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Tag No.: A0093
Based on record review and interview, the hospital's Governing Body failed to ensure the medical staff had written policies and procedures for appraisal of any/all medical emergencies, initial treatment, and referral when appropriate since the hospital did not have a dedicated Emergency Department.
Findings:
Review of hospital policies and procedures provided by S2DON as current, revealed current policies pertained to inpatients. Further review revealed no policy & procedure for appraisal of emergencies, initial treatment, and transfer as appropriate for any emergency in the hospital that included persons not a current patient.
Review of the Medical Staff Bylaws and Rules and Regulations, provided by hospital staff as current, revealed no documentation referring to the appraisal for medical emergencies occurring to any/all persons at the facility.
In an interview 8/01/18 at 1:00 P.M. S2DON confirmed the hospital did not have an Emergency Department. S2DON further verified the hospital did not have a policy for the appraisal for emergencies, initial treatment, and referral, when appropriate, that covered any emergency, including those that did not involve a hospital patient.
Tag No.: A0144
Based on observations, interviews, and record reviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others.
Findings:
On 7/30/18 between 10:20 a.m. and 12:20 p.m. an observation of the Esplanade 3, Decatur, and Rampart Units revealed the following safety concerns:
Esplanade 3 Unit
1. The patient bathrooms on the short and long hall contained the following ligature risks:
a. Elongated sink faucet with flanged handles,
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets,
c. Light fixture hanging in the long hall bathroom,
d. The patient telephone in the common area has a metal cord which could allow a patient to place the cord around their neck.
2. Numerous non-tamper proof screws were noted throughout the unit to include screws attaching:
a. Pictures to the walls on halls and in the common areas,
b. Vents,
c. Bathroom stall dividers,
d. The TV wooden boxes.
On 7/30/18 at 10:20 a.m. in an interview S11URDir verified the above concerns.
Review of the hospital's incident report logs revealed that on 6/10/18 Patient #13 had been found cutting himself with 2 screws he had found on the unit (Esplanade 3).
Decatur Unit
1. The patient bathrooms on the short and long hall and common area contained the following ligature risks:
a. Elongated sink faucet with flanged handles,
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets,
c. Light fixture hanging in the long hall bathroom.
d. Elongated sink faucet with flanged handles,
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets,
2. The Serenity Room vents pose a ligature risk.
3. The Staff Bathroom near the Seclusion Room was unlocked and revealed the following ligature risks:
a. Staff lockers with 10 metal handles and 10 pad locks,
b. A water control valve with gaps around the pipes.
4. The Staff Bathroom also revealed the following safety concerns:
a. A can of hand held sanitizer spray was on the counter near the sink accessible to patients which could be use for harm to self or others.
b. The fire alarm strobe was hanging on the wall with exposed wires on the back which could cause electrocution.
c. The door was lockable from the inside which could allow the patient to barricade themselves from staff and cause injury to oneself.
5. Numerous non-tamper proof screws were noted throughout the unit to include screws attaching:
a. Pictures to the walls on halls and in the common areas,
b. Vents,
c. Bathroom stall dividers,
d. The wooden boxes TV enclosure boxes.
On 7/30/18 at 10:54 a.m. in an interview S11URDir, S8PlantOps and S7Maintenance verified the above concerns and verified the staff bathroom should be lock at all times.
Rampart Unit
1. The patient bathrooms on the short and long hall and common area contained the following ligature risks:
a. Elongated sink faucet with flanged handles,
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets,
c. The long hall bathroom light fixture was hanging,
d. Elongated sink faucet with flanged handles,
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets,
2. The Serenity Room vents pose a ligature risk as patients could tie a piece of clothing through the vent and around their neck.
3. Numerous non-tamper proof screws were noted throughout the unit to include screws attaching:
a. Pictures to the walls on the halls and in the commons areas,
b. Vents,
c. Bathroom stall dividers,
d. The wooden boxes TV enclosure boxes.
In an interview on 7/30/18 at 12:20 p.m. with S7Maintenance, S8PlantOps and S9DirClinSer, they verified the above findings.
Esplanade Unit 1
Observations conducted on 7/30/18 at 10:50 a.m. revealed the following safety concerns:
1. Numerous non-tamper resistant screws attaching:
a. Pictures to the walls on halls and in the common areas,
b. Vents
c. The wooden boxes TV enclosure boxes.
d. Bathroom stall dividers.
2. The patient telephone in the common area has a metal cord which could allow a patient to place the cord around their neck.
3. The Serenity Room vents potential ligature anchor point.
4. Non ligature resistant air conditioner vents (large slots) throughout the unit (including but not limited to patient rooms, meeting room, bathrooms, and seclusion room).
The above referenced identified patient safety risks were confirmed with S17Therapist, who was present when the observations were made.
Observations conducted on 7/31/18 at 4:10 p.m. of Esplanade Unit 1 revealed the following safety concerns:
1. Bathroom 1- long hall:
a. air vent - potential ligature anchor point
b. non-tamper proof screws on the door handle and lock cover
c. elongated sink faucet with flanged handles- potential ligature anchor point
d. Commode stall doors and the stall wall between the commodes contained gaps with brackets- potential ligature anchor point.
2. Bathroom 2- short hall:
a. non-tamper proof screws on the door handle and lock cover
b. elongated sink faucets with raised knob handles- potential ligature anchor points
c. Commode stall doors and the stall wall between the commodes contained gaps with brackets- potential ligature anchor point.
d. exposed toilet plumbing/flushing mechanism in bathroom stall #2 - potential ligature anchor points
The above referenced identified patient safety risks were confirmed with S7Maintenance, who was present when the observations were made.
