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Based on observation, interview, record review and recognized standards of practice, the facility continued to fail to ensure patients were provided care in a safe setting. The facility failed to ensure that:
- Lavatory faucets were replaced with suicide prevention faucets in 52 of 52 patient rooms as previously identified by the facility stating a completion date of 08/22/12;
- Electric cords approximately six feet in length that provided a hanging hazard for one of 31 electric beds were shortened or secured by the facility stating a completion date of 08/13/12. One (Patient #17) in the room with the unsecured cord was currently on suicide precautions on the Acute Geriatric Psychiatric Unit; and
- Patient lift equipment (equipment used to lift patients that require assistance to get in and out of beds, chairs, etc.) was stored in a locked area when not in use.

At the time of the survey one of 76 psychiatric patients were on Suicide Precaution I (check patient every ten minutes). Although the facility has three levels of suicide precautions (Levels I, II and III), at the time of survey no patients were on suicide precaution levels II or III which are more restrictive and indicate a patient at even higher suicide risk. The facility census was 120.

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;
- Cords should be too short to use to wrap around a neck and hang from any securing point.
- Procedure: Establish a plan of corrective action, including priorities and deadlines for correction, based on the level of risk and available funding.
For each environmental safety concern that is identified, a plan of corrective action shall be developed by the team leader and the unit nurse manager in conjunction with appropriate engineering and environmental services staff members. The plan shall note who is responsible for implementing the correction and the deadline for completion.

2. 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;
- SP I: Intermittent Observation: Check patient every ten (10) 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 safely 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 and every 10 minutes for patients with Suicidal 1 precautions. New observation round sheets are to start everyday at 0700 (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.

Record review of the facility policy titled, "Room Checks and Environmental Surveillance" revised 12/11, showed the following direction to staff:
- It is the policy of Psychiatric Services to provide a safe and therapeutic environment for patients. Environmental surveillance is conducted on an ongoing basis (during observation rounds);
- As part of routine safety rounds all occupied areas including patient rooms should be surveyed for safety. Rooms should be visually scanned for anything that could be used as a weapon to harm oneself or others;
- A complete environmental surveillance should be conducted and documented at change of shift. The surveillance should include at least the following: Each patient room, inspecting beds and patient. Any medical beds in use on either the Acute Psych [Psychiatric] unit or Gero [Geriatric] Psych will have the electrical cord shortened and secured to the head of the bed;
- Bathrooms to include the showers;
- Walls and furniture should be inspected for damage and lose or chipped areas;
- All doors;
- Any discovered safety threat should be immediately reported to the Charge RN (Registered Nurse), Nurse Manager/Supervisor;
- The Charge RN or Nurse Manager/Supervisor to review and ensure appropriate corrective action is taken to deal with any unsafe conditions.

3. Observation on 09/10/12 at 1:45 PM showed lavatory sinks in all 52 psychiatric patient rooms, just outside of the patient bathrooms. The faucets were silver colored metal, 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 with protruding handles on either side of the water spout.

4. During an interview on 09/10/12 at 1:45 PM, Staff N, Registered Nurse (RN), Psychiatric Nurse Manager, stated that the faucets had not been replaced on any of the psychiatric units as cited on two previous surveys. The facility's completion date to replace the faucets was 08/22/12. Staff N stated that patient rooms cannot be locked on any of the psych units and all rooms are open and accessible at all times.

5. During an interview on 09/11/12 at 8:55 AM, Staff G, Plant Manager, stated that the facility ordered the replacement faucets on 08/22/12 but they have to be custom made and hadn't been shipped by the supplier yet. He stated there was no way that the faucets could have been replaced by 08/22/12 as stated on the previous survey's plan of correction.

6. Record review of a document provided by Staff G, titled "Suicide Faucets Time Line of Installation" submitted on 09/12/12 showed the company providing the suicide prevention faucets should deliver them to the facility by 10/12/12. The time line showed it would take about two weeks for installation for a completion date of approximately 10/31/12.

7. During an interview on 09/11/12 at 12:58 AM, Staff A, Chief Executive Officer, (CEO), stated that he investigated the suicide prevention faucets himself and determined which faucets would be best to purchase. He also stated that 08/22/12 was not meant to be the completion date of installation of the faucets.

8. Observation on 09/10/12 at 1:45 PM on the Acute Geriatric Psychiatric Unit showed one electric bed in room 346 with a six foot long cord attached and hanging underneath the bed. Bed #1 was occupied by Patient #16, an amputee with assault, fall and close observation precautions. Bed #2 was occupied by Patient #17, who was 20 years old and on Suicidal I, assault and elopement precautions.

