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Based on medical record review, interview and policy and procedure review the facility failed to show that 3 out of 13 (#12, #31, and #39) patients received and were able to invoke their patient rights to refuse treatment prior to initiating treatment, which has the potential for providing treatment against a patient's will. Additionally, the facility failed to provide documentation that 1 current patient (#31) of 31 inpatients and 1 discharged patient (#39) of two discharged and closed records were admitted according to facility policies and did not violate patients' civil rights.
Findings include:
On 10/9/13 at approximately 1400 during review of patient #12's medical record it was revealed that the patient came to the emergency department (ED) on 9/28/13 via ambulance with complaints of wanting to hurt a member of the group home he came from for stealing his tobacco. According to a "Security Department Offense/Incident Report", the following events occurred at approximately 0035 on 9/28/13, "At approximately. 0035 the investigating security officer was called by the ER secretary to come to A2. I went back into the treatment are and observed an angry belligerent and profane patient #12. The suspect seemed to calm down momentarily so I returned to the security desk in the ER reception area. I then noticed patient #12 leaving hospital out the ER door, the nurse and I followed him into the circle drive and told him to put out his cigarette and get back into the hospital. Patient #12 complied and followed us back into the ED and informed us that he wanted to be transported to St. Joe's. He then stated that he wanted to go AMA (Against medical advice)..." the report continues on to explain that the doctor told security "the patient wasn't going anywhere" and to restrain the patient. The patient was placed in 4-point leather restraints and placed in the isolation room. The doctor requested a psychiatric evaluation, which was completed and the patient subsequently was admitted under voluntary circumstances. There was no physician certification or petition on the medical record for review and the patient was subsequently held against his will.

On 10/10/13 at approximately 0930 during policy and procedure review it was found in the undated policy titled, "Admission and Intake Procedure:Voluntary and Involuntary Recipients" under the section titled, "Admission to Floor-Involuntary Recipient" states, "Prior to the recipient's arrival on the unit, an RN shall verify the Recipient has the following documents: An original, valid Petition (completed and signed within the past 10 days). The initial Clinical Certification completed and signed the day of admission." The patient didn't sign the voluntary admission form until he was already held against his will in the ED and transferred for admission on the psychiatric unit.

Based on observation, document review, and interview the facility failed to ensure a safe setting relating to falls, code blues, and rapid responses for four of four patients who experienced unsafe events (#13, #17, #44, and #45). Additionally, the facility failed to report, monitor, and analyze unsafe events and failed to develop and implement interventions in order to mitigate future unsafe events. Findings include:

On 10/10/2013 at approximately 1010 during medical record review of patient #45 a document labeled "code blue event" dated 7/22/2013 at 1815, was reviewed. The document labeled "code sheet" revealed one vital sign recording with a "blood pressure of 212/120 and a heart rate of 140." Subsequent nursing interventions listed in "nursing documentation" stated "a jaw thrust and cardiac monitoring." On 7/22/2013 at 1816 a "heart rate of 78" was the only additional information documented either in the nursing documentation area or the code sheet.

On 10/10/2013 at approximately 1100 an interview with nursing manager, staff J was conducted. When asked what the expectation would be in reference to a code blue situation and nursing actions in regards to vital sign documentation and intervention it was stated "an additional set of vital signs should be documented after the initial set of vital signs were obtained along with interventions". When asked if the code sheet showed that an "additional set of vital signs were obtained or additional interventions" were listed, the nursing manager (staff J) stated, "No. And that is one of our critical care nurses who documented the code."

On 10/10/2013 at approximately 1115 during medical record review of patient #44 a "Rapid Response" document dated 7/25/2013 at 0145 was reviewed. Rapid response documentation shows an initial set of vital signs were obtained at 0148 with an "unpalpable blood pressure, heart rate 210, respiratory rate 16, blood sugar (test result of) 206, and a saturated pulse oxygen of 98 %." The next sets of vital signs documented were at 0215 with a "blood pressure of 73/44, heart rate 105, respiratory rate 17, and a saturated pulse oxygen of 92 %."

