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Based on medical record review, policy review, and staff interview, the physician, failed to write discharge orders for two (2) of two (2) discharged patients (Patients #28 and #29).

Findings included ...

Review of the facility's policy titled, "Individuals' Admissions and Discharge," revision dated 12/2014, showed that " The psychiatrist writes and signs all orders."

Review of the facility's policy titled, Medication and Non-Medication Orders," dated 3/2020, showed that " ...non-medication orders shall be entered by a provider when admitting, discharging, or transferring an individual."

A. The physician admitted Patient #28 on 06/16/2021 at 3:25 PM with diagnoses to include Schizoaffective Disorder. A review of Patient #28's medical record on 12/10/2021 at approximately 10:55 AM showed a discharge summary dated 06/02/2021. However, there were no physician discharge orders documented to discharge the patient.

The practice lacked evidence that the physician wrote a discharge order prior to discharging Patient #28, in accordance with the hospital policy.

The surveyor conducted a face-to-face interview on 12/10/2021 at approximately 3:20 PM with Employee #11, Quality Improvement Coordinator, regarding the missing physician's orders. According to Employee #11, he cannot access the physician's order after a patient is discharged. The employee acknowledged and confirmed the findings.

B. The physician admitted Patient #29 on 12/13/2017 with diagnoses to include Schizophrenia. A review of Patient #29's medical record on 12/10/2021 at approximately 11:50 AM showed a physician's discharge summary note dated 08/13/2021 at 8:24 AM stating, "Patient is medically stable and plan to discharge from [Hospital's Name] today."

Additional medical record review showed a physician's discharge summary note, dated 08/13/2021 showed the history of present illness, past psychiatric and substance abuse history, legal history, and hospital course.

A review of the medical record showed a social worker's discharge arrangements, dated 08/09/2021 at approximately 12:25 PM, which showed Patient #29 " ...has been accepted into Supportive Residence Group Home placement and is scheduled for discharge on Friday, August 13, 2021."

Further review of physician's orders revealed the medical record lacked documented evidence that the medical staff wrote an order instructing the clinical staff to discharge Patient #29.

The practice lacked evidence that the physician wrote a discharge order prior to discharging Patient# 29 in accordance with the hospital policy.

The surveyor conducted a face-to-face interview on 12/10/2021 at approximately 3:20 PM with Employee #11 regarding the missing physician's orders. According to Employee #11, he cannot access the physician's order after a patient is discharged. The employee acknowledged and confirmed the findings.

Based on medical record review, hospital policy review, and staff and patient interview, nursing staff failed to utilize interpretive services for a patient with limited English proficiency and a primary language of Spanish in one of two records reviewed (Patient # 13).

Findings included:

Review of the facility's policy titled, "Language Access for Individuals with Limited or No-English Proficiency, dated 6/19/2018, showed "Department of Behavioral Health Providers shall arrange for the provision of language access services at no cost to Limited or No-English proficient consumers. Document primary language information in consumer's clinical record at the point of entry with notations on how to engage the person in communication if unknown. All individuals that receive services and supports as a part of the DBH service delivery system or participate in DBH sponsored events have access to and receive language access services that meet their individual needs, including written and oral translations appropriate to their specific needs."

A medical record review was conducted on 12/08/2021 at approximately 11:00 AM with Employee # 22, Nurse Educator. According to Patient # 13's History and Physical, the patient was admitted on 10/21/2021 with diagnoses to include Herpes Simplex Infection, Allergic Rhinitis, and Right Knee Joint Pain. Further review of the History and Physical showed an assessment note from the physician stating, " Patient (Patient # 13) is a Spanish speaking male and an in-person Spanish language interpreter was not made available for the history and physical assessment as requested, but he is able to understand some English and answer questions."

A medical record review showed a document titled," Facesheet (Clinical)" entered on 10/21/2021 at 12:12 PM, with an undocumented entry for the primary language. In addition, the "Comprehensive Initial Nursing Assessment Report," dated 10/21/2021 at 2:02 PM, showed, there was no need for a translator, and the section for "Language" was not documented.

