HospitalInspections.org

Based on document review, meeting minutes review, the Governing Board (GB) Bylaws review, and interview, the Hospitals Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained.

Findings include:

The Hospital's Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained.

Please refer to A-309.

Based on observation, document review, policy review and interview, the Hospital failed for 3 of 3 Units to protect and promote each patient's rights by providing care in a safe setting.

Findings include:

1. The Hospital failed for 3 of 3 Units (North, South and West) to provide care in a safe setting without ligature and self-harm risks when 1). 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were not secured and accessible by unattended psychiatric patients (ligature risk); 2). A metal radiator/base board heating cover (North Unit, sensory room) was observed to be bent and misshaped and with unsecured exposed sharp edges and accessible to unattended psychiatric patients (ability to harm self or others); and 3). 3 of 3 Nurses stations contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves and could be reached by a patient and/or accessible to a patient if no staff were present.

Refer to A-0144.

Based on policy review, document review, meeting minutes review, and interview, the hospital failed to ensure there was an effective, ongoing, hospital-wide quality assessment and performance improvement (QAPI) effort that was data-driven, that measured, analyzed, and tracked quality indicators and assessed processes of care, hospital service and operations and that all improvement actions were evaluated.

Findings include:

1. The Hospital failed to ensure opportunities were identified for improvement and changes that were measured, analyzed, and that tracked quality indicators and assessed processes of care, hospital service, and operations.

Please refer to A-0283.


2. The Hospital's Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained.

Please refer to A-309.

Based on observation, document review, policy review, and interview, the Hospital failed for 3 of 3 Units (North, South, and West) to provide care in a safe setting without ligature and self-harm risks when 1). 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were not secured and accessible by unattended psychiatric patients (ligature risk); 2). A metal radiator/base board heating cover (North Unit, sensory room) was observed to be bent and misshaped and with unsecured exposed sharp edges and accessible to unattended psychiatric patients (ability to harm self or others); and 3). Nursing staff was not present at all times for 1 of 3 Nurse's stations which contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves and could be reached by a patient, thereby failing to protect and promote each patient's rights by providing care in a safe setting.

Findings include:

Review of the Hospital's Sharps and Potentially Dangerous Items Policy, effective 2/15/19, indicated the following:

*To provide a safe environment for all patients, staff and visitors and to minimize access to items which have the potential for harm to self and others.

1). The Facility failed to ensure that 2 of 3 ice machines (West and South Units), located in the activity/kitchen area of the Units had electrical cords that were secured and not accessible by unattended psychiatric patients (ligature risk).

On 4/10/25 at 9:30 A.M., the surveyors observed the West Unit activity/dining area which was observed to have an ice machine located on a counter top in the area. The surveyor observed the power cord of the ice machine to ensure it was secured and did not pose a ligature risk, The power cord had not been secured and the surveyor was able to extend the power cord to a length of approximately 10 to 12 feet long. The unsecured power cord posed a ligature risk as it had not been secured and is accessible by unattended psychiatric patients.

On 4/10/25 at 9:45 A.M., the surveyors observed the South Unit activity/dining area which was observed to have an ice machine located on a counter top in the area. The surveyor observed the power cord of the ice machine to ensure it was secured and did not pose a ligature risk. The power cord had not been secured and the surveyor was able to extend the power cord to a length of approximately 10 to 12 feet long. The unsecured power cord posed a ligature risk as it had not been secured and is accessible by unattended psychiatric patients.

During an interview on 4/10/25 at 11:45 A.M., the Director of Plant Operations said the ice machines had been installed by an outside contractor (not an employee of the Facility). He further said he believed the cords had been secured and was not aware that patients had the ability by to extend the cord to a length that posed a ligature risk.

2). The Facility failed to ensure a metal radiator/base board heating cover (North Unit, sensory room) that was observed to be bent and misshaped did not have unsecured exposed sharp edges and not accessible to unattended psychiatric patients (ability to harm self or others).

