HospitalInspections.org

Based upon review of the contracted services and staff interview, the Governing Body failed to: 1) Identify the destruction of expired narcotics was provided by a contract company, and 2) develop a mechanism to evaluate Contract Service A to ensure the service was provided in a safe and effective manner. Findings:

Observations made during inspection of the Pharmacy Department on 04/14/11 at 9:20 AM revealed a box of 75 count Temazepam 30 milligrams, due to expire 05/01/11, was being stored in a separate locked cabinet. Interview with the Pharmacist S10 revealed since the Temazepam was about to expire, it was removed from the medication stock and would be sent to a narcotic destruction company (Contract Service A) for disposal.

Review of the contract service book and the list of contracted services revealed there failed to be evidence the hospital had a contract with the narcotic destruction company (Contract Service A).

Based upon review of 2 of 20 medical records (#9, #14) and incident/accident reports, the hospital failed to ensure each patient or their representative was informed of their health status as evidenced by failing to inform patients #9 and #14 when medication errors had occurred. Findings:

Review of the medical record for patient #9 revealed the patient was admitted on 03/11/11 at 2pm with a diagnosis of Schizophrenia. Review of the Physician Orders signed by the physician on 03/12/11, time not legible, revealed an order for " Lexapro10 mg PO every day. " Review of the Physician ' s Orders dated 03/12/11 11am revealed an order to increase Lexapro to 20mg by mouth daily. Review of the Medication Administration Record (MAR) revealed Lexapro 10 mg was administered at 9am 03/12/11. Further review of the MAR revealed Lexapro 20 mg was transcribed to the MAR on 03/12/11 as Lexapro 20 mg by mouth B.I.D. (twice daily) instead of one time daily as per the physician ' s order. Documentation further revealed the Lexapro 20 mg was administered 03/12/11 at 9pm; 03/13/11, twice daily, 9am and 9pm; 03/14/11, twice daily, 9am and
9pm, 03/15/11, twice daily, 9am and 9pm, and 03/16/11 9am. Further review of the MAR revealed the Lexapro order transcription was changed to correctly read Lexapro 20mg by mouth daily and Patient #9 was administered the correct dose of Lexapro 20 mg once daily from 03/16/11 through 03/22/11

Review of the medical record for patient #14 revealed this 22 year old patient was admitted to the hospital on 04/06/11 with the diagnoses of Suicidal Ideation. Review of the physician orders dated 04/07/11 revealed " Benadryl Cream to rash BID (twice a day) x (times) 7 days " . Review of the Medication Administration Record revealed when LPN S13 transcribed the physician order onto the MAR she incorrectly entered " Benadryl Cream to rash Q (every) day x 7 days " . On 04/10/11 the transcription error was identified and corrected on the MAR.

Review of the incident/accident reports and the patient's medical records revealed there failed to be documentation the patient was notified when a medication error had occurred.

Based on record review and interview, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program by failing to measure, analyze, and track quality indicators that assess processes of care, hospital services and operations. This was evidenced by the hospital's failure to implement quality indicators for all service areas including Radiology Services, Respiratory Services, and the hospital identified problem prone area regarding timely Medical Consults for 2 of 3 contracted services reviewed for quality monitoring (Radiology, Respiratory) and 1 of 1 problem prone area identified by the hospital (Timeliness of Consults/ Patient #8). Findings:

Review of the QAPI (Quality Assurance Performance Improvement) data revealed no evidence to indicate the implementation of quality indicators for Radiology Services, Respiratory Services, and the hospital identified problem prone area regarding timely Medical Consults.

Patient #8:
Patient #8 was admitted to the hospital on 1/18/2011 and discharged on 3/23/2011 with diagnoses that included Schizophreniform disorder and Cannabis Use Disorder. Review of Patient #8's Physician's orders revealed an order dated 1/20/2011 at 2220 for a Medical Consult for tachycardia. Further review of Patient #8's Physician s orders revealed another order dated 3/08/2011 (no documented time) for a Medical Consult for tachycardia. Further review of Patient #8's Physician's orders revealed documentation that the order for a Medical Consult was taken off by the Registered Nurse on 3/08/2011 at 1330 (1:30 p.m.). Review of Patient #8's entire Medical Record revealed the only medical Consult provided for tachycardia was dated 1/21/2011 at 0700 (7:00 a.m./ one day following the 1/20/2011 Medical Consult Order). Review of Patient #8's entire Medical Record revealed no documented evidence that a face to face Medical Consult was provided in response to the physician's order dated 3/08/2011.

Review of Nursing Narrative Notes dated 3/09/2011 at 1650 (4:50 p.m.) revealed in part, "(Patient #8) has a consultation ordered for Medical (doctor) to see her but (Physician S20) was unable to see her today. She is to be seen in (morning)." Further review revealed Nursing Narrative Notes as follows: "3/10/11 at 1330 (1:30 p.m.) (Physician S20) notified again of Med (Medical) Consult for tachycardia. 1400 (2:00 p.m.) this nurse put another sheet for consult for (Physician S20). 3/10/2011 at 1515 (3:15 p.m.) (Physician S21) Medical Director notified of pt's (patient's) continued need for med (medical) consult regarding tachycardia. . . 3/10/2011 at 1700 (5:00 p.m.) (Physician S20) called and requested pulse rates of (Patient #8) today. He reviewed her medications. He order to monitor pt's (Patient's) pulse q (every) shift."

