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Based on review of documentation, and interview it was determined that the facility failed to ensure that there was documentation that all contracted services utilized by the hospital had been evaluated.

Findings were:
The facility was unable to provide documentation that all of the contracted services utilized by the facility had been evaluated. Additionally the facility did not have a current policy regarding how contracted services were to be evaluated. Review of facility document entitled: "Austin Oaks Hospital List of Contracted Services" updated as of 06/30/2016 listed 35 separate contracted services utilized by the hospital. 5 of these contracted services were listed as Admin, 4 were Business Office, 13 were listed as Clinical, 3 were Dietary, and 10 were EOC (environment of care). Examples of these contracted services included: Copy Machine & Faxes, Locum Tenens Services, Medicare Eligibility Information, Ambulance Transport, Educational Services for Patients, Laboratory Services, Pharmacy Management, Portable X-ray Services, Telemedicine Services, Dietician/Nutritional Services, Grease Trap Collection, Fire Alarm & Sprinkler Inspection, Hazardous Waste Pickup, Linen Supply, Medical & Patient Grooming Supplies, Pest Control, and Waste & Recycle Pickup.
The facility provided documentation that the contracted services of Pharmacy, Telemedicine, Dietary, Labcorp and Mobilex had been routinely reviewed. Review of facility document entitled: "Austin Oaks Hospital Performance Improvement 2015" revealed that the contracted services of Mobilex, Labcorp, and Dietary had been reviewed for 2015. Review of other facility documentation entitled: "Quality Council Report Sept 2015-Nov 2015" with a reported date of "Jan, 2016" revealed that contracted services for Mobilex, Dietary, and Labcorp had been evaluated. Review of facility document entitled: "Austin Oaks Hospital Quality Council Report Dec 2015-Feb 2016" with a reported date of "Apr, 2016" revealed that contracted services for Mobilex, Dietary and Labcorp had been evaluated. Review of facility document entitled: "Austin Oaks Hospital Quality Council Report Mar 2016-May 2016" with a reported date of "July, 2016 " revealed that the contracted services for Labcorp, Mobile Xray and Dietary had been evaluated. Review of Medical Executive Committee Meeting minutes and the Pharmacy and Therapeutics Committee Meeting minutes for 2015 and 2016 revealed that pharmacy services had also been routinely reviewed. Additionally a review of documentation from RediAnswer (telemedicine contractor) revealed that physicians providing telemedicine services had been reviewed within the last year.

On 8/02/2016, upon request by the surveyor the facility was unable to provide a copy of a current facility policy/procedure regarding how the facility is to evaluate contracted services. The surveyor was however shown two draft documents; one was a proposed policy (effective date of 8/17/16) entitled: "Contract Service Evaluation." The second draft document entitled: "Contract Services Evaluation" listed: "Pharmacy Services, Laboratory Services, Dietician, Psychologist, and Radiology Services." A column on this form listed specific performance indicators and there were areas for Q1 through Q4 and a comments section. In an interview with staff #12, (Risk Manager/Process Improvement Director) on the morning of 8/03/2016 it was confirmed that the hospital had not evaluated all of the contracted services utilized by the hospital. It was also confirmed in the same interview that the facility currently did not have a policy or procedure in effect regarding evaluation of contracted services.

Based on review of facility records, policies and procedures, and staff interviews, the facility failed to ensure that voluntary and involuntary patients were made aware of their rights. The facility failed to ensure medication consents were obtained by the patient or legally authorized representative for each individual medication prior to the administration of the medication. This could have resulted in potential patient harm due to lack of knowledge of harmful side effects of the medications to report to nursing staff. The facility failed to ensure patients were monitored at the level of monitoring specifically ordered by the physician in the medical record. This could have resulted in a potentially unsafe care setting for patients. The facility also failed to ensure patients were not secluded without physician orders. The facility failed to conduct the required face to face evaluation of a patient that had been secluded within an hour.

Cross refer to:
A0117, CFR 482.13(a)(1) Patient Rights: Notice of Rights
A0131, CFR 482.13(b)(2) Patient Rights: Informed Consent
A0144, CFR 482.13(c)(2) Patient Rights: Care in Safe Setting
A0168, CFR 482.13(e)(5) Patient Rights: Restraint or Seclusion
A0178, CFR 482.13(e)(12) Patient Rights: Restraint or Seclusion

Based on documentation review and interview, the facility failed to ensure that voluntary and involuntary patients were made aware of their rights.