Esplanade Unit 2
Observations conducted on 7/30/18 at 11:00 a.m. revealed the following safety concerns:
1. Numerous non-tamper resistant screws attaching:
a. Pictures to the walls on halls and in the common areas,
b. Vents
c. The wooden boxes TV enclosure boxes.
d. Bathroom stall dividers.
2. The patient telephone in the common area has a metal cord which could allow a patient to place the cord around the patient's neck.
3. The Serenity Room vents - potential ligature anchor point.
4. Non ligature resistant air conditioner vents (large slots) throughout the unit (including but not limited to patient rooms, meeting room, bathrooms, and seclusion room).
The above referenced identified patient safety risks were confirmed with S17Therapist, who was present when the observations were made.
Observations conducted on 7/31/18 at 4:10 p.m. of Esplanade Unit 2 revealed the following safety concerns:
1. Bathroom 1- long hall:
a. double sink with elongated sink faucets with raised knob handles- potential ligature anchor points
b. Commode stall doors and the stall wall between the commodes contained gaps with brackets- potential ligature anchor point.
2. Bathroom 2- short hall:
a. non-tamper proof screws on three shelf brackets.
b. double sink with elongated sink faucets with raised knob handles- potential ligature anchor points
c. Commode stall doors and the stall wall between the commodes contained gaps with brackets- potential ligature anchor point.
d. 2 metal face plates surrounding the shower heads in stalls #1 and #2 - 20 non-tamper resistant screws.
3. Non ligature resistant air conditioner vents (large slots) throughout the unit (including but not limited to patient rooms, meeting room, bathrooms, serenity room, and seclusion room).
The above referenced identified patient safety risks were confirmed with S7Maintenance, who was present when the observations were made.
Cypress Unit
A tour of Cypress Unit 7/30/18 from 10:15 a.m. to 11:05 a.m., accompanied by S4TherDir, revealed to following safety risks observed during the tour:
1.Seclusion room
a. a semi-circular metal door stop with ½ of the top surface protruding from the floor approximately 1-1/2 inches inside the room.
b. metal doorstop was attached to the floor with a large non-tamper resistant screw.
2. Shower Room
a. two (2) open shower stalls, both with floor drains with open (uncovered) drainage pipes approximately 2 inches in diameter.
b. self-closing door mechanism that could cause harm to patients.
c. Multiple non-tamperproof screws were found throughout the unit in all patient areas.
All observations referenced above were verified by S4TherDir during observation.
Willow Unit
Observations on 7/30/18 between 10:00 a.m. and 10:30 a.m. in the presence of S15RN revealed the following:
a.Non tamper proof screw heads were noted on the windows and doors throughout the unit (including but not limited to patient rooms, meeting room, bathrooms, serenity room, and seclusion room).
b. Non ligature resistant air conditioner vents (large slots) throughout the unit (including but not limited to patient rooms, meeting room, bathrooms, serenity room, and seclusion room).
c. Non ligature resistant faucet in patient bathrooms. S15RN verified the identified safety risks and also verified the screw heads were not tamper proof in the rooms listed above.
30420
30984
39791
Tag No.: A0145
Based on record review and interview, the hospital failed to report potential neglect (elopement) to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of discovery for 1 (# 17 ) of 3 (#7, #11, #17) sampled patients reviewed for potential neglect related to elopement.
Findings:
Review of the hospital policy titled," Abuse, Neglect of Patients, Reporting Allegations", Policy Number: RI-0800, revealed in part: 6. Neglect: Acts or omissions by a person responsible for providing care or treatment which caused harm to the patient, which placed the patient at risk of harm, or which deprived a patient of sufficient or appropriate services, treatment or basic care. Failure to provide appropriate services, treatment or by gross errors in judgement, inattention, or ignoring may also be considered a form of neglect. Examples include: c. Failure to provide a safe environment. e. Failure to supervise a patient such that the patient is placed in danger.
Review of the State Law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."
Review of hospital's incident reports revealed Patient #17 had eloped on 2/22/18 at 12:45 p.m. Further review revealed the patient had become upset after treatment team and as dietary staff opened the door to enter the building, the patient pushed through the door, climbed up the side of the building, to the roof, climbed down a ladder and ran into a wooded area. The patient was found at a local recreation/nature park at 1:00 p.m. and returned to the unit by staff.
Review of the hospital's self-reports of allegations of abuse/neglect submitted to LDH-HSS from 1/1/2018 -7/30/2018, presented as current by S2DON, revealed no documented evidence of a self-report regarding potential neglect related to Patient #17's elopement on 2/22/18.
In an interview on 7/31/18 at 2:30 p.m. with S2DON, she confirmed there had only been one self-report of alleged abuse/neglect to LDH since 1/2018 and that involved a choking incident. She confirmed the above referenced elopement had not been reported.
In an interview on 8/1/18 at 11:00 a.m. with S1CEO, he reported his understanding was that self - reports to LDH were related to alleged abuse and neglect, but this particular incident had fallen into the elopement category.
Tag No.: A0166
Based on record review and interview, the hospital failed to ensure the use of seclusion was in accordance with a written modification to the patient's plan of care for 1 (#9) of 1 patients reviewed for seclusion out of a total patient sample of 17.
