HospitalInspections.org

Based on observations, interviews and document review, the facility failed to have a functioning governing body to:

1. Ensure the criteria for medical staff selection are based on individual character, competence, training, experience and judgment.
(Refer to A-0050)
2. Ensure that the services furnished permitted the hospital to comply with all standards for the contracted services. ( Refer to A-0083)
3 Ensure hospital protected and promoted each patient's rights. (Refer to A-0115)
4. Ensure the medical staff had a system in place that was used to reappraise each of it's current members and their qualifications at regular intervals. (Refer to A-O340)
5. Ensure that members of the medical staff who hold medical staff privileges were subject to the medical staff's bylaws, rules, and regulation, in addition to all requirements of the Medical Staff Conditions of Participation. (Refer to A-0341

The cumulative effect of this systemic problem, resulted in a lack of oversight of medical staff, patient care and hospital services.

Based on interview and record review, the Governing Body (GB) did not ensure selection criteria outlined in the Medical Staff Bylaws was applied to four of four physician credentialing files reviewed (MDs 2, 3, 4, 5). There was no documented performance evaluation of the physicians or reappointment and privileging for two physicians, ( MD 2 and MD 3). Credentialing files for MD2,3,4,5 lacked comprehensive complete required credentialing materials as dictated by the Medical Staff Bylaws.

These failures created the potential risk of substandard services being provided by the medical staff.

Findings:

Hospital document titled, "Bylaws of the PHF Governing Board" dated 1/20/17, indicated in part..."The PHF Governing Board shall: b. Approve and ensure the implementation of written bylaws for the PHF Medical Staff, in accordance with legal requirements and the PHF's responsibility to the community and to the patients served (see Article 1V ).

A review of hospital document titled "Santa Barbara County Department of Behavioral Wellness, Bylaw of the Psychiatric Health Facility Medical Staff and Rules and Regulations," dated 9/14/16, indicated in part... pg 17... "Article V: Procedure for Appointment and Reappointment Section 1- General . The Medical Staff shall consider each application for appointment, reappointment and privileges, and the criteria and standards for membership set forth in the Bylaws and the Rules..." Further review of Bylaws indicated on page 18,... " b. Within ninety (90) days after receipt of the completed application for membership, the PHF medical Director shall make a written report of investigation to the PHF Medical Practice Committee. Prior to this report the PHF Medical Director shall examine the evidence of the character, professional competence, qualifications, and ethical standards of the practitioner and shall determine through information contained in references given by the practitioner and from other sources available whether the practitioner has established all the necessary qualifications for that category of membership and the clinical privileges requested by him/her..."

During a concurrent interview with MD1 and "credentialing file" review of MD2, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD2 hire date indicated 9/8/15, MD2 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " No I don't see anything, we have to set this up."

During a concurrent interview with MD1 and "credentialing file" review of MD3, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD3 hire date indicated 12/2/08, MD3 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " Yes I can see the gaps."

During a concurrent interview with MD1 and "credentialing file" review for MD5, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD5 hire date was 4/4/18, MD1 further acknowledged that MD 4, had no reference checks for initial application, no copies of or reference to current or at time of hire State License or DEA license.

During a concurrent interview with MD1 and "credentialing file" review for MD 4, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD 4 hire date was 5/27/17, further acknowledged that MD 4 did not have any information on reappointment in the file, did not have a evaluation in the file, that copy of medical board license with expiration of 6/30/18 had not been updated, no reference checks for initial application in the file, no Department of Justice background check located, form titled "Psychiatry Privilege Checklist," dated 5/11/17, had no approval checked off by Medical Practice Committee. MD1 was asked if any of these items might be located elsewhere, MD1 stated, "No I don't think so." When reviewing hospital bylaws and rules and regulations document that indicated these requirements, MD1 stated, "I think we will assign someone to start tracking these things."

During an interview with CEO on 7/18/19, starting at 9:45 a.m., when asked how the GB ensured that medical staff bylaws surrounding credentialing requirements were being met , CEO stated, "MD1 (name of physician) reviews and each process is vetted through the committee." When asked if CEO was aware that initial appointments and reappointments were not following/compliance with Medical Staff Bylaws, CEO stated, "OK".

Based on interview with facility staff and review of documents, the hospital failed to ensure the governing body was responsible for services furnished by the Sheriff Department for the in-patients of the Psychiatric Health Facility (PHF). The QAPI program did not assess the services furnished to monitor the effectiveness, quality of care and safety of services to ensure the services met acceptable standards of practice.

Findings:

During an observation on 7/15/19, at 12:20 P.M., observed sheriff deputy standing in hallway on the unit with a Tazer on the belt, while watching one sampled patient (Pt. 307). There were several other patients in the vicinity.

During interview on 7/15/19, at 12:20 P.M., with Custody Deputy (CD), asked what the duties are for the deputies while on the unit? CD stated, "I just follow her and make sure she doesn't attack anyone. If she attacks another patient or staff, I do put hands on her only. I don't touch any one else. The Tazer is for my protection only."Asked CD if it was felt that the Tazer was a safety issue? Stated, "No, I'm trained. No one will get hands on it." Asked CD if there was a written statement of duties while in the psychiatric unit? Stated, "No, it's my first day and was told to just keep an eye on her." (Pt. 307.)

Review of Memorandum of Understanding for The County of Santa Barbara Between The Department of Alcohol, Drug,, and Mental Health Services and The Sheriff's Department, dated 09-10 ADMHS Sheriff MOU final. doc, the MOU does not indicate that a Sheriff Deputy will remain with patients who transfer from the jail to the PHF, MOU did not include weapons allowed onto the locked psychiatric hospital unit. Confirmed no other MOU, informal or formal agreement in place.

During interview with the Chief Executive Officer (CEO), on 7/18/19, at 9:45 A.M., discussed the current Sheriff MOU not including an officer on-site with a Tazer. The CEO commented, "I don't think the MOU has ever been reviewed by the governing board. It has not been discussed with the (Governing) Board, not that I recall. We have not had this discussion."

During interview on 7/17/19, at 3:00 P.M., with Quality Care Manager (QCM), discussed QAPI indicators for sheriff officers services on site , QCM stated," It is not an indicator, hasn't been on QAPI. It (Tazers) hasn't been brought up."


