HospitalInspections.org

Based on document review and interview, it was determined that for 8 of 8 (Pts. #2 - Pt. #9) patients' observation log sheets reviewed for observation rounds, the Hospital failed to provide care in a safe setting by failing to conduct observation rounds every 15 minutes on the Centers for Mental Health Adolescent Unit, as required.

Findings include:

1. On 8/31/2020, the policy titled, "Suicide Prevention" reviewed by the Hospital on 3/13/2020 was reviewed. The policy included, "B. Moderate Risk for Suicide (SPII): When patient is deemed at moderate risk based on the SAFE -T assessment (Suicide Assessment five step evaluation and triage) patient is put on SPII precautions which are Q15 minute [every 15 minutes] checks. i Whereabouts of the patient must be known at all times. A designated staff person must observe the patient at least every fifteen minutes. 1. Observations are documented on the observation patient log."

2. On 8/31/2020, the clinical records for Pts. #2 - Pt. #9 were reviewed. Pts. #2 - Pt. #8 had orders for level 2 suicide precautions with every 15 minutes observations, and Pt. #9 had orders for aggression precautions with every 15 minutes observations.

3. On 8/31/2020 at 10:38 AM, during an observational tour of the Centers for Mental Health Adolescent Unit with the Director of the Centers for Mental Health (E #3) and the Manager of the Centers for Mental Health (E #2), the observation log sheets for the adolescent unit were reviewed. The observation log sheets lacked documentation of the location, behavior, activity, and visual appearance of Pts. #2 - Pt. #9, between 9:00 AM - 10:30 AM on 8/31/2020. At approximately 10:30 AM, Pts. #2 - Pt. #9 were observed walking down the hall, with a Mental Health Specialist (E #13), from the classroom on 4 West (Centers for Mental Health Adult Unit) toward 4 South (Centers for Mental Health Adolescent Unit).

4. On 8/31/2020 at 10:45 AM, an interview was conducted with the Manager of the Centers of Mental Health Unit (E #2). E #2 stated that all patient observations should be documented every 15 minutes. E #2 stated that Pts. #2 - Pt. #9 were in the classroom from 8:45 AM - 10:30 AM and were being monitored by staff. E #2 stated that the observation rounds should have been documented every 15 minutes while the patients were in the classroom.

5. On 9/1/2020 at 2:06 PM, an interview was conducted with a Behavioral Health Specialist (E #13). E #13 stated that she was in the classroom with Pts. #2 - Pt. #9 on 8/31/2020, between 8:45 AM - 10:30 AM. E #13 stated that the assigned teacher was unable to teach the class on 8/31/2020, due to personal reasons. E #13 stated that she monitored Pts. #2 - Pt. #9, but forget to take the observation log sheets into the classroom for documentation.

Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by labeling and dating opened food products and discarding expired food. This has the potential to affect the current census of approximately 250 patients.

Findings include:

1. The Hospital's policy titled, "Food Labeling" (revision date 2/2020), was reviewed on 9/1/2020, and required, "Prepared foods, and any items taken out of the the original case shall be labeled according to established practices...To ensure safety of food products...to ensure products are appropriately identified while in storage... Expired items are to be disposed of by the end of business..."

2. The Hospital's policy titled, "Storage" (revision date 3/2020), was reviewed on 9/1/2020, and required, "All foods...must be stored according to approved storage methods... To conserve the quality of the food supply during storage... Cover all refrigerated food and date while in storage with item name, date and time of prep, and use-by date..."

3. On 9/1/2020 at 12:05 PM, a tour of Dietary Services was conducted. The following observations were made:

- The walk-in freezer contained two (2) 5 pound bags of meat that were unlabeled and undated.

- The Dairy Refrigerator contained a box of oranges. Approximately six of the oranges had a greenish substance on them and were discarded by the Director of Food Services (E #19).

4. On 9/1/2020 at 12:20 PM, an interview was conducted with (E # 19). E # 19 stated that food that is not in the original container should be labeled and should be dated. E # 19 stated that expired food should be discarded right away, and there needs to be special attention made to fruit at this time of the season.