Findings included:

Review of the medical record reflected patient #19 was admitted on 6/12/16 as a transfer from a local acute hospital psychiatric emergency department. The admitting orders dated 6/12/16 at 2025 reflected admission type was POEC (Protective Order of Emergency Custody). The medical record of patient #19 did not contain the POEC document for patient #19. The following admission forms dated 6/12/16 were filled out with "pt on poec" and were not signed by patient #19 including Acknowledgement of Involuntary Status, Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives. The record reflected that patient #19 signed the Application for Admission and Consent for Treatment form requesting admission on a voluntary basis on 6/14/16 at 0900. The record did not contain Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives signed by patient #19 after requesting admission on a voluntary basis. In an interview with the quality assurance director, staff #12 on 8/3/16 at approximately 10:00 am in the conference room, staff #12 stated that the POEC for patient #19 was not in the medical record and was not found in the facility. Staff #12 also agreed the above listed patient admission forms were not signed by patient #19 after requesting admission on a voluntary basis.

Review of the medical record reflected that Patient #17 was admitted on 7/30/16 "on poec" (Protective Order of Emergency Custody). The medical record of patient #17 did not contain the POEC document for patient #17. The following admission forms dated 7/30/16 were filled out with "on poec" and were not signed by patient #17 including Acknowledgement of Involuntary Status, Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives. The record reflected that patient #17 signed the Application for Admission and Consent for Treatment form requesting admission on a voluntary basis on 8/1/16. The record did not contain Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient ' s Bill of Rights, and Patient Information: Consent and Advanced Directives signed by patient #17 after requesting admission on a voluntary basis. In an interview with staff #14 on 8/3/16 at approximately 3:15 pm in the office, staff #14 stated that the POEC for patient #17 was not in the medical record and was not found in the facility. Staff #14 also agreed the above listed patient admission forms were not signed by patient #17 after requesting admission on a voluntary basis.

Review of the medical record reflected that Patient #12 was admitted on 7/16/16 "on poec" (Protective Order of Emergency Custody). The following admission forms dated 7/16/16 were filled out with "on poec" and were not signed by patient #12 including Acknowledgement of Involuntary Status, Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives. The record reflected that patient #12 did not sign an Application for Admission and Consent for Treatment form requesting admission on a voluntary basis. The record did not contain Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives signed by patient #12 after the emergency detention expired (48 hours). In an interview with the staff #14 on 8/3/16 at approximately 3:15 pm in the office, staff #14 stated the above listed patient admission forms were not signed by patient #14 and she was held at the facility after the emergency detention expired without a court order or signing in voluntarily.

Facility policy, "Right of Involuntary Patients" policy number RI-20 stated, in part, Austin Oaks Hospital accepts involuntary patients after receiving the appropriate legal documents from a Texas Court of Law and observes all rights afforded to the patients as delineated in the Patient Rights documents ...1. Patient Rights are explained to all patients at the time of admission, regardless of involuntary status as deemed by a court order or legal document ...3. The explanation of the patient's rights and responsibilities shall be documented.

The above findings were confirmed in an interview with Staff #12 and Staff #14 the afternoon of 8/3/16 in the facility conference room.



20241

Review of the medical record found patient #27 (adult) was admitted to the facility on 07/27/16 with a (Protective Order of Emergency Custody) POEC. The admitting orders were dated 07/27/16 with a time of 2145 and the type of admission as a POEC. The following admission forms dated 7/27/16 were filled out with "pt refused on poec" and were not signed by patient #27 including Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives. The record reflected that patient #27 signed the Application for Admission and Consent for Treatment form with the request to be admitted as a voluntary patient on 7/29/16 at 1340. The record did not contain the following forms of Conditions of Admission, Financial Consent, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives signed by patient #27 after the request to be admitted on a voluntary basis.

Review of the medical record found patient #28 (adult) was admitted to the facility on 07/24/16 with a (Protective Order of Emergency Custody) POEC. The admitting orders were dated 07/24/16 with a time of 2150 and the type of admission as a POEC. The following admission forms dated 7/24/16 were filled out with "on poec" and were not signed by patient #28 including Patient's Bill of Rights and Patient Information: Consent and Advanced Directives. The record reflected that patient #28 signed the Application for Admission and Consent for Treatment form with the request to be admitted as a voluntary patient on 7/26/16 at 1340. The record did not contain the forms of Patient's Bill of Rights, and Patient Information: Consent and Advanced Directives signed by patient #28 after the request to be admitted on a voluntary basis.