38585

Based on observations, interview and record review, the hospital failed to protect and promote each patient's rights when:

1. The hospital imposed restrictions on food choices for second servings of food, regardless of diet order, without being based on individualized patient's plan of care and patient right's to the development of the imposed food restrictions.(Refer to A-0130)

2. The hospital failed to ensure physicians provided informed consents for five of 30 sampled patients receiving psychotropic medications. (Refer to A-0131)

3. The hospital failed to ensure the safety of the patients by allowing Sheriff Deputies to carry Tazers (electrical weapon, used to stun a person through the delivery of electrical current) onto the unit during admissions.
(Refer to A-0144)

4. The hospital failed to ensure staff honored one of 30 sampled patients wish to contact someone when he was placed in restraints. The hospital failed to ensure staff fully completed the "Psychiatric Health Facility Nursing Admission Assessment" document for two of 30 sampled patients. (Refer to A-0154)

5. The hospital failed to ensure staff maintain an accurate and updated treatment plan for nine of 30 sampled patients when patients were placed in restraints or seclusion. (Refer to A-0166)

6. The hospital failed to ensure staff used less restrictive measures for eight of 30 sampled patients prior to placing patients in seclusion and/or restraints (Refer to A- 0186)

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Patient Rights and failure to provide a safe and secure environment for patients.

Based on observation, interview and record review, the facility imposed restrictions on food choices for second servings of food, regardless of diet order, without being based on individualized patient's plan of care and patient right's to the development of the imposed food restrictions.

Findings:

On 7/16/19 during the lunch meal observation, the recovery assistant's (RA 1 and RA 2) were observed removing food from the steam table immediately after one lunch plate per patient was served.

Concurrently, a patient was observed to ask, "Any more pies? [referring to a slice of quiche for the noon meal]. RA 1 and RA 2 replied no. Another patient asked for more pasta [pesto pasta salad that was available for the noon meal], and was told no.

Concurrently, the registered dietitian (RD) stated one of the patients who asked for more carbohydrates was on a consistent carbohydrate diet. Further, the RD explained that the hospital had a policy in which patients were not allowed to have more food of their choice at meal times, including those patients on a regular diet, other than oatmeal, soup, fruit or vegetables. The lunch meal that was observed included polenta, quiche, spinach, cornbread, pesto pasta salad, a fruit cup, and 2% low fat milk.

The RD verified that the policy restricting patient choice of a second helping of food upon a patient's request, including those patients on a physician prescribed regular diet, applied to all patients across the board. The RD verified the policy restricting food choices for seconds was a policy applied to all patients. The RD explained the hospital developed the policy to apply to all patients due to patients who required medications for mental illness/disease states tend to gain weight due to the medications.

On 7/16/19 at 2:10 P.M., during a joint interview with the QCM (Quality Care Management Coordinator) and RD, it was verified the policy on restricting food choice for second servings was not based on individualized patient treatment/care planning. The policy was not intended to meet the individualized needs of the patient, involve the treatment team and the patients right related to aspects of decision making and ongoing participation in his or her treatment/care plan as it may be related to interventions for weight gain, weight maintenance or weight loss.

A copy of the facility's regular diet was requested from the facility's approved diet manual. The "Regular Diet" included, "...The diet is served when specific dietary modifications are not required..., Residents on a regular diet may select additional choices of fruits, vegetables, milk and grains from choices provided on the menu as desired..."

The hospital's policy and procedure titled Infection Control in the Kitchen, last approved 3/23/12, included, "...When diet orders permit, serve patients who request second portions on a clean plate..."

The hospital's policy and procedure titled Requests for Additional Food, approved on 8/19/16, included, "3.2 If a patient requests additional food and that patient is not on a therapeutic diet, he/she may be provided with an additional serving of oatmeal, soup, fruit or vegetables..."

The hospital's policy and procedure titled Treatment Planning, approved on 1/29/16, indicated, "Purpose; To establish standards and procedures for initiation, development, implementation and review of treatment plans for each patient..., Treatment plans are necessary to guide the multidisciplinary treatment team's efforts to assist the patient in his/her recovery and return to a less restrictive treatment environment..., Treatment Plan - a document that describes the patient's individualized diagnosis, strengths, disabilities, problem behaviors, needs, long-range goals, short-term goals, treatment interventions, and treatment providers..., Treatment Team - consists of the patient and [hospital] personnel from various disciplines. The treatment team's membership will be dictated by the particular needs, strengths, and preferences of the patient and may include: ... a dietitian ..., All treatment plans developed by [hospital] personnel must: 1. Be individualized to the needs of the patient; 2. Describe the least restrictive conditions and interventions necessary to meet the individual patient's needs; and 3. Clarify the patient's responsibilities, including a list of potentially therapeutic activities. Patients have the right to ongoing participation during the treatment planning process and a reasonable explanation of components in his/her treatment plan..., Each goal must be connected to and fully addressed by treatment modalities/interventions that are: ...5. Stated as specific interventions rather than general services..."

This is a repeat finding from a survey conducted at this facility, dated 6/27/16. Cross- Reference A -0629.

Based on record review and interview, the facility failed to ensure physicians provided informed consent to five of 30 sampled patients (Patients 101, 400, 401,405, and 414) receiving psychotropic medications before the administration of these medications.

This failure resulted in the patients not being fully informed of the risks, benefits and were not given the opportunity to make an informed decision in regards to these medications prior to the medications being administered.

Findings:

During a review of the "Informed Consent For Psychiatric Medications" documents for five patients (Patients 101, 400, 401,405, and 414) and concurrent interview with administrator (Admin 1) on 7/18/19 at 9:25 a.m., the informed consent document for Patient 101, dated 7/12/19, indicated patient was provided informed consent for Haldol, and Ativan (psychotropic drugs) medications on 7/12/19. Patient signed the consent document on 7/13/19. The same consent document indicated that on 7/14/19 another psychotropic drug (Zyprexa medication) was added to the consent document. On 7/16/19, two more psychotropic drugs (Invega and Risperdal medications) were added to the consent document. On 7/17//19, the Zyprexa medication dose was increased on the consent document. However, there was no evidence on the consent document or anywhere in the record indicating patient was provided informed consent for the added medications and the medication dose increase.

The informed consent document for Patient 400, dated 6/14/19, indicated patient was provided informed consent for Haldol, Ativan, Risperdal, Invega and Depakote (psychotropic drugs) medications on 6/14/19. Patient 400's public guardian signed the consent document on 6/17/19. The same consent document indicated that on 6/18/19 another psychotropic drug (Zyprexa medication) was added to the consent document. However, there was no evidence on the consent document or anywhere in the record indicating patient was provided informed consent for the added medications.

The informed consent document for Patient 401, dated 5/7/19, indicated patient was provided informed consent for Risperdal, Haldol, and Invega (psychotropic drugs) medications on 5/7/19. Patient 401 signed the consent document on 5/8/19. The same consent document indicated that on 5/13/19 two more psychotropic drug (Ativan & Depakote medications) was added to the consent document. However, there was no evidence on the consent document or anywhere in the record indicating patient was provided informed consent for the added medications.

