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Based on interview, review of grievance documentation for 1 of 4 patients who submitted grievances (Patient 19), review of P&Ps, and review of the hospital's POC, it was determined the hospital failed to fully implement its POC and fully develop its P&Ps related to grievance processes to ensure complete and timely written responses were provided to patients who submitted verbal and written grievances as follows:
* The P&Ps incorrectly reflected that verbally expressed grievances did not require a written response.
* The P&Ps did not clearly reflect the required timeline and process for initial and final written response to the patient for grievances that were forwarded to the OSH Ombudsman or OTIS for investigation.
* It was unclear what the investigation and resolution processes were for those grievances forwarded to the OSH Ombudsman or OTIS for investigation.

Findings include:

1.a. The hospital's POC dated 10/03/2022 attested that by 11/07/2022 "The OSH Grievance Policy (7.006) will be updated to: Provide that a Grievance Committee will review and respond to all grievances, as delegated by OSH's Governing Body, and requires a Grievance Committee to provide written responses to the grievant within seven days of the hospital receiving the grievance. Written responses will be either a Determination of an Ineligible Issue Form or the Grievance Response Form."

1.b. The "Policy: 7.006 ... Patient Grievances" dated 10/31/2022 was reviewed. It included the following direction:
* "All grievances must be managed according to process guidelines established by OSH Ombudsperson(s) ..."
* "Staff must provide a written response to a formal grievance per Procedures A within seven (7) calendar days after OSH receives a grievance. The written grievance response timeframe may be extended per Procedures A."
* "Only the OSH Ombudsperson(s) or a state agency authorized to investigate abuse allegations at OSH, [OTIS], may screen grievances alleging abuse and/or civil rights violation situations. Such screenings are conducted per Procedures A."

1.c. The "Policy Attachment Procedures A: Grievance Process" dated 10/31/2022 was reviewed and included the following information:
* "A verbally expressed grievance is considered an informal grievance. An informal grievance does not require a written response and is not subject to appeal. Staff must attempt to address informal grievances with the Grievant, including allegations of staff-patient abuse and/or civil rights violation(s)."
* "Written response/resolution to a grievance must be completed within the response timeframe established in OSH policy 7.006, 'Patient Grievances.' Staff must request a response timeframe exception from the OSH Ombuds office in advance of the response deadline if a grievance cannot be responded to/resolved within the timeframe stated in OSH policy 7.006. The response timeframe may be extended for a reasonable period to accommodate grievances including, but not limited to, the following: a. Grievances that are complex in nature and require additional time or investigation to adequately respond."
* "Formal Grievance Screening For Abuse and Civil Rights Violation Allegations. If a formal grievance includes allegations civil rights violations, the grievance must immediately be emailed to OSH Ombuds office. When a formal grievance is sent for screening under this process, the formal grievance response timeline stated in OSH policy 7.006 continues (i.e., grievances must be responded to within the stated timeline, even if sent for screening). The OSH Ombuds office will provide the sending unit Grievance Committee with a screening decision. When appropriate, the OSH Ombuds office will provide additional information to include in the Grievance Committee's formal grievance response/resolution. Formal grievances alleging abuse along with the formal written response/resolution must be submitted to OTIS as the final step in the formal grievance response/resolution process. Alleged abuse must also be reported per OSH policy 7.008, 'Patient Abuse Allegation Reporting.'"

1.d. The P&P and Attachment A had not been developed to ensure grievances were responded to as required:
* "Attachment A" was not accurate where it stated that "A verbally expressed grievance is considered an informal grievance. An informal grievance does not require a written response ..." The CMS Interpretive Guidelines for this regulation, CFR 482.13(a)(2), states that "A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR §489."
* It was not clear how and when patients would receive written responses to grievances that were forwarded to the OSH Ombudsman or OTIS for investigation, both an initial response that includes an estimated timeline for completion of the investigation if it is expected to taken more than seven days from the date it was received by the hospital, and a final response with the required elements once the investigation has been concluded.

2.a. Review of a "Patient Grievance" form for Patient 19 reflected the patient's grievance was received on 11/07/2022. In the section of the form for "Describe your grievance" the patient's description referred to a previous grievance submitted and included that staff "did not forward [that grievance] to O.T.I.S. even though there are claims of neglect and abuse of power."

2.b. The "Patient Grievance: Grievance Committee Response" form contained the following information and no other documentation was provided:
* "Date Unit Received: 11.7.22"
* "Date of Grievance Review. 11/7/22"
* The box next to "Patient declined to meet" was checked.
* "The following staff contributed to this response: [two first names]"
* "Information and unit response" reflected "grievance was forwarded to OTIS on 11/7/22."
* The box next to "Patient signature: Declined to sign" was checked.
* "Completion Date: 11/7/22"

2.c. During interview with staff that included OFS, DCNO, JCCA, and CMSPD at the time of the review on 11/16/2022 beginning at 1415 staff stated that Patient 19's allegations of abuse were not clear, that the patient refused to meet with unit staff on 11/07/2022, and the grievance was forwarded to OTIS on 11/07/2022 for review and follow-up. However, staff were unable to describe what follow-up by OTIS consisted of. Although there was no documentation of steps taken to clarify and investigate the patient's allegations, staff stated that the grievance was "closed."

