HospitalInspections.org

Based on Medical Record (MR) review, facility policy and procedure, and staff interviews, the hospital failed to assure the patient's plan of care was updated for 2 of 2 records reviewed for patients with restraints. This had the potential to affect all patients, and did affect MR # 7, and MR # 5.

Findings include:

Facility Policy: Treatment, Treatment Plan and Review
Policy number: CTS 1.2
Date revised: 02/15

Policy:

In order to ensure the appropriateness of care, treatment plans and reviews will be conducted for all consumers. All treatment plans and reviews will meet expected standards of the Alabama Department of Mental Health, Medicaid, The Joint Commission and other governing bodies.

...services must be individualized, well-planned, and should include treatment designed to enhance the consumer's abilities to recover and function in the least restrictive setting.

Procedure:

...2. The treatment plan will include clinical issues to be addressed in treatment and the services to be provided to address those issues... The treatment plan will state the expected outcomes for each goal.

...10. Treatment plans will be reviewed and updated...

12. The treatment plan is reviewed when major changes occur in age, presenting problems, or disabilities and is revised as necessary...

1. MR # 7 was admitted to the facility on 3/30/22 with diagnoses including Oppositional Defiant Disorder.

MR review revealed the patient was placed in restraints, a physical hold, on 4/7/22 from 1:05 PM to 1:30 PM. The 4/7/22 Seclusion/Restraint Order Description documentation was "due to imminent threat to others".

Review of the Hospital Treatment Plan Update, dated 4/13/22, signed electronically on 4/17/22 at 11:08 PM, revealed no documentation of the restraint on 4/7/22. The 4/13/22 Master problems documented were: At Risk for Self-Harm, Risk for Disturbed Sleep, and Discharge Planning. There was no documentation regarding restraint use or imminent threat to others. There were no treatment plan updates for the use of restraints.

In an interview conducted on 5/5/22 at 2:54 PM, Employee Identifier (EI) # 3, Associate Director confirmed there was no update to the treatment plan for restraint use.




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2. MR # 5 was admitted to the facility on 4/16/22 with diagnoses including Disruptive Mood Dysregulation Disorder.

MR review revealed the patient was placed in restraints, a physical hold, on 4/24/22 from 6:30 PM to 6:37 PM. The 4/24/22 Seclusion/Restraint Order Description documentation was "Assault on peer, imminent threat to others".

Review of the Hospital Treatment Plan Update, dated 5/3/22, revealed no documentation of the restraint on 4/24/22. The 5/3/22 Master Problems documented were: Aggression, and Discharge Planning. There was no documentation regarding restraint use and no treatment plan updates for the use of restraints.

An interview was conducted on 5/5/22 at 2:09 PM, with EI # 3, who confirmed there was no update to the treatment plan for restraint use.

Based on review of medical records (MR), facility policy and procedure, and staff interviews, it was determined the facility failed to ensure staff documented Q (Every)- 15 minute patient observations as directed per the facility policy.

This did affect 6 of 8 MRs reviewed including MR # 2, MR # 6, MR # 1, MR # 8, MR # 3, MR # 5, and had the potential of affect all patients served by this facility.

Findings include:

Facility Policy: One to One (1:1), Q-15, and Q 30 (Routine) Observations
Policy #: CTS 5.03
Revised: 12/17

Policy:

When a consumer is unable to function within the structure of the program due to acting out behaviors, being a possible elopement and/or verbalizing intention of harming self/others... 1:1, Q-15 and Q-30 Observations may be ordered as a safety measure.

A. 1:1 Observation:

When a consumer is placed on 1:1 status, it is typically because he/she has verbalized intentions of harming himself/herself, or someone else... The psychiatrist/CRNP (Certified Registered Nurse Practitioner) is the only staff member who is capable of initiating and discontinuing one to one observation orders for a consumer.

Procedure:

1. There are two types of 1:1 Observation; 1:1 Routine and 1:1 Two Arms Length:

a. 1:1 Routine - Employee must keep consumer within constant visual observation and within auditory contact at all times. The employee must remain within a safe distance/close enough to the delegated consumer and be immediately available to protect the safety of the consumer, peers and staff.

b. 1:1 Two Arms-Length - Employee must keep consumer within constant visual observation and within auditory contact at all times. The employee must remain within two arms-length distance from delegated consumer at all times.

2. The following items are to be completed for all 1:1 observations:

...e. Document on the Precautions Record form every 15 minutes via the IPad (Interactive Personal Application Device).

B. Q-15 Minute Observation

Q-15 minute observations means a consumer is to be monitored by staff every 15 minutes. The location, activity and behaviors of the consumer should be documented every 15 minutes.

Procedure:

1. Employee must locate consumer at least once every 15 minutes and document required information on the Precautions Record form. It is extremely important to document what the consumer is doing and to note behavioral observations on this form...

