not been concerns.

7. Refer also to the detailed findings under Tags A-144 and A-750 that reflected the majority of patient rooms were observed to be disorganized, cluttered and littered with piles of unfolded clothing and linens, numerous papers and documents, numerous food and beverage items, numerous containers of personal care products and other various types of items. Those were observed on floors, beds, under mattresses on beds, shelves, desktops, bedside stands and in bathrooms. Those conditions provided numerous opportunities for concealment of prohibited items, rendered floors and other surfaces to be not readily cleanable, and created inability to readily identify areas of disrepair.

These conditions contributed to an unsafe EOC for patients as it created unsafe conditions, not readily cleanable surfaces and sources of transmission of infection and potential for cross-contamination.



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Based on observations, interviews, review of incident documentation for Patient 6, review of P&Ps, and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 07/07/2022 to ensure that the infection prevention and control program included surveillance, prevention and control, including maintenance of a clean and sanitary environment to avoid sources of infection and cross-contamination, and to ensure the safety and well-being of all patients.

The observed conditions contributed to an unsafe EOC for patients as basic infection prevention principles including separation of clean and dirty, prevention of cross-contamination, maintenance of readily cleanable surfaces, and provision of a clean and sanitary EOC were not ensured as follows:
* Piles of numerous unfolded clothing and linen items in patient rooms were observed stored on floors, beds, desktops, in uncovered household type laundry baskets and overflowed from cabinet shelves. It was not evident which items were clean and which were dirty. Further, those conditions provided numerous opportunities for concealment of prohibited food and other items, and rendered floors and other surfaces to be not readily cleanable.
* Numerous papers, documents, food and beverage, personal care products and other various types of items were observed stored on floors, beds, desktops, shelves and under bed mattresses. The disorganization and clutter provided numerous opportunities for concealment of prohibited food and other items, and rendered floors and other surfaces to be not readily cleanable.
* Floors, beds, desktops, shelves, under mattresses in patient rooms and bathrooms, and surfaces in other rooms and areas, were observed with build-up of dirt, debris, and grime. Stainless-steel surfaces and fixtures in those areas were observed with build of of excessive streaks, spotting and grime.
* Surfaces in patient bathrooms and showers and in nourishment rooms that were exposed to water or moisture were observed with a build-up of brown, gray and black mold/mildew.
* Numerous personal care and hygiene products, including uncovered toothbrushes and used barsoaps, were observed on floors, windowsills, desktops, shelves and in bathrooms. In some rooms those items were observed stored in plastic baskets in which there was a build-up of hair, debris and other substances. Those items were not identified with patient names to prevent cross-contamination, including in double occupancy rooms.
* Numerous types and amounts of unidentified creme-like, lotion-like, gel-like, liquid and powder substances were observed in a variety of uncovered containers in patient rooms. It was not clear what those were and if they were approved for use.
* Handwashing sinks were not maintained in good working order and hand hygiene products available for use were observed to have expired or were not approved for use.
* Numerous food and fluid items were observed in patient rooms, some concealed under piles of patient clothing. Many of those prohibited items were ingredients for making "pruno."
* Food items were not properly stored in nourishment rooms. Frozen, refrigerated and dry food items were observed in unlabeled containers, and were not dated or had an incomplete date.

Findings include:

1.a. Refer to Tag A-144, Findings B.3., B.5., B.6., and B.8., and Tag A-701, Finding 5. Those findings reflected that patient rooms and other areas were not maintained to be organized and free of excessive clutter. Those conditions provided numerous opportunities for concealment of prohibited items and rendered floors and other surfaces to be not readily cleanable. Unclean and unsanitary conditions were observed in patient rooms and in other rooms and areas on the following units:
* MN3U on 07/26/2022 beginning at 1515 including in PtRms DD, EE, and FF.
* L2U on 07/27/2022 beginning at 1625 including in a Seclusion Rm, PtRms GG and HH, and a Storage Rm.
* F1U on 07/28/2022 beginning at 1015 including in two Nourishment Rms, and PtRms LL, MM, NN, and RR.