2.d. There was no documentation related to this grievance that reflected that Patient 19 had been informed in the written response of the reason that the grievance was forwarded to OTIS for investigation, and if the OTIS investigation was expected to take more than seven days, for good cause, an estimated date or timeframe when the patient would receive a final response that included the steps taken to investigate the allegations and the results of the investigation.


29708




40575

Based on observations, interviews, review of off-campus outing documentation for 6 of 6 patients (Patients 1, 2, 3, 4, 5, and 6), review of incident documentation for 1 of 9 patients reviewed for incidents (Patient 11), review of P&Ps, review of PERA/ERSA documentation, review of PESS audits, and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 11/07/2022 to ensure each patient's right to receive care in a safe setting in the following areas:
* All pre-outing tasks required prior to off-campus outings were not completed or clearly documented.
* All staff who escorted patients through secure doors did not complete all door security steps.
* Potentially unsafe, and prohibited items, were allowed in the EOC.
* The PERA/ERSA did not address all hazards and risks in the EOC.
* All monitoring of the EOC and of staff practices had not been conducted.

Findings include:

1.a. All pre-outing tasks required prior to off-campus outings were not completed or clearly documented in accordance with the POC and P&Ps:
* The POC dated 10/03/2022 attested that by 11/07/2022 the hospital had "Amended administrative directive to modify policy 6.006, 'On-grounds and Off-Grounds Outings' to: Add requirement that each trip slip identifies a group leader who is responsible for the pre- and post- trip meeting and documentation for each outing ... Add requirement that a 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 ... Develop a system template in electronic health record to document core elements of the pre-trip meeting."
* The "New Group Progress Note Template ... Pre-Trip Meeting" document dated 10/04/2022 was reviewed. It reflected that pre-trip meeting language "... will display in the Group Intervention field. You can add and/or alter any text in the template. Finalize your note as usual when it is complete." The language was "Pre trip meeting was held and included identification of staff and patient roles, individual patient's goals, potential triggers, rules, behavioral and safety expectations, and commitments which include staying within sight and speaking distance, following staff instructions, and avoid picking up contraband."

1.b. Documentation for an off-campus community outing that was conducted from the OSH-JC campus on 11/08/2022 and scheduled from 1300 to 1500 with Patient 1, Patient 2, and Patient 3 was reviewed. The documentation was not clear or complete,
* In the "Security Only" section of the off-campus outing form the "Trip Departure time" was entered as 1318, however, the "Depart Review" time was entered as 1449, one hour and 31 minutes later, and just 11 minutes prior to the "Return time" of the outing entered as 1500.
* An outing "Group Note" for Patient 1 dated/timed 11/08/2022 at 1705 reflected in the "Group Interventions" section of the note that "Group will discuss the limits of liability, go for a leisure hike, have a pre outing meeting to include outing protocol, expectations, goal setting, purpose of group, and to answer and [sic] concerns of participants while bringing awareness of any possible triggers known for today's outing." In the "Behavior ... Comments" section of the note it reflected that "11:15 on 11/08/22 Pre meeting for outing. [Patient 1] attended pre for today's 2:4 off grounds outing and agreed to group expectations and outing protocol, [patient] set a goal to have community exposure, and [patient] shared no concerns or questions."
* An outing "Group Note" for Patient 2 dated/timed 11/08/2022 at 1732 reflected in the "Group Interventions" section of the note that "Group will discuss the limits of liability, go for a leisure hike, have a pre outing meeting to include outing protocol, expectations, goal setting, purpose of group, and to answer and [sic] concerns of participants while bringing awareness of any possible triggers known for today's outing." In the "Behavior ... Comments" section of the note it reflected that "1105 Outing Pre meeting 11/08/22 [Patient 2] participated in pre meeting with staff on unit. [The patient] made a goal to use DBT skills as needed and shared ideas of what can be triggering for [them] during outings in the community. [Patient 2] also shared concerns about the new security protocol for pat downs ... agreed to be assertive and share [their] concerns as needed respectfully. [Patient 2] agreed to outing protocol and expectations."
* An outing "Group Note" for Patient 3 dated/timed 11/08/2022 at 1646 reflected in the "Group Interventions" section of the note the "Group will discuss the limits of liability, go for a leisure hike, have a pre outing meeting to include outing protocol, expectations, goal setting, purpose of group, and to answer and [sic] concerns of participants while bringing awareness of any possible triggers known for today's outing." In the "Behavior... Comments" section of the note it reflected that "pre Meeting note at or about 11:15 on 11/08/22 [Patient 3], along with other group member on unit, met with me to discuss today's outing. [Patient 3] agreed to outing expectations, [patient] set a goal for practicing being in the community and doing an activity."