Review of Patient #8's entire Medical Record revealed no documented evidence that Patient #8 had ever been seen by Physician S20 in response to an order for a Medical Consult to evaluate the patient's tachycardia (rate of 98 to 110 in 22 year old female) dated 3/08/2011.

During a face to face interview on 4/13/2011 at 11:20 a.m., Quality Consultant S30 indicated a problem had been identified through quality assurance regarding Physician S20's failure to respond to a physician ordered consult for Patient #8; related to ongoing tachycardia, with a face to face medical evaluation of the patient. S30 indicated the event had been reviewed in a Governing Board Meeting dated 3/31/2011 (confirmed with record review of minutes). S30 indicated in response to identifying the problem, the decision had been made to revise the hospital's bylaws which failed to identify a time line for response to Consultation Requests.

During a face to face interview on 4/14/2011 at 9:10 a.m., Quality Control Director S26 indicated the hospital had identified a problem with the failure of Physician S20 to provide a timely consult in response to a Physician's Order for a Medical Consult to evaluate tachycardia for Patient #8 on 3/08/2011 as ordered by Patient #8's treating psychiatrist. At the time of the survey S26 indicated no Quality Indicators had been added, tracked, or trended for ensuring the problem prone area had been corrected and remained corrected.

The Director of Performance Improvement and Education (S7) was interviewed on 4/14/2011 at 9:10 a.m. S7 reviewed the QAPI data and confirmed that the QAPI data did not include quality indicators for all service areas of the hospital. S7 confirmed that there were no indicators for Respiratory Services, Radiology Services, and the hospital identified problem prone area regarding timely Medical Consults. S7 further indicated the hospital was in the process of completely revising their Quality Assurance Performance Improvement Program with the assistance of a Consultant (S30).

Based upon review of 5 of 5 credential files, Medical Staff Bylaws, and staff interview, the medical staff failed to follow established Bylaws as evidenced by failing to verify reference information to determine the character, professional competence, qualifications, and ethical standing of the applicant (Physicians S20, S21, S23, S24, and Family Nurse Practitioner S22). Findings:

Review of the physician credential files for physicians S20, S21, S23, S24 and Family Nurse Practitioner S22, revealed there failed to be documented evidence the professional references listed were verified. Interview with Medical Staff Coordinator S42 on 04/14/11 at 10:00 AM revealed when asked about the reference verification, she replied during the appointment/re-appointment process the references were not verified unless needed.

Review of the Medical Staff Bylaws revealed Article VI: Procedures for Appointment and Reappointment, Section III: Appointment Process, (a) "Upon receipt of the application for appointment, the Medical Staff Coordinator shall determine whether the application is complete, as well as verify the evidence of the character, professional competence, qualifications, and ethical standing of the applicant. The Medical Staff Coordinator will verify information contained in references given by the applicant and from other sources available to the committee, including an appraisal from the clinical service for which privileges are sought, whether he has established and meets all of the necessary qualifications for the category of staff appointment and the clinical privileges requested by him."

The medical staff failed to follow established bylaws and ensure during the appointment/reappointment process the physician's references were verified.

Based upon reviews of 1 of 20 medical records (#3), credentialing files (S22), and interview, the Medical Director failed to ensure the History and Physicals performed by the Family Nurse Practitioner (S22 FNP) indicated all medical issues the patient (#3) may have experienced upon admission were documented as to ensure the patient received needed care as evidenced by the FNP's failure to assess and document a wound on patient #3's lower right leg. Findings:

Review of patient #3's History and Physical (H&P), dated 02/25/11, revealed S22 Family Nurse Practitioner (FNP) documented under a section titled "MUSCULOSKELETAL: ...Right and left lower extremity inspection and palpation reveals no misalignment, asymmetry, crepitus, tenderness or masses...". On the section titled "SKIN", S22 FNP documented: "Inspection of the skin and subcutaneous tissue without rashes, lesions or ulcers."

Review of a medical consult, dated 03/2/11, 11:00am, revealed S20 physician documented: "Pt (patient) had a burn in the inner aspect of Rt. (right) leg. Pt not sure what happened but she mentioned a motorcycle that she had fell on. Looks like a rectangular patch, size 6" (inch) in diameter with excoriation and scab in the middle area, tender, red. No abn (abnormal) discharge, no fever...AP (assessment/plan) 1st and 2nd degree burn of the rt. leg..."

Review of S22 FNP's credentialing file revealed he had a collaborative agreement with S20 physician and had current privileges to perform H&Ps. S22's performance had been evaluated; however, the medical staff/medical director failed to ensure S22's quality of care provided was complete and thorough as evidenced by a missed leg burn during an admission assessment on patient #3.

Telephone interview, 04/14/11 at 11:20am, with S21 Medical Director/Physician revealed when questioned if he was familiar with patient #3 and the right leg burn that she had upon admission, and that both the admitting Registered Nurse (S44 RN) and Nurse Practitioner (S22 FNP) who performed the H&P missed the wound; he replied, "I was aware the patient apparently had a burn on her leg that was missed when she was admitted and the nurses involved have been fired." Further questioning of S21 Medical Director revealed when questioned as to what action had been taken on S22 FNP, he replied, "he should be placed on probation for missing this on his assessment."

