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Based on administrative record review, and interview, the hospital failed to maintain a complete list of all contracted services that included delineation of the scope of services provided and the contractor's responsibility to the hospital for the services provided by Company C for 1 of 30 contracted services. This failure had the potential to result in ensuring the contracted service responsibilities were delineated as provided.

Findings:

During an administrative record review of the Sempervirens Vendor List Nature And Scope of Service, revised 6/10/16, included the list of 29 vendors, the nature and scope of services provided. The list of contracted services did not include services provided by Company C (shredding of confidential documents). Review of the contract with Company C indicated the agreement was signed on 8/13/15. Review of the document "SV (Sempervirens) Contract Monitoring Summary Report, revised 11/23/16, found no documentation of an evaluation of Company C's services.

During an interview and concurrent document review on 8/2/17 at 3:07 p.m., the Performance Manager corroborated that Company C was not on the list of contracted vendors and that it had also been omitted from the Contract Monitoring Summary Report. Performance Manager stated, "I missed it."

Based on staff interviews, document review, personnel file review, medical record review, and policy and procedure review, the facility failed to ensure patients' rights were protected as evidenced by:

1. All staff were not trained in HIPAA (Health Insurance Portability and Accountability Act) privacy on an annual basis per facility policy, and there was no system in place to track the location/disposition of patients' health records (Cross Reference A147);
2. The master treatment plan for one sampled patient (Patient 9) did not address the behaviors related to the use of restraints and seclusion (Cross Reference A166);
3. Sampled patients (Patients 9, 10, and 11) were not assessed every 15 minutes while in restraints and/or seclusion (Cross Reference A175);
4. Sampled patients (Patients 9, 10, and 11) did not have Face to Face assessments done within one hour after the initiation of restraints and/or seclusion (Cross Reference A178);
5. All staff did not receive annual training in the use of restraints and seclusion (Cross Reference A196);
6. All staff did not receive annual training in Management of Assaultive Behavior [(MAB) a violence prevention course designed for healthcare workers] (Cross Reference A200);
7. All staff did not receive annual training in Patient Transfers, Medical Screening Examinations, Age Appropriate Health Screening Assessments, Restraints and Seclusion, and Face to Face Assessments (Cross Reference A202);
8. All staff did not receive annual training in One Hour Face-to-Face Assessments (for patients in seclusion or restraints) (Cross Reference A205);
9. The facility did not conduct all staff performance evaluations in a timely manner (Cross Reference A208).

The cumulative effect of these systemic problems resulted in untrained staff providing patient care and/or not providing care in accordance with hospital policy which had the potential to deny patients their right to confidentiality and safe, competent care.

Based on interview, personnel file review, and training records review, the facility failed to 1) ensure 2 of 10 sampled staff were trained in HIPAA (Health Insurance Portability and Accountability Act) privacy on an annual basis per facility policy, and 2) ensure a tracking system for patients' medical records after they were handed off to the medical record department. These had the potential to deny patients their right to confidentiality of their patient information.

Findings:

1) Review of personnel files on 8/2/17 found 2 of 10 sampled staff (Interim Mental Health Director and Infection Preventionist) were delinquent in HIPAA training. The most recent HIPAA training for the Interim Mental Health Director was dated 11/19/15. In a concurrent interview Employee Services Staff B stated, "She's overdue." Regarding HIPAA training for the Infection Preventionist, Employee Services Staff B stated she had signed the HIPAA agreement on 11/7/16, but had not attended the December 2016 training as she should have. Employee Services Staff B stated the HIPAA training is required every year.

Review of the undated policy titled, "Privacy and Security Training," indicated: "Employees will participate in privacy and security training within thirty (30) days of hire and annually thereafter."


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2) During a concurrent interview with the Medical Record Manager and Medical Record Supervisor on 8/1/17, at 11 a.m., the Medical Record Manager stated after the ward clerk handed off patients' medical records (The medical records contain patients' protected health information) to the medical record department, the medical record staff scanned the medical records to the Avatar, which was a computer system for medical records. The Medical Record Manager stated the medical records from the crisis stabilization unit were destroyed after being scanned to the Avatar; the medical records from the inpatient unit were retained for 18 months before being destroyed. The Medical Record Manager stated he assumed the staff scanned the medical records to the Avatar after received from the ward clerk. The Medical Record Manager stated they did not have a tracking system to keep track of the medical records received, scanned, or destroyed. The Medical Record Supervisor also stated they would not know what might have happened to the health records after being handed off by the ward clerks and before scanning to the Avatar. The Medical Record Supervisor stated they did not know how many medical records they received or scanned.

The facility's policy and procedure titled "Security of Protected Health Information Designated for Destruction," dated 1/27/14, indicated "...PHI [protected health information] and confidential information must be consistently protected and managed through its entire life cycle, from origin to destruction..."

Based on interview and record review, the facility failed to ensure the master treatment plan (a written plan of care/treatment, which addresses the patient care/treatment plan based on the comprehensive assessment by the treatment team members. The written plan also serves as a communication tool among the team including the patient) addressed the behaviors related to the use of restraint (physical) and seclusion for one of 12 sampled patients (Patient 9). This failure had the potential for Patient 9's behaviors not being adequately monitored and treated.

Seclusion is involuntary confinement of a patient alone in a room or an area from which the person is physically prevented from leaving.

Physical restraint is the use of manual hold to restrict freedom of movement of all or part of a person's body or restricts normal access to the person's body that is used as a behavioral restraint.

Findings:

Patient 9's admission record, dated 7/19/17, indicated Patient 9 was admitted on 7/13/17 with a primary diagnosis of persistent mood disorder (unspecified mental disorder). Patient 9 was discharged on 7/18/17.

The Initial Orders dated 7/13/17, at 10:39 a.m., indicated a physician's order for seclusion and restraint with "5 point leather (restraint belt applied to the patient's torso and limbs)."

The restraint and seclusion sheet dated 7/13/17, indicated Patient 9 was on restraint from 10:40 a.m. to 11:45 a.m. due to aggressive behaviors including banging head and being combative.

The Master Treatment Plan initiated on 7/16/17, did not address Patient 9's aggressive behaviors and the use of seclusion and restraint.

During a concurrent interview and record review on 8/4/17, at 1:45 p.m., the Director of Nurses (DON) reviewed Patient 9's master treatment plan and acknowledged the master treatment plan did not include the use of seclusion and restraint or the aggressive behaviors. The DON stated the master treatment plan should have addressed the use of seclusion and restraints, or the aggressive behaviors.

The facility's policy and procedure titled "SECLUSION AND RESTRAINTS," revision dated 4/20/15, indicated "...The use of seclusion or restraint must be used in accordance with a written modification to the patient plan of care..."

The facility's policy and procedure titled "Treatment Planning," revision dated 6/6/14, indicated "Each patient must have an individualized, comprehensive Treatment Plan that must be based on an inventory of patient strengths and disabilities...A Master Treatment Plan is developed by the Treatment Team...Additional problems identified during treatment are to be added to the plan, with appropriate goals and interventions listed by the appropriate discipline during morning rounds...Treatment Plans are reviewed on a constant, daily basis with notations indicating the date of identification and planning of new problems or the date a goal was met..."

Based on interview and record review, the facility failed to ensure staff followed their policy and procedure or the instructions on the 2100 - RN REASSESSMENT (RN Reassessment) form to assess/monitor patients when patients were in seclusion or restraints (physical) for three of 12 sampled patients (Patient 9, 10, and 11). This failure resulted in Patients 9, 10, and 11's vital signs (temperature, pulse, respiration, and blood pressure), range of motion (ROM), and/or circulation not all being measured/monitored or documented in the RN Reassessment form. This failure also had the potential to result in patient injuries from the seclusion/restraint and further compromise patients' safety and health.

Seclusion is involuntary confinement of a patient alone in a room or an area from which the person is physically prevented from leaving.

Physical restraint is the use of manual hold to restrict freedom of movement of all or part of a person's body or restricts normal access to the person's body that is used as a behavioral restraint.

