HospitalInspections.org

1. Based on a review of facility documentation, interview and policy review, the facility failed to provide oversight of the contracted dialysis service to ensure water culture results were obtained in a timely manner. The finding includes the following:
a. Review of the hemodialysis monthly water cultures identified that October cultures of the Reverse Osmosis (RO) system and two machines were obtained on 10/24/13. The facility was unable to provide the cultures results on the day of survey (11/5/13). Subsequent to surveyor request, the test results were obtained and identified the following results: Reverse Osmosis (RO) system #1, 300 CFU's (acceptable level <50 CFU's), RO #2 was 130 CFU's, Machine #1 was 80 (action level required if > than 50 CFU's) and Machine #2 was 70 CFU's. Interview with the Biomedical staff on 11/5/13 at 1:30 PM stated although the RO and machines were disinfected after the cultures were sent, the dialysis unit should have been notified of the test results on 10/28/13 and repeat samples should have been obtained. Review of the Dialysis policy indicated the action level in the product water shall be 50 CFU's and levels 50-199 CFU's require steps to be taken to interrupt the trend towards higher unacceptable levels. The policy further indicated that colony counts of 200 CFU's or greater, require immediate action.


2. Based on clinical record review, interview, and contract review the facility failed to ensure that the hospital's respiratory services are integrated into its hospital-wide QAPI program. The findings include:

a. Patient #39 was admitted on 1/15/13 and required CPAP (continuous positive airway pressure). The clinical record indicated a physician's order dated 10/3/13 that directed RT (respiratory therapy) to adjust the CPAP. Interview with the Nurse Manager indicated that a call to the contracted RT facility had been placed and that "someone" from respiratory had been to see the patient, however he/she was not sure of the persons credentials. The Nurse Manager indicated the Respiratory Therapy (RT) services are a contracted service and that they respond when called. However, the RT staff do not document in the clinical record. Interview with the Director of Quality on 11/6/13 at 2:00 PM indicated that the contracted service was contacted to clarify the credentials of the staff member that provided respiratory services at the hospital. Interview with the Quality Director on 11/13/13 at 8:30 AM indicated that a respiratory technician had come to evaluate Patient #39 and fitted the patient for a new mask. The Quality Director indicated that the RT contract was for respiratory equipment and did not provide respiratory therapist services.


Review of the contract identified that equipment would be provided to the faciltiy but did not identifiy professional services as part of the contract.

In addition review of hospital documentation failed to identfy that the contracted service of respiratory services were reviewed as part of the hospitals QAPI program. Interview with the Director of Quality on 11/5/13 identified that they had a current contract but no documentation of quality review.





19907


3. Based on review of hospital documentation and interviews with facility personnel, the facility failed to ensure that contracted services were evaluated as part of the hospital wide QAPI program.

The findings include:

a. Review of contracted services and hospital documentation identfied that the contracted services of radiology, dialysis and respiratory services were not being reviewed as part of the hospitals QAPI program. Interview with the Director of Quality on 11/5/13 identified that they had current contracts but no documentation of quality review.

Based on review of clinical records, review of hospital policy and interviews with hospital staff for one patient (Patient #35) that was involved in a psychiatric emergency, the hospital failed to ensure that the hard wired code button was properly functioning for a timely emergency response, and failed to ensure that the facility was designed and maintained in such a manner as to promote the safety and well-being of patients.
The findings include:
a. Patient #35 was admitted to the hospital on 7/29/13 with delusional disorder and history of assaultive behavior in the past. On 11/4/13 at 1:30 PM a psychiatric emergency was observation on M3D unit involving Patient #35. Patient #35 was observed to be very agitated, yelling, screaming and assaulted a hospital staff member. The hospital staff member sustained a head injury as a result of this assault. During the debriefing session, it was identified by hospital staff members that there was a delay in the emergency response time. MHW #1 identified that the hard wired code button (used to call for help during a psychiatric emergency) did not work. The code button did not activate an overhead emergency notification, and another hard wired code button needed to be pressed, therefore causing a delayed response. It was noted during the debriefing session that this hard wired code button had not worked for some time. Review of the All Available Code for Psychiatric Emergencies Policy identified that the staff member would initiate the "All Available Code" by pressing a hard wired code button. The policy indicated that once the button was pressed, an alarm signal was simultaneously sent to the Telecommunications Center and an overhead page would be announced. In the case of this witnessed psychiatric emergency, the hard wired code button failed to function properly for a timely psychiatric emergency response.

b. On 11/04/13 at 1:00 PM, the surveyor, while accompanied by the General Trades Worker and the Assistant Fire Chief and upon a tour of the off-site, Blue Hills Nursing Units, the following were observed:
That nearly all of the patient rooms within the Blue Hills Nursing Unit on the 2nd floor were provided with a system that was intended to cover over abandoned, conduits and penetrations through the floor for heating pipes which were no longer secured to the floor and now have the potential to harm or injure patients if handled or abused; i.e. caps placed over breaches in the floor no longer secured & sharp materials are now accessible.


c. On 11/04 and 11/05/ 13 at various times throughout the days, the surveyors, while accompanied by the General Trades Workers, Assistant Fire Chief, Fire Chief and Facilities Plant Engineer(s) and upon a tour of the off-site and on-site Nursing Units, the following were observed:
That the patient bathrooms and shower rooms throughout were not provided with soap dispensers that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used;

That not every electric, patient bed located throughout the nursing units were provided with power cords that are listed and approved as "institutional" in construction and are deemed appropriate for use in the environment in which they are installed and located; i.e. longer than needed power cords can injure patients if mis-used-facility was to tie-wrap questionable cords as interim measure and install looming and clips as permanent fix-neither exist in some applications;

That the patient bathrooms and shower rooms throughout the Battell Building were not provided with fluorescent light diffusers (lenses) that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type diffusers can injure patients or others if mis-used-not tamper resistant;

That the newly renovated Seclusion Room in the Battell Building-4th Floor North was not provided with blind spot mirror and a door hardware set that were listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. door knob & mirror have potential to be ligature point.