1. MR # 2 was admitted to facility on 4/22/22 with diagnoses including Generalized Anxiety Disorder.

Review of the physician's orders dated 4/22/22 at 1:12 PM included, "Q-15 minute Observation".

Review of the Behavioral Health-Patient Observation Sheet dated 4/24/22 revealed an observation check at 2:30 PM and the next observation was documented at 3:04 PM, which was 34 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 4/30/22 revealed an observation check at 10:31 AM and "Gym" (Gymnasium) from 10:31 AM - 11:13 AM. The next observation was documented at 11:24 AM, which was 57 minutes later.

An interview was conducted on 5/5/22 at 2:55 PM with Employee Identifier (EI) # 8, Assistant Director, who verified the staff failed to document Q-15 minute observations as ordered.

2. MR # 6 was admitted to the facility 4/28/22 with diagnoses including Disruptive Mood Dysregulation Disorder.

Review of the physician's orders dated 4/22/22 at 10:46 AM included, "Q-15 minute Observation, Unpredictable Behavior Precautions".

Review of the Behavioral Health-Patient Observation Sheet dated 4/28/22 revealed an observation check at 10:26 AM and "Playground 10:26 AM - 11:17 AM accompanied by Rec (Recreational)/Nursing Staff". There were no Q-15 minute observations documented for 51 minutes from 10:26 AM to 11:17 AM on 4/28/22.

Further review of the Behavioral Health-Patient Observation Sheet dated 4/28/22 revealed an observation check at 3:21 PM and "Playground 3:21 PM - 5:16 PM accompanied by Rec/Nursing Staff" and the next observation was documented at 5:22 PM. There were no Q-15 minute observations for 121 minutes from 3:21 PM to 5:22 PM on 4/28/22.

Review of the Behavioral Health-Patient Observation Sheet dated 5/1/22 revealed an observation check at 2:17 PM and "Gym" from 2:17 PM - 2:57 PM. The next observation was documented at 3:08 PM, which was 51 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 5/2/22 revealed an observation check at 12:30 AM and the next observation was documented at 1:04 AM, which was 34 minutes later.

Further review of the Behavioral Health-Patient Observation Sheet dated 5/2/22 revealed an observation check at 8:19 AM and "Playground 8:19 AM - 10:35 AM accompanied by Rec/Nursing Staff" and the next observation was documented at 12:47 PM. Additionally, an observation check was documented at 6:57 PM and an "Individual Session 6:57 PM - 7:26 PM accompanied by Rec/Nursing Staff" and the next observation was documented at 7:30 PM.

There were no Q-15 minute observations documented for 148 minutes from 8:19 AM to 10:35 AM and 33 minutes from 6:57 PM - 7:30 PM on 5/2/22.

An interview was conducted on 5/5/22 at 2:36 PM EI # 8 who verified the staff failed to document Q-15 minute observations as ordered.


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3. MR # 1 was admitted to the facility on 4/22/22 with diagnoses including Major Depressive Disorder, recurrent, moderate.

Review of the Client Profile-Orders Details documentation revealed physician's orders dated 4/22/22 at 12:56 PM for Q-15 minute Observation, unpredictable behavior precautions.

Review of the Behavioral Health-Patient Observation Sheet dated 4/24/22 revealed an observation check at 2:30 AM and the next observation was documented at 3:04 AM, which was 34 minutes later. There was an observation documented at 3:54 AM and the next observation was 42 minutes later at 4:38 AM.

Review of the Behavioral Health-Patient Observation Sheet dated 5/1/22 revealed an observation check at 2:26 PM and the next observation was documented at 4:42 PM, which was 136 minutes later. There was an observation documented at 6:45 PM and the next observation was 35 minutes later at 7:20 PM.

An interview was conducted on 5/5/22 at 3:15 PM with EI # 3, Assistant Director, who verified the staff failed to document q-15 minute observations as ordered.

4. MR # 8 was admitted to the facility on 4/23/22 with diagnoses including Reaction to Severe, unspecified.

Review of the Client Profile-Orders Details documentation revealed physician's orders dated 4/23/22 at 1:36 PM for Q-15 minute Observation, elopement precautions, unpredictable behavior precautions.

MR review revealed Nurse Narrative documentation dated 4/27/22 at 11:42 AM and the nurse documented, consumer was in a physical altercation around 11:20 AM with another consumer after a verbal altercation, consumer received Benadryl 50 milligram and will spend time in the quiet room.

Review of the 4/27/22 Behavioral Health-Patient Observation Sheet included Q-15 minute observations at 11:15 AM, 11:38 AM, and 12:02 PM, the consumer location was OR (observation room), behaviors documented were CM (calm) and /or AS (appears sleeping). The next 4/27/22 Behavioral Health-Patient Observation Sheet documentation was an Individual Session from 12:02 PM-1:45 PM, Accompanied by REC (recreation)/Nursing Staff. There was no documentation of a nursing session from 12:02 PM-1:45 PM, no Hospital Progress Note and no Hospital Group and Individual Progress note for the 12:02 PM-1:45 PM period.

