HospitalInspections.org

Based on review of facility documents, medical records (MR), observations and interview with staff (EMP), it was determined the Governing Body failed to ensure facility accountability for Patient Rights (0115); failed to ensure that required members of the treatment team participated in the comprehensive treatment planning process (0130); failed to ensure a safe setting (0144); failed to ensure updates to the patient's treatment plan (0166); failed to ensure a physician's order for seclusion was written in accordance with the facility's policy (0169); failed to ensure quality data was collected, tracked and analyzed (0273); physical environment (0700) and maintenance of physical plant (0701)

Findings include:

Review on November 2, 2018, of facility document "AMENDED AND RESTATED OPERATING AGREEMENT OF PROSPECT CCMC, LLC(a Pennsylvania limited liability company)" dated January 1, 2017, revealed "This Operating Agreement (this "Agreement"} of Prospect CCMC, LLC (the "Company") is entered into by the Company and Prospect Crozer, LLC, a Pennsylvania limited liability company, as the sole member (the "Member") as of January 1, 2017. 1.2 Purpose. The Company is formed for the object and purpose of, and the nature of the business conducted and promoted by the Company is, engaging in any lawful act or activity for which limited liability companies may be formed under the Act and engaging in any activities necessary or incidental to the foregoing, including without limitation, owning and operating a licensed acute care hospital in Delaware County, Pennsylvania known as Crozer Chester Medical Center (the "Hospital"). "

Review on November 2, 2018, of facility document "AMENDED AND RESTATED OPERATING AGREEMENT OF PROSPECT CCMC, LLC (a Pennsylvania limited liability company)" dated January 1, 2017, revealed "ARTICLE IV. BOARD OF MANAGERS 4.1 Powers. Subject to the provisions of the Act and any limitations requiring approval by the Member, the business and affairs of the Company shall be managed and all corporate powers shall be exercised by or under the direction of the Board of Managers ("Board of Managers"). The Board of Managers may delegate management of the day-to-day operation of the Hospital business to its officers and employees and the Local Advisory Board (as defined below), a management company, another governing board or other person, and/or a Committee of the Board of Managers; provided that the business and affairs of the Company shall be managed and all corporate powers shall be exercised under the ultimate direction of the Board of Managers."

Review on November 2, 2018, of facility document "AMENDED AND RESTATED OPERATING AGREEMENT OF PROSPECT CCMC, LLC (a Pennsylvania limited liability company)" dated January 1, 2017, revealed 4.15 Role and Function of the Board of Managers. The Board of Managers shall: (a) Assure the provision of appropriate physical resources and personnel required to meet the needs of the patients and participate in planning to meet the health needs of the patients and health needs of the community. (b) Approve short-range and long-range plans for the development of the Hospital. (c) Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.

Cross Reference with:
482.13 Patient Rights, Condition
482.13(b)(1) Patient Rights: Participation In Care Planning, Standard
482.13 (c)(2) Care in a Safe Setting, Standard
482.13(e)(4)(i) Patient Rights: Restraint Or Seclusion, Standard
482.13(e)(6) Patient Rights: Restraint Or Seclusion, Standard
482.21(a),(b)(1)(b)(2)(i),(b)(3) Data Collection & Analysis, Standard
482.41 Physical Environment, Condition
482.41(a) Maintenance Of Physical Plant, Standard

Based on review of facility documents, medical records, observation and interview with staff (EMP), it was determined the Governing Body failed to ensure the facility's accountability for the rights of each patient (0043); failed to ensure that required members of the treatment team participated in the comprehensive treatment planning process (0130); failed to ensure a safe setting (0144); failed to ensure updates to the treatment plan (0166); failed to ensure a physician's order for seclusion was written in accordance with the facility's policy (0169); failed to provide a safe physical environment (0700); and failed to ensure maintenance of the physical environment (0701).


Findings include:

Review on November 7, 2018, of the facility's policy "Patient Rights and Responsibilities" last revised April 2018 revealed "... . As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation."


Cross Reference with:
482.12 Governing Body, Condition
482.13(b)(1) Patient Rights: Participation In Care Planning, Standard
482.13 (c)(2) Care in a Safe Setting, Standard
482.13(e)(4)(i)Patient Rights: Restraint Or Seclusion, Standard
482.13(e)(6) Patient Rights: Restraint Or Seclusion, Standard
482.41 Physical Environment: Condition
482.41(a) Maintenance Of Physical Plan, Standard

Based on review of facility policy, observations, medical records (MR), and interview with staff it was determined the facility failed to ensure patients were maintained in a safe environment and patients with diagnoses of Suicidal and Hallucinative Ideations Disorder received monitored care in an environment identified with safety risks according to facility policy.