Based on clinical record review, interview and policy review the facility failed to ensure for 1 of 2 patient (Patient #41) who was on intake and output (I&O) that the physician was notified with a change of condition, and/or that 1 of 4 patients (Patient #41) receiving oxygen that the patients oxygen saturations were monitored, and/or for 2 of 4 patients (Patients #38 & 45) that weights and vital signs were obtained. The finding includes the following:

a. Patient #41 was admitted to the facility on 8/30/13 with polysubstance abuse, COPD, asthma and morbid obesity. Review of the clinical record with the Nurse Director and the Nurse Manager on 11/6/13 identified that physician's orders dated 10/30/13 directed intake and output (I&O) monitoring for fourteen days and to "push" oral fluids. Review of I&O documentation for the period of 10/30/13 through 11/3/13 indicated that the patient consistently had a higher intake than output. The I&O for 11/4/13 and 11/5/13 indicated that although the patient had an intake of 1500 cc's and 2170 cc's respectively the patient had no urinary output. The nurse's note dated 11/4/13 in the evening indicated that the patient was complaining of weakness. The note indicated that the patient was "resistive to fluids and had no intake or output, continue to monitor". The clinical record failed to reflect if the physician had been notified regarding the patient's weakness and of the patient's fluid intake or output.


b. Patient #41's physician's order dated 8/30/13 directed to utilize BiPAP while sleeping and Oxygen 3 liters as needed. The Multidisciplinary Treatment Plan (MTP) dated 9/30/13 identified respiratory distress as an active problem with the intervention to monitor Oxygen saturations as needed. A physician order dated 11/4/13 directed Oxygen 2 liters when lying down. Review of the clinical documentation indicated that the patient received oxygen 2 liters and 3 liters at times. The clinical record failed to reflect if the conflicting orders were clarified. A nursing note dated 11/4/13 indicated that the patient was weak and was on Oxygen 3 liters. Observation on 11/4/13 at 10:45 AM indicated that a medical emergency was called secondary to the patient being obtunded. Review of the clinical record with the Nursing Director and the Manager failed to reflect that oxygen saturation rates had been completed for the period of 8/30/13 through 11/5/13. The Nursing Director indicated that he/she was not sure why saturations had not been monitored.


c. Patient #45 was admitted on 12/21/05 with schizophrenia, paranoid behaviors, hypertension, dysphasia, diabetes and a tracheostomy. Review of a physician's order dated 10/15/13 directed to monitor oxygen saturation rates's every day and to keep the patient's oxygen saturation above 90%. The record indicted that the patient was sent to the emergency department (ED) on 10/26/13 for shortness of breath and was identified to have a mucous plug. Physician orders dated 10/26/13 upon return from the ED directed to keep the patient's oxygen saturation rate above 92% and suction the patient every shift for three days. Review of the treatment record indicated that on 10/27/13 and again on 10/30/13 Patient #45's oxygen saturation rate was 91%. The record failed to reflect that the low oxygen saturation rate had been addressed on either day and/or that the patients oxygen level had been titrated to maintain the patient's oxygen saturation above 92% as ordered. Interview with the RN on 11/6/13 at 10:00 AM indicated that the order was to maintain the saturation above 90% and that the order to maintain above 92% was only for three days, however staff failed to clarify the order.

In addition review of the treatment sheet for November indicated that oxygen saturations had not been obtained on 11/1/13, 11//2/13, 11/3/13 and 11/5/13.


d. Patient #38 was admitted on 8/3/07 with schizoaffective disorder, Post Traumatic Stress Disorder and polysubstance abuse. Review of the MTP dated January 2013 directed to obtain monthly weights and vital signs. Review of the clinical record with the Nursing Director and the Charge Nurse indicated that during the period of January 2013 to October 2013, weights were only completed on 1/20/13, 3/2/13 and 8/5/13. The Charge Nurse indicated that Patient #38 refuses weights and vitals signs frequently, however the treatment sheet failed to reflect refusals and/or that further attempts had been made to obtain Patient #38's weight and/or vital signs.

Based on review of clinical records, review of hospital policy and interviews with hospital staff, the hospital failed to ensure that a comprehensive Multidisciplinary Treatment Plan (MTP) was developed 5 of 15 patients. For one patient with obesity (Patient #41), the hospital failed to ensure that the dietician was included in the preparation of the Multidisciplinary Treatment Plan (MTP), failed to ensure that a comprehensive MTP was developed for one patient (Patient #31) regarding respiratory needs, failed to ensure that diabetic monitoring and education were completed for one patient (Patient #35) with diabetes mellitus Type II, failed to ensure patient safety for one patient (Patient #25) with history of suicidal ideation, and failed to include all medical diagnoses and corresponding interventions into the treatment plan for one patient (Patient #29). The findings include:


a. Patient #41 was admitted to the facility on 8/30/13 with polysubstance abuse and morbid obesity. The clinical record indicated that on admission the patient weighed in excess of 700 pounds with a BMI of 86.4 (goal 27-28). The clinical record indicated that a nutrition consult was completed on admission, that indicated to place the patient on a 4,000 calorie diet. The nutrition note dated 9/12/13 recommended a high protein, high calorie diet and to encourage fluids. Review of the MTP's dated September 2013 and October 2013 identified an active problem for obesity with the interventions in part for nursing staff to educate the patient on obesity related health issues, monitor weight as ordered and encourage healthy food choices. Review of the MTP with the Dietician failed to reflect that the dietician was involved in the creation of the nutritional MTP.

