HospitalInspections.org

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights.

An Immediate Jeopardy situation was declared under the Condition of Patient Rights on 07/23/13 at 3:46 p.m. The facility failed to ensure that direct patient care staff was adequately trained and educated to respond to patient emergencies involving Basic Life Support and administration of emergency medications. The facility failed to ensure that clothing worn by patients did not contain cords/ties, considered contraband by the facility, which could have been used for patient self-injury or injury to others.

An acceptable plan to remove the Immediate Jeopardy situation was received and the IJ was removed on 07/24/13 prior to exit, while still on site. The Condition of Patient Rightts remains out of compliance.
Plan to remove the IJ included:
Staff Education regarding location of emergency equipment: All working staff received a spot education regarding the Emergency Cart/Equipment and procedure for code blues for days and nights on 7.23.13 and days for 7.24.13. All RN's not scheduled to work received telephonic education and will have follow-up 1:1 prior to next shift worked. All other staff not scheduled on the 23rd or 24th will receive education prior to working their next shift
Equipment in the emergency cart not complete/missing/or expired: Emergency equipment bags were checked to ensure all required supplies were present and up to date. Emergency cart contents are attached to the yellow emergency bag with expiration dates listed and security lock in place. Nightly checklist that is completed by the RN on Unit A was updated to check expiration dates as well as a monthly verification of all items on the 15th of the month. Verification of Emergency equipment check has been added to the night supervisor checklist to be completed nightly.
Mock codes were conducted for all staff present on 7-23-13, for both shifts and all staff starting 7.24.13. Code Blue drills will be conducted minimally once per shift per week on each unit until all staff have been deemed competent and then one per month per unit on a go forward basis.
Concern about drawstring pants: All draw string pants were removed from the facility and replaced with elastic band scrubs.
Evaluations of Code blues will be added back to standing agenda for both MEC and QC starting in August. Evaluation from code blues for July were shared with the members of the QC and Med Exec.
The facility failed to meet the following standards under the Condition of Patient Rights:

Cross Reference Tag A0144 - Patient Rights: Care in a Safe Setting. The patient has the right to receive care in a safe setting.
The facility failed to ensure that direct patient care staff was adequately trained and educated to respond to patient emergencies involving Basic Life Support and the administration of emergency medications. The facility failed to ensure that clothing worn by patients did not contain cords/ties, considered contraband by the facility, which could have been used for patients' self-injury or injury to others.

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Quality Assurance and Performance Improvement(QAPI). The facility failed to ensure that data obtained from Code Blue drills was used to improve the performance of facility staff during emergency events.

The facility failed to meet the following standards under the Condition of Participation of Quality Assurance and Performance:

Reference Tag A0273 - QAPI: Data Collection and Analysis. The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes. The facility failed to ensure that direct patient care staff was adequately trained and educated to respond to patient emergencies involving Basic Life Support. The facility failed to ensure that data obtained during Code Blue drills was utilized to improve staff performance during emergencies involving basic life support.

a) On 07/24/13, meeting minutes from the facility's Quality Council were reviewed for the year 2013. A total of 7 Quality Council Meetings were found documented in the facility's Quality Council binder. The meetings were dated; 01/22/13, 02/28/13, 03/26/13, 04/23/13, 05/30/13, 06/28/13, and 07/11/13. Meeting minute agendas, detailed documentation of issues discussed, and supporting documentation, revealed no discussion of the facility's Code Blue drills and evaluation of these drills.

b) On 07/24/13 at 1:39 p.m., an interview was conducted with the facility's Medical Director, who stated s/he started as Medical Director on 05/01/13. The Medical Director stated s/he had attended Medical Executive Committee meetings, Governing Body meetings, and to date, had attended 1 meeting of the Quality Council. The Medical Director stated s/he was not made aware of deficiencies identified from staff Code Blue drills.

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Infection Control. The facility failed to ensure that facility practices were performed in a manner that would prevent communicable diseases.

This failure contributed to patients and staff being exposed to potentially infectious agents.

Findings:

1. The hospital did not ensure that staff restrooms were supplied with soap.

a) On 07/23/13 at 8:10 a.m., the staff restroom on patient Unit A was viewed. The staff restroom had a soap dispenser mounted on the wall, but no soap was contained in the dispenser. No other soap was viewed in the staff restroom.

b) On 07/23/13 at 8:35 a.m., the staff restroom on patient Unit A was again viewed by two surveyors. The soap dispenser remained empty of soap and no other soap was viewed in the staff restroom. Behavioral Health Technician (BHT) #2 was notified that the staff restroom on Phase I had no soap. BHT #2 verified there was no soap in the restroom and stated this was the only staff restroom on this unit. BHT #2 stated that s/he would have housekeeping refill the soap dispenser. BHT #2 stated that until housekeeping refilled the soap dispenser, that nursing staff could walk across the hall to the nourishment room after using the restroom and use the sink there. The nourishment room contained patient snacks, including food and drink.

c) On 07/23/13 at 9:51 a.m., the staff restroom on patient Unit A was again viewed by two surveyors. The soap dispenser remained empty and no other soap was available in the staff restroom.

d) On 07/23/13 at 10:21 a.m., an interview was conducted with BHT #3. BHT #3 stated that s/he was unaware of any other staff restrooms that were contained in the unit and that s/he was unaware of who to contact if soap was needed in the staff restroom.

e) On 07/23/13 at 10:25 a.m., the staff restroom on patient Unit A was again viewed by two surveyors. The soap dispenser remained empty and no other soap was available in the staff restroom.

f) On 07/23/13 at 11:05 a.m., an interview was conducted with the facility's Director of Quality Management (DQM) and the facility's Director of Nursing (DON). The DON stated that this facility contracted with another facility in the same building to provide housekeeping services. The DON stated it was his/her expectation that facility staff would know to contact housekeeping if the staff restroom was out of soap.