On 10/10/2013 at approximately 1120 an interview was conducted with the clinical nurse educator staff W where it was asked what the expectation was for monitoring and documentation for a rapid response. Staff W stated "this should have turned into a code blue". When asked what the expectation was for the frequency of vital sign monitoring when a blood pressure was not "palpable", Staff W responded "another set of vital signs should have been obtained when the blood pressure was not palpable.'

On 10/10/2012 at approximately 1125 a review of the "Code Blue (CPR)" policy with a revision date of 11/01/2008 occurred. According to the policy under "responsibilities of the registered nurse: (patient's nurse or first RN to arrive)" #4 stated "take blood pressure initially and as needed". Staff W was asked if the blood pressure for patient #44 was monitored appropriately and the response was "no."


30988

On 10/8/13 at approximately 1600 during medical record review of patient #17's closed record, documentation of a fall on 9/28/13 at 1005 was found. Nursing documentation was not recorded until 10/8/13 at 1821. An occurrence report was never located for this incident and no follow-up investigation was completed for performance improvement purposes.

Interview of staff J on 10/9/13 at approximately 1600 confirmed "that's right, the occurrence report was never completed."

On 10/9/13 at approximately 1645 a review of Policy # ADM-0-1 titled "Occurrence Report" revised 9/13/12 states "I. Policy.- Patient occurrences are addressed immediately, documented and assessed using the appropriate reporting form before the end of shift by the person discovering the occurrence....V. Procedure.-...4. Notify the director of quality or hospital administrator if a patient is injured or his medical condition deteriorates as a result of the event. The director of quality will coordinate with clinical and medical staff regarding appropriate notification of the event to patient and/or family. 5. For behavioral medicine patients, the recipient rights advisor must be notified within 24 hours of the event. 6. Staff: fax a copy of the occurrence report to the director of quality by the end of the shift in which the occurrence was identified."

On 10/9/13 at approximately 1400 during observation on 4 South (the behavioral health unit) staff J was asked if any current patient had fallen during their stay, to which they replied "patient #13." The medical record of patient #13 was reviewed. Documentation of a fall was found on 9/26/13 at 1805. Staff J was asked if the occurrence form and the quality follow up investigation had been completed as stated in the policy. Staff J stated, "I think so." The occurrence form for the above mentioned fall could not be located. Staff C, the director of quality, could not find the completed form and stated "without the form being sent, a follow up (investigation/analysis) is not done."

On 10/10/13 at approximately 0900 the occurrence report for patient #13 was located. No quality management review was completed. This was confirmed with staff C on 10/10/13 at approximately 0930.

Based on record review and interview the facility failed to ensure that patients are free from restraint in 1 of 6 restrained patient records reviewed (#17). This has the potential to affect all patients seen at this facility who may require the use of restraint to ensure patient safety. Findings include:

On 10/8/13 at approximately 1600 during medical record review of patient #17 a telephone order for "2-point restraints for up to 4 hours" was written on 9/28/13 at 1010. This was signed and dated 9/28/13 but not timed, there were no further restraint orders. The record for patient #17 lacked face to face assessment by the physician, within one hour of the restraint order.

The "restraint/seclusion flow sheet" was initiated 9/28/13 at 1025 and continued through 9/28/13 at 2140, there was no documentation of alternative measures, and no documentation of "15 minute releases every 2 hours." The patient was transported to computerized tomography (CT) and returned to the floor 10/28/13 at 2052. No further restraint documentation is found, the patient was transferred to another facility 2/29/13 at 0025.

The treatment plan dated 9/27/13 does not include a plan for the use of any restraints.

Interview of staff C and staff J on 10/10/13 at approximately 0900 confirmed that "there is no further documentation (for restraint use), the record is complete".