Findings:
Review of the hospital policy titled,"Restraint/Seclusion", Policy Number: TX7-0102, revealed in part: L. Reassessment/Continuation Protocol: 4. The Clinical /Program Director will coordinate a team meeting to: a. Assess if additional resources are needed to facilitate discontinuation. b. Review and update the treatment plan of care.
Review of Patient #9's medical record revealed the patient had been placed in seclusion on 4/30/18 for 55 minutes due to threatening behavior, with a weapon (hole puncher), toward a physician. Further review revealed there was no written modification to Patient #9's treatment plan to include the use of seclusion.
In an interview on 7/31/18 at 3:50 p.m. with S2DON, she confirmed Patient #9's treatment plan should have been modified to include the use of seclusion.
Tag No.: A0395
Based on observation, record reviews, and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
1. failing to ensure male and female patients were not allowed to enter unsecured rooms, undetected, to engage in sexual activity for 2 (#10, #16) of 2 patients reviewed for having sexual intercourse from a total patient sample of 17 (#1-#17); and
2. failing to ensure a patient (#7 ) on elopement precautions was confined to the unit, as ordered, resulting in a second elopement attempt for 1(#7) of 3 (#7,#11,#17) patients reviewed for elopements from a total patient sample of 17 (#1-#17).
Findings:
1. Failing to ensure male and female patients were not allowed to enter unsecured rooms undetected to engage in sexual activity.
Patient #10
Review of Patient #10's medical record revealed an admission date of 6/14/18 with an admission diagnosis of depression with suicidal ideations. Further review revealed the patient's legal status was PEC (6/13/18 at 4:18 p.m.) due to being dangerous to self and gravely disabled.
Review of a critical incident/injury and adverse reporting assessment revealed Patient #10 was documented as having consensual sex with a peer on 6/16/18 between 9:00 p.m. and 10:00 p.m.
Review of Patient #10's Patient Observation and Locator Form, dated 6/16/18 for 3:00 p.m. - 11:00 p.m., revealed the patient was on Close Staff sight level of observation (defined by hospital policy as documentation of patient location and activity every 10 minutes). Further review revealed the patient was documented as being on suicide, elopement, and withdrawal precautions.
Review of the Incident Report involving Patient #10, dated 6/18/2018, revealed in part: "Patient came to me telling me she had sex with Patient #16 and she is now pregnant for him." Further review revealed the following Risk Management investigation notation: "Both patients (#10 and #16) admit to consensual sexual activity with no coercion."
Patient #16
Review of Patient #16's medical record revealed the patient's legal status was PEC'd on 6/15/18 due to being brought in on an order of protective custody due to violent behavior. Further review revealed the patient was dangerous to others and unable to seek voluntary admission. Patient #16 had an admission diagnosis of Paranoid Schizophrenia.
Review of the Incident Report involving Patient #16, dated 6/18/2018, revealed in part: Patient #16 told staff he had sex with Patient #10, that Patient #10 asked him to but he did not want to. Further review revealed the following Risk Management investigation notation: "Both patients (#10 and #16) admit to consensual sexual activity with no coercion."
In an interview on 8/1/18 at 10:55 a.m. with S16RN, she reported she had completed the incident report related to the sexual activity involving Patient #10 and Patient #16. She further reported she had not been present when the actual incident occurred and could not remember who had reported it to her. She said the patients had initially denied having sex, but later admitted they had sex. S16RN reported the sexual activity had been consensual for both of them with no coercion.
In an interview on 8/1/18 at 11:30 a.m. with S2DON, she confirmed both Patient #10 and Patient #16 had been PEC'd ( Patient #10) and PEC/CEC (Patient #16) at the time of their sexual encounter. S2DON reported the hospital discouraged any type of sexual activity between patients. S2DON reported she thought the patients had been on every 15 minute observations. S2DON indicated she was not sure where the encounter had taken place, but agreed the patients had access to some type of area that had not been secured. S2DON further indicated she could not pinpoint the timeframe nor the place where the incident had occurred. She reported video had been reviewed on the unit and they could not determine where the incident had taken place. When asked where the documentation of the investigation was she reported she did not have the documentation. S2DON confirmed all doors, including closets, should be locked at all times on all units to prevent unsupervised patient access.
2. Failing to ensure patients on elopement precautions were confined to the unit as ordered to avoid additional elopement.
Review of Patient #7's medical record revealed an admission date of 4/27/18 with an admission diagnoses of Bipolar Disorder and Oppositional Defiant Disorder. Further review revealed Patient #7 was PEC'd due to suicidal ideation.
Review of Policy Number: TX.7-0200 titled: "Elopement" revealed in-part:
Purpose: to identify interventions that help to protect the welfare of patients and the community.
Definition of Elopement is Patient has left the grounds without prior authorization; and Definition of Attempted elopement is remain in line of sight.
Procedures: Utilize following guidelines to decrease the opportunity for elopement.
--Before passes and prior to any activities that takes the patient out of the enclosed areas of the campus.
--Patient at risk for elopement will be placed on elopement precautions.
--A locked door policy is established facility wide and must be followed by all staff in order to minimize opportunity for elopement.
--Designated enclosed outdoor areas should be utilized for patient activities whenever possible.
--Ground privileges should exclude high risk patient and patient on precautions for elopement.
--During fire drill, patient remain on unit. In event of fire, escorted by staff 1:1.
--A MD order is required along with the elopement risk.
Elopement Precautions:
--Elopement precautions are indicated for patient that threaten, attempt or are at high risk for runaway or who...runaway or who have a documented history of attempted elopements.