9. During an interview on 09/10/12 at 1:45 PM, Staff O, RN, Psychiatric Nurse Manager, stated that the cords were supposed to be shortened and secured to prevent a looping mechanism for hanging. She stated that charge nurses were not supposed to allow a bed with an unsecured cord to be on any of the Psychiatric Units and had no idea how it could have been there. She stated the only patient on suicidal precautions was Patient #17 in the same room as the unsecured cord. Staff O stated that the Shift Change Safety Checklists were being completed after every shift. She stated that what was upsetting is that the bed is on the more acute unit with younger patients.

10. Record review of the facility document attached to the above policy titled, "Shift Change Safety Checklist" revised 08/12, showed the following:
- Perform visual scan of all patient areas including patient rooms for unsafe conditions;
- Any cords on the electrical beds have been shortened and/or secured to the head of the bed;
- Any additional issues and/or issues that require follow up;
- Was the House Supervisor or Nurse Manager notified?
- Departing shift RN staff signature.

11. Record review of two facility documents titled "Shift Change Safety Checklist" both dated 09/09/12 for two consecutive shifts (day and evening), showed the following:
- Perform visual scan of all patient areas including patient rooms for unsafe conditions . . .;
- Any cords on the electrical beds have been shortened and/or secured to the head of the bed; and
- Was the House Supervisor or Nurse Manager notified: No.
The document was signed by Staff P, Clinical Team Leader.

12. During the concurrent interview on 09/10/12 at 1:45 PM, Staff N, RN, Psychiatric Nurse Manager, stated that Staff P had not received the education on the electric beds because she hadn't been working when she was here to do the training. Staff O, RN, also a Psychiatric Nurse Manager stated that she disagreed and that Staff P had been educated on everything except the Shift Change Safety Checklist updated form.

13. Record review of Staff P's personnel files showed education and training on "Room Checks and Environmental Surveillance" completed 07/25/12.

14. During an interview on 09/10/12 at 3:35 PM, Staff P, RN, Clinical Team Leader, stated that Patient #16 had been admitted through the emergency department on 09/09/12 at 12:45 AM. She stated that she called housekeeping for a bed and the bed with the cord was delivered by housekeeping sometime later. She stated that housekeeping said they didn't have any other beds for the patient so she accepted the bed knowing it had an unsecured cord. Staff P stated she did not call her supervisor and she did not write any information for the following shift in the comment section of the Shift Change Safety Checklist. She stated that she did sign both of the shift forms but could not explain her actions for failing to follow policy and procedure.

15. During a concurrent interview on 09/10/12 at 3:35 PM, Staff O, RN, Psychiatric Nurse Manager, (Supervisor to Staff P) stated that the Gero (Geriatric) Psychiatric Unit was not full and Staff P should have refused the bed by housekeeping with the unsecured cord and requested a bed from the Gero Psych Unit.

16. During an interview on 09/11/12 at 8:35 AM, Staff L, Housekeeping Supervisor, stated that all housekeeping personnel have been trained and inserviced on the electric beds for the psychiatric units and that "they all know not to take a bed with a cord to that floor". She stated that she had not been informed of the incident surrounding Patient #16 and had not been told that Staff Q, Housekeeping Staff, had delivered a bed to the psychiatric unit with an unsecured cord. She stated that her staff would again receive inservices so that the incident would not be repeated.

17. During an interview on 09/11/12 at 12:58 PM, Staff A, CEO, stated that he had completed a walk through of the psychiatric units yesterday (Monday, 09/10/12) and missed observing the bed with the unsecured cord.

18. During an interview on 09/12/12 at 8:30 AM, Staff AA, RN, Psychiatric Charge Nurse, stated she had received education on the requirements for electric beds and cords on the psychiatric units. She stated that if she had the same situation occur she would refuse the bed and call the house supervisor.

19. During an interview on 09/12/12 at 8:45 AM, Staff CC, RN, Psychiatric Charge Nurse, stated she had received education on the requirements for electric beds and cords on the psychiatric units from Staff N, RN, Psychiatric Nurse Manager. She stated she wouldn't let a bed that didn't have a secured cord on the unit with her patients.

20. During an interview on 09/12/12 at 8:50 AM, Staff DD, RN, Psychiatric Charge Nurse, stated she would not accept a bed that didn't have a secured cord. She stated she had received education on the requirements for electric beds and cords on the psychiatric units.

21. During an interview on 09/12/12 at 9:00 AM, Staff N, RN, Psychiatric Nurse Manager, stated that all the nurses had been educated about beds with unsecured electrical cords but after the last survey they did one to one education with each of the nurses.

22. Observation on 09/10/12 at 1:55 PM on the Gero Psychiatric Unit, room 343 showed a closed door with two patients (# 22 and #23) in their beds. In the adjoining bathroom was a patient lift, approximately four feet tall with protruding metal parts that could be used for ligature points. The patients were unattended in the room.