The RN Reassessment form indicated RN (registered nurse) reassessment of a patient, who is in seclusion/restraint, is required at least every 15 minutes. This form indicated vital signs and range of motion must be completed every 15 minutes and on release. The reassessment included assessment of the patient's O2Sat (oxygen saturation refers to the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood. Normal range is 95-100%) and if the restraint applied properly. The reassessment also includes patient's current situation and behavior/mental status, circulation/skin, nutrition/hydration, elimination, explaining the reasons for seclusion/restraint and behavior criteria for release of seclusion/restraint, need to continue or discontinue procedure, and interventions implemented to assist in meeting release criteria and active treatment provided.

Findings:

1. Patient 11's Admission Record, date 6/14/17, indicated Patient 11 was admitted to the facility on 6/13/17 with a primary diagnosis of psychotic disorder (a mental disorder). The admission record indicated Patient 11 had hearing disabilities and the primary language was American Sign Language (ASL).

The assessment completed by the admitting practitioner dated 6/14/17, revealed Patient 11 was deaf from Meningitis infection (infection of the tough layer of tissue that surrounds the brain and the spinal cord) at age 4.

The master treatment plan initiated on 6/15/17, indicated Patient 11 had identifiable disabilities including "...Presents with disorganized behavior, paranoid ideation, psychotic agitation, violence, thought blocking and confusion..."

The physician's initial orders, dated from 6/13/17 to 7/11/17, revealed Patient 11 was in seclusion or restraints due to behaviors including being combative toward staff resulting in severe injuries.

Reviewed a sample of 200 RN reassessments, for the period of 6/13/17 at 5 p.m. to 6/24/17 at 7:15 a.m. when Patient 11 was in seclusion or restraints. The following issues were identified:

a) 52 of the 200 RN reassessments' vital signs and range of motion (ROM) sections in the RN Reassessment forms were blank. There was no documentation to explain reasons for the vital signs and ROM were not performed/documented. Also, the reassessments did not explain how staff communicated to the patient and how the patient's responded to the explanation of the procedure/interventions when the patient was deaf.

a-1) 9 of these 52 RN reassessments indicated Patient 11 was in both seclusion and 5 point restraints; these 9 reassessments did not check or explain if the patient's body temperature and capillary refill (two of the measures to monitor patient's circulation) within normal limit/range when the patient was under a 5 point restraint (restraint belt applied to the patient's torso and limbs). These continuous omissions of vital signs, O2Sat, ROM, and/or circulation were as long as up to one hour.

a-2) 43 of these 52 reassessments indicated Patient 11 was on seclusion. Of the 43 reassessments, the longest continuous omission of vital signs, O2Sat, ROM, and/or circulation was 7 hours and 45 minutes on 6/23/17, from 7:30 a.m. to 3:15 p.m. 23 of these 43 reassessments indicated Patient 11's current situation and behavior/mental status was "Laying in bed." The section for Interventions implemented to assist in meeting release criteria and active treatment provided was either left blank (6/22/17, from 11 a.m. to 1:15 p.m.) or documented "provide food, comfort, special bedding for suicidal statement" every 15 minutes as long as up to continuous 7 hours and 45 minutes (6/23/17, from 7:30 a.m. to 3:15 p.m.).

b) 75 of the 200 RN reassessments had a check mark next to the "Patient's behavior renders this impossible or unsafe for either the patient or the staff" in the v/s documentation section. However, the current situation and behavior/mental status of the patient during the reassessments included: patient sitting on bed quiet, lying down quiet, lying on bed, quiet, at door window communicating with peer or looking into hallway, calm, sitting on floor, lying in bed appears to be sleeping, calm and appearing accepting of his situation, lying down under blanket, or sleeping while the same interventions implemented to assist the patient in meeting release criteria and active treatment provided were providing "food, comfort, special bedding for Suicide statements" for all 75 reassessments. These reassessments did not explain what patient behaviors rendered v/s taking impossible or unsafe for the patient or staff. These reassessments did not indicate how the staff communicated with Patient 11 when the patient was deaf.

During a concurrent interview and record review on 8/4/17, at 4 p.m., the Director of Nurses (DON) acknowledged not all RN reassessments had vital signs, O2Sat, or range of motion done every 15 minutes. When discussed their policy indicated vital sign every one hour versus the RN Reassessment form required every 15 minutes, the DON stated she was not sure if the policy required every 15 minutes vital signs, but the RN Reassessment form required vital signs every 15 minutes.

2. Patient 9's admission record, date 7/19/17, indicated Patient 9 was admitted on 7/13/17 with a primary diagnosis Persistent mood disorder (unspecified mental disorder).

The Initial Orders, dated 7/13/17 at 10:39 a.m., indicated a physician's order for seclusion and restraint with "5 point leather."

The Restraint and Seclusion Sheet dated 7/13/17, indicated Patient 9 was in restraints from 10:40 a.m. to 11:45 a.m. due to aggressive behaviors including banging head and being combative.

The RN Reassessment form, dated 7/13/17, at 11 a.m., revealed Patient 9's pulse, O2Sat were measured, but temperature, respiration rate, blood pressure, and ROM were not measured or monitored. The form did not indicate the reasons for not measuring or monitoring these vital signs or ROM. The form indicated Patient 9 was on seclusion and restraint with 5 point leather.

The RN Reassessment form, dated 7/13/17, at 11:15 a.m., revealed Patient 9's respiration rate was documented and a check mark near "Patient's behavior renders this impossible or unsafe for either the patient or the staff."

The RN Reassessment form, dated 7/13/17, at 11:30 a.m., revealed Patient 9's respiration rate was documented. The form indicated a check mark near "Patient's behavior renders this impossible or unsafe for either the patient or the staff." However, the form documented Patient 9's "Current situation and behavior/mental status: Resting, occasional jerks on own Restraints." The plan was to continue on seclusion and restrain, but did not indicate interventions implemented to assist in meeting release criteria and active treatment provided. The form also indicated the seclusion and restraint was discontinued at 11:45 a.m. There was no vital sign documented on release of seclusion and restraint.

3. Patient 10's admission record, date 7/24/17, indicated Patient 10 was admitted to the facility on 7/23/17 with a primary diagnosis schizophrenia (a mental disorder).

The initial order, dated 7/27/17, at 2:20 p.m., revealed a physician's order for containment (a form of restraint, which the staff places hands on the patient causing restriction of freedom of all or part of the patient's body or restricts normal access to the patient's body) and physical restraint.

The Restraint & Seclusion Sheet, dated 7/27/17, indicated Patient 10 was in restraints on 7/27/17, from 2:20 p.m. to 3:20 p.m. due to Patient 10 spitting and banging on windows.

The RN Reassessment forms, dated 7/27/17, at 2:20 p.m., indicated Patient 10 was in 5 points restraints. The form indicated vital signs, and range of motion were not documented with a check mark near "Patient's behavior renders this impossible or unsafe for either the patient or the staff."

The RN Reassessment forms, dated 7/27/17, at 2:35 p.m. and 2:50 p.m., indicated Patient 10 was in 5 point restraints. The forms revealed Patient 10's vital signs and range of motion were not documented. There was no documentation of the reasons for not measuring/monitoring the vital signs and range of motion.

The RN Reassessment forms, dated 7/27/17, at 3:05 p.m., and 3:20 p.m., revealed vital signs and range of motion were not documented. There was a check mark near "Patient's behavior renders this impossible or unsafe for either the patient or the staff." However, the form at 3:20 p.m. indicated Patient 10 was calm and will follow directions and the restraint was discontinued at 3:20 p.m. The form did not explain what patient behaviors rendered the measuring/monitoring of vital signs and the range of motion.

During interviews on 8/3/17, at 2:30 p.m., and on 8/4/17, at 1:45 p.m., the Director of Nurses (DON) reviewed Patient 9 and 10's health records and acknowledged not all vital signs and monitoring done/documented in the RN Reassessment forms every 15 minutes. The DON stated staff should have measured/monitored vital signs and range of motion every 15 minutes as indicated in the forms. The DON stated reassessment every 15 minutes to monitor if patients were physically stable because the patients were in crisis. The DON stated they also needed to monitor if the effectiveness of medications including the side effect of medications (i.e. increase blood pressure). The DON stated they should be able to obtain vital signs when patients were on 5 point restraints.