On 4/7/25 at 11:30 A.M., during an environmental tour of the North Unit, the sensory room was observed to have a radiator cover, located on the baseboard of the wall. The radiator cover had an exposed, bent, sharp edge posing a risk for self-harm.

During an environmental tour with the Director of Plant Operations on 4/7/25 at 11:30 A.M., he visualized the exposed bent sharp edge on the radiator cover and acknowledged the safety hazard posing a risk for self-harm and the need to be secured.

During the environmental tour of the North unit on 4/7/25 at 11:45 A.M., the North Unit Charge Nurse was notified and observed the exposed bent sharp edge on the radiator cover. She said that she never noticed it before and acknowledged the safety hazard posing a risk for self-harm.

During an interview on 4/8/25 at 4:45 P.M., the CEO and the DON were notified of the metal radiator/base board heating cover (North Unit, sensory room) that was observed to be bent and misshaped with unsecured exposed sharp edges. Neither the CEO or the DON had been notified of the concern. The DON and the surveyor proceeded to the sensory room on the North Unit and she agreed that it was a hazard posing a risk for self-harm and it needed to be secured more effectively. The DON further stated that she would notify the the current employee in plant operations on duty and if the risk could not be taken care of immediately she would have the room locked and the patients would not be able to access the room until there was no longer a risk for self injury by a patient.

During an interview on 4/8/25 at 5:15 P.M., the DON said that the current plant operations employee could not address the risk correctly tonight, but she would have it taken care of in the morning. She said the room had been locked and no patient would have access.

3). The Hospital failed to ensure that nursing staff were present at all times on 1 of 3 Nurses stations (West Unit) which contained hazardous items that were close to the nursing station door (half door) such as BP cuffs, office supplies, pens and several boxes of latex gloves that could be reached by a patient and/or accessible to a patient.

During an observation on 4/8/25 at 11:20 A.M., the West Unit nurse's station was observed by the surveyor to be unattended by staff, for approximately 2 minutes. The nurse's station was observed to have items, including but not limited to, computer and phone cords, a free-standing vital sign machine with a corded blood pressure cuff (BP), scissors, medical plastic gloves, pens and pencils. These items could be considered hazardous, if left unattended.

During an interview on 4/10/25 at 9:30 A.M., the West Unit Charge Nurse said that although there is no policy, there should always be a staff member in the nurse's station.

During an interview on 4/10/2025 at 11:06 A.M., the DON said that there is no formal policy or procedure regarding that one staff member is to be present at the nurses station at all times. She further stated that she was aware of this practice by the Facility because she had been told of this practice when she was hired in 2016. The DON said that this practice is communicated to staff by word of mouth on orientation, but there is no formal policy addressing the practice. She said that staff are aware, she however could not provide a formal policy or any documentation that all staff were aware of this practice.


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Based on record review, policy review and interview, the Hospital failed to ensure opportunities were identified through their Quality Assessment and Performance Improvement program (QAPI) identified as the Process Improvement Program, for improvement and changes that were measured, analyzed, and that tracked quality indicators and assessed processes of care, hospital service, and operations.

Findings include:

Review of the facility policy titled, Process Improvement Program, last reviewed January 2023, indicated but was not limited to the following:

Purpose:
*The Process Improvement Program is designed to provide a coordinated objective and systematic approach to facility-wide quality assurance activities. The program is based upon and integrated and collaborative approach of measurement-based care to increase the probability of desired patient outcomes by assessing and improvement those governance, managerial, clinical and support processes that most affect patient outcomes.

Scope:
*The Program provides a system for the measurement and assessment of processes or outcomes related to patient care and organizational functions Data is collected and analyzed for improvement opportunities. Process improvement activities include utilization management, management of information, infection control, medication use, safety, risk management and quality control activities Quality assessment findings are communicated to the Medical staff and the Governing Board at least quarterly.

