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Based on a tour of the facility's inpatient psychiatric units, interviews with facility personnel and review of facility documentation, the hospital's governing body failed to ensure that environmental hazards, posing a threat to the safety of psychiatric patients, were acted upon for remediation. The findings include:

During a tour of the inpatient psychiatric unit and behavioral health unit of the emergency department on 8/9/10 multiple environmental hazards, posing a threat to the safety of psychiatric patients, were observed. Although a review of the facility's environmental risk assessment of the same psychiatric units dated 2/5/10 identified many of the same hazards, a review of the facility's Safety Committee Meeting Minutes dating to 2008 and interviews with facility staff (facility's engineer and maintenance personnel and quality/risk personnel), failed to identify that the hazards were reported or acted upon by hospital administration. (See A 0144; A0701)

Based on observations, interviews with staff, and review of policies for 7 patients (Patients #36, #38, #39, #40, #60, #61, and #62) who were receiving care in the main emergency department (ED), the hospital failed to ensure that each patient received care in a private and dignified manner. The findings include:

a. Patient #36 was admitted to the ED on 9/8/10 at 7:26 AM following a motor vehicle accident. The patient was observed on a stretcher in the hallway with all wrists and ankles restrained to the stretcher. The patient was struggling against the restraints and attempting to get off the stretcher. Patient #36 was not afforded privacy during this restraint episode that was deemed to be a necessary treatment. Interview with RN #9 at 9:50 AM identified that he/she placed Patient #36 in the hallway so he/she could keep an eye on the patient. Upon surveyor inquiry, the patient was moved to an empty patient care area with a sitter for safety.

b. A tour of the ED was conducted with the Quality Manager and Nurse Manager on 9/8/10 at 9:30 AM. Patients #36, #38, #39, and #40 were observed to have 11 by 14 inch yellow signs hanging on their stretchers that read " CAUTION. " Staff identified that the caution signs were meant to convey to other staff that the patient in the stretcher might be a fall risk. The hospital failed to provide a dignified atmosphere for the patients when the patient ' s were labeled with caution signs.

c. During the tour of the ED with the Quality Manager and Nurse Manager on 9/8/10 at 10:10 AM, a video screen was observed hanging from the ceiling at one corner of the staff work desk. The monitor depicted live video of patients #39, #40, #60, #61, and #62 laying in their beds and/or moving about their rooms. This video screen could be viewed from two main hallways used by patients, visitors, and non-clinical staff. The hospital failed to ensure that live video footage of patients were viewed in a private and dignified manner.

Based on a tour of the hospital, the facility failed to ensure that the Behavioral Health Unit was designed and maintained in such a manner as to promote the safety and well being of patients. On 08/09/10 at 08:30 AM, during a tour of the Behavioral Health Unit, while accompanied by the Behavioral Health Unit Director and the Interim Director of Engineering the following was observed:

1. That the resident rooms within the Behavioral Health Unit (Pond 4) had non-tamper proof screws and fasteners, curtains that had washers/weights within them, shower curtains & rod assemblies that do not break away, anchor point-free toilet paper dispensers, grab rails, faucet and shower controls, non-institutional style sprinkler heads, door handles, under sink piping and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.

2. That the behavioral rooms within the Emergency Department had non-tamper proof screws and fasteners, non-institutional style sprinkler heads, open ceiling/wall HVAC registers & grilles, door handles, and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.

3. That the bathroom within the Emergency Department that is designated for use by behavioral patients had non-tamper proof screws and fasteners, non-institutional style sprinkler heads, and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.


A list of capitol approved items for the behavioral health unit identified costs for remediation of fixtures, plumbing, curtains (cubical and shower), toilet valves, door locks, grab bars shelves, toilet paper holders and soap dishes, however the list failed to identify a time line for implementing the approved expenditures.

Based on clinical record review and facility documentation, the facility failed to ensure that restraints applied for one patient with violent behaviors were released at the earliest possible time. The findings include:

Patient # 44, a child less than nine years of age, was admitted to the Emergency Department (ED) on 8/5/10 with a chief complaint of emotional disturbance. The patient was evaluated by the psychiatric crisis team and was held in the emergency department through 8/10/10 pending disposition to a specialized inpatient unit. Review of ED documentation including the Violent Patient Monitoring and Intervention Record identified that the patient was placed in two point restraints on 8/6/10 at 12:10 a.m. through 4:10 a.m. Nursing documentation (8/5/10 11:39 p.m.) identified that the patient was " sound asleep at shift change .... " Documentation dated 8/6/10 at 4:24 a.m. noted that the patient had slept through the shift and remained in two point restraints (total time in restraints greater than 4 hours). Facility policy regarding restraint and seclusion directs that release of violent patients will occur when the behavior that necessitated the restraint has ceased.





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Based on clinical record review, interviews with staff, and review of policies for 1 patient (Patient #63) who was threatening others with physical harm, the hospital failed to identify the situation as a criminal activity and place the perpetrator in the custody of local law enforcement when a Security Officer dispensed OC foam to the patient ' s face to gain control of the patient. The findings include:

a. Patient #63 was admitted on 8/16/10 with diagnoses that included bipolar disorder with manic phases, borderline personality, and probable schizoaffective disorder. Between 8/16/10 and 8/27/10, the patient experienced multiple assaultive and destructive out of control behaviors requiring restraint and seclusion episodes and had commitment papers filed with the Probate Court. On 8/25/10 at 8:58 AM, Patient #63 was in his/her bedroom screaming and kicking and picked up a chair to throw at any staff member who entered the room. Three security officers were called to the floor and attempted to deescalate the patient without success. Security Officer #1 directed the patient to put the chair down, the patient raised the chair in a threatening manner, and the Officer discharged OC foam (pepper spray) towards Patient #63. The patient continued to raise the chair and the officer discharged a second dose of OC foam. The patient put the chair down, medical treatment was provided to relieve the effects of the OC foam, and the patient was placed in restraints.