There were no Q-15 minute observation checks documented on 4/27/22 from 12:02 PM-1:59 PM which was 119 minutes.

MR review revealed a Hospital Group and Individual Progress Note dated 5/1/22 10:15 AM-10:30 AM for a Social Service Skill Based session.

Review of the Behavioral Health-Patient Observation Sheet dated 5/1/22 revealed an observation check at 10:29 AM in the dayroom. The next documentation on the Behavioral Health-Patient Observation Sheet was "Individual Session, 10:29 AM-1:31 PM, Accompanied by REC/Nursing Staff."

MR review revealed on 5/1/22 at 11:30 AM the nurse documented currently in dayroom with peers.

Further record review revealed a Hospital Group and Individual Progress Note dated 5/1/22, 12:30 PM -1:30 PM, Topic REC-Enjoyment with documentation the consumer actively participated in "GYM stations...appeared to increase exercise and fitness".

There were no Q-15 minute observations documented for 196 minutes from 10:29 AM to 1:46 PM on 5/1/22 which included 11:30 AM in which the consumer was observed to be in the dayroom.

In an interview conducted on 5/5/22 at 1:49 PM, EI # 3 reported Q-15 minute observations were not documented. EI # 3 confirmed on 4/27/22 there was no documentation an individual session was conducted 12:02 PM-1:45 PM, no documentation Q-15 minute observations were documented for 119 minutes on 4/27/22 and on 5/1/22 for 196 minutes.



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5. MR # 3 was admitted to the facility on 3/28/22 with diagnoses including Oppositional Defiant Disorder with Chronic Irritability and Anger.

Review of the physician's orders dated 3/28/22 at 3:54 PM included Q-15 minute Observations.

Review of the Behavioral Health-Patient Observation Sheet dated 3/29/22 revealed an observation check at 11:50 AM and Gym from 11:50 AM - 12:19 PM. The next observation was documented at 12:26 PM, which was 36 minutes later.

Review of the physician's orders dated 4/6/22 included 1:1 Observations, Two Arms Length.

Review of the Behavioral Health-Patient Observation Sheet dated 4/7/22 revealed an observation check at 3:51 AM and the next observation was documented at 4:35 AM, which was 44 minutes later. Further review of the 4/7/22 sheet revealed an observation check at 7:44 AM, and the next observation was documented at 8:14 AM, which was 30 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 4/9/22 revealed an observation check at 11:19 AM and the next observation was documented at 12:03 PM, which was 44 minutes later. Further review of the 4/9/22 sheet revealed the following observations that were greater than 15 minutes, and not as ordered:

12:03 PM to 1:02 PM, 59 minutes.
1:02 PM to 1:33 PM, 31 minutes.
1:33 PM to 2:16 PM, 43 minutes.
2:16 PM to 3:02 PM, 46 minutes.
3:43 PM to 4:15 PM, 32 minutes.
4:40 PM to 5:27 PM, 47 minutes.
6:21 PM to 7:55 PM, 94 minutes.

Review of the Behavioral Health-Patient Observation Sheet dated 4/11/22 revealed an observation check at 3:07 PM and the next observation was documented at 3:42 PM, which was 35 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 4/12/22 revealed an observation check at 7:21 AM and the next observation was documented at 7:56 AM , which was 35 minutes later. Further review of the 4/12/22 sheet revealed the following observations that were greater than 15 minutes, and not as ordered:

12:22 PM to 12:54 PM, 32 minutes.
12:54 PM to 1:27 PM, 33 minutes.

Review of the Behavioral Health-Patient Observation Sheet dated 4/22/22 revealed an observation check at 4:27 AM and the next observation was documented at 5:18 AM, which was 51 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 4/25/22 revealed an observation check at 10:11 PM and the next observation was documented at 10:57 PM, which was 46 minutes later.

Review of the Behavioral Health-Patient Observation Sheet dated 4/30/22 revealed an observation check at 1:03 PM and the next observation was documented at 1:48 PM, which was 45 minutes later.

An interview was conducted on 5/5/22 at 3:15 PM with EI # 3, who confirmed staff failed to document the 15 minute observations as ordered.

6. MR # 5 was admitted to the facility on 4/16/22 with diagnoses including Disruptive Mood Dysregulation Disorder.

Review of the physician's orders dated 4/16/22 revealed Q - 15 minute observations.

Review of the Behavioral Health-Patient Observation Sheet dated 4/17/22 revealed an observation check at 8:41 AM and Gym from 8:41 AM to 9:37 AM. The next observation was documented at 9:41 AM, which was 45 minutes later. Further review of the 4/17/22 sheet revealed no observations documented from 10:00 PM to 12:00 PM, which was 2 hours.

