HospitalInspections.org

Based on review, observation, and interviews the Governing Body failed to:

A. develop and implement appropriate plan to keep patients safe in an environment with known, identified ligature risks and other safety hazards. Patients were allowed to be in areas of the geriatric unit that had identified ligature attach points and other hazards for up to 30 minutes at a time without staff supervision. This provided patient with enough time to harm themselves and/or others without staff present to intervene. Items were identified in the environment that could be used by a violent or aggressive patient as a weapon to attack other patients or staff.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-refer to Tag A0115


B. provide a sanitary environment in 6 (Laboratory, Central Supply, Laundry, Geriatric unit, Unit 7A/B, and Administration building entrance) of 9 areas (dietary, radiology, and sterile processing) of the hospital for 6 months January 2019 through June 13, 2019.

Cross-refer to Tag A0747


C. ensure funding was provided to demolish decayed and structurally unsound buildings on campus.


D. Prevent the possible spread of waterborne and insect diseases from standing water in decayed buildings.


E. Protect the patients and visitors from possible harm from falling buildings, asbestos debris, and wild animals living in vacant buildings in 4 (#517, 519, 520, and 522) of 4 buildings observed.


Findings for C, D, and E, were as follows:

During a pre-survey investigation of the facility, a video was found of abandoned and decayed buildings on social media. The video revealed bathtubs full of murky water and standing water on the floors of the building. On 6-10-19 in the afternoon, an interview was conducted with Staff #1 and #7. Staff #1 and #7 confirmed that there had been some trespassing on the grounds. Staff #7 confirmed multiple buildings were vacant and in disrepair.

During a tour of the facility grounds on 6-11-19 revealed multiple buildings were found in decaying and structurally unsound condition. Building 519 was located on the path between the adolescent unit (718) and the onsite school (682) the children attend. A red, mesh, plastic fence approximately 3 ft tall was around the building. Adult patients can have passes to walk around the grounds. There is nothing to prevent patients from touching the buildings or from entering the porches, stairs, or balcony of the structure.

Building 519 was found to be a two-story brick and masonry building. Staff #7 confirmed it was 18,795 square feet and was built in 1932. The building was overgrown with foliage that was on the outside of the building and growing on the inside. The roof has caved in in multiple sections causing the plaster walls, flooring, and windows in disrepair. Multiple windows were broken. The flooring was unsound and buckled on the second floor. There were bath tubs and commodes full of green contaminated water. Mosquito larva was seen in the water. There was animal infestation noted from feces and torn materials for rat's nest. Staff #7 confirmed there was an ongoing animal infestation of rats, raccoons, vultures, opossums and various other wildlife living in and around the buildings. Staff #7 had made multiple attempts to contain the wild life with no avail. On the second floor, the ceiling water pipes were growing stalactites and stalagmites.

Building 520 was sitting in the middle of the grounds. Staff #7 stated at one time it was the administrative offices. The building was 2 -story made of masonry and brick. The building has pier and beam foundations approximately 11,529 square feet. Most of the roof had caved in and the building was exposed to elements, rodents, and animals. The building was not entered by the surveyor or staff due to danger of the unsound structure. Staff #7 confirmed there was sinks and commodes still within the building to harbor insect infestation. The plaster walls, confirmed by staff #7 of having asbestos, were exposed to the elements and was not contained.

Building 517 was found to be a brick multi- floored building overgrown with foliage that was on the outside of the building. The building was constructed in 1938. Staff #7 confirmed the building was unsound and had an infestation of fleas. Staff #7 reported that he had hired exterminators to spray the building multiple times. Staff #7 reported that he had also placed moth balls in the building to help eliminate fleas with no avail. Staff #7 confirmed there were raccoons in the building.

Building 522 was found to be a two-story brick building built in 1934. The building was vacant and decayed. The roof was caving in and the building was covered in green foliage. Staff #7 confirmed this building also held bath tubs, sinks, commodes, and the floors and walls were exposed to nature and elements.

An interview was conducted with Staff #7 on 6-11-19. Staff #7 stated, the building was on a list for demolition for multiple years now but there have been no funds provided for demolition. Staff #7 provided evidence from the HHSC/DSHS Real Property Change Approval/Denial Memo. The memo revealed that building 519 had a proposal for demolition in 2006. Reports from sample analysis revealed the building had lead paint and asbestos content. Staff #7 reported the facility had sent in the Capitol Construction Project request yearly for demolition. Staff #1 confirmed that the buildings had been approved for demolition but there had been no monies allocated.

According to the Occupational Safety and Health Act (OSHA) describes asbestos as:

"What is asbestos?