Although the hospital had a policy directing the use of the OC foam, the policy did not reflect State and/or Federal guidelines in the use of OC foam, in that if the OC foam was used by security staff to protect patients or staff from harm, the situation would be handled as a criminal activity and the perpetrator would be placed in the custody of local law enforcement

Based on clinical record review, facility documentation and staff interview, the facility failed to ensure that restraints utilized for one patient with violent behaviors were implemented in accordance with a modification to the patient ' s plan of care. The findings include:

Patient # 44, a child less than nine years of age, was admitted to the Emergency Department (ED) on 8/5/10 with a chief complaint of emotional disturbance. The patient was evaluated by the psychiatric crisis team and was held in the emergency department through 8/10/10 pending disposition to a specialized inpatient unit. Review of ED documentation including " Violent Patient Restraint & Seclusion Assessment & Order Sheet " ; " Violent Patient Monitoring And Intervention Record " ; " Close Observation Flow Sheet " ; and nursing progress notes identified that the patient was restrained in four point and/or two point restraints on multiple occasions including for a period of time on 8/5/10 from 12:10 p.m. through 8:30 p.m. (greater than 8 hours) and on 8/6/10 from 12:10 a.m. through 4:10 a.m. ( 4 hours). Additional periods of physical restraint were documented on 8/8/10, 8/9/10 and 8/10/10. Review of the patient ' s Behavioral Health Patient Care Plan (Emergency Department) failed to identify the patient ' s repeated need for restraints. Although the Patient Care Plan identified the need for structured activities for pediatric patients, the care plan and/or the Structured Activity and ADL ' s Flowsheet failed to identify any plan and/or attempt at diversionary activities as part of an approach to limit the need of restraints. Upon interview on 9/15/10 at 2:30 p.m., the Director of the ED Crisis Unit stated that activities were attempted with the patient, however, did not sustain her attention. The ED Crisis Unit Director also stated that communication between staff consisted of ongoing conversations between nursing and the crisis Director and snacks were utilized as part of a reward system to redirect the patient. Although progress notes dated 8/10/10 identified an instance of water play provided to the patient which provided a calming effect for the patient, neither this activity nor other approaches utilized with the patient were identified on the patient ' s care plan or the patient ' s Structured Activity and ADL ' s Flow sheet.

Based on clinical record review, facility documentation and staff interview, the facility failed to ensure that a physician order for each instance of restraint was obtained for one patient with violent behaviors. The findings include:

Patient #44, a child less than nine years of age, was admitted to the Emergency Department (ED) on 8/5/10 with a chief complaint of emotional disturbance. The patient was evaluated by the psychiatric crisis team and was held in the emergency department through 8/10/10 pending disposition to a specialized inpatient unit. Review of ED documentation including " Violent Patient Restraint & Seclusion Assessment & Order Sheet " ; " Violent Patient Monitoring And Intervention Record " ; " Close Observation Flow Sheet " ; and nursing progress notes identified that the patient was restrained in four point and/or two point restraints on multiple occasions including for a period of time on 8/5/10 from 12:10 p.m. through 8:30 p.m. (greater than 8 hours) and on 8/6/10 from 12:10 a.m. through 4:10 a.m. ( 4 hours). Additional periods of physical restraint were documented on 8/7/10, 8/8/10, 8/9/10 and 8/10/10. Review of physician orders for restraints identified that orders were lacking for each initiation of restraints on 8/6/10, 8/7/10, 8/8/10 and 8/9/10. Numerous documented instances of physical restraint, as noted on undated monitoring sheets, lacked corresponding physician orders for restraint. In addition, physician orders for restraints initiated on 8/5/10 were unsigned and Close Observation Flow Sheets of 8/7/10 identified that the patient was in bilateral wrist restraints from 12:45 to 2:15 p.m. without corresponding documentation of physician orders. Facility policy regarding physical restraints directs that a new order is required prior to reapplying restraints that have been discontinued. Upon interview on 9/15/10 at 2:30 p.m., the Director of the ED Crisis Unit stated that the patient was in and out of restraints frequently and did not know if the physician was contacted each and every time.

Based on clinical record review, facility documentation and staff interviews, the facility failed to ensure that the orders for restraints for a violent patient under 9 years of age were renewed every hour (up to a total of 24 hours). The findings include:

Patient #44, a child less than nine years of age, was admitted to the Emergency Department (ED) on 8/5/10 with a chief complaint of emotional disturbance. The patient was evaluated by the psychiatric crisis team and was held in the emergency department through 8/10/10 pending disposition to a specialized inpatient unit. Review of ED documentation including " Violent Patient Restraint & Seclusion Assessment & Order Sheet " ; " Violent Patient Monitoring And Intervention Record " ; " Close Observation Flow Sheet " ; and nursing progress notes identified that the patient was restrained in four point and/or two point restraints on multiple occasions including for a period of time on 8/5/10 from 12:10 p.m. through 8:30 p.m. (greater than 8 hours) and on 8/6/10 from 12:10 a.m. through 4:10 a.m. ( 4 hours). Additional periods of physical restraint were documented on 8/7/10, 8/8/10, 8/9/10 and 8/10/10. Review of physician orders for restraints identified that orders were lacking for each initiation of restraints on 8/6/10, 8/7/10, 8/8/10 and 8/9/10. Documentation was lacking to reflect that renewal of orders for restraints were obtained when time frames for the restraints had lapsed on 8/5/10 and 8/6/10. Review of facility policy regarding restraints directs that when restraints are initiated by an RN, the Health Professional Affiliate (HPA) must be consulted about the patient ' s care and a restraint order is written on the restraint order form. Restraints are limited to one hour for patients under nine years of age. If the time frames are exceeded a new order is obtained.