During an interview on 8/4/17, at 4:20 p.m., the Medical Director stated the every 15 minutes vital signs should be done for patient safety. The Medical Director stated there was no reason for not being done if this was indicated on the reassessment form.

The facility's policy and procedure titled "SECLUSION AND RESTRAINTS," revision dated 4/20/15, indicated direct care staff to "Monitor vital signs every Hour using the 2100 RN Reassessment. In the event the patient's behavior renders this impossible or unsafe for either the patient or the staff this will be documented in the medical record...Provide the patient in restraints range-of-motion (ROM) exercise every hour on each extremity...An RN will assess the patient in seclusion/restraint every 15 minutes or as otherwise noted. Document the following on the 2100 Registered Nurse Reassessment:...Patient circulation of all limbs, Restraints remain properly applied...Assessment of physical status every hour, Vital signs every hour...Reason for restraint/seclusion explained, Behavioral criteria for release explained, Interventions implemented to assist in meeting release criteria and active treatment provided..."

Based on interview and record review, the facility failed to ensure all the One Hour Face to Face Assessments for Patients in Seclusion and Restraints (One Hour Assessment) were performed by a physician, trained physician assistant (PA) or registered nurse (RN), or completed the One Hour Assessment in a timely manner for 3 of 12 sampled patients (Patient 9, 10, and 11). These failures had resulted in 1) 130 of 133 of Patient 11's One Hour Assessments were performed/signed by a RN who was not trained, 2) Patient 10's One Hour Assessment was completed 20 minutes late by a RN who was not trained, and 3) Patient 9's One Hour Assessments were performed/signed by a RN who was not trained. These failures also had the potential that patients were not being assessed accurately, the restraints were not applied properly, or patients were prevented from being released from seclusion or restraints as early as possible which could further compromise patients' health and safety.

Seclusion is involuntary confinement of a patient alone in a room or an area from which the person is physically prevented from leaving.

Physical restraint is the use of manual hold to restrict freedom of movement of all or part of a person's body or restricts normal access to the person's body that is used as a behavioral restraint.

The One Hour Face to Face Assessment for Patients in Seclusion and Restraints (One Hour Assessment) is required to be completed within one hour after the onset/initiation of the seclusion/restraint procedure. The assessment included the patient's behaviors and mental status, rationale for the procedure, patient's immediate situation or reaction to the procedure, physical assessment, and interventions to assist the patient to meet the release criteria (criteria for the release of the seclusion/restraint).

Findings:

1. Patient 11's Admission Record, date 6/14/17, indicated Patient 11 was admitted to the facility on 6/13/17 with a primary diagnosis of psychotic disorder (a mental disorder).

The physician's initial orders, dated from 6/13/17 to 7/11/17, revealed Patient 11 was on seclusion or restraint.

133 of Patient 11's One Hour Assessment dated from 6/13/17 at 5:45 p.m. to 7/11/17, at 2:33 p.m. were performed/signed by RNs.

During a concurrent interview and record review on 8/4/17, at 4 p.m., the Director of Nurses (DON) reviewed all Patient 11's One Hour Assessment from 6/13/17 to 7/11/17. The DON stated only three of these (133) assessments were done and signed by a trained RN. The DON stated all other assessments were done and signed by RNs who were not trained.

2. Patient 10's admission record, date 7/24/17, indicated Patient 10 was admitted to the facility on 7/23/17 with a primary diagnosis of schizophrenia (a mental disorder).

The initial order, dated 7/27/17, at 2:20 p.m., revealed a physician's order for containment (a form of restraint, which the staff places hands on the patient causing restriction of freedom of all or part of the patient's body or restricts normal access to the patient's body) and physical restraint.

The restraint and seclusion sheet, dated 7/27/17, indicated Patient 10 was in restraints on 7/27/17, from 2:20 p.m. to 3:20 p.m. due to Patient 10 spitting and banging on windows.

The One Hour Assessment, dated 7/27/17, at 3:40 p.m., was signed by a RN. The assessment was completed in 1 hour and 20 minutes after the initiation of the restraint, which was 20 minutes late.

3. Patient 9's admission record, date 7/19/17, indicated Patient 9 was admitted on 7/13/17 with a primary diagnosis of Persistent mood disorder (unspecified mental disorder).

The Initial Orders, dated 7/13/17 at 10:39 a.m., indicated a physician's order for seclusion and restraint with "5 point leather (restraint belt applied to the patient's torso and limbs)."

The restraint and seclusion sheet dated 7/13/17, indicated Patient 9 was in restraints from 10:40 a.m. to 11:45 a.m. due to aggressive behaviors including banging head and being combative.

The One Hour Assessment, dated 7/13/17, at 11 a.m., was signed by a RN.

During a concurrent interview and record review on 8/3/17, at 2:30 p.m., the DON reviewed Patient 9 and 10's One Hour Face to Face Assessment for Patients in Seclusion and Restraints. The DON stated Patient 9's assessment was done and signed by Licensed Staff KK who was not trained or certified to perform the assessment. The DON stated Patient 10's assessment was done and signed by Licensed Staff G who was not trained or certified to perform the assessment and the assessment was completed 20 minutes late. The DON stated it was important to perform the assessment on time (within one hour after the initiation of seclusion or restraint) by a trained licensed staff to ensure restraints were properly applied; patients were physically healthy and had no injury after the procedure.

During an interview on 8/4/17, at 4:20 p.m., the Medical Director stated the One Hour Face to Face Assessment for Patients in Seclusion and Restraints should be done by trained personnel because the training included the "why" and how to talk to the patient in order to develop rapport with the patient, which would not "gear up the fire." The Medical Director stated the trained personnel should be able to assess the patient appropriately in order to help the patient to be released from seclusion or restraint quicker, for patient and staff safety.

The facility's policy and procedure titled "SECLUSION AND RESTRAINTS," revision dated 4/20/15, indicated "...A Physician/NP/PA during scheduled working hours, a Physician Assistant, or a trained RN in other circumstances will conduct a face-to-face evaluation of the patient within one (1) hour after initiation of the procedure and document as indicated below. Document on the 2099 Face to Face Evaluation each time a face-to-face assessment is completed..."

Based on staff interview and document and policy and procedure review, the facility failed to ensure all staff received annual training in the use of restraints and seclusion. This had the potential to create an unsafe environment for patients placed in restraints and seclusion by untrained staff.

Findings:

Review of facility-submitted documentation of "RN Competencies," dated current as of 6/20/17, indicated 5 of 17 current Registered Nurses (RN) were delinquent in their annual competencies for Seclusion and Restraints:
Licensed Staff (LS) KK--completed training on 4/28/16
LS LL--3/15/16
LS M--8/25/15
LS MM--4/18/16
LS E--6/20/16

During an interview and concurrent review of the "RN Competencies" documentation on 8/2/17 at 3:35 p.m., the Director of Nurses (DON) stated there are five competencies RNs must complete and pass every year: Patient Transfers, Medical Screening Examinations, Age Appropriate Health Screening Assessments, Restraints and Seclusion, and Face to Face Assessments. She acknowledged not all staff were current with their annual training for use of Seclusion and Restraints.

Review of the policy titled, "Competency Testing," last reviewed 4/17/14, indicated: "The Medical staff Bylaws have identified that a Registered Nurse may perform age-related, specific assessment once the Registered Nurse has proven the skill and knowledge needed to provide such care effectively. Competency testing will occur following a new employee orientation and then annually thereafter. A registered nurse will only be able to perform those assessments in areas in which they have passed the competency test requirements. All Registered Nurses will be required to pass competency testing in the following areas before they will be allowed to perform these duties without supervision: 1. Nurses Physical Health Screen; 2. Medical Screening Examination; 3. Acute Transfers." The policy did not address Restraints and Seclusion, nor Face to Face assessments.

Review of the policy titled, "Seclusion and Restraints," revised 4/20/15, did not address RN competencies.

