HospitalInspections.org

Based on observation and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

Review of the hospital's policy titled, Security Rounds, reviewed in part, to provide a safe and secure facility for the patients and staff.

A tour of the hospital on 10/18/2021 between 11:00 a.m. and 11:45 a.m. revealed:
1) Patient rooms a, b, c, d, e toilets and the men's shower toilet and seclusion room toilet with flip up toilet seats that could be used as a ligature point
2) Non Tamper resistant screws: on the dead bolt to dirty linen closet; hallway electrical panel cover, 15 chairs in day room, the outdoor area key pad for the gate handle and hinge and the men's shower room light switch covers and tub hand rails.
3) A container of Lysol wipes in the seclusion bathroom.
4) Male and female shower rooms had a tub in each shower room with a faucet and hot/cold control handle that provided anchoring points and was a potential ligature risk.
5) Patient room f had two 8 oz. bottles of body wash and three lotion packets in the patient room. This finding was verified by S2DON on 10/18/2021 at 10:15 a.m.

In an interview on 10/18/2021 at 11:45 a.m., S8Dir Plant Ops verified the above information.


38777

Based on record review and interview, the hospital failed to ensure radiologists providing interpretation of radiologic tests from the contracted service were credentialed and granted privileges to provide the services by the hospital's medical staff and governing body for 1 (S11MD) of 1 contracted radiologists reviewed providing services to hospital patients.

Findings:

Review of the hospital's medical staff bylaws revealed the telemedicine staff category shall consist of Physicians who, upon being credentialed pursuant to these Bylaws, perform professional services to Hospital patients via a telemedicine link. Such Staff category may include, but is not limited to, teleradiologists, telepathologists, and psychiatrists performing telemedicine services at Hospital.

A review of Patient #5's medical record revealed an x-ray of the left shoulder and left wrist. Both x-rays were performed on 03/06/2021 by the contracted service. Further review revealed both x-rays were read by S11MD.

In an interview on 10/19/2021 at 4:05 p.m. S3Quality confirmed S11MD was not credentialed by the hospital.

Based on record review and interview, the hospital failed to ensure there was an UR committee consisting of two or more practitioner members who were doctors of medicine or osteopathy, who did not have a financial interest in the hospital, and who were not professionally involved in the care of patients being reviewed to carry out the UR function.

Findings:

Review of the hospital's policy titled, Plan for Utilization Review, revealed in part, no committee may participate in the review of any case if he/she was professionally involved in the care or treatment of the patient whose case in being reviewed or has a direct financial interest (for example, an ownership interest) in the hospital.

An interview was conducted on 10/20/2021 at 9:00 a.m. with S6UR. S6UR revealed the only two physicians on the UR Committee was S4Med Director and S5MD. She further confirmed S4Med Director and S5MD reviewed their own patient's cases since they are the only physicians on the committee.

Based on observation and interviews, the infection control officer failed to ensure the hospital system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standard of practice. This deficient practice is evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Review of hospital policy titled "Infection Control for Behavioral Health" revealed in part, to establish guidelines for prevention and control of infections in a Behavioral Health Hospital; to reduce the risk of hospital-associated infections of patients and personnel.

In an observation on 10/18/2021 at 10:55 a.m. revealed a torn mattress that could not be disinfected in patient room g.

In an interview on 10/18/2021 at 10:55 a.m., S1Adm confirmed the torn mattress in patient room g.

An observation was conducted on 10/18/2021 at 11:15 a.m. of the biohazard waste room. On the floor of the biohazard waste room was a clear plastic bag with linen in the bag.

An interview was conducted with S2DON on 10/18/2021 at 11:15 a.m. S2DON confirmed the bag of linen should not be stored on the floor in the biohazard waste room.


44763

Based on interview, the hospital failed to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services as evidenced by having no individual designated as the director of rehabilitation services.

Findings:

In an interview on 10/19/2021 at 10:10 a.m., S2DON stated the hospital does not have anyone designated as the Director of Rehabilitation Services.

38777

Based on record reviews and interviews, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination for 2 (#1,#7) of 9 (#1-9) patient records reviewed for a completed neurological examination at the time of the admission physical examination.

Findings:

Patient #1
Review of Patient #1's medical record revealed a history and physical dated 10/11/2021 at 6:15 p.m. With further review revealed an incomplete neurological assessment and no documentation of a cranial nerve exam.

An interview was conducted with S2DON on 10/18/2021 at 3:00 p.m. S2DON reported S5MD conducted the history and physical via telemedicine and had no one in the facility that could assist him in assessing the patient's cranial nerves.

Patient #7
On 10/19/2021, a review of Patient #7's medical record revealed the history and physical was completed via telemedicine by S5MD on 10/16/2021 but failed to reveal a completed Cranial Nerve Examination.

In an interview on 10/19/2021 at 2:40 p.m., S2DON verified Patient #7's medical record failed to contain a completed Cranial Nerve Examination.

Based on record review and interview, the hospital failed to ensure the treatment received by the patient was documented in such a way to assure that all active therapeutic efforts are included. This deficient practice was evidenced by the hospital failing to document 1 (#7) of 4 (#2,#3,#7,#8) patients received all the aspects of treatment to which the hospital has committed itself based upon his/her assessment, evaluation and plan of care.

Findings:

A review of Patient #7's Multidisciplinary Integrated Treatment Plan revealed:
1) Provide Group Psychotherapy 1 x per day for 2 weeks;
2) Provide Cognitive Stimulation Therapy Groups 1 x per day x 2 weeks

Further review of the medical record failed to reveal documentation that Patient #7 was offered Group Psycho Therapy on 10/17/2021 and 10/19/2021 and Cognitive Stimulation Therapy Group on 10/16/2021, 10/17/2021 or 10/19/2021.

In an interview on 10/19/2021 at 2:40 p.m., S2DON verified Patient #7's medical record failed to reveal documentation that Patient #7 was offered Group Psycho Therapy on 10/17/2021 and 10/19/2021 and Cognitive Stimulation Therapy Group on 10/16/2021, 10/17/2021 or 10/19/2021.

Based on record review and interview, the hospital failed to have an available psychologist to provide psychological services to meet the needs of the patients. This deficient practice was evidenced by failure of the hospital to have a full-time, part-time, or consulting psychologist to provided psychology services.

Findings:

Review of the hospital policy titled, Psychological Consultation, revealed in part, a psychological consultation will be provided by a clinical psychologist only upon order of a staff physician or non-physician practitioner within their scope of practice.

An interview was conducted with S1Adm on 10/19/2021 at 3:30 p.m. She reported the hospital no longer has a consulting psychologist to provide psychology services to the patients.

Based on record review, observation, and interview, the hospital failed to provide a therapeutic activities program. This was evidenced by the hospital failing to conduct any recreational groups since reopening last month (September 2021).

Findings:

Review of the Unit Program Schedule revealed recreational therapy was scheduled to be conducted at 10:00 a.m. and 2:15 p.m. Monday through Friday.

An observation was conducted on 10/19/2021 at 10:00 a.m. of the common room and there was no evidence recreational therapy was being conducted with the patients.

An interview was conducted with S1Adm on 10/19/2021 at 9:30 a.m. She reported the hospital had recently starting the hiring process of a recreational therapist and activity staff. She further reported they had been unable to provide recreational therapy since reopening in September 2021.