Based on clinical record review, facility policies and interviews with staff for one patient restrained in the Emergency Department, the facility failed to ensure that consultation by the registered nurse with the licensed independent providers and/or assessment by a licensed independent provider was completed when restraints were implemented for a violent patient.
The findings include:

Patient # 44, a child less than nine years of age, was admitted to the Emergency Department (ED) on 8/5/10 with a chief complaint of emotional disturbance. The patient was evaluated by the psychiatric crisis team and was held in the emergency department through 8/10/10 pending disposition to a specialized inpatient unit. Review of ED documentation including " Violent Patient Restraint & Seclusion Assessment & Order Sheet " ; " Violent Patient Monitoring And Intervention Record " ; " Close Observation Flow Sheet " ; and nursing progress notes identified that the patient was restrained in four point and/or two point restraints on multiple occasions between 8/5/10 and 8/10/10. Review of physician documentation and/or progress notes failed to identify that the patient was evaluated by an HPA within two hours of the initiation of physical restraints in accordance with facility policy. Additionally, Close Observation Flow Sheets of 8/7/10 identified that the patient was in bilateral wrist restraints from 12:45 to 2:15 p.m. without corresponding documentation of an RN or LIP assessment and/or monitoring sheets. Review of the psychiatrist progress notes throughout the patient ' s ED stay identified that the patient was seen one time per day by the psychiatrist who noted only retrospectively that the patient required restraints on 8/5/10, 8/9/ and 8/10 and failed to specifically address the patient ' s need for restraints in progress notes dated 8/6, 8/7, and 8/8/10. Facility restraint policy directs that the HPA must conduct an in-person evaluation within two hours of the initiation of restraints for patients 17 years of age and younger. Upon interview on 9/15/10 at 2:30 p.m., the Director of the ED Crisis Unit stated that the patient was in and out of restraints frequently and did not know if the physician was contacted each and every time.

Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #64), the facility failed to ensure that the medical management of the patient was completed in a timely manner.

The findings include:


Patient #64 was born at the hospital on 3/23/10. Review of the postpartum flowsheets dated 3/25/10 at 4:00am identified that Patient #21 had been feeding Patient #64 when she put the baby on her chest then feel asleep. Patient #21 had awakened when she heard Patient #64 crying and found the baby on the floor. Patient #64 had fallen approximately 4 feet on the hardwood floor. Patient #64 was brought to the newborn nursery. Review of the newborn record dated 3/25/10 at 4:00am identified that Patient #64 had no obvious trauma or abrasions with an appropriate neurological exam with balloting sutures on right skull. APRN #2 recommended to nursing staff to observe the patient on pulse oximetry in the nursery. Further review failed to identify that any diagnostic tests and/or orders for monitoring were completed at the time of the injury. Review of the NICU flowsheet dated 3/25/10 at 5:40am identified that Patient #64 had vomited a large amount of formula. At 8:30am, (3 hours later), Patient #64 was evaluated by MD #12 (pediatrician) and found to have right parietal crepitus with balloting sutures and no ecchymosis. Patient #64 was suspected to have a skull fracture. MD # 12 ordered a CT scan of the head and sent the patient to the NICU for monitoring. Review of the CT scan report dated 3/25/10 at 9:37am identified that the patient had a right parietal skull fracture with probable bifurcation anteriorly, two separate areas of epidural hematoma adjacent to the fracture and a probable contrecoup injury involving the left frontal cortex with a small focus of hemorrhage. At 1:30pm, Patient #64 was transferred to a hospital that provided a higher level of care and neurosurgical consultation. Interview with MD #11 (neonatologist) on 10/6/10 identified that he was not notified regarding Patient #64 and would have recommended an immediate CT scan and transfer to the NICU for monitoring.

Based on interviews with staff and review of staffing levels, the hospital failed to ensure that staffing levels were sufficient to ensure that nursing personnel were able to provide necessary care and document the care provided. The findings include:

Patient #19 was admitted on 7/16/10 with diagnoses that included asthma exacerbation, and had a history of chronic pain, anxiety, and bipolar disorder. Between 7/19/10 and 7/23/10, Patient #19 was identified as anxious, restless, pacing, agitated, banging his/her head on the door, refusing to remain in bed due to a medical condition, leaving his/her room without proper precautions (isolation due to MRSA in a wound), and interfering with medical devices (oxygen and cardiac monitor). The patient was also identified with probable alcohol withdrawal and was placed on alcohol withdrawal assessments and treatment.
In addition, Patient #19 experienced unexplained episodes of unresponsiveness requiring medical intervention on 7/19/10 and again on 7/22/10. Following the 7/22/10 unresponsive episode, a physician ordered a one to one sitter to monitor Patient #19, which was discontinued on 7/23/10 at 8:50 AM.
Interview with RN #14 on 9/9/10 at 11:30 AM identified that he/she was responsible for the care of Patient #19 on 7/23/10 from 3 PM until 7 PM. During that time, the patient required close to 3 hours of RN #14 ' s time due to a minor medical issue, not staying in his/her room, not following infection control practices, and not following medical instructions. RN #14 identified that he/she requested a sitter (from the Supervisors office) for Patient #19 twice during the 4 hour shift and was told no because they didn't have anyone (to send). Interview with RN #16 (Supervisor) on 9/16/10 at 7:25 AM identified that he/she was only aware that they " may " need a sitter to help redirect Patient #19. RN #16 identified that there were 2 patient care assistants on the unit (who could have acted as a sitter).
Review of Patient #19 ' s clinical record and interviews with RN #14 and the Director of Quality on 9/16/10 at 7:25 AM and correspondence received on 9/14/10 at 2:11 PM identified that RN #14 did not document a progress note on 7/23/10 because the floor was very busy and he/she did not have a chance to do so.

