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Observation, review of documentation, and interview, revealed that the hospital failed to ensure that patient personal property was returned upon discharge. Cross refer: CFR 482.13(b) Patient Rights: Exercise of Rights


Observation, interview, and review of documentation, revealed that the facility failed to provide a safe setting for the psychiatric patients as ligature risks were observed and identified during the tour of unit 1C and the admissions lobby. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting. The facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring specified in accordance with facility policy; this presents a risk for harm to a patient or staff due to a patient not being monitored as ordered. Cross refer: CFR 482.13(c)(2) Patient Rights: Care in a Safe Setting


Review of documentation, clinical records, and interview, revealed that the facility failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care for 4 out of 6 restraint/seclusion records reviewed. This was not in accordance with facility policy. The use of restraint or seclusion constitutes a change in a patient's plan of care. Cross refer: CFR 482.13(e)(4)(i) Patient Rights: Restraint or Seclusion


Record review and interview, revealed that the facility failed to ensure that the attending physician was consulted when another physician ordered a patient restraint or seclusion in 5 of 5 (patient #18, 19, 20, 21, 24) records reviewed. This presents a risk that the physician who has overall responsibility and authority for the management and care of the patient may not be aware of the patient's condition to promote continuity of care and to ensure patient safety. This was not in accordance with facility policy. Cross refer: CFR 482.13(e)(7) Patient Rights: Restraint or Seclusion



Review of documentation and interview, revealed that the facility failed to conduct a face to face evaluation within an hour for patients that had been restrained or secluded. This presents a risk that a patient may not receive a prompt evaluation for a serious medical or psychological need that warranted the use of a restraint or seclusion. This was not in accordance with facility policy. Cross refer: CFR 482.13(e)(12) Patient Rights: Restraint or Seclusion

Based on observation, review of documentation, and interview, it was determined that the hospital failed to ensure that patient personal property was returned upon discharge.


Findings were:


Patient personal property was not returned upon discharge. During a tour of the medication room on the child/adolescent unit on the morning of 8/28/2018, an examination of the contents of a drawer revealed a blue plastic dental retainer case (containing a clear plastic type dental retainer) which had a label with the name of patient # 27. This plastic dental retainer case was found lying loose in the drawer. Staff member #42 confirmed that the name on the label was a former patient who had been discharged on 6-8-2018.


Review of hospital policy entitled: "Patient Property Management" with a review date of 4/20/2017 stated: "Proper labeling and storage of individual patient supplies and belongings are essential in providing quality patient care, maintaining a clean and safe environment, and preventing loss of property." The procedure section stated: "3. Every effort will be made to send valuable property home to the patient's family. Patients will be instructed that they are choosing to keep any valuable items at their own risk." Page two of the policy stated: "At the time of Discharge: All patient property is returned to the patient at discharge (unless restricted by physician order). He/she will sign the valuables release form demonstrating receipt of any submitted property." "Unit staff shall contact the patient / patient's family / guardian, to notify them of any items remaining at the hospital after discharge." "Any items left in the hospital by discharged patients shall be returned to the Property Room for safe storage and shall be disposed of according to hospital procedure."


Review of "Patient's Valuables/Clothing List" form for patient # 27 revealed the following comment: "Valuables retained by Patient: Please check appropriate box and indicate the quantity and brief description of each item retained by the patient:" In the area labeled "Other", someone had written the word "retainer" and "clothing (currently on patient)." The section immediately below was labeled: "Valuables retained by Hospital" in this area was the handwritten comment: "1 bag - food and drink" and also found was the comment: "no property" which appeared to have been lined through. The comment: "The undersigned hereby acknowledges receipt of all items and money (if applicable) listed above. The "Upon Discharge Only" section" contained signatures in the areas where the patient and a hospital patient registration representative had signed.


In an interview with staff member #42 on the morning of 8/28/2018 it was confirmed that patient # 27 did not receive all their personal belongings upon discharge as the dental retainer case (containing the clear plastic type dental retainer) was found still on the unit approximately 80 days after discharge from the hospital.

Based on observation, interview, and review of documentation, the facility failed to provide a safe setting for the psychiatric patients as ligature risks were observed and identified during the tour of unit 1C and the admissions lobby. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting. The facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring specified in accordance with facility policy; this presents a risk for harm to a patient or staff due to a patient not being monitored as ordered.