It was confirmed through interview, 04/14/11 at 11:20am, with S21 Medical Director that there had not been disciplinary action taken on S22 FNP as a result of him missing the wound to patient #3's lower leg upon her admission.

The medical staff failed to follow their bylaws and monitor and evaluate the quality of care provided to patients by members with delineated clinical privileges to ensure all patients received H&Ps that addressed anything in the patients overall condition (#3's right leg wound) that would affect the planned treatment such as a new condition that required additional interventions (treatment of burn) to reduce risk to the patient (potential for infection).

Based upon reviews of 1 of 20 medical records (#3), policies and procedures, Quality/Risk Management Report of Event, and interviews, the hospital failed to ensure the Registered Nurse followed hospital policies and procedures and performed a complete admission assessment and documented the findings on the Initial Nursing Assessment form as evidenced by patient #3 having a burn on her lower right leg and a lack of documentation of this burn. Findings:

Review of patient #3's medical record revealed a 35 year-old female admitted, 02/24/2011 with diagnosis of psychosis to the services of S19 psychiatrist. Review of the initial screening/nursing assessment form revealed, on page 10, a diagram of the human body, front and back. The nurse was to utilize this diagram to indicate any bruising, incisions, lacerations, rash, decubitus, scar, lesions, tattoo, piercing, operative site, and other abnormal findings. The review of this form revealed a check mark in the box titled "NSF" (normal skin findings). Continued review of the initial screening/nursing assessment form indicated S44 Registered Nurse (RN) signed and dated the form 02/24/11 at 5pm. S44 RN had signed that she had completed the evaluation and had reviewed the initial assessment, 02/24/11 at 5pm.

Review of patient #3's medical record revealed a form titled "Interdisciplinary Progress Note" that the nurses used to document daily shift assessments. 02/24/2011 through 02/26/2011 under the section titled "Skin" for the 7a-3p (S47 RN) and 3p-11p (S45 RN) shifts, the nurses had documented patient #3's skin as "normal". (There lacked documentation for the 11p-7a shifts).

Continued review of the interdisciplinary progress note revealed on 02/26/11, 3pm, S46 Licensed Practical Nurse (LPN) documented: "Mom asked for nursing staff to come to the cafeteria to look at daughter's leg. Has some bruising and skin has peeled back leaving a portion exposed... Assured mother her daughter would be taken care of..."; at 6:45pm S46 LPN documented: "Mother and sister called to state concern about patient...Making sure her wound was attended to..."

Further review of the nursing documentation revealed: 02/27/11, 7a-3p shift, S47 RN documented "irritation" to patient #3's right lower leg. S45 RN documented 02/27/11, 5:30p (3p-11p shift) "...wound per R (right) (lower) leg, covered c (with) gauze..." 02/28/11, 7a-3p shift, S47 RN documented irritation to right lower leg. 03/01/11, 7a-3p shift, S47 RN documented "see wound sheet" for her skin assessment (did not locate a wound sheet in patient #3's medical record). 03/01/11 at 6:30p on the 3p-11p shift, S48 RN documented "burn area" right lower leg. "Medical consult done for burn to inner lower right leg."

Review of nursing documentation, 03/02/11 at 7:30am, S47 RN documented: "Physical assessment completed...Abrasion noted to R (right) ankle area currently open to air. Abrasion obtained prior to admission to hospital. Bruised area or discolored area noted around skin area-apparent 6-8 inch (with) irregular shape in center of wound white discoloration noted in center of wound no discharge noted from wound...Pt (patient) stated this wound was from a fall on road while upset with father, same story told in treatment team on Monday (02/28/11) (with) (name S19 psychiatrist)..."

Review of patient #3's History and Physical (H&P), dated 02/25/11, revealed S22 Family Nurse Practitioner (FNP) documented under a section titled "MUSCULOSKELETAL: ...Right and left lower extremity inspection and palpation reveals no misalignment, asymmetry, crepitus, tenderness or masses...". On the section titled "SKIN", S22 FNP documented: "Inspection of the skin and subcutaneous tissue without rashes, lesions or ulcers."

Review of a medical consult, dated 03/2/11, 11:00am, revealed S20 physician documented: "Pt (patient) had a burn in the inner aspect of Rt. (right) leg. Pt not sure what happened but she mentioned a motorcycle that she had fell on. Looks like a rectangular patch, size 6" (inch) in diameter with excoriation and scab in the middle area, tender, red. No abn (abnormal) discharge, no fever...AP (assessment/plan) 1st and 2nd degree burn of the rt. leg..."