Review of the Behavioral Health-Patient Observation Sheet dated 4/18/22 revealed Gym from 11:45 AM to 12:34 PM, which was 54 minutes with no documentation of Q - 15 minute observations.

Review of the Behavioral Health-Patient Observation Sheet dated 4/22/22 revealed Gym from 11:33 AM to 12:46 PM, which was 73 minutes with no documentation of Q - 15 minute observations.

Review of the Behavioral Health-Patient Observation Sheet dated 4/26/22 revealed Gym from 11:41 AM to 12:27 PM, which was 53 minutes with no documentation of Q - 15 minute observations.

Review of the Behavioral Health-Patient Observation Sheet dated 4/30/22 revealed Gym from 8:37 AM to 9:41 AM, which was 64 minutes with no documentation of Q - 15 minute observations.

An interview was conducted on 5/5/22 at 2:09 PM with EI # 3, who confirmed staff failed to document observations every 15 minutes, as ordered.

Based on review of Medical Records (MR), hospital policy and procedure, and interview, it was determined the hospital staff failed to assure all patient ordered medications:

1. Were administered per physician orders and documented in the record.

2. Administered on an as needed (prn) basis included the complaint (reason) for administration and the results (response/effectiveness) of the prn medication documented in the record.

3. Amount of medication administered.

This affected MR # 7, MR # 4, MR # 8, MR # 3, 4 of 8 inpatient medical records reviewed and had the potential to affect all patients served by the hospital.


Hospital Policy # (number) CTS 3.0
Program/Department: All Programs
Subject: Medication Storage, Control, Assistance and Administration
Revised: 07/16/2021

...Procedure:

A. Medication Documentation

3. All medications received must be documented on the MAR by the nurse...

7. Anytime that a medication is not given documentation of the reason...for the missed dose must be made on the MAR...

C. Medication Administration/Assistance

8... staff must document information related to a patient receiving a PRN (on an as needed basis)...medication including...complaint...amount of medication given...and results.

Findings include:

1. MR # 7 was admitted to the facility on 3/30/22 with diagnoses including Oppositional Defiant Disorder.

MR review revealed physician medication orders dated 3/30/22 at 1:59 PM for Intuniv 4 mg (milligram) oral tablet at bedtime (hs), Focalin XR (extended release) oral capsule 40 mg every morning, and Benadryl 25-50 mg IM (intramuscularly) every 4-6 hours prn for acute agitation. In addition, there were physician medication orders dated 4/15/22 at 1:03 PM for Lexapro 20 mg oral tablet every morning.

Review of the eMAR (electronic medication administration record) revealed no documentation Intuniv was administered on 4/6/22 at bedtime.

Review of the 4/17/22 Patient Observation Sheet documentation revealed the patient was in an individual session from 2:02 PM until 3:31 PM. In addition, review of the eMAR revealed Benadryl 50 mg IM was administered on 4/17/22 at 3:24 PM. There was no reason for administration documented in the MR and no documentation of the results or therapeutic effectiveness of the IM prn Benadryl.

Review of the eMAR revealed no documentation Focalin 40 mg and Lexapro 20 mg were administered on 4/27/22. There was no documentation MR # 7 refused the medications.

In an interview conducted on 5/5/22 at 2:54 PM, Employee Identifier (EI) # 3, Associate Director confirmed there was no documentation the above medications were administered as ordered. Also, EI # 3 confirmed staff failed to follow the hospital policy and procedure and document the reason for and the results/effectiveness of the prn medications.

2. MR # 4 was admitted to the facility on 4/22/22 with diagnoses including Other Symptoms and Signs involving appearance and behavior and Oppositional Defiant Disorder.

Review of the Client Profile-Orders Details documentation included orders dated 4/22/22 at 11:07 PM for Benadryl 50 mg oral capsule prn insomnia, and 4/27/22 at 3:03 PM Tylenol 325 mg oral tablet every 4-6 hours prn pain.

Review of the eMAR revealed Benadryl 50 mg oral capsule prn was administered for insomnia on 4/25/22 at 9:32 PM and 4/26/22 at 9:14 AM. There was no eMAR or Nurse documentation on 4/25/22 and 4/26/22 to reveal the results/effectiveness of the prn Benadryl.

Further eMAR review revealed Tylenol 325 mg oral tablet prn was administered on 4/27/22 at 3:33 PM for a headache. There was no eMAR and no Nurse documentation on 4/27/22 of the results/effectiveness of the Tylenol.

Review of the Nurse Narrative Note documentation revealed on 4/29/22 at 8:39 PM MR # 4 complained of poor sleep and leg pain. The nurse documented "ADMIN (administer) Benadryl and Tylenol. There was no eMAR documentation Benadryl and Tylenol were administered and no results/response of prn Tylenol and Benadryl were documented.