Review of the policy titled, "Inservice Program," revised 1/23/17, indicated: "The facility will ensure annual inservice is available to staff that shall include but not be limited to...one hour Face to Face After Seclusion and Restraints."

Based on staff interview, facility document and policy review, the facility failed to ensure all its staff were trained or current in Management of Assaultive Behavior [(MAB) a violence prevention course designed for healthcare workers]. This had the potential that staff would not be proficient in managing violent patient behavior on the mental health units which could negatively affect patient and staff safety.

Findings:

Review of facility-submitted staff MAB tracking logs indicated 14 of 50 staff members were past-due in their annual MAB training and 7 of 50 had never received MAB training:

Past Due Staff:
Licensed Staff (LS) M--due 12/2015
Mental Health Worker (MHW) F--4/2016
LS N--4/2016
MHW O--5/2016
MHW P--8/2016
MHW Q--11/2016
LS R--11/2016
LS AA--11/2016
MHW BB--12/2016
DON--1/2017
LS CC--1/2017
MHW DD--4/2017
MHW EE--4/2017
Administrator--4/2017

Staff Never Trained:
LS E
LS FF
LS D
MHW GG
MHW HH
MHW II
MHW JJ

During an interview and concurrent MAB document review on 8/1/17 at 11:10 a.m., the DON stated the yellow highlighted areas indicated staff who were either late in getting annual MAB training or staff who had never had MAB training. She stated MAB training is required annually, and added, "You can see that's not been done."

Review of the policy titled, "Employee Requirements," last reviewed 4/23/14, indicated annual MAB training is required for the Director of Nursing, Supervising Psychiatric RN, Licensed Psychiatric Technician, Licensed Vocational Nurse, Mental Health Workers, Activity Therapists, Mental Health Discharge Planner and Social Workers.

Based on staff interview and document and policy and procedure review, the facility failed to ensure all staff received annual training in Patient Transfers, Medical Screening Examinations, Age Appropriate Health Screening Assessments, Restraints and Seclusion, and Face to Face Assessments. This had the potential to create an unsafe environment for patients being transferred or placed in restraints and seclusion by untrained staff and the potential that staff would not be competent to perform examinations and assessments.

Findings:

Review of facility-submitted documentation of "RN Competencies," dated current as of 6/20/17, indicated 5 of 17 current Registered Nurses (RN) were delinquent in their annual competencies for Patient Transfers, Medical Screening Examinations, Age Appropriate Health Screening Assessments, Seclusion and Restraints, and Face to Face Assessments:
Licensed Staff (LS) KK--completed training on 4/28/16;
LS LL--3/15/16, 4/23/16, and 5/6/16;
LS M--8/25/15
LS MM--4/18/16
LS E--6/20/16

During an interview and concurrent review of the "RN Competencies" documentation on 8/2/17 at 3:35 p.m., the Director of Nurses (DON) stated there are five competencies RNs must complete and pass every year: Patient Transfers, Medical Screening Examinations, Age Appropriate Health Screening Assessments, Restraints and Seclusion, and Face to Face Assessments. She acknowledged not all staff were current with their annual training for use of Seclusion and Restraints.

Review of the policy titled, "Competency Testing," last reviewed 4/17/14, indicated: "The Medical staff Bylaws have identified that a Registered Nurse may perform age-related, specific assessment once the Registered Nurse has proven the skill and knowledge needed to provide such care effectively. Competency testing will occur following a new employee orientation and then annually thereafter. A registered nurse will only be able to perform those assessments in areas in which they have passed the competency test requirements. All Registered Nurses will be required to pass competency testing in the following areas before they will be allowed to perform these duties without supervision: 1. Nurses Physical Health Screen; 2. Medical Screening Examination; 3. Acute Transfers." The policy did not address Restraints and Seclusion, nor Face to Face assessments.

Review of the policy titled, "Seclusion and Restraints," revised 4/20/15, did not address RN competencies.

Review of the policy titled, "Inservice Program," revised 1/23/17, indicated: "The facility will ensure annual inservice is available to staff that shall include but not be limited to...Registered Nurse Competencies, Cardio Pulmonary Resuscitation (CPR),...one hour Face to Face After Seclusion and Restraints."

Based on staff interview and document and policy and procedure review, the facility failed to ensure all staff received annual training for the One Hour Face-to-Face Assessment (for patients in seclusion or restraints). This had the potential to create an unsafe environment for patients placed in restraints and seclusion by untrained staff.

Findings:

Review of facility-submitted documentation of "One Hour Face to Face Assessment for Patients in Seclusion and Restraints," indicated training was conducted several dates in November 2014. Of the 25 staff members included on the sign-in sheet, only three were currently employed at the facility (Licensed Staff CC, the Inpatient Nursing Supervisor, and the Director of Nurses).

During an interview and concurrent review of the "One Hour Face to Face Assessment for Patients in Seclusion and Restraints," the Director of Nurses (DON) stated the last time the facility conducted the Face to Face training was in November 2014. She acknowledged most of the current nursing staff had not been trained in how to conduct Face to Face assessments.

Review of the policy titled, "Inservice Program," revised 1/23/17, indicated: "The facility will ensure annual inservice is available to staff that shall include but not be limited to...one hour Face to Face After Seclusion and Restraints."

Based on staff interview, personnel file review, and policy and procedure review, the facility failed to ensure all staff received timely performance evaluations. This had the potential that staff would not be proficient in carrying out their duties and responsibilities which could negatively affect patient care.

Findings:

Personnel file review on 8/2/17 at 9:20 a.m., indicated the Infection Preventionist (date of hire to position 2/27/17) and the Director of Nurses (date of hire to position 4/9/17) did not have current performance evaluations on file. In a concurrent interview, Employee Services Staff B stated, they were both "overdue."

Review of the policy titled, "Performance Evaluations," effective date 7/10/13, indicated probationary period evaluations would be conducted three months from the date of hire, two weeks prior to the completion of the six month probation period, and annually thereafter.




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During a concurrent interview and review of personnel files on 8/2/17, at 9 a.m., Licensed Staff J and R's file did not contain a current performance evaluation. Employee Services Staff K stated Licensed Staff J's performance evaluation was two months overdue (last evaluation was on 5/23/16). Employee Services Staff K stated Licensed Staff R's performance evaluation was two years overdue (last evaluation was on 5/24/15). Employee Services Staff B also assisted with personnel files review and stated staff performance evaluation should be done on time because they needed to know if the staff performed their jobs properly.

Based on policy review and administrative staff interview, the facility failed to ensure all of its policies and procedures were reviewed and/or revised every three years per facility policy. This had the potential for the policies to be outdated and/or not consistent with current law or Standards of Practice.

Findings:

Review of facility-submitted policies indicated the following most current review/revision dates:
"Client Problem Resolution Process"--1/30/14;
"Employee Requirements"--4/23/14;
"Competency Testing"--4/17/14;
"Unit Orientation Checklist"--effective date 11/25/13, no review/revision date;
"Nursing Scheduling"--3/13/12;
"Search Policy Nursing Procedures"--4/27/14;
"Suspected Dependant Adult and Elder Abuse Reporting"--8/15/13;
"Patient Rights"--6/10/14;
"Emergency Dietary Services Plan-Water"--effective date 4/14/14, no review/revision date;
"Visitors"--2/21/13;
"Paging System Use in Emergency"--11/12/13;
"Threat Response Policy"--11/12/13;
"Volunteers"--2/24/14;
"Suspected Child Abuse Reporting"--7/14/14;
"Patient's Right Advocate"--3/17/14;
"Panic Buttons and Response"--effective date 6/22/12, no review/revision date;
"Safety Committee''--11/12/13;
"Control and Organization of Policy Manuals"--6/2/14.

During an interview on 8/3/17 at 3 p.m., Administrative Staff A stated the policies and procedures are not being reviewed/revised every three years per facility policy.

Review of the policy titled, "Control and Organization of Policy Manuals," revised 6/2/14, indicated: "Policies and Procedure [sic] are required to be reviewed, revised, and/or retired during a three year 'life' of a policy...The goal of a policy review is to identify changes due to legislation, rules, regulations, or changes in practice that will be accurately reflected in the procedural section of a policy."