A medical record review of the "Comprehensive Initial Psychiatric Assessment Report", dated 10/21/2021 at 02:23 PM, by the admitting psychiatrist showed, "Patient (Patient # 13) has limited English proficiency ... and the interview was conducted in Spanish, as this writer is a native speaker."

The medical record lacked evidence that Patient #13's primary language was documented, and interpretive services were utilized as requested per hospital policy.

The surveyor conducted an interview with Patient # 13 via telephone on 12/10/2021 at approximately 11:40 AM in the presence of a nurse supervisory consultant and Employee # 11, Quality Improvement Coordinator. A Spanish interpreter was at the patient's bedside. The surveyor introduced self in English and asked Patient #13 about his care and preferred language. Patient # 13 responded, "I don't understand." Spanish interpreter (unknown) stated, "The patient would like to use an interpreter." The surveyor requested the name of the interpreter from Employee #11, but the information was not provided.

Employee # 11 acknowledged and confirmed the findings at the time of the interview.

Based on observation, hospital policy review, and staff interviews, the nursing staff failed to secure prohibited items that pose a risk to the health, safety, and welfare of individuals in care, staff, and visitors, in three of three observations.

Findings included ...

Review of the policy titled " Management of Ligature Risks" dated 06/13/2018 under " Monitoring the Environment of Care" showed " 4. Nursing shall remove prohibited items (including cords, belts, shoe laces and so on) as from patient care areas ..."

The surveyor toured unit 2A on 12/09/2021 at approximately 1:50 PM with Employee # 15, Chief Nursing Executive (CNE), Employee #16, Nurse Manager, and Employee #17,Charge Nurse. The surveyor observed three headphones, each attached to cords that were connected to a charging station on the countertop, at the nursing station. The charger cords were available to patients and passersby.

The practice lacked evidence that the nursing staff maintained a safe environment, per hospital policy.

The surveyor conducted a face-to-face interview with Employees # 16 on 12/07/2021 at approximately 3:27 PM. When queried regarding the cords connected to the headphones, Employee # 16 stated the cords could be described as a ligature risk for the patients. The employee further stated, " There is always staff at the nursing station who are responsible for monitoring the headphones."

The surveyors conducted a face-to-face interview with Employee # 10, Compliance and Performance Improvement, on 12/07/2021 at approximately 3:44 PM. The employee stated the charger cords were a little more than 12 inches long. The employee further stated the cords should not have been on the countertop and were moved to the lower desk at the nursing station. According to Employee #10 mitigation risks were in place and education was provided to the staff to ensure a secure location to store the cords.

Employees #16 and #10 acknowledged and confirmed the findings at the time of the observation.

1. Based on medical record review and staff interview, nursing staff failed to follow physician's orders for Continuous Positive Airway Pressure (CPAP) therapy in one of two medical records reviewed (Patient #11).

Findings included:

The physician admitted Patient #11 on 05/25/2021 with diagnoses to include Post- Traumatic Stress Disorder, Unspecified with a medical history to include Obesity, and Chronic Obstructive Pulmonary Disease (COPD).

Review of the medical record on 12/09/2021 at approximately 3:47 PM showed the " Electronic Medication Administration Record (eMAR)" which revealed the physician order for " CPAP___cm H20 DURING NIGHT SLEEPING HOURS CPAP THERAPY 8 TO 16 CM H20 ... Reason: SLEEP APNEA, OBSTRUCTIVE" on 06/23/2021 at 1:39 PM.

Further review of the eMAR showed from 06/04/2021 through 6/16/2021, approximately 13 days, the medical record lacked documentation of the patient receiving CPAP therapy as ordered.

According to Employee #12, Registered Nurse, the order for CPAP in the eMAR was " Flagged" from 06/04/2021 to 06/16/2021, indicating CPAP therapy was not provided to the patient. Further medical record review showed no documentation explaining why the patient was not administered CPAP therapy. Additionally, the nursing progress notes lacked documentation indicating the patient was provided CPAP therapy from 06/04/2021 through 06/16/2021.