1.b. Refer to Tag A-144, Findings B.3., B.5., B.6., and B.8. as described above, and Finding B.10. regarding Patient 6, that reflected numerous food and fluid items observed and found in patient rooms were items used to make "pruno."

Review of the CDC website on 03/10/2022 revealed the following information: "Pruno: A Recipe for Botulism ... quick way to make a kind of homemade alcohol that goes by many different names, including pruno, hooch, brew, prison wine, and buck ... It can give you botulism, a life-threatening illness ... Botulism is a rare but serious illness caused by a toxin (poison) that attacks the body's nerves and can lead to paralysis and death. Because the disease can paralyze the muscles used in breathing, people can die soon after symptoms first appear. Even those who get medical treatment right away may be paralyzed and hooked up to a ventilator (breathing machine) for many weeks. One way people get botulism is by eating or drinking something that has the toxin in it ... after making and drinking pruno ... anyone who drinks this kind of alcohol is at risk ... When people make pruno, they usually ferment fruit, sugar, water, and other common ingredients for several days in a sealed plastic bag. Making alcohol this way can cause botulism germs to make toxin (poison). The toxin is what makes you sick ... If you make pruno, you put yourself and anyone who drinks it in danger of getting botulism. The alcohol in your drink won't destroy the toxin (make it harmless). The only way to be sure you don't get botulism from pruno is to not drink it ... batches of pruno that gave people botulism used at least one of these ingredients: o Potatoes o Honey o Food from bulging cans ... if you [drink pruno] and you have symptoms of botulism, get medical help immediately ... Some of the symptoms of botulism are: o Double vision o Blurred vision o Drooping eyelids o Slurred speech o Difficulty swallowing o A thick-feeling tongue o Dry mouth o Muscle weakness ... o Difficulty breathing o Paralysis (can't move your body)."

Online recipes for pruno reflected that it can be made with ingredients such as: fruit, sugar, honey, ketchup and bread. The recipes also reflected techniques for brewing in plastic bags, or in bottles using a condom over the bottle opening "with a small hole pricked in it as a release valve of sorts." They also indicated that for fermentation "5 - 7 days is a pretty standard length of time but the more time the better."

1.c. In regards to Tag A-144, under Finding B.8. related to food storage and labeling in unit nourishment rooms, the P&P titled "Food and Nutrition Services Department Protocols" dated 05/13/2021 was reviewed. The P&P included the following stipulations:
* "Food packaged or repackaged by Food Service must be labeled and dated with a clear discard date..."
* "[Food Services] staff must mark food containers with appropriate discard date and clearly identify contents if not visibly clear."
* "Perishable potentially hazardous food must be dated with a 3 day discard date. · Protein & Dairy products"
* "Non-perishable food must be dated with a 7 day discard date. · Raw vegetables · Gelatin · Hummus"
* "Shelf stable food must be dated with a 30 day discard date · Peanut butter · Dried fruits & nuts · Jellies & Jam"
* "Food removed from frozen state must be dated with a 4 day, plus date removed from freezer date."
* "Frozen foods, non-perishable and shelf stable food follow guidelines above."

The P&P did not clearly delineate food storage and labeling requirements. For example:
* It specified that food must be "dated with a clear discard date." However, the "dates" observed were incomplete and consisted of only two of three elements of a complete date, i.e. "8/22." At least three OSH staff who observed the food items in the nourishment room at the time of the tour did not know whether the partial date was a packaged date or an expiration date and whether the second element of the date was the day or the year.
* The P&P indicated that food items removed from the manufacturer's original container were to be labeled with the contents "if contents not visibly clear." However, it was not clear who the contents were to be "visibly clear" to and assumed that individuals who did not work in Food Services and who did not repackage the food items would properly identify the unlabeled contents.
* The P&P referred specifically to eight types of food and it was not clear that it applied to any other food items.
* It was not clear how it was determined that raw vegetables and hummus were "Non-perishable" food.
* It was not clear what "Frozen foods, non-perishable and shelf stable food follow guidelines above" meant.

1.d. Refer to Tag A-144, Findings B.3., B.5., B.6., and B.8., regarding the numerous types and quantities of unidentified substances in various containers observed in patient rooms. It was not evident what those substances were, how old they were and whether they were approved for use in the manner observed.