Organization:
*The Board has the ultimate responsibility and authority to establish, maintain and support an effective process improvement program. The Governing Board assures the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. It receives and acts upon recommendations regarding quality assessment and improvement activities.

*Management staff provide leadership for and actively participate in process improvement activities and establish criteria for assessing and improving Facility performance of both clinical and non-clinical processes and patient outcomes. They assure implementation of appropriate quality assessment and improvement activities and report the results to the Governing Board.

*The Quality Council is the steering committee for the Program (QAPI) and will design, maintain, support and document evidence of an ongoing program to systematically measure, assess, and improve patient outcomes and Facility performance.

*The Director of each department, service, and program is responsible for leading process improvement activities with in the individual department, service or program.

Review of the Quality Council (QAPI) meeting minutes indicated that a meeting was held on 7/23/2024, with no further QAPI/Quality Council meetings held by the Facility after 7/23/2024.

Review of the Department Directors meeting minutes, held on 10/24/2024, indicated the previous employee who was responsible for the Facility's PI/QAPI had resigned his position in August 2024. The meeting minutes/discussion indicated the previous employee resigned in August 2024, and that the Facility was looking to restructure the position and ensure continuity.

The meeting is structured so that each Department Director had an opportunity to bring forward concerns/issues/updates which are then open for discussion by the members. The meeting minutes indicated that Performance Improvement/HRO discussion did not take place due to the vacancy. There had been no action/follow-up documentation or discussion as to any/a remedial plan moving forward until the position had been filled.

During an interview on 4/8/2025 at 9 A.M., the Director of Quality and PI said that she was recently hired in March 2025. She confirmed that there had been no Quality Council meeting since the last one on 7/23/2024. She said that she in the process of resuming the Quality Council/QAPI process and has scheduled her first meeting 4/28/2025. She further said that an email will be sent requesting data from each department director as they are responsible for leading process improvement activities with in their individual department.

Review of the Governing Board (GB) meetings minutes, dated 12/3/2024 and 3/5/2025, indicated the GB did not address the PI position vacancy or indicate any/a remedial plan be put into effect until the position was filled, to ensure PI/QAPI would continue to function.


During an interview on 4/8/25 at 11:50 A.M., the surveyor met with the following GB members, CEO, Chief Financial Officer (CFO), Chief Medical Officer (CMO), Director of Nursing (DON), and the Manager of Administrative Services who said that the PI position remained vacant for 8 months, resulting in no Quality Council/QAPI meeting since 7/23/2024 (9 months) and with no remedial plan put into effect by the GB.

Based on document review, meeting minutes review, the Governing Board (GB) Bylaws review, and interview, the Hospital's Governing Body, which assumes full legal authority and responsibility for operations of the hospital, failed to ensure that an effective Quality Assessment and Performance Improvement Program (QAPI) was implemented and maintained.

Findings include:

Review of the amended and restated Governing Board Bylaws, reviewed and signed into effect on March 5, 2025, indicated but was not limited to the following:

*The Governing Board (GB) is ultimately accountable for the safety and quality of care, treatment and services provided by the Facility. The primary function of the Governing Board is to assure the Facility and its Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the Managing Member has delegated to the Governing Board the authority to receive and evaluate periodic reports from the Medical staff and its officers, to decisions regarding Medical Staff appointment and Clinical Privileges, to oversee Quality assessment and improvement,(QAPI) utilization review, risk management and similar matters regarding the provision of quality patient care at the facility and to establish policies regarding these matter.

*The Chief Executive Officer (CEO) is responsible for the overall management of the Facility. The CEO's duties include but are not limited to the following:

*Supporting the Facility's QAPI and ensuring as necessary that new, modified and appropriate care, treatment and services processes are in place.

Review of the Quality Council (QAPI) meeting minutes indicated that a meeting was held on 7/23/2025. There had been no other QAPI meeting minutes to review, as no further QAPI/Quality Council meetings had been held by the Facility after 7/23/2025.