In an interview with registered nurse, staff #38 on 8/3/16 at approximately 10:30 am in the adult nursing station, staff #38 agreed the above listed patient admission forms were not signed by patients #27 and #28 after the request to be admitted on a voluntary basis.

Review of the medical record found patient #29 (adolescent) was admitted to the facility on 07/28/16 with a (Protective Order of Emergency Custody) POEC. The admitting orders were dated 07/28/16 with a time of 1753 and the type of admission as a POEC. The following admission forms dated 7/28/16 were filled out with "Pt on poec" and were not signed by patient #29's "parent/legally authorized representative" including Acknowledgement of Involuntary Status, Conditions of Admission, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, Disclosure Statement. The record did not reflect that patient #29's "parent/legally authorized representative" signed the Application for Admission and Consent for Treatment form with a request that patient #29 be admitted as a voluntary patient. The record did not contain Conditions of Admission, Receipt of Notice of Privacy Practices, Admission Education, Notice of Seclusion and Restraint, Patient's Bill of Rights, Disclosure Statement signed by patient #29's "parent/legally authorized representative" after the emergency detention expired (48 hours).

In an interview with the Quality Assurance Director, staff #12 on 8/3/16 at approximately 10:10 am in the adolescent nursing station, staff #12 agreed the above listed patient admission forms were not signed by patient #29's "parent/legally authorized representative" and that she was held at the facility after the emergency detention expired without a court order or signing in voluntarily.

Based on a review of facility records, policies and procedures, and staff interviews, the facility failed to ensure that medication consent was obtained by the patient or legally authorized representative for each individual medication prior to administration of the medication. Medication consents were signed indicating class of medication and not for each individual medication.

Findings included:

Facility policy, "Consent for Psychotropic Medication" policy number RI-27 stated, in part, "3. prior to the administration of the medication, the specific consent for psychotropic medication for must be signed by the patient or LAR. Easy psychotropic medication requires a separate authorization form ...5. The nurse much check the medication consent forms prior to first administration to ensure consent has been granted prior to administration."

Review of the medical record for Patient #2 revealed that there was no specific medication selection on the medication consent forms signed on 5/20/16, including a consent form for anticonvulsants (medication class) and anti-histamines (medication class). On 5/21/16, Patient #2 signed consent forms for anti-histamines and anti-cholinergic, narcotic analgesics, antipsychotics, and antidepressants: SSRI - SSNRI (medication class).

Review of the medical record for Patient #19 revealed that he signed consent forms on 6/13/16 for "antipsychotics" (medication class). On 6/16/16, Patient #19 signed consent forms for antipsychotics, anti-anxiety-Benzodiazepines, and Anti-histamines and anti-cholinergic medications, by medication class.

Review of the medical record for Patient #18 revealed that medication consent forms were signed for the following class of medications on 5/13/16: Antidepressants: SSRI - SSNRI, Antipsychotics.

Review of the medical record for Patient #12 revealed that medication consents were signed for the following class of medications on 7/20/16: Anti-anxiety - benzodiazepines.

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Review of the record for Patient #17 revealed that the following medication was administered before obtaining informed consent:
Vistaril was administered on 7/30/16 at 1025; consent form was not signed until 7/30/16 at 2155.

Review of the record for Patient #11 revealed that the following medications were administered before obtaining informed consent:
Prazosin was administered for nightmares on 7/20/16 at 2350; consent form was not signed until 7/21/16 at 0030.
Risperidone was administered for psychosis on 7/20/16 at 2350; consent form was not signed until 7/21/16 at 0030.
Trazadone was administered for insomnia on 7/20/16 at 2350; consent form was not signed until 7/23/16 at 1320.

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on a review of records, and staff interview, the facility failed to ensure that patients were monitored at the level of monitoring specified in the medical record and ordered by the physician.

Findings included:

Review of the medical record and Patient Observation/MHT Progress Note for Patient #16 revealed that on 7/27/16 Patient #16 was on Q15 minute monitoring for "Suicide" and "Self Harm". There was no documentation of the time, location, behaviors or initial for 0130 or 0700 for Patient #16 during those times. In addition, on 8/2/16, there was no documentation of monitoring at 0700 for Q 15 minute monitoring.

Review of the medical record and Patient Observation/MHT Progress Note for Patient #12 revealed that the monitoring level (Q15, 1:1, or other) was left blank. In addition, there was no date on the form to indicate the date the patient was being monitored at an undetermined level. There was no indication of the precaution type for Patient #12.
On 7/19/16, there was no monitoring level (Q15, 1:1, or other) for Patient #12 to indicate the level of need to monitor Patient #12. This presents a risk that the patient may not be monitored as ordered for patient safety.