Review of policy/procedure #AS-00-001 titled "Assessments, Initial Screening and Other" revealed: "PURPOSE: To provide a mechanism for initial identification of actual/potential health problems, as well as the need for further assessment...GENERAL GUIDELINES ...Complete all blanks in hand-written assessments, whether to specify a negative assessment, a not applicable (N/A) status, or that the patient is unable to recall or supply the information requested...NURSING ADMISSION ASSESSMENT The RN will complete the nursing admission assessment within eight hours of patient's arrival on the unit...A review of systems will be completed by the RN with documentation of any identified medical problems. The patient's body will be examined for any marks, i.e. bruises, swelling, scratches, and appropriate documentation noted...NURSING REASSESSMENT ...at the time of discharge or any time that the patient incurs an injury or there is a significant change in the patient's condition. This re-assessment could be a full re-assessment of the patient or a re-assessment of specific systems related to the patient's injury or change in condition. It is written in a narrative form on the Interdisciplinary Progress Note form. The patient's body will be reassessed for any marks, i.e. bruises, swelling, scratches, and appropriate documentation noted on the Admission Worksheet at the time of admission. Any further marks, i.e. bruises, swelling, scratches, incurred during their admission will be documented in narrative form on the Interdisciplinary Progress Note..."

Review of a Quality/Risk Management Report of Event, dated 03/01/11, 6:30pm, revealed S 48 RN documented "During PM assessment pt stated 'I have a place here on my leg'. Upon inspection there was a white bandage approx. (approximately) the size of a 4 X 4 with tape on it. Found what appeared to be a burn on inner R (right) leg above the ankle She stated she came here with the bandage on leg." (It was noted on 03/01/11 3p-11p shift, this was the first time for S48 RN to provide care to this patient)

Interview, 04/14/11, 9:25am, with S2 Director of Nursing (DON) revealed she received the above report on 03/02/11 (the next morning after S48 RN completed it) and began her investigation. After S2 DON's investigation, she concluded that patient #3 was admitted with a wound to her lower right leg. S2 DON stated the wound was not documented by the admit nurse (identified as S44 RN) or any other nursing personnel until 02/26/11 when S46 LPN documented the patient's mother wanted nursing staff to examine the wound on patient #3's right leg. The documentation, on 02/26/11 at 3:00pm, by S46 LPN was not followed through; and all RNs from admit until 03/01/11 did not document the burn on patient #3's right leg. S2 DON stated as a result of her investigation 3 RNs (S44, S45, S47) and 1 LPN (S46) were placed on 2 day suspensions and 60 day probation "as a result of failure to thoroughly assess and document findings on admission and thereafter".

S2 DON confirmed RN (S44) failed to follow policy and procedure and identify and document patient #3's actual skin condition upon admission; nor did any other RN (S44, S46) until 3/1/11 when S48 RN performed her assessment and discovered the wound on the patient's lower right leg.

Based on record review and interview the hospital failed to ensure the nursing plan of care was kept current for 1 of 1 patients reviewed for updating the care plan regarding sexual inappropriateness/precautions out of a total sample of 20. (Patient #7). Findings:

Patient #7's medical record was reviewed on 4/12/2011 at 11:00 a.m. Review of Patient #7's medical record revealed the patient was admitted to the hospital on 4/07/2011 with diagnoses that included Psychotic Disorder Not Otherwise Specified and Oppositional Defiant Disorder. Review of Patient #7's Physician's Progress notes dated 4/09/2011 at 1340 (1:40 p.m.) revealed in part, "It was brought to my attention that in his old record the patient has a history of acting out sexually during last admission here in 2009. . . We discussed the consequences of inappropriate behavior. . ." Review of Patient #7's Physician's orders revealed an order dated 4/09/2011 at 1:34 p.m. for "Sexual precautions and no room mate." Review of Patient #7's entire medical record revealed no documented evidence of updating the patient's treatment plan regarding Sexual Inappropriateness with Sexual Precautions. Further review revealed no documented evidence on Patient #7's Observation Flow sheet that the patient was to be observed for Sexual Precautions.

During a face to face interview on 4/13/2011 at 1535 (3:35 p.m.), Director of Nursing S2 confirmed there was no documented evidence of an updated Treatment Plan identifying sexual inappropriateness as a problem and outlining the Individualized Interventions to be utilized in implementing Patient #7's Sexual Precautions. S2 indicated patient's treatment plans should be kept current.

Review of the hospital policy titled, "Master Treatment Planning and Review Process, AS-00-011" presented by the hospital as their current policy revealed in part, "It is the policy of (hospital) that the setting and services required are determined to meet patients care needs. These needs are identified on admission and reassessed throughout the treatment process. . . Problems, measurable goals, objectives and interventions will be identified, implemented, and reviewed in a timely fashion in order to address the patient's needs. ."

Based on record review and interview the hospital failed to ensure medications were administered as ordered as evidenced by failing to accurately transcribe physician's orders to the Medication Administration Record (MAR) resulting in medication administration errors for 2 of 20 sampled patients. (Patient #9 and Patient #14). Findings:

Patient #9: The medical record for Patient #9 was reviewed. Patient #9 was admitted on 03/11/11 at 2pm with a diagnosis of Schizophrenia. Review of the Physician Orders signed by the physician on 03/12/11, time not legible, revealed an order for "Lexapro10 mg PO every day." Review of the Physician's Orders dated 03/12/11,11am revealed an order to increase Lexapro to 20mg by mouth daily. Review of the Medication Administration Record (MAR) revealed Lexapro 10 mg was administered at 9am 03/12/11. Further review of the MAR revealed Lexapro 20 mg was transcribed to the MAR on 03/12/11 as Lexapro 20 mg by mouth B.I.D. (twice daily) instead of one time daily as per the physician's order. Documentation further revealed the Lexapro 20 mg was administered 03/12/11 at 9pm; 03/13/11, twice daily, 9am and 9pm; 03/14/11, twice daily, 9am and 9pm, 03/15/11, twice daily, 9am and 9pm, and 03/16/11, 9am. Further review of the MAR revealed the Lexapro order transcription was changed to correctly read Lexapro 20mg by mouth daily and Patient #9 was administered the correct dose of Lexapro 20 mg once daily from 03/16/11 through 03/22/11.

