HospitalInspections.org

36293

Based on observation and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients admitted for acute inpatient psychiatric services due to being a danger to themselves and/or others. This deficient practice had the potential to affect 17 patients receiving care in the main hospital and 7 patients in the offsite campus.

Findings:

Observations beginning on 5/7/18 at 11:45 a.m. revealed the following:
a. Multiple ligature points on the patient beds in rooms a, b, c, d, e, f, g, h, j, k, l, and m. Each room had 2 patient beds for a total of 24 beds with multiple ligature points.
b. The clothing cabinet in room j was not secured to the wall and could tip over and fall on a patient.
c. Multiple ligature points (handles on the drawers) on the bedside cabinets for: 2 bedside cabinets in room g, 1 in e, 2 in f, 1 in h, 1 in k, 2 in d, 2 in a, and 2 in c for a total of 13 bedside cabinets with ligature points
d. Lock tumbler missing in the patient clothing cabinets in rooms a, c, d, f and j, which creates a ligature point through the hole in the cabinet door.
e. Phillips head screws noted in clothing cabinet and memo board in room b, which could be removed by the patients.

During an interview on 5/8/18 at 3:05 p.m., S1CEO and S2CNO acknowledged the multiple ligature risks on the beds, the ligature risks on the clothing cabinets and the ligature risks on the bedside cabinets were a safety risk. They continued to acknowledge patients could remove the Philip's head screws and the clothing cabinet that was not secured to the wall were safety risks.

On 05/07/18 at 12:15 p.m., observation revealed a bathroom located betwen the dining room and the open hallway with an entrance door on each side of the room had the following ligature risks: a long pull cord attached to the call bell located behine the toilet, grab bars located on the wall by the toilet and in the shower stall with openings between the bar and wall, the spigot on the shower faucet, an empty wire-style dispenser attached to the wall by the sink with holes, open gaps in the door hinges, linens and disposable gloves accessible in the cabinet underneath the counter by the sink and linen in a dirty linen cart by the shower. There was also a biohazard waste container with biohazard contents in it near the shower.
An interview at this time with S3ADON revealed ambulatory patients are allowed to use the bathroom and are able to lock themselves inside the room without supervision of staff. She confirmed the above findings as ligature risks.

On 05/08/18 at 7:45 a.m., observation of the offsite hospital revealed the following ligature risks in rooms n, o, p, q, r, s and t:
a. faucets located on the walls of the bathrooms in unused shower stalls with handles that could be used to tie a piece of material on and present a danger of hanging;
b. hooks on the railing in the bathrooms that projected out and could be used to tie a piece of material on and present a hanging risk;
c. open gaps in the hinges of the closet doors and bars for hanging clothes that did not break away with moderate pressure applied;
d. bedside tables with handles on the drawers that one could loop material through to present a hanging risk;
e. window handles that projected out and could be used to tie material to, presenting a hanging risk;
f. patient beds with multiple ligature points in the frames, headboards, footboards and rails, including side rails;
g. room s, bed a had the overbed light covering missing, exposing the flourescent glass light bulbs.
On 05/08/18 at 10:00 a.m., obseravtion and interview with S2CNO confirmed the above findings presented ligature risks to the patients.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This deficient practice is evidenced by failing to include diagnosis of Type II Diabetes for 3 patients (#1, #2, #10), and failing to include diagnoses of Suicidal ideations, hallucinations and depression for 1 (#4) of 10 patient records reviewed.

Findings:

Patient#1
Review of patient #1's medical record revealed she had been admitted on 05/04/18 with a diagnosis that included Type II Diabetes. Physician's orders dated 05/04/18 revealed accuchecks BID and Humulin R insulin sliding scale. Further review of the care plan revealed no goals or interventions for Diabetes documented.

Patient #2
Review of patient #2's medical record revealed he had been admitted on 04/24/18 with a diagnosis that included Type II Diabetes. Physician's orders dated 04/24/18 revealed accuchecks ac and QHS, Glipizide 5mg po QAM and Metformin 1000mg po BID. Further review of the care plan revealed no goals or interventions for Diabetes documented.