Review of the policy indicated that a nutritional care plan should be developed by the Registered Dietician with the multidisciplinary team and integrated into the MTP.


b. Patient #31 was admitted to the hospital on 10/31/13 for Alchohol Dependency. Review of the physician's order dated 11/1/13 identified that the patient was to receive CPAP (continuous postive airway pressure) at 10cm. Review of the nursing plan of care failed to identify that the patient's respiratory needs and interventions were identified in the MTP. Interview with the Nursing Director of Addiction Services on 11/5/13 identified that the patient needed to have a treatment plan that addressed the utilization of CPAP.

c. Patient #35 was admitted to the hospital on 7/29/13 with diagnoses that included delusional disorder and diabetes mellitus Type II. Review of the physician orders from admission through 10/23/13 directed a regular diet for the patient. A nutrition assessment dated 8/1/13 indicated to provide education as appropriate, and identified that the patient declined accuchecks or bloodwork. Review of the clinical record identified that nutrition education was completed 3 months later, as well as the bloodwork, insulin and oral medication orders. Review of laboratory results dated 10/28/13 identified the patient's blood glucose was 228 (normal 70-110) and HgA1C was 9.1 (normal < 7). Subsequently, insulin and Metformin were ordered on 10/28/13 and diabetic education was implemented. Although Patient #35 initially refused bloodwork, the clinical record failed to reflect attempts were made for diabetic education and monitoring for 3 months.

d. Patient #25 was admitted to the hospital on 6/24/13 with major depression and a history of multiple suicide attempts. During tour of the M4D unit, an observation was made in the patient room (Room 124D) of an IPod earbuds/headset that was hanging down from the patient's bookshelf. The room was shared with two other patients and the headset was approximately 2 - 2.5 feet in length. Review of the physician order dated 9/3/13 directed that the patient may have music at the RN's discretion. Review of the Patient Personal Property Policies did not identify patient headsets. Interview with RN #3 on 11/4/13 at 11:00 AM identified that the headset was given to the patient, but could not explain when the patient would receive and/or return the headset. Documentation and interviews failed to reflect that a mechanism was in place for patient headset storage and/or dispensing in order to ensure patient safety.

e. Patient #29 was admitted to the hospital with diagnoses that included schizo-effective disorder, borderline personality disorder, alcohol and drug abuse, hepatitis C and noninsulin dependent diabetes mellitus (NIDDM). Physician's orders indicated Patient #29 was receiving Metformin extended release 500 mg. twice a day. According to Patient #29's MTP, active discharge to a community residential care program was in progress. In review of the treatment plan the medical record lacked documentation that interventions related to NIDDM and education in preparation for discharge was addressed.
During a review of the medical record with the Chief Nursing Executive (CNE) on 11/5/13 the CNE indicated Patient #29's NIDDM and should have been included in the treatment plan.






19907







19952





26703

Based on observations and interviews with facility personnel, the facility failed to ensure that safe food handling practices were maintained by staff.

The findings include:

a. During tour of the dietary department on 11/5/13, it was observed during the tray line that a dietary staff member picked up a pot holder that had fallen on the floor and started using it to handle the pans during the serving of food. In addition, further observation identified that a dietary staff member did not change gloves when moving pans on/off the tray line and proceeded to go back to serving food. Review of hospital policy identified that single use gloves will be worn for only one task and discarded when interruptions occur in the operation. Interview with the Director of Food Services on 11/5/13 identified that the staff member will need re-education on safe food handling practices.

Based on a tour of the hospital, the facility failed to ensure that the facility was designed and maintained in such a manner as to promote the safety and well-being of patients.

1. On 11/04/13 at 1:00 PM, the surveyor, while accompanied by the General Trades Worker and the Assistant Fire Chief and upon a tour of the off-site, Blue Hills Nursing Units, the following were observed:

a. That nearly all of the patient rooms within the Blue Hills Nursing Unit on the 2nd floor were provided with a system that was intended to cover over abandoned, conduits and penetrations through the floor for heating pipes which were no longer secured to the floor and now have the potential to harm or injure patients if handled or abused; i.e. caps placed over breaches in the floor no longer secured & sharp materials are now accessible.

2. On 11/04 and 11/05/ 13 at various times throughout the days, the surveyors, while accompanied by the General Trades Workers, Assistant Fire Chief, Fire Chief and Facilities Plant Engineer(s) and upon a tour of the off-site and on-site Nursing Units, the following were observed:

a. That the patient bathrooms and shower rooms throughout were not provided with soap dispensers that are listed and approved as " institutional " in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used;

b. That not every electric, patient bed located throughout the nursing units were provided with power cords that are listed and approved as "institutional" in construction and are deemed appropriate for use in the environment in which they are installed and located; i.e. longer than needed power cords can injure patients if mis-used-facility was to tie-wrap questionable cords as interim measure and install looming and clips as permanent fix-neither exist in some applications;

c. That the patient bathrooms and shower rooms throughout the Battell Building were not provided with fluorescent light diffusers (lenses) that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type diffusers can injure patients or others if mis-used-not tamper resistant;

d. That the newly renovated Seclusion Room in the Battell Building-4th Floor North was not provided with blind spot mirror and a door hardware set that were listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. door knob & mirror have potential to be ligature point;



19952


3. Based on observations and interview with hospital personnel, the hospital failed to keep a clean, sanitary and safe environment. The findings include:
a. During tour of the M2AB Unit, an observation was made in the patients' laundry room of the washing machine that was not level, was vibrating loudly and had moved from its original location. The washing machine leg was noted to be broken with books underneath it in order to keep it level.
b. During tour of the M2DE Unit, an observation was made of the storage closet located in the lounge snack room area. The floor was dirty and the bottom shelf (which held food items) was located approximately one inch from the dirty floor.
c. During tour of the physical therapy department, an observation was made of long telephone cords on the phones located in the patient examination/treatment areas. Interview with the physical therapy staff indicated that patients were not left alone in those areas and physical therapy personnel were always in attendance.
d. Tour of Battel 2 North on 11/5/13 at 11:30 AM identified that in the womens' restroom, the handicapped toilet failed to provide privacy for the patients. The handicapped toilet area lacked a partition to allow for privacy from other patients and/or staff when in use.
e. Tour of Battel 3 North on 11/6/13 at 9:00 AM identified one case of dietary supplements on the refrigerator in the patient kitchen, ready for use, that had expired on 11/1/13.

