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Based on staff interview and document review, the facility failed to ensure operational policies were consistent with medical staff bylaws.

Findings include:

Review of the medical staff bylaws that were approved on 7/25/13, indicated in Article XV1: Rules, Regulations, Policies and Procedures, Section 3-G within 24 hours of admission to psychiatric observation unit or inpatient unit, each patient shall have a thorough psychiatric evaluation.

The Assistant Psychiatric Medical Director stated on 3/12/14, the medical staff bylaws were current and had no revisions in section 3-G.

Review of the Interdisciplinary Evaluation agency wide policy and procedure with an effective date of 12/2013, regarding multi-disciplinary assessments were conducted to ensure individuals received quality care specific to the patient's needs; revealed in Section C - Psychiatric Evaluation, "...is completed by a medical staff member in the Electronic Medical Record and shall be: a..., b. Newly completed for all new IP (inpatient) admissions within 60 hours of admission to the IP."

The Assistant Psychiatric Medical Director and Administrator of the facility indicated during a governing body interview on 3/12/14, the medical staff bylaws and the policies and procedures of the facility should be consistent regarding time limits for conducting patient psychiatric evaluations.

Based on observation, interview, medical record review and document review, the governing body failed to ensure the policies were in place regarding handling emergency situations at the facility, and failed to ensure all staff were knowledgeable regarding the process of assessing individuals who presented to the facility after hours and required emergency care.

Findings include:

The facility's policy titled, "After Hours Response," revised date 3/6/14, documented:
- "III. Definitions: ...
- B. After hours - Normal business hours are Monday through Friday 8:00 AM - 5:00 PM. Any hours outside normal stated business hours and recognized Federal and State holidays....
- IV. Procedure: ...
- D. 1. In the event a Security Guard encounters an individual requesting services after normal business hours he/she shall inform the individual of normal business hours.
- 2. In the event the Security Guard encounters an individual on campus in medical distress after normal business hours he/she shall immediately contact 911.
- 3. In the event the Security Guard encounters an individual on campus requesting services or in medical distress he/shall log this individual in the daily log and submit to the Hospital Administrator the following business day. ...
- G. In the event an employee encounters an individual on the campus after normal scheduled hours requesting services he/she shall inform the individual of normal business hours. The employee shall document the encounter on the Rawson - Neal Building EMTALA (Emergency Treatment and Active Labor Act)
- H. In the event an employee encounters an individual on campus after normal business hours in medical distress he/she shall contact 911.
- 1. Contact the Admissions Office Nurse for assistance.
- 2. Stabilize the individual to the decree (sic) capable until 911 personnel arrive and take over treatment.
- 3. Complete and compile all COBRA (Consolidated Omnibus Reconciliation Act) forms and communicate to the receiving health care facility.
- 4. Document the information on the Rawson-Neal Building EMTALA log, and
- 5. Complete an agency incident report per policy OF-PI-04: Incident/Accident Reports - SNAMHS Internal.
- I. In the event an employee encounters an individual on campus after normal scheduled hours in behavioral medical distress prior to initiating a L2K (Legal 2000 - Nevada Process for Civil Commitment) he/she shall:
- 1. Contact the Admissions Office Nurse for assessment.
- a. The Admission Office nurse shall complete an assessment (the health review) and notify a physician if the nurse suspects a L2K is indicated.
- b. The physician shall determine the status of the individual's symptoms, determine if a L2K is indicated, coordinate to ensure the individual is stabilized to the level capable for transport and coordinate to insure the individual is appropriately transferred per the Agency COBRA policy.
- c. When a L2K is warranted, the Admissions Office Nurse shall document all activities necessary to treat, stabilize and transport the individual. Copies of these documents shall be given to the emergency transport personnel following Agency COBRA policy. ...
- 2. The medical exam area outside the POU (Psychiatric Observation Unit) shall be used to complete the assessment."

Review of the Security Guards logs dated 1/27/14 through 3/16/14, revealed the following notations:
- "1/31/14 at 2405 (12:05 AM) - I was told that the WF (white female) came back and was being vulgar. I informed her that she needs to leave and if she needs any help she can go to ER (Emergency Room) but she can not stay here."
- "1/31/14 at 3:30 AM - The WF was still harassing employees and an ambulance...She stated she wished she had something to fire at me....I called patrol supervisor and then police... 3:45 they spoke with her and got an ambulance and was taken at 3:20 AM."

An incident report was completed. There was no documentation noted on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person. There was no documented evidence the name of the WF was obtained or documented.

- 2/11/14 at 1814 (6:14 PM) - Gentleman arrived to see a doctor. I advised him that he would have to come back tomorrow and he advised me that he felt like he was a danger to himself. I asked if he would like me to call an ambulance and at 1824 (6:24 PM), the gentleman was taken to the hospital.