The practice lacked evidence that the nursing staff followed the physician's orders for CPAP therapy.

The surveyor conducted a face-to-face interview with Employee # 12 on 12/09/2021 at approximately 4:00 PM. Employee # 12 stated, "The nurse should document that the CPAP was used or a reason why the patient did not receive the therapy." During the Quality Assurance & Performance Improvement (QAPI) meeting on 12/10/2021 at 1:56 PM, Employee #3, Chief Nursing Officer, stated "The nurses should document if the patient used the CPAP or note on a regular basis for CPAP use."

Employees #12 and # 3 acknowledged and confirmed the findings at the time of the medical record review and QAPI meeting.


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2. Based on medical record review, and staff interview, nursing staff failed to follow physician's orders and provide nursing care in one of one medical record review (Patient #14).

Findings included:

A medical record review was conducted on 12/10/2021 at approximately 10:00 AM, with Employee # 22, Nurse Educator. According to Patient # 14's History and Physical, the patient was admitted with diagnoses to include Alcohol-Induced Persisting Dementia, Essential Hypertension, and Convulsions/ Seizure Disorder.

Medical record review showed the Interdisciplinary Recovery Planning, dated 10/19/2021, "Patient #14 is a high seizure risk. Patient will participate in management of primary history of seizures as evidenced by not drinking excessive amount of fluid. Documentation will be done in the nursing update note."

Further record review showed a psychiatry resident's progress note, dated 12/2/2021 at 05:03 PM, "Patient is hyponatremic ( low Sodium), so his fluid intake must be watched closely. He must not be allowed to rummage through the garbage for bottles with fluid or be allowed to drink indiscriminately from the faucet, as he is at risk of seizures."

According to the nursing progress note, Patient # 14 was transferred to a higher level of care on 12/07/2021 to evaluate seizure disorder. Patient #14 was discharged back to the facility on 12/08/2021 with discharge instructions to include following up with a Neurologist and continuing antiepileptic medication.

The medical record showed renewal physician's orders, dated 12/09/2021, "Special Precautions. One liter Fluid restriction for Hyponatremia. Please record Oral Fluid intake and output with one liter/day fluid restriction and document in Avatar. He is incontinent of urine, but you should be able to document oral fluid intake." Further review showed no documentation of fluid intake recorded in Avatar per physician order.

The medical record lacked documented evidence that oral intake and output were documented as ordered.
The surveyor conducted a face-to-face interview with Employee #22 on 12/10/2021 at approximately 10:00 AM who acknowledged and confirmed the findings.

Based on medical record review, the clinical staff failed to provide necessary care and treatment to reflect a change in the patient's status as evidenced by a delay in following up with abnormal laboratory results in one of one record reviewed (Patient # 14).

Findings included ...

A medical record review was conducted on 12/10/2021 at approximately 10:00 AM with Employee # 22, Nurse Educator. Review of the medical record showed Patient# 14 was admitted on 10/05/2006 with diagnoses of Alcohol-Induced Persisting Dementia, Convulsions/Seizure Disorder, and Essential Hypertension.

According to the patient's "Active Medications" on the "Facesheet (Clinical)", Phenytoin Sodium Extended (Dilantin) 200 MG was started on 11/05/2021 twice a day for seizure disorder. Further review of the medical record showed the physician ordered Phenytoin and Phenytoin Free laboratory tests on 11/30/2021. On 11/30/2021 at 07:12 AM, Phenytoin abnormal labs results showed an abnormal low Phenytoin of "7 mg/L - below low normal"(Laboratory range from 10-20 mg/L). According to the Nurse practitioner's progress note, the previous Phenytoin level was 21.6 mg/L on 10/28/2021.