During the same interview, the DQM stated that all facility staff were provided individual bottles of hand sanitizer to carry on them at all times. The DQM stated that although staff had hand sanitizer, s/he would prefer them to use soap.

g) On 07/23/13 at 12:49 p.m., the staff restroom on patient Unit A was again viewed by two surveyors. The soap dispenser in the staff restroom remained empty and no other soap was available in the staff restroom. After viewing the restroom, an interview was conducted with BHT #4. BHT #4 stated that s/he was aware that was currently no soap in the staff restroom and that after using the restroom that s/he had walked from the staff restroom to the locked patient nourishment room, containing patient food and drink, across the hall to wash his/her hands.

h) On 07/24/13 at 11:49 a.m., the facility's policy,"Hand Hygiene," was reviewed. The policy stated, "All health care workers will use appropriate hand hygiene to reduce the transmission of microorganisms." The policy further stated,"When hands are visibly dirty or contaminated, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water....Decontaminate hands before eating, after going to the bathroom and after sneezing and coughing wash hands with soap and water...Because alcohol does not kill Clostridium difficile (an infectious organism) spores, use of soap and water is more efficacious than alcohol-based hand rubs." The facility's DQM verified this was the current policy.

Based on observations, document review, and interviews, the facility failed to ensure the safe care of patients.

This failure created the potential for negative patient outcomes including patient injury or harm.
Findings:
1. The facility failed to ensure that staff were educated on the location of emergency equipment that was needed to respond to emergency situations requiring Basic Life Support interventions.

a) From 07/22/13 through 07/24/13, a sample of 30 patient medical records were reviewed. The sample included both open and closed medical records of patients admitted from 06/07/13 through 07/21/13. The ages of the sample patients ranged from 55 years of age to 95 years of age. Further breakdown of the patient medical records sampled revealed 3 patients were in their 50's, 8 patients were in their 60's, 8 patients were in their 70's, 8 patients were in their 80's, and 3 patients were in their 90's. Documented psychiatric diagnoses upon admission included, but was not limited to; multiple categories of dementia, anxiety, depression, schizoaffective disorder, schizophrenia, bipolar disorder, acute psychosis, Post Traumatic Stress Disorder, suicidal ideation, altered mental status, and delusions.

Review was conducted of the medical diagnoses of the 30 sample medical records. Fifteen of 30 medical records reviewed revealed an admission diagnosis of hypertension (Sample Patients #1, #2, #3, #4, #7, #13, #16, #19, #20, #22, #23, #27, #28, #29, and #30.) Five of 30 medical records revealed a history of seizure disorder upon admission (Sample Patients #3, #4, #5, #27, and #28). Ten of 30 medical records reviewed revealed a history of gastroesophageal reflux disease or esophageal reflux disease and stenosis (Sample Patients #3, #6, #7, #11, #15, #19, #20, #26, #29, and #30). Sample Patient #3 had a documented admitting diagnosis of orthostatic hypotension, and Sample Patient # 29 had a documented history of "frequent falls." Sample Patient #7 had a documented admitting diagnosis of Chronic Heart Failure, Sample Patient #12 had a documented history of "heart arrhythmias," Sample Patient #19 had a documented history of subacute stroke, Sample Patient #21 had a documented history of atrial fibrillation, Sample Patient #23 had a documented history of Coronary Artery Disease with a previous myocardial infarction, Sample Patient #25 had documented, "heart disease with minor heart attacks on 3 occasions," and Sample Patients #28 and #29 had documented Coronary Artery Disease. Sample Patient #11 had documented "long standing swallowing difficulty" upon admission, and Sample Patients #15 and #20 had documented episodes of decreased serum potassium upon admission. This is a sample, and not an all-inclusive list, of medical diagnoses upon admission, that could have led to emergency medical situations for patients in which facility staff would be required to respond with Basic Life Support.





b) On 07/22/13 at 1:47 p.m., a tour of the facility's patient Unit A was conducted. During the tour, an interview was conducted with Registered Nurse (RN) #3, regarding the location of emergency equipment, including the facility's portable suction and emergency response cart. RN #3 led the surveyors to an examination room located at the end of a hallway in patient Unit B and stated this was where the portable suction and emergency response cart were located. Upon entering the examination room, no emergency response cart or portable suction was observed. RN #3 stated that if the emergency cart was not in the room that it meant it was "being worked on by someone." RN #3 stated that there was portable suction in the patient dining room, but was unable to state the location of another emergency cart in the facility.

c) On 07/22/13 at 1:15 p.m., a review of 3 Registered Nurse (RN) and 3 Behavioral Health Technicians (BHTs) personnel files, who all worked as full-time employees at the facility, was conducted. All 6 personnel files contained documentation that the the employees were currently certified in Basic Life Support. None of the 6 personnel files contained documentation that the employees had been oriented to the location of emergency equipment needed to perform procedures during emergencies.

d) On 07/22/13 at 4:15 p.m., an interview was conducted with the facility's Director of Quality Management (DQM) and the company's Vice President of Nursing. Both the DQM and the Vice President of Nursing were informed that RN #3 was unable to locate the facility's emergency response cart. The DQM stated s/he believed that all staff had participated in Code Blue drills and should know where emergency items were located.