Findings included:


During a tour of the admissions unit in the admissions lobby at approximately 11 am on 8/28/18, there were 3 doors observed with a large overhead hinge on each door. These hinges present a ligature risk as the hinge could be used as an anchor point for hanging. There were a minimum of 2 patients present in the admissions lobby during the surveyor tour of the area. A psych tech was observed in the admissions unit lobby area. However, the psych tech was not present in the lobby at all times while the patients were in the lobby. In an interview with staff #4 during the tour of the admissions unit, staff #4 confirmed the large overhead hinges and their previous awareness of the ligature risks.


During a tour of the unit 1C, the exit and entrance door openers were observed to have ligature risks. The physical environment for patients at risk for suicide or other forms of self-harm or violent behaviors toward others, should be free of ligature risks.


In an interview during the tour of unit 1C on 8/27/18 at 2:45 pm accompanied by staff #11 and staff #13, staff # 13 RN said the doors are locked except exiting and entering the unit. The surveyor informed staff # 13 the doors should be equipped with anti-ligatures.


Facility document "UTHealth Harris County Psychiatric Center Patient Guide" provided to the survey team the morning of 8/28/18 in the facility conference room stated, in part, "3. You have the right to a clean and humane environment in which you are protected from harm ..."


In an interview at approximately 12:15 pm on 8/29/18 in the facility conference room, staff #1 and staff #8 stated that the overhead hinges in unit 1C had already been identified by the facility. Staff #1 and staff #8 stated that the facility procedure was that when patients were in the area with the overhead door hinges/ligature risks, staff members would accompany the patients. Staff #1 stated that was acceptable per the accrediting organization of the facility; staff #8 confirmed the statement by staff #1.


Continuous visual observation is an option for an interim patient safety measure while the ligature risks are being mitigated. However, there was no documented plan or other indication provided to the survey team that the facility intended to mitigate the ligature risks on unit 1C in a manner other than staff observation.


"Many hospital facilities management professionals manage and mitigate ligature risks on a daily basis. It is up to the facilities team-along with other departments and staff-to understand, identify, and correct physical environment fixtures and objects that may pose a ligature, or hanging, risk to behavioral health patients.
A complete risk assessment of the physical environment may be required which can include any area where the patient may be moved and treated...
Some examples of risks include ... door hinges and hardware ...
The smallest risks must be identified and eliminated ..."
Giovinazzo, G. (2018) Healthcare Facilities Today. Compliance 101: Mitigating ligature risks in behavioral health patient care environments. Retrieved 9/1/2018 from https://www.healthcarefacilitiestoday.com/posts/Compliance-101-Mitigating-ligature-risks-in-behavioral-health-patient-care-environments--17684


Facility policy, "Unit Rounds/Patient Surveillance" last reviewed 6/17 stated, in part, "Quality treatment is providing a safe environment and ensuring the safety of individual patients. Unit rounds provide a mechanism whereby patient safety can be monitored ...The duties of nursing staff assigned to conduct rounds for patients who are on precautions are as follows ...

Document the patient's behavior and location (utilizing the appropriate code(s) on the Precautions Checklist every 15 minutes ...The Charge Nurse is ultimately responsible for assuring that rounds are conducted correctly, completely and accurately."


Review of the electronic medical record for patient #20 the afternoon of 8/28/18 in the facility conference room revealed an incomplete Precautions Checklist. Patient #20 was admitted on 7/31/18. There was no documented evidence of an observation for patient #20 between 0200 and 0230 on 7/31/18. This was confirmed with staff #66 the afternoon of 8/28/18 in the facility conference room.

Based on a review of documentation, clinical records, and interview, the facility failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care for 4 out of 5 restraint/seclusion records reviewed. This was not in accordance with facility policy. The use of restraint or seclusion constitutes a change in a patient's plan of care.


Findings included:


Review of the Electronic Medical Record (EMR) for Patient #24 on the morning of 8/29/18 revealed that the patient was secluded 2 times, on 6/15/18 and on 6/18/18.


Review of the "Master Treatment Plan" for Patient #24 on the morning of 8/29/18 revealed no updated documentation of the patient's personal restraint and seclusion that occurred on 06/15/18 and 06/18/2018. The document noted it was last updated on "Jun-19-18 09:44."



Review of the Electronic Medical Record (EMR) for Patient #18 on the afternoon of 8/28/18 revealed that the patient was secluded on 8/9/18.


Review of the "Master Treatment Plan" for Patient #18 on the afternoon of 8/28/18 revealed no updated documentation of the patient's personal restraint and seclusion that occurred on 08/09/18. The document stated in part "electronic signature by the attending physician (Staff #62) (Signed Aug-13-18 08:06) Authored: Problems/Priorities/Weekly Review, Aggression Last Updated: Aug-15-18 15:21"



Review of the Electronic Medical Record (EMR) for Patient #19 on the morning of 8/29/18 revealed that the patient was restrained 2 times on 8/11/18 and was secluded 2 times, on 8/11/18 and on 8/12/18.