Review of the "Medication Incident Report" dated and timed 03/16/11, 4:30pm and signed by S17, LPN , revealed the medication error was identified as wrong dose given and order inaccurately transcribed to MAR with a contributing factor of improper interpretation of order. Further review of the "Medication Incident Report" revealed the report was reviewed by S7, Quality Assurance (QA) and a copy was sent to the Pharmacist and the Director of Nursing (DON).

S10, Registered Pharmacist was interviewed face to face on 04/13/11 at 1:25pm. S10 reviewed the record for Patient #9 and confirmed the Lexapro 20 mg had been administered twice daily on 03/13/11, 03/14/11 and 03/15/11 instead of once daily as per the physician ' s order. Further S10 indicated she had addressed the incident with staff and presented education on Medication Errors-Identify and Prevention. S10 presented sign in medication education sheets signed by staff. Review of the sign in sheets revealed in part, "Corrective Action: Q (every) shift chart checks-compare MAR to physician's orders." Further review of the "Medication Education" sign in sheets revealed staff had attended a 26 minute DVD on knowledge and skills for administering medications orally, topically, rectal, vaginal suppositories and inhalants. Staff verified by signature they had a better understanding on how to avoid medication errors in these areas.

Patient #14: Review of the medical record for patient #14 revealed this 22 year old patient was admitted to the hospital on 04/06/11 with the diagnoses of Suicidal Ideation. Review of the physician orders revealed on 04/07/11 the physician ordered "Benadryl Cream to rash BID (twice a day) x (times) 7 days". Review of the Medical Administration Record (MAR) revealed when LPN S13 transcribed the physician order onto the MAR she incorrectly entered "Benadryl Cream to rash Q (every) day x 7 days" On 04/10/11 the transcription error was identified and corrected on the MAR.

Review of the hospital policy entitled "Medication Administration" presented as the hospital's current policy, revised 01/2011, revealed in part, II. Transcription of Medication Order: "D. If medication ordered is regular scheduled medication, enter order date, medication, route, frequency, and stop date on MAR and on the Kardex. Then enter times to be given in appropriate place on MAR. If times to be given are not specified by physician then times will be as follows: Q Daily = 9am Adults Services; BID = 9am, and 9pm Adult Services." V1. Review of Physician Orders: A. R.N. or L.P.N. is to confirm that the order is accurately and completely transcribed to MAR and Kardex. B. If order has been accurately transcribed, place a red check and initial next to the order on the physician's order sheet and also next to the order on the MAR."

There failed to be documented evidence the RNs and LPNs confirmed the medications ordered by the physicians were actually and completely transcribed onto the MAR as indicated in the policy for patients #4, 9, and 14.

The hospital failed to follow policy and procedure related to the transciption of medication orders by failing to ensure the Registered Nurse or Licensed Practical Nurse confirmed the medication order was accurately and completely transcribed to the Medication Administration Record.

Based on record review and interview the hospital failed to ensure all entries into the Medical Record were timed for 5 of 20 sampled patient's records reviewed (Patients #5, #6, #7, #8, #19). Findings:

Review of Patient #5's medical record revealed a "Child/Adolescent Psychosocial Assessment" dated 4/08/2011 with no documented time.

Review of Patient #6's medical record revealed a "Child/Adolescent Psychosocial Assessment" dated 4/08/2011 with no documented time. Further review of Patient #6's medical record revealed an "Adjunctive Therapy Assessment for Activity and Recreational Therapies" dated 4/08/2011 with no documented time.

Review of Patient #7's medical record revealed an "Adjunctive Therapy Assessment for Activity and Recreational Therapies" dated 4/08/2011 with no documented time.

Review of Patient #8's medical record revealed phone ordered physician's orders for a Medical Consult to evaluate tachycardia dated 3/08/2011 with no documented time.

Review of Patient #19's medical record revealed an "Adult Psychosocial Assessment" dated 4/06/2011 with no documented time.

Review of the hospital policy titled, "Authentication of Medical Records, IM-00-003, dated 6/27/2000" presented by the hospital as their current policy revealed in part, "All entries made in the medical record must be dated, timed, and authenticated by the author of the entry. . ."

During a face to face interview on 4/13/2011 at 1535 (3:35 p.m.) Director of Nursing S2 confirmed the above findings and indicated staff should follow hospital policy.