--A doctor's order is required along with the elopement risk assessment to support need for elopement precautions.
Elopement precautions will:
--Be restricted to the unit, except for necessary medication care/evaluation.
--Remain under supervision with unit doors locked.
--Be transported by vehicle with 1:1 staff for any required trips.
--Eat all meals on the unit. The MD can order the removal of visitation privileges.
--Remain on the unit. The MD can order the removal of visitation privileges.
Patient on elopement precautions may be placed in scrubs 24 hours/day with MD written order.
Discontinue of elopement precautions requires a physician's order and progress note justification. Patient should be monitored following discontinuation of precautions to look for signs that the risk of elopement no longer exists.
Review of hospital's incident log dated 4/30/18 revealed Patient #7 was on Cypress Unit and had two elopements. Further review of hospital records revealed two incident reports for Patient #7.
-The first incident summary for Patient #7 revealed an elopement on 4/30/18 at 10:30 a.m. Further revealed Patient #7 scaled wooden fence in front of staff and peers. No injury or treatment. Intervention stated Patient #7 placed on unit restriction.
-The second incident summary for Patient #7 revealed an attempted elopement on 4/30/18 at 11:15 a.m. (45 minutes after the patient had been placed on elopement precautions with unit restriction). Further revealed Patient #7 scaled the fence in the courtyard. He was quickly apprehended and returned to his unit.
Further review of Patient #7's medical records revealed a physician's order on 4/30/18 at 11:40 a.m. for Elopement Precautions.
In an interview on 8/1/18 at 10:30 a.m. with S9DirClinSer, she verified Patient #7 had two elopements on 4/30/18 She also verified Patient #7 eloped on 4/30/18 at 10:30 a.m., had been placed on elopement precautions with unit restriction (to remain on locked unit), and 45 minutes later, at 11:15 a.m., Patient #7 attempted to elope again in the courtyard.
In an interview on 8/1/18 at 12:30 p.m. with S2DON, she verified Patient #7 was placed on unit restriction and eloped shortly after. She verified the patient should not have gone outside.
In an interview on 7/31/18 at 5:15 p.m. with S18Risk revealed she was aware of Patient #7's elopements on 4/30/18 and stated we sometimes don't let the patient's go outside, but this is a hospital, not a prison.
39791
Tag No.: A0450
Based on record review and interview, the hospital failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. This deficient practice was evidenced by failure of the hospital to ensure the patients' Observation and Locator Logs included the correct observation levels, precaution levels, reason for precautions/observation levels and were signed by the charge nurse for 5 (#1, #5, #6, #11, #13) of 17 #1-#17) total sampled patient records reviewed.
Findings:
Review of the Policy "Level of Observation and Precaution" Policy Number: TX.7-1001 Reviewed: 4/24/2018 revealed in part: Monitoring: 2. The RN Charge Nurse is directly responsible for assigning staff and monitoring precautions. 3. The RNS/ RNM will monitor during rounds.
Patient #1
Review of Patient #1's medical record revealed an admission date of 6/12/18. Further review revealed Patient #1 was on ordered close staff sight with suicide precautions on admit.
Review of Patient #1's Observation and Locator Forms, dated 6/12/18-6/20/18, revealed the patient was on every 10 minute checks and the level of observation was close staff sight. The reason for the patient being on an increased level of observation was left blank.
Further review revealed the following incomplete Patient Observation and Locator Form entries:
On 6/15/18 and 6/20/18: The RN Charge Nurse failed to sign the observation sheets;
Observation sheets dated 7/19/18 and 7/23/18 revealed Patient #1 had been increased to 1:1 observation level with no reason documented for being increased to 1:1 supervision.
Patient #5
Review of Patient #5's medical record revealed and admission date of 5/30/18. Further review revealed Patient #5 was ordered to be on 1:1 observation.
Review of Patient #5's 1:1 Patient Observation and Locator Forms revealed the RN Charge Nurse failed to sign on the following dates and shifts:
7/18/18 7:00 a.m.- 3:00 p.m., 3:00 p.m.- 11:00 p.m., 11:00 p.m.- 7:00a.m.
7/19/ 18 7:00 a.m.- 3:00 p.m.
7/20/18 7:00 a.m.- 3:00 p.m., 3:00 p.m.- 11:00 p.m., 11:00 p.m.- 7:00 a.m.
7/21/18 3:00 p.m.- 11:00 p.m., 11:00- 7:00 a.m.
7/23/18 7:00 a.m.- 3:00 p.m., 3:00 p.m.- 11:00 p.m., 11:00 p.m.- 7:00a.m.
In an interview on 8/1/18 at 10:40 a.m. S2DON confirmed the charts had missing signatures that had been discovered during a chart audit. S2DON reported the charts were tagged because the charge nurse had not signed the documents.
Patient #6
Review of Patient #6's medical record revealed an admission date of 9/21/17 with an admission diagnosis of Judicial Commitment.
Review of Patient #6's Observation and Locator Forms for 7/4/18, 7/5/18, 7/6/18, 7/7/18, 7/8/18, 7/27/18 and 7/28/18 revealed no documentation of Level of Observation, Precautions, or Intervention. Further review revealed three additional Observation Locator Forms without the above information, but unable to identify the date (there is no date listed on the front or back of this form).
Patient #11
Review of Patient #11's medical record revealed an admission date of 11/13/17. Further review revealed the patient had eloped on 2/14/18 and had been placed on elopement precuations.