e) On 07/23/13 at 8:45 a.m., a tour of the facility's patient Unit A was conducted. During the tour, Behavioral Health Technician (BHT) #1 was interviewed in regard to the location of emergency equipment, including the facility's automated external defibrillator (AED), portable suction, and emergency response cart. BHT #1 stated that all of the items were located in an examination room at the end of the hallway in patient Unit B, which was the same room RN #3 had shown surveyors the previous day. BHT #1 was unable to state any other location where these items were located. The examination room at the end of the hallway in patient Unit B was observed by the surveyors, but did not contain any emergency equipment.

f) On 07/23/13 at 10:35 a.m., the facility's Quality Management binder for 2013 was reviewed with the facility's Director of Quality Management (DQM). The facility's DQM verified this was the current binder for the year. Inside the binder, documentation of emergency drills including Code Blues drills (cardiac/respiratory arrests) were documented. The binder contained three documented Code Blue drills between 01/01/13 and the current date of 07/23/13. The mock Code Blues were documented on the facility's "Code Blue Evaluation" forms. The dates and times of the Mock Code Blues were documented as 01/09/13 at 3:47 p.m., 05/27/13 at 2:50 a.m., and 07/16/13 at 2:40 p.m.

The Code Blue Evaluation forms contained an area to document the evaluation of staff response to the Code Blue drills. It was documented on the evaluation form dated 01/09/13 at 3:47 p.m., that staff did not bring all necessary equipment to the Code Blue drill, including the AED and the emergency medications. It was also documented that the Registered Nurse did not make appropriate staff assignments during the code blue drill, and that the Behavioral Health Technicians did not know their roles and responsibilities during the Code Blue drill.

It was documented on the evaluation form dated 05/27/13 at 2:50 a.m., that the bags of emergency equipment, that were contained on the emergency cart, were missing items and contained documentation stating, "see note of missing items." No note of missing items was located in the Quality Management binder. The facility's DQM stated that s/he was unaware of what items were missing and was unable to locate a list of the missing items.

It was documented on the evaluation form dated 07/16/13 at 2:40 p.m., that the facility staff did not bring all necessary equipment, including a vital signs machine and a backboard, to the Code Blue drill.

The DQM stated s/he believed these Code Blue drills were discussed at Quality Meetings. The Quality Management binder contained no documentation that the Code Blue drills or their evaluations had been discussed at quality meetings. The DQM was unable to provide any documentation, including meeting minutes, that the Code Blue drills or their evaluations had been discussed at the facility's quality meetings.

g) On 07/23/13 at 10:53 a.m., an interview with the facility's Director of Nursing (DON) and DQM was conducted. The DON stated that s/he had been alerted by the DQM on 07/22/13 that nursing staff and Behavioral Health Technicians (BHTs) could not locate emergency equipment in the facility. The DON stated that during shift change on 07/22/13, s/he had educated nursing and BHT staff on the location of emergency equipment, but was unable to provide documentation of this education. The DON stated that all emergency equipment was located on patient Unit A and that the AED was behind the nursing station and the emergency cart and portable suction were located in the copy room on patient Unit A. The DON was made aware that on the morning of 07/23/13, BHT #1, who had worked on both 07/22/13 and 07/23/13, was still unaware of the location of emergency equipment.

h) During the same interview, the facility's policy, "Code Blue," was reviewed with facility's DON and DQM. The policy stated, "The DON will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by The Director of Nursing to identify training needs, process issues, etc. Results of the evaluations will be submitted to Quality Council and Medical Executive Committees." The DQM and DON verified this was the facility's current policy, but were unable to provide documentation of how the Code Blues drills and evaluations were addressed at Quality Council or Medical Executive Committee. The DON stated that it was his/her expectation that the Code Blue evaluations would be discussed at Quality meetings and that Code Blue drills would be conducted more frequently.

i) On 07/24/13 at 9:32 a.m., an interview was conducted with RN #1. RN #1 stated s/he had attended a Code Blue drill the night before on 07/23/13, and also another Code Blue drill on the morning of 07/24/13, at the facility. RN #1 stated that during the Code Blue drill, staff members got the actual emergency equipment, including portable suction, an AED, and emergency medications. RN #1 stated s/he participated in these Code Blue drills, but was unable to state where the emergency medications were located or how to access them in case of an emergency situation.

2. The facility provided to patients, and allowed patients to wear, scrubs that contained cording/ties in the waist of pants that could have been used by patients for self-harm or harm to others.