Medical record review of the " Clinical Record Progress Notes" written by the Psychiatry Resident on 12/02/2021 showed "Labs Phenytoin was 7mg/dl (L) (low) on 11/30 but will monitor." Further review showed no interventions were ordered to address low Phenytoin levels. Subsequently, Patient #14 had a seizure on 12/07/2021 and was transferred to a higher level of care to evaluate seizure disorder. Review of the " [Hospital's Name] Patient Visit Information" dated 12/08/2021, showed Patient #14 was discharged back to the facility and instructed to continue medication for seizures and follow up with a Neurologist.


The practice lacked evidence that the clinical staff followed up with abnormal findings to determine whether the medication results were in a therapeutic range to allow for appropriate corrective action.


The surveyor conducted a face-to face interview with Employee #22 on 12/10/2021 at approximately 10:00 AM who acknowledged and confirmed the findings.

Based on policy, regulations, and medical record review, the staff failed to administer the patient medication (Patient #4). Refer to A508.

Findings included ...

On 3/21/2021, Patient #4 on Unit 1B the physician ordered Latanoprost 0.005% ophthalmic solution for each eye every night at bedtime. The patient's record showed that the hospital staff administered the eye drops to the patient from 10/01/2021 to 12/08/2021. Additionally, the nursing staff documented the date the drops were opened (10/01/2021) on the auxiliary sticker attached to the vial. However, the surveyor and Employee #27, the Clinical Pharmacist, discovered the eyedrops were unopened and sealed. Therefore, it is unknown if the patient received the eyedrop.

Employee #27, acknowledged and confirmed the findings.

Based on medical record review, hospital policy review, and staff interview, nursing staff failed to maintain records and document medical interventions of a code blue event-based in one of one record reviewed (Patient #22).

Findings included ....

Review of the hospital's policy titled," Post -Code Blue Notification and Review Procedures", dated 12/18/2014, showed, "The Medical Emergency Response Flow Sheet is completed by the Registered Nurse (RN) recorder and submitted for inclusion into the medical record immediately post event. The hospital shall complete all actual Code Blue events that result in some type of medical intervention (taking of vital signs, administration of oxygen, first aid, etc)."

A medical record review was conducted on 12/09/2021 at approximately 2:00 PM, with Employee # 22, Nurse Educator. According to Patient# 22's History and Physical, the patient was admitted on 11/05/2019 with diagnoses to include Hypertension, Pulmonary Nodules, and Chronic Schizophrenia.

Further review showed a nursing progress note, dated 09/19/2021, Patient #22 stated, " I can't breathe, I need help." The nurse documented the patient became unresponsive and suddenly stopped breathing. On 09/19/2021 at 12:12 PM, staff initiated a code blue.

Review of the medical record on 12/09/2021 at approximately 2:00 PM showed the "Medical Emergency Response Flow Sheet", which revealed CPR was initiated on 09/19/2021 at 12:12 PM, but in the "Interventions" including the "Vital Signs", "Oxygen", and "Medications Administered" sections, were left blank.

The medical record lacked evidence that the staff maintained records according to the hospital policy.

The surveyor conducted a face-to-face interview on 12/10/2021 at approximately 3:00 PM with Employee # 3, Chief Nursing Officer, who reviewed the flowsheet and acknowledged and confirmed the findings.

Based on a review of hospital documents to include Pyxis Automated Dispensing Machine (ADM) Schedule II, III, IV, and V Controlled Substance Transactions by patient report, physicians' orders, and the Medication Administration Record (MAR), the hospital staff failed to document the administration, wasting properly, or handling of controlled substances, in three of nineteen records reviewed (Patients, #40, #45, and #49).

Findings included ...

On 12/07/2021, the ADM, for controlled substances schedule II-V, generated a seventy-two (72) hour all stations event report for all nursing units. The survey of records was started on 12/07/2021, at approximately 10:00 AM, and completed on 12/09/2021, at approximately 11:00 AM.