Review of the Governing Board (GB) meetings minutes on 12/3/2024 and 3/5/2025 indicated the GB did not address the PI position vacancy or indicate any/a remedial plan be put into effect until the position was filled, to ensure PI/QAPI would continue to function.

During an interview on 4/8/25 at 11:50 A.M., the surveyor met with the following GB members, CEO, Chief Financial Officer (CFO), Chief Medical Officer (CMO), Director of Nursing (DON), and the Manager of Administrative Services who said that the PI position remained vacant for 8 months, resulting in no Quality Council/QAPI meeting since 7/23/2024 (9 months) and with no remedial plan put into effect by the GB. This resulted in the failure of the GB to implement and maintain the QAPI process/program as as required.

Based on clinical record review and interview, the Hospital failed to consistently provide entries into the medical record that were legible for 2 of 30 medical records reviewed (#2 and #27).

Findings include:

1. The surveyor reviewed the clinical record of Patient #2 on 4/7/25. The surveyor was unable to decipher the hand writing on the Psychiatry progress notes dated 3/22/25, 3/29/25, and 3/30/25. Specifically, clinical status since last visit, Diagnosis/Assessment/Impression, medication adjustments (if any), and signature.

The Provider was later identified by the Director of Medical Records as Physician #1.

2. The surveyor reviewed the closed clinical record of Patient #27 on 4/8/25. The surveyor was unable to decipher the hand writing on the Psychiatry progress note dated 1/27/25. Specifically, clinical status since last visit, diagnosis/Assessment/Impression, medication adjustments (if any), and signature.

The Provider was later identified by the Director of Medical Records as Physician #2.

During an interview on 4/9/25 at 2:30 P.M., the Director of Medical Records said this has been a long standing problem, and then she identified the signatures to the surveyor.

During an interview on 4/10/25 at 10:00 A.M., The Medical Director said he was aware of the illegible hand writing by some staff.

Based on observations and interview, the hospital failed to appropriately secure controlled substances in a medication room, within a nursing unit, in accordance with applicable standards of practice and/or state law.

Findings include:

The Mass.gov's guideline "General accountability guidelines for controlled substances in hospitals and clinics with pharmacies" under the section nursing units, states "All refrigerated controlled substances must be double locked and maintained in a dedicated medication refrigerator accessible only by licensed staff."

The surveyor conducted a tour of the South Unit on 4/7/25 at 1:15 P.M., and again on 04/08/25 at 11:00 A.M. The surveyor observed the refrigerated lorazepam (a schedule IV controlled substance medication) was located inside a lockbox that was attached to a refrigerator shelf in the refrigerator. However, the refrigerator shelf, along with the attached lockbox, was able to be fully removed from the refrigerator.

During an interview on 4/8/2025 at 4:45 P.M., the DON said she had not been made aware of the ativan(lorazepam) not being double locked. She said that all controlled substances need to be doubled locked.

Based on observation, documentation review, and interview, the hospital failed to ensure that the condition of the physical plant was maintained in a manner to ensure the safety and well being of patients on 3 of 3 Units.

Findings include:

South Unit

On 4/7/25 at 11:30 A.M., during an environmental tour of the South Unit, the dining room floor was observed to have large areas throughout the room where the top layer of laminate had been peeled off, leaving areas on the floor that were rough and uneven, causing concern for potential risk of safety for patients. Further observation of the dining room walls identified areas throughout the room where paint was chipped off and peeling.

During an observation of room 109, the surveyor identified a strip of flooring missing the top layer of laminate, exposing a rough area, causing concern for potential risk of safety for patients.

During an interview on 4/9/25 at 9:30 A.M., Registered Nurse #3 said the floor in the dining room had been replaced a few years back and said it had not worn well. She said the peeling areas of the floor really do need to be replaced because it could be a potential risk for patients.

On 4/10/2025 at 9:20 A.M. the following observation of the kitchen area/activities on the South Unit included the following:

The counter top/cabinet area had numerous areas where the laminate was no longer present.