Review was conducted on 30 patient medical records. Admission diagnoses and psychiatric evaluations were reviewed. Seventeen of 30 medical records (Sample patients #1,
#2, #4, #5, #6 ,#7, #8, #10, #13, #14, #20, # 21, #23, #24, #25, #28, #29) documented the patient was at risk to her/himself or others due to aggressive or assaultive behaviors or had expressed suicidal ideation leading to admission into the facility.
Sample Patient #1 medical record psych evaluation documented aggressive behavior towards caregivers, threatening to kill staff. Further documentation stated patient behaviors needed to be addressed to avoid the patient injuring her/himself or others.
Sample Patient #2 medical record psych evaluation documented aggression in the recent past, injuring another resident in her/his prior facility and increased aggressive behaviors.
Sample Patient #4 medical record documented the patient was placed on an M1 hold at an acute care hospital as s/he was deemed unsafe due to increased aggressive and combative behaviors.
Sample Patient #5 medical record documented in the psych evaluation at previous facility, the patient had increased aggression and agitation, hitting staff, peers and family members. "Patient is very violent -hits and hurts people."
Sample Patient #6 medical record psych evaluation documented sudden change in behavior, more aggressive, representing increased risk of harm to others.
Sample Patient #8 was admitted on an M1 hold secondary to danger to others. The patient in their previous facility was documented as hitting, shoving staff, residents and visitors at the facility.
Sample Patient #10 was admitted from a long term care facility due to behavior changes, screaming, yelling and trying to trip other residents.
Sample Patient #13 was admitted with depression. The psych evaluation documented the patient had expressed suicidal thoughts but did not want to act on them.
Sample Patient #14 medical record psych evaluation documented the patient was physically aggressive and stated s/he was verbalizing more suicidal ideation.
Sample Patient #20 was admitted on an M1 hold after assaulting her/his roommate with broken glass, cutting and injuring the roommate. The patient was considered a danger to self and others.
Sample Patient #21 was admitted with depression. The patient was on an M1 hold and expressed suicidal ideation but never acted on it.
Sample Patient #23 medical record documented the patient was physically assaultive and combative. Earlier, prior to the psych evaluation at this facility the patient's shoelaces were removed. The patient became upset and attempted to hit a staff member on the head with the shoe.
Sample Patient #24 was admitted from an acute care hospital after being placed on an M1 hold. The patient was walking around town with a plastic bag over his head. The patient reported s/he was thinking of killing her/himself.
Sample Patient #25 was admitted on an M1 hold after attempting to set fire to her/his apartment and stating s/he wanted to end her/his life.
Sample Patient #28 was admitted on an M1 hold at an acute care hospital. The medical record documented that "the patient denies SI (suicidal ideation) but told someone that today is a good day to die". That person told staff that the patient was thinking of killing her/himself.
Sample Patient #29 was admitted on an M1 hold due to aggressive and violent behavior toward other residents.. The patient was considered a danger to her/himself and others. Four days after admission at this facility, the patient became aggressive, attempted to hit another patient and was put on LOS (line of sight).

a) On 07/22/13 at 12:43 p.m., observation of the 2 patient units was conducted. In both patient Units A and B, a number of patients were noted wearing blue scrubs as clothing. The scrubs were 2 piece, consisting of a top and pants.

b) On 07/22/13 at 1:30 p.m., observation was conducted in the patient shower room in patient Unit A. On a shelving unit inside the shower room, sets of folded, blue scrubs were noted, both tops and pants. The pants of the scrubs were noted to have cords/ties at the waist.

c) On 07/23/13 at 8:38 a.m., observation of patient Units A and B were conducted. On Unit A, patients in rooms 128, 130, and 133 were observed wearing blue scrubs. A patient walking down the hallway in front of the nurses' station was also observed wearing blue scrubs. All scrub pants had cords/ties at the waist that were visible. RN #4 confirmed these patients were wearing scrub pants with cords/ties at the waist. On Unit B, multiple patients were observed in the hallways wearing blue scrubs with cords/ties visible at the waist.

d) On 7/23/13 at 8:44 a.m., an interview was conducted with BHT #2, who stated s/he had worked in the facility for approximately 3 years and that scrubs had been available for patients to wear during this time. S/he stated all the scrub pants had cords/ties at the waist, not elastic. S/he stated no scrub pants had been provided to patients, in his/her 3 years as an employee, with elastic in the waist. The cords/ties were noted to be sewn in at the back seam of the pants. It was noted that the pant waist material could be moved to the back seam which allowed approximately 24 inches of cording, on each side of the pants, to be available for a total of 48 inches of available cording. BHT #2 stated no discussion of the cords, or education of staff regarding the cords, had been conducted with staff in the 3 years s/he had been employed at the facility. BHT #2 stated it was possible for the cording/ties on patient scrubs to be used by patients for self-harm or harm to others.

e) On 07/23/13 at 08:50 a.m., an interview was conducted with RN #2, who stated s/he had been employed at the facility for approximately 5 years, that scrubs had been available for patient use during this time, and that no education had been provided to staff regarding possible safety issues with the cording/ties in the scrub pants.

f) On 07/23/13 at 9:51 a.m., an interview was conducted with BHT #5, who stated s/he had been employed at the facility for just less than 1 year. S/he stated if patients were on suicide watch, they would still be provided, and could wear, the scrubs that contained the cord/tie drawstring waist. S/he stated a number of items that patients who were deemed suicidal could not have, including belts or anything that could be used to injure themselves. BHT #5 stated s/he had received no education regarding the cording/ties in scrub pants and possible safety issues, including safety issues with patients on suicide watch having access to cords.

g) On 07/23/13 at 10:12 a.m., an interview was conducted with BHT #6, who stated s/he had been employed at the facility for the past 9 months. S/he stated scrubs were provided by the facility to any patient who wished to wear them, including patients who were suicidal. BHT #6 stated certain items that patients on suicide watch could not have including "no strings or shoe laces" and that staff would not wear lanyards around their necks when caring for suicidal patients, as a safety precaution. BHT #6 stated s/he had received no education regarding the cording/ties in scrub pants and possible safety issues, including safety issues with patients on suicide watch having access to cords.

h) On 07/23/13 at 10:25 a.m., an interview was conducted with BHT #3, who stated s/he had been employed at the facility on an as-needed basis for 1.5 years. S/he stated patients on suicide watch could wear scrubs provided by the facility and that s/he had not received education regarding possible patient safety issues of scrubs with cording/ties at the waist.

i) On 07/22/13 at 2:16 p.m., the facility policy titled, "Contraband," revised date, June, 2011, was reviewed. The policy listed items that would be taken from patients at the time of admission, as these were considered to be contraband. Among the items listed were, "Belts, shoelaces, handkerchiefs, scarves, and clothing with ties or drawstrings."