Based upon tour observations, review of receipt and distribution records of scheduled narcotic drugs, and staff interview, the pharmacist failed to ensure a perpetual inventory was maintained on expired scheduled narcotic drugs. Findings:

During the tour observations of the Pharmacy Department on 04/14/11 at 9:20 AM, a 75 count box of Temazepam 30 milligrams, due to expire on 05/01/11, was being stored separately from the useable narcotics. Interview with the Pharmacist S10 during this observation revealed once narcotic medications expired, such as with the Temazepam, they were stored in a locked cabinet and an inventory was not completed until the medication was sent to the drug destruction company. Review of the perpetual inventory sheet for the Temazepam, a class IV narcotic, revealed the medication was removed from stock on 04/01/11 and the amount had not been counted since the removal.

Based on record review (Contracts, Medical Staff Bylaws, Medical Staff Roster) and interview, the hospital failed to ensure a qualified radiologist was appointed to the medical staff.
Findings:

Review of hospital contracts revealed an agreement with an Imaging Service to perform radiological services to the hospital.

Review of the Medical Staff Roster, presented by the hospital as the current list of credentialed physicians, revealed no documented evidence of a radiologist appointed to the medical staff.

In a face-to-face interview on 04/13/11 at 11:15am S7, QA confirmed there was no radiologist appointed to the medical staff.

Based on observation and record review the hospital failed to ensure the Infection Control Officer developed a system for controlling the risk of infections when handling contaminated supplies and/or linens for 2 of 2 units reviewed for proper disposal of soiled linen and/or contaminated items. (Adult and Adolescent Unit)

Observations on 4/13/2011 at 9:20 a.m. revealed one plastic container lined with a plastic red biohazard bag to be located in the Adult Unit's Soiled Linen Closet. Further observation revealed the container/biohazard bag to contain several urine specimen cups with visible yellow tinged liquid in the containers (cups).

During a face to face interview on 4/13/2011 at 9:20 a.m., Mental Health Technician S33 indicated if there were any soiled linen containing blood or body fluids on the unit, he would use the Personal Protective Equipment kit and follow the directions located on the bag to collect the linen. S33 further indicated he would then place the soiled linen in the same red biohazard bag/container located in the linen room that contained the fluid filled urine cups. S33 confirmed the container held soiled plastic urine cups and indicated that he would also place red bagged soiled linen in the same container with the urine cups if the linen had been soiled with blood or body fluids.

During a face to face interview on 4/13/2011 at 9:40 a.m., Mental Health Technician S29 indicated the Container in the Soiled Linen Room should only contain Soiled Linen and all other contaminated items; such as used urine specimen cups, should have been disposed of in the Medication Room.

During a face to face interview on 4/13/2011 at 9:45 a.m., House Keeper S8 indicated Soiled Linen and/or other bags of contaminated items such as urine cups would be picked up by housekeeping and taken to the biohazard storage area in the back of the hospital. S8 indicated she did not know what nurses would do during the hours that housekeeping was not present. S8 indicated there was no 24 hour/ 7 day per week coverage by housekeeping.

During a face to face interview on 4/13/2011 at 10:00 a.m., Mental Health Technician S40 indicated Soiled Linen should be placed in a red biohazard bag inside the plastic storage containers located in the Soiled Linen Closet on the Adult or Adolescent unit depending upon where the item was located when soiled. S40 further indicated she had no knowledge as to where to dispose of other soiled items such as dirty urine cups.

Observations on 4/13/2011 at 9:55 a.m. revealed a biohazard waste bin to be located in the medication room on the Adult Unit. Further observation revealed the bin to be located on the right side of the room (upon entering), to the immediate right side of the medication preparation counter, and behind an un-covered E-Cylinder Oxygen Tank.

During a face to face interview on 4/13/2011 at 9:55 a.m., Infection Control Officer S28 indicated it had been the practice/expectation at the hospital for staff to dispose of soiled linen in the red bag located in the Soiled Linen Closet and all other contaminated items; such as dirty urine specimen cups, were to be disposed of in the biohazard bin located in the unit's medication room. S28 confirmed disposing of contaminated items in the biohazard bin located in the Medication Room could result in contamination of clean items due to the route of travel. S28 confirmed contaminated items would have to travel over the oxygen e-cylinder tank located in the medication room in front of the biohazard bin and would also be traveling immediately to the right of the counter where medications where prepared for administration. S28 indicated the hospital's practice could possibly result in contamination of items located in the medication room to include the counter where medication was prepared and/or the oxygen tank.

The personnel files for 5 employees were reviewed with Infection Control Officer S28 on 4/13/2011 at 10:10 a.m. for education regarding disposal of contaminated items, supplies, and/or linen. This review revealed Mental Health Technician S41 failed to have any documented evidence of annual re-orientation since 2009. S41 attended one In-service Training on Hand Hygiene dated 1/12/2011. Further review revealed Mental Health Technician S16 attended Hospital Annual Re-Orientation on 2/18/2011 with no documented evidence of Infection Control Training and/or Competency Evaluation. Review of Mental Health Technician S42's personnel file revealed Hospital Re-Orientation dated 3/04/2011 with no documented evidence of Infection Control Training and/or Competency Evaluation. Review of Mental Health Technician S15's personnel file revealed Hospital Re-Orientation dated 3/04/2011 with no documented evidence of Infection Control Training and/or Competency Evaluation.