Patient #10
Review of patient # 10's medical record revealed he had been admitted on 05/02/18 with a diagnosis which included Type II Diabetes. Review of a physician's order for patient #10 revealed an order dated 5/4/18 for blood glucose monitoring every a.m. Review of patient #10's Master Treatment Plan revealed no problem and interventions had been identified for diabetes.

Patient #4
Review of patient # 4's medical record revealed she had been admitted on 05/04/18 with diagnoses which included suicidal ideations, audible hallucinations and depressive dementia. Review of a physician's order for patient #4 revealed an order for line of sight monitoring. Review of patient #4's Master Treatment Plan revealed no problem and interventions had been identified for suicidal ideations, audible hallucinations or depressive dementia.

Interview on 05/08/18 at 11:30 a.m. with S3ADON confirmed that patient #1, #2, and #10 care plans did not include goals and/or interventions for Type II Diabetes, and that the care plan for patient #4 did not address her suicidal ideations, audible hallucinations or depressive dementia.

Based on record review and interview, the hospital failed to ensure a medical history and physical examination was completed and placed in the patient's medical record within 24 hours after admission for 2 (#9, #10) of 10 sampled records reviewed.

Findings:

Patient #9
Review of Patient #9 medical record revealed he had been admitted on 04/13/18. Further review revealed the History and Physical had not been transcribed until 04/16/18.

Patient #10
Review of Patient #10's medical record revealed he had been admitted on 5/2/18 at 5:30 p.m. Further review revealed the History and Physical had not been transcribed until 5/4/18 at 7:04 a.m.

Interview on 05/09/18 at 1:30 p.m. with S3ADON confirmed that the History and Physical documentation was not on the medical records within 24 hours for patient #9 and patient #10.



30364

Based on record review and interview, the hospital failed to ensure hospital policies and procedures were developed and followed related to completion of medical records that were delinquent for greater than 30 days as evidenced by: 1) having 1 (#6 ) of 3 discharged records reviewed (#5, #6, #7) not completed within 30 days of discharge, and 2) having 39 of 50 records listed on the Delinquent Charts Report not completed within 30 days of discharge. Findings:

1. Review of patient # 6's medical record revealed the patient was discharged from the hospital on 2/13/18 and the Discharge Summary was not completed until 3/25/18 revealing the chart was not completed within 30 days of discharge.

During an interview on 5/8/18 at 3:05 p.m., S3ADON acknowledged patient #6's medical record was not completed within 30 days of discharge.

2. Review of the policy 705.1 Discharge Summary revealed in part ...The discharge summary shall be signed and entered into the patient's chart within 30 days of discharge. There was no documented procedure for followup with the physician for enforcement of the policy.

On 05/09/18 at 9:15 a.m., an interview with S10HIM revealed the incomplete records are pulled and left on a cart for the physicians to complete, but they did not have an ongoing process of monitoring the records for completion and follow-up with the physicians to ensure the timelines are met.

Review of the Delinquent Charts Report presented by S3ADON for patients discharged 03/01/18-04/04/18 revealed 17 records had been completed beyond 30 days after discharge and 22 records were currently delinquent over 30 days.

In an interview on 05/09/18 at 11:00 a.m. with S3ADON, she confirmed there were currently 22 delinquent medical records greater than 30 days after discharge. S3ADON was unaware if there was anyone following up with the incomplete records, and confirmed there was no policy in place to enforce completion of the medical records.

Based on review of contract services, list of hospital personnel, and interview, the hospital failed to ensure there was a full-time, part-time or consultant pharmacist responsible for supervising activities of the pharmacy services as evidenced by:
1) Failure to have documented evidence of a written agreement with a pharmacist.
2) Failure to identify the responsibilities of the pharmacist.

Findings:

Review of the list of Contracted Services revealed pharmacy services was to be provided by Contract A, however, in reviewing the current contract on file dated 06/01/16 there was no provision in the agreement naming a pharmacist director of pharmacy services.

