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Based on record review and interviews the hospital failed to ensure 1 (#2) of 5 (#1, #2, #3, #4, #5) medical records reviewed was accurately written as evidenced by: 1) failure to ensure Patient #2's Physician Emergency Certificate, PEC, was completed; 2) failure to ensure a Patient #2's Columbia- Suicide Severity Rating Scale was completed and 3) Failure to ensure Patient #2's offer for a formal voluntary admission, request for transfer and the hospitals attempts to locate an accepting facility was documented in the patient's medical record.

Findings:

1) Failure to ensure Patient #2's Physician Emergency Certificate, PEC, was completed

A review of the PEC signed by S10NP on 03/31/2020 at 1:50 p.m. revealed S10NP failed to complete the section Physical Findings (Medical History, Current Medications ETC) nor did she check one of the two boxes identified as Patient # 2 was "not willing" or "unable to seek voluntary admission".

On 10/01/2020 at 10:38 in an interview S10NP, stated she was not sure why she did not complete the Physical Findings section or check the box for "unable to seek voluntary admission" or "unwilling" box on the Physician Emergency Certificate. She also admitted she should have completed the areas.


2) Failure to ensure a Patient #2's Columbia- Suicide Severity Rating Scale was completed

A review of the Columbia Suicide Severity Rating Scale completed by S9MSW dated 03/31/2020 at 12:15 revealed she checked "Yes" to question #2 Have you actually had any thoughts of killing yourself? The form then states: If Yes to 2, ask questions 3,4,5 and 6. If No, go directly to question 6. S9MSW failed to answer questions 3, 4 and 5:
3) Have you been thinking about how you might do this?
4) Have you had these thoughts and had some intention of acting on them?
5) Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan?

On 10/01/2020 at 12:15 p.m. in an interview S9MSW stated she was not sure why she did not complete the initial Columbia Suicide Severity Rating Scale.

On 10/01/2020 at 2:00 p.m. S1Admin and S8COO verified Patient #2's Columbia Suicide Severity Rating Scale dated 03/31/2020 at 12:15 questions 3, 4 and 5 were blank.

3) Failure to ensure Patient #2's offer for a formal voluntary admission, request for transfer and the hospitals attempts to locate an accepting facility were documented in the patient's medical record.

On 09/30/2020 at 11:00 a.m. a review of Patient #2's medical record failed to reveal documentation Patient #2 was offered the ability to sign a Formal Voluntary Admission nor did the record reveal any attempts to locate an accepting hospital for transfer as per the patient's request.

On 10/01/2020 at 12:15 p.m. in an interview S9MSW stated Patient #2 was offered a Formal Voluntary Admission multiple times. She said she spoke with Travis St. Julian her supervisor and then she contacted the doctor on call to see about getting a PEC for Patient #2. She remembers Patient #2 stating he would like to go somewhere else, she stated she called three other facilities close by as the patient requested, but none had an available bed. States she did not document the attempts to locate another facility in the medical record as Patient #2 requested, because Patient #2 ended up staying at their hospital. She confirmed that she should have documented her attempts as well as the offer and refusal of the Formal Voluntary Admission.

On 10/01/2020 at 2:00 p.m. S1Adm and S8COO verified Patient #2's medical record failed to contain documentation Patient #2 was offered and refused to sign a Formal Voluntary Admission and failed to contain documentation the hospital tried to find a different hospital for the patient to be admitted as he requested.

Based on policy reviews, observations and interviews, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices. This deficient practice is evidenced by:
1) failure of staff members (S5MHT, S6RecThe, S7AdmCou) to wear a face mask when indicated and/or to wear a face mask properly;
2) failure to ensure multiuse medications were dated and timed when opened;
3) failure to document patient medications and nourishments were maintained at the appropriate refrigerated temperature.

Findings:

1) Failure of staff members (S5MHT, S6RecThe, S7AdmCou) to wear a face mask when indicated and/or to wear a face mask properly.

A review of the hospital policy titled Universal Masking issued 05/27/2020 revealed in part:
Staff:
1. All employees and practitioners will be asked to wear facial covering or mask as appropriate while on duty.
2. Facial coverings or mask are requested to be worn prior to entering the building and removed only during meals and breaks.

On 09/30/2020 at 9:00 a.m. an observation of the secured entry door to the intake office hallway revealed a sign that reads: "NOTICE FACE MASK REQUIRED ALL EMPLOYEES AND VISITORS MUST WEAR A FACE MASK OR A PROTECTIVE FACE COVERING"

On 09/29/2020 during the tour of hospital revealed S5MHT, S6RecThe and S7AdmCou were not wearing their face mask over their mouth and or nose while within 6 feet of patients.

On 09/29/2020 at 3:50 p.m. in an interview S8COO verified the staff were not wearing their mask appropriately.

2) Failure to ensure multiuse medications were dated and timed when opened.

A review of the hospital policy titled Multi-Dose/ Single- Dose Medications revealed in part:
4.1 All multi-dose vials must be dated with an expiration date of 28 days after first use.

On 09/29/2020 at 12:10 an observation of the West Unit medication refrigerator revealed 2 open bottles of Insulin Humulin R with expiration dates of 10/22 not labeled or dated when opened.

On 09/29/2020 at 12:10 in an interview S1Adm and S2LPN confirmed the medication was opened and not labeled with the opened dates and was available for patient use.

3) Failure to document patient medications and nourishments were maintained at the appropriate refrigerated temperature.

A review of the hospital policy titled Refrigerators- Cleaning and Temperature Monitoring revealed in part:
2.0 Policy: The temperature shall be monitored and documented daily when in use (unless otherwise indicated).
3.2 Check and document the refrigerator temperature daily.

A review of the Refrigerator Monitoring Sheet attached to the front of the pediatric unit refrigerator revealed in part:
Temperatures must be taken twice daily (day shift and night shift) on all refrigerators and freezers.

On 09/29/2020 at 12:10 a review of the West Unit medication refrigerator temperature log failed to reveal a month and unit name as well as documented temperatures on the following days; 2, 3, 4, 7, 8, 11, 12, 13, 16, 17, 21, 22, 25, 26, 27.

On 09/29/2020 at 12:10 in an interview S1Adm and S2LPN verified the form was for the month of September and the dates with missing documented temperatures.

On 09/29/2020 at 12:20 p.m. a review of the North Unit medication refrigerator temperature log revealed missing documented temperatures for the following dates:
a) July:1, 2, 3, 6, 7, 11, 12, 15, 16, 17, 19- 31;
b) August had 2 temperature logs:
#1: 1-4, 6-9-, 13, 14, 17-19, 21-31;
#2: 1-5, 16, 24, 29;
c) September: 2, 7, 8, 16, 17, 21, 25, 26, 27.

On 09/29/2020 at 12:20 p.m. in an interview S1Adm and S3RN confirmed the above missing documented temperatures.

On 09/29/2020 at 12:30 p.m. an observation of the pediatric unit nourishment refrigerator temperature logs revealed:
a) Only one temperature was documented per day for the months of June, July, August and September 2020;
b) September 2020 failed to have documented temperature checks on 24 - 28.

On 09/29/2020 at 12:30 p.m. in an interview S1Adm and S4LPN confirmed the above information.