1.c. Documentation for an off-campus community outing conducted from the OSH-Salem campus on 11/10/2022 and scheduled from 0900 to 1100 with Patient 4, Patient 5, and Patient 6 was reviewed. The documentation was not clear or complete as follows:
* In the "Security Only" section of the off-campus outing form the "Trip Departure Time" and the "Depart Review" time were entered as 0912. However, the "Money Confirmation" and "Personal Search" fields were not checked to indicate that those tasks/steps had been completed.
* In the "Security Only" section of the off-campus outing form the "Return time" and the "Return Review" time were entered as 1103. However, the "Personal Search" field was not checked to indicate that that task/step had been completed.
* An outing "Group Note" for Patient 4 dated/timed 11/10/2022 at 1143 reflected in the "Group Interventions" section of the note that "The group starts with a pre-trip meeting regarding group rules/procedures, the group activity and plan, staff and participant roles and safety expectations."
* An outing "Group Note" for Patient 5 dated/timed 11/10/2022 at 1136 reflected in the "Group Interventions" section of the note that "The group starts with a pre-trip meeting regarding group rules/procedures, the group activity and plan, staff and participant roles and safety expectations."
* An outing "Group Note" for Patient 6 dated/timed 11/10/2022 at 1151 reflected in the "Group Interventions" section of the note that "The group starts with a pre-trip meeting regarding group rules/procedures, the group activity and plan, staff and participant roles and safety expectations."

1.d. Regarding documentation of the pre-trip meeting, the "core elements of the pre-trip meeting" were not consistent with the POC and the "template," from one outing to another, and from one patient to another. Not all of the following were clearly documented for each patient on both outings: "identification of staff and patient roles, individual patient's goals, potential triggers, rules, behavioral and safety expectations, and commitments which include staying within sight and speaking distance, following staff instructions, and avoid picking up contraband" nor were the "rules" and "behavioral and safety expectations" specified.

1.e. During interview with staff that included DTS, DTM, DQM, CMSPD, and CS at the time of the review on 11/16/2022 beginning at 1600 findings were confirmed and no additional documentation was provided.

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2.a. All staff who escorted patients through secure doors did not complete all door security steps in accordance with the POC and P&Ps:
* The POC dated 10/03/2022 attested that by 11/07/2022 the hospital had "updated" the P&P 6.024 "Transportation and Supervision Ratios," and that it would "Provide training to all staff related to door closure to prevent patient elopement and entry into unauthorized areas."
* Training documentation titled "Stop, Look, Listen" reflected it was "A training to help you verify the closure or doors behind you while in the secure perimeter or when transporting patients ... This training is an addendum to policy 6.024 and supports staff in verifying the closure of doors behind them ..." The training reflected: "STOP ... Take a moment to survey the scene before letting a door close after patient(s) have gone through ... LOOK ... around to make sure the patient or patients that you are transporting are accounted for. After the last patient has passed through the door, look to verify that all doors and gates are latched closed and locked after entering or exiting an area. LISTEN ... for the door to latch and completely close. After stopping, looking, and listening for door closures and patient accountability, you may safely continue transporting patients ... All staff are responsible to maintain situational awareness for closure of secure doors, whether or not they are the last person to exit the door. This includes even when staff are NOT transporting patients."

2.b. During tour at OSH-Salem with staff that included DON-Salem, DSS, SCPD, and CS on 11/15/2022 at approximately 1620 a staff member was observed to escort a patient through an off-unit secure door near the East Plaza. The staff person and the patient walked from the interior hallway, through the secure door into the exterior courtyard area, without stopping. The staff person did not "Stop, Look, and Listen" at the secure door as required by the P&P and training.

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3.a. Potentially unsafe, and prohibited items, were allowed in the EOC contrary to the POC and P&Ps:
* The POC dated 10/03/2022 attested that by 11/07/2022 the hospital had "Conducted unit resets where security and unit staff went through each patient room to remove prohibited items, potential ligatures and other disallowed items from patients' living spaces. This supports the removal of contraband, unsafe and prohibited items creating a new baseline of items in patient care areas. Unit resets allow staff to supervise patients in their environments with less clutter. Patients are searched upon re-entry into the secure perimeter from an outing. This is to verify that patients are not bringing any contraband or prohibited items into the secure perimeter. Retrained MHTs, LPNs, RNs, Nurse Managers and Unit Administrators on nursing protocol 2.020 'Continuous Rounds, Census, Milieu (RCM) Management' which includes the requirement for surveillance of unit environment three times an hour and removal of prohibited items, elimination of ligature risks, and verification of items in use which are allowed and have ligature risk mitigation plans in place. This action is intended to support staff following protocols which keeps prohibited items out of the unit environment. Additionally, the actions required by this protocol represent one way that patients are continually supervised while on the unit. Updated policy 8.024 'Tool & Sharp Security.' This addresses the concern of contraband in patient rooms, unsafe and prohibited items, and the supervision of patients and environment." The POC also attested that by 11/07/2022 the hospital would "Update Administrative Directive for policies 8.044 'Contraband and Prohibited Items' and 8.037 'Patient Property and Valuables.' Modify the patient property/item access list to prevent access to unsafe and prohibited items and to clarify what items are allowed. Establish property limits to support patient supervision and prevention of patient access to contraband, unsafe and prohibited items that can be used for suicide attempts, self-harm, or harm to others."