23. During an interview on 09/10/12 at 1:55 PM, Staff O, RN, Psychiatric Nurse Manager, stated that the patient lift should not be placed or stored in the patients' room. She stated the lift should have been taken to the storage area down the hall behind locked doors until needed. Staff O, stated that she didn't understand why the staff would leave the chair lift in the patients' bathroom accessible to the patients.

This deficient practice remains uncorrected. For additional examples please refer to the 2567 dated 08/02/12.

Based on interview and record review the facility continued to fail to ensure discharged patient medical record documentation was completed within thirty days of discharge for seven (Patient #2, #9, #10, #11, #12, #14 and #15) of fifteen medical records reviewed for completion within thirty days of discharge. The facility census was 120.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations, Appendix B, Section B. Medical Records" revised 09/26/11 showed the following direction:
-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).
-Paragraph 9 a. Physicians will have thirty (30) days from the date of discharge to complete a medical record. If a medical record is not completed within thirty (30) days of discharge, the record becomes delinquent.

2. Record review on 09/11/12 of Patient #2's discharge summary showed the patient was discharged on 08/10/12 and the physician failed to sign (complete) the document.

3. Record review on 09/11/12 of Patient #11's medical record showed the patient was discharged on 07/31/12 and the physician signed a discharge summary on 09/06/12.

4. During an interview on 09/11/12 at 10:38 AM Staff S, Manager of Health Information Management (HIM), reviewed the medical record for Patient #2 and Patient #11 and confirmed the physicians failed to sign a discharge summary within thirty days of each patient's discharge.

5. Record review on 09/11/12 of Patient #9's face sheet showed the patient was discharged on 08/04/12 and the physician failed to complete a discharge summary.

6. Record review on 09/11/12 of Patient #10's face sheet showed the patient was discharged on 07/12/12 and the physician failed to document a discharge summary.

7. Record review on 09/11/12 of Patient #12's medical record showed the patient was discharged on 07/27/12 and the physician failed to document a discharge summary.

8. Record review on 09/11/12 of Patient #14's medical record showed the patient was discharged on 07/26/12 and the physician failed to document a discharge summary.

9. Record review on 09/11/12 of Patient #15's medical record showed the patient was discharged on 08/09/12 and the physician failed to document a discharge summary.

10. During an interview on 09/11/12 at 10:38 AM, Staff S reviewed the medical records for Patients #9, #10, #12, #14 and #15 and confirmed the physicians failed to document a discharge summary in each record.





















29047

This deficient practice remains uncorrected. For additional examples please refer to the 2567 dated 08/02/12.

Based on observation, interview and record review facility dietary staff continued to fail to clean and maintain kitchen equipment. The facility census was 120.

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 direction that 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 09/10/12 at 1:55 PM in the facility walk-in dairy refrigerator and the facility walk-in meat refrigerator showed staff stored foods under condenser fan blade guards covered with gray lint and unknown black debris thick enough to pull a one eighth inch by one eighth inch wad of the debris off of the surface of the guard. A line of black, slimy unknown debris was present around the flange (where the fan blade guard was attached to the condenser housing). Accumulated gray lint was present on the metal housing of the condenser.

Further observation showed staff stored four uncovered steam table pans of gelatin on a cart under the soiled fan blade guards so that accumulated debris could fall onto the unprotected gelatin as the fans were blowing cooled air into the walk-in refrigerator.

3. During an interview on 09/10/12 at 1:55 PM Staff E, Director of Dietary confirmed the condenser fan blade guards and metal housings in both walk-in refrigerators still needed cleaning and the four pans of uncovered gelatin were for use in the cafeteria and for patient meal service.

4. 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.

5. Observation on 09/10/12 at 1:50 PM in the facility kitchen showed a table mounted can opener in the cook's area with brown rust colored splotches along the post and black debris caked in the gears behind the blade. Staff Z, Maintenance was observed attempting to remove the can opener mounting plate from the table (held down by three rusted and debris covered bolts). Once removed from the table by Staff Z, the accumulated debris under the plate was brown, sticky and approximately one eighth inch thick.

6. During an interview on 09/10/12 at 1:50 PM Staff D, Dietary Staff stated that he was currently cleaning the table mounted can opener and had just run the post with bladders and gears through the dish washing machine.

7. During an in interview on 09/10/12 at 1:55 PM Staff E confirmed the table mounted can opener mounting plate had been removed for cleaning on 08/09/12 and the current soil had accumulated since that time.

8. Observation on 09/11/12 at 10:19 AM in the cook's area showed the table mounted can opener remained spotted with rust colored splotches and unknown debris.

