HospitalInspections.org

Based on document review and staff interview, the facility failed to assure 2 of 7 contracted services were included in the facility's quality assurance/performance review (QAPI) program.

Findings:

1.) Review of documentation with Employee #4 indicated laundry services and biohazard waste were not included in the facility's QAPI program.

2.) Interview with Employee #4 indicated laundry services and biohazard waste were not included in the facility's quality review. No further information was provided prior to survey exit.

Based on policy and procedure review, personnel file review, and interview, the facility failed to ensure that inpatient staff were trained in CPI (crisis prevention intervention) techniques for 1 RN (registered nurse), 1 LPN (Licensed Practical Nurse) and 1 MHT (mental health technician). (P4, P5 and P9)

Findings:
1. at 11:30 AM on 4/5/11, review of the policy and procedure "Seclusion and Restraint of Inpatient Clients", with an approval date of March 4, 2010, indicated:
a. in section 11.0.2, it reads: "Crisis Prevention Intervention (CPI) training must be completed by the employees before he/she may participate in restraint/seclusion. .3 Continual training for all inpatient unit staff with demonstrated competence for restraint/seclusion on their performance evaluations annually."

2. review of personnel files at 2:45 PM on 4/5/11 and 8:50 AM on 4/6/11 indicated:
a. staff member P4 had documentation in the employee file that CPI competence had expired 2/19/11
b. staff member P5 had documentation in the employee file that CPI competence had expired 6/12/10
c. staff member P9 had documentation in the employee file that CPI competence had expired 2/19/11

3. interview at 11:45 AM on 4/6/11 with staff member NA indicated:
a. a March 2011 CPI training class had to be cancelled--it was assumed that staff members P4 and P9 were going to attend that class
b. staff member P5 thought they had taken a class for CPI in June of 2010, but no documentation to confirm this could be found
c. there is no connection between human resources and staff supervisors in monitoring expiration dates of CPI training to ensure that staff stay competent and do not extend beyond their expiration dates

Based on policy and procedure review, personnel file review, and interview, the facility failed to ensure that staff demonstrated competency in the application of restraints or for the use of CPI (crisis prevention intervention) for 9 of 9 personnel files reviewed. (P1 though P9)

Findings:
1. at 11:30 AM on 4/5/11, review of the policy and procedure "Seclusion and Restraint of Inpatient Clients", with an approval date of March 4, 2010, indicated:
a. in section 11.0.2, it reads: "Crisis Prevention Intervention (CPI) training must be completed by the employees before he/she may participate in restraint/seclusion. .3 Continual training for all inpatient unit staff with demonstrated competence for restraint/seclusion on their performance evaluations annually."
b. in section 11.0.4, it reads: "Facility staff shall be trained in the safe implementation of restraint or seclusion in accordance with the following requirements: .1 Staff will be trained and able to demonstrate competency in the application of restraints,....3 Subsequently on an annual basis and as needed..."

2. review of personnel files at 2:45 PM on 4/5/11 and 8:50 AM on 4/6/11 indicated:
a. staff members P1, P2, P4, P5, P6, P8 and P9 had education presented at a staff meeting 10/18/10 in relation to restraint and seclusion
b. there is no documentation of the demonstration of safe application of restraints for staff members P1 through P9
c. the employee files (P1 through P9) were lacking documentation of the demonstration of CPI techniques taught

3. interview with staff member NA at 11:45 AM on 4/6/11 indicated:
a. staff are demonstrating safe and appropriate application of restraints but documentation at the time of the training is not getting to human resources for placement in employee files (documentation could not be provided prior to exit)
b. there is no documentation in the employee files of staff demonstration of CPI techniques taught

Based on facility policy and procedure review, personnel file review, and staff interview, the facility failed to ensure that staff had current certification in CPR (cardiopulmonary resuscitation) for 1 of 4 RNs (registered nurses) and 2 of 4 MHTs (mental health technicians). (P1, P8 and P9)

Findings:
1. at 11:30 AM on 4/5/11, review of the policy and procedure "Seclusion and Restraint of Inpatient Clients", with an approval date of March 4, 2010, indicated:
a. in section 11.0.2.7, it reads: "All clinical staff members will be trained in the use of first aid techniques and be certified in the use of cardiopulmomary resuscitation, including required periodic recertification."