j) On 07/23/13 at 10:45 a.m., the facility policy titled, "Suicide Precautions," revised date, June, 2011, was reviewed. The policy stated, as part of the facility's procedure for patients at risk for suicide and other self-destructive behavior, "5) Staff will perform interventions specific to suicide observation: a) Perform a thorough search of the patient's clothing. Articles and belongings will be completed to ensure that any items which might be used in a self harmful way are confiscated. i) Remove belts, cords, glasses and sharp objects." The policy stated, "Although a one-to-one ratio or line of sight may not be needed, close supervision is required. a) Staff will perform these interventions: i) Program staff will closely observe and do safety checks on the patient at least every 15 minutes. (1) Staff will request that the patients make them aware of their whereabouts when not in the common use area."

k) On 07/23/13 at 11:01 a.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing. The findings regarding the use of scrub pants with cords/ties were reviewed. The DON stated at other facilities where s/he had worked, scrub pants provided for patient use did not have cords/ties but instead had elastic waistbands. The Vice President stated it was his/her understanding that scrub pants provided to patients would have elastic in the waist and s/he was unaware of scrub pants being used in this facility that had cords/ties. The Vice President stated scrub pants for patient use should not have cords/ties as part of the clothing. Staff present for the interview confirmed the "Contraband" policy and the "Suicide Precautions" policy were current and to be used by facility staff.

Based on observation, interviews, and facility document review, the facility failed to ensure that nursing staff and certified nursing assistants (Behavioral Health Technicians) were trained on how to respond to emergency situations after lapses in training were identified.

This failure created the potential to cause harm to all patients served by the facility. The facility failed to ensure that data collected from Code Blue drills was used to identify areas for improvement regarding staff response to emergency situations requiring Basic Life Support interventions.


Findings:

1. The facility did not use data/information collected from Code Blue drills to identify areas for improvement regarding staff response to emergency situations requiring Basic Life Support interventions.

a) On 07/23/13 at 10:35 a.m., the facility's Quality Management binder for 2013 was viewed with the facility's Director of Quality Management (DQM). The facility's DQM verified this was the current binder for the year. Inside the binder, documentation of emergency drills, including Code Blues drills (cardiac/respiratory arrests) were documented. The binder contained three documented Code Blue drills between 01/01/13 and the current date of 07/23/13. The Code Blue drills were documented on the facility's "Code Blue Evaluation" forms. The dates and times of the Mock Code Blue drills were documented as 01/09/13 at 3:47 p.m., 05/27/13 at 2:50 a.m., and 07/16/13 at 2:40 p.m.

The Code Blue Evaluation forms contained an area to document the evaluation of staff response to the Code Blue drills. It was documented on the evaluation form dated 01/09/13 at 3:47 p.m., that staff did not bring all necessary equipment to the Code Blue drill, including the Automated External Defibrillator (AED) and the emergency medications. It was also documented that the Registered Nurse (RN) did not make appropriate staff assignments during the Code Blue drill and that the Behavioral Health Technician (BHT) did not know his/her role during the Code Blue drill.

It was documented on the evaluation form dated 05/27/13 at 2:50 a.m., that the bags of emergency equipment, which were contained on the emergency cart, were missing items. The Code Blue evaluation form contained documentation stating, "see note of missing items." No note of missing items was located in the Quality Management binder. The facility's DQM stated that s/he was unaware of what items were missing and was unable to locate a list of the missing items.

It was documented on the Code Blue evaluation form dated 07/16/13 at 2:40 p.m., that the facility staff did not bring all necessary equipment, including a vital signs machine and a backboard, to the Code Blue drill.

The DQM verified only 3 Code Blue drills were documented from January 1, 2013 until the current date of 07/23/13. The DQM stated s/he believed an additional Code Blue drill had been conducted in June, but could not find any documentation of the Code Blue drill occurring.

b) During the Quality binder review, an interview was conducted with the DQM. The DQM stated s/he believed these mock codes were discussed at Quality Meetings. The Quality Management binder contained no documentation that the Code Blue drills or their evaluations had been discussed at Quality meetings. The DQM was unable to provide any documentation, including meeting minutes, that the Code Blue drills or their evaluations had been discussed at the facility's Quality meetings.

c) On 07/23/13 at 10:53 a.m., an interview with the facility's Director of Nursing (DON) and DQM was conducted, and the facility's policy, "Code Blue," was reviewed. The policy stated, "The DON will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by the Director of Nursing to identify training needs, process issues, etc. Results of the evaluations will be submitted to Quality Council and Medical Executive Committees."

The DQM and DON verified this was the facility's current policy, but were unable to provide documentation of how the Code Blue evaluations were addressed at Quality Council. The DON stated it was his/her expectation that the Code Blue evaluations would be discussed at Quality meetings.

d) During the same interview, the DON was asked what s/he had done to address the areas for improvement identified in the Code Blue evaluations. The DON stated that nursing staff were re-educated by the Charge Nurse or other staff member organizing the Code Blue drill at the time it happened. The DON stated that s/he planned to implement additional Code Blue training for the entire staff but had not done it as of yet.

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Based on observation, document review, and interviews, the facility failed to ensure that all medication errors were documented and reported to the facility's Quality Committee for review.

This failure created the potential for medication errors to be underreported by staff, specifically nursing staff.