Facility policy, "Patient Observation Levels" policy number PC-S-9 stated, in part, "1. Routine Observation ...d. Staff will document that they observed patient every 15 minutes on the Patient Observation sheet ....2. Special Observation ...b. The level of observation ... must be specified."

Facility policy, "Assignment of Patient Care" policy number NR-6 stated, in part, Registered nurses shall be responsible for the assignment of nursing care according to an assessment of each individual's needs, and for supervision and evaluation of nursing care."

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on review of records and interview, the facility failed to ensure that physician ordered the seclusion of a patient.

Findings included:

Review of the medical record revealed that patient #12 was secluded without an order signed by a physician. Patient #12 was secluded on 7/17/16 at 2123. There was a verbal order documented, however there was no signed order by a physician for this seclusion as of 8/3/16.

Facility policy, "Seclusion and Restraint" policy number PC-C-3 stated, in part, "5. Physician's order - Only a physician member of the facility's medical staff may order restraint or seclusion ...6. If restraint or seclusion was ordered by telephone, the ordering physician must personally sign, time, and date the telephone order within 24 hours of the time the order was originally issued."

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on review of documentation and interview, the facility failed to conduct a face to face evaluation of a patient that had been secluded within an hour.

Findings included:

Review of the medical record revealed that Patient #12 was released from seclusion at 2132 on 7/17/16. The Restraint/Seclusion/Emergency Medication Order form stated "7. Post intervention Evaluation (to be completed by QRN within 1 hour of initiation of intervention):". The post intervention evaluation was completed on 7/18/16 at 0800, greater than 10 hours after the release of the patient from the intervention. There was a handwritten note on the form which stated, "QRN review completed at 0800 due to there being no QRN (qualified registered nurse) on staff overnight."

Facility policy, "Seclusion and Restraint" policy number PC-C-3 stated, in part, "Face-to-face evaluation. 1. A physician, Licensed Independent Practitioner or RN trained in face-to-face evaluation, must conduct a fact-to-face evaluation of the individual following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion and to approve its continuation, if indicated. 2. The face to face evaluation must be conducted within one hour following the initiation of restraint or seclusion. 3. The face to face evaluation is performed even in those situations where the person is released prior to the one hour point."

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on review of facility records, policies and procedures and staff interviews the facility failed to supply adequate numbers of licensed nurses and other personnel to provide nursing care to all patients as needed per the nurse staffing plan. In addition the facility failed to ensure that patients were assessed by a registered nurse for abnormal vital signs.

Cross refer to:
A0392, CFR 482.23(b) Staffing and Delivery of Care
A0395, CFR 482.23(b)(3) RN supervision of Nursing Care

Based on review of documentation and interview, the nursing service did not supply adequate number of licensed registered nurses and other personnel to provide nursing care to all patients as needed and per the nurse staffing plan.

Findings included:

Facility policy, "Nurse Staffing Plan and Mandatory Overtime" policy number NR-9 stated, in part, "Determining the appropriate staffing mix is the responsibility of the Director of Nursing, The Assistant Director of Nursing, and the Nurse Supervisors."

Facility policy, "Assignment of Patient Care" policy number NR-6 stated, in part, "Monitoring of staffing and unit acuity levels ensures the safety of patients and staff through the monitoring of the environment of care of the units. Registered nurses shall be responsible for the assignment of nursing care according to an assessment of each individual's needs, and for supervision and evaluation of nursing care."

Facility policy, "Patient Observation Rounds" policy number PC-S-3 stated, in part, "2. Staff Roles and Responsibilities a. Charge Nurse 1) Assigns responsibility for completion of patient observation rounds at the beginning of each shift. 2) Documents the assignments on the unit staff assignment sheet."

Facility policy, "Nurse Staffing" policy number NR-7 stated, in part, "Nurse Staffing Committee, shall be in place in order to ensure that a staffing plan providing adequate number and skill mix of nurses is available to meet the Hospital's patient care needs."