On 10/10/13 at approximately 0930 a review of the Policy and procedure titled "Restraint/Seclusion-Behavioral" #BMD-R-5" dated 5/16/13 revealed:
"Procedure...........
6. Subsequent re-evaluation of the Recipient/patient must be performed with timed documentation within the age-specific time frame. The face-to-face evaluation must be performed by a physician. (Attachment D- form titled "Behavioral Medicine Restraint Order/Documentation" states, "Phone order must be confirmed by the physician in person within 1 hour," and space provided for "Physician Face to Face Assessment."
7. Continued use of restraint/seclusion is authorized for renewal periods of 4 hours for adults up to a total of 8 hours, and ordered by the physician based on the examination of the Recipient/patient. This must be a written order. Verbal or telephone orders are not permitted. ........
10. Restraints shall be removed every 2 hours for not less than 15 minutes unless medically contraindicated......
11. Intervention surrounding each episode of restraint/seclusion is provided in the Recipient/patient's medical record in order to provide clinical justification for use and clinical oversight. This documentation includes but may not be limited to: A. Alternatives considered/utilized. B. Relevant orders for use and face-to-face evaluation by a physician.....
12. The use of restraint/seclusion must be: a. In accordance with a written modification to the Recipient/patients plan of care....".

Based on medical record review and policy and procedure review the facility failed to monitor patient condition while in restraints and document the observations for 1 out of 1 (#12) restrained patients, which has the potential for patient harm.
Findings include:

On 10/9/13 at approximately 1330 during medical record review of patient #12, it was found that the patient was in 4-point leather restraints and in an isolation room for being "belligerent, angry and non-compliant" in the ED on 9/28/13 at approximately 0030. On the document titled, "Restraint Order/Documentation," it was documented that the patient was in "4-point leather restraints with an agitated behavior." Further review of restraint documentation it was found on the form titled, "Restraint Flowsheet-Medical/Surgical," there was no justification documentation for restraints being used, the classification of restraints according to policy should have been for the "Violent Restraints/Seclusion." The patient was in restraints and isolation for 2 hours and there was a single documented monitor of the patient with comments of, "Pt. very belligerent and threatening."

On 10/10/13 at approximately 1000 during policy and procedure review it was found in the undated policy titled, "Restraint/Seclusion-Behavioral," states under the section titled, Procedure, #8, "Continuous in-person observation and monitoring will occur while the Recipient/patient is in restraint/seclusion, with supportive documentation every 15 minutes during restrain/seclusion episode" and #15, "Restraint may not be used simultaneously with seclusion unless the Recipient/patient is continually monitored face-to-face by an assigned staff member...".

Based on medical record review, interview and policy and procedure review the facility failed to ensure that 3 out of 5 (#9, #11 and #17) patients in restraint/seclusion received a face-to-face assessment by a physician within one hour of initiation of restraint/seclusion, which has the potential for patient harm.
Findings include:

On 10/9/13 between approximately 1300-1330 during medical record review of patients #9 it was revealed that the patient was in restraints and seclusion for violent/self-destructive behavior and failed to receive the required one hour face-to-face assessment by a physician.

On 10/9/13 between approximately 1300-1330 during medical record review of patients #11 it was revealed that the patient was in restraints and seclusion for violent/self-destructive behavior and failed to receive the required one hour face-to-face assessment by a physician.

On 10/10/13 at approximately 1000 during policy and procedure review it was found in the undated policy titled, "Restraint/Seclusion-Behavioral" it states under the section, Procedure, #5, "The physician must provide a face-to-face evaluation of the Recipient/patient within one hour of restraint/seclusion initiation...".


30988

On 10/8/13 at approximately 1600 during medical record review for patient #17 it was found that the patient was restrained beginning 9/28/13 at 1010. No documentation of a follow-up face-to-face by a physician was found.

These findings were confirmed on 10/10/13 at approximately 0900 by staff C and J, who stated, "There is no other documentation (for a face-to-face assessment by the physician)."