MR review revealed Nurse Narrative Notes documentation dated 4/30/22 at 10:25 PM that MR # 4 complained of menstrual cramps and poor sleep, nursing assessment complete and ADMIN Benadryl per order for sleep and Tylenol for cramping. There was no eMAR documentation Benadryl and Tylenol were administered. There were no results/response of the prn Tylenol and Benadryl documented.

In an interview conducted on 5/5/22 at 11:16 AM, EI # 4, Director of Compliance confirmed staff failed to document the results/response of all prn medications and all medications administered were not documented in the eMAR.

3. MR # 8 was admitted to the facility on 4/23/22 with diagnoses including Reaction to Severe, unspecified.

Review of the Client Profile-Orders Details documentation revealed orders dated 4/23/22 at 1:36 PM for Benadryl oral capsule 50 mg prn insomnia, Benadryl 25-50 mg oral capsule every 4 to 6 hours prn for acute agitation and Benadryl 50 mg/1 ml (milliliter) injection solution 25-50 mg every 4 to 6 hours prn acute agitation.

Review of the eMAR revealed Benadryl 25-50 mg oral capsule prn was administered on 5/1/22 at 3:13 PM for acute anxiety. The amount of Benadryl administered on 5/1/22 and the results/effectiveness of the prn Benadryl was not documented in the record.

Further eMAR review revealed on 5/2/22 at 5:23 PM Benadryl 25-50 mg oral capsule prn was administered. The reason for Benadryl administration, the amount administered, and the results/effectiveness of the prn Benadryl were not documented in the record.

In an interview conducted on 5/5/22 at 1:49 PM, EI # 3 confirmed staff failed to follow the hospital policy and procedure and document the reason for and results/effectiveness of prn medication and the dosage administered.




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4. MR # 3 was admitted to the facility on 3/28/22 with diagnoses including Oppositional Defiant Disorder with Chronic Irritability and Anger.

Review of the physician orders dated 3/28/22 at 3:54 PM revealed an order for Benadryl 25 mg oral capsule, 25 - 50 mg at bedtime as needed for Insomnia.

Review of the MR revealed MR # 3 was administered Benadryl on 4/3/22 at 9:12 PM. There was no documentation how much Benadryl was given to the patient.

An interview was conducted on 5/5/22 at 3:15 PM with EI # 3, who confirmed staff failed to document the amount of medication administered to MR # 3.

Based on a tour of the dietary department, interview, and facility policy, it was determined the facility failed to ensure foods were stored food in a safe and sanitary manner.

This had the potential to affect all persons served by the facility.

Findings include:

Facility Policy: Storage
Policy Number: SOP204

Purpose: All food, chemicals, and supplies should be stored in a manner that ensure safety and quality of products...

Instructions: Employees who receive and store food maintain storage areas, including dry, refrigerated, and freezer storage, by following these steps:

Storage upon Receiving:

7. Store food in original container... After a food package is opened, remaining product can be stored,... labeled and airtight containers.

Monitoring

Storeroom sanitation:

...Dispose of items that beyond expiration or "use by" dates.

Temperature Control:

11. Defrost all units on a regular schedule to aid in proper maintenance and air circulation.

1. During a tour of the dietary department on 5/3/22 at 1:00 PM, the following items were observed in the cooler area:

1 gallon container of Classic Caesar Salad Dressing with 1/8 contents remaining - opened and not dated.

1 gallon container of Chipotle Ranch Dressing with 1/4 contents remaining - opened and not dated.

1 gallon Sweet Coleslaw with 1/4 contents remaining - dated, "use by 4/30/22", which was 3 days earlier.

The following were observed in freezer # (number) 1 - Kitchen:

1 large "saran wrap" bag of Season Blend - undated.

Large amount of ice build-up upon entrance on left side of freezer wall and on top of 2 boxes on the back shelf and left back wall side of the freezer.

An interview was conducted on 5/3/22 at 1:20 PM with Employee Identifier (EI) # 9, Cook, and EI # 2, Director of Nursing, who verified the staff failed to store the foods as directed per the facility policy.

Based on observations, facility policies and procedures, and interviews it was determined the facility failed to ensure:

1. The environment was clean and safe.

2. Expired supplies in the emergency cart were not available for patient use.

Findings include:

Facility Policy: Cleaning of Patient Care and Equipment and the Environment
Policy number: IC (Infection Control) 3.7
Policy Update: 3/18

Policy:

Each AltaPointe Health, Inc. (Incorporated) program will ensure that the environment is maintained in a clean and sanitary condition. The accumulation of dust, soil, and microbial contaminants on environmental surfaces is both aesthetically displeasing and a potential source of healthcare-associated infections... Employees and housekeeping personnel share responsibility for maintaining a safe and sanitary environment for consumers and visitors.

Appendix BID #2021-0001

Baypointe Hospital

Cleaning Specifications

Consumer Rooms

Showers, toilets, sinks, cleaned and disinfected daily. Bathroom floors and mirrors to be cleaned daily.

