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Based on observation, interview, record review and policy review, the facility failed to ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to:
- Ensure lavatory handwashing faucets did not pose looping and/or hanging hazards in 52 of 52 patient rooms;
- Ensure that corridor bedroom door hinges prevented a looping or hanging hazard in 52 of 52 patient rooms;
- Ensure that wooden shelving over patients' beds in the Geriatric Psychiatric Unit did not provide a looping or hanging hazard in 31 of 31 patient rooms;
- Ensure that electric cords approximately six feet in length that provided a hanging mechanism were shortened or secured for 31 of 31 electric beds on the Geriatric Psychiatric Unit; and
- Ensure that 15-minute observation checks were completed in the 15-minute time frame for six of six patient Daily Observation Flowsheets reviewed.

Twenty-six of the 74 currently admitted patients were on suicide precaution observation.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Based on observation, interview, record review and recognized standards of practice, the facility failed to ensure patients were provided care in a safe setting. The facility failed to:
- Ensure that hand washing faucets did not pose looping or hanging hazards in 52 of 52 patient rooms The configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation).
- Ensure that corridor bedroom door hinges prevented a looping or hanging hazard in 52 of 52 patient rooms;
- Ensure that wooden shelving over 31 of 31 patients' beds in the Geriatric Psychiatric Unit did not provide a looping or hanging hazard for suicidal patients;
- Ensure that electric cords approximately six feet in length that provided a hanging mechanism were shortened or secured for 31 of 31 electric beds of which five (Patients #69, #70, #71, #72 and #73) of 21 patients were currently on suicide precautions on the Geriatric Psychiatric Unit; and
- Ensure that 15-minute observation checks were completed in the 15-minute time frame for six (Patients #11, #12, #13, #15, #16 and #17) of six Daily Observation Flowsheets reviewed. Potentially suicidal/assaultive patients were left unmonitored for periods of time in which they could potentially harm themselves or others.

At the time of the survey 26 of 74 psychiatric patients were on Suicide Precaution I (check patient every fifteen [15] minutes). The facility admitted patients with suicidal ideation, history of suicidal ideations, attempts at self harm and assaultive tendencies. The facility census was 128.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:
The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
- Institutional faucets will not provide an anchor point for hanging;
- Three point hinges designed and installed so they do not protrude providing an anchor point for hanging;
- All items must be secured to the wall in a manner that prevents removal or use as a weapon or for self-harm. It must be flush with the wall or beveled in a manner so that it cannot be used as an anchor for hanging; and
- Cords should be too short to use to wrap around a neck and hang from any securing point.

Record review of the facility policy titled, "Suicide Precautions" revised 12/11, showed the following:
- Purpose: To specify criteria for determining suicide risk and to delineate the procedures implemented by nursing staff to ensure patient safety;
- It is the policy of Psychiatric Services to place a patient determined to be a suicide risk on special precautions;
- Documentation will include: Level of observation and frequency of staff contact;
- Suicide Precautions (SP) I: Intermittent Observation: A. Check patient every fifteen (15) minutes.

Record review of the facility policy titled, "Patient Observation/Safety Rounds" revised 12/11, showed the following direction to staff:
- Purpose: To provide a mechanism that ensures patient safety while hospitalized;
- It is the policy of Psychiatric Services to ensure the safety for all patients during their hospital stay by way of observation rounds;
- Upon patient admission to the unit an observation sheet will be instituted for each patient. Staff will document on the observation sheet the patient's precautions as indicated by the physician order as well as the patient's whereabouts every 15 minutes. New observation round sheets are to start every day at 7:00 AM;
- Staff will receive inservicing during Psych (Psychiatric) Specific Orientation, unit preceptorship, Psych Recertification and periodically thereafter on observation rounds and are instructed to: Ask for help before getting behind on assigned rounds;
- All staff will complete rounds as assigned.

2. Observation on 07/30/12 while on tour, which began at 3:45 PM, showed hand washing sinks in all 52 psychiatric patient rooms. The sinks were located inside the patient's rooms, just outside of the patient bathrooms. The silver colored metal faucets were center-set faucets made on a single 4-inch base unit. The single-lever faucets were approximately four inches high and three inches in diameter on either side of the water spout with protruding handles.