2. review of personnel files at 2:45 PM on 4/5/11 and 8:50 AM on 4/6/11 indicated:
a. staff member P1 was a RN hired 7/6/09 with a CPR card in the employee file that expired 6/10
b. staff member P8 was a MHT hired 3/16/09 with a CPR card in the employee file that expired 3/20/11
c. staff member P9 was a MHT hired 2/2/09 with a CPR card in the employee file that expired 2/20/11

3. interview with staff member NA at 11:45 AM on 4/6/11 indicated:
a. staff member P1 thought the CPR class had been taken in June, 2010, but no card or documentation of the class could be found prior to exit
b. it is unknown why staff members P8 and P9 have not yet renewed their CPR certification
c. it is unclear whether human resources or staff supervisors are monitoring expiration dates for CPR certification of staff members so that certification does not expire for inpatient staff

Based on policy and procedure review, personnel file review, and interview, the facility failed to ensure that an individual training RNs (registered nurses) in assessing psychological status of a patient, during and after restraint and seclusion, was qualified to provide this training. (staff member P10)

Findings:
1. at 11:30 AM on 4/5/11, review of the policy and procedure "Seclusion and Restraint of Inpatient Clients", with an approval date of March 4, 2010, indicated:
a. in section 11.0.2.8, it reads: "Individuals providing staff training will be qualified as evidenced by education, training, and experience in techniques used to address consumers' behaviors."

2. review of personnel files at 2:45 PM on 4/5/11 and 8:50 AM on 4/6/11 indicated:
a. staff member P10 is a RN
b. the personnel file for staff member P10 is lacking any documentation of training or education related to qualification as a trainer in relation to the psychological assessment of patients

3. interview with staff member NA indicated:
a. staff member P10 provides the training to RNs related to completing an on going, and one hour face to face, psychological evaluation of patients after a restraint or seclusion event
b. there is no documentation in the personnel file for P10 that would indicate qualification for training psychological assessment to RNs

Based on patient medical record review, policy and procedure review, and interview, the facility failed to ensure that a dietician consult occurred within 48 hours of notification for 3 of 15 patients. (pts. N3, N4 and N6)

Findings:
1. at 4:10 PM on 4/4/11, review of the policy and procedure "Referring Clients to a Dietitian" with an approval date of September 23, 2009, indicated:
a. under "4.0 Procedures", it reads: "4.1 Inpatient Services: At admission, intake staff shall complete a nursing admission assessment inclusive of, a nutritional screening....5 The registered dietitian shall respond to the request and interview the client within forty-eight (48) hours and document a dietary assessment and plan in the clinical record...on form C466 Nutritional Assessment."

2. review of patient medical records at 1:10 PM and 3:45 PM on 4/4/11 indicated:
a. pt. N3:
A. had a nursing "Nutrition Screening" on form C464 performed on 2/4/11 and indicated: "Dietician contacted: 2/4/11 9:00 PM"
B. lacked a form C466 indicating a dietician assessment had been performed
C. was discharged 2/8/11

b. pt. N4:
A. had a nursing "Nutrition Screening" on form C464 performed on 2/6/11 and indicated: "Dietician contacted: 2/6/11 3:00 AM"
B. lacked a form C466 indicating a dietician assessment had been performed

c. pt. N6:
A. had a nursing "Nutrition Screening" on form C464 performed on 2/16/11 and indicated: "Dietician contacted: 2/16/11 @ 0700..."
B. had a brief note by the dietician on 2/17/11 and 2/18/11 that did not include an assepssment and/or plan
C. was lacking the assessment form C466

3. interview with staff member NA at 3:45 PM on 4/4/11 indicated:
a. dietician assessments for pts. N3 and N4 could not be found
b. this staff member recalled that the dietician reported not having form C466 (had run out) at one time and assumes it was for pt. N6

Based on document review and interview, the facility failed to ensure a UR committee consisting of at least two members of the committee being doctors of medicine or osteopathy members.

Findings:
1.) Review of documentation with Employee #A4 indicated the facility has only one MD on the UR committee.

2.) Interview with Employee #A4 indicated the facility has only one MD on the UR committee. No further documentation was provided prior to survey exit.

Based on observation, policy and procedure review, manufacturer operator's guide review, and interview, the facility failed to ensure that the AED (automated external defibrillator) was maintained per policy and manufacturer's recommendations for one AED observed and failed to ensure that expiration dates on supplies were monitored.

Findings:
1. at 5:00 PM on 4/5/11, while on tour of the patient unit in the company of staff members NA, NB and NJ, it was observed that the AED in the nursing station area:
a. had an X in the status indicator window
b. prompted the user to "change batteries" when the machine was turned on and the audio message was heard

2. at 9:10 AM on 4/6/11, review of the Zoll AED Plus operator's guide indicated:
a. under the "Set-up and Check-out Procedure" section, it reads: "7. Check AED Plus unit periodically to ensure that green check symbol... appears in status indicator window."