3.b. During tour of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415 the following observations were made:
* Three sets of OSH issued corded earbuds were observed in each of PtRm-VV and PtRm-YY. Those cords had potential to be intertwined together to create a ligature. Review of the OSH "Patient Property/Item Access List" did not clearly reflect the corded earbuds, either the item or the number of those permitted to be in a patient's possession.

3.c. During tour of MN2U with the JCPD, a CS and other unit staff on 11/16/2022 beginning at 1152 observations included, but were not limited to, the following items:
* In PtRm-jj, a green herbal plant-like product was observed on a tray on the desk and in a small box on the nightstand. The MN2U CN was unable to identify the product at the time of the tour.
* Additionally, in PtRm-jj there was a blanket with five, large hardback text books wrapped up inside and tied closed with a black nylon band. During interview with the JCPD at the time of the observation, they stated the patient used this as a weight to carry while walking back and forth on the unit for exercise. There was no information provided about whether the homemade weight was determined to be safe.
* In PtRm-kk, a CD laying upside down on the desk was observed. It was unclear who the CD belonged to and what was on the CD as it was not labeled. The patient had a blues CD and DVD titled "Ten Commandments" on the property list in the medical record. The CD was not checked out and it should have been according to the JCPD.
* Additionally, in PtRm-kk a small plastic container of putty that was not labeled was sitting on the night stand in the same room. The MN2U CN was unable to provide information on where it came from. It was later determined the item was given to the patient at an outside appointment and was not identified upon returning to the unit.

3.d. Incident documentation for Patient 11 reflected that on 11/07/2022 at approximately 0930 staff reported that the patient "... was pacing the halls for exercise with OSH linens filled with water bottles and tied together. RN and NM approached and asked [Patient 11] to turn [sic] the homemade weight in explaining [they] could have 1-2 water bottles at a time and could not tie linens together. [Patient 11] briefly complained about the request and then retrieved the item, dropping it on the floor. [The patient] stated [they] would wrap [their] library books in [their] blanket and use this for weight. [The patient] was encouraged not to. We took the homemade weight to the exam room where we untied the linens and poured the water out of the 8-1 liter bottles that had been refilled from the tap. The weight was approximately 19 pounds." Incident investigation documentation by an RN Unit NM dated 11/08/2022 reflected that the patient had stated that as an alternate they would "use library books to carry as weight, wrapped in [their] weighted blanket." The investigation documentation reflected that staff "talked to [Patient 11], explaining why [they] could not have 8 one liter water bottles and that [they] could not tie a sheet in knots. I talked to several staff present about not allowing any patient to have more than 1-2 water bottles at a time and not modifying linens. The staff were encouraged to address this type of issue in the moment rather than pass it on to a manger as a modified linen is considered contraband and a safety concern." The next entry on the investigation was recorded by the JCPD and dated 11/09/2022 and reflected "Treatment services manager to follow up on OT assessment and [sic] if any additional assessments could benefit team/patient." There was no additional documentation.

The investigation was not clear or complete. For example:
* There was no indication to reflect whether staff had identified how Patient 11 had acquired the numerous water bottles.
* There was no indication that the handmade weight made from altered items had been evaluated as a potential weapon.
* There was no indication that clear and appropriate actions to prevent the patient from manufacturing a similar type of item had been taken. Including, but not limited to, that clear limits and expectations were not communicated to both the patient and staff, as the patient was only "encouraged not to" alter items to make a weight, and staff were only "encouraged to address this type of issue in the moment ..."

Refer to the finding under 3.c. above in this Tag that reflects observation of a manufactured weight made from a blanket and books in PtRm-jj on 11/16/2022 during this survey.

3.e. Refer to the findings related to observations of prohibited and unsafe items cited at Tag A-750 under CFR 482.42(a)(3) - Standard: Infection Prevention Clean and Sanitary EOC.

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4.a. The PERA/ERSA did not address all hazards and risks in the EOC in accordance with the POC and P&Ps:
* The POC dated 10/03/2022 attested that by 11/07/2022, "To ensure OSH's system for evaluating the risks and hazards in the physical environment is complete and comprehensive, the hospital will · Identify each process and team that reviews the EOC (whether that be weekly, monthly, biannually and annually) · Determine if gaps exist in existing processes · If necessary, develop strategy to eliminate gaps in environmental risk evaluation methods."