Review of Patient #11's Observation and Locator Form for 2/14/18 revealed elopement precautions had not been documented on the observation record.
Patient #13
Review of Patient #13's medical record revealed an admission date of 10/24/17. Further review revealed Patient #13 was placed on suicide watch on 7/9/18.
Review of Patient #13's Observation and Locator Form for 7/9/18 revealed suicide watch precautions had not been documented on the observation record.
Review of Patient #13's Observation and Locator Form for 7/12/18 revealed the RN Charge Nurse had not signed the form.
On 7/31/18 at 9:30 a.m. in an interview with S2DON, she confirmed the above referenced findings.
38777
39791
Tag No.: A0701
Based on record reviews, observations, and interviews, the hospital failed to ensure the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients was maintained. This deficient practice was evidenced by failure of the hospital to ensure the patient care environment was treated for ants in a timely manner resulting in one patient (Patient #14) being bitten by ants in room "b" and ants being present in another patient's bed in patient room "a".
Findings:
Patient #14
Review of Patient #14's medical record revealed the following nurses' notes entry dated 7/28/18 for 7:00 p.m. - 7:00 a.m. shift: Patient had multiple ant bites to neck, back, and abdomen. Further review revealed no documented evidence that the patient's room had been blocked and treated for ants. Patient #14 was in room "b".
Review of the Facility Unit Safety Search documentation revealed in part: 7/30/18 8:00 p.m. Room "a" contraband: food and ants in bed. Further review revealed no documented evidence that any actions had been taken to eliminate the ants.
In an interview on 7/31/18 at 4:30 p.m. with Patient #15 (currently in Room "a"), he reported he had seen ants crawling on the wall under the windowsill next to his bed. The patient pointed out this area during an observation of room "a" which had been conducted during the interview.
In an interview on 7/31/18 at 3:23 p.m. with S7Maintenance, he reported patient rooms with ants or any kinds of insect issues requiring treatment were usually blocked for treatment for 45 min to 1 hour to allow for spray to dry. He reported as of 7/31/18, at the time of the interview, they had not treated room "a" because one of the patients refusal to leave the room. He reported room "b" had not been sprayed until 2:00 p.m. on 7/31/18 (3 days after Patient #14 had been bitten).
In an interview on 8/1/18 at 12:40 p.m. with S9DirClinSer, she confirmed room "a" still had not been treated for ants.
Tag No.: A0724
Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1. failing to ensure the Glucometer Calibration and Control Log was documented.
2. failing to ensure the physical environment was free of peeling paint and rust and the furnishings were free from chips/cracks/removal of surface coverings.
Findings:
1. Failing to ensure the Glucometer Calibration and Control Log was documented.
A review of the hospital policy titled," Glucometer- Blood Glucose Testing", Policy Number: NS-4045 revealed in part: E. Documentation of Control Test 1. Recorded on the Glucometer Quality Control Record.
b. On a daily basis, the 7:00 p.m. - 7:00 a.m. shift RN/LPN will conduct quality control and record the time, code, low and high results, signature and corrective action, when applicable.
On 7/30/18 at 10:44 a.m. a review of the Esplanade 3 Glucometer Calibration and Control Log failed to reveal documentation of calibration checks on the following dates: 7/10/18, and 7/17/18 - 7/24/18.
In an interview on 7/30/18 at 10:44 a.m. with S11URDir and S12LPN, the above missing documentation and policy were verified.
On 7/30/18 at 11:10 a.m. a review of the Decatur Glucometer Calibration and Control Log failed to reveal documentation of calibration checks on the following dates: 7/18/18, 7/20/18 through 7/23/18, 7/26/18, 7/27/18 and 7/29/18.
In an interview on 7/30/18 at 11:12 a.m. S14LPN verified the above missing documentation.
2. Failing to ensure the physical environment was free of peeling paint and rust and the furnishings were free from chips/cracks/removal of surface coverings.
Esplanade 2
On 7/30/18 at 10:30 a.m. an observation was made of a table in the television room on Esplanade 2. The table surface had been scraped off on one corner of the table revealing the particle board.
Esplanade 1
On 7/30/18 at 11:00 a.m. an observation was made of a table in the television room on Esplanade 1 unit. The edge of the table was missing the top layer of stripping, exposing the second layer of particle board.
S17Therapist verified the findings during the observation.
Rampart
On 7/30/18 at 12:15 p.m. an observation of the Rampart Unit Long Hall Bathroom revealed:
a. peeling paint in the shower,
b. rust on the metal in the commode stalls,
c. chipped paint on the door frame.
In an interview on 7/30/18 at 12:20 p.m. S7Maintenance, S8PlantOps, and S9DirClinSer verified the above findings.
Willow
Observations of the Willow Unit on 7/30/18 between 10:00 a.m. and 10:30 a.m. with S15RN revealed the following: a. bathroom stall without a door had area of missing paint approximately 3 feet in diameter on the wall adjacent to a toilet;
b. located on the floor below the wall of missing paint was a pile of paint peelings; and
c. window ledge in the bathroom and patient rooms with chipped paint.
S15RN verified the above Willow Unit physical environment findings during the observation.
30984
39791
Tag No.: A0749
Based on observations, record reviews, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice as evidenced by:
1) failure to maintain a sanitary environment in the hospital, evidenced by multiple observations of equipment and practices that did not provide infection control during a hospital tours;
2) failure to clean and disinfect the hospital glucometer after performing a capillary blood glucose as by hospital policy;
3) failure to ensure expired supplies and foods were not available for use, as evidenced by multiple observations in patient care areas and the kitchen;and
4) failure to ensure the medication and nourishment temperature logs contained temperature check documentation.