B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by maintaining a sanitary environment. This has the potential to affect the current census of approximately 250 patients.

Findings include:

1. The Hospital's policy titled, "Environmental Services Cleaning Responsibilities" (revised date 12/19), was reviewed on 9/1/2020, and required, "Environmental Services have established cleaning responsibilities in the Food and Nutrition Services Department...6. Cleaning all ceiling vents in the kitchen..."

2. On 9/1/2020 at 12:05 PM, a tour of Dietary Services was conducted. During the tour, the ceiling vent that was above the food preparation area was noted to have an excessive build-up of dust.

3. On 9/1/2020 at 1:00 PM, an interview was conducted with the Director of Food Services (E # 19.) E # 19 stated that the vents should be free of dust and cleaned at least once a month.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on September 1-3, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on September 1-3, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that for 2 of 2 crash carts in the Family Birth Place (FBP), the Hospital failed to ensure that the crash carts were checked daily and did not contain outdated medications/supplies in order to maintain an acceptable level of safety and quality. This potentially affected 17 adult patients and 6 newborns on census in the FBP on 8/31/2020.

Findings include:

1. The Hospital's policy titled, "Code Blue (Cardiopulmonary Resuscitation) Standard Procedure" (dated 5/1/2018), was reviewed on 9/2/2020 and required, "...Crash carts will be checked at least once per day in areas that serve 24 hours a day... Restocking of crash carts: ...Adult and Pediatric crash carts are maintained by pharmacy 24 hours per day..."

2. During a tour of the Mother/Baby Unit on 8/31/2020, at approximately 10:26 AM, the crash cart contained the following outdated medications/supplies:

- 1 of 1 syringe of succinylcholine (drug used as an anesthetic during intubation) with an expiration date of 8/12/2020.
- 1 of 1 bag of electrodes with an expiration date of 8/22/2020.

3. During a tour of the Labor & Delivery (L&D) Department on 8/31/2020, at approximately 12:50 PM, the crash cart log from 8/1/2020 to 8/31/2020 was reviewed and lacked documentation of daily safety checks on 8/3/2020, 8/12/2020, 8/14/2020, 8/15/2020, 8/23/2020 and 8/29/2020.

4. An interview was conducted with the Pharmacy Distribution Manager (E#7) on 8/31/2020, at approximately 10:34 AM. E#7 stated that pharmacy keeps track of the emergency cart contents and will replace the outdated items as needed. E#7 stated that in this case, the cart should have been swapped out over the weekend but it was missed.

5. An interview was conducted with the Manager of L&D (E#14) on 8/31/2020, at approximately 12:56 PM. E#14 stated, "The crash cart should be checked daily. I don't know what happened on those days but I will follow up with staff."

A. Based on observation, interview, and document review, it was determined that for 1 of 1 Unit (Medical/Oncology), the Hospital failed to ensure that proper isolation signage was posted, in order to prevent and control the transmission of COVID-19. This has the potential to affect all 31 patients on the unit's census.

Findings include:

1. The Hospital's policy titled, "Responsibilities for Carrying Out Isolation Precautions" (dated 5/27/15), was reviewed on 9/2/2020, and required, "...Appropriate signage will be placed on the door/patient care area as soon as possible. Healthcare workers are responsible for complying with Isolation Precautions and for tactfully calling lack of compliance to the attention of offenders..."

2. The Hospital's Isolation Droplet Precautions signage required, "...A. Green droplet precautions sign on the door..."

3. The clinical record for Pt #29 was reviewed on 8/31/2020. Pt #29 was admitted on 8/28/2020 with a diagnosis of COPD (chronic obstructive pulmonary disease) with acute respiratory infection. The COVID-19 Symptoms Screening (dated 8/31/20 at 8:21 AM) included, "...What are your symptoms?: Cough, Shortness of Breath..."
Pt. #29's Physician Orders (dated 8/29/20) included, "Droplet/Contact Isolation: Positive Symptoms".