Findings include:

Review of facility policy "Video Surveillance" dated December 20, 2012, revealed "Policy. The Crozer Chester Medical Center ("CCMC") will use video surveillance in designated nursing units to allow continuous visual observation of patients whose mental status and/or clinical needs present safety risks that can be reduced through ongoing monitoring of these patients. Procedure. 3. Video monitors used for such surveillance are located at clinical workstations for viewing by hospital personnel only. If a patient is determined to be a risk for self-harm, a healthcare worker will be assigned to observe the monitor. ...Signs will be posted in areas where video monitoring is used informing patients and visitors that cameras are being utilized for monitoring of patients."

1. Observation on October 31, 2018, at 4:00PM to 4:15PM and from 4:50PM to 5:00PM of the nurses station revealed two video monitors. Video Monitor One was positioned at the front of the nurse's station and the monitor was "off " without video reception. Video Monitor Two was positioned at the rear of the nurse's station and the video monitor was "on" displaying patient activity in various areas of the behavioral unit. Further review revealed the nurses at the nurse's station were not observing patient activity on Video Monitor Two while at the nurse's station.

An interview conducted on October 31, at 4:30PM with EMP7 confirmed that the nursing staff was not assigned to monitor Video Monitor One and Video Monitor Two at the nurse's station. EMP7 stated " The monitor in the rear of the nurse's station is working and sometimes we look at it but we are not required to monitor patient activity on the unit by viewing the monitors. Further interview confirmed that the video monitor position at the front of the nurse's station was not properly working and was in need of repair.

2. Observation on November 2, 2018, at 10:00AM to 10:10AM and from 11:30 AM to 11:37 AM revealed two Video Monitors at the nurse's station. Video Monitor One was "off" without video reception and Video Monitor Two was "on" displaying various areas of the behavioral unit. Further review of Video Monitor Two at the rear of nurse's station revealed the nursing staff was not monitoring patient activity in various areas of the unit on Video Monitor Two.

An interview conducted on November 2, 2018, at 1:57 PM with EMP2 and EMP4 confirmed that nursing staff was not required to monitor patient activity via the video monitors. EMP3 stated we do not have adequate nursing staff to sit at the video monitors.

3. Observation on November 2, 2018, at 10:40AM with EMP2 and EMP3 in the Dining/Activity Room revealed seven patients sitting in the Dining/Activity Room without nursing staff Further observation revealed two wall mounted televisions which were not flush to the wall with protruding loopable brackets and electrical cords, five lightweight plastic lawn chairs with loopable shaped arms and Dining/Activity Room exiting double doors that contained door hardware that provided an anchor point for a loopable device. Further observation revealed the Dining/Activity Room sink had a loopable faucet with hot and cold water loopable knobs.

An interview conducted on November 2, 2018, at 10:45AM with EMP2 and EMP4 confirmed seven patients siting in the Dining/Activity Room without nursing staff. Further interview confirmed the the lawn chairs were a ligature risk to the unattended patients in addition to the wall mounted televisions and the double door exiting the Dining/Activity Room. EMP2 stated "We will need to address this issue with the staff immediately as a nursing staff member should be present in this room when patients are in here." In addition, EMP2 stated that the facility does not maintain a specific list of patients with the diagnoses of Suicidal and Hallucinative Ideations. "We would have to check each chart to obtain that information." On November 2, 2018, at the request of the survey team, EMP2 presented the survey team with a list of current inpatients with the diagnoses of Suicidal and Hallucinative Ideation Disorder.

4. Observation on November 2, 2018, at 10:55 AM revealed patients using hallway telephones designated for patient. Further observation revealed patient using the designated telephones without nursing staff supervision. Further observation revealed coiled telephone cords plugged into the telephone headset which was approximately 12 inches in length, a ligature risk.

An interview conducted on November 2, 2018, at 11:00 AM with EMP2 and EMP4 confirmed that the staff frequently did not accompany patients requesting to make telephone calls on the designated patient telephones located in the both of the unit hallways. Further interview confirmed that the coiled telephone cords attached to the telephone headsets was a ligature risk. After the survey team expressed concern for the safety of the patients on the behavioral unit, EMP2 removed the coiled telephone cords and placed the cords at the nurse's station. EMP2 immediately announced to the staff presently on the unit that "Phone cords and receivers will be stored at the Nurse stations, unless requested by a patient."