Based on Quality Assessment Performance Improvement (QAPI) program review and interview, the facility failed to maintain an ongoing program for patient outcomes (A 273), failed to determine priorities for QAPI (A 309) and failed to provide adequate resources for QAPI (A 315). See the following QAPI citations:

Based on document review and interview, the facility failed to to maintain program patient outcome data for the past six (6) months. Findings include:

Review of the most recent QAPI data with the Administrative Director of Quality, on 10/10/13 at approximately 1000, revealed that patient outcome data had not been captured or reported since April 2013. The Administrative Director verified that many people who were responsible for capturing and reporting the data had left employment at the facility and that the outcome data was not available. Additionally, the data reported prior to April 2013 lacked documentation of analysis and specific action plans.

A "Summation Report" (undated) placed in the September 2013 (no member sign in) QAPI section documented:

"Core Measures Score Card (AMI, Pneumonia, Heart Failure, Out Patient Measures)--No data for this has been submitted for the year. Responsibility: Unknown, has to do with RN care."

"No data for Restraints have been recorded since April 2013."

"Surgical Care Improvement Plan (SCIP)--No data information entered for the year. Responsibility: Unknown".

"Pharmacy--Medication Errors/Adverse Drug Reaction has not been done. (Director Pharmacy) is responsible for this data."


29955

On 10/11/2013 at approximately 1400 during an interview with staff U and staff V of the surgical unit, it was asked who was responsible for the collection of data for the Surgical Care Improvement Project (SCIP). Staff U responded "our former manager did all the quality data collection and reporting. I'm not sure who has been collecting the data since she left." Staff V confirmed the information has not been collected and reported.

Based on file review and interview, the governing body failed to determine QAPI priorities and provide for an ongoing program. Findings include:

File review of performance improvement information provided revealed no documentation of priorities, data evaluations or an ongoing QAPI program. Interview with the Administrative Director of Quality on 10/10/13 at approximately 1000, verified that the governing body had not specified priorities for performance improvement. An ongoing program for patient outcomes was not maintained or documented after April 2013.

Governing Body 'Summation Report' of September 27, 2013 documented the following:

"Discharges--No data has been submitted since April 2013 for 5N (Med/Surg) and for Behavioral Health..."
"Core Measures Score Card (AMI, Pneumonia, Heart Failure, Out Patient [sic] Measures)--No data for this has been submitted for the year..."
"Pharmacy--Medication Errors/Adverse Drug Reaction has not been done..."
"No data for Restraints have been recorded since April 2013."
"Surgical Care Improvement Plan (SCIP)--No data information entered for the year..."

Based on document review and interview, the facility failed to provide adequate resources for sustaining the hospital's QAPI program. Findings include:

Review of QAPI data provided by the facility on 10/8/13 and through 10/10/13 revealed that patient outcome data had not been documented since April 2013. Review of QAPI minutes with the Administrative Director of Quality, on 10/10/13 at approximately 1000, revealed that only five of fifteen staff members attended the QAPI meeting on 8/10/13. The Administrator verified that her role was Administrator and Director of Quality. She verified that she did not know who was to provide QAPI patient outcome data to her for Core Measures, Surgery Improvement (SCIP) or Restraints.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:
See the individually and below cited K-tags dated October 9-10, 2013 for Buildings #1 & 2.
Building #1
K-0015
K-0017
K-0020
K-0025
K-0029
K-0034
K-0050
K-0052
K-0062
K-0067
K-0076
K-0104
K-0147
Building#2
K-0012
K-0056
K-0062
K-0064
K-0144
K-0147


19647

Based on Physical Environment program review, facility tour and interview, the facility failed to maintain the physical plant (A-701), failed to ensure adequate emergency fuel and water supply (A-703), failed to ensure adequate supplies (A-724), and failed to provide proper ventilation and illumination (A-726). See the following Physical Environment citations:

Based on observation and interview, the facility physical plant was not being properly maintained as evidenced by:

1. The hot water supply temperature at hand washing sinks exceeded the safe temperature limit of 120 F in four out of five sinks tested on the first day of the survey:
- the hand wash sink in Room 511 measured 132 F at 2:43 PM on 10/8/13.
- the hand wash sink in Room 512 measured 134 F at 2:44 PM on 10/8/13.
- the hand wash sink in Room 544 measured 140 F at 3:00 PM on 10/8/13.
- the hand wash sink in the dining room on 4S Psych unit measured 134 F at 3:10 PM on 10/8/13.