Based on clinical record reviews, interviews with staff, and review of policies for four patients (Patients #20, #32, #47 and #53) who had problems with pain, the hospital failed to identify how pain would be assessed/reassessed in a non-communicative patient, and failed to assess and/or reassess the patients ' pain. The findings include:

a. Patient #20 was admitted on 5/9/10 with self-injurious behaviors and had a perirectal abscess that was incised and drained. The patient was non-communicative and was unable to notify staff when he/she experienced pain related to the incision and drainage of the abscess and unable to communicate if relief was obtained following administration of pain medications. Patient #20 ' s physician orders identified to administer Dilaudid 0.5 mg every 4 hours as needed. Review of the medication administration record (MAR) identified that Patient #20 received Dilaudid 0.5 mg IV and was not reassessed for the effectiveness of the pain medications on the following dates and times: 5/9/10 at 1:54 PM, 5/9/10 at 4:11 PM, and 5/11/10 at 12:32 AM. In addition, the clinical record was reviewed with Quality Manager #1 on 9/23/10 at 1:30 PM. A nursing progress note dated 5/11/10 at 2:30 PM identified that Patient #20 received Dilaudid 0.5 mg IV with good effect by discharge at 4:30 PM. However, review of Patient #20 ' s MAR failed to identify that Dilaudid was administered around the stated time frame.

b. Patient #32 was admitted to the hospital ' s off-campus care center on 9/7/10 at 8:08 AM
with a complaint of severe stomach pain that was an 8 out of 10 in severity. Following an examination by a physician, the patient was discharged at approximately 9:15 AM with prescriptions for antibiotics and pain medications. The clinical record failed to address the patient ' s pain level prior to being discharged.


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c. Patient #47 was admitted to the hospital on 8/24/10 with a diagnosis of metastatic cancer. The plan of care dated 8/24/10 identified pain related to abdominal cancer and interventions included the administration of analgesia per physician orders and ongoing assessment. Physician's orders dated 9/6/10 directed Dilaudid 5 milligrams (mg) intravenously (IV) continuously with 1mg of IV Dilaudid every 10 minutes as needed via patient controlled analgesia (PCA). The medication record and/or pain assessment/reassessment flow sheet noted that the patient received the Dilaudid from 9/6/10 to 9/7/10 and patient's pain level was assessed at 9:50 AM on 9/6/10 and was not reassessed until 9:45 AM on 9/7/10. Interview with Patient #47's nurse on 9/7/10 at 10:35 AM indicated that the patient's pain level was to be recorded every four hours. The pain policy for PCA and/or plus infusion pump identified that all patients using the PCA are monitored for sedation/analgesia level at least every four hours.


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d. Review of the physicians orders for Patient #53 dated 8/31/10 directed Percocet one tablet every four hours as needed for pain and the order dated 9/1/10 directed Dilaudid 0.5 mg every two hours as needed for pain. Review of the flow sheets for the period of 9/1/10 through 9/7/10 identified that although the patient received either Percocet or Dilaudid on five occasions, the facility failed to ensure that the patient was reassessed to determine the effectiveness of the pain medication. Review of the facility policy indicated the patients pain level should be reassessed after each pain management intervention has taken place.




For two patients (Patient #28 and #59) reviewed, the facility failed to ensure that skin breakdown was assessed in a timely manner. The findings are based on review of the clinical record, review of the facility policy and interview and includes the following:

a. Review of Patient #28's clinical record indicated that the patient was admitted on 8/29/10 from the long-term care facility. The admission assessment indicated that the patient had a stage 2 pressure ulcer on the buttocks that measured 0.7 cm by 0.5 cm by 0.3 cm. Review of the chart on 9/7/10 failed to identify that further measurements and/or an assessment of the pressure ulcer had been completed since 8/29/10. Review of the hospital's skin policy directed weekly measurements of skin breakdown once identified.

b. Review of Patient #59's clinical record indicated that the patient was admitted on 8/1/10. The clinical record indicated that the patient was on a ventilator. Review of the respiratory flow sheets indicated that the patient had a stabiltube holder in place and on 8/12/10 the flow sheet indicated that the patient had skin breakdown on the upper lip. The respiratory therapist failed to notify the patient's nurse of the skin breakdown. Review of the respiratory flow sheets, nursing flow sheets and the progress notes for the period of 8/12/10 through 8/18/10 failed to reflect that an assessment of the patient's skin was completed and/or that the physician was notified. Review of the skin/wound documentation dated 8/18/10 indicated that the patient had a deep tissue injury to the upper lip that measured 3 cm by 0.5 cm. Interview with the Manager on 9/9/10 indicated that she was not aware that respiratory staff identified the breakdown on 8/12/10 and once aware, directed an assessment of the patient's skin breakdown.