The informed consent document for Patient 405, dated 2/6/19, indicated patient was provided informed consent for Zyprexa, Ativan, Haldol, Risperdal, and Invega (psychotropic drugs) medications on 2/6/19. On 2/7/19 another psychotropic drug (Thorazine medication) was added to the consent document. Patient 405 signed the consent document on 2/7/19, unclear if consent document was signed by patient before or after the Thorazine medication was added to the consent document. The same consent document indicated that on 2/8/19 another psychotropic drug (Prozac medications) was added to the consent document. However, there was no evidence on the consent document or anywhere in the record indicating patient was provided informed consent for the added medications.

The informed consent document for Patient 414, dated 7/10/19, indicated patient was provided informed consent for Haldol, Ativan, Clonazepam, and Trazadone (psychotropic drugs) medications on 7/10/19. Patient 414 signed the consent document on 7/11/19. The same consent document indicated that on 7/15/19 one more psychotropic drug (Risperdal medication) was added to the consent document. However, there was no evidence on the consent document or anywhere in the record indicating patient was provided informed consent for the added medication.

The administrator (Admin 1) acknowledged and confirmed the consent documents for the five patients (Patients 101, 400, 401,405, and 414) indicated informed consent was not provided to patients receiving psychotropic medications when the medication dose was increase or medication was added.

During an interview with the facility's medical director (MD) on 7/18/19 at 9:35 a.m., the MD was made aware there were patients that were not being provided with informed consent for psychotropic medications, when a new medication was added or when a medication dose was increase to the treatment regime. MD acknowledged the current physician informed consent practice and indicated that all patients receiving psychotropic medications must be provided with informed consent regarding the psychotropic medications. When a physician provides informed consent to a patient, the physician and the patient should sign the consent at the time. There is no reason for the patient to sign the consent at a different time/date, than the date, the consent was provided. Furthermore, MD indicated a new consent document should be created when there is a medication dose increase and/or medications are added to the medication regime.

The facility's policy and procedure tiled "Informed Consent for Psychotropic Medications", dated 8/23/18, in the Policy part indicated "2.1 Informed consent shall be acquired prior to the administration of psychotropic medications for all patient, both voluntary and involuntary, admitted to the Psychiatric Health Facility (PHF) 2.3. Informed consent requires that a full explanation of the proposed course of treatment be given to the patient ...2.4 If the patient agrees with the administration of the medication, both the patient and the prescriber will sign the Informed Consent for Mental Health Medication form ..."

Based on observation, interview, and review of facility documents, the facility failed to ensure the safety of the patients by allowing Sheriff Deputies to carry Tazers (electrical weapon, used to stun a person through the delivery of electrical current) onto the unit during the admissions of 4011's ( California Code, Penal Code in regards to an inmate who requires medical or psychiatric care in a hospital) and 5150's from jail (72 hour legal hold for danger to self, danger to others, or gravely disabled who are still inmates) admitted to the locked in-patient psychiatric unit.

The facility failure had the potential to place all patients in harms way with Tazers on the unit.

Findings:

During an observation on 7/15/19, at 12:20 P.M., observed sheriff deputy standing in hallway on the unit with a Tazer on the belt, while watching one sampled patient (Pt. 307). There were several other patients in the vicinity.

During interview on 7/15/19, at 12:20 P.M., with Custody Deputy (CD), asked what the duties are for the deputies while on the unit? CD stated, "I just follow her and make sure she doesn't attack anyone. If she attacks another patient or staff, I do put hands on her only. I don't touch any one else. The Tazer is for my protection only."Asked CD if it was felt that the Tazer was a safety issue? Stated, "No, I'm trained. No one will get hands on it." Asked CD if there was a written statement of duties while in the psychiatric unit? Stated, "No, it's my first day and was told to just keep an eye on her." (Pt. 307.)

During interview on 7/15/19, at 3:30 P.M., with Nursing Supervisor (NS), stated, "You should probably talk to the managers who deal with deputies. Orientation process with staff is where we let staff know there are no weapons on the unit. Staff are not allowed to have weapons at all. If someone did, they wouldn't be allowed on the unit. Human Resource would get involved. It would be potential danger to others if a patient got hold of it. Safety Awareness meeting upon hire. We discuss basic things like safety." Asked NS if deputy was to care for patient? stated, " No, we care for them, just as all patients. I can't speak to what their responsibility is, but we just know they are here to watch the patient. Deputies oversee the patients that are jail patients." Asked NS about what deputies are overseeing? NS stated, "couldn't speak to that. There is a judge order to be at PHF or 5150 criteria but are still jail custody. There is paperwork. 4011- transfer order that gives jail permission to come to PHF (Psychiatric Health Facility) and 5150 criteria at jail because jail can't care for them."

During interview on 7/17/19, at 3:00 P.M., with Quality Care Manager (QCM), discussed QAPI indicators, QCM stated," It is not an indicator, hasn't been on QAPI. It (Tazers) hasn't been brought up."

Review of facility Policy and Procedure, titled Code of Conduct, dated 12/01/09, page 13, indicates in part... "Not bring dangerous weapons to the workplace, out of the work location or onto any county operated worksite, including parking lots. A dangerous weapon is a firearm or any other instrument capable of causing bodily harm...or that would cause a reasonable person to have concern for their safety or the safety of another."

During interview on 7/17/19, at 8:50 A.M., with Administration Manager (Admin 1), stated, "We are concerned also, County Council okayed the Tazers." Explained that 4011 and 5150 jail transfers happens maybe once a month. Admin 1 indicated that it is a training issue with the sheriff department.

Review of "PHF Monthly P 1370/4011 report for 06/01/18 through 06/30/19", indicated a total of 20 patients who were 4011's (still jail inmates) or jail 5150's. Length of stays varying from 1 day to 21 days that the deputy remains on the unit 24 hours every day of in-patient stay.

Review of Memorandum of Understanding for The County of Santa Barbara Between The Department of Alcohol, Drug,, and Mental Health Services and The Sheriff's Department, dated 09-10 ADMHS Sheriff MOU final. doc, does not indicate that a deputy will remain with the 4011 or 5150 patient from jail while a patient at the PHF. MOU did not include weapons allowed on psychiatric hospital unit. Confirmed no other MOU, informal or formal agreement in place.

During interview with the Chief Executive Officer (CEO), on 7/18/19, at 9:45 A.M., discussed the Sheriff MOU not including an officer on-site with a Tazer. The CEO commented," I don't see the sheriff's come over to the PHF with a patient. We did observe a Tazer. It has not been discussed with the (Governing) Board, not that I recall. We have not had this discussion. I don't know about Tazers. I was not aware of sheriff's with Tazers. My staff have never discussed Tazers with me....My preference is that Tazers not be brought into the facility. They know that the County Sheriff will not be involved with take downs and County Council says that it is "ok"."