Interview on 05/08/18 at 4:00 p.m. with S2CNO confirmed S6Pharmacist was the Director of Pharmacy services for the hospital.

Interview on 05/08/16 at 4:50 p.m. with S6Pharmacist revealed that she was not the Director of Pharmacy services for the hospital.

Interview on 05/09/18 at 9:00 a.m. with S1CEO confirmed there was no Director appointed over Pharmacy services.

Based upon review of Contract Services, the absence of Radiologic Services Policies and Procedures, Medical Staff Roster, and staff interviews, the hospital failed to meet the Condition of Participation for Radiology Services as evidenced by:

1. Failure to ensure a full-time, part-time, or consulting Radiologist provided supervision of the Radiology Services (see findings tag A-0546); and

2. Failure to develop policies and procedures related to ionizing radiological services to ensure the services were provided in a safe manner for patients and personnel (see findings tag A-0535)

Based upon review of Contract Services, the absence of hospital Policies and Procedures, and staff interviews, the hospital failed to develop policies and procedures related to radiology services to ensure ionizing radiological procedures were provided in a safe manner for patients and personnel.

Findings:

Review of Service Agreement dated March 10, 2015 revealed, in part, the following:
1.a. Hospital A shall make available to the Hospital (Facility) the following services for the Facility("Service(s)"), as described in more detail in this Agreement:
c. Radiology and Other Imaging Services- Hospital A shall provide, upon request by the Facility and to the extent of its then existing capabilities, the technical component of radiological and other diagnostic imaging services available at Hospital A as ordered by a member of the Facility's Medical Staff for a patient of the Facility. STAT and other diagnostic imaging services in the same manner that it provides to its patients in Hospital A's ICU.

During an interview on 5/7/18 at 2:50 p.m., S1CEO stated the hospital does not have policies for Radiologic Services.

During an interview on 5/7/18 at 2:50 p.m., S1CEO confirmed the hospital does not have policies for Radiologic Services.

During an interview on 5/9/18 at 12:30 p.m., S3ADON stated the hospital uses Radiology1 for the portable x-rays performed within the hospital and they send the patients to Hospital A for all other imaging and radiology studies.

Based upon review of Contract Services, Medical Staff Roster, the absence of Policies and Procedures, and staff interviews, the hospital failed to ensure a consulting radiologist supervised radiology services and interpreted radiological testing. This was evidenced by the failure to have a Radiologist appointed either to the Medical Staff or on contract to provide supervision of the radiological services.

Findings:

Review of the list of contracted services revealed Radiological Services were provided by contract; however, the contract failed to identify a Radiologist who was responsible for the service. Review of the Medical Staff Roster revealed a Radiologist was not on the Medical Staff.

During an interview on 5/7/18 at 2:50 p.m., S1CEO stated the hospital does not have policies for Radiologic Services.

During an interview on 5/7/18 at 2:50 p.m., S1CEO confirmed the hospital did not have a full-time, part-time, or consulting Radiologist on the Medical Staff.

During an interview on 5/9/18 at 12:30 p.m., S3ADON stated the hospital uses Radiology1 for the portable X-rays performed within the hospital and sends the patient's to Hospital A for all other imaging and radiology studies.

Based on record review and interview, the hospital failed to ensure that the person designated as the hospital's infection control officer was qualified through ongoing education, training and experience as evidenced by the infection control officer not having specialized training in infection control.

Findings:

The personnel record of the hospital's designated infection control officer, S4RN, was reviewed and failed to reveal any specialized training for infection control.

During an interview on 5/9/18 at 10:20 a.m., the hospital's infection control office, S4RN, stated she has not received any specialized training in infection control.

During an interview on 5/9/18 at 10:25 a.m., S2CNO stated S4RN is the hospital's Infection Control Officer.