In the presence of Employee #27, Clinical Pharmacist, the physician's order, ADM records, and the Electronic Medication Administration Record (eMAR) were reviewed for accuracy. Withdrawals from the ADM were compared with the dose administered, the administration times, and the dispositioning of the controlled substances. The following were observed:

A. On 11/16/2021, at 10:30 AM Patient #49, on Unit 1G, the physician ordered Clonazepam 0.25 mg by mouth every evening. On 12/03/2021, at 7:29 PM, the nursing staff removed one tablet of Clonazepam 0.5 mg and administered 0.25 mg at 7:57 PM. However, the nursing staff wasted the remaining 0.25 mg at 11:07 PM, over three hours later.

B. On 11/24/2021, at 10:46 AM, Patient #40, on unit 1A, the physician ordered Lorazepam 0.5 mg (milligram) by mouth every night at bedtime. On 12/03/2021, at 7:41 PM, the nursing staff removed one dose and administered it at 8:50 PM. Over one hour later.

C. On 11/23/2021, at 09:16 AM, Patient #45, on Unit 1C, the physician ordered Clonazepam 1 mg (milligram) by mouth twice daily. On 12/01/2021, at 07:51 AM, the nursing staff documented the dose was administered. However, there was no documentation the nurse removed the controlled substances from the ADM.

Based on policy review and observation the staff failed to secure the code cart.

Findings included ...

A review of the policy titled "Emergency Medications in Crash Carts" shows that the pharmacy staff secures the cart with a numbered break-away lock and logs the lock number into the Emergency Medication Cart Log.

During a tour of Unit 2B on 12/07/2021 at 11:20 AM. The surveyor observed the lock number was not documented in the December 2021 emergency medication cart log.

Employees #27, Clinical Pharmacist, and #29, Registered Nurse, acknowledged and confirmed the findings.

1. Based on policy review. The hospital and pharmacy staff failed to dispose of expired supplies and medications.

Findings included ...

A review of policy titled "Storage of Medications" effective 07/12/2018 showed that expired medications shall be returned to the pharmacy.

A. During a tour of Unit 1B on 12/08/2021, at approximately 11:00 AM, with Employees #27, Clinical Pharmacist and #28, Registered Nurse 1B, the surveyor observed fifteen syringe needles, expiration 10/31/2020, stored in the medication room cabinets.

B. During a tour of the Auxiliary medication room on 12/09/2021, at approximately 3:25 PM, with Employee #27, the surveyor observed one vial of expired Tuberculin Purified Protein Derivative (PPD), expiration 11/30/2021, stored in the medication refrigerator.

Employees #27 and #28 acknowledged and confirmed the findings.

2. Based on policy review and observation, the hospital and pharmacy staff failed to document the appropriate expiration date (beyond use date) for multidose drugs (Patient #4 and Patient #56).

Findings included ...

A review of policies titled "Storage of Medications" showed that multi-dose vials shall be dated with the beyond-use date according to facility policy and United States Pharmacopeia (USP) Chapter <797>.

During a tour of Unit 1B on 12/08/2021, at 3:25 PM, the surveyor observed two vials of Latanoprost 0.005% ophthalmic drops for Patient #4 and Patient #56 with an expiration date three months from the date the staff opened the eye drops. One box opening date is 11/21/2021 with an expiration date of 03/07/2022. Box #2 open date 10/01/2021 with an expiration date of 01/08/2022. The manufacturer expiration dates show the drops expire in 6 weeks after opening.

Employee #27 acknowledged and confirmed the findings.

Based on policy, regulations, and medical record review, the staff failed to administer the patient medication (Patient #4). Refer to A411.

Findings included ...

On 3/21/2021, Patient #4 on Unit 1B the physician ordered Latanoprost 0.005% ophthalmic solution for each eye every night at bedtime. The patient's record showed that the hospital staff administered the eye drops to the patient from 10/01/2021 to 12/08/2021. Additionally, the nursing staff documented the date the drops were opened (10/01/2021) on the auxiliary sticker attached to the vial. However, the surveyor and Employee #27, the Clinical Pharmacist, discovered the eyedrops were unopened and sealed. Therefore, it is unknown if the patient received the eyedrop.