Review of California Department of Public Health, AFL(All Facility Letter) 07-03, dated July 03,2007, titled, Appropriate Use of Tasers in Hospitals, indicates in part.. "CMS does not consider the use of weapons in the application of restraints as safe appropriate health care interventions. We consider the term "weapons" to include pepper spray, mace nightsticks, tazers, cattle prods, stun guns, pistols and other devices."...The use of weapons by security staff is considered as a law enforcement use and not a health care intervention."

Review of CMS ref: S&C: (Survey & Certification) 16-21- All, titled Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals, dated May 03,2016, (revised 12/23/16) indicates in part...CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention....the term "weapon" includes, but not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns and pistols.... The use of weapons by security staff is considered as a law enforcement use and not a health care intervention."

Based on observation, record review and interview, the facility failed to:

1. Ensure staff honor one of 30 sampled patients (Patient 409) wish to contact someone when he was placed on restraints.
2. Ensure staff fully completed the "Psychiatric Health Facility Nursing Admission Assessment" document for two of 30 sampled patients (Patient 401 and 403).

These failures resulted in Patient 409's wish not being honored in regards to contacting someone when patient was placed on restraints and had the potential for other patients' wishes not being honored when the assessment documents were not fully completed.

Findings:

1. During a review of the clinical record for Patient 409 and concurrent interview with the administrator (Admin 1) on 7/18/19 at 9:45 a.m., Admin 1 explained that a "Psychiatric Health Facility Nursing Admission Assessment" is performed or completed for every patient admitted to the facility. In this assessment, the patient's wish is asked if s/he wish for the facility staff to contact someone if the patient should require the use of seclusion and/or restraints. If the patient's wish is for staff to contact someone, the name and contact number of the person is documented on the Seclusion and Restraint Assessment part of the document, in order for the patient's wish to be honor. The name of the person contacted, who made the contact, and all of that pertinent information will be documented on the subpart "Other" of the Debriefing Session Record.

The "Psychiatric Health Facility Nursing Admission Assessment" document, dated 12/10/18, for Patient 409 was reviewed. The assessment indicated patient's wish was to contact [Contact's Name and a telephone number was included] if s/he should require the use of seclusion/restraints. The record indicated patient was placed on mechanical restraints on 12/17/18 at 10:40 a.m., and removed at 11:55 a.m. The Debriefing Session Record, dated 12/17/19, indicated the patient's wish was not honored by the facility's staff, since, no staff contacted the Contact person, when the patient was placed on restraints. The administrator (Admin 1) acknowledged and agreed that according to the Debriefing Session Record, dated 12/17/19, the patient's wish was not honored by the facility's staff, since, no staff contacted the Contac person, when the patient was placed on restraints.

The facility policy and procedure titled "Seclusion and Restraint", dated 4/24/19, in part 4 of the policy indicated "4.3 Licensed nurse staff (LNS) will document contact information for the family member, domestic partner, significant other or authorized representative designated by the patient who is contacted, if the patient requires use of seclusion and/or restraints."

2. During a review of the clinical records for Patient 401 and 403 and concurrent interview with the administrator (Admin 1) on 7/18/19 at 9:45 a.m., Patient 401's Psychiatric Health Facility Nursing Admission Assessment document, dated 5/7/18 and Patient 403's Psychiatric Health Facility Nursing Admission Assessment document, dated 3/30/19, were observed incomplete. Both patients were not asked, if they wish to have staff contact someone, in case they should require the use of seclusion and/or restraints. The administrator (Admin 1) acknowledged the observation and stated "I agree; the assessments are incomplete." Indicating the patients' wishes cannot be honored, since, the staff did not complete the assessments.

The facility policy and procedure titled "Seclusion and Restraint", dated 4/24/19, in part 4 of the policy indicated "4.3 Licensed nurse staff (LNS) will document contact information for the family member, domestic partner, significant other or authorized representative designated by the patient who is contacted, if the patient requires use of seclusion and/or restraints."

The facility policy and procedure titled "Assessments", dated 8/15/11, in the Procedure part of the policy indicated "Upon arrival to the unit each patient will be assessed by a licensed nursing staff ... A completed Nursing Admission Assessment will be performed ..."

Based on record review and interview, the facility failed to ensure staff maintain an accurate and updated treatment plan for nine of 30 sampled patients (Patient 400, 404, 405, 406, 408, 409, 411, 412, and 413) when the patients were placed on restraints or seclusion.

This failure had the potential of patients not receiving the appropriate treatment due to their treatment plan not being accurate and/or updated.

Findings:

The facility policy and procedure titled "Treatment Planning", dated 1/29/16, in number 5, Mandatory Treatment Plan Documentation, part of the policy indicated "All treatment plans must include an accurate and precise description of the patient's: 4. Short-and long-term goals; and 5. Treatment modalities/interventions." In the Treatment Plan Reviews, part of the policy further indicated "8.1 The treatment plan is reviewed regularly and revised in a manner designed to promote more effective treatment and less restrictive treatment conditions. 8.2 Reviews will occur: 2. Whenever, there is a significant change in the patient's condition, such as changes resulting in the need for more restrictive interventions (e.g. seclusion/restraint) ...

During a review of the Treatment Plans for Patients' 400, 404, 405, 406, 408, 409, 411, 412, and 413 and concurrent interview with the administrator (Admin 1) on 7/16/19 at 1:53 p.m., the Treatment Plans for these 9 patients were observed without addressing that the patients have been on seclusion and/or restraints. Each Treatment Plan document was reviewed by Admin 1, in attempts to locate documentation on the Treatment Plan addressing that the patient had been place on seclusion and/or restraints, the interventions performed, the goals for the patient in regards to the use of restraints, or modalities/treatment to prevent future use of restraints/seclusion etc. However, Admin 1 was not able to locate anywhere on the Treatment Plan where the seclusion and/or restraints were addressed. Admin 1 stated "I agree, there is notation about the restraints or seclusion on the treatment plan ...The treatment plans need to address this (restraints/seclusion)." Admin 1 acknowledged and agreed that when a patient is placed on seclusion or restraints the Treatment Plan needs to be modified and /or updated to reflect the use of restraints/seclusion.

Based on record review and interview, the facility failed to ensure staff used less restrictive measures for eight of 30 sampled patients (Patient 401, 403, 404, 405, 406, 409, 411, and 414) prior to placing patients on seclusion and/or restraints.

This failure violated the patient's right to be free of restraints/seclusion.

Findings:

The facility policy and procedure titled "Seclusion and Restraint", dated 4/24/19, indicated "3.1. The PHF is committed to reducing and preventing the use of seclusion and restraint through early identification and intervention of high-risk behaviors or events when possible. Nonphysical interventions are the preferred method of intervention and the use of seclusion and restraint is considered an exception and not a standard of practice. 3.4 Seclusion and restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm."