Review of the "Master Treatment Plan" for Patient #19 on the morning of 8/29/18 revealed no updated documentation of the patient's personal restraints and seclusions that occurred on 8/11/18 and 8/12/18. The document stated in part
"Authored: Aug-11-18 01:22" Last Updated: Aug-16-18 23:47"



Review of the Electronic Medical Record (EMR) for Patient #20 on the morning of 8/29/18 revealed that the patient was secluded 1 time on 8/1/18 and was restrained 1 time on 8/4/18.


Review of the "Master Treatment Plan" for Patient #20 on the morning of 8/29/18 revealed no updated documentation of the patient's personal restraint on 8/4/18 and seclusion on 8/1/18. The document stated in part "Authored: Jul-31-18 20:38" Last Updated: Aug-6-18 08:50". Updated treatment plan for Patient #20 stated in part, "Authored Aug-06-18 13:24." Last Updated "Aug-13-18 13:20" There was no documentation of the restraint or seclusion in the treatment plan.



Facility policy, "Master Treatment Planning/Review Process" last reviewed 8/18, provided to the survey team the afternoon of 8/27/18 stated, in part, "MTP [Master Treatment Plan] Review ...The MTP will also be updated to address the individual needs of the patient as his/her acuity or condition changes. Formal reviews will be started on a new document in the EMR for easy access and reference ...Additions, deletions or revisions of goals and interventions may be warranted. The patient/family participates in the process as appropriate."


Facility policy, "Seclusion/Restraint Process", last reviewed 07/2018, provided to the survey team on 8/27/18 stated, in part,

"I. Assessment and Monitoring Patients - Seclusion / Restraint

Staff will monitor and assess patients in seclusion/restraint to ensure physical safety ...

Re-evaluation

The team will discuss the use of seclusion/restraint for a patient in the treatment planning session to include, but not limited to, the following:

- Alternate strategies to assist the patient to control his/her behavior

- Implication for family/significant other(s) notification

- Relatedness to the individual's treatment plan ..."


The above findings were confirmed in an interview the morning of 8/29/18 with staff #7 in the facility conference room.

Based on record review and interview, the facility failed to ensure that the attending physician was consulted when another physician ordered a patient restraint or seclusion in 5 of 5 (patient #18, 19, 20, 21, 24) records reviewed. This presents a risk that the physician who has overall responsibility and authority for the management and care of the patient may not be aware of the patient's condition to promote continuity of care and to ensure patient safety. This was not in accordance with facility policy.


Findings included:


Facility policy, "Seclusion/Restraint Process", last reviewed 07/2018, provided to the survey team on 8/27/18 stated, in part,

"If the physician who ordered the intervention is not the treating physician, or the designee, the physician ordering the intervention shall consult with the treating physician, or physician designee, as soon as possible. The physician who ordered the intervention shall document the consultation in the individual's medical record.
Face-to-Face Evaluation ...

If the face-to-face evaluation is completed by a physician other than the treating physician, or the physician designee, he/she shall consult the treating physician / designee who is responsible for the individual's care as soon as possible after the completion of the one hour face-to-face evaluation, and document the consultation in the individual's medical record ..."


Review of the Electronic Medical Record (EMR) for Patient #24 on the morning of 8/29/18 revealed that the patient was secluded 2 times, on 6/15/18 and on 6/18/18. These 2 interventions were ordered by a different practitioner and not by the attending physician of record for Patient #24.


Review of the Electronic Medical Record (EMR) for Patient #18 on the afternoon of 8/28/18 revealed that the patient was secluded 1 time on 8/9/18. This intervention was ordered by a different practitioner and not by the attending physician of record for Patient #18.


Review of the Electronic Medical Record (EMR) for Patient #19 on the morning of 8/29/18 revealed that the patient was restrained 2 times on 8/11/18 and was secluded 2 times, on 8/11/18 and on 8/12/18. These 4 interventions were ordered by a different practitioner and not by the attending physician of record for Patient #19.


Review of the Electronic Medical Record (EMR) for Patient #20 on the morning of 8/29/18 revealed that the patient was secluded 1 time on 8/1/18 and was restrained 1 time on 8/4/18. These 2 interventions were ordered by a different practitioner and not by the attending physician of record for Patient #20.