9. During an interview on 09/11/12 at 10:19 AM Staff E confirmed Staff D had soaked the table mounted can opener and he had attempted to clean it however, the can opener remained soiled looking and she would probably have to purchase a new one.

This deficient practice remains uncorrected. For additional examples please refer to the 2567 dated 08/02/12.

Based on observation, interview, record and policy review the facility continued to fail to ensure:
-A sanitary environment was maintained in four (#2, #3, #4 and #5) of four operating rooms (OR) when intravenous (IV) poles and instrument carts with rusted bases 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 120.

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 all four OR's (#2, #3, #4 and #5) on 09/12/12 at 10:00 AM showed two instrument carts in each room with rusty casters and in three OR's (#3, #4, #5) there were two IV poles in each room with rusty bases.

3. During an interview on 09/12/12 at 09:35 AM Staff I, stated that it was not possible to remove all of the equipment at one time. She stated that the replacement casters had been ordered but had not yet been received. She stated that she was not aware that all of the casters should have been replaced by 08/31/12 according to the Plan of Correction submitted by the facility from the 08/02/12 survey.

4. Record review of the facility policy titled "Storage Times and Temperatures" #B 007, reviewed 11/10 showed the following direction:
-Once opened or prepared, products have limited shelf life.
-Refrigerated storage was 41 degrees Fahrenheit or less.

5. Observation on 09/10/12 at 2:15 PM in the dry food store room showed staff stored an opened, partially full one gallon container of soy sauce labeled by the manufacturer with "refrigerate after opening" on a shelf unrefrigerated.

6. Observation on 09/10/12 at 2:20 PM in the cook's area showed staff stored an opened, partially full one gallon container of soy sauce unrefrigerated on a shelf under the cooks table labeled by the manufacturer "refrigerate after opening."

7. During an interview on 09/10/12 at 2:20 PM Staff E, Director of Dietary confirmed the following:
-Both one gallon containers of soy sauce were labeled by the manufacturer with "refrigerate after opening."
-Both one gallon containers were opened.
-Both were incorrectly stored unrefrigerated on shelving in the dry food store room and in the cook's area.
-She was unaware that soy sauce (labeled refrigerate after opening) had to be refrigerated.

8. Observation on 09/10/12 at 2:20 PM in the cook's area showed staff stored an opened partially full five ounce bottle of steak sauce labeled by the manufacturer with "refrigerate after opening" unrefrigerated out on a shelf.

9. During an interview on 09/10/12 at 2:20 PM Staff E stated she was not aware that steak sauce (labeled refrigerate after opening) had to be refrigerated.

10. 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 "Food and Supply Storage Procedures" reviewed 11/10 showed direction for facility dietary staff to store dry and staple items at least six inches above the floor.

11. Observation on 09/10/12 at 2:15 PM in the dry foods storeroom showed staff stored a thirty five pound container of liquid frying oil on the floor or the storeroom.

12. During an interview on 09/10/12 at 2:15 PM Staff E confirmed the following:
-The container of liquid frying oil was being used as a door stop to prop open the door of the dry food storeroom.
-She knew it should not be on the floor.
-The container of liquid frying oil had been on the dry food storeroom floor since sometime that morning.

13. Review of the facility's policy titled, "Uniform Dress Code (HACCP, Hazard analysis and critical control points, a systematic preventive approach to food safety)", reviewed 12/10 showed the following direction:
-Wear approved hair restraint when on duty.
-Long facial hair must be covered with a surgical mask and/or hood.
-Mustache and/or sideburns must be neatly trimmed.
-Mustache should not extend below the corners of the mouth; sideburns should not grow beyond the earlobe.

14. Observation on 09/10/12 at 1:50 PM in the cook's area of the Dietary department showed the following:
-Staff Z, Maintenance seated on the floor attempting to remove a soiled, rusted table mounted can opener base from a table.
-Staff Z, with a full beard, long moustache and sideburns, failed to wear a surgical mask/hood or other hair restraint.
-Staff D, Dietary staff, attempted to clean a table mounted can opener.
-Staff D with a moustache, failed to wear surgical mask/hood.

15. During an interview on 09/10/12 at 2:03 PM Staff E confirmed Staff Z failed to wear appropriate hair restraint.

16. Review of the USDHHS, PHS, FDA, 2005 Food Code, Chapter 5-501.113 Receptacles and waste handling containers shall be kept covered.

17. Observation on 09/10/12 at 2:03 PM in the dietary department showed staff maintained partially filled trash cans (approximately fifty gallon) in the cold food preparation area and in the cook's area without trash can lids.

18. During an interview on 09/10/12 at 2:15 PM Staff E confirmed the Dietary department maintained eight large trash cans and none of them had a trash can lid.






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