The counter top/cabinet area had a drawer facing that was no longer in place, however the tracks remained in place.

The facing of the cabinets (not functional/not used) had screws/nails in place so that the cabinets/drawer could not be used that had begun to come loose.

During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed.

During an observation on 4/10/25 at 10:00 A.M., the sensory room on the South Unit was noted to have a 2 x 2 square foot area where the floor had been replaced. The uneven edges of the area caused a potential safety risk for patients.

West Unit

On 4/10/25 at 9:20 A.M., during an environmental tour of the West unit hallways, the surveyor observed multiple room identifier plaques that were missing letters, making it difficult to identify what the room is used for. Further observation of the West unit identified peeling paint on the medication room door, peeling paint on the doorframe of room 309, and peeling paint on the door where patient belongings were stored.

The kitchen area/activities room walls identified areas throughout the room where paint was chipped off and peeling. There was peeling paint on the windowsills.

On 4/10/2025 at 9:20 A.M. the following observation of the kitchen area/activities on the West Unit included the following:

The counter top/cabinet area had numerous areas where the laminate was no longer present revealing the wood.

The facing of the cabinets (not functional/not used) had screws/nails in place so that the cabinets/drawer could not be used that had begun to come loose.

During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed.

North Unit

On 4/8/2025 at 2:00 P.M. the following observation of the kitchen area/activities on the North Unit included the following:

The counter top/cabinet area had numerous areas where the white laminate was no longer present revealing the particle board.

The facing of the cabinets (not functional/not used) had screws in place that had begun to come loose.

The side of the counter top/cabinet area (that had the refrigerator located next to the area) was noted to be bulging, cracked, with multiple areas of particle board exposed and had a black discoloration to the particle board that was closest to the floor.

The cabinets were in disrepair with areas of particle board lifting from the cabinet frame.

The back splash was no longer attached to the wall, creating a large gap between the wall and the back splash.

The window sill next to the refrigerator no longer had any paint, and the plaster was exposed.

The walls throughout the room had areas of chipped paint and white spots where holes had been repaired and not repainted.

During an interview on 4/10/25 at 10:00 A.M., the Director of Plant Operation said that the area needed to be fixed.

Based on record review, observation, interview, and policy review, the hospital failed to ensure its staff employed effective methods for preventing and controlling the transmission of infections within the hospital. Specifically, the hospital failed to 1.) ensure 9 (Activity Therapist #1, Behavioral Health Associates [BHA] #3 and #4, Licensed Practical Nurse [LPN] #14, Registered Nurses [RN] #19 and #20, Social Worker [SW] #21, and Nurse Supervisors #22 and #23) of 10 direct patient care staff, from a total of 23 employee files reviewed, completed the required N95 (a respiratory protective device worn to filter airborne particles) Fit Testing (a test conducted to assess the fit of the respirator and the wearer's face); and 2.) ensure dietary staff wore appropriate facial hair restraints in a food service area.

Findings include:

1. Review of the facility's policy, entitled Employee Health Services, revised August 2024, indicated the following:

* Employees in a job role that requires use of a N95 or higher respirator will be Fit Tested when hired, and when there are facial changes that impact the fit of the respirator.

Review of 9 employee records indicated the required N95 Fit Testing had not been completed upon hire:
* Activity Therapist #1 with a date of hire (DOH) of 9/3/19.
* BHA #3 with a DOH of 2/3/25.
* BHA #4 with a DOH of 1/30/24.
* LPN #14 with DOH 5/31/2022.
* RN #19 with a DOH 5/21/2018.
* RN #20 with a DOH of 6/28/21.
* SW #21 with a DOH of 7/10/23.
* Nursing Supervisor #22 with a DOH of 8/23/22.
* Nursing Supervisor #23 with a DOH of 1/4/21.

During an interview on 4/10/24 at 11:25 A.M., the Director of Human Resources said that Fit Testing had not been completed for employees, as required by the facility's policy.