Review of the facility policy indicated that the nurse should measure the identified pressure area once identified and that any new wound should be reported to the physician/health professional. The mechanical ventilation policy indicated that Respiratory Therapists would check the ventilators every two hours and the check would include an assessment for skin breakdown and that the therapists would notify the nurse and document this in the comment section.



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Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #64), the facility failed to ensure that neurological assessments/monitoring were completed after a fall.

The findings include:

Patient #64 was born at the hospital on 3/23/10. Review of the postpartum flowsheets dated 3/25/10 at 4:00am identified that Patient #21 had been feeding Patient #64 when she put the baby on her chest then feel asleep. Patient #21 awakened when she heard Patient #64 crying and found the baby on the floor. Patient #64 had fallen approximately 4 feet on the hardwood floor. Patient #64 was brought to the newborn nursery. Review of the NICU flowsheet dated 3/25/10 failed to identify that a complete assessment including neurological assessments were completed post fall. In addition, the hospital failed to have a policy on post fall assessments. Interview with the MD #11 (neonatologist) on 10/6/10 identified that neurological checks and close monitoring should be done every half hour for a newborn with a head injury.


Based on clinical record reviews and interviews with facility personal for one sampled patient (Patient #55), the facility failed to ensure that newborn assessments were completed including vital signs and/or for one of one sampled patient (Patient #22), the facility failed to ensure that physician orders/hospital policy was followed including maternal /fetal monitoring during labor.

The findings include:

a. Patient #55 was born at the hospital on 9/7/10. Review of the nursery flowsheet dated 9/7/10 identified that although a newborn assessment and vital signs were completed every 15 minutes for the first hour, the clinical record failed to reflect that continued assessments including vital signs were completed per unit standard. Review of hospital policy identified that newborn assessments and vital signs are to be completed every 30 minutes for the first two hours of life. Interview with the Nurse Manager on 9/8/10 identified that the newborn assessments are to be completed every 30 minutes for the first two hours.
In addition, review of the newborn physician order sheet dated 9/8/10 identified that the order sheet identified that vital signs were to completed every 4 hours for the initial 24 hours, then every 8 hours, however the unit standard is every 30 minutes for the first two hours of life. Interview with the Nurse Manager on 9/8/10 identified that the physician's order sheet was not updated yet to reflect the changes in policy.

b. Patient #22 was admitted to the hospital on 4/24/10 for a delivery of a baby. Patient #22 had an epidural placed at 5:29am. Review of physician orders dated 4/24/10 identified that the patient was to have respiratory rate, pain scale and sedation level monitored every fifteen minutes for the first two hours, then every hour until four hours postpartum. Review of the labor and delivery flowsheet dated 4/24/10 identified that although the patient had vital signs completed, the clinical record failed to identify that pain score and sedation levels were completed as ordered. Review of hospital policy "Labor Epidural Analgesia Management" identified that the registered nurse is to monitor vital signs, mobility. level of consciousness, motor function, sensation and pain level.

In addition, review of the labor and delivery flowsheet dated 4/23/10 at 10:50pm to 4/24/10 at 10:08am failed to identify that the fetal heart rate was monitored every fifteen minutes including fetal heart rate prior to C-Section induction. Review of hospital policy "AWHONN (Association of Women's Health, Obstetric and Neonatal Nursing) Fetal Heart Monitoring" identified that during the active phase of the first stage of labor, the fetal heart rate should be determined and evaluated every fifteen minutes. In addition, before epidural anesthesia is initiated, the fetal heart rate should be assessed before and after the procedure, either intermittently or continuously, as possible, during the procedure.


Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #65), the facility failed to ensure that the standard of care was followed with initial newborn assessments.

The findings include:

Patient #65 was born at the hospital on 4/24/10 at 10:36am. Review of the newborn record identified that the Apgar scores were 7 at one minute and 9 at 5 minutes, with normal heart rate and increased color and that the infant was suctioned for increased secretions. Review of the nursery flowsheet dated 4/24/10 at 10:50am identified that although the initial newborn assessment was completed, the nursery flowsheet failed to identify any other newborn assessments were completed. At 11:20am, Patient #65 was brought to mother for breastfeeding with good latch. At 11:48am, the nurse took Patient #65 from mother because she found the newborn to be limp and apneic. Patient #65 was brought to the radiant warmer, quiet, hypotonic and stimulated without response At 11:50am, Patient #65 had no heart rate and a code was called with cardiopulmonary resuscitation efforts unsuccessful. Review of hospital policy " Admission and Care of the Normal Newborn" identified that newborn assessments were to be completed hourly for the first three hours however review of "AWHONN Guidelines for Perinatal Care" identified that temperature, heart, respiratory rates, skin color, adequacy of peripheral, type of respiration, level of consciousness, tone, and activity should be monitored and recorded at least once every 30 minutes until the newborn's condition has remained stable for two hours. Interview with the Nurse Manager on 9/8/10 identified that hospital policy had been changed to reflect the current perinatal standard.



Based on review of the clinical record and interviews with facility policy for one sampled patient (Patient #65), the facility failed to ensure that when cardiopulmonary resuscitation was performed, the recording of the code was complete.

