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Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that psychiatric patients were provided personal privacy. This had the potential to affect the 10 patients on census on the Behavioral Health Unit on 5/28/19. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure that the patients were provided personal privacy. See deficiency at A - 143.

Based on document review, observation, and interview, it was determined that for 1 of 1 Behavioral Health Unit (2 East), the Hospital failed to ensure that patients were provided personal privacy. This potentially affected the 10 patients on census 5/28/19.

Findings include:

1. The Hospital's policy titled, "Patients' Rights and Responsibilities" (revised 02/2018), was reviewed on 5/28/19 and required,"...The patient has the right to every consideration of privacy... this includes at a minimum, that patients have privacy during personal hygiene activities (e.g., toileting, bathing, dressing), during medical/nursing treatments, and when requested as appropriate..."

2. The Hospital's policy titled, "Special Observation" (revised 03/2014), was reviewed on 5/29/19 and included, "...All patient rooms are video monitored for safety..."

3. An observational tour of the 2 East Adult Behavioral Health Unit was conducted on 5/28/19, between 9:10 AM and 11:42 AM. The unit had 7 patient rooms (rooms #272, #273, #274, #275, #276, #277, and #278). All were semi-private (2 beds each) except for one private (1 bed) room (#275). Each patient room had a video camera present on the ceiling. The monitor screen at the nurses' station displayed the interior of all 7 patient rooms and was on during the entire tour.

4. An interview was conducted with the Director of Behavioral Health (E #3) on 5/28/19, at approximately 9:30 AM. E#3 stated that, the cameras are "to monitor the patients at all times." E #3 stated that, the cameras are never turned off and that the monitor screen stays on at the nurses' station 24/7 (24 hours a day, 7 days a week), even when the patients are sleeping. E #3 stated that the cameras do not record.

Based on document review and interview, it was determined that for 1 of 2 (Pt #15) patient records reviewed for behavioral restraint use, the Hospital failed to ensure that telephone verbal orders for restraints were verified and signed by the physician.

Findings include:

1. The Hospital's policy titled, "Restraints, Patient" (04/2018), was reviewed on 5/28/19 and included, "...The physician must be notified immediately without time restriction of the emergency application of restraints for a patient exhibiting violent or self-destructive behaviors and a verbal order is obtained. The verbal order must be co-signed by the physician within 24 hours..."

2. The clinical record of Pt. #15 was reviewed on 5/28/19. Pt. #15 was a 42 year old male, admitted on 4/21/19, with a diagnosis of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy and activity levels). The Restraint Log, dated 4/21/19, indicated that Pt. #15 was in 4 point (both wrists and ankles) restraints from 1:00 PM to 3:15 PM. A "Restraint Order for Violent/Self Destructive Behavior" dated 4/21/19 at 1:00 PM, included, "T.O.R.B [Telephone Order Read Back]" along with the nurse's signature; however, lacked a signature by the physician.

3. An interview was conducted with the Charge Nurse on the Behavioral Health Unit (E #5) on 5/28/19, at approximately 11:19 AM. E #5 stated that, all telephone orders are faxed to the physician and should be signed within 24 hours. E #5 confirmed that the physician's signature was not documented on the restraint order and stated that she was not able to find a signed copy in the patient's medical record.

4. The Hospital's Bylaws and Rules and Regulations dated January 2018, was reviewed on 5/31/19 at approximately 10:30 AM and included, "Page 85...C. General Conduct of Care: 1. All orders for treatment, whether verbal, telephone, fax...shall be authenticated within forty-eight (48) hours..."

Based on document review and interview, it was determined that for 1 of 2 (Pt. #2) records reviewed for patients receiving pain medication, the Hospital failed to ensure that the patient's pain level was reassessed after taking pain medication.