5) failure to ensure the nourishment and medication refrigerator was clean to prevent possible infection.
Findings:
1)Failure to maintain a sanitary environment in the hospital.
Cypress Unit
A tour of Cypress Unit 7/30/18 from 10:15 a.m. to 11:05 a.m., accompanied by S4TherDir revealed to following infection control:
Air conditioner vents located in the Serenity room and the seclusion room with dust that hung from the vents.
In the laundry room a plastic laundry basket full of clothing on top of dryer was observed with no name or label as to clean/dirty , a large brown paper bag sitting on the dryer contained laundry with no label(s), 2 open blue plastic bags of unfolded linens sitting on floor, in laundry room cabinets, above the washer and dryer were 2 pairs of light blue shorts, and a pair of slip-on sneakers with no name or indicator as to whether they were clean or not.
An observation of the clean supply room, accessed from the nursing station revealed clean patient care supplies, with unfolded clothing articles sitting on top of some supplies.
In an interview 7/30/18 at 10:15 a.m. S6LPN reported the clothes belonged to a patient. She further reported the clothes were being taken by another patient, so they were keeping them in the closet. The observation was verified by S4TherDir, present during the tour. She verified the patient clothes should not be kept in the clean supply closet.
Further observation revealed, in the patient food area on the patient care unit, a shelving unit noted to have 3 plastic basins filled with plastic eating utensils (2 with forks and 1 with spoons) open to air, and not individually wrapped. Under the counter was a large cardboard box with the top opened of unwrapped plastic forks (the box said 1000 forks). The inside and outside of the lower cabinet doors were soiled with multiple brown splatter and drip marks.
Patient shower room with two (2) open shower stalls, both with floor drains with open (uncovered) drainage pipes approximately 2 inches in diameter, covered with rust.
A door to outside at the end of hall with a large buildup of dark brown substance on top of bar handle attachment. S4TherDir, present throughout the tour verified the findings.
Willow Unit
An observation of Willow Unit on 7/30/18 between 10:00 a.m. and 10:30 a.m. accompanied by S15RN revealed rips to mattress pads in patient room 103 (#1), 104 (#1), and 105 (#1). Further observation revealed rust on the screen covering the bathroom window. These findings were verified by S15RN.
Kitchen
An observation of the kitchen 8/1/18 from 9:30 a.m. to 10:00 a.m., accompanied by S7Maintenance and S13DietMgr, revealed, in the area where dirty dishes, pots/pan, and utensils were brought and rinsed before being put in the dishwasher revealed a 5 shelf wire storage rack with cleaned large colanders , large bowls, large cutting boards, and containers of utensils stored. The wire storage rack was noted to be about 30 inches from the counter and sink used to rinse dirty equipment and dishes. This observation and distance was verified by S7Maintenance, present for the observation.
An observation in an area with clean cooking equipment and utensils revealed 33 large flat pans and 5 deep flat pans with a dark brown-black build-up of substance around the outer edges.
During the tour S19Maintenance was observed to walk into the kitchen and through the food preparation and cooking area with only a ball cap, with (head) hair exposed from his ears down. S20Kitchen staff was observed to be filling containers from the ice bin, located in the main kitchen area with only a ball cap on, with (head) hair exposed from his ears down.
In interviews during the tour of the kitchen and food storage areas, S13DietMgr and S7Maintenance verified all above observations. S13DietMgr reported she did not have a policy and procedure for labeling opened foods. She verified there was no specific procedure for the labeling of opened foods. She confirmed some of the foods observed did not have an expiration or "use by" date. She verified the foods with no expiration date or use by date should not have been available for use. S7Maintenance verified the findings of insect wings and debris in the bouffant caps from the container outside the kitchen, and open to the outside environment. S13DietMgr and S7Maintenance verified that all persons entering the kitchen area s were supposed to wear head coverings that contained all of their hair.
2)Failure to clean and disinfect the hospital glucometer after performing a capillary blood glucose as by hospital policy.
Review of hospital policy #IC-4004 titled, "Equipment Management-Prevention of Infection", provided by S4TherDir as current, revealed in part, under "Glucometer/Nurses" (5) the meter [glucometer] must be disinfected with a hospital-approved disinfectant after each use.
Review of the manufacturer's manual for the glucometer revealed in part under cleaning and disinfecting your meter, that the was to be cleaned and disinfected to ensure germs and disease causing agents were destroyed on the meter. A list of commercial disinfectant agents acceptable were listed with times that each must be wet for adequate disinfection. Alcohol was not listed as an agent for disinfecting the meter.
In an interview 7/30/18 at 10:50 a.m. S6LPN reported she cleaned the unit's glucometer (used for capillary blood glucose readings on patients) with alcohol wipes between patients. When asked if that was the hospital's procedure she reported, "I'm not sure if there is a policy."
In an interview 7/30/18 at 11:00 a.m. S7RN, Charge Nurse reported he performed capillary blood glucose readings on patients. He reported he cleaned the glucometer (used for capillary blood glucose readings on patients) with alcohol wipes between patients.
In an interview 7/31/18 at 2:40 p.m. S3IC reported that all glucometers should be disinfected after each use, using the disinfectant wipes on each unit, as per the hospital policy.