Review of the Electronic Medical Record (EMR) for Patient #21 on the morning of 8/29/18 revealed that the patient was secluded 1 time on 7/26/18 and was secluded 1 time on 8/1/18. These 2 interventions were ordered by a different practitioner and not by the attending physician of record for Patient #21.


There was no documented evidence in the EMR that the attending physician of record was notified of the restraint or seclusion interventions follow up for each of the above 5 patients (patient #18, 19, 20, 21, 24). In an interview with staff #7 the morning of 8/29/18, staff #7 confirmed that there was no documentation that the attending physician of record or their designee was notified in accordance with facility policy.

Based on review of documentation and interview, the facility failed to conduct a face to face evaluation within an hour for patients that had been restrained or secluded. This presents a risk that a patient may not receive a prompt evaluation for a serious medical or psychological need that warranted the use of a restraint or seclusion. This was not in accordance with facility policy.


Findings included:


Facility policy, "Seclusion/Restraint Process", last reviewed 07/2018, provided to the survey team on 8/27/18 stated, in part,

"Face-to-Face Evaluation

A physician shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

The face-to-face evaluation required includes, but is not limited to, an assessment of the:

a) individual's immediate situation

b) individual's reaction to the restraint or seclusion

c) individual's medical and behavioral condition; and

d) need to continue or terminate the restraint or seclusion."


Medical records for patients with a restraint or seclusion intervention were reviewed the afternoon of 8/28/18 and the morning of 8/29/18 in the facility conference room.


Review of the Electronic Medical Record (EMR) for Patient #24 revealed a physician order for seclusion for Patient #24 dated "06/15/2018 at 13:11" stated in part "Seclusion-Adol/Child (under 9-17)-NTE 2 hours...From:12:43 Requested By physician (Staff 64)" Start date 15-Jun-2018 Starting at 12:43" A "Face to Face Evaluation" was documented with an electronic signature by "(Staff #64) (Signed Jun-15-18 16:53)" This "Face to Face Evaluation" was performed approximately four hours after the start of the seclusion and restraint.


Review of the Electronic Medical Record (EMR) for Patient #19 revealed a physician order for restraint for Patient #19 dated 08/11/2018 at 00:12 for a personal restraint. There was no "Face to Face Evaluation" observed or provided to the survey team for this intervention during the review of the medical record for Patient #19.
There was a physician order for restraint for Patient #19 dated 8/11/18 at 10:20 for personal restraint. There was no "Face to Face Evaluation" observed or provided to the survey team for this intervention during the review of the medical record for Patient #19.
There was a physician order for seclusion for Patient #19 dated 8/11/18 at 17:56. A "Face to Face Evaluation" was documented with electronic signature by the physician at 19:08, greater than an hour after the start of the intervention.


Review of the Electronic Medical Record (EMR) for Patient #20 revealed a physician order for restraint for Patient #20 dated 08/01/2018 at 03:10 for a personal restraint. There was no "Face to Face Evaluation" observed or provided to the survey team for this intervention during the review of the medical record for Patient #20.
There was a physician order for seclusion for Patient #20 dated 8/4/18 at 21:48. A "Face to Face Evaluation" was documented with electronic signature by the physician dated 8/5/18 at 02:55, greater than an hour after the start of the intervention.


Review of the Electronic Medical Record (EMR) for Patient #21 revealed a physician order for seclusion for Patient #21 dated 08/01/2018 at 17:01. A "Face to Face Evaluation" was documented with electronic signature by the physician dated 8/1/18 at 18:17, greater than an hour after the start of the intervention.


The above findings were confirmed in an interview the morning of 8/29/18 with staff #7 in the facility conference room.

Based on review of documentation and interviews, the facility medical staff failed to complete medical records within 30 days of discharge as there were 76 delinquent records not completed over 30 days of discharge in July 2018. The medical staff rules and regulations set a standard for the overall hospital monthly delinquency rate at 50% or below which was not in compliance with the regulatory requirement that medical records were completed within 30 days of discharge.


The findings were:


The facility report "Delinquent Medical Records Rate" for July 2018 was reviewed on the afternoon of 8/28/18 and listed 11 physicians with delinquent medical records over 30 days after discharge. There was a total of 76 delinquent records not completed within 30 days after patients were discharged. The total discharges for July 2018 were 695 and the actual delinquency rate was listed as 10.9%.