1.e. Refer to Tag A-144, Findings B.3., B.5., B.6., and B.8., regarding the numerous containers and types of personal care products observed in patient rooms, including double-occupancy patient rooms. Those included uncovered and used toothbrushes and used bars of soap in patient bathrooms. Most of those were not identified with patient names and it was not evident that there were systems in place to prevent cross-contamination between patients.


29708


2. During tour of MN2U on 07/26/2022 beginning at 1500 with the DCNO, OSH-JC DON and DSW the following observations were made:
* A wall mounted Purell Hand Sanitizer dispenser was observed in the corridor outside the soiled utility room. The dispenser was locked and there was no visible expiration date observed regarding the contents of the dispenser. In addition, the hospital's POC reflected "... hand sanitizer dispensers will be removed from the patient units. Due to supply chain issues, we cannot guarantee they will remain filled. Instead, patients have access to sinks with soap and water, or hand sanitizer provided by staff on request."
* An oval-shaped, plastic household type laundry basket containing towels was observed on the floor near the shower room in an alcove in the corridor. The basket had no lid and had manufacturer made openings along the sides large enough to visualize items inside the basket. A towel was draped over the top edge of the basket. It was unclear if the towels were clean or dirty. During an interview with staff at the time of the observation, it was stated the towels in the basket were soiled.
* In PtRm-BB, a double occupancy room, two similar household type laundry baskets were observed on the floor. One of the baskets had clothes in it. It was unclear who the clothes belonged to and if the clothes were clean or dirty.
* A container of "Raw Sugar" hand sanitizer was observed in the med room. During an interview with the CMSPD on 07/28/2022 at 0920, he/she stated "Raw Sugar" hand sanitizer was not approved for use by the hospital.
* Refer also to Tag A-144, Finding B.4. related to food items found in patient rooms, and Tag A-701, Finding 4 related to a handwashing sink drainage and water temperature that had not been maintained.

3. During tour of BTM on 07/27/2022 at 1640 with the BPPD, a DOS, and other staff present, a locked, wall mounted Purell Instant Hand Sanitizer dispenser was observed in the BTM with a hand-written expiration date "6-8-22". This was confirmed with staff present at the time of the observation.

4. During tour of B3U on 07/27/2022 beginning at 1640 with the BPPD, a DOS, and other staff present the following observations were made:
* In PtRm-KK a household type laundry basket with clothes and a towel in it was observed on the floor in a patient room. A towel was draped over the side of the basket and onto the floor. A pillow with pillowcase on it was observed on one of the beds. The "white" pillowcase was deeply wrinkled with a large yellow discolored area where the patient's head would likely be positioned when sleeping.
* The surveyor washed his/her hands at the handwashing sink in the nurse's station. The water did not drain effectively and created a situation where the sink filled with soapy water, and it was not possible to rinse his/her hands without touching the water that had accumulated inside the sink.
* Observations in the medication room revealed:
- A blue container with a recycle symbol on it over-filled with a cardboard box protruding from the top of it.
- The floor was generally dirty with hair, brown dirt, and dark and brownish-black areas along the floor moulding near the medication pass windows and door. Used gloves, empty pill packages, empty capsules, and bits of paper were observed on the floor.
- Observations at the handwashing sink counter revealed a circular, orange-stained area and other areas of orange staining.
- The surveyor turned on the hot water at the handwashing sink and it took more than 30 seconds for the water to reach a warm temperature necessary for appropriate handwashing.
* Refer also to Tag A-144, Finding B.7. related to food items found in patient rooms.

5. During tour of T2U on 07/28/2022 beginning at 1015 with the BPPD, a DOS, and other staff present the following observations were made:
* The floor was sticky in a patient room and a puddle of standing water with small brown flecks was observed in the adjoining patient bathroom.
* Linear black marks, black and brown dirt, dust, small pieces of paper, stands of hair, and yellow, pink and brown drip marks were observed on the linoleum floor in the medication room. Black and brown dirt was observed along the edges and corners of the floor and floor moulding.
* Refer also to Tag A-144, Finding B.9. related to food items found in patient rooms.