Based on interview and record review, the facility failed to ensure 1. Staff completed a master treatment plan (a written plan of care/treatment, which addresses the patient care/treatment plan based on the comprehensive assessment by the treatment team members. The written plan also serves as a communication tool among the team including the patient), and 2. Staff implemented the master treatment plan for five of 12 sampled patients (Patient 12, 13, 14, 15, and 16). These failures resulted in Patient 12 receiving care/treatment without a written plan and patients' weights were not monitored as care planned. These failures also had the potential to result in unplanned weight gain/loss, which could further compromise patients' physical and psychosocial well-beings.

Findings:

1. Patient 12's admission record dated 7/31/17, indicated Patient 12 was admitted to the facility on 7/26/17 with a primary diagnosis of psychosis (a mental disorder). Patient 12 was discharged on 7/30/17.

Patient 12's Nutritional Screening completed by a registered nurse (RN), dated 7/26/17, indicated Patient 12 had recent weight loss of 10 lbs. (pounds) or more within the last six months (4 points), poor appetite (4 points), nutrition related diagnosis (eating disorder, 5 points). The total points from the screening was 13, which indicated Patient 12 was at high nutritional risk and required to consult with registered dietician (RD) and monitor nutritional status.

Patient 12's Nutritional Screening completed by a RN, dated 7/29/17, indicated Patient 12 had recent weight loss of 10 lbs. or more within the last six months (4 points), fair appetite (2 points), numbers of medications taking daily (1 point). The total points from the screening was 7, which indicated Patient 12 was at moderate nutritional risk and required to consult with RD and monitor nutritional status.

Patient 12's master treatment plan, initiated on 7/27/17, indicated Patient 12 had strengths including family support. The treatment plan did not address Patient 12's disabilities. The treatment plan included a problem "Refusing meds [medications] and refusing food." The long-term goal was to "Get into school, obtain a Cello, and own housing." The short-term goal was "Money, Food, Shelter." The intervention was "Discharge Plan for Continuing care." The treatment plan did not address how the facility monitored Patient 12's nutritional status and what approaches were taken for the nutritional risks. The long-term goal and short-term goal were not measurable and had no interventions planned toward achieving the goals. The treatment plan was signed by the patient, staff, and a physician.

During a concurrent interview and record review of Patient 12's health records on 8/3/17, at 2:30 p.m., the Director of Nurses (DON) reviewed Patient 12's master treatment plan. The DON stated the master treatment plan was incomplete. The DON stated the master treatment plan gave directions to staff, let patient know what he/she was here for, initiated a discharge plan, and used for communications among team members. The DON stated the master treatment plan should be started within 24 hours and completed within 72 hours after the patient's admission.

During a concurrent interview and record review on 8/4/17, at 1:45 p.m., the DON stated Patient 12's master treatment plan was started but was not completed. The DON stated the goals on the treatment plan were not measurable. The DON stated the nurse should have written the treatment plan and reviewed the plan with the patient.

The facility's policy and procedure titled "TREATMENT PLANNING," revision dated 6/6/14, indicated "Each patient must have an individualized, comprehensive Treatment Plan that must be based on an inventory of patient strengths and disabilities. A Nursing Problem will be started within 24 hours of admission by the registered nurse, under the direction and supervision of the attending physician, with input from all disciplines. Thereafter, a Master Treatment Plan will be developed by all disciplines within 72 hours of admission...Short Term Goals and Target Dates: Expected behaviors that will be demonstrated prior to accomplishment of the long term goals. Each short term goal will have a realistic target date, and be written in measurable terms. Long Term Goals (Discharge Objectives): Expected behaviors prior to discharge. (The treatment team's objective for discharge)..."

2. Patient 13's admission record, dated 8/2/17, indicated Patient 13 was admitted to the facility on 7/7/17 with a primary diagnosis of schizophrenia (a mental disorder) and other diagnoses including Methamphetamine (highly addictive drug which affects the central nervous system) dependence and cannabis (marijuana) dependence.

Patient 13's master treatment plan, initiated on 7/10/17, indicated a problem was "Grave disability (per the DON, a patient has grave disability when the patient is not able to provide food, clothing and shelter to self." Interventions included "Nutritional screening done on admit then in 72 hours then weekly...Weights taken 3x/week [three time per week]..."

Patient 13's Nutritional Screening completed by a RN on 7/8/17, indicated Patient 13's weight was taken on 7/7/17, which was 105 lbs with a height 60 inches.

Patient 13's Nutritional Screening completed by a RN on 7/11/17, 7/18/17, 7/25/17, and 8/1/17, did not document Patient 13's weight.

During concurrent interviews and record reviews on 8/3/17, at 2:30 p.m., and on 8/4/17, at 1:45 p.m. regarding Patient 13's weight monitoring, the DON acknowledged that Patient 13's weights were not documented on the RN Nutritional Screening for Patient 13 on 7/11/17, 7/18/17, 7/25/17, and 8/1/17. The DON stated she reviewed Patient 13's health records and printed out the vital signs report. The vital signs report printed on 8/4/17, indicated that Patient 13's weights were taken on 7/7/17, 7/10/17, 7/12/17, 7/14/17, 7/21/17, and 7/31/17. The DON stated Patient 13's weight was not taken three times per week from 7/15/17 to 8/1/17. The DON stated there was no documentation of the reasons for not taking the patient's weight. The DON stated Patient 13's weight should be taken three times per week as care planned. The DON stated taking patients' weight three times per week was also the facility's standard to monitor patients' weight.

3. Patient 14's admission record dated 8/2/17, indicated Patient 14 was admitted to the facility on 7/16/17 with a primary diagnosis of acute psychosis (a mental disorder).

Patient 14's master treatment plan, initiated on 7/20/17, indicated interventions including "Nutritional assessment is done on admit, at 72 hours, then weekly and as needed. Weight is assessed three times weekly..."

Patient 14's Nutritional Screening by RN on 7/19/17, indicated Patient 14's weight was taken on 6/30/17. The Nutritional Screening by RN on 7/26/17, indicated Patient 14's weight was taken on 7/24/17.

During concurrent interviews and record reviews on 8/3/17, at 2:30 p.m., and on 8/4/17, at 1:45 p.m., regarding Patient 13's weight monitoring, the DON stated she reviewed Patient 14's health records and printed out the vital signs report. The vital sign report printed on 8/4/17, indicated Patient 14's weight was taken on 7/19/17, 7/21/17, and 7/24/17. There was not weight recorded from 7/25/17 to 8/1/17 and no documentation for the reasons of weight not being taken. The DON acknowledged that the weight was not taken for the week of 7/25/17 - 8/1/17.

4. Patient 15's admission record, dated 5/5/17, indicated Patient 15 was admitted to the facility on 4/8/17 with a primary diagnosis of psychosis. Patient 15 was discharged on 5/4/17.

Patient 15's master treatment plan, initiated on 4/10/17, indicated Patient 15's problem was "Gravely Disabled [as manifested by] delusions preventing her from staying at her home, eating, and sleeping." The interventions included "Nutritional assessment done on admit, then in 24 hours, then weekly...Weights taken three times a week."

Patient 15's Nutritional Screening by RN on 4/8/17, 4/11/17, 4/14/17, 4/21/17, 4/28/17, did not record Patient 15's weights. There was no documentation of the reasons for weights not being taken.

During concurrent interviews and record reviews on 8/3/17, at 2:30 p.m., and on 8/4/17, at 1:45 p.m., the DON reviewed Patient 15's health records and acknowledged that the Nutritional Screening did not record a weight. The DON provided a copy of Patient 15's vital signs report printed on 8/4/17, with a hand written "weight 92 lbs on admission..." The vital signs report revealed Patient 15's vital signs only being measured on 4/19/17 and 4/22/17 and there was no weight being recorded. The DON stated there was no weight being recorded after admission and only two days vital signs recorded for Patient 15's hospital course 4/8/17 - 5/4/17, which was almost a month. The DON stated Patient 15 might have refused vital signs and weight, but they did not have documentation of the refusal or other reasons for vital signs and weight not being taken.