36293

Based on observation and interview, the infection control officer failed to maintain the hospital's system for controlling infections as evidenced by failing to maintain a sanitary environment. Findings:

Observation on 5/7/18 at 11:45 a.m. revealed the mattress on the bed closest to the doorway in room m had a tear in it.

During an interview on 5/8/18 at 3:05 p.m., S1CEO and S2CNO acknowledged the torn mattress could not be sanitized and was an infection control issue.

Observation of the offsite campus on 5/08/18 at 7:45 a.m. revealed the following: patient rooms n, o, p, q, r, s, and t had tears in the vinyl cushions in the chairs; a gerichair located in the hallway outside room s had tears in both arms covered with a corban dressing, and the arms were broken and loosely hanging from the frame of the chair.
An interview with S2CNO on 5/08/18 at 10:00 a.m. confirmed the above findings were infection control issues.

Based upon record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Services as evidenced by:

1. Failure to ensure there were organized respiratory care services with appropriately trained and qualified staff to provide the scope and complexity of therapeutic respiratory services offered as defined by its policies. (See findings under tag A-1152)

2. Failure to ensure there was a director of respiratory care services who is a doctor of medicine or osteopathy with knowledge, experience and capabilities to supervise and administer the service properly. (See findings under tag A-1153)

3. Failure to ensure a respiratory therapist was available to provide respiratory care needs of the patients. (See findings under tag A-1154)

4. Failure to identify the qualifications, education and training of the personnel authorized to perform the respiratory treatments and identify the type of personnel qualified to provide direct supervision over respiratory care services. (See findings under tag A-1161)

Based on record review and interview, the hospital failed to ensure there were organized respiratory care services. This was evidenced by the hospital's failure to have appropriately trained and qualified staff to provide the scope and complexity of therapeutic respiratory services offered as defined by its policies. Findings:

Review of the hospital's organizational chart revealed Respiratory Services was not identified.
Review of the governing body meeting minutes revealed no evidence that a director of respiratory services was appointed.

Review of the hospital's policies and procedures revealed comprehensive Respiratory Services would be provided through effective communication between the nursing and respiratory care departments. Services included oxygen therapy, nebulizers, EKG's, ABG's, tracheostomy care, etc. The respiratory therapist would be notified of all respiratory therapy orders, would bring all necessary equipment and record the treatment. Respiratory therapy will perform all EKG's and ABG's, unless the RN is adequately trained and verified in arterial sticks.

On 05/08/18 at 3:00 p.m., an interview with S3ADON revealed the hospital did not have a respiratory therapy department and did not have a director of respiratory services. She stated that respiratory treatments and oxygen therapy were provided by the nursing staff. She further confirmed that if more complex respiratory services were ordered, the nurses would have to be trained to provide the service, and that they had no contracted therapist to provide the services or training. S3ADON confirmed that the hospital did not have appropriately trained and qualified personnel to provide the respiratory services as defined by the hospital's policies and procedures for respiratory services.

Based on record review and interview, the hospital failed to ensure there was a director of respiratory care services who is a doctor of medicine or osteopathy with knowledge, experience and capabilities to supervise and administer the service properly. Findings:

Review of the hospital's organizational chart revealed that the director of respiratory services was not addressed.
Review of the governing body meeting minutes revealed no documented evidence that a director of respiratory had been appointed.

On 05/08/18 at 3:00 p.m., an interview with S3ADON confirmed the hospital did not have a respiratory therapy department and the hospital did not have a director of respiratory services.

Based on record review and interview, the hospital failed to ensure a respiratory therapist was available to provide respiratory care needs of the patients as per the hospital's policy. Findings:

Review of the hospital's policies and procedures revealed comprehensive Respiratory Services would be provided through effective communication between the nursing and respiratory care departments. Services included oxygen therapy, nebulizers, EKG's, ABG's, tracheostomy care, etc. The respiratory therapist would be notified of all respiratory therapy orders, would bring all necessary equipment and record the treatment. Respiratory therapy will perform all EKG's and ABG's, unless the RN is adequately trained and verified in arterial sticks.