This finding was confirmed in a face to face interview with Infection Control Officer S28 on 4/13/2011 at 10:10 a.m. S28 indicated she functioned in the role of Educator and Infection Control Officer. S28 indicated on 4/01/2011 she realized that she had forgotten to add Infection Control Training to the annual re-orientation for nursing staff to include Mental Health Technicians. S28 indicated she had added Infection Control Training and Evaluation to the annual re-orientation training for all employees scheduled after the date of 4/01/2011; however, the employees that attended prior to that date did not have Infection Control Training in the annual re-orientation. S28 indicated (confirmed with record review) that there had been training in Hand Washing Hygiene during the year's (2011) In-service Training Education outside of the Annual Re-orientation..

Review of the hospital policy titled, "Prevention of HIV Transmission in the Hospital, # IC-00-666, last revised 1/26/07" revealed in part, "Non disposable equipment that is contaminated with blood or blood containing bodily fluids should be rinsed off with tap water and cleaned with a hospital wide germicide and allowed to dry."

Review of the hospital policy titled, "Linen distribution and Use, #IC-00-030, last revised 3/22/2006" presented by the hospital as their current policy revealed in part, "Soiled Linen: All soiled linen is to be deposited into a closable bag prior to removal of the linen from the collection site. Housekeeping employees will be responsible for daily, and the "as needed" changing of patient linen and transporting the linen to the soiled Linen Room. Housekeeping employees will clear patient rooms of soiled linen upon discharge of the patient. Housekeeping staff will transport soiled linen to the receiving area to be export soiled linen to the receiving area to be exchanged for clean linen. Universal precautions will be observed."

Review of the hospital policy titled, "Handling and Transport of Used Linen, # IC-00-032, last revised 3/22/2006" presented by the hospital as their current policy revealed in part, "Wear appropriate protective clothing if linen is wet (e.g., gloves, gowns where applicable). Keep linen hamper covered until hamper is full. Transport closed dirty linen bag to the soiled utility room immediately. . . Note. Sometimes linen becomes heavily soiled with secretions, excretion, or blood. Place two clean plastic bags inside the white linen container so that leaks will be avoided. All soiled linen is treated as bio-hazard by linen service. No red bags used for soiled linen. No linen will be put into red biohazard bags. Proper handling of soiled linen will decrease the spread of infectious microorganisms. Handling of soiled linen will meet infection control standards."

Review of the hospital policy titled, "Dirty Linen Rooms, #IC-00-050, last revised 3/22/2006" presented by the hospital as their current policy revealed in part, "contaminated linen does not have to be separated from other linen, however; it may require being double bagged for the safety of housekeeping/nursing staff. . ."

Review of the hospital policy titled, "Removal of Infectious and Contaminated Waste, # IC-00-027, last revised 4/08/2011" presented by the hospital as their current policy revealed in part, "Transport all waste from site of generation to location designated by the hospital, for trash collection (small Biohazard Medal building behind facility). Bag all waste in red bag containers, identified by color and markings as noted in Infection Control Manual. Take to designated building and place in biohazard boxes that have been lined with an additional red bag to prepare for pick up. Deliver waste to coincide with disposal schedule."

Based on record review and interview the hospital failed to ensure the nursing plan of care was kept current to include specific treatment modalities utilized in providing precautions for sexual inappropriateness for 1 of 1 patients reviewed for updating the care plan regarding sexual inappropriateness/precautions out of a total sample of 20. (Patient #7). Findings:

Patient #7's medical record was reviewed on 4/12/2011 at 11:00 a.m. Review of Patient #7's medical record revealed the patient was admitted to the hospital on 4/07/2011 with diagnoses that included Psychotic Disorder Not Otherwise Specified and Oppositional Defiant Disorder. Review of Patient #7's Physician's Progress notes dated 4/09/2011 at 1340 (1:40 p.m.) revealed in part, "It was brought to my attention that in his old record the patient has a history of acting out sexually during last admission here in 2009. . . We discussed the consequences of inappropriate behavior. . ." Review of Patient #7's Physician's orders revealed an order dated 4/09/2011 at 1:34 p.m. for "Sexual precautions and no room mate." Review of Patient #7's entire medical record revealed no documented evidence of updating the patient's treatment plan regarding Sexual Inappropriateness with Sexual Precautions. Further review revealed no documented evidence on Patient #7's Observation Flow sheet that the patient was to be observed for Sexual Precautions.

During a face to face interview on 4/13/2011 at 1535 (3:35 p.m.), Director of Nursing S2 confirmed there was no documented evidence of an updated Treatment Plan identifying sexual inappropriateness as a problem and outlining the Individualized Treatment Modalities/Interventions to be utilized in implementing Patient #7's Sexual Precautions. S2 indicated patient's treatment plans should be kept current.

Review of the hospital policy titled, "Master Treatment Planning and Review Process, AS-00-011" presented by the hospital as their current policy revealed in part, "It is the policy of (hospital) that the setting and services required are determined to meet patients care needs. These needs are identified on admission and reassessed throughout the treatment process. . . Problems, measurable goals, objectives and interventions will be identified, implemented, and reviewed in a timely fashion in order to address the patient's needs. ."