3. During an interview on 07/30/12 at 3:45 PM, Staff M, Registered Nurse (RN), Psychiatric Nurse Manager, stated that the faucets had not been replaced on any of the psychiatric units as cited on a previous survey. She stated there was no formal plan to replace the faucets and no date set for completion. She said administration had been looking at different styles of suicide prevention faucets but had not yet decided on which style to purchase. Staff M stated that patient rooms cannot be locked on any of the psychiatric units and all rooms are open and accessible at all times.

4. During an interview on 07/30/12 at 3:55 PM, Staff L, RN, stated that the only changes put in place for patient safety since the previous survey were 15-minute observations on all patients and changes in patient gowns that did not have strings attached.

5. During an interview on 08/01/12 at 10:45 AM, Staff GG, Plant Manager, stated that they (administrative staff) had an idea of what kind of replacement faucets to order but had not made a decision. He stated that he could talk to Administration and see when they could order the replacement faucets and give an estimated date of installation.

During an interview on 08/01/12 at 12:55 PM, Staff GG, Plant Manager, provided an order worksheet for the Suicide Prevention Faucets that they were going to order. He stated that the faucets would be delivered in six weeks (09/12/12) and installation of the faucets could be completed by 10/01/12.

6. Observation on 07/30/12, which began at 3:45 PM showed all 52 psychiatric unit corridor doors had three protruding hinges on the inside of every patient room that could be used as a ligature point for hanging. These hinges left an opening between the door frame and the hinge and provided a potential ligature point, which was a hanging or looping hazard.

7. During an interview on 07/30/12 at 3:45 PM, Staff M, RN, Psychiatric Nurse Manager, stated that the door hinges had never been identified as a risk for safety.

8. During an interview on 08/01/12 at 10:45 AM, Staff GG, Plant Manager, stated that the bathroom hinges had all been replaced with suicide prevention piano hinges (a continuous hinge, which runs the entire length of the door and eliminates the opening between the door frame and the hinge ) but there was no plan to replace the corridor door hinges on the psychiatric units.

9. Observation on 08/01/12, which began at 9:33 AM on the Geriatric Psychiatric Unit showed wooden shelves approximately three feet long and six inches wide bolted to the wall approximately six feet off of the floor over all 31 patient bed. These shelves had square corners and were very sturdy, which potentially provided a ligature point for hanging.

10. During an interview on 08/01/12 at 9:33 AM, Staff L, RN, Psychiatric Nurse Manager, stated that the shelves were put there to provide storage space for tissues or personal items.

11. Observation on 08/01/12, which began at 9:33 AM on the Geriatric Psychiatric Unit showed all 31 beds were electric beds with six foot long cords attached and hanging underneath the beds. This created a looping mechanism for hanging. Of the 21 current patients on the unit five (Patients #69, #70, #71, #72 and #73) were on suicide precautions.

12. During an interview on 08/01/12 at 9:33 AM, Staff L, RN, Psychiatric Nurse Manager, stated that the cords were supposed to be shortened and secured with a zip tie (a type of fastener), to prevent a looping mechanism for hanging. She stated that had been the facility's policy all along. No written policy was provided upon request by the facility.

13. During an interview on 08/01/12 at 10:45 AM, Staff GG, Plant Manager, stated that nothing further had been done about the electric bed cords on the Geriatric Psychiatric Unit because they thought the cords were shortened with the zip ties and would take care of the problem. He stated they just checked all of them (the electric bed cords) a couple of weeks ago. Staff GG was unaware that the zip ties were not on the cords and was not aware of any continuous monitoring system.

14. Record review of the facility's document titled, "Daily Observation Flowsheet" dated 06/11 showed a sheet with the following information:
- Date;
- Location Codes:
- Activity Codes;
- Level of Observation;
- Precautions;
- Time;
- Location/activity;
- Staff initials.

This sheet is completed on each psychiatric patient every day by assigned staff from 7:00 AM to 6:45 AM (24 hours) the following day. The flow sheets are then placed in the patients' permanent medical record.

15. During an interview on 07/30/12 at 1:45 PM, Staff HHH, PCT (Patient Care Technician), stated that when he completes rounds he has always been able to find the patients and has never had a problem with completing the 15-minute rounds. During an interview on 08/02/12 at 9:30 AM, Staff HHH, PCT, stated that if he couldn't complete the rounding in 15 minutes that he would get the nurse and have someone else do the rounding.