The findings include:

Patient #65 was born at the hospital on 4/24/10 at 10:36am. Review of the newborn record identified that the Apgar scores were 7 at one minute and 9 at 5 minutes. with normal heart rate and increased color and that the infant was suctioned for increased secretions. At 11:20am, Patient #65 was brought to mother for breastfeeding with good latch. At 11:48am, the nurse took Patient #65 from mother because she found the newborn to be limp and apneic. Patient #65 was brought to the radiant warmer, quiet, hypotonic and stimulated without response At 11:50am, Patient #65 had no heart rate and a code was called with cardiopulmonary resuscitation (CPR) efforts unsuccessful. Review of the code sheet dated 4/24/10 indicated that the code sheet lacked a physician signature, identification of staff present at the code, vital signs, code strips and a complete list of interventions that were completed during the code. Review of hospital policy "Cardiopulmonary Resuscitation" identified that a CPR report must be completed following each arrest including the nurse recording the resuscitation. Interview with RN # 19 on 9/10/10 identified that she was responsible for recording the code however left the room and finished recording the code in another room while the newborn was being resuscitated.


Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #56), the facility failed to ensure that reassessments were completed after a patient received pain medication.

The findings include:

Patient #56 was admitted to the hospital on 9/7/10 for a delivery. Review of the physician's orders dated 9/7/10 identified that the patient was to receive Motrin 800mg every eight hours as needed for a pain level of 4-7 and Percocet 1 tab every four hours for a pain level of 4-7. Review of the postpartum flowsheet dated 9/7/10-9/8/10 identified that the patient received pain medication on 9/7/10 at 9:30pm and on 9/8/10 at 4:34am and 9:00pm. Further review failed to identify that pain reassessments were completed. Review of the pain management policy indicated the patients' pain level should be reassessed after each pain management intervention has taken place. Interview with the Nurse Manager on 9/8/10 identifed that pain reassessments were not documented.

Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #51), the facility failed to ensure that patient teaching was completed for a new PICC line placement in the infusion center.

The findings include:

Patient #51 was admitted to the infusion center for IV therapy for sepsis via PICC line. Review of the flowsheets dated 9/2/10-9/8/10 identified that the patient had IV therapy provided. Review of the interdisciplinary teaching record failed to identify that patient teaching in the infusion center was completed for PICC line care, maintenance and complications while the patient was undergoing IV therapy. In addition, review of the progress notes dated 9/2/10 indicated that nurses notes were never completed. Interview with the Nurse Manager on 9/8/10 identified that the clinical record failed to indicate that patient teaching was completed while the patient was seen in the infusion center.

Based on clinical record review, interviews with staff, and review of policies for 3 patients (Patients #19, #20, and #63), the hospital failed to ensure that the care plans addressed the patients' current problems and/or failed to update the care plan when new problems occurred. The findings include:

a. Patient #19 was admitted on 7/16/10 with diagnoses that included asthma exacerbation, and had a history of chronic pain, anxiety, and bipolar disorder. Between 7/19/10 and 7/23/10, Patient #19 was identified as anxious, restless, pacing, agitated, banging head on door, refusing to remain in bed due to a medical condition, leaving his/her room without proper precautions (isolation due to MRSA in a wound), and interfering with medical devices (oxygen and cardiac monitor). On 7/21/10 Patient #19 was evaluated and treated by psychiatry and identified with depression 8 out of 10, anxiety 6 out of 10, and pain 8 out of 10. The patient was also identified with probable alcohol withdrawal and was placed on alcohol withdrawal assessments and treatment. The patient ' s care plan was reviewed with Quality Manager #1 on 9/23/10 at 1:30 PM. The care plan failed to identify patient specific interventions to address the patient ' s anxiousness, and/or behaviors including restlessness, agitation, refusal to follow direction/redirection, and interfering with medical devices. And failed to identify the patient ' s alcohol withdrawal.
Patient #19 experienced unexplained episodes of unresponsiveness requiring medical intervention on 7/19/10 and again on 7/22/10. Following the 7/22/10 unresponsive episode, a physician ordered a one to one sitter to monitor Patient #19, which was discontinued on 7/23/10. Review of Patient #19's care plan failed to identify interventions to address the unresponsive episodes, failed to address the need for a sitter, and failed to address possible interventions staff should use when the sitter was discontinued.

b. Patient #20 was admitted on 5/9/10 with self-injurious behaviors and had a perirectal abscess that was incised and drained. Due to the self-injurious behaviors, hand mitts were placed on the patient ' s hands and a sitter was placed at the bedside. On 5/9/10 at 12 PM, the patient experienced one episode of attempting to hit his/her self on the head. Between 5/9/10 at 12 PM and 5/11/10 at 8 AM, the patient did not exhibit any self-injurious behaviors and a physician discontinued the sitter. Patient #20's care plan was reviewed with RN #11 on 9/14/10. The care plan failed to identify the patients potential for self-injurious behaviors, failed to identify the need to use hand mitts, and failed to address the need for and discontinuation of a sitter.
In addition, Patient #20 was non-communicative and was unable to notify staff when he/she experienced pain related to the incision and drainage of the abscess. The care plan failed to address how and when the patient's pain would be assessed.

c. Patient #63 was admitted on 8/16/10 with diagnoses that included bipolar disorder with manic phases, borderline personality, and probable schizoaffective disorder. Between 8/16/10 and 8/27/10, the patient experienced multiple assaultive and destructive out of control behaviors requiring restraint and seclusion episodes and had commitment papers filed with the Probate Court. On 8/25/10 at 8:58 AM, Patient #63 was in his/her bedroom screaming and kicking and picked up a chair to throw at any staff member who entered the room. Three security officers were called to the floor and attempted to deescalate the patient without success. Security Officer #1directed the patient to put the chair down, the patient raised the chair in a threatening manner, and the Officer discharged OC foam (pepper spray) towards Patient #63. The patient continued to raise the chair and the officer discharged a second dose of OC foam. The patient put the chair down, medical treatment was provided to relieve the effects of the OC foam, and the patient was placed in restraints. Patient #63 ' s treatment plan dated between 8/16/10 and 8/27/10 was reviewed. Although the plan identified that the patient was violent towards others, self destructive, and assaultive, the plan failed to identify any interventions to address the stated problems including the patients multiple restraint episodes.