The Rules and Regulations of the Organized Medical Staff of the Harris County Psychiatric Center with an effective date 7/28/16 reflected in part "Section E. Delinquent Medical Records. A medical record is considered delinquent if not completed thirty days after discharge of a patient. Physicians are notified weekly by the Health Information Management Department of his/her delinquencies. The Executive Committee has set the standard for the overall-hospital's monthly delinquency rate at 50% or below."


In an interview with the medical staff coordinator, staff #61 on the afternoon of 8/28/18 in the administration office, staff #61 confirmed that there were 76 delinquent medical records over 30 days after discharge for July 2018.

Based on observation, review of documentation and interview, it was determined that the hospital failed to ensure that expired medications and supplies were removed and not available for use.


Findings were:


Expired medications and expired supplies were found and available for patient use. During a tour of the geriatric unit on the afternoon of 8/27/2018, an examination of the medication room revealed 10 bottles of Haloperidol Oral Solution USP, 10mg/5ml, the packaging label stated: "EX 06/2018." These medications were found in an unlocked cabinet inside the medication room.


Review of hospital policy entitled: "Medication Management-Selection and Storage", dated August 2018 stated under section A, Selection and Procurement that: "5. Stock will be rotated to prevent waste and the likelihood of dispensing and administering an expired drug."


Expired supplies were also found and available for patient use. During a tour of the geriatric unit on the afternoon of 8/27/2018, an inspection of the unit's examination room revealed expired supplies to include: 6 red top vacutainer specimen tubes, found in an unlocked wall cabinet, each of the tubes had an expiration date of 2018-07-31. In the same cabinet was a portable (plastic open topped container with handle containing specimen tubes, needles, etc..) blood draw kit, in this kit there were 5 red top specimen tubes with expiration dates listed as 2018-07-31. There was 1 gray top tube with an expiration date of 2018-06-30. In the same kit were a pair of bandage scissors which had what appeared to be rust spots on the cutting surfaces and the hinged area of the scissors was reddish and discolored in appearance. In an interview on the afternoon of 8/27/2018 with staff member #24, the surveyor was told that patients have their labs drawn in this room. Also found in the same cabinet was an opened package containing a Mckesson Skin Staple Remover with Gauze Pad. The gauze pad was missing and the package labeling stated: "Sterile Single Use"


In an interview with staff member #22 and #24 on the afternoon of 8/27/2018 the above findings were confirmed.

Based on observation, review of documentation, and interviews, the dietary director failed to ensure that food temperatures on the patient tray line were documented according to facility policy as there were 7 days from 7/1/18 to 8/26/18 where food temperatures were partially or completely not documented, and an additional 2 days where the temperature logs could not be found. This potentially could result in food being served to patients at temperatures outside of safe temperature ranges potentially increasing the risk of food borne illness.


The findings were:


During a tour of the dietary department on the afternoon of 8/27/18, the "Patient Tray Line Temperature Log" sheets for the period of time from 7/1/18 to 8/26/18 were reviewed with the following findings.

1. On 7/11/18, no tray line temperature was recorded for breakfast cold items.

2. On 7/13/18, no tray line temperature was recorded for dinner cold items.

3. On 7/18/18, no cook's temperature or tray line temperature were recorded for lunch hot items and no tray line temperature was recorded for lunch cold items.

4. On 7/20/18, no cook's temperature or tray line temperature were recorded for dinner hot and cold items.

5. On 7/23/18, no tray line temperature was recorded for breakfast cold items.

6. The Patient Tray Line Temperature Log sheets for 7/28/18 and 7/29/18 could not be found.

7. On 8/11/18 and 8/12/18, there were no tray line temperatures recorded for all breakfast, lunch and dinner items.


The facility policy entitled "Food Temperatures" #FS8.5 dated 4/18 reflected in part, "6. All food will be checked and documented for proper cooking temperature and before service for appropriate temperature. 7. These temperature logs will be maintained as part of HACCP and the Quality Control process."


In an interview with the food service manager, staff #53 on the afternoon of 8/27/18 in the dietary office, staff #53 acknowledged that the temperatures were not documented on the Patient Tray Line Temperature Log sheets as listed above and that the sheets for 7/28/18 and 7/29/18 could not be found.

Based on observation, review of documentation, and interview, the facility failed to maintain equipment to ensure an acceptable level of safety and quality as evidenced by a non-functional defibrillator found available for use in a patient care area. This potentially could have resulted in unsafe or ineffective medical equipment being used in patient care during an emergency. The facility also failed to maintain proper use of equipment as clinical staff stored their personal food in designated patient refrigerator.