An incident report was completed. There was no documentation on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person.

- "2/17/14 at 0708 (7:08 AM) - Walkin subject let in by staff. House notified. Stood by with subject. Went back with subject to old clinic area per request. Subject transferred to ER."

The patient's name was entered on the facility's EMTALA log and an assessment was completed by the facility's staff. Transfer forms were completed.

- "2/17/14 at 1816 (6:16 PM) - Patient walked in to see a doctor and was advised of hospital hours and was asked if she felt like she was a threat to herself or others and she replied yes. Ambulance was called and at 1823 arrived and took her to the hospital."

An incident report was completed. There was no documentation on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person. There was no documented evidence the name of the patient was obtained or documented

-" 2/19/14 at 2400 (12:00 AM) - At 0100 (1:00 AM), (Patient Name) came to the hospital wanting to get some help. He stated that he felt like killing himself. He was informed of the policies and was informed to go to the emergency room of the nearest hospital to get help. He left the property at 0110 (1:10 AM)."

There was no evidence an incident report was completed. There was no documentation on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person. There was documentation that the Administrator was notified of the incident the following day.

- "2/21/14 at 2:55 (2:55 AM) - White male in the early forties came to the door intoxicated. He stated he was suicidal, and he didn't want to live. I called 911, and was asked to ask him if he has a previous mental diagnosis...At 2:40 (2:40 AM), ambulance came and one patrol care. He was taken at 2:55 (2:55 AM)."

An incident report was completed. There was no documentation on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person. There was no documented evidence the name of the person was obtained or documented

- "3/5/14 at 2013 (8:13 PM) - Patient wanted to see a doctor. I advised him to come back tomorrow or go to building one. He advised me that he felt suicidal and I asked if he wanted an ambulance, to which he said yes. I called for an ambulance and at 2050 (10:50 PM), the patient was taken to the hospital."

There was no documentation of an incident report. There was no documentation on the facility's EMTALA log. There was no documented evidence the Admissions Nurse or House Supervisor were notified to assess the person. There was no documented evidence the name of the person was obtained or documented

On 3/3/11/14 at 3:30 PM, the Security Guard (SG) verbalized when a person presented after hours at the door, or was found on the hospital property after hours, he would notify the person of the facility's hours, which were 8:00 AM - 5:00 PM Monday through Friday. If the person indicated they needed to see a physician or stated they were at risk to harm themselves or others, he would call 911. If he encountered a person in medical distress, he would call 911 and start CPR (Cardio - Pulmonary resuscitation) if applicable. He would remain with the person outside until emergency personnel responded.

The SG added he would document the incident on his security log and complete an incident report which was turned into the administrator's office and the security guard's office in the morning. He indicated he would not contact the House Supervisor to assess the patient prior to or after calling 911.

On 3/11/14 at 3:45 PM, the evening supervisor verbalized when a security guard encountered a person who presented after hours at the hospital, the security guard should call 911. It was not expected that the security guard would contact the admissions nurse or notify the house supervisor of these events.

The House Supervisor added, if she or a member of the staff encountered an individual who was in medical or psychiatric crisis, it was expected that the employee would remain with the person outside of the facility. The staff member would contact the admissions staff to perform an assessment, stabilize as appropriate and have the person transferred to an acute care facility for treatment. The physician who was at the facility until 10 PM, may also be called to do an assessment. There Nursing staff would complete an assessment form, and complete the transfer paperwork.

Patient #31

The security guard's log documented:
-- "2/23/14 1820 (6:20 PM) - Contacted house supervisor about person in crisis. (Patient #31). They were transported to (Hospital Name) by AMR (American Medical Response Ambulance) at 2029 (8:20 PM)."

Patient #31's progress notes dated 2/23/14 at 2045 (8:45 PM), documented the patient approached the security guard and was seeking hospitalization. The patient was assessed by the Admissions Nurse (Employee #9). Based on this assessment, the patient was made a L2K (Legal 2000 (State of Nevada's involuntary civil commitment process)) and transferred to the acute care facility for medical clearance and further treatment.

On 3/11/14 at 4:00 PM, the Psychiatric Nurse II (PNII) from the Admission office (Employee #9) was interviewed. The PNII verbalized she was notified of Patient #31, and went to assess the patient. The PNII verbalized she remained with Patient #31 outside of the building. The employee called the On-Call physician. It was determined the patient needed additional treatment. The PNII called 911, and completed the L2K paperwork. The PNII called the receiving hospital and gave report.

The PNII indicated when patients present after hours and need further treatment, the staff remain with them outside the facility. The patient was not brought into the building for the evaluation.