Observation on November 2, 2018, at 3:13 PM with EMP2 of the patient designated telephones in hallways of the behavioral unit revealed the coiled telephone cords had been reattached to the headsets of the designated patient telephones and were unattended by the nursing staff.

An interview conducted on November 2, 2018, at 3:18 PM with EMP2 and EMP4 confirmed the coiled telephone cords had been reattached to the hallway designated patient telephone headsets by nursing staff and no nursing staff was in attendance at the patient designated telephones. EMP2 stated " The staff will need a lot more education to break this habit. I clearly agree that the coiled telephone cords are a safety risk for our patients"


5. Observation on November 2, 2018 at 11:10 AM with EMP2, EMP3 and EMP5 at the Nurse's Station revealed two portable fans actively blowing air. It was also noted by the survey team that the unit was extremely warm and humid. MR3, a patient, approached the survey team, EMP2 and EMP3 and stated "It is not fair that the nurses have fans to help them cool off and we have nothing. I have COPD [chronic obstructive pulmonary disease] and it is very difficult to breath in here because it is too hot. Would you please have someone fix this for us?"

An interview conducted on November 2, 2018, at 11:15 AM with EMP2, EMP3 and EMP5 confirmed that the behavioral unit temperature frequently fluctuates depending on the seasons of the year. EMP5 stated that the Lease Provider controls the temperature of the behavioral unit. EMP5 further stated that the Crozer Chester Medical Center Facility Department Director would speak with the Lease Provider immediately and have the temperature of the unit corrected. EMP5 stated "We will buy temperature probes and monitor the temperature daily in various areas of the behavioral unit and in the behavioral unit hallways.

Cross Reference with:
482.12 Governing Body: Condition
482.13 Patient Rights: Condition
482.41 Physical Environment: Condition

Based on review of the facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the treatment plan was updated in accordance with the facility's policy for one of one medial record reviewed (MR2).

Findings include:

A review of facility policy "Treatment Plan" dated March 9, 2017, revealed "Comprehensive Treatment Plan...5. A new Comprehensive Treatment Plan will be developed for patients who remain hospitalized 30 days and every 30 days thereafter. 6. If the treatment plan provides for restraints and/or seclusion, the basis for the necessity for same will be stated in the plan as what less restrictive alternatives were considered and if/why there were utilized."


Review of MR2 on November 6, 2018, revealed the patient was placed in seclusion on October 31, 2018. Further review of MR2 revealed no evidence of documentation that the patient's treatment plan was updated for the use of seclusion on October 31, 2018, by the treatment team.

An interview conducted on November 6, 2018, at 2:30 PM with EMP2 confirmed there was no documented evidence that the treatment plan in MR2 was updated by the treatment team
for the use of seclusion on October 31, 2018.
__________

Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure a Comprehensive Treatment Plan was signed or initialed and dated by the required treatment team members for two of two medical records reviewed (MR1 and MR2).

Findings include:

Review on November 14, 2018, of facility policy "Treatment Plans" last reviewed March 9, 2017, revealed "Comprehensive Treatment Plan. 1. Within 3 days of admission, at the time of the first Treatment Team meeting, a comprehensive plan is developed, and includes the following: a. Date of admission, b. Date of initial treatment, c. Date of present plan, d. Identified problems, described in behavioral terms. 1) The number and type of problems which are identified should be realistic taking into account what can be reasonably achieved within the short, acute hospitalization. 2. The responsibility for documenting the plan is shared by the physician, nurse, and social worker... . The plan is signed and dated by the physician, nurse, social worker, and patient. The plan is reviewed at Treatment Team Meeting, with the date of review indicated on the plan, participants at the Treatment Team meeting initial the review to signify their participation..."

1. Review on November 6, 2018, of MR1 revealed a Comprehensive Treatment Plan dated August 3, 2018. The Comprehensive Treatment Plan was not signed or initialed and dated by the nurse who was a required treatment team member.

An interview conducted on November 6, 2018, at 2:55 PM with EMP3 confirmed that MR1's Comprehensive Treatment Plan dated August 3, 2018, was not signed or initialed and dated by the nurse who was a required treatment team member.