5. Patient 16's admission record, dated 7/31/17, indicated Patient 16 was admitted to the facility on 7/28/17 with a primary of diagnosis schizoaffective disorder (a mental disorder) and other diagnoses including underweight due to inadequate caloric intake.

Patient 16's master treatment plan, initiated on 7/31/17, indicated Patient 15's problem was "Gravely Disabled [as manifested by] patient reportedly not eating and requiring extensive prompting and encouragement from staff to eat his meals resulting in significant weight loss..." The interventions included "...Nutritional assessment is done on admit, at 72 hours, then weekly and as needed. Weight is assessed three times weekly..."

Patient 16's Nutritional Screening by RN on 7/29/17, indicated Patient 16's weigh on 7/28/17 was 130 lbs. with a height 66 inches. The Nutritional Screening by RN on 8/1/17 did not record patient's weight.

During concurrent interviews and record reviews on 8/3/17, at 2:30 p.m., and on 8/4/17, at 1:45 p.m., the DON acknowledged the Nutritional Screening by RN on 8/1/17 did not record patient's weight. The DON stated she reviewed Patient 16's health records and printed out the vital signs report. The vital signs report printed on 8/4/17, indicated Patient 16's weight was taken on 7/28/17 and 7/31/17. There were neither weights nor documentation for the weights not being taken documented after 7/31/17. The DON stated they should have taken Patient 16's weight on 8/2/17, Wednesday. The DON stated their standard was to weight all patients on Monday, Wednesday, and Friday, three times a week. The DON stated it was important to monitor patients' weight to make sure patients not significantly gain or lose weight because patients' disorders could have affected their eating habits. The DON stated the medications patients taking might have side effects resulting in weight gain/loss; it was important to monitor weights and to change diet as needed.

The facility's policy and procedure titled "TREATMENT PLANNING," revision dated 6/6/14, indicated "There are several steps that are crucial to developing an individualized, comprehensive Treatment Plan...The interventions are actions carried out by the Multidisciplinary Treatment Team members to help the patient resolve problem behaviors and accomplish goals..."

Based on observation, interview, and document review, the facility failed to administer medications in accordance with the physician order and manufacturer's recommendations.

Findings:

1. During a medication pass observation on 8/2/17 at 8:05 a.m., PT U, a Psychiatric Technician, administered an ear drop, a generic for Cortisporin (medication containing antibiotics and steroid) otic (ear) suspension to Patient 25.

The patient's medication record indicated there was a physician order on 7/29/17 for Cortisporin Otic Drops, 4 drops four times a day for 7 days, which was later clarified on 7/31/17 to be administered to the patient's left ear.

According to the manufacturer's recommendation for Cortisporin Otic Suspension, the ear drop should be shaken well prior to administration.

A suspension is a mixture containing solid particles in liquid. The solid particles do not dissolve but settle at the bottom if not agitated.

In an interview on 8/2/17, at 8:30 a.m., PT U acknowledged he did not shake the ear drop before administering to the patient.

The form, "Medication Administration Evaluation by Pharmacist," which is used by the CP to evaluate monthly the facility staff medication pass was reviewed and it indicated one of the criteria for evaluation the following:

"Shakes bottle properly as instructed..."

2. During a medication pass observation on 8/2/17 at 8:05 a.m., PT U, a Psychiatric Technician, administered an ear drop, a generic for Cortisporin (medication containing antibiotics and steroid) otic (ear) suspension to Patient 25's right ear.

The patient's medication record indicated there was a physician order on 7/29/17 for Cortisporin Otic Drops, 4 drops four times a day for 7 days, which was later clarified on 7/31/17 to be administered to the patient's left ear.

In an interview on 8/2/17, at 11:45 a.m., PT U stated he administered the ear drop to the patient's right ear because the patient complained of ear pain in her right ear and agreed that he should have contacted the physician to receive an order to administer in the right ear instead of the left ear.

The facility's policy and procedure titled, "Administration of Medications" last revised, 4/3/17, read, in part:

"...Medications will be administered by licensed staff as ordered by the physician..."

Based on observation, interview, and record review, the facility failed to ensure staff followed their policy and procedure to complete all medical records within 30 days following discharge. This failure had the potential to result in medical records that lack vital patient health care information being available for the patients' continuing care after discharge.

Findings:

During a concurrent observation and interview with Ward Clerk H and the Medical Record Manager on 8/1/17, at 9:10 a.m., in the ward clerk office, two shelves contained medical records. Ward Clerk H stated one of the shelves contained medical records waiting for audit. Ward Clerk H counted the medical records and stated there were 77 medical records waiting for audit and the discharge dates were from 6/7/17 (55 days following discharge) to 7/26/17. Ward Clerk H counted the medical records in another shelf and stated there were 125 medical records awaiting for corrections. Ward Clerk H stated they should have completed the medical records within 30 days after the discharge date. The Medical Record Manager checked on the computer and stated the oldest discharge date was 4/29/16, which was greater than a year following discharge. The Medical Record Manager printed out the MD (medical doctor) Chart Correction Report/Summary and the Nursing Chart Correction Report/Summary and stated there were 81 medical records to be audited and 154 medical records in need for corrections.

The MD Chart Correction Report/Summary, dated from 6/1/17 to 7/28/17, indicated "51 audited charts needing corrections have a discharge date greater than 30 days...There are a total of 12 charts that need a Discharge Summary; 9 are out-of-compliance. There are 81 charts to be audited; 45 are out-of-compliance..."

The Nursing Chart Correction Report/Summary, dated from 5/11/17 to 7/28/17, indicated "154 audited charts in need of corrections have a discharge date greater than 30 days..."

During an interview on 8/1/17, at 1:50 p.m., when asked how to ensure accuracy of health information when corrections being done months or greater than a year after patients being discharged, the Medical Record Manager stated it depended on what kind of correction needed. The Medical Record Manager stated they sent out the correction request to department supervisors and the supervisors should have monitored the correction.

During an interview on 8/3/17, at 2:30 p.m., regarding medical records not being completed within 30 days, the Director of Nurses (DON) stated "They constantly notified me," and she knew it was "very badly late" and needed to be done. When asked if they had an action plan for the corrections, the DON stated "No. I don't have an action plan." When regarding accuracy of making corrections 30 days or greater than one year after patients being discharged, the DON stated staff could make late entries and might remember the situation, but it was challenging.

The facility's policy and procedure titled "INPATIENT CHART GUIDELINES," revision dated 5/8/15, indicated "Policy: Inpatient charting will be complete and correct within 30 days of patient discharge. Procedure: ...3. Charts for discharged clients will be checked out by the Medical Staff Coordinator who will deliver them to the discharging/dictating physician for dictation of the discharge summary. Delivery to the MD completing the dictation will take place within one business day of client discharge (exceptions to this time frame must be approved by Medical Records and the Medical Director)...7. The Ward Clerk then audits the chart for completion and clerical accuracy...8. any identified corrections are completed by the original documenter...9. All of the above steps will be completed within 30 days of client discharge..."

Based on interview and document review, the facility failed to ensure all activities of pharmacy services were provided by the facility's consultant pharmacist (CP) including disposition/destruction of pharmaceutical wastes, coordination of drug recalls, and consulting on the development of the formulary.

Findings:

In an interview on 8/3/17, at 9:30 a.m., the CP stated he was not involved with the drug recall process indicating the contracted pharmacy would be the one to inform the facility about the drug recalls.

The CP stated he was not involved in destruction of the controlled substances (CS) since the last DON stopped working a few years ago and the contracted pharmacy would be one taking care of the CS destruction.

The CP stated the facility had its own county pharmacy providing pharmacy services until it closed. During that time the facility used the Medi-Cal (California Medicaid) formulary and the contracted pharmacy would be responsible for providing formulary medications. The CP further stated he was not involved in consultation of formulary decisions and did not think there was any formulary restrictions.