Findings include:

1. On 5/28/19 at 2:00 PM, the Hospital's policy titled, "Medication Administration - Administering and Charting Medication," (reviewed by the Hospital on 1/2018), was reviewed. The policy included, "General Procedures for Administering Medication... Some medications require assessment and verification of patient condition prior to, or as a result of, dosing... f. Pain scale status, as scored by the patient, before and after administration of an analgesic..."

2. On 5/28/19 at 9:30 AM, Pt. #2's clinical records was reviewed. Pt. #2 was an 86 year old male, admitted on 5/24/19, with the diagnoses of asthenia (lack of energy and strength), dizziness, and chronic kidney disease. Pt. #2's physician's order dated 5/24/19 at 2:59 PM, included hydrocodone (used to treat severe pain)/acetaminophen (acetaminophen, used to treat pain), 5/325 (5 milligrams (mg) of hydrocodone and 325 mg of acetamin), PO (by mouth), q 4 PRN (every 4 hours when needed). Pt. #2's medication administration record dated, 5/28/19 at 5:44 AM, included administration of hydrocodone/acetamin for a pain level of 6 (using a 1 - 10 strength pain scale with 10 as the worst pain). However, there was no documentation of a pain reassessment after the medication was administered.

3. On 5/28/19 at 9:40 AM, an interview was conducted with the Charge Nurse (E #2) on the 4th Floor Medical Surgical Unit. E #2 stated that, Pt. #2's pain level "had not been rechecked yet," and pain reassessment should be done 2 hours after receiving the medication.

Based on document review, observation, and interview, it was determined that the Hospital failed to label and date the food products to ensure that they were safe for consumption, potentially affecting 49 patients on census on 5/29/19.

Findings include:

1. On 5/29/19 at 1:15 PM, the Hospital's policy titled, "Ready to Eat Potentially Hazardous Food, Date Marking," (revised 1/2/15), was reviewed. The policy required, "Policy: Date Marking... Procedure: 1. Food prepared on premises shall be held... for no more than 7 days... 2. Food shall be properly labeled. Include on the label: a. Date Prepared, b. Time, c. Product Name, [and] d. Initials of Preparer."

2. On 5/29/19 at 1:25 PM, the Hospital's policy titled, "Food Protection," (revised 1/2/15), was reviewed. The policy required, "Procedure... C. All dry products that are not used up from the package, put contents or the package folder over into a covered container. Label to be used in 10 days."

3. On 5/29/19 at 11:20 AM, an observational tour was conducted in the dietary area and the following was found:

- There were 3 trays of hash browns in the walk-in freezer (#1). There was no label to identify the date the hash browns were prepared or any other information.

- There was a box containing 3 packages of "wheat thins" (a soft round bread like substance, approximately 4 inches in diameter), in a walk-in refrigerator (#2). Each package contained 8 wheat thins. The wheat thin box label was dated 2/21/19 (date of packaging).

- There were 3 (three) 250 pound capacity containers holding: brown sugar, sugar, and flour. The containers were half to three quarters full, but were not labeled with the date the containers were filled.

3. On 5/29/19 at 10:40 AM, an interview was conducted with the Dietary Director (E #4). E #4 stated that the hash browns should have included a date label. The wheat thins had been in the freezer, but were moved to the refrigerator for use. E #4 did not know how long the wheat thins had been in the refrigerator, nor when the wheat thins would be used. E #4 stated that the brown sugar, sugar, and flower bins were emptied and cleaned once a year, but had no log or documentation of the removal process or how long the food products were held.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Re-Certification Survey conducted on June 4 - 5, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Re-Certification Survey conducted on June 4 - 5, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review, observation, and interview, it was determined, for 1 of 1 medication syringe in the Emergency Department (ED), the Hospital failed to ensure that medication in a syringe was labeled and not left unattended, potentially affecting an average of more than 25 patients treated each day in the ED.

1. On 5/30/19 at 10:30 AM, the Hospital's policy titled, "Medication Administration - Labeling of Medications and Solutions in Procedural Settings," (reviewed by the Hospital in January 2018), was reviewed. The policy required, "1. All medications and solutions are labeled immediately whenever they are transferred from the original packaging to another container and are not immediately administered... a. Solutions include... medications... b. Containers include... syringes... 9. Any medications or solutions found unlabeled will be immediately discarded..."