During an interview on 4/10/25 at 11:30 A.M., the Nurse Educator/Infection Control Nurse said she is responsible for the fit testing and completed training for Fit Testing in December 2024. She said the expectation of the facility is that all direct care staff be fit tested.


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2. The facility failed to ensure that 3 dietary staff wore appropriate beard covering in the kitchen during food preparation, meal service, and clean up.

Review of the 2022 FDA Food Code, indicated the following:
*2-402 Hair Restraints.
*2-402.11 Effectiveness.
*(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

During the initial tour of the kitchen on 4/7/25, with follow up visits including observation of food preparation, meal service, and meal delivery, the following was observed:

*Cook #1 was observed preparing the noon meal and although wearing a hairnet on his head, he was observed to have a full beard that was not covered with an appropriate hair restraint. Cook #1 was also observed without a beard restraint during the meal service, afternoon food prep, and clean up.

*Dietary staff (aide) #1 was observed to have a full beard that was not covered. At the time of the observation, Diet Aide #1 was delivering food carts, from the kitchen to the units, during the noon meal observation.

*Dietary staff (aide) #2 entered the kitchen during the noon meal observation to begin afternoon meal preparation. Diet Aide #2 was observed to have a beard that was not covered.

During an interview on 4/7/25 at 3:30 P.M., the Director of Food Service (DFS) said that since his arrival to the facility in November 2024, staff have never used beard restraints in the kitchen.

During a follow up interview on 4/8/25 at 8:30 A.M., The DFS said there is general information in the facility handbook for employees about appearance, but there was no policy to address dietary staff dress code, including hair and beard restraints.


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Based on observations, interviews and hospital policies, the Hospital failed to maintain a clean patient care environment that avoided sources and transmission of infection.

Findings include:

Review of the Hospital 2025 Infection Prevention and Control Program Plan, indicated the following:

*The purpose of the Infection Prevention and Control Program is to reduce transmission of pathogenic organisms for the safety of patients, staff, and visitors.

*Surveillance:
Infection prevention and control surveillance methodology is centered on the current risk assessment, the outcomes of the annual evaluation, and data collected from infection control environmental surveillance rounds, handwashing observations, outbreak investigations, and employee health data.

*Surveillance monitoring will focus on:
*Hand hygiene.
*Healthcare associated infections.
*Environmental cleaning and management of infectious waste.
*Equipment cleaning and supply management.
*Employee knowledge and infection prevention competency.
*Patient screening and implementation of transmission-based precaution.
*Employee TB screening and illness reporting.

Review of the Hospital Infection Control Surveillance Rounds, dated 3/13/25, indicated that multiple vents had dust accumulation and that a work order was placed.

On 4/10/25 at 10:45 A.M., the surveyor toured the inpatient floor with the Infection Control Nurse and observed the following:

*West Unit Group room:
-Three of 3 ceiling vents observed had a large buildup of dust, and spider webs, the metal heating element covers were rusty and dirty and in need of cleaning.
*North Unit Group room:
-Two of 3 ceiling vents observed with large buildup of dust.

On 4/10/25 at 10:00 A.M., during an environmental tour of the South Unit, the surveyor observed the unit dining room. There was dust and debris on the window treatments and the metal heating element covers were rusty and dirty and in need of cleaning.

During an interview on 4/10/25 at 10:55 A.M., the Infection Control Nurse said that air vents are part of her infection control surveillance. She said she does monthly environmental rounds with the Director of Plant Operation and Environmental Supervisor to check air vents. She said that during last months environmental rounds, multiple air vents were identified to have dust accumulation, but was not sure why they still have dust buildup.

During an interview on 4/10/25 at 11:45 A.M., the Director of Plant Operation said they clean the air vents when they replace the air filters monthly. He said the air vents that were identified by the surveyor were dusty along with the window treatments. He also said that the heating element covers were dirty and rusty and needed to be either cleaned or replaced.