16. During an interview on 07/30/12 at 1:51 PM, Staff N, PCT (Patient Care Technician), stated that if she couldn't find a patient when doing the observation rounds she would keep looking until she found them. She stated that she has never exceeded the 15 minute time frame when looking for a patient. Staff N stated that the staff takes turns doing the 15-minute observations and are usually assigned to do the rounds 2 ½ hours at a time.

17. During an interview on 08/02/12 at 9:17 AM, Staff FFF, PCA (Patient Care Assistant), stated that she completes the Daily Observation Flowsheet for patients and she had never gone past the 15 minute time frame for observing the patients.

18. During an interview on 08/02/12 at 9:25 AM, Staff GGG, PCT, stated that she completes the Daily Observation Flowsheet for patients and if she couldn't find a patient she would just continue looking. She stated that she didn't think she had ever gone past the 15 minute time frame.

19. Record review of the Daily Observation Flowsheet for Patient #11 showed the following information:
- Date of 07/30/12;
- Level of Observation - routine 15-minute observation;
- Precautions: Suicide, fall, seizure, assault/homicidal, other (self-harm by cutting).
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 14 times on this date.

20. Record review of the Daily Observation Flowsheet for Patient #12 showed the following information:
- Date of 07/28/12;
- Level of Observation - routine 15-minute observation;
- Precautions: Elopement, assault/homicidal.
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 28 times on this date.

21. Record review of the Daily Observation Flowsheet for Patient #13 showed the following information:
- Date of 07/30/12;
- Level of Observation - blank (this was not filled out);
- Precautions: Fall, assault/homicidal.
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 33 times on this date.

22. Record review of the Daily Observation Flowsheet for Patient #15 showed the following information:
- Date of 07/30/12;
- Level of Observation - routine 15-minute observation;
- Precautions: Assault/homicidal.
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 24 times on this date.

23. Record review of the Daily Observation Flowsheet for Patient #16 showed the following information:
- Date of 07/30/12;
- Level of Observation - routine 15-minute observation;
- Precautions: Suicide, elopement, fall, seizure, other (not explained).
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 14 times on this date.

24. Record review of the Daily Observation Flowsheet for Patient #17 showed the following information:
- Date of 07/30/12;
- Level of Observation - routine 15-minute observation;
- Precautions: Suicide, fall, seizure, assault/homicidal, other (not explained).
The flow sheet reflected that the 15-minute observation checks had exceeded 15 minutes 16 times on this date.

25. During an interview on 08/01/12 at 3:10 PM, Staff B, RN, Performance Improvement and Risk Manager, stated that there is no monitoring system in place for the Daily Observation Flowsheet time frames.

26. During an interview on 08/02/12 at 8:45 AM, Staff L, RN, Nurse Manager, stated that she didn't know if anyone monitored the Daily Observation Flowsheet for accuracy. She stated that the floor nurses take turns doing the 15-minute observations but she didn't know if they looked at the flowsheet for accuracy.

Based on interview and record review the facility failed to ensure discharged patient medical record documentation (discharge summaries, and admission histories and physicals) was completed within thirty days of discharge for six (Patient #36, #39, #43, #45, #47 and #51) of nine medical records reviewed for completion within thirty days of discharge. The facility census was 128.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations," revised 02/11 showed the following direction:
-Section A. Admission and Discharge of Patients, paragraph 3. Discharge and Final Diagnosis: At time of discharge, the Attending Physician shall see that the medical record is complete.
-Section B. Medical Records, paragraph 1. Record Keeping: All entries shall be complete legibly written in ink or typewritten, dated, timed and authenticated (i.e., signed by the author).
-Section B. Medical Records, paragraph 3. Completed Medical Record: No medical record shall be considered complete until all required contents are assembled and authenticated, including the required discharge summary or final progress note, and all final diagnoses, complications and surgical procedures performed are recorded.

2. During an interview on 07/31/12 at 12:30 PM Staff VV, Manager of Health Information Management confirmed patient medical records were required to be complete within thirty days of discharge, completion of documents in the records included signatures on all documents and these requirements were established by the Medical Staff Rules and Regulations.

3. Record review on 08/01/12 of Patient #36's discharge summary showed the patient was discharged on 06/28/12 and the physician failed to sign (complete) the document.

During an interview on 08/02/12 at 8:25 AM Staff VV confirmed the physician failed to sign and complete the patient's discharge summary within thirty days of discharge as required.