...Floors are to be dust mopped and mopped daily.

...Hallways and Corridors, Seclusion Rooms on... CHU (Children's Hospital Unit)

Swept and mopped daily.

...Day Rooms and Galleys

...Trash removed and trash cans cleaned daily, may require emptying multiple times daily...

Offices, Administrations, Lobbies, Common Areas, Intake Rooms.

Sweep, mop, vacuum daily.
...Remove trash daily...

Facility Policy: Health and Safety (Environment of Care)
Policy Number: HS 1.0
Date revised: 12/21

Policy:

Altapointe Health Systems, Inc. will maintain a Health and Safety program encouraging proper attention toward injury and illness prevention on the part of both supervisors and employees. The personal health and safety of patients, visitors and staff is of primary importance. To the greatest degree possible, the organization will provide all mechanical and physical facilities required for personal safety and health...

Procedure:

The Health and Safety/ Environment of Care program will include:

...2. Conducting a program of health and safety inspections to find and eliminate unsafe working conditions or practices; to control health hazards...

1. During a tour of the facility on 5/3/22 at 8:40 AM with Employee Identifier (EI) # 1, Chief Hospital Officer, and EI # 10, Coordinator, the following was observed:

Room 503- Comfort Room, had peeling paint with pieces of paint chips on the floor, approximately 1 inch and 2 inch sized pieces, and a pile of debris/ dust that had been swept into a pile. There was no one present with a broom.

Room 505- Conference Room, contained 4 plastic garbage bags and 4 boxes full of clothing. EI # 10 stated, "It might be donated clothing." On the table and in the floor, were completed activity sheets with a child's hand writing, and a used cup. Waded up paper was on the floor. EI # 10 further stated, "...these items should not be in here."

Room 507- Consumer Room, was observed to have an approximate 5 to 6 inch hole in the wall, between the sets of mounted shelves. The floors had dirt/dust piled in the corners. The bathroom had a patched hole, with an approximate 3 inch hole in the center. The floor had dust and dirt in the corners.

Room 513- Consumer Room, was observed to have peeling, patched paint by the bathroom mirror.

Room 514- Consumer Room, was observed to have peeling paint by the door frame. The wall at the head of the bed, closest to the door, had peeling paint and sheetrock.

Room 512-Consumer Room, was observed to have peeling paint at the head of the bed, closest to the door. There was cracked and peeling caulk around bathroom mirror. Also in the bathroom, was a plastic toothbrush and toothpaste. EI # 1 stated, "... they are supposed to return items to their bin after use, and not store them in the bathroom."

Room 510- Consumer Room, was observe to have dust, dirt, and crayon wrapper pieces on the floor all around the bed, and between wall and head of bed. A plastic toothbrush was in the bathroom.

Room 508- Consumer Room, was observed to have a pile of white powder/ sheetrock dust in the corner.

During the tour, EI # 1 and EI # 10 confirmed the rooms were not clean, and items were not stored properly.



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2 During a tour of the facility on 5/3/22 from 8:45 AM to 10:30 AM with EI # 3, Associate Director and EI # 8, Associate Director, the following observations were made:

Room 407-Consumer room-missing baseboard, ligature resistant door hinge without top metal cover with an exposed top pin, which is a ligature risk, floors with dirt build up around baseboards, Keril safety pad in consumer room with a 5 inch tear in the vinyl. EI # 8 reported the hospital was in the process of cleaning the hallway floors.

Room 408-Consumer room-peeling paint.

Room 415-Consumer room-loose baseboard along door entry.

Room 410-Consumer room-a hairbrush and graffiti on the cabinets.

Room 417-Consumer room-hair products including 4.2 ounces of hair oil, 4 ounces fresh scent; excess hair (loss) in the shower. All hair products were removed by EI # 3.

Room 414-Consumer room-peeling paint above the bed, peeling window tint, graffiti on the end of bed frame.

Room 419-Consumer room-consumer bed closest to door, no sheets were on the bed and the bed frame had significant dirt buildup and crayon coloring on the bed frame surface; an open/exposed area in the sheet rock above the base board in the bathroom, dirt build up on the bathroom floor.

Room 416-Consumer room-in the bathroom were 3 used wash cloths, 4 empty bottles of hair products including a full paper cup of hair gel (contents verified by EI # 3), and a hairbrush. EI # 3 stated housekeeping is still making rounds.

Room "42"-laundry-washer had wet paper in washer bottom and fabric dispenser.

Room 418-Time Out room-missing base board along on the right wall. While touring the Time out room the surveyor observed a consumer exit the rest room adjacent to Room 418.

Consumer restroom adjacent to Room 418-3 hinges along the inside of door were not ligature resistant. EI # 3 reported this rest room is locked and staff must let consumers in.