2. Review on November 6, 2018, of MR2 revealed a Comprehensive Treatment Plan dated October 31, 2018. The Comprehensive Treatment Plan was not signed or initialed and dated by the required treatment team members which included the physician, nurse and social worker.

An interview conducted on November 6, 2018, at 3:00 PM with EMP2 confirmed that MR2's Comprehensive Treatment Plan dated October 31, 2018, was not signed or initialed and dated by the required treatment team members which included the physician, nurse and social worker.


Cross Reference with:
482.12 Governing Body, Condition
482.13 Patient Rights: Condition








Cross Reference with:
482.12 Governing Body: Condition
482.13 Patient Rights: Condition

Based on review of facility policy and medical record (MR), and interview with staff (EMP), it was determined the facility failed to ensure the physician's order for seclusion was written in accordance to facility policy for one of one medical record reviewed (MR2.)

Findings include:

Review of facility policy "Seclusion/Restraints" last reviewed March 9, 2017, revealed "When seclusion/restraint is indicated, a physician's order is required. b. The order must include the following: 1. Date and time of order. 2. Rationale for use of seclusion/restraint. c. The order is time limited as follows: a. Adults: 4 hours. d.[sic] Standing and PRN (as needed) orders are not permitted."

Review of MR2 revealed a physician order for Seclusion dated October 31, 2018, at 11:55 AM. The physician's order listed a time limit of continuous and failed to indicate the reason for the treatment of Seclusion.

A telephone interview conducted on November 22, 2018, at 7:22 PM with EMP1 confirmed the physician's order was for Seclusion with a time limit of "continuous". Further interview confirmed the order did not contain a rationale for the treatment of Seclusion. EMP1 stated " I thought this was an issue that was identified and we fixed earlier this year."


Cross Reference with :
482.12 Governing Body: Condition
482.13 Patient Rights: Condition

Based on review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure the Behavioral Health: Environmental Assessment- Rejuvenations risk assessment for ligatures and safety dated February 12, 2018, was reported to the Hospital Service Committee in compliance with the facility's policy.

Review on November 14, 2018, of the facility's policy "Hospital Service Committee Charter" dated May 2015 revealed "The Hospital Services Committee (HSC) serves as a multidisciplinary forum for monitoring and evaluating the quality and safety of patient care, treatment and services as well as patient and family experience care. The Committee provides Leadership for planning and implementing an organized and systematic approach to quality assessment and improvement throughout the Crozer Keystone Health System by setting priorities for overall Quality, Patient Safety and Performance Improvement activities, and will evaluate the effectiveness of these programs through ongoing reviews and evaluations in achieving performance/outcome goals that are contributory to the overall System's mission and Vision of delivering quality, safe patient care...The Committee standard membership will be comprised of the following, in addition to the Chairperson:...Environment of Care-Safety: May include: Facilities/Security/Materials Management. Committee Responsibilities/Activities: ...Data are collected on processes, procedures, performances, outcomes and other activities that help the hospital improve its ability to provide quality and safe care, that include: Focus on high-risk, high-volume, or problem prone areas..Affect health outcomes, patient safety, and quality of care. Action is taken on improvement opportunities and priories...2. When opportunities of improvement are identified the Hospital Service Committee may undertake one or more of the following:...Request follow-up monitoring/evaluation to ensure that improvements are achieved and/or sustain the acceptable level of performance and will help determine if a measure has matured enough to then close out the Department can move..."


Review of facility policy "Crozer Chester Medical Center 2018 Safety Management Plan
The purpose of the Safety Management Plan is to outline the elements necessary to provide a safe and supportive environment for patients and other individuals served by or providing services at Crozer Chester Medical Center... .The Safety Management Plan is designed to provide a physical environment free of hazards and to manage staff activities to reduce the risk of human injury. Scope. Crozer established and maintains a Safety Management Plan. The Safety Management Plan is risk based, describes how the organization will provide a physical environment free of hazards, and manages staff activities to reduce the risk of injuries. The plan provides processes for...The EOC team conducts specific yearly ligature risk assessments in the Behavior Health Unit on North Campus, Rejuvenations, Acute Substance Abuse Unit, First Steps Residential, the Crisis Center and each of the Emergency Rooms of Crozer Chester Medical Center...Results of the risk assessment process are used to create new or revise existing policies and procedures, hazard surveillance performance improvement standards. The primary objective of the safety management program is to reduce injuries to patients, visitors and staff. To achieve the objective, Crozer has set the following goals: A. Comply with all relevant safety standards and regulations...F. Provide a physical environment free of hazards and for managing staff activities to reduce the risk of human injuries."