3)Failure to ensure expired supplies and foods were not available for use, as evidenced by multiple observations in patient care areas and the kitchen;
An observation on 7/30/18 between 10:00 a.m. and 10:30 a.m. accompanied by S15RN revealed the patient nourishment room refrigerator on Willow Unit contained 5 expired cartons of milk verified by S15RN.
An observation of the kitchen 8/1/18 from 9:30 a.m. to 10:00 a.m., accompanied by S7Maintenance and S13DietMgr, revealed, in the kitchen walk-in cooler, a previously opened large plastic container of prepared mustard (8 # 6 oz) opened 6/26/18, with an expiration date of 4/20/18, a previously opened plastic container ½ full of mayonnaise (8# 6 oz) with no "opened" date or expiration date, a 16 oz. bottle of red food coloring with a opened date of 10/12/17, but no expiration or "use by" date.
In an interview 8/1/18 at 9:40 a.m. S13DietMgr verified the above findings. S13DietMgr. reported the hospital did not have a policy or procedure for the labeling of food and/or food containers when opened. She confirmed she could not provide an expiration date for the container of mayonnaise or red food coloring without looking it up. She confirmed these foods should not be available for use if staff could not ensure the products had not expired or was beyond a "use by" date. She verified there was no procedure for determining how long a food item could be used once opened, or a procedure for labeling the food.
4) Failure to ensure the medication and nourishment temperature logs contained documentation of the temperature monitoring.
A review of the facility policy Medication Storage Area Guidelines Policy # RX.TX.3-5030 Reviewed 1/9/15 revealed in part: 7. Temperature Monitoring: a. Temperatures must be monitored and documented at least twice daily for the medication refrigerator/ freezer and medication storage room(s). Medication refrigerators in the Medication Rooms are equipped with temperature monitors.
b. It is the responsibility of the person discovering unacceptable temperature, to provide follow- up action. Instructions for follow-up of out of range temperatures are indicated on the monitoring sheets.
A review of the facility policy Care and Cleaning of Refrigerators/ Freezers Policy# IC-0313 Reviewed 7/26/18 revealed in part: B. Temperature Control 2. Night shift designated Nursing Staff must check refrigerator/ freezer daily and record temperature on the refrigerator monitoring log.
On 7/30/18 at 10:15 a.m. review of Willow patient medication refrigeration log failed to reveal documented temperatures on 7/3/18, 7/4/18, 7/6/18. 7/7/18, 7/8/18, 7/9/18, and 7/29/18.
On 7/30/18 at 10:20 a.m. review of Willow patient nourishment refrigeration log failed to reveal documented temperatures on 7/1/18, 7/4/18, 7/5/18, 7/6/18, 7/8/18, 7/9/18,7/12/18, 7/13/18,7/18/18, 7/21/18, and 7/23/18.
On 7/30/18 at 10:35 a.m. a review of the Esplanade 3 patient nourishment freezer failed to reveal documented temperatures on 7/4/18, 7/6/18 and 7/7/18.
On 7/30/18 at 10:40 a.m. a review of the Esplanade 3 medication refrigerator failed to reveal documented temperatures on the following dates and shifts:
7/1/18 7:00 a.m. to 7:00 p.m. shift and 7:00 p.m. to 7:00 a.m. shift
7/17/18, 7/20/18, 7/24/18, 7/28/18 and 7/29/18 7:00 p.m. to 7:00 a.m. shift.
In an interview on 7/30/18 at 10:44 a.m. the above missing documentation was verified by S11URDir and S12LPN.
On 7/30/18 at 11:00 a.m. a review of the Decatur patient nourishment freezer failed to reveal documented temperatures on 7/3/18 and 7/19/18.
On 7/30/18 at 11:05 a.m. a review of the Decatur medication refrigerator failed to reveal documented temperatures on the following dates and shifts:
7/20/18 7:00 a.m. to 7:00 p.m. shift and 7:00 p.m. to 7:00 a.m. shift
7/23/18 7/25/18 through 7/27/18 7:00 a.m. to 7:00 p.m. shift
7/29/19 7/29/18 7:00 p.m. to 7:00 a.m. shift
In an interview on 7/30/18 at 11:12 a.m. S14LPN verified the above missing documentation.
5)Failure to ensure the nourishment and medication refrigerator was clean to prevent possible infection.
A review of the facility Care and Cleaning of Refrigerators/ Freezers Policy# IC-0313 revealed in part:
IV: Cleaning of Refrigerators/ Freezers
A. Responsibility: All refrigerators/ freezers will be cleaned and disinfected weekly.
1. In each patient care area, Nursing Service staff on the night shift are responsible.
An observation on 7/30/18 between 10:00 a.m. and 10:30 a.m. accompanied by S15RN revealed the patient nourishment room refrigerator on Willow Unit had dried spills and hair on a shelf and in a drawer verified by S15RN.
On 7/31/18 at 9:40 a.m. an observation of the Esplanade 3 Nourishment Refrigerator revealed the inside contained a brownish gray material on the shelves.
In an interview on 7/31/18 at 9:40 a.m. with S10RN verified the refrigerator was not clean at the time of the observation and the night shift was responsible for cleaning them weekly.
On 7/30/18 at 11:05 a.m. an observation of the Decatur medication refrigerator revealed the inside contained a brownish gray material and hair on the shelves.
In an interview on 7/30/18 at 11:112 a.m. S14LPN verified the refrigerator was not clean at the time of the observation.
38777
39791
Tag No.: B0116
Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included supportive information utilized to determine intellectual level of functioning, judgment, insight, impulse control, and memory functioning for 4 (#1, #2, #3,#4) of 4 (#1- #4) patient records reviewed for psychiatric evaluations from a total patient sample of 17.