Based on review of Infection Prevention Committee (IPC) meetings and interviews with staff, the hospital failed to ensure that key hospital departments were represented in the ICP meetings. The findings include:

During an interview with the Medical Director, Infection Control Preventionist (ICP) and Director of Nursing on 11/6/13, it was identified that pharmacy and dental department representatives were not present at the IPC meetings from January through June 2013.

1. Based on observation, interview and policy review the facility failed to ensure that hand hygiene was completed after patient care. The findings include the following:

Observation on 11/5/13 at approximately 10:45 AM identified a medical emergency was initiated. Observation during the period of 10:45 AM through 11:30 AM identified staff in the patients room with gloves on. MHW #10 was observed to exit the room, remove gloves and exit the unit with the gloves in his/her hand, RN #10 was observed to exit the room, remove gloves walk down the hall, enter the nurse's station and utilize hand gel. RN #10 was observed to obtain gloves, prepare medications, enter the patient's room, administer the medications, exit the room and walk down the hall and enter the medication room to discard the syringe. Interview with the staff indicated that staff should wash hands however there are no sinks and/or hand gel dispensing station to perform hand hygiene.




19907


2. Based on observations and interviews with facility personnel, the facility failed to ensure that soiled linen was stored in a dirty area to prevent contamination.

The findings include:

a. During tour of the Woodward Building on 11/4/13, it was observed that soiled utility bins were being stored in a tub room that is utilized by patients. Interview with the Nursing Director on 11/4/13 identified that the units do not have a soiled utility area for soiled linen.

b. During tour of the Woodward II unit on 11/3/13, it was observed that a toilet in the men's bathroom was heavily rusted. Interview with the Nursing Director on 11/5/13 identified that the facility going to remove the toilet immediately.

Based on clinical record review, and interview the facility failed to ensure that respiratory services were provided in an appropriate manner. The finding includes the following:

Patient #39 was admitted on 1/15/13 and required CPAP (continuous positive airway pressure). The clinical record indicated a physician's order dated 10/3/13 that directed RT (respiratory therapy) to adjust CPAP. Review of the clinical record with the Nurse Manager and the Nursing Director on 10/5/13 failed to reflect that Respiratory therapy had seen the patient. Interview with the Nurse Manager indicated that a call had been placed and that "someone" from respiratory had been see the patient however he/she was not sure of the persons credentials. The Nurse Manager indicated the RT services are a contracted service and although they do respond when called, they do not document in the clinical record.

Interview with the Nursing Director and the Nurse Manager on 10/5/13 at 10:00 AM identfied that they did not know the name and/or credentials of the contracted employee. Interview with the Director of Quality on 11/6/13 indicated that he did not know the name and/or credentials of the contracted employee however the contracted service was contacted to clarify the credentials of the staff member from the contracted service. Interview with the Quality Director on 11/13/13 at 8:30 AM indicated that a respiratory technician had come to evaluate Patient #39 and fitted the patient for a new mask.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for 1 of 2 sampled patients (Patient #31), the facility failed to ensure that CPAP (continuous postive airway pressure) orders contained the appropriate parameters.
The findings include:
a. Patient #31 was admitted to the hospital on 10/31/13 for Alchohol Dependency. Review of the physician's order dated 11/1/13 identified that the patient was to receive CPAP at 10 cm. Further review failed to identify the specific parameters including the amount of oxygen to be utilized. Review of hospital policy identified that an order for treatment shall be written which includes the mode, presssures, and as applicable the respiratory rate and supplemental oxygen if indicated. Interview with the unit physician on 11/5/13 identified that was how they have written CPAP orders.

Based on record review and staff interview, the facility failed to develop individualized psychiatrically focused interventions for 1 of 3 active sample patients (A12) and 5 of 7 non-sample patients (N2, N3, N4, N6 and N7). The interventions are generic and denote routine clinical responsibilities for the clinical discipline rather than being patient specific. This deficiency results in treatment plans that do not reflect a comprehensive, integrated individualized approach to patient care.

A. Record Review: (date of Master Treatment Plan in parentheses)

Patient A12 (10/31/13) had the following interventions for the short term goal, "[Patient] will detox safely. Will attend groups to gain some insight about his addiction. Will complete the rehab program and remain clean and sober:"

1. "Nursing staff will facilitate discussions related to group living dynamics and available detox supports."

2. "MD will discuss risks and benefits of treatment with methadone, monitor mental status, educate re: health risks, discuss lab results."

3. "Nursing will educate on transmission, prevention & treatment for HIV and hepatitis."

4. "Social work will meet with the group every Monday with information to promote, demonstrate, discuss and explore spirituality, and how it works within recovery."

5. "Substance Abuse Counselor will facilitate discussions which support recovery."

6. "Substance Abuse Counselor will facilitate open topic discussion groups as well as speaker/discussion groups with client guest speakers from the men's and women's rehab units."

The following interventions were for the short term goal: "Will detox safely from opiates and be medically stable. [He/She] will verbalize daily to a nurse a decrease in withdrawal symptoms within 3-5 days:"

1. "MD assesses daily and provides Medication Management. Evaluate/adjust medications as indicated. Educate about the risks/benefits and adverse drug reactions of medication."

2. "Nursing will provide health education re: emotional, physical and biophysical effects of substance dependence. Provide Methadone/Suboxone education re: risks/benefits."

3. "Nursing will administer medication as ordered and monitor effectiveness. Evaluate daily for opiate withdrawal symptoms."

4. "Nursing will encourage participation in required groups & unit activities."