4. Record review on 08/01/12 of Patient #39's face sheet showed the patient left the facility against medical advice (AMA) on 05/06/12 and the physician failed to complete/document a discharge summary.

During an interview on 08/02/12 at 8:30 AM Staff VV reviewed the patient's medical record and confirmed the physician failed to document a discharge summary as required.

5. Record review of Patient #43's face sheet showed the patient was discharged on 04/03/12 and the physician completed/signed an admission history and physical on 05/23/12 (fifty days after discharge).

Further review of the patient's medical record showed the discharge summary was completed/signed on 06/02/12 (fifty nine days after discharge).

During an interview on 08/02/12 at 8:35 AM Staff VV reviewed the patient's medical record documentation and confirmed the history and physical and the discharge summary were not completed within the required time.

6. Record review of Patient #45's face sheet showed the patient was discharged on 06/12/12 and the physician failed to document a discharge summary.

During an interview on 08/02/12 at 8:20 AM Staff W confirmed the physician failed to document a discharge summary as required.

7. Record review on 08/01/12 of discharged Patient #47's medical record showed the patient left the facility without notifying staff on 06/15/12 and did not return to the facility. The medical record did not contain a discharge summary.

During an interview on 08/01/12 at 1:45 PM, Staff F, Manager of multiple nursing units verified that she could not locate a discharge summary in Patient #47's medical record. Staff F stated that a discharge summary should be included in all discharged patient medical records, including patients who leave on their own accord.

8. Record review on 08/01/12 of Patient #51's discharge summary showed the patient was discharged on 04/26/12. The physician completed the discharge summary on 06/27/12 (62 days after the patient was discharged). The physician failed to complete and sign the patient's discharge summary within 30 days of discharge as required.

During an interview on 08/01/12 at 1:45 PM Staff F verified that Patient #51's discharge summary was completed by the physician greater than 60 days after the patient was discharged, but did not know how long the physician had to complete the discharge summary.





29047

Based on observation, interview and record review facility dietary staff failed to clean and maintain kitchen equipment. The facility census was 128.

Findings included:

1. Review of the US Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code, Chapter 3-305.11 Food Storage showed the following direction; Food shall be protected from contamination by storing in a clean, dry location, where not exposed to splash, dust or other contamination and at least six inches above the floor.

Record review of the facility's policy titled, "Infection Control / Required Cleaning Sanitation" reviewed 12/10 showed direction for facility dietary staff to clean non-food contact surfaces as often as necessary and to keep equipment free of accumulation of dust, dirt, food particles and other debris.

2. Observation on 08/01/12 at 9:45 AM in the facility walk-in dairy refrigerator and the facility walk-in produce refrigerator showed staff stored foods under a condenser fan blade guard covered with gray lint and unknown black debris thick enough to pull a one quarter inch by one eighth inch wad of the debris off of the surface of the guard.

During an interview on 08/01/12 at 9:45 AM Staff HH, Assistant Food Production Manager confirmed the condenser fan blade guards in both the dairy walk-in refrigerator and the produce walk-in refrigerator were soiled and stated that it was a responsibility of the dietary staff to clean the fan blade guards and both fan blade guards should be cleaned.

3. Review of the USDHHS, PHS, FDA, 2005 Food Code, Chapter 4-601.11 showed the following direction; Equipment, food contact surfaces, non-food contact surfaces and utensils shall be clean to sight and touch.

4. Observation on 08/01/12 at 9:50 AM, in the facility kitchen showed a table mounted can opener in the salad preparation area and a table mounted can opener in the cooks area each with metal can shavings imbedded into blackened tar like debris on the blade, gears behind the blade and on the metal plate holding the can opener to the table.

During an interview on 08/01/12 at 9:50 AM Staff HH confirmed the table mounted can openers in the salad preparation and in the cook's areas were soiled and should be cleaned.

Based on observation, interview, record and policy review the facility failed to ensure::
-A sanitary environment was maintained in two (#2 and #3) of two operating rooms (OR) when an intravenous (IV) pole and instrument carts with rusted base and casters were not cleaned, repaired or replaced. Rusted equipment in the OR rendered that equipment to be functionally not cleanable and a source of contaminants to transmit infections.
-Foods used for patients, staff and visitors were stored in a safe sanitary manner to protect against cross contamination and spoilage. The facility census was 128.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, May 2009, showed: "A safe, clean environment should be reestablished after each surgical procedure. Routine cleaning and disinfection reduces the amount of dust, organic debris and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practice in health care organizations helps to reduce infections associated with contaminated items."