Asbestos is the generic term for a group of naturally occurring, fibrous minerals with high tensile strength, flexibility, and resistance to heat, chemicals, and electricity.

In the construction industry, asbestos is found in installed products such as sprayed-on fireproofing, pipe insulation, floor tiles, cement pipe and sheet, roofing felts and shingles, ceiling tiles, fire-resistant drywall, drywall joint compounds, and acoustical products. Because very few asbestos containing products are being installed today, most worker exposures occur during the removal of asbestos and the renovation and maintenance of buildings and structures containing asbestos.

What are the dangers of asbestos exposure?

Asbestos fibers enter the body when a person inhales or ingests airborne particles that become embedded in the tissues of the respiratory or digestive systems. Exposure to asbestos can cause disabling or fatal diseases such as asbestosis, an emphysema-like condition; lung cancer; mesothelioma, a cancerous tumor that spreads rapidly in the cells of membranes covering the lungs and body organs; and gastrointestinal cancer. When asbestos products start to deteriorate or are cut, sanded, drilled, become wet or disturbed in any way, microscopic fibers enter the air."

According to the mayoclinic.org/discussion/infectious-diseases-standing-water-and-diseases. Jessica Sheehy, infectious diseases physician assistant at Mayo Clinic Health System in Mankato, says, "Standing flood water can be a breeding ground for mosquitoes, which carry diseases such as West Nile Virus and encephalitis."

According to the Centers for Disease Control and Prevention (CDC), "Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). These mosquitoes bite during the day and night.

Plague

Plague is a disease that affects humans and other mammals. It is caused by the bacterium, Yersinia pestis. Humans usually get plague after being bitten by a rodent flea that is carrying the plague bacterium or by handling an animal infected with plague. Plague is infamous for killing millions of people in Europe during the Middle Ages. Today, modern antibiotics are effective in treating plague. Without prompt treatment, the disease can cause serious illness or death. Presently, human plague infections continue to occur in the western United States.

Rabies

Rabies is a fatal but preventable viral disease. It can spread to people and pets if they are bitten or scratched by a rabid animal. In the United States, rabies is mostly found in wild animals like bats, raccoons, skunks, and foxes. However, in many other countries dogs still carry rabies, and most rabies deaths in people around the world are caused by dog bites.

The rabies virus infects the central nervous system. If a person does not receive the appropriate medical care after a potential rabies exposure, the virus can cause disease in the brain, ultimately resulting in death. Rabies can be prevented by vaccinating pets, staying away from wildlife, and seeking medical care after potential exposures before symptoms start."

Based on interview and record review, the hospital failed to provide a process with written policies and procedures for evaluation, stabilizing treatment, and referral, when appropriate, from October 2018 through June 13, 2019, eight months.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings:

On the morning of 6/11/2019, the area identified by leadership staff as the emergency treatment and admissions area was observed. A room of sufficient size was identified as the triage room. The room contained equipment to obtain vital signs. Staff confirmed they had access to an AED (Automated External Defibrillator).

Staff #6 confirmed the above mentioned room and adjacent area was where after hours psychiatric admissions were admitted, and if any person who was not a staff or patient came for emergency treatment, the area would serve as the emergency treatment room. No other emergency first aide supplies were identified as available.

On the afternoon of 6/13/2019, an interview with the assistant Superintendent confirmed there was no established process, written or understood, to adequately document the evaluation, stabilizing treatment, and discharge/transfer of persons who might come to the hospital seeking emergency treatment. Staff #5 confirmed, there were no policies or procedures for emergency treatment of medical patients.

Further interview revealed, most of the community understood the hospital provided psychiatric services, but several times through the year, someone from the community would come to the hospital for emergency treatment.

A request was made to review the emergency treatment log. Staff 6# confirmed, the facility had not established a treatment log. When asked how they tracked, who and how many persons were treated in their emergency treatment area, they had no way to know. Each record held in the electronic system had to be opened in order to determine the diagnosis and thereby know who was a psychiatric patient versus a patient seen for emergency treatment.

A further investigation revealed, medical records that were generated in the emergency treatment area for medical emergencies were not provided to the medical records department and kept under the same security as medical records for psychiatric admissions patients.

A review of medical record for two (2) patients from the community who came to the hospital for emergency evaluation were reviewed.


Patient #10, was a 62 year old female, who came to the Hospital emergency area on 11/7/2018. The Psychiatrist on call documented his evaluation on the hospitals approved Psychiatric intake form. The Psychiatrist evaluated the patients strengths and weaknesses and screened her social issues and functional rehabilitation. The Documentation further recorded, "Medical screening complete", "Disposition: Medical condition exist. Possible right arm fracture". The Psychiatrist further documented the action taken to stabilize and transfer individual: Husband will take her to a general hospital", "Husband will take her to _______Hospital".