Review of the hospital policy titled, "Observation Status Categories, AS-00-006, last revised 1/07/2011" presented by the hospital as their current policy revealed no documented evidence how the hospital would define, implement, or individualize sexual precautions

Based on record review and interview the hospital failed to ensure the nursing plan of care was kept current to include the responsibilities for each member of the treatment team in providing interventions for sexual inappropriateness/ precautions for 1 of 1 patients reviewed for updating the care plan regarding sexual inappropriateness/precautions out of a total sample of 20. (Patient #7). Findings:

Patient #7's medical record was reviewed on 4/12/2011 at 11:00 a.m. Review of Patient #7's medical record revealed the patient was admitted to the hospital on 4/07/2011 with diagnoses that included Psychotic Disorder Not Otherwise Specified and Oppositional Defiant Disorder. Review of Patient #7's Physician's Progress notes dated 4/09/2011 at 1340 (1:40 p.m.) revealed in part, "It was brought to my attention that in his old record the patient has a history of acting out sexually during last admission here in 2009. . . We discussed the consequences of inappropriate behavior. . ." Review of Patient #7's Physician's orders revealed an order dated 4/09/2011 at 1:34 p.m. for "Sexual precautions and no room mate." Review of Patient #7's entire medical record revealed no documented evidence of updating the patient's treatment plan regarding Sexual Inappropriateness with Sexual Precautions. Further review revealed no documented evidence on Patient #7's Observation Flow sheet that the patient was to be observed for Sexual Precautions.

During a face to face interview on 4/13/2011 at 1535 (3:35 p.m.), Director of Nursing S2 confirmed there was no documented evidence of an updated Treatment Plan identifying sexual inappropriateness as a problem and outlining the Individualized Interventions to be utilized in implementing Patient #7's Sexual Precautions. S2 confirmed there was no documented evidence as to the responsibilities for each team member in implementing physician ordered Sexual Precautions. S2 indicated patient's treatment plans should be kept current.

Review of the hospital policy titled, "Master Treatment Planning and Review Process, AS-00-011" presented by the hospital as their current policy revealed in part, "It is the policy of (hospital) that the setting and services required are determined to meet patients care needs. These needs are identified on admission and reassessed throughout the treatment process. . . Problems, measurable goals, objectives and interventions will be identified, implemented, and reviewed in a timely fashion in order to address the patient's needs. ."

Review of the hospital policy titled, "Observation Status Categories, AS-00-006, last revised 1/07/2011" presented by the hospital as their current policy revealed no documented evidence how the hospital would define, implement, or individualize sexual precautions

Based on record review and interview the hospital failed to complete Recreational Assessments for 4 of 20 sampled patient records reviewed. (Patients #2, #5, #10, #11) Findings:
Patient #2: The medical record for Patient #2 was reviewed. Patient #2 was admitted on 4/06/2011 with a diagnosis of Depression. Continued review of his medical record revealed an Activity Therapy Assessment with a completion date of 4/12/2011.
Patient #5: The medical record for Patient #5 was reviewed. Patient #5 was admitted on 4/06/2011 with a diagnoses of Intermittent Explosive Disorder. Review of the entire record on 4/12/11, 7 days after admit, revealed no documented evidence of a Recreational (Activity) Assessment.
Patient #10: The medical record for Patient #10 was reviewed. Patient #10 was admitted 04/06/11 with a diagnosis of Intermittent Explosive Disorder. Review of the entire record on 04/12/11, 7 days after admit, revealed no documented evidence of a Recreational (Activity) Assessment.
This finding was confirmed by S2, Director of Nursing on 04/12/11 at 12:15pm.
Patient #11: The medical record for Patient #11 was reviewed. Patient #11 was admitted 04/05/11 with a diagnosis of Depression, Cannabis and ETOH Abuse. Review of the entire record on 04/12/11, 8 days after admit, revealed no documented evidence of a Recreational (Activity) Assessment.
This finding was confirmed on 04/12/11 at 2:30pm by S39 , Transcriptionist on 04/12/11 at 2:30pm. S38 indicated the Recreational Assessment should be on the record within 72 hours.
S9, Director of Social Services was interviewed on 04/12/11 at 3:10pm. S9 indicated the Recreational Assessment should be done within 36 hours of the patients admit date.
Review of the hospital policy titled, "Plan for the Provision of Patient Care- 2010, #LD-00-003, last revised 1/21/2010" presented by the hospital as their current policy revealed in part, "Recreation Therapy Services. The patient is recognized as a unique individual whose needs, interest and ability are identified, evaluated and integrated into the treatment approach. . . Objectives. Assess each patient's interests and needs and incorporate the assessment in the treatment plan. . . Evaluate and revise systems, techniques and programs in order to keep services current and thus meeting the needs of the patients. . . The services provide are evaluation of each service. . Aspects of care: Timeliness of Services. . ."
Review of hospital policy #AS-00-001 titled " Assessments, Initial Screening and Other " revealed: " ...Activity Therapy Services Assessment The Activities Therapist will complete the Activities Therapy Assessment within 72 hours after admission. The activity therapist will summarize the information from the assessment on the Therapist ' s ' summary ' sheet, and identify the strengths and weaknesses from this information. In the ' Therapist ' s Recommendation ' section, document recommendations for interventions ... "











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