4.b. During tour of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415 the following observations were made:
* On the BF1U in the on-unit dining room a microwave oven observed on an open counter was found to have an electrical cord that was ~ four feet in length.
* On the BF1U "medical beds" were observed in patient rooms and the frames of those beds were found to have ligature points and risks.
* On the BFIU and on the B1U, the heavy-gauge "aircourt" screens that enclosed those patio-like areas were observed to have significant openings/gaps between the ground and the bottom of the screens, and between the screened wall and the screened door to the exterior grounds. Those openings/gaps varied from ~ 1/2 inch to several inches and were large enough to allow for passing of items and contraband between patients spending time in the exterior, secure "quad" activity areas and patients inside the "aircourts." The openings/gaps were also a potential entry for rodents, birds and pests.

4.c. The OSH PERA/ERSA dated 10/03/2022 was reviewed with the SEMM, DQM, SCPD, DCNO, and CS on 11/16/2022 beginning at 1105. The review revealed that the PERA/ERSA did not include or clearly address all risks observed on 11/15/2022 and the following information was provided and confirmed during interview with the staff present:
* The microwave oven cord observed in the BF1U on-unit dining room was not reflected in the PERA/ERSA.
* The BF1U on-unit dining room was not identified on the "Room Risk Level and Inventory" dated "August 2022" that specified the amount of supervision required for spaces/rooms in the hospital.
* Although ligature risks related to the "medical beds" observed on BF1U were addressed for those patients who had those beds, the PERA/ERSA related to the "medical beds" dated 08/26/2022 did not address the potential risks to other patients on the unit who might enter the rooms in which those beds were located.
* The BF1U and B1U "aircourt" openings/gaps were not reflected in the PERA/ERSA.

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5.a. All monitoring of the EOC and of staff practices had not been conducted in accordance with the POC and P&Ps:
* The POC dated 10/03/2022 attested that by 11/07/2022 the hospital had "Developed unit and treatment mall protocol to monitor patient safety, infection control measures, and EOC 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. Issued administrative directive to modify policy 8.009, 'OSH Safety Programs' to: Implement PESS on 9/7/2022, to assess the physical environment on patient care units and in treatment mall spaces on a weekly basis."

5.b. Review of PESS monitoring/audit activity for week of 11/07/2022 reflected that four of 21 HLOC units (L1U, L3U, FW3U, and LH1U) and one of five Treatment Malls (JCTM) had not submitted the required PESS documentation for that week. Staff present during the review on 11/16/2022 beginning at 1440 included APD, PIPM, and DA staff who confirmed those findings during interviews at that time.


29708




























40575

Based on observations, interviews, review of incident documentation for 1 of 9 patients (Patient 11), 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 abuse and neglect. Investigation of, and response to an incident that reflected a potential for patient harm, was not clear and complete to prevent recurrence.

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 findings for Patient 11 cited under Tag A-144, CFR 482.13(c)(2), CoP Patient's Rights - Standard: Right to safe care.

Based on observations, interviews, review of off-campus outing documentation for 6 of 6 patients (Patients 1, 2, 3, 4, 5, and 6), review of incident documentation for 1 of 9 patients reviewed for incidents (Patient 11), review of P&Ps, review of PERA/ERSA documentation, review of PESS audits, and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 11/07/2022 to ensure that RNs were responsible to ensure the provision of safe and appropriate care for each patient.

Findings include:

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

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


40575

Based on observations, interviews, 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 fully developed P&Ps.
* PO medication was prepared, and injectable medication was pre-filled in a syringe, in advance of possible administration, and set aside in an unlabeled medication cup and an unlabeled syringe.
* Office supplies were used to open single-dose pill packages.

Findings include:

1.a. The hospital's POC dated 10/03/2022 attested that by 11/07/2022 it would "Update nursing protocol 2.060, 'Medication administration.'"

1.b. Review of the P&P titled "Medication Administration" dated 09/30/2022 directed that "At OSH, nurses must practice the following eight rights: a. right patient; b. right medication; c. right dosage; d. right route; e. right time; f. right reason; g. right documentation; and h. right of refusal by the patient ... When preparing and administering injectable medications, special care must be taken to insure [sic] medication integrity, dose accuracy, patient comfort, and safety ... Medication that has been retrieved from the ADC, but is not able to be immediately administered by the nurse who retrieved it, whether because of patient refusal or for any other reason, may not be set aside or held in reserve. If the medication is still in its original and intact packaging, it must either be: i. given to another nurse who is able to immediately administer it to the patient for whom it was retrieved (following the process previously described); or ii. returned to Pharmacy via the ADC external return bin ... b. If the medication has already been removed from its packaging, it must be wasted, discarded, or returned to Pharmacy as described in Attachment B. Note - If the same medication is later needed for administration, the nurse must retrieve a new dose from the ADC, following all the previously described identification, verification, and administration processes."