Found in the emergency cart drawer at the nurse station on the 400 unit was:

5 of 5, 20 gauge 1 1/4 inch Protect IV (intravenous) catheters expired 5/2019
4 of 4, 18 gauge 1 1/4 inch Protect IV catheters expired 3/17/2020
1 of 1 Suction tubing expired 5/2021

In an interview on 5/3/22 at 9:45 AM, EI # 11, Registered Nurse, Nurse Manager confirmed the emergency supplies available for patient use had expired. EI # 11 removed the expired supplies.

During the unit tour on 5/3/22 from 8:40 AM to 10:35 AM, the above observations were reviewed with EI # 3 and EI # 8 who confirmed all consumer and general care areas were not kept clean and safe.



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3. During a tour of the facility on 5/3/22 at 8:40 AM with EI # 2, Director of Nursing, and EI # 11, Registered Nurse Manager, the following were observed:

Room 607- Consumer room - baseboards and floor had dirt/dust piled in the corners and peeling paint on the wall. Bathroom had brown stains on the wall.

Room 609- Consumer room - light in room not working

Room 615- Consumer room - large dead bug lying on the floor next to the bed.

Room 614 - Consumer room- peeling window tint. Bathroom floor had a large amount of white powder/ sheetrock dust covering the corner.

Hallway between rooms 606 - 614: 3 large areas of the wall with sheetrock, not painted.

During the unit tour on 5/3/22 from 8:40 AM to 9:15 AM, the above observations were reviewed with EI # 2 and EI # 11 who confirmed all consumer and general care areas were not kept clean and safe.

Based on observations, review of policies and procedures, and staff interviews, it was determined the facility failed to ensure the staff:

1. Performed hand hygiene when preparing and administering medications per facility policy.

2. Cleaned and disinfected consumer rooms and examination (exam) room per facility policy.

3. Disinfected surfaces with disinfectant products not expired.


This did affect 2 of 3 observations conducted for medication preparation and administration, including unsampled patients, and medical record (MR) # 3 and 1 of 1 observation conducted for terminal cleaning of an unsampled consumers room.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Hand Washing
Policy #: IC (Infection Control) 3.2
Update: 3/18

Policy:

All AltaPointe Health Systems employees are responsible for appropriate hand hygiene.

According to guidelines from the Center for Disease Control and Prevention (CDC) handwashing is the single most effective way to prevent infection...

Procedure:

Indications for hand hygiene:

...Before handling food and medications

...After contact with inanimate objects or medical equipment close to the consumer

Recommended hand-washing procedure:

Prepare paper towel for use.
Wet hands with warm water...Work up lather with soap, and vigorously rub...all surfaces...of hands...for at least 20 seconds...Dry hands thoroughly. Use paper towel to turn off water...

Facility Policy: Cleaning Specifications
Policy: BID# 2021-001

Consumer Rooms

Beds, mattresses are to be cleaned and disinfected when there is not linen on them.

Facility Policy: Cleaning of Patient Care Equipment and the Environment
Policy #: IC 3.7
Update: 3/18

Policy:

Each AltaPointe Health...program will ensure...environment is maintained in a clean and sanitary condition. The accumulation of...microbial contaminants on environmental surfaces is...a potential source of healthcare-associated infections...
Employees and housekeeping personnel share responsibility for maintaining a safe and sanitary environment for consumers...

1. During a tour of the facility on 5/3/22 from 9:00 AM-10:35 AM accompanied by Associate Directors, EI (Employee Identifier) # 3 and EI # 8, the surveyor toured the 400 unit including the teleheath/exam room. There was one fabric chair, the chair back rest was a print fabric, and the chair seat was black fabric (print worn completely off.) The fabric chair was unable to be disinfected between consumers.

In addition, after the 2 master locks were cut when unable to locate a key, the 2 locked cabinets in the telehealth/exam room were opened, 1 of 1 Super Sani Cloth Wipes canister was found with an expiration date 4/2020.

During the tour on 5/3/22 at 10:20 AM, EI # 3 confirmed the Sani Wipes had expired and were available for use and the consumer chair was unable to be disinfected.

2. An observation was conducted on 5/3/22 at 10:06 AM to observe EI # 5, License Practical Nurse (LPN) prepare and administer oral medications to an unsampled consumer. EI # 5 prepared the unsampled consumers medications and upon the unsampled consumer placing the medication into his/her mouth the pill spilled to the floor. EI # 5 retrieved the pill from the floor and proceeded to the medication room. EI # 5 then obtained a new medication from the medication drawer without performing hand hygiene when handling medications as directed per the facility policy.

An interview was conducted on 5/5/22 at 3:45 PM with EI # 2, Director of Nursing, who verified the staff failed to follow the facility policy for hand hygiene.

3. An observation of care was performed on 5/3/22 at 11:04 AM with EI # 5, LPN for medication preparation and administration for 4 consumers. EI # 2 was present during the observations.