These interventions are routine clinician expectations and generic. They do not address individualized treatment or psychiatric issues.

Patient N2 (11/5/13) had the following interventions for the short term goal, "Patient will attend groups and meetings to gain insight about his addition. Will go to rehab and learn how to cope with cravings:"

1. "Nursing will meet 1:1 twice weekly for 10 minutes to reinforce skills learned in groups and meetings."

2. "Counselor will provide both educational and interactive presentation designed to assist patient in determining whether 12 Step Programs can be useful or significant part of aftercare/recovery plan."

3. "LCSW will facilitate education/discussion group focused on learning to skill build specifically as it is related to dealing with craving and triggers for substance use."

4. "MD will start patient on methadone per opioid detox protocol. Will make patient aware of side effects and risks/ benefits of meds."

5. "Substance abuse counselor will conduct group in which patients can explore discharge possibilities. Patients will be provided with lists of community resources by region."

The following intervention was for the short term goal, "[Patient] will learn the 12 step recovery process to help with the desire to stay clean and sober:"

1. "Substance abuse counselor will meet with the patient at group and individually to educate about the process of 12 step."

The following intervention was for the short term goal, "Patient will meet 1:1 with clinical social worker and develop an action plan that will include case management, attending NA/AA meetings and using six coping skills when in high risk situations:"

1. "Clinical Social Worker will use role play to teach patient how to apply coping skills in high risk situations."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

Patient N3 (10/25/13) had the following interventions for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on [his/her] as evidenced by correctly stating them to the staff for four consecutive weeks:"

1. "Substance abuse counselor will offer an opportunity to participate in a 12-step community activity once during their stay based on their risk level."

2. "Social work will conduct group one time a week for 90 minutes for client to learn the role of family members in the recovery process."

3. "Nursing will educate about HIV and hepatitis one time during client's stay."

4. "Recreation will teach about sober recreation/leisure activities."

5. "MD will educate patient weekly about biological treatments/medications for the treatment of opiates and nicotine dependence including potential side effects."

6. "Case Coordinator will meet with client at least weekly to discuss progress toward treatment goals, discharge planning, and other concerns."

7. "Nursing will meet with patient to discuss and reinforce learned skills two times per week."

8. "Rehab therapist and Art therapist will assist patient in completing at least one project related to recovery."

9. "Rehab therapist will provide a variety of structured fitness activities three times per week."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

Patient N4 (10/30/13) had the following interventions for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on his life as evidenced by correctly stating them to the staff for four consecutive weeks:"

1. "Rehab therapist will provide a variety of structured fitness activities 3 to 4 times a week."

2. "Social work will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use."

3. "Nursing will provide education about HIV and hepatitis one time during client's stay."

4. "MD will meet weekly to educate patient about biological treatments/medications for the treatment of opiates and nicotine dependence."

5. "The Case Coordinator will meet weekly with the client to discuss progress toward treatment goals, discharge planning and other concerns."

6. "Rehab therapist will assist client in identifying the benefits of healthy sober recreational activities and identify ways to structure free time."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

Patient N6 (10/31/13) had the following interventions for the short term goal, "[Patient] will participate in education about addiction and recovery:"

1. "Rehab therapist will offer client the opportunity to participate in a 12-step community activity once during their stay."

2. "Social worker will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use."

3. "Nursing will meet with client one time during the client ' s stay for 60 minutes to provide education about HIV and hepatitis."

4. "Nursing will meet two times a week for 60 minutes to educate client on the physiological effects of various substances and common diseases."

5. "Rehab therapy will hold three 75 minute sessions weekly to discuss how a balanced lifestyle and sober recreation/leisure activities support recovery."

6. "Substance abuse counselor will meet one time a week for 30 minutes throughout client ' s stay to educate client on how to support relapse prevention using 12-step and other strategies."

7. "Nursing will meet with client 2x each week for at least 15 minutes to review and reinforce skills learned in groups."

The following intervention is for the short term goal, "Patient will make at least 2 motivational statements as to why [he/she] wants to stop using substances."

1. "Social worker will meet individually with patient to engage in treatment interventions, engage in family sessions and work towards a safe discharge."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

Patient N7 (11/6/13) had the following interventions for the short term goal, "[Patient] will identify at last two harmful outcomes that using illicit substances has had on [his/her] life as evidenced by correctly stating them to staff for four consecutive weeks."

1. "Social worker will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use."

2. "Social worker will conduct group one time a week for 90 minutes throughout the client's stay to learn the role of family members in the recovery process."

3. "Nursing will conduct group one time during the client's stay for 60 minutes to provide education about HIV and hepatitis."

4. "Rehab therapy will provide a variety of structured fitness activities three times per week."

5. "MD will meet with client at least one time a week to educate about biological treatments/medications for the treatment of opiates and nicotine dependence."

6. "Case Coordinator will meet at least weekly with client to discuss progress toward treatment goals, discharge planning and other concerns."

7. "Rehab therapist will conduct four 60 minute groups over 2 weeks to discuss how a balanced lifestyle and sober recreation/leisure activities support recovery."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

B. Staff Interview

On 11/7/13 at 11AM, RN 4 stated, "Yes, I can see that these interventions are not individualized. They are not related to psychiatric issues because patients are here for substance abuse."

Based on record review and interview, the Medical Director failed to ensure the development of individualized psychiatrically focused interventions for 1 of 3 active sample patients (A12) and 5 of 7 non-sample patients (N2, N3, N4, N6 and N7) on the Addiction Services Unit. The interventions are generic and denote routine clinical responsibilities for the clinical discipline rather than being patient specific. This failure of focused interventions results in the lack of clear, individualized and directed psychiatric care for patients in a psychiatric hospital. (Refer to B122)

Based on record review and interview, the Director of Nursing failed to ensure that nursing staff developed interventions on the Master Treatment Plans that addressed the individual needs for 1 of 3 (A12) active sample patients and 5 of 7 non-sample patients (N2, N3, N4, N6 and N7). The Master Treatment Plans included written nursing interventions that were routine, generic discipline functions that could be provided for any patient regardless of specific goals and needs. This deficiency results in treatment plans that do not reflect a comprehensive, integrated individualized approach to patient care.