A review of census and staffing sheets and staffing grid for the Adult Unit revealed the following shifts that were staffed below the minimum staffing standard established by the facility:
5/2/16, census of 24 patients on 3-11, required 3 MHTs, actual 1 MHT
5/22/16, census of 26 patients on 7-3, required 4 MHTs, actual 3 MHTs.
5/22/16, census of 30 patients on 3-11, required 4 MHTs, actual 2 MHTs.
5/22/16, census of 30 patients on 11-7, required 2 MHTs, actual 1 MHT.
7/11/16, census of 34 patients on 7-3, required 4 MHTs, actual 3 MHTs.
7/11/16, census of 31 patients on 11-7, required 2 MHTs, actual 1 MHT.
7/18/16, census of 32 patients on 7-3, required 3 nurses, actual 2 nurses.
7/18/16, census of 28 patients and one 1:1 on 3-11, required 4 + 1 MHT, actual 4 MHTs.
7/24/16, census of 31 patients on 7-3, required 4 MHTs, actual 3 MHTs.
7/24/16, census of 32 patients on 11-7, required 2 MHTs, actual 1 MHT.
7/31/16, census of 31 patients on 11-7, required 2 MHTS, actual 1 MHT.


A review of census and staffing sheets and staffing grid for the Child/Adolescent Unit revealed the following shifts that were staffed below the minimum staffing standard established by the facility:
5/22/16, census of 26 patients on 7-3, required 4 MHTs, actual 3 MHTs.
5/22/16, census of 26 patients on 3-11, required 4 MHTs, actual 3 MHTs.
7/27/16, census of 19 patients on 7-3, required 2 nurses, actual 1 nurse.

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on review of records and staff interviews, the facility failed to ensure that patients were assessed by an RN as there were abnormal vital signs documented on patients with no documentation that the patients were assessed for the vital signs, the facility failed to ensure that patients were monitored at the level of monitoring specified in the medical record, and the facility failed to ensure that a debriefing was conducted or attempted for a patient that had been secluded.

Findings included:

Review of the "Austin Oaks Hospital Vital Signs Flow Sheet" revealed abnormal vital signs parameters, including the following:
Adult
Blood pressure: <90 / 50 or > 140/90
Pulse: < 60bpm or >100bpm
Respiration: <12 or >20
Temperature: <96.8 or >98.6
Pulse Oximeter/PO%: <95%

Adolescent
Blood pressure: <110 / 65 or < 135/85
Pulse: <60 bpm or > 90 bpm
Respiration: < 12 or >18
Temperature: <97.4 or > 99.6
Pulse Oximeter/PO%: <96%
The form stated, "**NOTIFY RN IMMEDIATELY if any vital sign falls outside the above parameters**"

Review of the patient medical records revealed the following:

Patient #20 (adult): pulse was 56 on 4/15/16. There was no documented evidence in the medical record that the abnormal result was reported or assessed.

Patient #16 (adolescent): pulse was 95 on 7/28/16. Blood pressure was 105/59 on 7/28/16, 100/50 on 7/29/16, 95/51 on 7/30/16. Pulse Ox was 95% on 7/29/16, 93% on 8/2/16. There was no documented evidence in the medical record that the abnormal results were reported or assessed.

Patient #17 (adult): pulse was 115 on 8/2/16. Blood pressure was 153/70 on 8/1/16. There was no documented evidence in the medical record that the abnormal results were reported or assessed.

Patient #11 (adult): pulse was 114 on 7/27/16. Pulse Ox was 85% on 7/22/16. There was no documented evidence in the medical record that the abnormal result was reported or assessed.

Patient #18 (adolescent): Temperature was 97.0 on 5/18/16. Pulse was 120 on 5/17/16. Blood pressure was 106/18 on 5/20/16, which would present a medical emergency. There was no documented evidence in the medical record that the abnormal results were reported or assessed.

Patient #12 (adolescent): Temperature was 97.3 on 7/25/16. Pulse was 107 on 7/20/16. There was no documented evidence in the medical record that the abnormal results were reported or assessed.

Facility policy, "Patient Observation Levels" policy number PC-S-9 stated, in part, "1. Routine Observation ...d. Staff will document that they observed patient every 15 minutes on the Patient Observation sheet ....2. Special Observation ...b. The level of observation ... must be specified."

Review of the medical record and Patient Observation/MHT Progress Note for Patient #16 revealed that on 7/27/16 Patient #16 was on Q15 minute monitoring for "Suicide" and "Self Harm". There was no documentation of the time, location, behaviors or initial for 0130 or 0700 for Patient #16 during those times. In addition, on 8/2/16, there was no documentation of monitoring at 0700 for Q 15 minute monitoring.