Employee #27 acknowledged and confirmed the findings.

Based on observations during the survey it was determined that foods were not always stored and prepared in a sanitary environment. These findings were observed in the presence of Employee # 49, Director of Dietary Services at approximately 10:45 AM on 12/06/2021 and 12/07/2021 between 9:30 AM and 3:45 PM.

Findings included ...

A. The interior surfaces of open drains were soiled with debris in the Cook's Preparation Area in two of four observations, while food was being prepared.

B. The interior surfaces of exhaust vents were soiled with dust, in Storage Rooms 163.04 and 163.06 in two of two observations.

1. Based on observations during the survey, it was determined that Housekeeping and Maintenance Services, were not adequate to ensure that the facility is maintained in a safe and sanitary manner.

Findings included ...

The following findings were observed during a tour of Unit 1D, at approximately 3:10 PM on 12/09/2021, in the presence of Employees, # 50, Director of Building Operations, Employee # 58, Supervisor of Inventory Control, Employee # 59, Inventory Management Specialist, and Employee# 60, Program Support.

A. Cleaning equipment such as a buffer and vacuum cleaner were soiled with dust in the Janitorial Closet, in Room 1D09.

B. The sink in the hallway near Room 1D09, was partially clogged and drained slowly.

C. The bottom shelf surfaces of the linen cart were soiled and stained in Room 1D05.

D. The Nutrition entrance door surfaces were marred and scarred.

E. Caulking around the bottom of the toilet was soiled and damaged in rooms 1D54 and 1D55.

F. Wall surfaces were soiled from toothpaste inscriptions in Room 1D56.

G. Window and chair seat surfaces were soiled in Room 1D63.

H. The stainless-steel cover near the bathroom faucet was soiled and stained in Rooms 1D23 and 1D24.

I. The interior areas of the bathroom sink, and shower curtain surfaces were soiled and stained in Room 1D25.

J. The outer surfaces of the ceiling exhaust louvers were soiled, marred and louver surfaces needed repainting in 1D26.

K. The exterior and interior surfaces of exhaust vents were soiled with dust in Room 1D21.

L. Floor surfaces were soiled in corners and in the rear of equipment in
Treatment Room 1D20.

M. Cabinets bins were soiled with dust in the Comfort Room, and baseboards were marred in the hallway outside of the room.

N. Floor surfaces and restroom curtains were soiled and stained in Room 1D47.

O. Caulking around the base of the toilet was soiled, and painted surfaces around the door were marred in 1D43.

2. The following findings were observed during a tour of Unit 1B at 3:00 PM on 12/09/2021. These findings were observed and acknowledged in the presence of Employees #50 , #58, #59, and #60.

A. The lower wall surfaces were marred and stained in Staff Bathroom 1B10.

B. The bottom shelf surfaces of the linen cart were soiled with spillages and hard water stains in Room 1B06.

C. The lower wall surfaces were marred in 1B10.

D. The lower shelf surfaces of the linen cart were soiled with dust and water stains in Room 1B05.

E. Wall surfaces were marred near the tables in the Dining Room.

F. The entrance door outside of the Nutrition Area was marred and scarred on Unit 1B.

G. Floor and wall surfaces were soiled in the Medication Room.

H. Floor surfaces behind the entrance door to Room 1B20 were soiled.

I. Shower curtain surfaces were soiled and stained at the entrance to Room 1B55.

J. Bed frame surfaces were soiled with dust, and wall surfaces were marred in Room 1B62.

K. Windowsill surfaces were marred, and the bed frame surfaces were dusty in 1B56.

3. The following findings were observed during a tour of Unit 2A, between 2:30 PM and 3:30 PM on 12/10/2021. These findings were observed and acknowledged in the presence of Employees # 50, #58, #59, and #60.