Findings:
Patient #1
Review of Patient #1's medical record revealed an admission date of 6/12/18 with admission diagnoses of Schizophrenia, Bipolar Disorder, and mood disorder.
Review of Patient #1's Psychiatric Evaluation, dated 6/12/18 12:00 p.m. revealed the following:
Memory (recall, recent, and remote) was documented as grossly intact with no methodology for assessment documented.
Intellectual functioning was documented as below average per vocabulary with no other description of method of assessment of intellectual functioning.
Judgement, Insight, Impulse Control were all documented as poor with no methodology for assessment documented.
Patient #2
Review of Patient #2's medical record revealed an admission date of 7/27/18. The patient's legal status was PEC due to being dangerous to self, dangerous to others, gravely disabled, and unwilling/unable to seek voluntary admission.
Review of Patient #2's Psychiatric Evaluation, dated 7/28/18, revealed the following:
Judgement, Insight, Impulse Control were all documented as limited with no documentation of methodology for assessment.
In an interview on 7/31/18 at 3:50 p.m. with S2DON, she confirmed the methodology used to assess the above referenced areas on Patient #1 and Patient #2 's Psychiatric Evaluations should have been documented.
Patient #3
Review of Patient #3's medical record revealed an admission date of 6/0518 with an admission diagnosis of Schizophrenia, Neurocognitive Disorder (Dementia).
Review of Patient #3's Psychiatric Evaluation, dated 6/6/18, revealed the patient's intellectual functioning was documented as average. Further review revealed the following documentation: patient's memory was documented as "1/3 3'", Judgment as "poor", insight as "poor", and Impulse control as "Impulse Control as "poor". Additional review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's intellectual functioning or memory.
In an interview 7/30/18 at 11:05 a.m. S4TherDir verified the findings noted above.
Patient #4
Review of Patient #4's medical record revealed an admission date of 3/18/18 with an admission diagnosis of Major Depressive Disorder, recurrent, Schizoaffective Disorder, Bipolar Type.
Review of Patient #4's Psychiatric Evaluation, dated 3/19/18 revealed her intellectual functioning was documented as "Borderline/below avg.", Judgement as "poor", Insight as "poor", and Impulse Control as "poor". Further review revealed no documentation of supportive information/methodology utilized for determining the patient's intellectual functioning. or memory.
In an interview 8/1/18 at 12:30 p.m. S2DON verified the findings for Patient #4.
30984
Tag No.: B0118
Based on record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan. This deficient practice is evidenced by failing to update the treatment plan after self harm attempts and elopement for 3 ( #7, #9, #11) of 12 (#1-#12 ) patients comprehensively reviewed from a total patient sample of 17 (#1-#17).
Findings:
Review of the hospital policy titled "Elopement", Policy Number: TX.7-0200, revealed in part: I. Return from elopement: 2. Appropriate action in the form of treatment plan adjustment will be made to reduce reoccurrence of elopement, including placement on elopement precautions and privilege consequences, according to unit program.
Patient #7
Review of Patient #7's medical record revealed an admission date of 4/27/18, a discharge date of 5/9/18, with an admission diagnoses of Bipolar Disorder, Type I and Oppositional Defiant Disorder. The patient's legal status was PEC'd for suicidal ideation.
Further review of Patient #7's medical record revealed patient eloped on 4/30/18 at 10:30 a.m. Patient #7 was placed on unit restriction. On 4/30/18 at 11:15 a.m. Patient #7 attempted to elope.
Further review of Patient #7's medical record revealed on 4/30/18 at 11:40 a.m. an order for Elopement Precautions.
Review of Patient #7's treatment plan revealed no documented evidence of an update after the patient's elopements and placement on unit restriction and elopement precautions.
Patient #9
Review of Patient #9's medical record revealed an admission date of 4/7/18 with admission diagnoses of Bipolar Disorder, Depression, Suicidal Ideation with plan and a history of self-harm/cutting behaviors. Further review revealed the patient's legal status was PEC due to being a harm to self.
Review of the hospital's incident reports revealed a report, dated 4/30/18, involving Patient #9. Further review of the incident summary revealed Patient #9 had tied a sheet around his neck in an attempt to stop breathing and he had broken a piece of floor tile and attempted to cut his throat. Additional review revealed the patient had been increased to visual contact precautions (defined per hospital policy as patient within immediate visual and physical accessibility) precautions. The patient's previous level of observation had been close staff sight (defined per hospital policy as to directly observe location and activity of patient with documentation every 10 minutes). .
Review of Patient #9's treatment plan revealed no documented evidence of an update reflecting the above referenced attempts at self harm and change in observation level status.
Patient #11
Review of Patient #11's medical record revealed an admission date of 11/13/17, a discharge date of 3/14/18, with admission diagnoses of Schizophrenia and Cannabis use. The patient's legal status was judicially committed for competency restoration.
Further review of Patient #11's medical record revealed the patient had eloped on 2/14/18 at 4:58 p.m. and upon return the patient was placed on elopement precautions.
Review of Patient #11's treatment plan revealed no documented evidence of an update after the patient's elopement and placement on elopement precautions.
In an interview on 7/31/18 at 3:50 p.m. with S2DON, she verified elopements, patient self harm/injury, and change in observation level/precautions should have been addressed on the patients' treatment plans. S2DON confirmed the above referenced patients' plans should have been updated.
39791