During a review of the seclusion and/or restraints records for Patients' 401, 403, 404, 405, 406, 409, 411, and 414 and concurrent interview with the administrator (Admin 1) on 7/16/19 at 2:30 p.m., the section of the record titled "Preventive Measure(s) Used Prior to Interventions", was noticed to be blank. There was no documentation of the less restrictive measures that were attempted, in any of the categories listed on this section, prior to the patient being placed in seclusion and/or application of the restraints. Admin 1 reviewed this section of each record, in attempts to locate the less restrictive measures that were implemented, prior to placing the patient in seclusion or applying the restraints. However, no less restrictive measures were located on this section of the record or anywhere else in the record. Admin 1 acknowledged and agreed that the staff needed to document the less restrictive interventions performed, on this section of the record, prior to placing the patients in seclusion or applying the restraints. Furthermore, Admin 1 explained that the "Preventive Measure(s) Used Prior to Interventions", section of the record contain seven categories listed where the staff should document the specific measure performed, in the corresponding category. Making checks or writing the word "Yes" on this section of the record was not acceptable because this section was designed for staff to write down the specific measure performed for each category.

Based on record review and interview, the facility failed to:

1. Ensure the Quality Assessment and Performance Improvement (QAPI) Indicators for Restraints/Seclusion use of Alternative Methods/Less Restrictive Measures, and Restraints/Seclusion Inclusion in Treatment Plan activities and results were accurate.
2. Ensure a high volume, high risk and a priority indicator, (Completion of Psychotropic Medication Consents), was prioritized, focus on and monitor.

These failures resulted in patients placed on restraints/seclusion without the use of less restrictive measures, restraints/seclusion not included on the treatment plans and psychotropic medications administered without consent.

Findings:

1. A review of 14 clinical records of patient who were placed on seclusion/restraints from August 2018 to July 2019 was conducted on 7/16/19, eight of 14 records indicated patients were placed on seclusion/restraints without any less restrictive measures implemented first.

A review of 14 Treatment Plans of patient who were placed on seclusion/restraints from August 2018 to July 2019 was conducted on 7/17/19, nine of 14 records indicated seclusion/restraints were not included on the Treatment Plans for these patients.

During a review of the facility's QAPI indicators quarterly reports for 2018 and 2019 and concurrent interview with the quality care manager (QCM) on 7/17/19 at 2:55 p.m., the reports indicated 100% compliance for the Restraints/Seclusion use of Alternative Methods/Less Restrictive Measures, and Restraints/Seclusion Inclusion in Treatment Plans. The QCM was asked how those two QAPI indicators were being monitor because their report indicated 100% compliance. However, during the review of the 14 clinical records of patient who were placed on seclusion/restraints, eight records indicated no less restrictive measures were implemented and nine records did not include the restraints/seclusion in the Treatment Plans. The QCM acknowledged that the QAPI report results were incorrect and indicated not being sure how the indicator audits were being performed.

2. A review of 16 clinical records of patient who were administered psychotropic medications was conducted on 7/16/19, five of 16 records indicated patients were administered psychotropic medications without consent.

During a review of the facility's QAPI Indicators Complete List, dated 3/21/18, and concurrent interview with the quality care manager (QCM) on 7/17/19 at 2:55 p.m., the QCM was asked how was quality monitoring for the Psychotropic Medication Consents. According to the QAPI Indicators Complete List, the Psychotropic Medication Consents, is a high volume, high risk, and a priority indicator. The QCM indicated that the Psychotropic Medication Consents are not being monitor by quality. The QCM acknowledged and agreed the Psychotropic Medication Consents, is a high volume, high risk, and a priority indicator and stated "We will monitor this indicator from now on".

Based on interview and record review, the hospital failed to ensure the evaluations and periodic appraisal of two of two sampled physicians were completed as per the hospital's Medical Staff Bylaws. This failure created the risk of substandard services provided by members of the medical staff.

Findings:

A review of Santa Barbara County Department of Behavioral Wellness, Bylaw of the Psychiatric Health Facility Medical Staff and Rules and Regulations," dated 9/14/16, indicated in part... pg. 9, "Section 4- Conditions and duration of Appointment, b. Initial appointment and reappointments shall be made for a maximum of two years...c. A reappraisal is conducted every twenty four months to evaluate the suitability of continuing the Medical Staff membership or privileges each individual practitioner, to determine if that individual practitioner's membership or privileges should be continued, discontinued or revised...."

During a concurrent interview with MD1 and "credentialing file" review of MD2, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD2 hire date indicated 9/8/15, MD2 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " No I don't see anything, we have to set this up."

During a concurrent interview with MD1 and "credentialing file" review of MD3, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD3 hire date indicated 12/2/08, MD3 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " Yes I can see the gaps."

Based on interview and record review the facility failed to ensure that 4 of 4 sampled credential physician files reviewed were complete and comprehensive and contained all the required credentials dictated by the Medical Staff Bylaws. The deficient practice eliminated mechanisms by which the hospital could ensure new members of the medical staff had current competence to perform the privileges being requested.

Findings:

A review of Santa Barbara County Department of Behavioral Wellness, Bylaw of the Psychiatric Health Facility Medical Staff and Rules and Regulations," dated 9/14/16, indicated in part... pg 17... "Article V: Procedure for Appointment and Reappointment Section 1- General . The Medical Staff shall consider each application for appointment, reappointment and privileges, and the criteria and standards for membership set forth in the Bylaws and the Rules..." Further review of Bylaws indicated on page 18,... " b. Within ninety (90) days after receipt of the completed application for membership, the PHF medical Director shall make a written report of investigation to the PHF Medical Practice Committee. Prior to this report the PHF Medical Director shall examine the evidence of the character, professional competence, qualifications, and ethical standards of the practitioner and shall determine through information contained in references given by the practitioner and from other sources available whether the practitioner has established all the necessary qualifications for that category of membership and the clinical privileges requested by him/her..."


During a concurrent interview with MD1 and "credentialing file" review of MD2, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD2 hire date indicated 9/8/15, MD2 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " No I don't see anything, we have to set this up."

During a concurrent interview with MD1 and "credentialing file" review of MD3, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD3 hire date indicated 12/2/08, MD3 file revealed that there was no reappraisal and or reappointment information within the file, MD1 stated, " Yes I can see the gaps."

During a concurrent interview with MD1 and "credentialing file" review for MD5, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD5 hire date was 4/4/18, MD1 further acknowledged that MD 4, had no reference checks for initial application, no copies of or reference to current or at time of hire State License or DEA license.