On the second day of the survey at approximately 9:30 AM, the heating unit for the domestic hot water supply was observed via temperature gauge on the unit to be delivering hot water to the building loop at temperature over 135 F.

2. As observed the morning of 10/8/13 during the facility survey, the water in the plumbing lines are not being flushed regularly to help prevent buildup of sediment and bacteria such as Legionella. There was gross discoloration and scale in the toilet bowls for rooms 706, 707, 709, 710 and throughout most of the vacant areas. Since there were two complete patient sleeping floors that are vacant and shut down, along with a number of other units throughout the hospital (OB, cath labs, oncology, pediatrics, etc.), the water in the piping to these vacated areas would become stagnant due to essentially dead-ended lines. Bacteria in the accumulated biofilm in these lines can be sloughed off and travel to active parts of the hospital creating an infection control hazard for any patient that is not immune competent.

3. As observed on 10/9/13 at approximately 4:00 PM, there was an accumulation of dirt and debris under the Pyxis unit in the medicine room at the Urgent Care in building #3. Also, rather than making needed repairs to a hand wash sink, the water supply to the hand wash sink in the patient toilet room at this Urgent Care building #2 was turned off so it could not be used. In addition, the carpet seam at one of the corridor entrances to this urgent care was loose resulting in a potentially serious trip hazard.

4. As observed at approximately 4:30 PM on 10/9/13 in building #3, the isolated panel alarm in OR #1 was not sounding until after the milliamps of leakage current had exceeded 7 milliamps as opposed to the standard alarm limit of 5 milliamps. The alarm for OR 2 was also delayed in sounding; it was alarming at 6 milliamps. The acting maintenance director (also biomedical director) verified that annual preventive maintenance was being done, but not any monthly testing for these isolated power systems.

Based upon observation and interview the facility failed to maintain adequate emergency gas and water supplies as evidenced by:

1. The maintenance director explained that the hospital typically keeps two pallets of bottled water for emergencies in the loading dock supply room. During a tour of the loading dock supply area the afternoon of 10/9/13, we did not find any on-site supply of bottled water. The maintenance director did not know what had happened to the bottled water. This water is essential for use as drinking water during any interruption of the city water supply.

2. The facility has three underground diesel fuel tanks. A fuel monitoring report was printed at 2:00 PM on the second day of the survey (10/9/13) which indicated that Tank #1, which has a 5,000 gallon (gal) tank capacity serving the two emergency generators had 2326 gal of fuel and that the two remaining tanks # 2 & # 3 (both 30,000 gal capacity) had 5,058 gal and 4,756 gal respectively. The fuel monitoring system was in alarm condition indicating that delivery of fuel was needed. The same alarm condition was identified in a previous survey in August 2013. Since these tanks are so large, according to the maintenance director, the hospital has elected to continue burning down the old fuel and not to have the tanks refilled. No recent fuel survey was available. No record was available to document recent testing of the two main hospital boilers using alternate fuel (i.e. diesel fuel). Without routine testing (e.g. annual), the facility cannot ensure that these boilers will be able to operate during an interruption of natural gas supply.

Based on observation and interview the facility failed to ensure that the equipment and supplies were maintained in an acceptable level of safety and quality resulting in the potential for patient harm. Findings include:

On 10/8/13 at approximately 1400 during tour of the Urgent care area, the traveling crash cart was inspected (this cart is taken with the physician to any codes called in the hospital). There was no record of the defibrillator being checked after 9/30/13. Further inspection revealed that the following medications were expired and available for use; 2 ampules (amps) of Dextrose with a manufacturer's expiration date of 9/30/13 and 2 amps of Calcium Chloride with a manufacturer's expiration date of 9/30/13.

Interview of staff G the urgent care manager, revealed "we haven't had time to develop a policy and procedure (for expiration outdates and defibrillator checks) since we changed management from an emergency room to an urgent care."