2.a. During observation at OSH-Salem in the LH2U medication room on 11/15/2022 beginning at 1555, a plastic medication cup was observed on a counter with a thick, brown substance inside it. The RN at the counter indicated they had pre-prepared an Ativan pill in the cup with pudding. Also on the counter, an open single use vial of Ativan injectable was observed. The nurse indicated they prepared the Ativan pill in the pudding for the patient and if the patient would not take it by mouth, they would administer an Ativan injection. The RN stated they had already drawn up the Ativan medication into a syringe and it was in a cabinet across the room. When the unlocked cabinet door was opened, an unlabeled, pre-filled syringe was observed stored on a shelf labeled "CUP, PAPER, COLD 5OZ." The syringe contained two mls. of clear liquid. The shelf also contained paper cups and cups of pre-made pudding. The syringe was not labeled with any information including the date/time it was prepared and by whom, the contents, expiration date, and lot number.

2.b. The P&Ps contained no provisions for preparing medication other than immediately prior to administration, no provisions for preparing two different medications in advance of possible administration of just one of them, and no provisions for pre-filling syringes of injectable medication.

3.a. During observation at OSH-JC in the MT1U medication room on 11/16/2022 beginning at 1255, a long-handled, office staple remover was observed on a tray below the computer keyboard. During interview with an RN at the time of the observation they stated "we use a staple remover to open pill packaging."

3.b. The P&Ps contained no provisions for use of office supplies in the medication preparation process.





29708




40575

Based on observations, interviews, and review of PERA/ERSA documentation it was determined that the hospital failed 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 patients as follows:
* The PERA/ERSA did not address all hazards and risks in the EOC.
* EOC surfaces, a light switch, and on-unit kitchen equipment were observed in disrepair or not in working order.

Findings include:

1. Refer to the findings related to the PERA/ERSA cited at Tag A-144 under CFR 482.13(c) - Standard: Privacy and Safety.


29708


2. During tour of A2U on 11/15/2022 beginning at 1430 with the APD, CS, and AUA the following observations were made:
* Observation of the A2U double entry secure doors revealed rubber molding along the door edges where the doors joined when closed. The molding was peeling away and had separated from one of the doors. Holes were observed in areas of the molding and when the doors were closed, a thin gap was observed between the two doors where molding was missing.
* In the kitchenette, a coffee maker carafe was observed on the floor with a sign on it that read "Broken."

3. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* In PtRm-aa, the light switch in the adjoining bathroom was not working properly. The surveyor and a staff member had to turn the light switch on and off multiple times before the light turned on.
* In the medication room, the wall next to the wall-mounted sharps container had an irregular shaped area with layers of paint removed, exposing the wall material beneath it. The wall within and next to the exposed wall was discolored in a rectangle shape and appeared as if a sign or piece of paper had been attached to the wall at one time, and had been torn off.
* In the kitchenette, a coffee maker was observed on the counter next to the microwave. At the time of the observation, a staff entered the kitchenette and stated the coffee maker was not working.


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4. During tour of MN2U on 11/16/2022 beginning at 1152 with the JCPD, CS and other staff the following observation was made:
* The MN2U kichenette's ice machine had a large amount of build up/corrosion.

Based on observations, interviews, review of P&Ps, and review of the hospital's POC it was determined that the hospital failed to fully implement its POC effective 11/07/2022 to ensure the maintenance of a clean and sanitary environment to avoid sources of infection and cross-contamination in the following areas:
* Soiled linens were not stored in covered containers.
* Some surfaces on units and in patient rooms were in need of cleaning.
* Patient personal care and hygiene products were not identified with patient names and in one instance were stored with a urine/stool collection device.
* Single use sundry items were not covered or labeled.
* Handwashing sinks and hand sanitizers were not maintained to accommodate hand hygiene.
* Prohibited food items, some that could be used for making "pruno," were observed in patient rooms, some concealed under patient clothing.
* Food items in kitchenettes did not have complete labels and in one instance were stored with patient care rehabilitation supplies.

Findings include:

1.a. Soiled linens were not stored in covered containers. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital would "Provide patients with covered laundry baskets to keep their dirty laundry separate from clean linens."

1.b. During tours of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415, household type laundry baskets that contained linen and clothing items were observed in patient rooms. The baskets did not have covers and were open on the top with openings on all four sides. During interview with staff present at the time of the observations they stated that the covered laundry baskets referenced in the POC had not been received due to supply issues.

1.c. Similar findings were observed in patient rooms during tours of A2U and LH2U with the APD, CS, and AUA on 11/15/2022 beginning at 1430 in PtRm-bb, PtRm-dd and PtRm-ee.

1.d. During tour of MN2U on 11/16/2022 beginning at 1152 with the JCPD, CS and other staff the following observations were made:
* In PtRm-ii, soiled linen was being stored in a paper bag while the laundry basket was full of cards and personal belongings.

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2.a Some surfaces on units and in patient rooms were in need of cleaning.