Review of facility documents "Hospital Services Committee Meeting Minutes" dated
March 1, 2018, April 5, 2018, May 3, 2018, June 7, 2018, August 2, 2018, September 6, 2018, and October 4, 2018, revealed no evidence of documentation that the results of the Behavioral Health: Environmental Assessment -Rejuvenations risk assessment for ligatures and safety dated February 12, 2018, was reported to the Hospital Services Committee for the dates and times listed above.

An interview conducted on November 6, 2018, at 11:00AM with EMP1 confirmed that the Behavioral Health Environmental Assessment-Rejuvenations risk assessment for ligature and safety dated February 12, 2018, was not reported to the Hospital Services Committee on March 1, 2018, April 5, 2018, May 3, 2018, June 7, 2018, August 2, 2018, September 6, 2018 and October 4, 2018.


Cross Reference with:
482.12 Governing Body, Condition
482.13 Patient Rights, Condition
482.13(c)(2) Patient Rights: Care in Safe Setting
482.41 Physical Environment: Condition

Based on review of facility policy, documents, observations and interviews with staff (EMP), it was determined the facility failed to maintain a safe environment for patients.

In accordance with 42 C.F.R. Part 489.3 this deficiency constitutes Immediate Jeopardy and is a situation in which noncompliance with the requirement of participation has caused, or is likely to cause, serious injury, harm, impairment or death.

Findings include:

Review of facility policy "Hospital Services Charter" last revised February 2016, revealed "The Hospital Services Committee (HSC) serves as a multidisciplinary forum for monitoring and evaluating the quality and safety of patient care, treatment and services as well as patient and family experience of care. The Committee provides Leadership for planning and implementing an organized and systematic approach to quality assessment and improvement throughout the Crozer Keystone Health System by setting priorities for overall Quality, Patient Safety and Performance Improvement activities, and will evaluate the effectiveness of these programs through ongoing reviews and evaluation in achieving performance outcome goals that are contributory to the overall System's Mission and Vision of delivering quality, safe patient care."

Review of facility policy " Crozer Chester Medical Center, 2018 Safety Management Plan" last revised May 3, 2018, revealed "the purpose of the Safety Management Plan is to outline the elements necessary to provide a safe and supportive environment for patients and other individuals served by or providing services at Crozer Chester Medical Center... .The Safety Management Plan is designed to provide a physical environment free of hazards and to manage staff activities to reduce the risk of human injury... . j. Environmental tours are conducted at least every six months in all patient 2 areas and at least annually in all non-patient areas. The authority for effective design, implementation and evaluation of the Safety Management Plan has been delegated by the Board of Managers to the Environment of Care Committee with the sponsorship of the Administrators... ."