The facility's policy and procedure titled, "Drug Recall" last reviewed, 9/13/16, read, in part:

"... [The Contracted Pharmacy] and [The Facility] Consulting Pharmacist will maintain membership on drug recall distribution lists through the Federal Drug Administration and independent sources. [The Facility] Consulting Pharmacist (by fax) will each, independently contact the Medical Director and the Director of Nursing about any notification they receive regarding recalled drugs by manufacturer, generic, and brand name, dose, expiration date, and lot number. They will provide a copy of the notice they receive about any recalled drug to both the Medical Director and the Director of Nursing. The notices will be maintained in the Drug Recall Binders (maintained in the Medical Staff Coordinator's office and [the Facility] Medication Room).

The Medical Director and the Director of Nursing will cross-reference the drug recall notice with [the Facility] Stock Medication Inventory and [the Facility] Refrigerated Medications Inventory (kept in the Drug Recall Binders). If the drug is included in any of the inventories, it will be removed, entered into the Drug Recall Log, and returned to dispensing pharmacy. The Medical Director will notify (by e-mail) all practicing Medical Staff. ..If no stock medications are found the recall notice will be placed in the Recall binder. The nurse who checks inventory will write a note on the notice which will include the date, whether meds were found or not, and sign the recall notice..."

The facility's policy and procedure titled, "Disposition of Drugs" lasted reviewed, 8/29/16, read, in part:

"...All narcotic medications to be destroyed will be destroyed as needed by the Consulting Pharmacist and DON (or RN designated by the DON) and written on the Narcotic Record, located in the SV Medication room. The name of the patient, name and strength of the medication, prescription number, and amount destroyed, date of destruction and signatures of the Consulting Pharmacist and RN will be written directly on the narcotic medication count sheet, at the time of destruction..."

Review of the contract between the contract pharmacy and the facility that runs through 6/30/18 indicated the following:

"Description of Services

Contractor shall provide pharmaceutical consultation services to [The Facility] including but not limited to...

Assist in the development, coordination, supervision and review of the pharmaceutical services...

Devote a sufficient number of hours during a regularly scheduled visit to [The Facility] for the purpose of coordinating, supervising and reviewing the pharmaceutical services at least quarterly..."

Based on interview and document review, the facility failed to ensure accurate accounting of controlled substances was in place that included timely destruction of controlled substances, proper documentation of destruction, and maintaining the destruction record in accordance with the facility's policy and procedure to potentially minimize the drug diversion.

Findings:

In an interview on 8/2/17, at 3:30 p.m., the Outpatient Director of Nursing (ODON) stated the controlled substances (CS) destruction had not occurred over a year and the destruction log could not be found to account for when and what CS were destroyed.

In an interview on 8/3/17, at 9:30 a.m., the CP stated he was not involved in destruction of the controlled substances (CS) since the last DON a few years ago and the contracted pharmacy would be one taking care of the CS destruction.

"Disposition of Drugs" lasted reviewed, 8/29/16, read, in part:

"...The Medication Destruction Sheets of narcotic and non-narcotic medications will be maintained for at least three years..."

Based on observation, interview, and document review, the facility failed to control drugs in effective manner for patient safety by failing to ensure:

1. The room temperature of the Drug Room met the acceptable range specified in the facility's policy and procedure consistent with the manufacturer's drug storage requirements;

2. Medications in the Drug Room had sufficient space to prevent storage of medications in a disorderly and crowded manner;

3. Documented evidence the drug recall notices were received, reviewed, updated, and kept in the Drug Recall Binder in accordance with the facility's policy and procedure;

4. Patients' own medications were positively identified by a pharmacist or a physician prior to administration to patients in accordance with the facility's policy and procedure.

Recalls are actions taken by a firm to remove a product from the market. Recalls may be conducted on a firm's own initiative, by FDA (Food and Drug Administration) request, or by FDA order under statutory authority.

Findings:

1. An inspection of the facility's Drug Room was conducted on 8/1/17, at 9:20 a.m., with the Director of Nursing (DON) and PT T, a Psychiatric Technician, and it was noted there was a portable air conditioner and the room inside temperature on the thermometer indicated 78 °F (degree Fahrenheit).

In a concurrent interview, PT T confirmed the temperature was 78 °F.

In a concurrent interview, DON stated the room was in the process of remodeling and agreed the room was warm.

The facility's policy and procedure titled, "Labeling and Storage of Drugs" last reviewed, 9/13/16, read, in part:

"...Medications shall be stored at appropriate temperatures...room temperature shall be from 15 °C (59 °F) to 25 °C (77 °F)..."


2. An inspection of the facility's Drug Room was conducted on 8/1/17, at 10:20 a.m., with the DON and PT 1 and it was noted there were two full trays containing different medications on one of the bottom shelves without any particular order. In addition, the medications on the shelves were stored in a crowded manner.

In a concurrent interview, PT 1 acknowledged the medications were stored in a crowded way.

The facility's policy and procedure titled, "Labeling and Storage of Drugs" last reviewed, 9/13/16, read, in part:

"...Medications shall be stored in an orderly manner in cabinets or drawers, not crowded and located in a well lit area to promote correct preparation and administration..."

3. In an interview on 8/2/17, at 2:45 p.m., DON stated she had not received any drug recall notices from either the Consultant Pharmacist (CP) or the contracted pharmacy since July 2016 and the facility did not have the Drug Recall Binder as indicated in the facility's policy and procedure.

In an interview on 8/3/17, at 9:30 a.m., the CP stated he was not involved with the drug recall process indicating the contracted pharmacy would be the one to inform the facility about the drug recalls.

The facility's policy and procedure titled, "Drug Recall" last reviewed, 9/13/16, read, in part:

"... [The Contracted Pharmacy] and [The Facility] Consulting Pharmacist will maintain membership on drug recall distribution lists through the Federal Drug Administration and independent sources. [The Facility] Consulting Pharmacist (by fax) will each, independently contact the Medical Director and the Director of Nursing about any notification they receive regarding recalled drugs by manufacturer, generic, and brand name, dose, expiration date, and lot number. They will provide a copy of the notice they receive about any recalled drug to both the Medical Director and the Director of Nursing. The notices will be maintained in the Drug Recall Binders (maintained in the Medical Staff Coordinator's office and [the Facility] Medication Room)..."

4. The medical record of Patient 26 was reviewed on 8/1/17 and the following was noted:

There was a physician order on 8/1/17 for liothyronine (thyroid hormone supplement to treat low thyroid hormone) 25 mcg (microgram) to be taken once in the morning - patient may take her own medications;

There was a physician order on 8/1/17 for Maxalt (medication used to treat migraine headache) 10 mg (milligram) to be dissolved in mouth at onset of migraine, may repeat once in two hours; may use own supply; and

The Medication Administration Record indicated a dose of liothyronine 25 mcg was administered at 6:30 a.m. and a dose of Maxalt 10 mg was administered at 10:52 a.m.

In an interview on 8/1/17, at 3:30 p.m., LVN S, a Licensed Vocational Nurse, stated the above medications were administered to the patient without a pharmacist or a physician's visual inspection and identifications of the medications.

In a concurrent interview, the Supervising Psychiatric Nurse (SPN) agreed the patient's own medications should have been verified by the pharmacist or a physician prior to use.

The facility's policy and procedure titled, "Personal Medications of Patients" last reviewed, 9/13/16, read, in part:

"Medications brought into the facility by a patient shall not be used unless the following conditions are met...The contents of the containers have been examined and positively identified by the pharmacist or physician..."

Based on observation, interview, and document review, the facility failed to ensure unusable medications were removed and not available for patient use.

Findings:

During an inspection of the facility's Drug Room was conducted on 8/1/17, at 10:20 a.m., with the DON and PT T, there was an open vial of Thiamine (injectable vitamin supplement to treat thiamine deficiency) 200 mg/2 ml with the open date of 11/18/16.

In a concurrent interview, PT 1 stated the medications in the drug room were inspected to identify expired medications. PT 1 stated the vial should not be used anymore and that she missed removing the vial from the shelf.