2.b. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* In the bathroom of PtRm-aa, two used bars of soap were observed on the sink edge with significant white soap residue and splatter. Dirt, dust, splatter marks, and brown matter where the floor tiles joined together were observed near the bathroom entry. Dirt and dust were observed on the floor at the shower entry. Gray-brown discoloration was observed along the grout at the threshold leading into the shower.
* In the kitchenette, a white folding table with metal legs was observed. Pieces of paper, a Lipton tea box, a cup, and pastel colored plastic or Styrofoam-like pieces were observed wrapped around the table legs. Dirt, a piece of paper, and hair were observed on the floor under the table and around the table legs. Approximately three plastic items that appeared to be tote lids were observed directly on the floor under the table with visible dust accumulated on them. Also under the table, an open package of paper towels and an unopened bag of Sun Chips were observed on an open brown wood-like shelf approximately two inches from the floor. The Sun Chips were tucked towards the back of the box under the table and were not readily visible.

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3.a. Patient personal care and hygiene products were not identified with patient names. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital would "Address concern for personal care items that are not marked, unclear to whom they belong, and to prevent cross contamination the following actions will be or have been taken: each patient received a shower caddy labeled with their name ... issue an Administrative Directive for storage requirements for patients' personal care items and labeling the patient's name on personal care items, and labels for items that contain contents such as lotion, gels, shampoos, and including when those items expire, if applicable ..."

3.b. During tour of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415 not all personal care/hygiene items and shower caddies were observed to be labeled with patient names in the following patient rooms: PtRm-UU, PtRm-VV, PtRm-WW, PtRm-XX, and PtRm-YY. Although many items were observed to be labeled, many were not.

3.c. Similar findings were observed with the APD, CS, and AUA during tour of LH2U on 11/15/2022 beginning at 1510 in PtRm-aa and PtRm-bb; and during tour of MN2U on 11/16/2022 beginning at 1200 in PtRm-ii and PtRm-jj.

3.d. In addition, during the tour of LH2U on 11/15/2022 in PtRm-aa bathroom, a urine/stool specimen collection "hat" for use in the toilet was observed on a shelf next to a tube of toothpaste.

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4.a. Single use sundry items were not covered or labeled. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital would "Address sundry items (such as creams, lotion, gels, liquids, and powders) that are un-identified, unclear ownership and unclear if they were allowed or were prohibited items. The OSH Nursing Services protocol 2.042 'Medical Treatment Supplies and Sundry Items' will be updated to include: Instructions to label single use items provided to patients with the name of the item, initials of the patient to whom it was given and the date the item is to be discarded." A laminated procedure poster for labeling of single-use "sundry" items was observed in the patient belongings and supply room on the BF1U on 11/15/2022 at 1515. It reflected "Label all medication cups that you give out to patient with the following information: Patient name: First and last initial, Product name, Tomorrow's date. All products dispensed in a medication cup must be discarded the next day. All un-labeled cups must be discarded."

4.b. During tour of B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1530 a thick, light-green substance was observed in an uncovered, plastic medication cup in PtRm-XX. It was unknown what the substance was, what patient it was for, and when it was to be disposed of. There was no label or any information documented on the cup.

4.c. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* In PtRm-ZZ bathroom, a paper drinking cup was observed in the shower with pink residue inside it. There was no label on the cup.
* In PtRm-aa bathroom, a paper drinking cup was observed in the shower with thick purple liquid inside it. There was no label on the container.
* In PtRm-bb, a plastic medicine cup was observed with white cream-like substance inside it. There was no label on the container.

4.d. During tour of MN1U on 11/16/2022 beginning at 1245 with the CS, JCPD, DON-JC the following observations were made:
* In PtRm-gg, a plastic medicine cup with gel-like substance inside was observed without a label, patient name, date, or any other information on it. This was confirmed with JCPD at the time of the observation.

4.e. During tour of MN2U on 11/16/2022 beginning at 1200 with the CS, JCPD, DON-JC the following observations were made:
* In PtRm-ii, a plastic medicine cup with white cream-like substance inside was observed without a label, patient name, date, or any other information on it. This was confirmed with JCPD at the time of the observation.

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5.a. Handwashing sinks and hand sanitizers were not maintained to accommodate hand hygiene. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital would "Address hand washing sinks in non-working order, a communication will be sent to all OSH staff as a reminder to submit a work order to have repairs completed by OSH Facilities Department" and it would "Update standard work for EOC rounds to include checking expirations [sic] dates of handwashing supplies and removing and replacing expired items if found."

5.b. During tour of A2U on 11/15/2022 beginning at 1430 with the APD, CS, and AUA the following observations were made:
* A handwashing sink was observed in the kitchenette. The hand washing sink was not readily available for use because a coffee carafe was inside the sink and coffee machine parts were observed on a soiled towel next to the sink and protruding over the edge of the sink.