Review of facility document on November 2, 2018, of facility document "Behavioral Health Risk Assessment dated February 12, 2018, revealed "... This Self-Assessment Questionnaire (SAQ) highlights areas of risk management and patient safety unique to behavioral health treatment facilities or units, with particularly emphasis on policies and procedures for safe environment of care, use of restraints and seclusion and suicide risk and prevention: 5. Are all fixed and movable items (e.g.) furniture) of sufficient integrity to make them difficult to dismantle and use as a weapon?-Yes 6. Are furniture, furniture pulls, sprinklers, smoke detectors, door hinges and light fixtures recessed or built into the was or ceilings?-Yes. 7. Does the design avoid thin plastic or rubberized baseboards around floors fixed by glue that could be used to hide contraband-No (Cove Bases in all Rooms). 8. Do all doors have continuous hinges-No (All pt rooms do, Laundry Room No. 10. Are freestanding air-conditioning units, fans/coil units, and radiators covered with vandal-proof covering?-No. 12. Are beds platform-style without removable drawers, with specially made mattresses free of springs?N/A (Hospital beds are in use for this population, Shorting Cords is fire issue. Shortened Cords. 14. Are these rooms (for use, as appropriate where beds are bolted to the floor?-No (Beds not bolted). 15. Do freestanding wardrobes and cabinets in patient rooms have doors (an thus hinges)-N/A (Do we want to take doors).17. Are all door handles "ligature resistant" or designed without a "neck" so they cannot bear weight?-No (On office, laundry, activity room doors. 23. Are electrical cords in the unit limited to nine inches in length and secured or otherwise monitored so that they cannot be used for ligature.-No. 25. Are electrical outlets covered with a tamper-resistant barrier to prevent patients from electrocuting themselves, starting fires, lighting cigarettes, or other prohibited activities? No (The outlets are tamper resistant, but are not covered. 33. Are sheets routinely removed from unoccupied beds to prevent patients from hiding or hoarding sheets?-No 35. Are trash can liners, if provided, made of breathable paper rather than plastic?-No. 57 Are the dispensing area and medication room equipped with doors or windows to protect staff? 59. Do corners and hallways have dome or convex mirrors for monitoring. 62. Are plastic bags, office supplies, daily use supplies, and other potentially harmful objects removed from all areas, accessible to patients, including nurses stations?-No. 65.2 Is there an isolation switch accessible to staff to control power to televisions? 66. Are telephones wall mounted and equipped with an on/off switch that only staff can control. and do they have a shielded cord of minimal length?-N/A. 80. Are the walls of seclusion and restraint rooms padded or constructed with impact resistant materials?-No.88. Has an area been identified as the most common site of self-injury or assaultive behavior, and if so is this area consistently monitored?-No. Action Plan. Question 30.1 Routine testing of breakaway hardware will be regularly conducted. Responsibility: Facilities Director, Target Date 04/15/2018, Question: 33 Sheets will be routinely removed from unoccupied beds to prevent patient from hiding or hoarding sheets: Clinical Director, Target Date 04/15/2018. Question 35. Trash can liners, if provided."

A tour of Rejuvenation Psychiatric Geriatric Behavioral Health Department conducted on November 2, 2018, at 11:05 AM with EMP1, EMP2, EMP3, EMP4 and EMP5 revealed:

1. Broken Bed in Room F116-01 with a bed cord (approx 2 feet) and a nonfunctioning wall nurse call unit and an approx 18 inch call light cord hanging from the annunciator panel above the hospital headboard. MR3, a patient in F116-01 was identifed as having a medical diagnosis of Suicidal Ideations and Self-Harm. as revealed on the Census Log dated November 2, 2018.
2. 20 Wardrobe Closet Units in each patient's room revealed each closet unit with double closing doors containing door latches with loopable hardware.
3. 20 Medical hospital beds in each double occupancy room with loopable adjustable side rails and bed cords in length approximate length of 18 inches.
4. Patient Bathrooms with loopable Vents/Drains.
5. Behavioral Unit Shower Room with loopable floor drains and storage area with wheel chairs stacked along side the west side of the shower room wall.
6. Wall Mounted Fire Extinguisher Signs with loopable entry points.
7. Two hallway patient telephones with coiled cords. Telephone coiled cord length was approximately 14 inches long.
8. Seven Lawn Chairs with loopable chair arms.
9. Mobile night stands in patient rooms (can be used for height variation to reach ligature resistant ceiling vents.
10. Unlocked Heater/Air Condition Unit Control Panel Door (Sharp Edges)
11. Two Televisions mounted on the wall in the Dining/Activity Room with loopable extending wall brackets and electrical cords.
12. Dome Shaped Call Light Unit above Door Way of each patient's room-loopable fixture.
14. Door Handles on Laundry, Clean Utility and Soiled Utility Room (loopable handles)
15. Patient Bed Room Chairs- Arms of chairs are loopable and mobile.
16. Seclusion Room with Full Size Bathroom Door (prevents direct view of patient )
17. Wall Mounted Boxed Fire Alarm Unit -Loopable fixture
18. Dining/Activity Room: Sink with a loopable faucet and hot and cold water loopable knobs.


An interview conducted on November 2, 2018, at 12:45 PM with EMP2, EMP3, EMP4 and EMP5 confirmed that the loopable/ligature risk items observed and identified during the tour on November 2, 2018, at 11:05 AM to 12:40PM listed above were still in need of correction for the safety of the patients on the locked behavioral unit. In addition, EMP2, EMP3 and EMP5 confirmed that there were items on the Behavioral Health Risk Assessment form which have a "No" response (no safety risk identified) that continue to be a safety risk issue for the patients on the behavioral unit. When question by the survey team as to the completion date for correcting the items identified on the risk assessment, EMP2 stated "We do not have a completion date for fixing these items, we just continue to work on them when the opportunity presents. EMP5 also confirmed that many items on the behavioral health risk assessment still needed to be corrected however no time frame for completion was identified by EMP2 and EMP5.