The facility's policy and procedure titled, "Labeling and Storage of Drugs" last reviewed, 9/13/16, read, in part:

"Multi-dosage containers will be dated and timed at the time of opening and will be disposed of per manufacturers guidelines or expiration date; whichever is first...

Outdated stock...shall be pulled from the shelf and placed in the "medication destruction box" for proper destruction..."

The Association for Professionals in Infection Control and Epidemiology (APIC) is the leading professional association for infection preventionists (IPs) with more than 15,000 members with a mission to create a safer world through the prevention of infection.

According to "APIC Position Paper: Safe Injection, Infusion and Medication Vial Practices in Healthcare (2016),"

"...Label a multidose vial with a beyond-use-date when first accessing it. The beyond-use-date after initially entering a multidose vial is 28 days, unless otherwise specified by the manufacturer. The beyond-use date must never be after the manufacturer specified expiration date..."

Based on observation, interview, and record review, the facility failed to ensure dietary services when:

1. Spices, seasonings, and breads were either expired or unlabeled/undated, which could have resulted in cooking with the wrong or expired seasoning and the expired spices had fewer flavors or were spoiled;

2. Dented cans were stored with cans ready for use, which could have resulted in serving spoiled food from the dented cans; and

3. Dietary staff did not test the disinfectant solution according to the manufacturer's guidelines, which could have resulted in inaccurate disinfectant solution concentration.

These failures also had the potential to cause foodborne illness among patients who consumed food from the kitchen.

Findings:

1. During a concurrent observation and interview on 8/1/17, at 3 p.m., in the food prep and cooking area of the kitchen, there were six unlabeled containers containing white, black, yellowish, light brown, or brown substance. Dietary Staff I identified the substance in the containers as salt/garlic/pepper/onion mixed in one container, salt, pepper, garlic, cinnamon, and onion. Dietary Staff I stated they "never label these [the above identified items]" and just recognized items.

During the same concurrent observation and interview on 8/1/17, at 3 p.m., in the food prep and cooking area of the kitchen, spices in containers were dated as following:
a) Ground Turmeric 16 oz (ounce) received 10/29/15 and opened 6/28/16;
b) Ground Allspice 16 oz received 10/29/15 with no open date;
c) Poultry Seasoning 10 oz received 7/21/16 and opened 7/23/16;
d) Cayenne Hot Pepper 16 oz received 11/2/15 and opened 11/15/15;
e) Cream of Tartar 2 lb 6 oz received 10/29/15 and opened 11/1/15;
f) Ground Coriander 20 oz received 12/2/15 and opened 12/12/15;
g) Rubbed Dalmation sage 9 oz received 10/29/15 and opened 11/7/15;
h) Whole Tarragon dated 4/27/17, which had opened with no indication of receive or open date; and
i) Whole Mediterranean Oregano dated 3/2/17, which had opened with no indication of receive or open date;

Dietary Staff I validated the observation and stated the above identified seasonings and spices were in use for cooking. Dietary Staff I stated the spice were "OK" for one year after the open date.

During the observation in the dry storage after observing the spice and seasoning, there were 14 plastic bags of bread with no receive or expiration date in the shelf. Dietary Staff I validated the observation and stated they "never put dates on the bread." Dietary Staff I stated the bread was being used very fast. Dietary Staff I further stated that the bread was received today, but she did not know why they (the manufacturer) did not put a date.

The facility's policy and procedure titled "FOOD STORAGE AND RECEIVING," review dated 8/27/14, indicated "...Place repackaged food in a leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. Label the container with the name of the contents and date (when the item was transferred to the new container)...Food Storage Guidelines will be followed..."

The "DRY GOODS STORAGE GUIDELINES," undated, indicated ground or whole spices, unopened or opened, were to be stored on shelf for one year.

2. During the continuous concurrent observation and interview on 8/1/17, started at 3 p.m., in the dry storage, there were three dented cans (one can of sliced apples 104 oz, and two cans of cranberry sauce 14 oz each) on the shelf with the cans ready for use. Dietary Staff I validated the observation. Dietary Staff I stated the staff who stocked the cans should have checked the cans and removed the dented cans.

The facility's policy and procedure titled "FOOD STORAGE AND RECEIVING," review dated 8/27/14, indicated "Store dented cans that are to be returned to the vendor in a designated area away from the other food..."

3. During the continuous concurrent observation and interview on 8/1/17, started at 3 p.m., Dietary Staff I demonstrated the procedures to test the quaternary ammonium disinfectant solution. Dietary Staff I dipped the test strip into the solution and immediately removed the test strip from the solution and read the result.

The manufacturer's guidelines for testing the quaternary ammonium disinfectant solution, undated, indicated "1. Dip about one inch of a test paper into the solution to be tested and hold there for 90 seconds. 2. Then compare the test paper color against the color standards shown above."

When asked for policy, Dietary Staff I stated she could not find the policy in the binder which contain policies for the dietary department.

During interviews on 8/2/17, at 10:45 a.m., and on 8/4/17, at 9 a.m., the Dietary Working Supervisor (DWS) stated she worked as a full time cook and a supervisor. Regarding the expired spices, the DWS stated she should have checked the spices "but I didn't." The DWS stated the dented cans should not be used because air might have entered the can and spoiled the food. The DWS also stated they changed the disinfectant solution to the quaternary ammonium disinfectant solution about three to four months ago and they did not have a policy yet. She stated the contracted registered dietitian provided all inservices on all kinds of subjects. The DWS stated the seasonings should be labeled. When asked for a policy for labeling the food, she provided the job descriptions for the dietary services, which indicated "Stores leftover food appropriately, inventories and maintains stocks of food and supplies..."

During an interview on 8/4/17, at 11:05 a.m., the Registered Dietitian (RD) stated the seasonings should be labeled with a used by date. He stated they should not use the spices after one year from the open date. The RD stated staff should have followed their policy. He stated the dented cans should be taken out and "they should know this." The RD also stated they should follow the manufacturer's guideline for testing the quaternary ammonium disinfectant solution.

Based on staff interview, personnel file review, and document review, the facility failed to ensure 1. Its Infection Preventionist (IP) was trained in Infection Control practices; and 2. All staff were screened for Tuberculosis (TB). This had the potential to contribute to the spread of infectious diseases in the facility due to lack of TB screening, and lack of training in proper infection control practices and current Standards of Practice.

Findings:

1. During an interview on 8/1/17 at 1:55 p.m., the Infection Preventionist was asked if she was trained or certified in Infection Control. She stated, "No." When asked how she learned about Infection Control she stated it was through infection control magazines, her general nursing experience, her Master's level education, and by being a member of APIC (Association for Professionals in Infection Control and Epidemiology) and receiving their daily e-mails.

Review of the Infection Preventionist's personnel file on 8/2/17 found no documentation of formal Infection Control training or certification.

Review of the policy titled, "Infection control Preventionist Qualifications," revised 1/23/17, indicated the IP should be qualified in "Epidemiology-Basis principles."

2. Review of personnel files on 8/3/17 at 9 a.m., indicated 4 of 10 sampled employees (Licensed Staff D, Licensed Staff E, Mental Health Worker F, and Interim Mental Health Director) were delinquent in their annual TB screening tests. In a concurrent interview, Employee Services Staff B stated Licensed Staff D's TB screening was due on 9/24/16. Review indicated the Interim Mental Health Director's TB screening was due on 5/1/16. Employee Services Staff B stated: "This is another one who's overdue." Review of Mental Health Worker F's personnel file indicated she was due for TB screening on 9/24/16.

Review on 8/3/17 at 2:50 p.m. of TB screening documentation for Licensed Staff E indicated he was due for TB screening on 5/2/17. In a concurrent interview the Infection Preventionist corroborated the screening was delinquent.

Review of the policy titled, "Employee Health, Immunization and Communicable Disease Screening," revised 6/6/16, indicated: "Staff will be screened for tuberculosis (TB) on hire according to the Centers for Disease Control and Prevention requirements...Annual PPD's (a screening test for TB) are required for all Psychiatric Health Facility (PHF) personnel after initial TB screening: compliance with this annual screening is a condition of continued employment."