The Psychiatrist documented meds entered on pre-admit meds form. The patient was not admitted therefore no medications were recorded. No medical history was taken other than the patient's Chief Complaint of "I fell down and I am afraid of having a fracture". Her vitals signs were recorded as, "Blood pressure 171/95, temperature 98.2, pulse rate 110 and respiratory rate of 18. She denied any pain over her right arm. We provided the nearby hospital as Sunnyvale medical center, but they stated they would go to another hospital".

A review of the nurse (unknown as to licensed vocational or registered nurse), provided the following account, "Client arrived with her husband. They went to administration building with complains (sic) of arm pain. Security escorted her to admissions. She initially didn't want to come in. She came in with her husband. She reported she fell over a bucket and landed on her Right arm. She is moving the arm all around while talking. She was more afraid of being kept here. She was reassured we were just checking on her. No swelling observed. Vitals signs 171/95, P-110, R-18, T-98.2. She report a pain scale at 7. She was laughing but husband getting frustrated with her. They were given print out to Sunnyvale hospital. Husband reported they might go to another acute care facility. No acute distress. Dr. on site and spoke with them.


Patient #11, was "a 47 year old female who walked into the clinic, (emergency treatment area", around 3:40 p.m. with complaint of left facial numbness from this morning. She believes she is having a stroke and is here for imaging. She woke up this morning with numbness of the left of the face with no weakness or slurred speech or swallowing difficulties. She went to see her primary care physician for this and he has recommended her to go to the emergency room for imaging and further evaluation of this. So, she came here thinking this is a medical hospital to get help accompanied by her son. She has no medical problems, except for hyperlipidemia. Her family history is significant for her grandmother having a stroke in her 70's. She had no surgeries in the past. On exam her vitals while she was here were temperature of 97.1, blood pressure 156/86, heart rate 84, saturation 99% on room air.

Middle-aged woman seated on exam table in no distress. She walked into the clinic with stable gait and complained of only numbness of the left side of the face. Her gait was normal. Motor strength was intact. She denied any facial muscle weakness, but complains of feeling different over the left side of her face involving the forehead, eye, cheek, and jaw area...."

The plan included summary of complaint and an "offer to call EMS for her to be taken to the nearest hospital. She declined and wanted to go with her son who drove her here and they left. Date of dictation 12/11/2018."

The patient's record contained no consent to treat forms in their medical record.

Based on review of records, observation, and interview, the facility failed to develop and implement appropriate plan to keep patients safe in an environment with known, identified ligature risks and other safety hazards. Patients were allowed to be in areas of the geriatric unit that had identified ligature attach points and other hazards for up to 30 minutes at a time without staff supervision. This provided patient with enough time to harm themselves and/or others without staff present to intervene. Items were identified in the environment that could be used by a violent or aggressive patient as a weapon to attack other patients or staff.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-refer to Tag A0144

Based on review of records, observation, and interview, the facility failed to develop and implement appropriate plan to keep patients safe in an environment with known, identified ligature risks and other safety hazards. Patients were allowed to be in areas of the geriatric unit that had identified ligature attach points and other hazards for up to 30 minutes at a time without staff supervision. This provided patient with enough time to harm themselves and/or others without staff present to intervene. Items were identified in the environment that could be used by a violent or aggressive patient as a weapon to attack other patients or staff.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings:

On 6-11-2019 at 11:00 AM, an interview was conducted with Staff #7 concerning the annual ligature risk assessment. Staff #7 stated that the assessment had been completed and that plans to mitigate the risks had been implemented while the ligature risks were being corrected. Staff #7 provided a 350-page document that listed each ligature risk identified throughout the entire facility. Staff #7 explained that due to budgeting constraints, the work had been ongoing since fiscal year 2016-2017 with additional funding allocated fiscal year 2018-2019. Staff #7 stated that work proposals were due to go out on July 2, 2019 with contracts to be awarded in September 2019.

Interview was conducted with Staff #45 concerning the annual ligature risk assessment and plan to mitigate the risk of having patients in an environment with known ligature points. Staff #45 stated that high risk patients were placed on a 1:1 (one staff member to one patient) observation. This was based on physician order and based on the suicide risk assessment completed by the nursing staff. During the day time, staff rounded on patients every 30 minutes, unless the patient had been identified as high-risk and had a physician order for increased monitoring.