4. On 8/31/2020 at 9:58 AM, a tour of the Medical Oncology unit was conducted. During the tour, the 7th Floor Unit Manager (E #16) stated that there was one COVID PUI patient (patient under investigation - presenting with COVID symptoms) on the unit (Pt #29). At the time of the tour, Pt #29's room door lacked a sign for droplet precautions.

5. On 8/31/2020 at 10:30 AM, an interview was conducted with E #16. E #16 stated that there should have been a droplet precautions sign on Pt #29's door.

B. Based on document review, observation, and interview, it was determined that for 1 of 1 unit (Pre-Operative Services), the Hospital failed to ensure that medication was stored in a manner to prevent and control the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Medication Storage and Security" (dated 5/1/2020), was reviewed on 9/2/2020, and required, "This policy provides that medication will be stored securely to protect the safety of patients..."

2. On 9/1/2020 at approximately 9:55 AM, a tour of Pre-Operative Services was conducted. During the tour, a Pre/Post Operative Registered Nurse (E #17) was observed with a syringe (Cefazolin/antibiotic used to prevent infection) in her uniform pocket, which also contained her personal cell phone. E #17 stated that she was keeping it on her person prior to giving it to the patient.

3. On 9/1/2020 at 10:00 AM, an interview was conducted with the Pre/Post Operative Manager (E #18). E #18 stated that the nurses should not store or keep medication in their pockets due to infection control purposes.

Based on document review and interview, it was determined that for 4 of 4 immediate-use steam sterilization (IUSS)logs reviewed, the Hospital failed to ensure that records of IUSS were completed as required, in order to monitor the use of IUSS for appropriateness and to trace any surgical infections that may have resulted. This had the potential to affect the average 691 patient surgeries conducted every month.

Findings include:

1. The Hospital's Procedure for "Operating the Autoclave for Immediate Use Sterilization" (dated 7/1/2018) was reviewed on 9/2/2020 and required, "...Document the necessary information (e.g., patient's name, surgeon's name, load number, item being sterilized and reason for IUSS) on the Flash Load Instrument/Implantable Devices Load Record... The log must be completed for each use of every autoclave..."

2. The IUSS logs from 8/3/2020 to 8/31/2020 for 4 of 4 steam sterilizers (Ortho L-1, Ortho R-2, Cysto, and Cardiac) in the OR (operating room area) were reviewed on 9/2/2020. The logs indicated that 50 IUSS loads were completed during this time period and lacked documentation of the following:

- For 13 IUSS loads completed on 8/3/2020 (2 loads), 8/4/2020, 8/5/2020, 8/6/2020 (2 loads), 8/7/2020, 8/25/2020, 8/26/2020, 8/27/2020, and 8/28/2020 (3 loads), the records lacked documentation of what specific/type of instrument was sterilized in the "Description of Implant/Item" field .

- Patient name was left blank on 5 IUSS loads completed on 8/3/2020, 8/6/2020 (3 loads) and 8/7/2020.

- The reason for the IUSS was left blank for 9 IUSS loads completed on 8/7/2020 (3 loads), 8/13/2020 (2 loads), 8/18/2020, 8/20/2020, 8/24/2020, and 8/28/2020.

3. An interview was conducted with an OR Registered Nurse (E#12) on 9/2/2020, at approximately 1:55 PM. E#12 stated that the type of instrument flashed [IUSS] should be written on the sheet, although some staff only write "Inst."

4. An interview was conducted with the OR Manager (E#10) on 9/2/2020, at approximately 10:20 AM. E#10 stated that staff are expected to complete the flash [IUSS] log completely including what was flashed, the patient's name and the reason. E#10 stated that the specific item flashed should be documented to "better track" any possible infections that may result. E#10 stated, "It's an opportunity for education."

5. An interview was conducted with the Director of Perioperative Services (E#9) on 9/2/2020, at approximately 10:40 AM. E#9 stated that the flash logs are reviewed every month with the Infection Control Committee to see if there are any increasing trends in flashing for a specific instrument and/or reason. E#9 stated that information on the flash logs is needed to be able to identify these trends and trace back any potential surgical site infections.