Review of the medical record and Patient Observation/MHT Progress Note for Patient #12 revealed that the monitoring level (Q15, 1:1, or other) was left blank. In addition, there was no date on the form to indicate the date the patient was being monitored at an undetermined level. There was no indication of the precaution type for Patient #12.
On 7/19/16, there was no monitoring level (Q15, 1:1, or other) for Patient #12 to indicate the level of need to monitor Patient #12. This presents a risk that the patient may not be monitored as ordered for patient safety.

Facility policy, "Assignment of Patient Care" policy number NR-6 stated, in part, Registered nurses shall be responsible for the assignment of nursing care according to an assessment of each individual's needs, and for supervision and evaluation of nursing care."

Review of the medical record of Patient #12 revealed that she was secluded on 7/17/16 at 2123 and released at 2132. Review of the Restraint/Seclusion/Emergency Medication Order form revealed the following, "6. Patient Debriefing (To be completed after intervention when patient calmed but no later than 24 hours)" On 7/18/16 at 0800, the RN documented that "pt still sleeping". There was no documentation of an attempt to conduct a debriefing of the patient, as the staff merely noted that the patient was sleeping. There was no documented evidence of another attempt to debrief the patient in the 24 hours following the seclusion.

Facility policy, "Seclusion and Restraint" policy number PC-C-3 stated, in part, "Debriefing 1. With patient - As soon as possible after an episode of restraint or seclusion, available staff members involved in the episode, supervisory staff, the individual, the LAR, and, (with the consent the individual) family members must meet to discuss the episode."

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.

Based on observation, review of documentation and interviews with facility staff, the facility failed to provide laboratory services in accordance with facility policy and manufacturer's recommendations as a glucometer case found in the outpatient nurse's area contained expired test strips and quality control procedures were not being performed on the glucometer. This potentially could have resulted in erroneous blood glucose results.

The findings were:

The facility policy entitled "Glucometer" #WT-3 with a review date 3/29/16 reflected in part "1. Quality control procedure shall be conducted to ensure the instrument is operating properly and that the values are accurate as follows: a. once per day when in use for diabetic patients; b. each time a new vial of test strips is opened; c. when test results contradict clinical systems; d. when monitor has been dropped; e. if test strips have been exposed to extreme heat, cold or humidity. 2. Additional equipment: True Balance Glucose Monitor; True Balance Glucose Test Strips; Level I and Level II Control Solutions ...3.a. Control Testing ...13. Record the result in on (sic) the Glucometer Control Test Log. b. Validation Testing 1. Between the 1st and 15th of each month a patient who is having blood drawn that includes glucose will be identified. At the same time this patient's specimen will be designated for validation testing using the same blood sample ...3. Document results on Blood Glucose Control Log under Validation Testing."

The True Balance Owner's Booklet found in the outpatient glucometer case reflected in part "Control tests should be performed: For practice to ensure your testing technique is good; Occasionally as you use the vial of strips."

During a tour of the facility on the morning of 8/1/16, a True Balance glucometer was observed in the outpatient nurse's cubicle in a case with a partially used bottle of 50 True Balance test strips which were expired 3/15. In an interview with the outpatient nurse, staff #7 during the tour on 8/1/16 at approximately 11:10 am, staff #7 was asked if quality control procedures were being performed on the glucometer. Staff #7 stated she was unable to find control solution for the glucometer or any documentation that quality control procedures had been performed on the glucometer.

Based on observation and interviews with the dietary director the dietary department failed to maintain a safe environment. One staff was observed preparing food without gloves. Clean food containers and utensils were observed in contact with dirty utensils. Buildup of black brown greasy substance was observed on several shelves and pans.

Findings were:

During a tour of the dietary department on the morning of 8/1/2016 accompanied by staff # 18 dietary director the following was observed;
1. Brown blackish greasy substance was observed on the shelves inside food warmer, oven, and the bottom of sheet pans. Multiple horizontal surfaces were greasy to touch.
2. Dietary worker was observed chopping food without gloves.
3. Small skillet with black peeling nonstick finish was observed on the shelf.
4. 2 Boost Glucose Control drink boxes were found in the dry storage room with an expiration date of 5/23/16.
In an interview with Staff #18 dietary director on the morning of 8/1/16 during the tour staff #18 acknowledged the finding above.

Based on observation and interviews with facility staff, the facility failed to ensure that the facility and equipment are maintained at an acceptable level of safety and quality. These findings could potentially result in the equipment not working properly when used.