15482

For one patient (Patient #59) with an endotracheal tube the facility failed to ensure that preventative measures were instituted and/or the care plan was updated to address the actual skin breakdown and/or for one patient (Patient #18) who was identifed as a fall risk and was made NPO (nothing by mouth) the facility failed to ensure that the care plan was individualized and/or addressed the possible effects of abruptly discontinuing psychotropic medications. The findings are based on review of clinical records, interviews, and review of facility policy and include the following:

a. Review of Patient #59's clinical record indicated that the patient was admitted on 8/1/10. The clinical record indicated that the patient was on a ventilator. Review of the respiratory flow sheets indicated that the patient had a stabiltube holder in place and on 8/12/10 the flow sheet indicated that the patient had skin breakdown on the upper lip. Review of the skin/wound documentation dated 8/18/10 indicated that the patient had a deep tissue injury to the upper lip that measured 3 cm by 0.5 cm. Review of the care plan with the Manager on 9/9/10 failed to reflect that the skin breakdown had been addressed until 8/18/10. Although the care plan addressed the skin breakdown on 8/18/10, the facility failed to develop specific interventions to prevent skin breakdown related to the use of the ventilator.


b. Patient #18 was admitted on 5/18/10 with diagnoses that included Down's syndrome with cognitive developmental delay. On 5/18/10, the patient had an anterior cervical diskectomy at C2-3 with allograft and plate implants with an order for the patient to wear a collar at all times. Review of the admission assessment identified that the patient was incontinent of bowel and bladder and exhibited agitation, anxiety and may become aggressive. The patient was identifed as a high risk for falls. On 5/18/10, a fall risk care plan was developed that included nonspecific interventions that included to evaluate the degree of inherent risk and implement fall risk protocol, assist to reduce risk factors, discuss need for additional resources for supervision, and assess patient behavior, safety and wellbeing. A self-care deficit careplan identified nonspecific interventions that included assess self care, engage Case Management early in hospitalization, PT/OT/ST evaluations as appropriate and involve family in education. Although review of progress notes during the period of 5/19/10 through 5/22/10 identifed that the patient made repeated attempts to remove the collar and/or refused to wear the collar, the hospital failed to develop a plan of care to address the patient's noncompliance. The hospital failed to develop a plan of care that met the individualized needs of the patient.
A nurse's note dated 5/24/10 indicated that at 5:30 AM the patient's bed alarm sounded and upon entering the room the patient was found on the floor in front of the chair. The patient sustained a C2-3 subluxation with a questionable new fracture as the screw had pulled out.


c. Patient #18 was admitted on 5/18/10 for a C1-C5 decompression. Review of the admission assessment indicated that the patient had a history of Downs Syndrome. Review of the physician's orders dated 5/18/10 directed administration of Aricept 10 mg each day, Prozac10 mg daily, and Risperidone 0.25 mg three times a day and 0.5 mg at hour of sleep. The physician's note dated 5/19/10 indicated that a Speech Therapist recommended that the patient have nothing by mouth (NPO) until a more extensive evaluation could be completed. The physician subsequently gave a telephone order that directed to change the patient's diet to NPO. Review of the medication administration record (MAR) for the period of 5/20/10 through 5/25/10 indicated that while the Aricept and Prozac were not administered, staff administered two doses of Risperidone on 5/20/10, 5/23/10 and 5/24/10. Review of the manufacturers guidelines identified that stopping Risperidone can result in Parkinsonism, Somnolence, Dizziness, and Dystonia. The hospital failed to revise and/or review the careplan to address the discontinuation of the patients antipsychotic medications and potential side affects.

Review of the hospital's careplan policy directed that the care plan is to be reviewed at least every twenty-four hours and revised if necessary.

For one patient reviewed (Patient #28) the facility failed to ensure that medications were titrated consistently. The findings are based on review of the clinical record, and interview and includes the following:

Review of the clinical record for Patient #28 indicated that the patient was admitted on 8/29/10 from the long-term care facility. The physician's order dated 8/30/10 directed Levophed 4 mg in 250 cc's of dextrose at 5 mcg per minute to maintain a systolic blood pressure greater than 95 with a maximum dose of 30 mcgs. The physician's order failed to direct titration increments. Review of the flow sheets dated 8/30/10 through 9/9/10 indicated that the Levophed was increased and/or decreased in increments that ranged from 2 mcgs to 5 mcgs. Interview with the Nurse Manager on 9/7/10 indicated that the facility does not have a policy that directs how medications should be titrated, that it is up to the RN to choose the dose change to maintain the goal identified.