A. The base of the toilet was soiled, and caulking was cracked in Room 2A46.

B. Windowsill and bed frame surfaces were soiled with dust in Room 2A44.

C. The lower surfaces of the Linen Cart were soiled and stained in Room 2A38.

D. Wall surfaces were marred in the rear of the Pyxis Machine in Room 2A21.

E. The open drain in the Shower Room was partially clogged with mop fibers in rooms 2A23 and 2A24.

F. Mattress surfaces were worn and torn in Room 2A32.

G. The lower shelf surfaces of the Linen Cart were soiled with dust and water stains in Room 2A07.

H. The floor drain was partially clogged, and wall surfaces were cracked in Room 2A66.

I. Caulking was cracked around the base of the toilet and wall surfaces were cracked in Room 2A55.

J. Windowsill surfaces, the top surfaces of the desk, and the bed frame was soiled with dust in 2A64.

K. The armchair surfaces on a chair in the Day Room were worn on Unit 2B.

4. The following findings were observed during a tour of Unit 2B, between 12:00 PM and 1:00 PM on 12/10/2021 in the presence of Employees #50, #58, #59, and #60.

A. The lower shelf surfaces of the Linen Cart were dusty, and hard water stains were observed, in Room 2B05.

B. The base surfaces of the toilet were soiled, and caulk was cracked around the base of the toilet in Room 2B08.

C. Mattress surfaces were soiled and damaged in Room 2B64.

D. Window surfaces were soiled, spider webs covered the exterior window surfaces, and cabinet shelf surfaces were soiled in the Day Room.

E. The interior surfaces of exhaust vents were soiled with dust and stains in Room 2B49.

F. The interior louver surfaces of exhaust vents were soiled with dusty and privacy curtain hooks were detached in Rooms 2B48 and 2B49.

G. Floor and faucet surfaces on the sink were soiled in Room 2B47.

H. Shower curtain surfaces were soiled, stained and the interior surfaces of vents were soiled in Shower Room 2B46.

I. The horizontal surfaces of the bed frames were soiled with dust in Room 2B49, 2B45, and 2B48

J. Windowsill surfaces were soiled with dust in Room 2B38.

K. Cabinet shelf surfaces were soiled with dust in the Lounge in the hallway on the A-side of unit 2B.

L. The lower surfaces of the toilet were soiled, and the caulking needed repair in Room 2B25.

M. The horizontal surfaces of the bed frame were soiled with dust, in Room 2B32.

N. Windowsill surfaces were soiled and dusty in Rooms 2B20 and 2B26.

O. The horizontal surfaces of the bed frame were soiled with dust in 2B32.

P. Floor surfaces under the bed were soiled with dust in 2B20.



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2. Based on observation and staff interview, hospital staff failed to ensure an oxygen tank was secured and safely stored in one of one observation.

Findings included ...

During a tour of unit 2A on 12/07/2021 at approximately 2:20 PM, the surveyor observed one full unsecured oxygen tank sitting in an upright position on the floor in the treatment room behind the Code Cart.

The practice lacked evidence that the hospital staff safely stored and secured the oxygen tank.

The surveyor conducted a face-to-face interview with Employees #18, Registered Nurse, and Employee #17, Charge Nurse, and both stated the oxygen tank should be secured in a cart.

Employees #17 and #18 acknowledged and confirmed the findings at the time of the observation.

Based on observations during the survey, it was determined through record review and interview, that the emergency generator power is not transferred automatically during weekly exercises. Power is currently transferred manually to an electrical designated plate load of 1000 KW (Kilo Watts) each week to test the generators operation. The following findings were observed and acknowledged during a review of the Generator Exercise Log, between 1:00 PM and 2:30 PM on 12/09/2021 and between 9:00 AM and 11:00 AM on 12/10/2021 in the presence of Employee #57, Facilities Specialist.

Findings included ...


According to NFPA 99 Chapter 2, "NFPA treats emergency generators as part of the essential electrical System (ESS) Which is a system which is defined as, "A System comprised of alternate sources of power and all connected distribution systems comprised of alternate sources of power all connected distribution systems and ancillary equipment designated areas and for health a health care facility during distribution of normal sources, and to minimize disruption within the internal wiring system."