The findings were:

During a tour of the facility on the morning of 8/1/16 with the Director of Environmental Services (Staff #36) it was observed that there was water/condensation in the overhead florescent light fixture in the linen room on Unit B. This light fixture was adjacent to the ceiling mounted air conditioning vent.

In an interview with Staff #36 on the morning of 8/1/16, Staff #36 acknowledged the finding above.

During the tour of the water room on the morning of 8/2/16 with Staff #36, it was observed that the brine tank was filled with approximately 12 inches of clear liquid and no visible salt or salt pellets.

The surveyor requested documentation for when the brine tank was last checked and refilled from Staff #36. Staff #36 stated, "I don't have one. I don't remember when it was last refilled." Staff #36 was further asked, "Who is responsible for refilling the brine tank." Staff #36 responded, "I am."

The manufacturer's "Installation, Operating and Service Instructions," for the water softener states, "Fill the salt storage container ... Note: The salt level must be checked frequently to the brine tank, the control valve must be manually cycled to the fast rinse/brine refill cycle to create the required amount of brine for the unit's first regeneration ... A water softener in daily use on a potable water supply generally requires no special attention other than keeping the salt tank filled."

In an interview with Staff #36 on the morning of 8/2/16, Staff #36 acknowledged the finding above.



29934

During a tour of the facility on the morning of 8/1/16, the emergency equipment case located in the Unit B nursing station was observed to contain a "Just in Case" cold compress instant cold pack with an expiration date 8/15. The "Nursing Daily Equipment Checklist" for July 2016 located in the Unit B nursing station reflected the emergency equipment had not been checked on 7/12/16, 7/13/16, 7/14/16, 7/27/16, 7/29/16, 7/30/16, and 7/31/16. In an interview with the environmental services director, staff #36 during the tour on 8/1/16 at approximately 10:25 am, staff #36 agreed that the cold pack was expired and that the emergency equipment had not been checked on the dates noted above.

The facility policy entitled "Emergency Equipment Checklist" #NR-15 with a review date of 3/29/16 reflected in part "Daily Equipment Check. 1. Emergency supplies, including the AED, Oxygen tank and emergency medication box must be checked daily by a nurse or supervisor and documented on a checklist ...b. The CNO/DON should audit the checklist a minimum of two times per month for verification, completeness and follow-up actions ...3. Check daily to ensure the emergency equipment is ready for use: a. Emergency Supplies are in date."

Based on observation, review of documentation and interview it was determined that the facility failed to ensure that housekeeping services were adequately maintained in patient care areas thus increasing the possibility of infection transmission.

Findings were:

Housekeeping services were not adequately maintained in patient care areas.
1.) During a tour of the facility on the morning of 8/01/2016 in the patient admission screening area, a brown paper bag containing "Thermoscan" ear probes was found stored in an undersink area.

From American Journal of Infection Control, Volume 28, Number 2, April 2000, APIC State-of-the-Art Report: The role of infection control during construction in health care facilities: "Cabinets: Areas beneath sinks should not be considered storage areas due to proximity to sanitary sewer connections and risk of leaks or water damage. Clean or sterile patient items should be not be placed beneath sanitary sewer pipe connections or stored with soiled items; cleaning materials are the only items acceptable to be stored under sinks, from a regulatory aspect." In an interview with the Director of Nursing on the morning of 8/01/2016 it was confirmed that the "Thermoscan" ear probes were found in the undersink area.

2.) During a tour on the adolescent unit at approximately 10:15am, the seclusion room bathroom toilet (used by patients) was observed to have not been flushed; as the water in the toilet bowl was yellowish in color suggesting it had been urinated in, additionally the floor area directly in front of the toilet was wet in appearance. In seclusion room B (adjacent to the seclusion room bathroom) a fitted sheet was found on top of the mattress in a jumbled, disorganized manner suggesting that the seclusion room had not been cleaned after recent use by a patient.

Review of facility policy and procedure ICPOL 308, (effective date of June 10, 2013) entitled: "Cleaning of Seclusion Room" stated under the procedure section: "A. After each use of the seclusion room, the charge nurse shall notify Housekeeping to clean the room. " The policy also stated: "B. After each use of the floor mat, the charge nurse shall notify Housekeeping to clean and disinfect the mat. C. If Housekeeping is not available, the charge nurse is to assign nursing staff to clean and disinfect the floor and surrounding floor, walls and door as necessary." Review of facility policy and procedure ICPOL 107, (effective date of June 1, 2014) entitled: "Blood Borne Pathogen Exposure Control Plan" stated under the item C section: "Cleaning of Blood and Body Fluid Spills" that: "2. All spills of blood and body fluids are to cleaned up IMMEDIATELY." Section E of the policy stated: "Environmental Services 1. The worksite will be maintained in a clean and sanitary condition."