3. at 12:40 PM on 4/6/11, review of the policy "Use of AED's" with an approval date of September 9, 2005, indicated:
a. in section 4.3 "General Maintenance", it reads: ".1 The designated safety representative for each location shall visually inspect the AED ready light each month and mark the EOC (environment of care) monitoring form accordingly..."

4. interview with staff member NB at 9:15 AM on 4/6/11 indicated:
a. the EOC monthly safety rounds performed at this location do not include checking the AED
b. the EOC monitoring form for this location does not include checking the AED
c. there is no safety rep at this location
d. it is unknown if anyone has been checking the AED
e. the AED policy is an "old one", it has been updated
f. the "updated"/current AED policy could not be located

5. interview with staff member NH at 12:15 PM on 4/6/11 indicated:
a. the AEDs at out patient locations are being checked by safety reps or maintenance staff, but no one has been checking the AED at this location
b. it is unknown when the batteries of the AED were last changed

6. at 4:50 PM on 4/5/11, while on tour of the nursing storage room, in the company of staff members NA, NB and NJ, it was observed that 3 boxes of glucometer control solutions had expired 1/21/11

7. at 5:10 PM on 4/5/11, while on tour of the nursing station area, in the company of staff members NA, NB and NJ, it was observed in an "emergency kit" that 1 box of Optium test stirps for the glucometer had expired 6/30/10

8. interview with staff member NA at 5:15 PM on 4/5/11 indicated:
a. the emergency kit has not been used for a long time
b. it is unknown when expiration dates were last checked

The infection control officer failed to implement the facility policies related to TB (tuberculosis) testing and Hepatitis B vaccination for 6 of 9 personnel. (P1, P4, P5, P6, P7 and P9)

Findings:
1. at 12:40 PM on 4/6/11, review of policy and procedure "Tuberculosis (TB) Testing Among...Employees" with an approval date on October 22, 2004, indicated:
a. under 4.0 "Procedures", it reads "4.1 Mandatory Testing: .1 Employees assigned to work in Inpatient,...Services shall be required to have TB testing....2 Upon initial assignment to one of the above programs, the employee shall be given PPD (purified protein derivative) skin testing, at the Center's expense, within one (1) week of hire..."
b. under 4.2 "Annual TB Testing", it reads: ".1 All employees assigned to work in Inpatient,...Services are required to be tested for TB annually with one (1) TB test..."

2. at 12:45 PM on 4/6/11, review of policy and procedure "Hepatitis B Vaccination" with an approval date of July 21, 2009, indicated:
a. under section 4.2, it reads: "The Hepatitis B vaccine shall be made available at no charge to employees who may be exposed to blood or other potentially infectious materials as part of their job duties. This includes employees working within 24-hour services of...[the center]"
b. in section 4.5, it reads: "The Infection Control Nurse or designee shall give each employee written information about Hepatitis B vaccine and a consent form prior to receiving the hepatitis vaccine...4.8 The Infection Control Nurse or designee shall witness and date the consent form...4.16 All completed consent forms shall be placed in the employee's medical file in the Human Resources Department..."
c. in section 4.19, it reads: "Declining the Hepatitis Vaccination: .1 When an employee declines the Hepatitis B vaccination, a check mark shall be made in the section on the consent form to decline receiving the Hepatitis B vaccine at this time..."

3. at 2:45 PM on 4/5/11 and 8:50 AM on 4/6/11, review of personnel files indicated:
a. P1 and P4 (both RNs) were hired 7/6/09 and 2/2/09, respectively, were lacking the Hepatitis B consent form referred to in the policy
b. P5, (a LPN--licensed professional nurse) hired 5/25/09, had a signed document requesting the Hepatitis B vaccination series, but was lacking any indication that the series was provided by the facility
c. P4 and P9, (MHTs--mental health technicians), were hired 8/09 and 2/09, respectively, and were lacking the Hepatitis B consent form referred to in the policy
d. P5, hired 5/25/09, had no documentation of having a TB test in the personnel file
e. P7, hired 1/31/11, had no documentation of having a TB test in the personnel file

4. interview with staff members NE and NG at 12:35 PM on 4/6/11 indicated:
a. Hepatitis B forms for P1, P4, P6 and P9 could not be found
b. there is no TB documentation for P7
c. the TB test is performed for new staff at the end of one of the orientation days, staff member P7 left early the day TB testing was performed, and failed to receive a TB test since starting 1/31/11

Based on interview, the facility failed to assure a written organ procurement agreement with an Organ Procurement Organization.

Findings:

1.) Employee #4 indicated the facility did not have a written organ procurement agreement with an Organ Procurement Organization.

2.) No further documentation was provided prior to survey exit.