Findings:

1. Facility Registered Nurse (RN) #1, was unaware how to complete documentation regarding a medical error that occurred in the facility on 07/23/13. Without questioning by surveyors, the medication error would likely have remained unreported and would not be available for review by the facility's Quality Committee.

a) Cross Reference Tag A0405- Nursing: Administration of Drugs: Staff RN #1 failed to observe the oral administration of a medication by Sample Patient #2 on 07/23/13, per facility policy, failed to inform any staff member, including the facility's pharmacy, that a dose of medication had been discarded and would result in a medication variance, and failed to complete a medication error report for review by the facility's Quality Committee.

b) On 07/24/13 at 2:54 p.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing, to review findings regarding the medication not administered to Sample Patient #2 and the lack of documentation of this issue. The facility's DON stated all nurses, including agency nurses, receive "med variance training" and that all nurses are expected to report medication errors on specific facility forms for review. Both the DON and the Vice President of Nursing confirmed the dose of Levaquin, not observed as taken by the patient, and the discarding of the dose by the RN, constituted a medication error. Both the DON and the Vice President of Nursing confirmed RN #1 should have made a note in the patient medical record regarding the discarded dose of Levaquin and why it was discarded. The DON reviewed the medical record for Sample Patient #2 and confirmed no nursing note was found regarding this issue. When asked if medication errors were reported by nursing staff and reviewed in Quality, the Vice President and the DON confirmed this was the expectation.

Based on observation, interviews, and facility document review, the facility failed to ensure that nursing staff and certified nursing assistants [Behavioral Health Technicians, (BHTs)] were trained on how to respond to an emergency situation.

This failure created the potential to cause harm to all patients served by the facility.

Findings:

1. The facility failed to ensure that staff was educated on the location of emergency equipment that was needed to respond to emergency situations requiring Basic Life Support interventions.

a) From 07/22/13 through 07/24/13, a sample of 30 patient medical records were reviewed. The sample included both open and closed medical records of patients admitted from 06/07/13 through 07/21/13. The ages of the sample patients ranged from 55 years of age to 95 years of age. Further breakdown of the patient medical records sampled revealed 3 patients were in their 50's, 8 patients were in their 60's, 8 patients were in their 70's, 8 patients were in their 80's, and 3 patients were in their 90's. Documented psychiatric diagnoses upon admission included, but was not limited to; multiple categories of dementia, anxiety, depression, schizoaffective disorder, schizophrenia, bipolar disorder, acute psychosis, Post Traumatic Stress Disorder, suicidal ideation, altered mental status, and delusions.

Review was conducted of the medical diagnoses of the 30 sample medical records. Fifteen of 30 medical records reviewed revealed an admission diagnosis of hypertension (Sample Patients #1, #2, #3, #4, #7, #13, #16, #19, #20, #22, #23, #27, #28, #29, and #30.) Five of 30 medical records revealed a history of seizure disorder upon admission (Sample Patients #3, #4, #5, #27, and #28). Ten of 30 medical records reviewed revealed a history of gastroesophageal reflux disease or esophageal reflux disease and stenosis (Sample Patients #3, #6, #7, #11, #15, #19, #20, #26, #29, and #30). Sample Patient #3 had a documented admitting diagnosis of orthostatic hypotension, and Sample Patient # 29 had a documented history of "frequent falls." Sample Patient #7 had a documented admitting diagnosis of Chronic Heart Failure, Sample Patient #12 had a documented history of "heart arrhythmias," Sample Patient #19 had a documented history of subacute stroke, Sample Patient #21 had a documented history of atrial fibrillation, Sample Patient #23 had a documented history of Coronary Artery Disease with a previous myocardial infarction, Sample Patient #25 had documented, "heart disease with minor heart attacks on 3 occasions," and Sample Patients #28 and #29 had documented Coronary Artery Disease. Sample Patient #11 had documented "long standing swallowing difficulty" upon admission, and Sample Patients #15 and #20 had documented episodes of decreased serum potassium upon admission. This is a sample, and not an all-inclusive list, of medical diagnoses upon admission, that could have led to emergency medical situations for patients in which facility staff would be required to respond with Basic Life Support.

b) On 07/22/13 at 1:47 p.m., a tour of the facility's patient Unit A was conducted. During the tour, an interview was conducted with Registered Nurse (RN) #3, regarding the location of emergency equipment, including the facility's portable suction and emergency response cart. RN #3 led the surveyors to an examination room that was located at the end of a hallway in patient Unit B, and stated this was where the portable suction and emergency response cart were located. Upon entering the examination room, no emergency response cart or portable suction was viewed. RN #3 stated that if the emergency cart was not in the room that it meant it was "being worked on by someone." RN #3 stated there was portable suction in the patient dining room, but was unable to state the location of another emergency cart in the facility.

c) On 07/22/13 at 1:15 p.m., a review of 3 Registered Nurse (RN) and 3 BHT personnel files, who all worked as full-time employees at the facility, was conducted. All 6 personnel files contained documentation that the employees were currently certified in Basic Life Support. None of the 6 personnel files contained documentation that the employees had been oriented to the location of emergency equipment needed to perform procedures during emergencies.

d) On 07/22/13 at 4:15 p.m., an interview was conducted with the facility's Director of Quality Management (DQM) and the company's Vice President of Nursing. Both the DQM and the Vice President of Nursing were informed that RN #3 was unable to locate the facility's emergency response cart. The DQM stated that s/he believed that all staff had participated in Code Blue drills and should know where emergency items were located.

e) On 07/23/13 at 8:45 a.m., a tour of the facility's patient Unit A was conducted. During the tour, Behavioral Health Technician (BHT) #1 was interviewed in regard to the location of emergency equipment, including the facility's automated external defibrillator (AED), portable suction, and emergency response cart. BHT #1 stated that all of the items were located in an examination room at the end of the hallway in patient Unit B, which was the same room RN #3 had shown surveyors the previous day. BHT #1 was unable to state any other location where these items were located. The examination room at the end of the hallway in patient Unit B was viewed by the surveyors, but did not contain any emergency equipment.

f) On 07/23/13 at 10:35 a.m., the facility's Quality Management binder for 2013 was viewed with the facility's Director of Quality Management (DQM). The facility's DQM verified this was the current binder for the year. Inside the binder, documentation of emergency drills including Code Blue drills (cardiac/respiratory arrests) were documented. The binder contained three documented Code Blue drills between 01/01/13 and the current date of 07/23/13. The mock Code Blue drills were documented on the facility's "Code Blue Evaluation" forms. The dates and times of the Mock Code Blue drills were documented as 01/09/13 at 3:47 p.m., 05/27/13 at 2:50 a.m., and 07/16/13 at 2:40 p.m.