The traveling crash cart was checked, restocked and daily checks begun before the completion of this survey.


19647

1. There was no high level disinfectant on site at the hospital on the second day of the survey (10/9/13) for use in high-level disinfection of endoscopes. The shipment of Metricide did not arrive, so the contaminated/used endoscopes had to be transported off-site to the ambulatory surgical center, located across town, to be processed according to an interview with staff U on 10/9/13 at approximately 1100.

Based upon observations the facility failed to maintain proper ventilation and lighting in patient care areas resulting in the potential for medical errors. Findings include:

1. On 10/8/13 at approximately 2:40 PM, the medicine prep room 532, which houses several Pyxis units, had two overhead ceiling lights with at least one bulb burned out in each overhead light resulting in poor illumination (i.e. below 50 foot-candles).

2. On 10/9/13 at approximately 4:00 PM. the medicine prep room for the Urgent Care located in building #3, had only 39 foot-candles of illumination versus the required minimum 50 fc.

3. During a survey of the second floor mechanical spaces of the main facility at approximately 9:30 AM on 10/9/13, it was observed that many of the maintenance log forms mounted to the sides of the major pieces of equipment were completely blank or had only a few entries documenting maintenance. According the the Maintenance Director, at the end of 2012, the hospital stopped using their computer generated preventive maintenance (PM) system work orders and switched to this manual record system. Specific observations include:
- Air handling unit # 1 (AHU1) which serves the ICU and OR, showed a record of PM on 1/10/13 and 5/18/13 but nothing since.
- The maintenance record sheet for ACU1 return fan was blank
- The maintenance record sheet for RF-2 was blank even though repairs had been made to the unit during this past summer.
- ACU 3 in the North mechanical room maintenance record sheet showed PM dates of 10/2012, 1/11/13, 6/2013 and 10/2013 which indicates gaps in the scheduled quarterly maintenance.

Based on observation and interview, the facility failed to:
1) Ensure staff are using personal protective equipment according to facility policy resulting in the potential for; ongoing acquisition of healthcare associated infections and transmission of infectious agents among patients and staff. (A-749)
2) Monitor, provide and maintain a sanitary environment.(A-749)
See cited tags below.

Based on observation and interview the facility failed to ensure that staff were using personal protective equipment (PPE) according to facility policy and failed to monitor and maintain a clean environment resulting in the potential for; ongoing acquisition of healthcare associated infections and transmission of infectious agents among patients and staff for 2 out of 5 patients (patient #3 and #5). Findings include:

On 10/08/13 at approximately 1400 during an initial tour of the Intensive Care Unit (ICU)-Medical/Surgical Unit (MED /SURG), it was determined that patient #3 and patient #5 were both on "contact isolation precautions". When Staff H was queried in regards to what the posted isolation precautions were, she stated that "gloves and gowns were to be worn." When the isolation cart located outside the two isolation rooms was observed, no personal protective equipment (PPE) was found. Staff H stated that the "hospital was short on supplies." Staff H and this writer entered the clean supply storage room where additional PPE equipment was found. There was one package of "White" impervious gowns. Staff was used to using "yellow gowns," of which there were 4 left in the clean storage area. Staff H was also queried in regards to contact isolation education given to the family members, who were sitting at the bedside for patient #3 without PPE donned. It was determined that there was no education documentation found for family members who visit in the isolation room for patient #3.

On 10/08/13 at approximately 1415 patient #5 returned from the placement of an Intravenous Line (IV). Neither department that the patient went to (Surgery or Ultrasound) had been notified that the patient was on contact precautions per Staff E. Staff E confirmed on 10/08/13 at 1420 that the facility did not follow proper contact precautions per policy.
On 10/08/13 at approximately 1415 during a review of the policy titled "Isolation and Room Placement" determined that the "Nurse is responsible for:
#4) Making sure protective barrier equipment is outside the door; i.e. goggles, masks, gowns, and gloves.
#6) Notifying the Patient Access Department via computer generated printed message "Special Handling" patient to private room for Isolation."