"The Monthly test must consist of electrically operating the transfer switch from the normal/standard position, to alternate position and then return to the normal standard/position." NFPA 110 (99), Sec 6-4.5; NFPA 110 (02). Sec 8.4.5.

During the survey a review of Generator Log Sheets, it was determined that weekly Emergency Generators exercises are performed without generators power being transferred through Automatic Transfer Switches. Generators are tested by activating transfer switches manually and are tested off of a designated plate load of 1000 KW (Kilo Watts). NFPA (National Fire Protection Agency), requires that generators are to be exercised for at least 30 minutes under load once per month. Power must be transferred through Automatic Switch Gear, to determine if power transfer would occur during an emergency.

A review of generator logs indicated that generators 1 and 2 transfer switches were operated manually during exercises, instead and electrical transfer of power between January 2019 and December 2021.

Employee #57 acknowledged and confirm the findings.

Based on medical record review, hospital policy review, and staff and patient interview, the clinical staff failed to include language barrier assessments and interventions in the treatment plan (Interdisciplinary Recovery Plan) for a patient with limited English proficiency and a primary language of Spanish in one (1) of two (2) records reviewed (Patient #13).

Findings included ....

Review of the facility's policy titled, "Language Access for Individuals with Limited or No-English Proficiency, dated 6/19/2018, showed "Department of Behavioral Health (DBH) Providers shall arrange for the provision of language access services at no cost to Limited or No-English proficient consumers. Document primary language information in consumer's clinical record at the point of entry with notations on how to engage the person in communication if unknown. All individuals that receive services and supports as a part of the DBH service delivery system or participate in DBH sponsored events have access to and receive language access services that meet their individual needs, including written and oral translations appropriate to their specific needs."

Review of the facility's policy titled "Interdisciplinary Recovery Plan for Inpatient Services" revised on 04/30/2015, showed " It is the policy of [Hospital's Name] that all individuals in care shall receive comprehensive Interdisciplinary Recovery Plans that reflect medically necessary care that is individualized, trauma-informed, recovery-oriented and integrated across all disciplines."

A medical record review was conducted on 12/08/2021 at approximately 11:00 AM with Employee # 22, Nurse Educator. According to Patient # 13's History and Physical, the patient was admitted on 10/21/2021 with diagnoses to include Herpes Simplex Infection, Allergic Rhinitis, and Right Knee Joint Pain. Further review of the History and Physical showed an assessment note from the physician stating, " Patient (Patient # 13) is a Spanish speaking male and an in-person Spanish language interpreter was not made available for the history and physical assessment as requested, but he is able to understand some English and answer questions."

A medical record review showed a document titled," Facesheet (Clinical)" entered on 10/21/2021 at 12:12 PM, with an undocumented entry for the primary language. In addition, the "Comprehensive Initial Nursing Assessment Report," dated 10/21/2021 at 2:02 PM, showed, there was no need for a translator, and the section for "Language" was not documented.

A medical record review of the "Comprehensive Initial Psychiatric Assessment Report", dated 10/21/2021 at 02:23 PM, by the admitting psychiatrist showed, "Patient (Patient # 13) has limited English proficiency ... and the interview was conducted in Spanish, as this writer is a native speaker."

The medical record lacked evidence that Patient #13's primary language was documented, and interpretive services were utilized as requested per hospital policy. Additionally, the IRP was not individualized to reflect the patient's language barrier.

The surveyor conducted an interview with Patient # 13 via telephone on 12/10/2021 at approximately 11:40 AM in the presence of a nurse supervisory consultant and Employee # 11, Quality Improvement Coordinator. A Spanish interpreter was at the patient's bedside. The surveyor introduced self in English and asked Patient #13 about his care and preferred language. Patient # 13 responded, "I don't understand." Spanish interpreter (unknown) stated, "The patient would like to use an interpreter." The surveyor requested the name of the interpreter from Employee #11, but the information was not provided.

Employee # 11 acknowledged and confirmed the findings at the time of the interview.