5.c. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* A wall mounted hand hygiene dispenser was observed just outside the LH2U entry doors. The surveyor attempted to obtain hand hygiene preparation from the dispenser and found it was empty.
* A handwashing sink was observed in the medication room with a wall mounted paper towel dispenser near the sink. The surveyor washed their hands in the sink and found the paper towel dispenser was empty and there were no other paper towels readily available for use without leaving the medication room which required going through a closed door into another room.
* A handwashing sink was observed in the kitchenette. The handwashing sink was not readily available for use because coffee machine parts and plastic pitcher lid were observed inside the sink

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6.a. Prohibited food items, some that could be used for making "pruno," were observed in patient rooms, some concealed under patient clothing. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital had "Updated Administrative Directive 6.047 'Patient Food' to not allow food in patient room [sic], with exception for patients in medical isolation" and would "Update OSH Infection Prevention Administrative Directive 2.001 'Infection Prevention Program' and protocol 1.010 'Infection Prevention Program' to allow for removal of items from patient rooms which could pose an infection risk. This includes removal of food, fluids except water ..."

6.b. During tour of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415 the following observations were made:
* Individually wrapped and unwrapped hard candies were found in PtRm-UU and PtRm-VV, including an open box of Lemonheads candies.
* Splenda packets were found in a paper cup in PtRm-XX.
* A cup with a wet tea bag inside of it was found in PtRm-YY.

6.c. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* In PtRm-bb, clothes were observed tightly packed into a cubbie-style shelving unit space. The clothes were removed and two whole oranges were observed concealed among the clothes.

6.d. During tour of MN2U on 11/16/2022 beginning at 1200 with the CS, JCPD, DON-JC the following observations were made:
* In PtRm-ii, a plastic cup with lid and brown liquid inside was observed without a label, patient name, date, or any other information on it. During an interview with the DON-JC at the time of the observation, they confirmed this observation and stated the liquid was vinegar.

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7.a. Food items in kitchenettes did not have complete labels. The POC dated 10/03/2022 attested that by 11/07/2022 the hospital would "Update Food and Nutrition Services protocol 310 'Dating of Food' to ensure all food containers are labeled with contents and expiration date." The P&P titled "Protocol 310 ... Dating of Food" dated 09/06/2022 reflected that "Food packaged or repackaged by Food Service must be labled and dated with a clear Use By Date sticker and will include the day/month/year ... FNS staff must mark food containers ... and clearly identify contents if not visibly clear." The P&P developed did not align with the POC that attested the food containers would be labeled with the contents.

7.b. During tour of BF1U and B1U with staff that included DON-Salem, DSS, SCPD, CS and unit staff on 11/15/2022 beginning at 1415 the following observations were made:
* In the BF1U kitchenette refrigerator in excess of 15 covered condiment containers of a thick beige substance were observed in a bin. The containers were labeled with a "Use By" date. However, some of the containers had a red label that reflected "Chicken Salad," some of the containers had a red label that reflected "Tuna Salad," and some of the containers were not labeled with the contents. It was unclear if those had chicken salad or tuna salad or were another item altogether, information important to ensure patient nutritional problems/needs met including patient food allergies, intolerances, and preferences.
* In the BF1U kitchenette refrigerator numerous covered condiment containers of other items were observed to not be labeled with the contents, including containers of a lumpy white substance, and containers of a thick brown substance.
* In a cabinet in the BF1U kitchenette an open four lb. bag of white sugar was observed. The bag was not sealed and there was a hole in the bottom that allowed sugar to spill out when the bag was lifted. The open sugar had a potential to attract ants or other insects.
* In the B1U kitchenette seven covered condiment containers of a moderately thick, red substance were observed in the refrigerator. Although the containers were labeled with a complete "Use By" date, the name of the substance was not on the container. Staff present did not know what the contents were and speculated that it could be a catsup or a hot sauce. Another staff person who entered the room stated they believed is was "Catalina" salad dressing.

7.c. During tour of A2U on 11/15/2022 beginning at 1430 with the APD, CS, and AUA the following observations were made in the kitchenette:
* A loaf of bread in a plastic bag was observed with no label with expiration or discard date.
* Four small plastic cups with lids were observed with orange fruit-like food inside them were observed in the refrigerator. None of the containers or lids were labeled with the contents, expiration date, discard date or any other information.
* A small plastic cup with with lid with red-orange liquid inside was observed in the refrigerator. There was no label with the contents, expiration date, discard date or any other information.
* A Styrofoam container with plastic lid containing green salad was observed in the refrigerator. There was no label with expiration date, discard date or any other information.
* A one-gallon pink pitcher with lid was observed in the refrigerator. The lid had "Dr Pepper" written on it. There was no label or other information on the pitcher or lid including no expiration date or discard date.

7.d. During tour of LH2U on 11/15/2022 beginning at 1510 with the APD, CS, and AUA the following observations were made:
* In the kitchenette a partial loaf of bread in a plastic bag was observed labeled with only "Best By 11/21."
* In addition, a cold pack covered in beige fabric with brown staining on it was observed in the refrigerator's freezer where bags of coffee were stored. The fabric cover had "occupational therapy" handwritten on it.


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