On 10/10/13 at approximatley 0930 an interview with staff E revealed that when asked who was responsible for overseeing the infection prevention program, she replied, "there is nobody assigned to that position currently".

Staff E was asked how and how often compliance to infection control protocols and environmental cleanliness was being monitored, she replied, "it is not (being monitored) at this time".


29955

On 10/8/2013 at approximately 1400 during an initial tour of the surgical area soiled utility room the biohazard bin was found without the protective lid covering the top of the bin with biohazardous waste contained in the container.

On 10/8/2013 at approximately 1403 staff V was interviewed and asked where the lid of the biohazard bin should be located. Staff V responded "it should be secured on the top of the biohazard bin. I'm sure someone forgot to place it back on top of the bin."

On 10/10/2013 at approximately 0918 during a tour of the physical therapy rehabilitation unit, the cool pack unit was found with a large accumulation of ice in between each of the cooling separators.

On 10/10/2013 at approximately 0918 staff R was asked if the unit was on a defrosting schedule and staff R responded "not that I am aware of."

On 10/10/2013 at approximately 0920 during the tour of the physical therapy rehabilitation unit, cleaning agents, hand lotion and visibly soiled coffee cups were stored on a ledge near the handwashing sink in the patient care area.

On 10/10/2013 at approximately 0921 staff R was asked if these items were supposed to be stored in this area. Staff R responded "no."

Based on document review and interview the facility failed to ensure that patients receive appropriate post-hospital care in 1 of 1 patients (#17) transferred to another another acute care hospital.
Findings include:

On 10/8/13 at approximately 1600 during review of the medical record of patient #17 it was found that the patient was transferred on 9/29/13 at 0025 to another acute care hospital. There was no transfer document available to be reviewed. Additionally, there were no lists of documents sent along with the patient.

An interview of staff C and staff J on 10/10/13 at approximately 0900 confirmed that "there was no transfer form filled out and there is no policy related to transferring patients to another hospital from the behavioral health unit."

Based on record review and interview the facility failed to maintain an ongoing Organ Procurement Organization (OPO) program with a potential to overlook a potential organ donors. Findings include:
See tags A-891 the hospital failed to work cooperatively with the OPO on a continuous basis and A-892 the hospital failed to assure that all deaths or imminent deaths were being referred to the OPO in a timely manner.

Based on interview and record review the facility failed to work cooperatively with the Organ Procurement Organization (OPO) Program regarding staff education, and incorporating the OPO program results into QAPI (Quality Assessment and Performance Improvement) for 5 out of 5 death records reviewed (patients #18, #19, #20, #21 and #22). Findings include:
On 10/10/13 at approximately 1100 during an interview with Staff E, it was determined that the facility had not documented staff educational activity in regards to the OPO program since 10/12/12. Patient #18 was the last documented death using the OPO trained processes on 10/12/12. There were no additional deaths documented noted in the OPO program. Further record review revealed that there were 24 additional deaths that occurred at the facility after 12/14/12 without documentation that family were approached for potential organ donation including patients #18, #19, #20, #21 and #22. There was also no documentation found in the QAPI program regarding the OPO program effectiveness. Staff E confirmed these findings on 10/10/13 at 1130.

Based on interview and record review the facility failed to work cooperatively with the designated OPO in reviewing death records, and making sure that the deaths were being referred to the OPO in a timely basis for 5 out of 5 death records reviewed (patients #18, #19, #20, #21 and #22) Findings include:
On 10/10/13 at approximately 1100 during an interview with Staff E, it was determined that the facility had not documented any activity with the OPO program for potential organ donation since 12/14/12 when patient #18 expired in the Emergency Department. Patient #18 was the last documented death using OPO trained processes for organ donation potential(10/12/12). Further record review revealed that there were 24 additional deaths including records reviewed for patients #19, #20, #21 and #22 that had occurred at the facility after 12/14/12 and also lacked information regarding OPO processes for organ donation potential. Staff E confirmed these findings on 10/10/13 at 1130.