The Code Blue Evaluation forms contained an area to document the evaluation of staff response to the Code Blue drills. It was documented on the evaluation form dated 01/09/13 at 3:47 p.m., that staff did not bring all necessary equipment to the code blue drill, including the AED and the emergency medications. It was also documented that the Registered Nurse did not make appropriate staff assignments during the code blue drill, and that the Behavioral Health Technicians did not know their roles and responsibilities during the Code Blue drill.

It was documented on the evaluation form dated 05/27/13 at 2:50 a.m., that the bags of emergency equipment, that were contained on the emergency cart, were missing items and contained documentation stating, "see note of missing items." No note of missing items was located in the Quality Management binder. The facility's DQM stated that s/he was unaware of what items were missing and was unable to locate a list of the missing items.

It was documented on the evaluation form dated 07/16/13 at 2:40 p.m., that the facility staff did not bring all necessary equipment, including a vital signs machine and a backboard, to the Code Blue drill.

The DQM stated s/he believed these Code Blue drills were discussed at Quality Meetings. The Quality Management binder contained no documentation that the Code Blue drills or their evaluations had been discussed at quality meetings. The DQM was unable to provide any documentation, including meeting minutes, that the Code Blue drills or their evaluations had been discussed at the facility's quality meetings.

g) On 07/23/13 at 10:53 a.m., an interview with the facility's Director of Nursing (DON) and DQM was conducted. The DON stated that s/he had been alerted by the DQM on 07/22/13 that nursing staff and Behavioral Health Technicians (BHTs) could not locate emergency equipment in the facility. The DON stated that during shift change on 07/22/13, s/he had educated nursing and BHT staff on the location of emergency equipment, but was unable to provide documentation of this education. The DON stated that all emergency equipment was located on patient Unit A and that the AED was behind the nursing station and the emergency cart and portable suction were located in the copy room on patient Unit A. The DON was made aware that on the morning of 07/23/13, BHT #1, who had worked on both 07/22/13 and 07/23/13, was still unaware of the location of emergency equipment.

h) During the same interview, the facility's policy, "Code Blue," was reviewed with facility's DON and DQM. The policy stated, "The DON will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by The Director of Nursing to identify training needs, process issues, etc. Results of the evaluations will be submitted to Quality Council and Medical Executive Committees." The DQM and DON verified this was the facility's current policy, but were unable to provide documentation of how the Code Blues drills and evaluations were addressed at Quality Council or Medical Executive Committee. The DON stated that it was his/her expectation that the Code Blue evaluations would be discussed at Quality meetings and that Code Blue drills would be conducted more frequently.

i) On 07/24/13 at 9:32 a.m., an interview was conducted with RN #1. RN #1 stated she had attended a Code Blue drill the night before on 07/23/13, and also another Code Blue drill on the morning of 07/24/13, at the facility. RN #1 stated that during the Code Blue drill, staff members got the actual emergency equipment, including portable suction, an AED, and emergency medications. RN #1 stated s/he participated in the Code Blue drills, but was unable to state where the emergency medications were located or how to access them in case of an emergency situation.

Based on observations, document review, and interviews, the facility failed to ensure a medication was administered to a patient, Sample Patient #2, as ordered by the patient's physician, and per the facility's policy.

This failure created the potential for negative outcomes to the patient and possibly to other patients in the facility.

Findings:

1. Nursing staff did not ensure an oral medication prescribed to Sample Patient # 2 was administered.

a) On 07/23/13 at 9:12 a.m., Sample Patient #2 was observed sitting at a table in the hallway of patient Unit B, holding a medicine cup which contained a pink colored tablet. No staff member was with the patient at the time.

b) On 07/23/13 at 9:15 a.m., Registered Nurse #1 (RN #1) was observed at the patient medication cart located behind the nurses' station on patient Unit A, preparing medications to be administered. RN #1 was notified by surveyors that Sample Patient #2 was holding a medication cup containing a tablet. Sample Patient #2 could not be found immediately, but walked by the nurses' station approximately 1 minute later. RN #1 took the medication cup and tablet from the patient and the patient walked away. RN #1 stated s/he thought the tablet could be a vitamin, but upon further check of the patient's medications, found in the medication cart, and a better look at the tablet, s/he stated the tablet was the antibiotic, Levaquin. RN #1 stated s/he had dispensed medications to patients at around 9:00, a.m., in the cafeteria, must have become distracted, and had not observed Sample Patient #2 take the oral dose of Levaquin. RN #1 stated it was facility policy to observe patients take their medications and s/he confirmed s/he had not done this for all medications s/he had administered to Sample Patient #2. RN #1 was observed discarding the Levaquin tablet into the sharps container located in the bottom drawer of the medication cart.