The findings were:


During the tour of the Electroconvulsive Therapy (ECT) unit on 8/27/18 with the ECT Nurse Manager (Staff #16), it was observed:


- A Zoll 200 Biphasic defibrillator was found on top of the crash cart in the ECT unit. The surveyor noted that the defibrillator was plugged into a wall outlet, the defibrillator battery was attached to the defibrillator and a light on the defibrillator's face plate indicate that the battery was charging. The surveyor turned the function dial to the "Monitor" function and it was observed that the visual output of the defibrillator that would show the rhythm was completely blank. The surveyor turned the function dial to the "Defib" function and it was observed that the visual output of the defibrillator that would show the rhythm was completely blank. The surveyor turned the function dial to the "Pacer" function and it was observed that the visual output of the defibrillator that would show the rhythm was completely blank.


- The ECT Medical Director (Staff #20) arrived and the surveyor informed the medical director that the defibrillator was not properly functioning. The surveyor and medical director replaced the defibrillator battery with a spare battery and continue to troubleshoot the device for an additional 30 minutes without any success of making the monitor display any data. The defibrillator's warning alarm continued to make a sound even after the function dial was turned to the "Off" position. The alarm sound would only stop after pushing the "Alarm Suspend" button.


- A facility document titled, "HCPC ECT Environmental Round Checklist," indicate that a staff member initialed the box labelled, "Cardiac Monitor Working," for 8/27/18. Staff #16 verbalized that the ECT unit had "five patients this morning." Surveyor spoke with the Registered Nurse (Staff #17) that assisted with the ECT procedures via phone and informed the staff member that the defibrillator was not working properly. Staff #17 verbalized that they did not check the defibrillator prior to the ECT procedures that were performed today.


- The electrocardiogram test strip was still attached to the defibrillator and it indicated that the last 30 joule test charge was performed on "20 Jul 18."


- The surveyor found a small refrigerator adjacent to the ECT procedure area underneath the nurse's station. The surveyor asked the ECT staff, "what should be stored in this (patient) refrigerator?" A clinical staff stated, "Just bottled water for patients." The surveyor opened the refrigerator and found:

o Leftover food in Styrofoam container

o 16 ounce container of sour cream

o 10.9 ounce container of shrimp wonton ramen

o 20 ounce half-empty bottle of soda

o 20 ounce half-empty bottle of carbonated water

o 11 ounce protein shake

In an interview with Staff #16 and Staff #20 on the afternoon of 8/27/18, Staff #16 and Staff #20 acknowledged the findings above.



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Based on observation and interview, the facility failed to maintain the facility in a safe manner as there were areas in need of cleaning, excessive dust and peeling paint was observed on patient units, dead insects were observed, and other findings. In the admissions unit area, an external door had insufficient door seals or weather stripping, there were holes noted in sheetrock, and water damaged ceiling tiles. The facility failed to ensure that supplies were stored in a safe manner as there were contaminated boxes stored with patient supplies, and boxes stored that could block a fire sprinkler system. These findings present a risk to patient safety and quality.


Findings included:


During the facility tour on the afternoon of 08/27/18 accompanied by the Associate Director of Nurses, Staff #7, and a Licensed Professional Counselor, Staff #34, and the surveyor found excessive dust on horizontal seals of the large windows in the open patient areas on Units 1B, 2C, 2E, 3C, 3D, and 3E. In the seclusion room on unit 2C there was an approximate round 5-inch area where the paint had been peeled from the back wall of the room. There was also a tooth brush on the floor of this seclusion room. In the seclusion room on unit 2E there was peeling paint on the left lower wall.

The above findings were confirmed by Staff #34 during the tour on the afternoon of 8/27/18.


A tour was conducted of the Admissions Unit the morning of 8/28/18. The "Constable Entrance" external door had insufficient door seals or weather stripping, leaving a gap between the doors and the door frame with outside light visible seen from inside the building on the top, the left, and the right side of the door. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects, rodents, and other environmental contaminants such as dust and debris.


In the Admissions Lobby, there were 4 holes in the sheetrock where a hand sanitizer dispenser had been removed. This presents a risk for contamination, as the sheetrock was porous and could not be properly disinfected and provided an entry for dirt particles or pests.


There was a water damaged, stained ceiling tile in the Admissions Lobby; the presence of water damaged tiles present a potential for contamination from moisture and airborne bacterial particles.


The lack of door seals, holes in the sheetrock, and stained ceiling tile were confirmed by staff #4 during the tour the morning of 8/28/18.