2. On 5/29/19 at 2:00 PM, an observational tour was conducted in the Emergency Department (ED). There was an unlabeled syringe, containing approximately 1 milliliter of a clear fluid, on the counter, in Room 1. The Patient (Pt. #12), in Room 1, had a lacerated left index finger and had received Lidocaine (a numbing medication) prior to suturing.

3. On 5/29/19 at 2:20 PM, an interview was conducted with the ED Director (E #6). E #6 stated that, "It [unlabeled Lidocaine syringe] shouldn't be there".

Based on document review and interview, it was determined that for 2 of 4 (Pt. #26 and Pt. #29) closed records reviewed for discharge planning, the Hospital failed to provide a comprehensive list of home health agency options.

Finding include:

1. The Hospital's policy titled, "Discharge Planning" (revised 09/2015), was reviewed on 5/30/19 and included, "Referrals to Home Health Care are made with physician/provider order for follow-up care post discharge... Documentation of the discharge planning activities will be found on the EMR [electronic medical record] discharge form." The Hospital's policy did not include the requirement that patients' are provided a list of services to meet the patients discharge needs.

2. The clinical record of Pt. #26 was reviewed on 5/30/19. Pt. #26 was a 92 year old male, admitted on 5/1/19, with a diagnosis of cerebrovascular accident (CVA / sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). Pt. #26 was discharged on 5/2/19.

- A Social Worker's (E#8) Discharge Planning notes, dated 5/2/19 at 8:34 AM and 8:41 AM, included, "...Referrals... Home Health:... Yes... Home Heath Agency: [the Hospital's home health service]... Met with patient he wants to go home with HHC [home health care] for PT [physical therapy] / OT [occupational therapy]..."

- The Discharge Summary, dated 5/2/19 at 9:45 AM, included, "...The patient wants to be discharged home - I will order for home health care for physical therapy and occupational therapy evaluation and treatment..."

- The clinical record lacked documentation that a list of participating home health agency options were provided and that the patient was given a choice of which home health agency to use.

3. The clinical record of Pt. #29 was reviewed on 5/30/19. Pt. #29 was a 81 year old male, admitted on 4/3/19, with the diagnoses of hypotension (low blood pressure) and anemia (low red blood cell count). Pt. #29 was discharged on 4/6/19.

- A Social Worker's (E#8) Discharge Planning note, dated 4/4/19 at 3:09 PM, included, "...Discussed the options for discharge ie [that is] Home with outpt [outpatient] PT [physical therapy] Home with HHC, or short term nursing home. They would prefer home..."

- The Discharge Summary, dated 4/6/19 at 9:29 AM, included, "...The patient will be discharged home today with home healthcare..."

- A referral form, dated 4/8/19, indicated that Pt. #29 was referred to the Hospital's home health service.

- The clinical record lacked documentation that a list of participating home health agency options were provided and that the patient was given a choice of which home health agency to use.

4. An interview was conducted with the Social Worker (E #8) on 5/30/19, at approximately 2:30 PM. E #8 stated "We should provide patients with a preferred provider list...we try to do them every time, but I can't tell you that it was done because I can't find it...If you ask me, do I give them routinely?...the answer is no..." E #8 stated that, she does not document whether a list was provided and did not document the patients' agency preference.

5. An interview was conducted with the Director of Care Coordination (E #9) on 5/30/19, at 4:05 PM. E #9 stated that, the discharge planning policy does not address providing a list of home health care agencies to the patient; however, E #9 stated that, a list should be provided to each patient so that the patient can make a choice of which agency to use. E #9 stated that, it should be documented in the medical record that a list was provided to the patient and what the patient's choice was. E #9 confirmed that a list of home health agencies was not scanned into Pt. #26's or Pt. #29's medical records.