Review of the hospital's organizational chart revealed Respiratory Services was not identified.
Review of the list of contracted services and list of hospital personnel revealed a respiratory therapist was not identified.

Review of 2 (S3ADON, S7LPN) of 2 nursing personnel files failed to reveal documented evidence of competencies and training related to the provision of respiratory treatments.

On 05/08/18 at 3:00 p.m., and interview with S3ADON confirmed the hospital did not have a respiratory services department and did not have a contract with a respiratory therapist to provide for the respiratory care needs of the patients or to train the nursing staff to provide the services. She further confirmed that the nursing staff provided respiratory treatments as ordered.

Based on record review and interview, the hospital failed to 1) identify the qualifications, education and training of the personnel authorized to perform the respiratory treatments and 2) identify the type of personnel qualified to provide direct supervision over respiratory care services. Findings:

Review of the hospital's organizational chart revealed respiratory care services was not identified.
Review of the governing body meeting minutes revealed no director of respiratory services was appointed.
Review of the list of contracted services and list of hospital personnel revealed a respiratory therapist was not identified.
Review of the hospital's policies and procedures revealed the personnel qualified to provide direct supervision was not addressed.

Review of 2 (S3ADON, S7LPN) of 2 nursing personnel files failed to reveal documented evidence of competencies and training related to the provision of respiratory treatments.

On 05/08/18 at 3:00 p.m., an interview with S3ADON confirmed that the hospital did not have a respiratory department, did not have a director of respiratory care services, and did not have a contract with a respiratory therapist to provide respiratory treatments or train the nursing staff to provide respiratory treatments.

Based on observation, record review, and interview, the hospital failed to meet the Condition of Participation specified in the following:

1) 482.26 (Radiology Services)
A) Failure to ensure a full-time, part-time, or consulting Radiologist provided supervision of the Radiology Services. (see findings tag A-0546)
B) Failure to develop policies and procedures related to ionizing radiological services to ensure the services were provided in a safe manner for patients and personnel. (see findings tag A-0535)

2) (Respiratory Services)
A) Failure to ensure there were organized respiratory care services with appropriately trained and qualified staff to provide the scope and complexity of therapeutic respiratory services offered as defined by its policies. (See findings under tag A-1152)
B) Failure to ensure there was a director of respiratory care services who is a doctor of medicine or osteopathy with knowledge, experience and capabilities to supervise and administer the service properly. (See findings under tag A-1153)
C) Failure to ensure a respiratory therapist was available to provide respiratory care needs of the patients. (See findings under tag A-1154)
D) Failure to identify the qualifications, education and training of the personnel authorized to perform the respiratory treatments and identify the type of personnel qualified to provide direct supervision over respiratory care services. (See findings under tag A-1161)

Based on record review and interview, the social services records failed to include an initial assessment for 1 (#4) of 10 patients reviewed. Findings:

On 05/08/18 at 8:15 a.m., review of the record for patient #4 revealed she was admitted to the offsite campus on 05/04/18 at 1:00 p.m. Further review revealed no documented evidence that the Biopsychosocial Assessment had been completed. The LCSW was not available for interview.

An interview with S3ADON on 05/08/18 at 2:30 p.m., confirmed that the assessment should have been completed within 24 hours following admit.

30364


Based on record review and staff interview, the Hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 2 (#4, #10) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) sampled patients. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Patient #4
Review of Patient #4's medical record revealed she had been admitted on 5/4/18 at 1:00 p.m. Further review revealed the neurological-cranial nerve assessment on the admission history and physical did not address each cranial nerve, but was simply marked "intact."

Patient #10
Review of Patient #10's medical record revealed he had been admitted on 5/2/18 at 5:30 p.m .Further review revealed the neurological-cranial nerve assessment had not been completed on the admission history and physical.

On 05/08/18 at 3:30 p.m., an interview with S3ADON confirmed the assessment of the cranial nerves should include an individual assessment of each nerve and that this assessment was not completed on patients #4 and #10.