EI # 5 performed hand hygiene at the sink and used his/her bare hands to turn off the faucet then dried hands with a paper towel. EI # 5 failed to per policy and procedure and turn off the faucet with paper towels.

Next, EI # 5 entered the medication room, accessed the Pyxis (medication dispensing system, and removed medications for 2 unsampled consumers. EI # 5 administered medication to the first consumer, exited the nurse station and unit onto another unit and entered the nurse station.

EI # 5 washed hands with soap for 6 seconds at the sink and not for at least 20 seconds per hospital procedure, turned off the faucet with bare hands and not a paper towel. EI # 5 accessed the Pyxis, removed medications, and administered the medication to the second consumer.

EI # 5 exited the unit and returned to first unit, washed hands with soap for 3 seconds at the sink, turned the faucet off with back of hands and dried hands with a paper towel. The consumer was not available for medications so EI # 5 stored the medications in a cabinet adjacent to the consumer nutrition refrigerator, exited the unit and entered the nursing station and medication room on another unit. EI # 5 accessed the Pyxsis, removed the medication for the third consumer then administered the medication to MR # 3.

EI # 5 failed to perform hand hygiene before accessing medication from the Pyxis and medication administration.

In an interview conducted following the observations on 5/3/22 at 12:10 PM, EI # 2 confirmed the staff failed to follow the hospital policy and procedure for hand hygiene.

4. An observation was conducted on 5/3/22 at 12:12 PM to observe EI # 6, Housekeeping Supervisor, perform terminal cleaning of an unsampled consumer's room after discharge. EI # 6 cleaned and disinfected the mattress and the top of the bed frame and proceeded to place the mattress on the bed without cleaning the bed frame.

An interview was conducted on 5/3/22 at 12:27 PM with EI # 6. The surveyor asked EI # 6, "How often are bed frames to be cleaned?" EI # 6 replied, "Daily and at discharge". EI # 6 then verified that he/she failed to clean and disinfect the bed frame per facility policy.



30952

Based on review of the facility Antibiotic Stewardship Program and staff interview, the facility failed to document the evidence-based use of antibiotics in all departments and services of the hospital.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 5/5/22 at 11:53 AM with Employee Identifier (EI) # 4, Director of Compliance.

EI # 4 was asked to provide documentation of the evidence-based use of antibiotics throughout the facility. EI # 4 stated, "...we are still developing the program."

Based on review of the personnel file, Director of Nursing (DON) job description, and interview, it was determined the facility failed to ensure the DON was qualified for the position or had oversight provided by a masters level psychiatric nurse.

This did affect Employee Identifier (EI) # 2, Director of Nursing, and had the potential to affect all persons served by the facility.

Findings include:

Organizational Title of Position: Director of Nursing
Location: Baypointe
Revised date: January 2022

Minimum Qualifications:

Bachelor degree with leadership experience in psychiatric/ behavioral health nursing. Master degree preferred... Knowledge in child/ adolescent and adult specialty, outlined below, to be attained with (6) six months of employment.

- Knowledge of psychiatric disorders in child/adolescent and adult populations.
- Knowledge of general and psychiatric nursing care.
- Knowledge of growth and development of child/ adolescent consumers as related to all intellectual, emotional, spiritual, and physical aspects of their development.
...Familiarity of psycho-pharmacy and the use of psychotropic medications...
-Knowledge of behavior management, crisis intervention, and interventions common to acute psychotic as well as to non-violent crisis intervention practice.
...Documented ongoing consultation with a nurse who holds a minimum of a Masters Degree in Psychiatric Nursing.

Primary Job Functions:

1. Clinical Responsibilities...
2. Supervision and Consultation:
a. Seeks clinical supervision and consultation needs.

During the entrance conference on 5/3/22 at 7:30 AM, EI # 2 explained she/he was new to the position of DON. EI # 2 further explained her/his previous job was a RN (Registered Nurse) in the emergency department of an acute care hospital, and had recently received a masters degree in leadership and management.

An interview was conducted on 5/5/22 at 10:31 AM with EI # 2 and EI # 1, Chief Hospital Officer, to review the Psychiatric Hospital special staff requirements. The surveyor asked if EI # 2 had a masters in psychiatric or mental health nursing, years of experience in psychiatric nursing, or oversight in place with a masters level psychiatric nurse, EI # 2 replied "No." EI # 1 stated the DON job description listed a requirement of oversight by a masters level psychiatric nurse.

Review of EI # 2's personnel file revealed a hire date of 3/28/22. Review of the DON Job Description, signed by EI # 2 on 3/28/22, revealed the Supervision Requirements section was left blank, with no number of hours of supervision required documented, and no time frame listed.

During the interview conducted on 5/5/22 at 10:31 AM, with EI # 1, it was confirmed EI # 2 did not have psychiatric nursing experience, and no oversight in place.