c) On 07/23/13 at 11:33 a.m., reviewed of the facility's policy titled, "Medication Administration and Documentation," revised June, 2011, was conducted. The policy stated, "Observe the patient take the drug. If the medication is taken orally, stay with the patient until he/she has swallowed the drug." The policy further stated, "Report any drug administration errors and adverse untoward drug reactions immediately to the attending physician, pharmacist, and patient and/or family (as appropriate). Prepare and submit reports as required by the facility...Isolate defective or questionable drugs and return them to the pharmacy with an explanation of the defect to questionable item."

d) On 07/24/13 at 9:00 a.m., review of the medical record for Sample Patient #2 was conducted. Sample Patient #2 was admitted to the facility on 7/18/13 and on 7/19/13 at 12:30 p.m., a physician order was noted in the medical record for Levaquin, 500 mg, to be given orally, each day for 7 days. The medical record reflected the patient had a urinary tract infection. The medical record for Sample Patient #2 contained no note by nursing staff regarding the discarded Levaquin tablet from 07/23/13, including no notation that pharmacy was contacted regarding this discarded medication.

e) On 07/24/13 at 9:58 a.m., an interview was conducted with RN #1. When asked if s/he had completed a facility medication error report regarding the Levaquin tablet not administered to Sample Patient #2 and instead discarded, RN #1 stated s/he did not know where the forms were kept or how to complete this form for reporting. When asked if s/he had spoken to anyone, any staff member, about the discarded Levaquin tablet from 07/23/13, s/he stated s/he could not remember speaking with anyone about this issue. When asked, RN #1 confirmed the lack of observing Sample Patient #2 take this oral medication and the discarding of the medication constituted a medication error. RN #1 confirmed s/he did not make a note in the patient's medical record regarding the dose of Levaquin that was discarded and why it was discarded. RN #1 stated s/he was an agency nurse and the last time s/he worked at this facility was a "few months ago" or even 6 months ago. RN #1 stated s/he could not remember the last time s/he worked at this facility prior to 07/23/13. RN #1 stated she was on the facility's schedule on 07/23/13 and today, 07/24/13, and was not on the schedule after today. RN #1 stated s/he received orientation to this facility just less than a year ago.

f) On 07/24/13 at 11:15 a.m., in a follow up interview with RN #1, s/he confirmed that s/he did administer the ordered dose of Levaquin to Sample Patient #2 at approximately 9:30 a.m., on 07/23/13. When asked if s/he had informed the pharmacy that a dose of Levaquin had been discarded, so that the pharmacy would be informed of a medication variance, RN #1 stated s/he had not notified the pharmacy, but would do so.

g) On 07/24/13 at 2:54 p.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing, to review findings regarding the medication not administered to Sample Patient #2 and the lack of documentation of this issue. The facility's DON stated all nurses, including agency nurses, receive "med variance training" and that all nurses were expected to report medication errors on specific facility forms for review. Both the DON and the Vice President of Nursing confirmed the dose of Levaquin not observed as taken by the patient, and the discarding of the dose by the RN, constituted a medication error. Both the DON and the Vice President of Nursing confirmed RN #1 should have made a note in the patient medical record regarding the discarded dose of Levaquin and why it was discarded. The DON reviewed the medical record for Sample Patient #2 and confirmed no nursing note was found regarding this issue. When asked if medication errors were reported by nursing staff and reviewed in Quality meetings, the Vice President and the DON confirmed this was the expectation.

Based on observations and staff interviews, the facility failed to ensure that supplies, equipment, and patient care areas were maintained to an acceptable level of safety and quality.

This failure contributed to patients being exposed to potential hazards that had the potential to cause patient injury.

Findings:

1. The facility did not ensure that patients did not have access to rooms that were not in use or were undergoing maintenance.

a) On 07/22/13 at 1:10 p.m., a tour of the facility's patient Unit A was conducted with Registered Nurse (RN) #2. During the tour, Patient Room 112 was viewed. The patient bathroom in Room 112 was viewed and had a towel on the floor that was wet and did not absorb all the water, leaving free-standing water on the bathroom floor. The baseboards along the bathroom's side wall were missing, exposing wet wood. RN #2 stated this had been caused by a backflow of water that happened the previous night. RN #2 stated that maintenance had been informed and that the room was not in use. Two beds were viewed in Room 112, both of which had covers and sheets in disarray and appeared to have been used. RN #2 stated that although Room 112 was not to be used by patients that "patients wandered" around the unit and 1 patient in particular was often found in Room 112. RN #2 stated that the staff kept the door to Room 112 closed, but had no other way to secure the room or the room's bathroom from patient use. RN #2 verified that there was no signage on the door of Room 112 to identify it as not in use.

b) On 07/23/13 at 8:40 a.m., a tour of the facility's patient Unit A was conducted. During the tour, Behavioral Health Technician (BHT) #1 was observed entering patient room 112, where a patient was lying in one of the beds. BHT #1 stated that the bathroom in Room 112 was still not fixed and that Room 112 was not to be used. BHT #1 stated the patient in the bed liked to wander and actually was supposed to be in another room down the hall. BHT #1 stated that there was no way to secure Room 112 from patient access, although it was not to be used. Room 112's bathroom was viewed with BHT #1. Room 112's bathroom was unchanged from the previous day, except that the towel had been removed from the bathroom floor. BHT #1 verified that there was no signage on the door of Room 112 to identify it as not in use.

c) On 07/23/13 at 11:05 a.m., an interview was conducted with the facility's Director of Nursing (DON) and the facility's Director of Quality Management (DQM). The DQM stated that room 112 should have been, "closed off," so that it could not have been used by patients. The DON stated that the room should not have been in use, but that there was,"no way to lock the door."