3.) In the patient snack room on Unit C, one of the two ceiling mounted air conditioning vents was observed to have a noticeable amount of dust on it. Review of facility policy and procedure ICPOL 317, (effective date of June 10, 2013) entitled: "Housekeeping Cleaning Occupied Room and Bath" stated under the procedure section: "3. Clean door and vents with cloth that has been dampened with an approved germicidal solution."

4.) During a tour of the Unit B laundry room on 8/01/2016 at approximately 10:30am it was observed that the "Washer & Dryer Disinfection Schedule" which was found in the laundry room been last filled out for 7/15/2016. An examination of the washer and dryer revealed damp laundry in the washing machine and dry laundry in the dryer.

A review of facility policy ICPOL 209.0 (effective date of June 1, 2014), entitled: "Routine Laundering of Patients Clothes" stated under the procedure section: "Environment of Care will ensure that the washer and dryer areas and the external and internal machines will be cleaned by Environment of Care Staff." In an interview with staff #36 (Director of Environmental Services)the facility safety officer on the morning of 8/01/2016, findings #2, #3 and #4 were confirmed.

Based on record review and staff interview, the facility failed to ensure a patient was discharged or a court order was obtained after a patient was eligible for discharge.

Findings included:

Review of the medical record revealed that patient #12 was admitted on an emergency detention on 7/16/16 at 2353. Patient #12 was not discharged until 7/26/16, yet there were no other involuntary orders received and Patient #12 did not sign a consent to voluntary treatment. Patient #12 was held for at least 7 days after being eligible for discharge without signing a voluntary treatment consent or obtaining a court order for protective custody.

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.



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Review of the medical record revealed that patient #3 (adolescent) was admitted on an (Protective Order of Emergency Custody) POEC on 7/25/16 at 0715. Patient #3 remained an inpatient in the facility during the survey on 08/03/16 at approximately 10:00 am yet there were no other involuntary orders received and patient #3's "parent/legally authorized representative" did not sign a consent to voluntary treatment. Patient #3 was held for at least 9 days after being eligible for discharge without signing a voluntary treatment consent or obtaining a court order for protective custody.

Review of the medical record revealed that patient #29 (adolescent) was admitted on an (Protective Order of Emergency Custody) POEC on 7/28/16 at 1715. Patient #29 remained an inpatient in the facility during the survey on 08/03/16 at approximately 10:15 am yet there were no other involuntary orders received and patient #29's "parent/legally authorized representative" did not sign a consent to voluntary treatment. Patient #29 was held for at least 7 days after being eligible for discharge without signing a voluntary treatment consent or obtaining a court order for protective custody.

The above findings were confirmed in staff interviews the morning of 8/3/16 in the adolescent nursing station with the Quality Assurance Director, Staff #12 and the Chief Operating Officer, Staff #37.

Based on record review and interviews, the facility failed to ensure that a neurological examination or screening was conducted on patients at the time of the admission physical examination.

Findings included:

The facility policy entitled, "History and Physical Examination" Policy PC-A-3 stated, in part, "The H&P, shall include the following elements: ...h. Neurological exam (adults only)."

Review of the medical record for patient #17 revealed that the History and Physical Examination conducted on 7/31/16 did not include an examination of cranial nerves; the space for "Examination of Cranial Nerves" was left blank.

Review of the medical record for patient #8 revealed that the History and Physical Examination conducted on 7/31/16 did not include an examination of cranial nerves; the space for "Examination of Cranial Nerves" was left blank.

Review of the medical record for patient #11 revealed that the History and Physical Examination conducted on 7/21/16 did not include an examination of cranial nerves; the space for "Examination of Cranial Nerves" was left blank. There was a handwritten note stated, "needs further assessment on 7/22/16" however there was no documented evidence in the medical record of an examination of cranial nerves.

Review of the medical record for patient #12 revealed that the History and Physical Examination conducted on 7/17/16 did not include an examination of cranial nerves; the space for "Examination of Cranial Nerves" was left blank. There was a handwritten note stated, "needs further assessment on 7/18/16" however there was no documented evidence in the medical record of an examination of cranial nerves.

The above findings were confirmed in an interview the afternoon of 8/3/16 in the office with Staff #14.