During a concurrent interview with MD1 and "credentialing file" review for MD 4, on 7/17/19, starting at 9:45 a.m., MD1 acknowledged that MD 4 hire date was 5/27/17, further acknowledged that MD 4 did not have any information on reappointment in the file, did not have a evaluation in the file, that copy of medical board license with expiration of 6/30/18 had not been updated, no reference checks for initial application in the file, no Department of Justice background check located, form titled "Psychiatry Privilege Checklist," dated 5/11/17, had no approval checked off by Medical Practice Committee. MD1 was asked if any of these items might be located elsewhere, MD1 stated, "No I don't think so." When reviewing hospital bylaws and rules and regulations document that indicated these requirements, MD1 stated, "I think we will assign someone to start tracking these things."

Based on interview and record review, the facility failed to insure a non-employee licensed nurse, the Infection Control Nurse Consultant (ICRN) was provided a recent performance evaluation to demonstrate she practiced and adhered to hospital practices, policies and procedures.

Finding:
1. On 7/16/19 at 1:20 PM, a record review was conducted of the hospital ICRN employee file. There was no documented evidence that ICRN was provided a recent performance evaluation.

According to the Nursing Supervisor, ICRN's last performance evaluation was given to her on 5/1/17 because they "Are behind on their evaluations."
During an immediate interview with the hospital Administrative Office Senior Professional, she stated it was the hospital's practice to provide employees performance evaluations every 3 months for the 1st year, during their probationary period then annually thereafter, based on the hire date. According to the Administrative Office Senior Professional, the ICRN was not given a current performance evaluation.

Based on review of the hospital's policies and procedures and interview with the hospital's staff, the hospital failed to ensure that 1 of 6 sampled patients clinical records (Patient 105), who had refused Risperdal 0.5 milligrams (mg) on four separate occasions (between 7/14/2019 and 7/16/2019), had been documented in this patient's clinical record, as outlined in the hospital's policy and procedure. The hospital also failed to notify the physician for 1 of 6 sampled patients (Patient 304), that this patient had not received his blood pressure medication (Lisinopril) without notifying the patient's physician of this for 21 days, as outlined in the hospital's policy and procedure. Both of these failures had the potential to prevent these patient's physicians from being able to adjust/change their drug regimens and ensure patient safety.

Findings:

Review of the hospital's policy and procedure on 7/16/2019 at 11:00 am, entitled: "Medication Administration", dated 1/4/2017, reads: "6.3 If the patient refuses any ordered medication, LNS (Licensed Nursing Staff) will inform the prescriber. The notification will be documented in the medical record." Review of the clinical record for Patient 105 on 7/16/2019 at 10:45 am revealed that this patient had refused their Risperdal 0.5 mg on 7/14/2019 at 9:00 pm, on 7/15/2019 at 9:00 am, on 7/15/2019 at 9:00 pm, and again on 7/16/2019 at 9:00 am. Contradictory to the hospital's policy and procedure, hospital staff had not documented these refusals in the patient's medical record. Interview with two hospital staff on 7/16/2019 at 10:55 am (NS2 and MN) concurrently, revealed that it was not the staff's understanding that patient medication refusals needed to be documented in the patient's clinical record.

Review of the hospital's policy and procedure on 7/18/2019 at 10:00 am, entitled: "Medication Administration", dated 1/4/2017, reads: "Based on his/her scope of practice, an LNS may place a medication on hold following an evaluation of the patient's disposition (e.g. blood pressure reading) and inform the prescriber." Review of the clinical record for Patient 304, on 7/17/2019 at 11:00 am revealed that this patient had a physician's order, which had been written on 6/26/2019, for Lisinopril 10 mg every day, hold for Systolic Blood Pressure (SBP) less than 130 mmHg. For a period of 21 days (from 6/26/2019 to 7/17/2019) during this patient's stay at the hospital, this patient never received this Lisinopril for his blood pressure, as his blood pressure never exceed 130 mmHg. During an interview with MD 6 on 7/17/2019 at 11:45 am, the patient's physician was asked (by the surveyor during a telephone interview), if any of the hospital's Nursing staff had relayed to MD 6 that this patient's Lisinopril had not been administered during this period. MD 6 indicated during the call that the patient's nonuse of the Lisinopril, had not been brought to his attention, as outlined in the hospital's policy and procedures above. During this interview, the physician stated that his expectation was that the hospital Nursing staff should have inform MD 6 of the patient's nonuse of the Lisinopril within 2 weeks. During the interview with this physician, he was asked if this patient would have been discharged from the hospital today, would this patient have received the Lisinopril as a part of his discharge medications to take home (even though this patient did not need this medication), the physician indicated that this could happen and that the hospital does not currently have a system in place to prevent this from happening with its patients.

Based on interview and record review, the facility failed to ensure patient informed consents contained the minimum required elements of a properly executed informed consent (documents which show granting permission in the knowledge of the possible consequences, typically given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for 12 of 30 sampled patients (Patient 101, 400, 401, 405, 406, 407, 409, 412, 413, 414, 501 and 502).

Findings:

1. During two (2) record reviews of Patients 501 and 502, on 7/17/19 at 9:15 AM, the following concerns were identified:
(a). Patient 501 was admitted on 7/12/19 at 2 AM. A document titled, "Informed Consent For Psychiatric Medications" did not contain the time that the physician discussed the treatment with the patient and did not contain the name of the facility where the treatment would take place.
(b) Patient 502 was admitted on 7/12/19 at 5:30 PM. A document titled, "Informed Consent For Psychiatric Medications" did not contain the time that the physician discussed the treatment with the patient and did not contain the name of the facility where the treatment would take place.
On 7/17/19 at 9:30 AM, a record review was conducted of a hospital policy titled, "Informed Consent for Psychotropic Medications, approved on 8/25/17." The policy stipulated, "Purpose/Scope 1.1. To establish standards and procedures for informed consent for administration of psychotropic medications at the ...(Name of facility)."
During an interview on 7/18/19 at 10 AM with the facility Administrator Manager, who reviewed the informed consents for patients 501 and 502, she stated, "Yes, it (referring to the informed consents) should have been timed and there is no area for that and the informed consent should have the facility name."


35399


The facility policy and procedure titled, "Informed Consent for Psychotropic Medications", dated 8/25/17. In the "Purpose/Scope" part of the policy indicated "1.1. To establish standards and procedures for informed consent for administration of psychotropic medications at the ...(Name of facility)."

2. A review of 16 "Informed Consent For Psychiatric Medication" (where patients sign indicating they consent for psychotropic medications to be administer) documents was conducted on 7/17/19. Ten (10) of 16 patients' (Patient 101, 400, 401, 405, 406, 407, 409, 412, 413, and 414), consents were not timed, as to the time, the patient signed the consent. Furthermore, the consent documents did not contain the facility's name, where the medications were going to be administer to the patients.

During an interview with administrator (Admin 1) on 7/18/19 at 10:00 a.m., Admin 1 acknowledged that the ""Informed Consent For Psychiatric Medication" documents were not timed, as to the time the patient signed the consent document and that the facility's name was not on the consent document, a different facility's name was on the consent document.