Findings include:

A. Record Review (date of Master Treatment Plan in parentheses)

Patient A12 (10/31/13) had the following interventions for the short term goal, "[Patient] will detox safely. Will attend groups to gain some insight about his addiction. Will complete the rehab program and remain clean and sober:"

1. "Nursing staff will facilitate discussions related to group living dynamics and available detox supports:"

The following nursing interventions were for the short term goal: "Will detox safely from opiates and be medically stable. [He/She] will verbalize daily to a nurse a decrease in withdrawal symptoms within 3-5 days:"

1. "Nursing will provide health education re: emotional, physical and biophysical effects of substance dependence. Provide Methadone/Suboxone education re: risks/benefits."

2. "Nursing will administer medication as ordered and monitor effectiveness. Evaluate daily for opiate withdrawal symptoms."

3. "Nursing will encourage participation in required groups & unit activities."

Patient N2 (11/5/13) had the following nursing interventions for the short term goal, " Patient will attend groups and meetings to gain insight about his addition. Will go to rehab and learn how to cope with cravings: "

1. "Nursing will meet 1:1 twice weekly for 10 minutes to reinforce skills learned in groups and meetings."

Patient N3 (10/25/13) had the following nursing intervention for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on [his/her] as evidenced by correctly stating them to the staff for four consecutive weeks:"
1. "Nursing will meet with patient to discuss and reinforce learned skills two times per week."

Patient N4 (10/30/13) had the following nursing intervention for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on his life as evidenced by correctly stating them to the staff for four consecutive weeks:"

1. "Nursing will provide education about HIV and hepatitis one time during client's stay."

Patient N6 (10/31/13) had the following nursing interventions for the short term goal, "[Patient] will participate in education about addiction and recovery:"

1. "Nursing will meet with client one time during the client's stay for 60 minutes to provide education about HIV and hepatitis."

2. "Nursing will meet with client 2x each week for at least 15 minutes to review and reinforce skills learned in groups."

Patient N7 (11/6/13) had the following nursing intervention for the short term goal, "[Patient] will identify at last two harmful outcomes that using illicit substances has had on [his/her] life as evidenced by correctly stating them to staff for four consecutive weeks:"

1. "Nursing will conduct group one time during the client's stay for 60 minutes to provide education about HIV and hepatitis."

B. Staff Interview:

On 11/7/13 at 11AM, RN 4 stated, "Yes, I can see that these interventions are not individualized. They are not related to psychiatric issues because patients are here for substance abuse."

Based on record review and staff interview, the Director of Social Work failed to ensure that social work interventions were individualized psychiatrically focused interventions for 1 of 3 active sample patients (A12) and 5 of 7 non-sample patients (N2, N3, N4, N6 and N7). The interventions are generic and denoted routine clinical responsibilities for the clinical discipline rather than being patient specific. This failure resulted in the lack of clear, individualized interventions for patients in a psychiatric hospital.

Findings include:

A. Record Review (date of Master Treatment Plan in parentheses)

1. Patient A12 (10/31/13) had the following interventions for the short term goal, "[Patient] will detox safely. Will attend groups to gain some insight about his addiction. Will complete the rehab program and remain clean and sober:"

"Social work will meet with the group every Monday with information to promote, demonstrate, discuss and explore spirituality, and how it works within recovery." This intervention is routine clinician expectations and is generic. It does not address individualized treatment or psychiatric issues.

2. Patient N2 (11/5/13) had the following interventions for the short term goal, "Patient will attend groups and meetings to gain insight about his addition. Will go to rehab and learn how to cope with cravings:"

"LCSW will facilitate education/discussion group focused on learning to skill build specifically as it is related to dealing with craving and triggers for substance use:" "Patient will meet 1:1 with clinical social worker and develop an action plan that will include case management, attending NA/AA meetings and using six coping skills when in high risk situations:" "Clinical Social Worker will use role play to teach patient how to apply coping skills in high risk situations." These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

3. Patient N3 (10/25/13) had the following interventions for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on [his/her] as evidenced by correctly stating them to the staff for four consecutive weeks:"

"Social work will conduct group one time a week for 90 minutes for client to learn the role of family members in the recovery process."

This intervention is a routine clinician expectation and is generic. "It does not address individualized treatment or psychiatric issues."

4. Patient N4 (10/30/13) had the following interventions for the short term goal: "[Patient] will identify at least two harmful outcomes that using illicit substances has had on his life as evidenced by correctly stating them to the staff for four consecutive weeks:"

"Social work will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use."

This intervention is routine clinician expectations and generic. It does not address individualized treatment or psychiatric issues.

5. Patient N6 (10/31/13) had the following interventions for the short term goal, "[Patient] will participate in education about addiction and recovery:"

"Social worker will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use."

The following intervention is for the short term goal, "Patient will make at least 2 motivational statements as to why [he/she] wants to stop using substances:"

"Social worker will meet individually with patient to engage in treatment interventions, engage in family sessions and work towards a safe discharge."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

6. Patient N7 (11/6/13) had the following interventions for the short term goal, "[Patient] will identify at last two harmful outcomes that using illicit substances has had on [his/her] life as evidenced by correctly stating them to staff for four consecutive weeks:"

"Social worker will conduct four sessions of 60 minutes each covering the stages of grief and its impact on substance use." "Social worker will conduct group one time a week for 90 minutes throughout the client's stay to learn the role of family members in the recovery process."

These interventions are routine clinician expectations and are generic. They do not address individualized treatment or psychiatric issues.

B. Staff Interview:

On 11/7/13 at 11AM, RN 4 stated, "Yes, I can see that these interventions are not individualized. They are not related to psychiatric issues because patients are here for substance abuse."