On the morning of 9-12-2019, a tour of the Geriatric unit was made. A patient was observed to be sitting in a small room at the end of the hallway by himself without staff present to observe him. This room was not visible from the nursing station. The room had a television mounted to the wall and was not protected by any type of covering. This presented a potential ligature point at the wall mounting, with accesses to the power cord. The television had the potential to be removed from the wall and thrown at another patient or staff members. Electrical outlets were not covered with tamper-proof covers, providing a potential hazard for a patient to try to electrocute themselves. Tour of the shower rooms revealed that shower curtains were suspended by tension bars. While the tension bars would not support a patient's weight, the bars could be pulled down by a violent patient and used as a weapon to assault other patients or staff members. Light weight chairs were in use in the day-rooms, bathrooms, and patient rooms. These chairs could be picked up easily and thrown or used to attack another patient or staff.

Interviews with Staff #40 and Staff #41 confirmed that patients who were admitted for suicidal ideation and involuntarily committed because they were a threat of harming themselves were not always placed on a 1:1 observation. Staff #40 and Staff #41 confirmed that patients could potentially be unsupervised for up to 30 minutes in areas with identified ligature risks or other environmental hazards.

Based on record review and interview, the hospital failed to establish a medical record format for non-patient, Emergency treatment and failed to establish and provide a process for safe storage, in a central location, designed to limit access for the Emergency medical record of non-patients from November of 2018 through June 13, 2019.


This deficient practice had the likelihood to effect all patients seeking emergency treatment.


Findings included.


On 6/12/2019 in the office of staff #30, the medical records for two (2) person from the community, who sought emergency treatment at the hospital, and were not patients, were reviewed.


On 6/12/2019 the medical record (MR) for patient #10 and #11 were requested from the medical record department. Staff #30, who was assisting with the electronic medical record review, was told by the Director of the medical records, the department did not have medical records for patients #10 and #11. The department director questioned whether these two patients were ever admitted.

Staff #30 was able to provide both Medical Records, (MR) with difficulty and assistance of multiple nurses. After several phone calls were placed, the medical record for patient #10 and #11 were identified by department nurses who worked in the Emergency treatment/admissions department. The final record was obtained from nurses who were familiar with the patient's visit.

When the electronic location of the medical records were revealed, review proceeded. Each medical record contained a nurses narrative and a physician's evaluation. The physician note varied in each patient with patient #10 having sparse history, no medication information, allergy information or past surgical information and a brief chief complaint. The entirety of the Medical Screening Exam (MSE) was entered into the hospital's psychiatric admission assessment form. The psychiatric questions preprinted on the admission form did not apply to the patient who presented with a medical emergency. The form was completed by the on call psychiatrist. Physician #31 failed to document a thorough medical screening exam.

Physician #32 documented a thorough medical screening exam of patient #11. A full evaluation and discussion of the options that were available at the hospital were documented well. An offer to send the patient via ambulance to a hospital with higher level of care was offered and declined by the patient. However,the hospital did not have a "Left against medical advice " form for the patient to sign. The physician documented she left with her son in a private car.

Neither medical record had been review by the medical records department for completion of the record. The MRs did not contain consent to treat. The entire record consisted of a nursing narrative and a physician's note. The record was not housed for retrieval or safety within the medical records department.


An interview with staff #5 confirmed the patients from the community who came to the hospital for emergency treatment were not billed for services. None of the patients who came for emergency department services were aware the hospital's primary service was for the treatment of psychiatric disorders.

On 6/13/2019 in the conference room, an interview with staff #5 confirmed there was no established format for a MR for a patient seeking emergency medical treatment and that there were no policies, procedures, or plan establish for the storage, and security of medical records for those persons who came to the hospital for emergency treatment of a medical nature.

Based on observation, document review, and interview, the hospital failed to provide a sanitary environment in 6 (Laboratory, Central Supply, Laundry, Geriatric unit, Unit 7A/B, and Administration building entrance) of 9 areas (dietary, radiology, and sterile processing) of the hospital for 6 months January 2019 through June 13, 2019.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings:


On 6/11/2019 during the morning tour of the lab, single use vinyl tourniquets were observed on the blood draw caddie. Staff #20 Confirmed, the tourniquets were wiped with a disposable sanitizing wipe and reused. She further explained, if the patient's skin appeared with open sores or other irritation the tourniquet would be disposed of after use.

Vinyl tourniquets are designated single use items. It was presented to staff #20 if a manufacturer's statement permitting re-use or national standard for re-use could be obtained and provided it would be accepted. No further documentation was provided.