During a tour of the geriatric unit on the afternoon of 8/27/2018 the following issues were observed:


In the unit exam room, the patient examination table which had a brown vinyl covering which was noted to have a circular hole (approximately the diameter of a number 2 pencil) in the vinyl located in the center area of the table and as a result the inner foam core of the cushion was exposed. In the male patient restroom (restroom number two), the movable curtain which provides the patient privacy if the patient is using the commode when the restroom door is opened was missing. No toilet paper was found in this restroom. The automatic faucet for the sink was able to be activated but did not turn off (note: faucet was running approximately a minute) and the faucet was spraying water which was observed to be dripping from the front edge of the sink onto the floor creating a wet surface which ultimately was a slip hazard. The sink in the patient nourishment area (located in the dayroom area) did not work. A ceiling tile near the handicap bathroom was noted to be stained/discolored.


In an interview with staff members #22 and #24 on the afternoon of 8/27/2018 the above findings were confirmed.


During a tour of the child/adolescent unit on the morning of 8/28/2018 the following issues were observed: the floor of the seclusion room was noted to be dirty in appearance, specifically there were 3-4 tangled strands of what appeared to be human hair and there was also what appeared to be the remains of dead insects on the floor. Additionally, a light greenish dried stain was observed on the floor and the overhead fluorescent light fixture was dirty in appearance. The fluorescent ceiling mounted light fixture in the laundry room was also dirty in appearance.


The top of the ice machine (in the patient nourishment area) was noted to be dusty. When the surveyor ran their hand across the top of the ice machine, visible floating pieces of dust were observed floating downward. In the dayroom area, it was observed that the three seat sofa had a hole in the vinyl covering (approximately the diameter of a number two pencil) on the top middle seat back rest area.


During a tour of the dual diagnosis unit on the afternoon of 8/28/2018 the following issues were observed: the top of the ice machine (in the patient nourishment area) was noted to be dusty. When the surveyor ran their hand across the top of the ice machine, visible floating dust pieces of dust were observed floating downward. In patient room # 76, the tan vinyl cover of the patient mattress was noted to cracking and worn on the side areas. In the medication room, one of the ceiling mounted fluorescent light tubes was not working.
In an interview with staff member #42 on the afternoon of 8/28/2018 the above findings were confirmed.


Review of hospital document entitled: "Housekeeping Duties HCPC" specified that nutrition centers were to be have a cleaning frequency of daily and times were to be throughout shift. The comments section stated: "All exterior surfaces, drawers, sink, microwave, ice machine, remove trash. Clean the inside of small patient refrigerator, microwave and ice machine."


Review of hospital document entitled: "Housekeeping Duties HCPC" specified that seclusion rooms were to be have a cleaning frequency of after each use, and times were to be throughout shift. The comments section stated: "Sweep, mop, deodorize, empty trash, clean counter areas, empty biohazard containers."


In first floor main storage area there were several unopened boxes of supplies in external shipping boxes which were stored above opened boxes of patient supplies. Storing patient use items in contact with a contaminated external shipping box/container, makes cross contamination likely.


"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust." (AAMI ST46-Section 5.2 Receiving items).


In an interview on 8/29/18 at 10:00 am with Director of Operations staff #8, he stated that the contaminated boxes should not be stored on the shelves over or with opened patient supplies, available for patient use.


On the second floor, room 2A16, housekeeping storage area had several boxes stored on the top shelves that were approximately 6 inches or less from the ceiling.


In an interview with Safety Manager staff #25, she stated that the storage supplies should be 18 inches or more from the ceiling for emergency purposes, as the supplies might block the sprinkler system in the event of a fire.


Record review at time of survey of facility document titled "Patient Care Safety Inspection Program & Non-direct Patient Care Safety Inspection Program" stated " ....Scenario 20; Materials are stored cleared of sprinkler heads (18 inches down and in diameter)".

Based on a review of facility documentation and an interview with the Chief Operation Officer (COO), the facility failed to have an agreement with an organ procurement organization (OPO) for organ donation of individuals whose death was imminent or who died in the hospital.


Findings were:


In an interview with staff #1 COO at the facility on 8/29/18 at 11:35 am, staff #1 said they are in the process of obtaining an agreement with an OPO.

Based on review of records and staff interview, the facility failed to ensure that the Seclusion/Restraint PI Monitor and Debriefing Questionnaire was completed in accordance with facility policy for 5 out of 5 patient records reviewed (Patients #18, 19, 20, 21 and 24). The form is to be completed after the intervention, however, documentation on the form was timed and dated before the intervention was discontinued. This was not in accordance with facility policy.