Based on a tour of the hospital, the facility failed to ensure that the facility was designed and maintained in such a manner as to promote the safety and well-being of patients.

1. On 11/04/13 at 1:00 PM, the surveyor, while accompanied by the General Trades Worker and the Assistant Fire Chief and upon a tour of the off-site, Blue Hills Nursing Units, the following were observed:

a. That nearly all of the patient rooms within the Blue Hills Nursing Unit on the 2nd floor were provided with a system that was intended to cover over abandoned, conduits and penetrations through the floor for heating pipes which were no longer secured to the floor and now have the potential to harm or injure patients if handled or abused; i.e. caps placed over breaches in the floor no longer secured & sharp materials are now accessible.

2. On 11/04 and 11/05/ 13 at various times throughout the days, the surveyors, while accompanied by the General Trades Workers, Assistant Fire Chief, Fire Chief and Facilities Plant Engineer(s) and upon a tour of the off-site and on-site Nursing Units, the following were observed:

a. That the patient bathrooms and shower rooms throughout were not provided with soap dispensers that are listed and approved as " institutional " in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used;

b. That not every electric, patient bed located throughout the nursing units were provided with power cords that are listed and approved as "institutional" in construction and are deemed appropriate for use in the environment in which they are installed and located; i.e. longer than needed power cords can injure patients if mis-used-facility was to tie-wrap questionable cords as interim measure and install looming and clips as permanent fix-neither exist in some applications;

c. That the patient bathrooms and shower rooms throughout the Battell Building were not provided with fluorescent light diffusers (lenses) that are listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type diffusers can injure patients or others if mis-used-not tamper resistant;

d. That the newly renovated Seclusion Room in the Battell Building-4th Floor North was not provided with blind spot mirror and a door hardware set that were listed and approved as "institutional" in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. door knob & mirror have potential to be ligature point;



19952


3. Based on observations and interview with hospital personnel, the hospital failed to keep a clean, sanitary and safe environment. The findings include:
a. During tour of the M2AB Unit, an observation was made in the patients' laundry room of the washing machine that was not level, was vibrating loudly and had moved from its original location. The washing machine leg was noted to be broken with books underneath it in order to keep it level.
b. During tour of the M2DE Unit, an observation was made of the storage closet located in the lounge snack room area. The floor was dirty and the bottom shelf (which held food items) was located approximately one inch from the dirty floor.
c. During tour of the physical therapy department, an observation was made of long telephone cords on the phones located in the patient examination/treatment areas. Interview with the physical therapy staff indicated that patients were not left alone in those areas and physical therapy personnel were always in attendance.
d. Tour of Battel 2 North on 11/5/13 at 11:30 AM identified that in the womens' restroom, the handicapped toilet failed to provide privacy for the patients. The handicapped toilet area lacked a partition to allow for privacy from other patients and/or staff when in use.
e. Tour of Battel 3 North on 11/6/13 at 9:00 AM identified one case of dietary supplements on the refrigerator in the patient kitchen, ready for use, that had expired on 11/1/13.

Based on review of clinical records, review of hospital policy and interviews with hospital staff, the hospital failed to ensure that a comprehensive Multidisciplinary Treatment Plan (MTP) was developed 5 of 15 patients. For one patient with obesity (Patient #41), the hospital failed to ensure that the dietician was included in the preparation of the Multidisciplinary Treatment Plan (MTP), failed to ensure that a comprehensive MTP was developed for one patient (Patient #31) regarding respiratory needs, failed to ensure that diabetic monitoring and education were completed for one patient (Patient #35) with diabetes mellitus Type II, failed to ensure patient safety for one patient (Patient #25) with history of suicidal ideation, and failed to include all medical diagnoses and corresponding interventions into the treatment plan for one patient (Patient #29). The findings include:


a. Patient #41 was admitted to the facility on 8/30/13 with polysubstance abuse and morbid obesity. The clinical record indicated that on admission the patient weighed in excess of 700 pounds with a BMI of 86.4 (goal 27-28). The clinical record indicated that a nutrition consult was completed on admission, that indicated to place the patient on a 4,000 calorie diet. The nutrition note dated 9/12/13 recommended a high protein, high calorie diet and to encourage fluids. Review of the MTP's dated September 2013 and October 2013 identified an active problem for obesity with the interventions in part for nursing staff to educate the patient on obesity related health issues, monitor weight as ordered and encourage healthy food choices. Review of the MTP with the Dietician failed to reflect that the dietician was involved in the creation of the nutritional MTP.

Review of the policy indicated that a nutritional care plan should be developed by the Registered Dietician with the multidisciplinary team and integrated into the MTP.


b. Patient #31 was admitted to the hospital on 10/31/13 for Alchohol Dependency. Review of the physician's order dated 11/1/13 identified that the patient was to receive CPAP (continuous postive airway pressure) at 10cm. Review of the nursing plan of care failed to identify that the patient's respiratory needs and interventions were identified in the MTP. Interview with the Nursing Director of Addiction Services on 11/5/13 identified that the patient needed to have a treatment plan that addressed the utilization of CPAP.

c. Patient #35 was admitted to the hospital on 7/29/13 with diagnoses that included delusional disorder and diabetes mellitus Type II. Review of the physician orders from admission through 10/23/13 directed a regular diet for the patient. A nutrition assessment dated 8/1/13 indicated to provide education as appropriate, and identified that the patient declined accuchecks or bloodwork. Review of the clinical record identified that nutrition education was completed 3 months later, as well as the bloodwork, insulin and oral medication orders. Review of laboratory results dated 10/28/13 identified the patient's blood glucose was 228 (normal 70-110) and HgA1C was 9.1 (normal < 7). Subsequently, insulin and Metformin were ordered on 10/28/13 and diabetic education was implemented. Although Patient #35 initially refused bloodwork, the clinical record failed to reflect attempts were made for diabetic education and monitoring for 3 months.