Review of the facility policy 6211-106 titled "Cleaning of Surgical Practice Setting" revised 07/12 showed:
-Purpose: To provide a clean environment for surgical patients and be carried out in a manner that minimizes health care workers and patients exposure to potentially infectious microorganisms.
-Procedure: Surgical procedure rooms and scrub/utility areas are terminally cleaned/disinfected daily using a hospital approved agent. To include: all furniture including wheels and casters.

2. Observation in OR #3 on 07/31/12 at 1:30 PM showed two instrument carts with rusted casters. Each cart had four casters and the rust continued up the legs where the casters attach to the cart. Carts were made of stainless steel. Casters scraped with fingernail showed visible rust particles. Operating Room #3 had one IV pole with a rusted base and casters. The IV pole base had five legs each with one caster and all were rusted.

3. Observation in OR #2 on 07/31/12 at 1:45 PM showed two instrument carts with rust covered casters. Each cart had four casters and the rust continued up the legs where the casters attach to the cart. Carts were made of stainless steel. Casters scraped with fingernail showed visible rust particles.

4. During an interview on 07/31/12 at 1:50 PM Staff SS, Director of Surgical Services, stated that rust would prevent the equipment from being cleaned properly. Staff SS stated that staff usually reports rusted equipment to her and she would arrange for maintenance to paint. Staff SS stated that no one had made her aware of the rusted equipment.

5. During an interview on 08/1/12 at 1:25 PM Staff CC, Infection Control Officer, stated that rust is a problem because it cannot be cleaned properly. Staff CC stated that rusted surfaces become porous and can't be disinfected.

6. During an interview on 08/1/12 at 1:45 PM Staff QQ, OR environmental service worker, stated that the rusted base and casters look cleaner after they are wiped down.

7. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-304.12 In-use utensils, between-use storage showed the following direction; Utensils shall be stored with their handles above the top of the food and the container.

Record review of the facility's policy titled "Food Supply and Storage" #B005, reviewed 11/10 showed direction for facility dietary staff to store all food in a manner to maintain wholesomeness of the food for human consumption.

8. Observations on 08/01/12 from 9:45 AM through 9:50 AM in the facility kitchen showed staff stored the following:
-A ten pound case of artificial bacon bits (plastic box liner opened to air) with a plastic cup imbedded into the bacon bits.
-A soiled bulk container of rice with a scoop handle lying on top of the food.
-A soiled bulk container of flour with a scoop handle lying on top of the food.

9. During an interview on 08/01/12 at 9:50 AM Staff II, Head Cook confirmed the scoops were routinely stored inside the bulk containers and on top of the foods.

10. Record review of the facility policy titled "Storage Times and Temperatures" #B007, reviewed 11/10 showed the following direction:
-Once opened or prepared, products have limited shelf life.
-Refrigerated storage was 41 degrees Fahrenheit or less.
-Unused portions of foods that require refrigeration were foods including cold desserts.

11. Observation on 08/01/12 at 9:45 AM in the dry food store room showed staff stored the following:
-An opened, partially full nineteen and a half ounce plastic bottle of chocolate dessert sauce labeled by the manufacturer with "refrigerate after opening."
-An opened, partially full seventeen ounce plastic bottle of caramel dessert sauce labeled by the manufacturer with "refrigerate after opening."
-An opened, partially full nineteen and a half ounce plastic bottle of caramel dessert sauce labeled by the manufacturer with "refrigerate after opening."

12. During an interview on 08/01/12 at 9:45 AM Staff HH, Assistant Food Production Manager confirmed the three opened partial bottles of dessert sauces were routinely stored unrefrigerated on shelving in the dry food store room.

13. Observation on 08/01/12 at 9:50 AM at 9:50 AM in the cook's area showed staff stored an opened bottle of lemon juice (labeled by the manufacturer with "refrigerate after opening") on a preparation table.

14. During an interview on 08/01/12 at 9:50 AM Staff JJ, Cook confirmed staff routinely stored opened bottles of lemon juice either on the cooks preparation table or in the dry food storeroom.







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