On 3/12/14 at 2:30 PM, the physician (Employee #11) was interviewed. The physician verbalized he received the call regarding Patient #31 and discussed the situation over the phone with PNII, since he was not present in the building at the time the patient presented. He did not do a face to face assessment of Patient #31. Based on the telephone conversation with the PNII, he decided that the patient should be a L2K and transferred to an acute care facility. The physician completed the progress note and signed the transfer form, after Patient #31 was transferred.

In summary, the facility failed to ensure all staff were knowledgeable regarding the process of assessing individuals who presented to the facility after hours and required emergency care. Failed to ensure staff notified appropriate resources in the facility including the House Supervisor and Admissions nurse. Failed to ensure a patient who needed an assessment was allowed into the appropriate area of the facility for the assessment.

Based on observation, the facility's contracted dietary staff failed to maintain a sanitary environment, observe good food protection practices, and maintain proper clearances for electrical panel access.

Findings include:

Observations made early afternoon on 03/10/14, in the dietary building, revealed the following:

1) The microwave's food contact surfaces (interior sides, interior platform, interior top, and interior door) had dried, encrusted food particles adhering to them.

2) Both of the large floor mixers' splash areas (food contact surfaces) were found unclean with dried food adhering to them.

3) The facility's walk-in refrigerator's internal thermometer was not positioned in the warmest part of the unit (near the door), but was positioned near the freezer door (approximately 6 feet away from the exterior walk-in door.

4) The facility's janitorial closet was equipped with a mop sink and also housed the fire alarm panel and three electrical panels. The room was approximately 12 feet by 6 feet. The dietary staff placed a storage table, cleaning chemicals, mop bucket, and other supplies within the room. These items were found stored in front of the electrical panels to where there was not three feet clearance in front of each of the electrical panels (for access).

Based on observation, interview and document review, the facility's maintenance staff failed to maintain the dietary building's infrastructure in a safe and sanitary environment

Findings include:

Observations made early afternoon on 03/10/14, in the dietary building, revealed the following:

1) The ceiling above and near the dish washing machine was not being maintained as described below:

a) Near the dish washing machine's dirty side exhaust, there was a missing support bracket for the ceiling tile. The missing bracket left a half inch by approximately 12 inch opening exposing the interstitial space above the ceiling to the dish cleaning area below.
b) The ceiling tile above and west of the dish washing machine were found unclean, had aged stains and were damaged.


2) The facility failed to adequately protect the potable water supply. The facility had three backflow devices within the building; one for the dietary kitchen hood cleaning system, one for the east dish room wall's hose reel/spray hose, and one for the west dish room wall's missing hose reel/spray hose. The backflow device for the hood cleaning system was an reduce pressure principle assembly and the two reel hose backflow devices were pressure vacuum breakers, and all devices are required to be tested upon installation and annually thereafter by a certified backflow tester.

a) The facility did not have any evidence that the east dish room wall's hose reel/spray hose backflow device had been certified tested.
b) The facility did have evidence that the west dish room wall's missing hose reel/spray hose backflow device had been currently tested. The device had a certified tester tag indicating that it was last tested in 2011.


3) The facility had non food grade caulking installed between and along the length of the dish tray line and the adjacent (east) wall.


The Acting Maintenance Director (AMD) provided forms called the,"Monthly Environmental and Safety Report, Attachment A," for review. These forms were dated January 2014 and February 2014, with the facility identifier of OF-EC-04. The AMD indicated that his department utilizes this document when conducting their monthly rounds/activities and for reporting purposes. Included in the form was a section labeled, "Buildings and Grounds Condition," and this section had seven subsections. One of the subsections was listed as, "All ceilings, doors, walls, glass, etc. in good repaired?"; and it was marked "Yes" as being inspected for both months.

The facility's,"Monthly Environmental and Safety Report, Attachment A," did not have a category for domestic water protection (to include backflow testing/maintenance and water temperature testing).

Based on observation, the facility failed to ensure two storage rooms were maintained in a clean and safe manner.

Findings include:

Observation of the storage room on Unit D utilized for storage of snack foods and beverages revealed on 3/10/14, the storage shelves were constructed in a manner that did not provide a minimum of 6 inches of clear space for cleaning beneath the shelf. A staff member's personal cup for beverages was left in the storage room.

Observation of storage room #F113 utilized for storage of paper/plastic supplies for medical purposes revealed on 3/11/14, a hole in the wall behind the door, storage shelves constructed in a manner that did not allow at minimum of 6 inches between the floor and bottom shelf for cleaning. Dust and debris was scattered across the floor in the storage room and the paint was chipped under the light switch.


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