d. Patient #25 was admitted to the hospital on 6/24/13 with major depression and a history of multiple suicide attempts. During tour of the M4D unit, an observation was made in the patient room (Room 124D) of an IPod earbuds/headset that was hanging down from the patient's bookshelf. The room was shared with two other patients and the headset was approximately 2 - 2.5 feet in length. Review of the physician order dated 9/3/13 directed that the patient may have music at the RN's discretion. Review of the Patient Personal Property Policies did not identify patient headsets. Interview with RN #3 on 11/4/13 at 11:00 AM identified that the headset was given to the patient, but could not explain when the patient would receive and/or return the headset. Documentation and interviews failed to reflect that a mechanism was in place for patient headset storage and/or dispensing in order to ensure patient safety.

e. Patient #29 was admitted to the hospital with diagnoses that included schizo-effective disorder, borderline personality disorder, alcohol and drug abuse, hepatitis C and noninsulin dependent diabetes mellitus (NIDDM). Physician's orders indicated Patient #29 was receiving Metformin extended release 500 mg. twice a day. According to Patient #29's MTP, active discharge to a community residential care program was in progress. In review of the treatment plan the medical record lacked documentation that interventions related to NIDDM and education in preparation for discharge was addressed.
During a review of the medical record with the Chief Nursing Executive (CNE) on 11/5/13 the CNE indicated Patient #29's NIDDM and should have been included in the treatment plan.






19907







19952





26703

1. Based on observation, interview and policy review the facility failed to ensure that hand hygiene was completed after patient care. The findings include the following:

Observation on 11/5/13 at approximately 10:45 AM identified a medical emergency was initiated. Observation during the period of 10:45 AM through 11:30 AM identified staff in the patients room with gloves on. MHW #10 was observed to exit the room, remove gloves and exit the unit with the gloves in his/her hand, RN #10 was observed to exit the room, remove gloves walk down the hall, enter the nurse's station and utilize hand gel. RN #10 was observed to obtain gloves, prepare medications, enter the patient's room, administer the medications, exit the room and walk down the hall and enter the medication room to discard the syringe. Interview with the staff indicated that staff should wash hands however there are no sinks and/or hand gel dispensing station to perform hand hygiene.




19907


2. Based on observations and interviews with facility personnel, the facility failed to ensure that soiled linen was stored in a dirty area to prevent contamination.

The findings include:

a. During tour of the Woodward Building on 11/4/13, it was observed that soiled utility bins were being stored in a tub room that is utilized by patients. Interview with the Nursing Director on 11/4/13 identified that the units do not have a soiled utility area for soiled linen.

b. During tour of the Woodward II unit on 11/3/13, it was observed that a toilet in the men's bathroom was heavily rusted. Interview with the Nursing Director on 11/5/13 identified that the facility going to remove the toilet immediately.

1. Based on a review of facility documentation, interview and policy review, the facility failed to provide oversight of the contracted dialysis service to ensure water culture results were obtained in a timely manner. The finding includes the following:
a. Review of the hemodialysis monthly water cultures identified that October cultures of the Reverse Osmosis (RO) system and two machines were obtained on 10/24/13. The facility was unable to provide the cultures results on the day of survey (11/5/13). Subsequent to surveyor request, the test results were obtained and identified the following results: Reverse Osmosis (RO) system #1, 300 CFU's (acceptable level <50 CFU's), RO #2 was 130 CFU's, Machine #1 was 80 (action level required if > than 50 CFU's) and Machine #2 was 70 CFU's. Interview with the Biomedical staff on 11/5/13 at 1:30 PM stated although the RO and machines were disinfected after the cultures were sent, the dialysis unit should have been notified of the test results on 10/28/13 and repeat samples should have been obtained. Review of the Dialysis policy indicated the action level in the product water shall be 50 CFU's and levels 50-199 CFU's require steps to be taken to interrupt the trend towards higher unacceptable levels. The policy further indicated that colony counts of 200 CFU's or greater, require immediate action.


2. Based on clinical record review, interview, and contract review the facility failed to ensure that the hospital's respiratory services are integrated into its hospital-wide QAPI program. The findings include:

a. Patient #39 was admitted on 1/15/13 and required CPAP (continuous positive airway pressure). The clinical record indicated a physician's order dated 10/3/13 that directed RT (respiratory therapy) to adjust the CPAP. Interview with the Nurse Manager indicated that a call to the contracted RT facility had been placed and that "someone" from respiratory had been to see the patient, however he/she was not sure of the persons credentials. The Nurse Manager indicated the Respiratory Therapy (RT) services are a contracted service and that they respond when called. However, the RT staff do not document in the clinical record. Interview with the Director of Quality on 11/6/13 at 2:00 PM indicated that the contracted service was contacted to clarify the credentials of the staff member that provided respiratory services at the hospital. Interview with the Quality Director on 11/13/13 at 8:30 AM indicated that a respiratory technician had come to evaluate Patient #39 and fitted the patient for a new mask. The Quality Director indicated that the RT contract was for respiratory equipment and did not provide respiratory therapist services.


Review of the contract identified that equipment would be provided to the faciltiy but did not identifiy professional services as part of the contract.

In addition review of hospital documentation failed to identfy that the contracted service of respiratory services were reviewed as part of the hospitals QAPI program. Interview with the Director of Quality on 11/5/13 identified that they had a current contract but no documentation of quality review.





19907


3. Based on review of hospital documentation and interviews with facility personnel, the facility failed to ensure that contracted services were evaluated as part of the hospital wide QAPI program.

The findings include:

a. Review of contracted services and hospital documentation identfied that the contracted services of radiology, dialysis and respiratory services were not being reviewed as part of the hospitals QAPI program. Interview with the Director of Quality on 11/5/13 identified that they had current contracts but no documentation of quality review.