Based on observation of one of the hospital's Emergency Supplies storage sheds, interview with the hospital's Dietitian, and review of the hospital's policy and procedures, the hospital failed to ensure that none of the emergency supplies (one first aid kit), had expired. The hospital had the potential to administer these expired medications to hospital staff or patient's during an emergency.

Findings:

During an observation/inspection of the hospital's Emergency Supplies storage shed on 07/15/19 at 10:00 am, one First Aid Kit containing several medications had been found inside this storage shed. The First Aid Kit contained the following medications inside: 10 -Triple Antibiotic Ointment packets, 10- Benzoyl Alcohol Antiseptic Wipes, 10- First Aid Burn Cream packets, and 1- Eyewash bottle 1 oz. This First Aid Kit had an expiration date of 3/2019. During an interview with the hospital's Dietitian on 07/15/19 at 10:03 am, she stated that she has no oversight of this First Aid Kit and the "Safety Officer" has been out on Medical Leave for a little while (for about 6 months) and the Safety Officer had been responsible for this medication supply. The hospital's Dietitian further stated that: "I am only responsible for the Dietary supplies in this storage shed". Review of the hospital's policy and procedure entitled: "Medication Labeling and Storage", dated 12/12/2018, reads: "4.9 Drugs shall not be kept in stock after the expiration date on the label ....".

Based on observation, interview and record review, the hospital failed to ensure safe food handling and sanitation when; 1. A disinfectant that was not approved for food contact surfaces was used to sanitize food contact surfaces, 2. Ice was stored in a nonfood grade liner, and 3. Correct hand washing procedures were not followed.

Findings:

1. On 7/15/19 at 10:30 A.M., inside the kitchenette, on top of the steam table was a container, with a red top, labeled as Sani-Cloth Plus. Concurrently, the registered dietitian (RD) stated the Sani-Cloth Plus wipes were used by the RA (recovery assistant) staff, and housekeeping staff, "to wipe down the steam table and any food particles." The RD directed to ask the housekeeping staff further questions since it was part of their responsibility.

On 7/15/19 at 10:43 AM, in the presence of the RD, RA staff (RA 1) verified the "red top" Sani-Cloth Plus wipes were used by RA's to clean up food particles from the steam table, and on the countertops.

On 7/15/19 at 10:47 A.M., in the presence of the RD, a housekeeping staff (HK 2) stated the "red top" Sani-Cloth Plus was used to clean equipment in the kitchenette, which included the steam table, countertops and to clean inside of the microwave. HK 2 stated she recently stopped using it inside the microwave because facility staff told her it was too smelly. HK 2 stated she currently cleaned the inside of the microwave with just water. The kitchenette included a refrigerator, freezer, microwave and steam table.

On 7/15/19 at 10:53 AM, the RD was requested to read the manufacturer's directions that was listed on the Sani-Cloth Plus container. The manufacturer's directions included, "...To disinfect: nonfood contact surfaces only..." The RD stated that she did not know how the hospital determined to use the Sani-Cloth Plus wipes on the food contact surfaces, and stated, "I'd have to ask the infection preventionist."

On 7/16/19 at 9:10 AM, in the presence of the RD, a housekeeper was observed using the Sani-Cloth Plus wipes to clean the steam table.

The hospital's policy and procedure titled Infection Control in the Kitchen, last approved 3/23/12, indicated, "Kitchen Clean-up; Housekeeping staff sweeps and mops the floors, and cleans and sanitizes tables, counters, and the steam table. Housekeeping staff also cleans the refrigerator and freezer on a regular basis."

According to the FDA Food Code 2017, "Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day ..." (Annex, 4-602.11 Equipment Food-Contact Surfaces and Utensils)
Per the FDA Food Code 2017, 4-701.10 Food-Contact Surfaces and Utensils, "EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. Frequency 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning ..., The sanitizing solution must stay on the surface for a specific contact time as specified in this Code and in accordance with the manufacturer's EPA-registered label ..." (FDA Food Code Annex 3-304.14)

2. On 7/15/19 at 10:25 AM, inside a reach- in refrigerator located in the kitchenette, was a red canvas type bag that contained ice inside a large black colored plastic bag. The registered dietitian (RD) observed the bag that contained ice and stated she did not know if that was a food grade bag. The RD stated the facility obtains the ice from outside contracted services.

On 7/16/19 at 9:30 AM, a telephone interview was conducted with the Dining Services Director (DSD) from the outside contracted services, in the presence of the RD. The DSD was asked if the liner that held the ice in the red transport bag for the ice was food grade. The observation of the large black plastic bag was shared with the DSD. The DSD stated he would find out and placed the call on hold. The DSD returned to the telephone and stated, "We don't have food grade liners." The DSD stated the hospital brings them the ice chest and they provide the ice. The DSD stated, "We don't provide liners." Concurrently, the hospital RD verified the hospital did not have food grade liners. The RD stated the large black bag she observed had appeared to be a large trash bag, and stated that it would have come from the outside contracted services. The DSD acknowledged that if ice was stored in a liner that it should be a food grade liner.

The hospital's policy and procedure titled Ice Procurement, Storage and Handling, last approved 8/18/16, indicated, "Purpose/Scope; To prevent the outbreak of foodborne illness caused by improper handling and dispensing of ice. Policy: Ice shall be procured from sources approved or considered satisfactory by federal, state, or local authorities and shall be transported, stored, and handled in a sanitary manner..., the [name of hospital] will procure ice solely from the facility's contracted food service vendor..., The bin and/or container must be equipped with protective plastic liners. Liners will be changed each time the ice supply is replenished..."

According to the United States Department of Agriculture (USDA), the use of plastic trash bags is not recommended for food storage or cooking because they are not food grade plastic and chemicals from them may leach into the food.

According to the FDA Food Code, "The safety and quality of food can be adversely affected through single service and single use articles that are not constructed of acceptable materials. The migration of components of those materials to food they contact could result in chemical contamination and illness to the consumer. In addition, the use of unacceptable materials could adversely affect the quality of the food because of odors, tastes, and colors transferred to the food. (FDA Food Code Annex; 4-102.11)

3. On 7/16/19 at 12:27 P.M., during observation of the lunch meal service located in the kitchenette, a recovery assistant (RA 2) was observed to readjust his beard hair restraint that was already placed on his face after hand washing was already done, then proceeded to put on a pair of gloves. The registered dietitian (RD) acknowledged the process of touching the beard guard after washing hands was not proper procedure.

The hospital's policy and procedure titled Food Handling and Handwashing, last approved 1/6/12, indicated, "Policy; Staff participating in food service shall keep their hands and exposed portions of their arms clean, following proper procedures for handwashing...disposable gloves will be worn appropriately..., During food service employees shall wash their hands in all of the following instances: ...After touching bare human body parts other than clean hands and clean, exposed portions of arms, Before donning gloves for working with food, ...after engaging in other activities that contaminate the hands..."