Cross reference with:
482.12 Governing Body: Condition
482.13 Patients Rights: Condition

Based on review of facility policy, observation and interview with staff the facility failed to ensure compliance with the facility's policy for maintaining temperatures for freezer and refrigerated patient items.

Findings include:

A review of facility policy "Nourishment Refrigerator/Freezer Temperature Management" last reviewed February 25, 2016, revealed "III. Policy. The temperature of all refrigerators and freezers will be maintained within the appropriate ranges indicated below and recorded on a log daily by Nutrition Services. For those areas not serviced by Nutrition Services, the department manager or their designee will document...IV. Cleaning. All Refrigerators and freezers should be cleaned regularly and as necessary for spills...Procedure. Nutrition Services will monitor and record daily the temperatures in all areas containing patient refrigerators and freezers and will be responsible for policy compliance in those areas. For areas not monitored by Nutrition Services, it will be the responsibility of the department manager to assure policy compliance. Nutrition Services and department manager or their designee shall be responsible for checking and documenting the refrigerator/freezer temperature daily."

1. Observation on November 2, 2018, at 12:30PM with EMP2, EMP3 and EMP4 in the Dining/Activity Room revealed a full size refrigerator/freezer. Further observation revealed signage on the refrigerator door labeled patient refrigerator items only. In addition, on the side of the refrigerator was a a document " Dining Room Log- Refrigerator Temperature Range 36-46 Farenheit and Freezer Log-Temperature Range -10 to 10 Farenheit" revealed the following information:

August 3, 2018, No documentation of Refrigerator Temperature.
August 5-6, 2018, No documentation of Refrigerator and Freezer Temperatures.
August 12, 2018, Refrigerator Temperature documentation was 18 degrees.
August 19-21, No documentation of Refrigerator and Freezer Temperatures.
September 9, 2018, Freezer Temperature documentation was 16 degrees.
September 10, 2018, Freezer temperature documentation was 18 degrees.
September 21, 2018, Documentation on log revealed "No thermometer in freezer"
September 27, 2018, Refrigerator Temperature documentation revealed 20 degrees. Further observation revealed no additonal temperatures were taken. In addition, further observation revealed the refrigerator contained dried spills of liquid, pieces of dried food on the shelves of the refrigerator and pieces of hair strands within the refrigerator.

An interview conducted on November 2, 2018, with EMP2, EMP3 and EMP4 confirmed the temperature log discrepancies for the months of August and September 2018 on the Dining Room Refrigerator and Freezer Log. EMP2 stated "We will have the staff clean the refrigerator and I will educate the staff on the importance of taking the temperatures for the refrigerator and freezer daily. EMP2 also stated, "We will revise the temperature log so that staff will know what to do when the temperatures are not within range."


2. Observation on November 2, 2018, at 12:25 PM with EMP2 and EMP3 in the Nutrition Room revealed a mid size refrigerator/freezer. Documentation received from EMP2 titled Nutrition Refrigerator/Freezer Log Temperature Range 36-46 Farenheit and Freezer Log-Temperature Range -10 to 10 Farenheit" revealed the following information:

July 1-25, 2018, "No Thermometer" Further observation revealed there was no refrigerator and freezer temperatures were taken.
August 5-6, 2018 No documentation of Refrigerator and Freezer Temperatures.
August 21, 2018, no documentation of Refrigerator and Freezer Temperatures.
October 7, 2018, Refrigerator Temperature documentation revealed 50 degrees.
October 11, 2018, Refrigerator Temperature documentation revealed 50 degrees.
October 14-14, 2018, No documentation of Refrigerator Temperatures.
Further observation revealed dried liquid stains in the freezer and refrigerator."

An interview conducted on November 6, 2018, at 1:20PM with EMP2 and EMP3 confirmed that the Nutrition Room refrigerator and freezer temperatures recorded on the log were not in compliance with the facilty's policy. In addition, EMP2 stated "I agree that the Nutrition Room refrigerator and freezer needs to be defrosted and cleaned. I will have the night shift staff take care of this and I will start to educate the staff on the importance of taking the refrigerator and freezer temperatures and what actions to take when the temperatures are not in range".

482.12 Governing Body: Condition
482.13 (c)(2) Care in a Safe Setting: Standard