32143

A tour was conducted on 6/11/2019 of the laundry and Central supply are's. The following items were identified:

Laundry

Staff #7 reported, the laundry was sent out to be processed at the state school. Staff #7 stated, the laundry was placed in open carts on the dirty side of the laundry building and loaded into the laundry truck. When clean laundry is brought to the facility, the laundry comes in open carts into the clean side. The laundry was separated and then wrapped with plastic to seal it. The laundry is then placed on covered shelves.

The truck caring the laundry to the state school was the same truck that delivered the clean laundry. The truck had a gate in the back that only closed half way. The inside of the truck was dirty and soiled with dirt and grime. The interior walls of the truck had bare wood. There was two large gaping holes in the front of the truck container allowing wind, dust, dirt to cover the laundry during transportation. The cargo area of the laundry truck had gaping holes in the front that allowed elements in that could contaminate laundry.

Staff #7 confirmed that the same truck transported dirty and clean laundry. Staff #7 was asked how the facility cleaned the inside of the truck before placing clean laundry in. Staff #7 stated, "They say they spray it down with something between deliveries." Staff #7 confirmed the truck was heavily soiled. bare wood was inside the truck and the holes in the front allowed the clean laundry to be exposed to the outside elements.

In the laundry room of the facility there was washing and drying machines for housekeeping items. The floor was flooded with water around the washer. There are no fire sprinklers in the laundry storage area.


Central Supply

Shipping boxes were found in the central supply room next to opened and shelved patient medical supplies.


36827

On 6-11-2019, a tour of the Geriatric unit was made. A shower area was observed. Staff #38 reported that the room had been cleaned and ready for patient use. The shower stall floor was observed to be soiled with a sticky, black substance. The plastic shower mat was draped over the back of the shower chair. The mat was observed to be visibly soiled with what appeared to be mildew. The approximately ¼-inch layer of non-slip surface on the floor was chipping and presented a sharp edge that could trap dirt and mildew. The edge was visibly soiled with what appeared to be mildew. Hardware for handrails and the shower-head were rusted and had build-up of hard water encrusting it. This provided a surface to trap dirt and mildew and could not be properly sanitized. The seat-back for the shower chair was visibly soiled with what appeared to be mildew. The legs of the chair had multiple strands of hair stuck to the rubber feet. The corners of the room were visibly soiled with dirt build-up.

Upon exiting the administration building on 6-11-2019, multiple dead insects were noted by the interior side-light glass panels.

A tour of the shower room was conducted on unit 7A. A plastic chair was observed to be visibly soiled all over (seat, back, and underneath) with what appeared to be mildew.

An interview was conducted with Staff #7 concerning the number of staff available to clean the facility. Staff #7 was asked to provide the number of housekeepers available per square foot, along with the number of housekeepers available to the Geriatric Unit and Units 7A/7B and the square footage they were assigned.

Review of the documents provided showed that the facility has a total of 632,059 square feet with 40 custodians. This was an average of 15,801 square feet to be cleaned by one person. The document showed that 2 housekeepers were responsible for building 679 and Unit 7A/B for a total of 16,900 square feet. Each housekeeper was responsible to keep 8,450 square feet sanitary each day. Two housekeepers were responsible for the Geriatric unit, Building C-2 and 625 for a total of 25,751 square feet. Each housekeeper was responsible for keeping 12,875 square feet sanitary each day. Staff #7 stated that staffing studies based on current industry standards with justification and requests for additional housekeeping staff had been submitted and denied.

Based on interview and record review, there was no defined timeline for notification of Organ Procurement Organization (OPO) and 1 (Staff # 3) out of 2 staff interviewed were unaware of the process.

Interview with staff#3 revealed the attending physician was to make the notifications to the OPO. When asked when the physician must notify the OPO, she stated "she did not know how long the physician had to notify." Interview with the Staff # 6 revealed there was a process to be followed and a check list staff must complete with notification of OPO on the checklist. However, there were no time frames listed for notification in either document. A second interview with Staff #3 revealed staff had not been trained on this process.

Review of the Organ Procurement Organization Agreement states "The OPO will be notified when death is imminent or immediately upon cardiac death." Review of the Policy 4-81 showed that the Attending Physician will notify the OPO, however no time frame is given for when the physician is notifying the OPO. Review of the Policy 4-39 "Procedures in the Event of Death," also outlined the notification of the OPO, and no timelines for notification were listed.

Based on interview and record review, staff had not been educated on the Organ Procurement Organization (OPO) or the policies associated with, and 2 (Staff # 3 and Staff #6) out of 2 staff interviewed were aware that no education had been conducted.
Interview with Staff #3 revealed staff had not been trained on this process or the OPO. Interview with Staff #6 revealed she was unaware of any ongoing education with the staff regarding the OPO and associated policies.
Review of personnel files revealed no training on the OPO had been done with staff.