Based on observation, interview and record review, the hospital failed to maintain the facility in a manner to ensure the safety of patients when the hospital failed to ensure that all restroom doors were ligature risk free.
The hospital's failure had the potential to place the admitted psychiatric patients occupying these rooms at risk for self-harm (hanging).


Findings:

The facility failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients are assured. (See A 701)

The effect of this systemic practice resulted in the failure of the facility to deliver statutorily mandated compliance with the Federal regulations for the Condition of Participation: Physical Environment.

Based on observation, and interview, the facility failed to ensure the restroom door in rooms 3, 5, 9, and 11 were ligature risk free.
This facility failure had the potential to place patients occupying these four rooms at risk for self-harm (hanging).

Findings:

Review of S&C Memo: 18-06- Hospitals, dated 12/08/17, indicates, in part...A ligature risk is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.

During an observation on 7/15/19, at 9:10 A.M., noted restroom door in rooms 3, 5, 9, and 11 were not ligature risk free. The doors were standard, rectangular shaped.

During interview on 7/16/19, at 9:15 A.M., with Program Manager ( Admin 2), when asked if the solid doors could be a potential problem? Admin 2 answered, "I don't know." When asked if a patient could go inside and close the door and hang from the corner area of door? Stated, "I hadn't thought of that. Possibly. Another hospital just changed the doors to slanted doors."

During interview on 7/16/19, at 11:00 A.M., with licensed nurse (LN 1), when asked if felt that a patient could utilize the top of the door to hang from unnoticed if they went inside and closed the door? LN 1 stated," Oh, I see how that could happen."

During interview on 7/16/19, at 11:20 A.M., with facility worker (FW), when asked the same question as above, FW stated, "Oh yes, they could use sheet or pajamas, right?"

During interview on 7/17/19, at 9:45 A.M., with administrative manager (Admin 1), stated, " I will lock them now until that are changed out. The patients in the rooms can use the community restrooms that all of the other patients use."

During interview on 7/17/19, at 10:40 A.M., with Facility Manager (FM), when asked if any work orders had been put in for the restroom doors in 3, 5, 9, and 11? Stated, "Not prior to yesterday when you spoke with FW."

During interview on 7/17/19, at 3:10 P.M., with Quality Control Manager (QCM), asked if the doors had been a concern and been an indicator for QAPI? QCM stated, " No, not until this audit."

Based on observation, interview and record review, the hospital failed to maintain their emergency water plan when the quantity of emergency water available included water that was past it's best by date as indicated by the manufacturer.

According to information provided by the manufacturer of the bottled water, "...We do have a "Best By" date to indicate when it may begin to lose its spring taste ..., Additionally, all current and available scientific evidence indicates that our bottled water packaging is safe when consumed by its "Best By" date..."

Findings:

On 7/15/19 at 9:40 A.M., the Registered Dietitian (RD) pointed to cases of bottled waters and indicated they were stored and available for use in the event of a disaster in which the emergency water was needed. The RD observed a date printed on the water bottles by the manufacturer that indicated "4/30/19". The RD stated the "4/30/19" date was an expiration date. The RD stated, "I didn't realize there is an expiration date on those." The hospital staff verified there were fifteen (15) liter (33 ounce) sized water bottles per case, in which there were twenty-four cases, dated "4/30/19."

Concurrently, ninety-one; five gallon jugs of water were available for the emergency water supply which was dated appropriately.

A review of the hospital's policy and procedure titled Disaster and Emergency Supplies for Dietary Services, last approved 9/14/16, indicated, "Purpose/Scope; To ensure that adequate food and nutrition is provided to Psychiatric Health Facility (PHF) patients and staff during a disaster and/or emergency. Policy; In the event of a disaster and/or emergency, the PHF shall utilize stored food and water supplies that will provide up to seven (7) days of nutrition and hydration for a minimum of fifty (50) patients and staff ..., Water Supply Procedures; For drinking purposes, at least one and half (1.5) gallons of water is required per person per day. The PHF will store a minimum of 525 gallons to ensure enough water is available for drinking, reconstitution of food and hand/equipment washing. The total calculation is as follows: 1.5 gallons water/day x 50 individuals x 7 day supply = 525 gallons. Ninety (90) 5-gallon water jugs = 450 gallons + three hundred sixty (360) 33-ounce bottles = 94 gallons; Total = 544 gallons..."

Based on observation, interview, and record review, the hospital failed to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases when:
The facility failed to ensure the washer used to clean patient clothing was not cleaned and maintained according to manufacture instructions for use (IFU). This resulted in improper cleaning and disinfection of the washer.

Findings:

1. On 7/15/19 at (9:28 AM, a tour was conducted of the facility laundry room. A washer was in use and according to a Team Lead Registered Nurses (TL), the washer was used to clean articles of clothing of patients who requested to have their clothing washed.
A sign located on the washer stipulated, "Cleaning and disinfection will be performed at the end of each night shift. Run an empty hot load in the washer with 2 cups of bleach ..." According to the TL, they had no documented evidence to show that night staff cleaned the washer.

On 7/16/19 at 10:38 AM, an observation was conducted of the washer, and the tour of the laundry room was conducted in the presence of the Infection Control Nurse Consultant (ICRN) and the Nursing Supervisor (NS).
The bottom of the internal chamber had thick white/green substance and the top surface of the chamber was covered with thick black and white//green substance. Around the lid of the washer was rough red orange exposed areas.
During an immediate interview with the ICRN, she stated "it looked as if the washer had not been cleaned, the white/green substance was lime and the red orange areas was corrosion". The ICRN also stated they had no documented evidence to show that staff cleaned the washer.
The NS used a sani cloth (a cloth used for cleaning and disinfecting surfaces), the thick black substance was easily removed with the cloth.

On 7/16/19 at 3:15 PM, a record review was conducted of the manufacture instructions for cleaning the washer. The manufacture instructions stipulated:
"This washer maintenance procedure should be performed, at a minimum, once per month or every 30 wash cycles, whichever occurs sooner, to control the rate at which soils and detergent may otherwise accumulate in your washer. To keep washer interior odor-free, follow these recommended monthly cleaning procedure: affesh washer cleaner cycle procedure (recommended for best performance): ..." Or "Chlorine bleach procedure (alternative): a. open the washer lid and remove any clothing or items. Add 1 cup (236 mL) of liquid chlorine bleach to the bleach compartment. NOTE: Use of more liquid chlorine bleach than is recommended above could cause washer damage over time ..."
There was no documented evidence to show that the facility cleaned the washer according to manufacture instructions.