Findings included:


Facility policy, "Medical Record Documentation" last reviewed 9/1/2017, provided to the survey team on 8/27/18 stated, in part,

"A complete, legible medical record on every patient admitted to UTHCPC must be under the oversight of an attending physician."


Facility policy, "Seclusion/Restraint Process", last reviewed 07/2018, provided to the survey team on 8/27/18 stated, in part,

"II. Documentation for Patients in Seclusion / Restraint ...

4. The RN completes a Seclusion/Restraint Performance Improvement Monitor after each occurrence of seclusion / restraint ...

III. Discontinuation / Debriefing - Restraint / Seclusion ...

5. Debriefing with staff and the patient

Immediately following the event, the nurse responsible for the patient will conduct a short debriefing with involved staff to obtain all information for documentation , to insure that there have been no injuries, and to process the episode for possible improvement recommendations, etc."


Review of the Electronic Medical Record (EMR) for Patient #24 revealed, a physician order for seclusion for Patient #24 dated "06/15/2018 at 13:11" stated in part, "Seclusion-Adol/Child (under 9-17)-NTE 2 hours...From:12:43. The intervention was discontinued at 14:30.


Review of the document titled "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire" revealed, the boxes for "Seclusion and Personal Restraint" checked. This document stated in part, "NOTE TO BE COMPLETED BY RN AFTER EACH SECLUSION/RESTRAINT/PHYSICAL INTERVENTION." This document was dated "6/15/18" with a time of "12:45pm" and signed by the "RN Initiating Seclusion or Restraint." There was no documentation to indicate the form was completed after the intervention in accordance with instructions on the form and facility policy.


Review of the Electronic Medical Record (EMR) for Patient #18 revealed a physician order for seclusion for Patient #18 dated "08/09/18 at 02:58" stated in part "Seclusion-Child (under age 9)-NTE 1 hour...From:02:54 Requested By physician (Staff 63)"


Review of the document titled "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire" for Patient #18 revealed, the box for "Personal Restraint" checked. This document stated in part, "NOTE TO BE COMPLETED BY RN AFTER EACH SECLUSION/RESTRAINT/PHYSICAL INTERVENTION." This document was dated "8/9/18" with a time of "0240" and signed by a staff RN as the "RN Initiating Seclusion or Restraint." There was no documentation to indicate the form was completed after the intervention in accordance with instructions on the form and facility policy.


In an interview in the hospital conference room on the morning of 8/29/2018, the Associate Director of Nursing, Staff #7, was asked what the stated time of "0240" was in reference to on the "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire" for patient #18. Staff #7 stated, "That time was the time that staff first place their hands on the patient for the personal restraint." When Staff #7 was asked where was the time documented for the completion of the "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire," Staff #7 stated, "There is no time field on the form for that." Staff #7 stated, the nursing staff turn in these forms at the end of each shift for all patient personal restraints and seclusions.


Review of the Electronic Medical Record (EMR) for Patient #21 revealed, a physician order for seclusion for Patient #21 dated "08/01/18 at 17:01". The intervention was discontinued at 18:45.


Review of the document titled "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire" for Patient #21 revealed, the box for "Seclusion" and "Personal Restraint" checked. This document stated in part, "NOTE TO BE COMPLETED BY RN AFTER EACH SECLUSION/RESTRAINT/PHYSICAL INTERVENTION." This document was dated "8/1/18" with a time of "1730" and signed by a staff RN as the "RN Initiating Seclusion or Restraint." There was no documentation to indicate the form was completed after the intervention in accordance with instructions on the form and facility policy.


In addition, Patient #21 was secluded on 7/26/18 from 01:58 until 03:45. The "SECLUSION/RESTRAINT PI Monitor and Debriefing Questionnaire" for this intervention was documented just after the intervention was initiated at 02:00, which was well before the intervention was discontinued.


Other PI forms not documented as completed after a restraint or seclusion intervention include the following:

Patient #20, restrained on 8/1/18 from 03:10 to 03:15; PI form timed 03:10.

Patient #20, secluded on 8/4/18 from 21:47 - 22:10; PI form timed 21:47.

Patient #19, restrained on 8/11/18 from 00:12 - 00:15; PI form timed 00:12.

Patient #19, restrained 8/11/18 from 10:20 - 10:25; PI form timed 10:20.

Patient #19, secluded on 8/11/18 from 1754 - 1755; PI form timed 17:54.

Patient #19, secluded on 8/12/18 from 12:45 - 14:25; PI form timed 12:50.


The above findings were confirmed in an interview the morning of 8/29/18 with staff #7 in the facility conference room.