Review of the facility guideline for titration medications indicated that titrating orders are acceptable provided there are parameters. The administration of continuous infusion medications must include name of medication, volume, and specific dose increments unless identified as "do not titrate"

Based on clinical record reviews, interviews with staff, and review of policies for 1 patient (Patient #20) who received IV pain medications, staff failed to ensure that the medication was administered as ordered. The findings include:

Patient #20 was admitted on 5/9/10 with self-injurious behaviors, and had a perirectal abscess that was incised and drained. Patient #20 ' s physician orders identified to administer Dilaudid 0.5 mg every 4 hours as needed. Review of the medication administration record identified that Patient #20 received Dilaudid 0.5 mg IV on 5/9/10 at 1:54 PM and again at 4:11 PM (2 hours and 17 minutes). Interview with Quality Manager #1 on 9/23/10 at 1:30 PM identified that the Dilaudid 0.5 mg IV on 5/9/10 at 4:11 PM was given in error and it appeared that the error.



15482

For one patient (Patient #18) who was made NPO the facility failed to ensure that staff considered the effects of abruptly discontinuing psychotropic medications and/or that staff clarified the NPO order. The findings are based on review of the clinical record, interview and include the following:

Patient #18 was admitted on 5/18/10 for a C1-C5 decompression. Review of the admission assessment indicated that the patient had a history of Downs Syndrome. Review of the physician's orders dated 5/18/10 directed administration of Aricept 10 mg each day, Prozac10 mg daily, and Risperidone 0.25 mg three times a day and 0.5 mg at hour of sleep. On 5/19/10, the patient had a chest x-ray completed which revealed bilateral infiltrates/pneumonia. The physician's note dated 5/19/10 indicated that a Speech Therapist recommended that the patient be NPO until a more extensive evaluation could be completed. The physician subsequently gave a telephone order that directed to change the patient's diet to NPO. The progress note dated 5/21/10 indicated that the Speech Therapist recommended that the patient be NPO secondary to secretion management. Review of the medication administration record (MAR) for the period of 5/20/10 through 5/25/10 indicated that while the Aricept and Prozac were not administered, staff administered two doses of Risperidone on 5/20/10, 5/23/10 and 5/24/10. The facility failed to address the patient's medication regimen including the effects of abruptly discontinuing psychotropic medications and/or a method of administration when the patient was made NPO.

Based on clinical record review, interview with staff, and review of hospital policies for 1 patient (Patient #1), the hospital failed to ensure that the medical record was complete and accurate, and included documentation of patient assessments. The findings include:

a. Patient #19 was admitted on 7/16/10 with diagnoses that included asthma exacerbation, and had a history of chronic pain, anxiety, and bipolar disorder. Patient #19 experienced unexplained episodes of unresponsiveness requiring medical intervention on 7/19/10 and again on 7/22/10. Following the 7/22/10 unresponsive episode, a physician ordered a one to one sitter to monitor Patient #19. A physician discontinued the sitter on 7/23/10 at 8 AM without a documented rationale.

b. Interview with RN #14 on 9/9/10 at 11:30 AM identified that he/she was responsible for the care of Patient #19 on 7/23/10 from 3 PM until 7 PM. During that time, the patient required close to 3 hours of RN #14 ' s time due to a minor medical issue, not staying in his/her room, not following infection control practices, and not following medical instructions. RN #14 identified that he/she requested a sitter (from the Supervisors office) for Patient #19 twice during the 4 hour shift and was told no because they didn't have anyone (to send). Review of Patient #19 ' s clinical record and interviews with RN #14 and the Director of Quality on 9/16/10 at 7:25 AM and correspondence received on 9/14/10 at 2:11 PM identified that RN #14 did not document a progress note on 7/23/10 because the floor was very busy and he/she did not have a chance to do so.

c. Patient #20 was admitted on 5/9/10 with self-injurious behaviors, and had a perirectal abscess that was incised and drained. Patient #20 ' s physician orders identified to administer Dilaudid 0.5 mg every 4 hours as needed. A nursing progress note dated 5/11/10 at 2:30 PM identified that Patient #20 received Dilaudid 0.5 mg IV with good effect by discharge at 4:30 PM. However, review of Patient #20 ' s MAR failed to identify that Dilaudid was administered around the stated time frame.



14528

Based on medical record reviews, a tour of the medical records department, review of hospital policies/documentation and interviews for two of five patients (Patients #48, #11) reviewed for discharge and/or physician completion of history and physicals and/or operative reports, the hospital failed to ensure record completion/accuracy and/or that an effective system was in place for the completion of medical records. The findings include:

a. Patient #11 was admitted to the "Express Care Unit" (Unit 3.6) on 9/29/09 at 9:06 AM from the hospital ED with a diagnosis of probable pneumonia and chronic airway obstruction. Physician orders dated 9/30/09 directed to remove the patient's IV lines and to discharge the patient. Discharge paperwork (summary and W-10) indicated that the patient was discharged to home with Visiting Nurse Service (VNA). Case Manager #2's notes dated 9/30/09 conflicted with the discharge paperwork and indicated that the patient would not receive VNA services because the patient was not homebound. Nursing documentation and/or case management documentation did not include a discharge note to reflect the time that the patient was discharged or to the location the patient was discharged. Interview with case Manager #2 on 9/20/10 at 1PM noted that h/she had arranged VNA services for the patient prior to the patient's discharge and in error did not update his/her case management note. The hospital discharge policy identified that the case manager will facilitate arrangements for implementation of a final discharge plan. On- going documentation will occur throughout the Medical record as appropriate in the nursing assessment tool, case management assessment/note, progress note, W-10 and discharge summary.

b. A tour of the medical records department was conducted on 9/7/10 at 11:10 AM. The medical record completion of two patients who were discharged on 8/3/10 was reviewed and identified that Patient #48's medical record was incomplete. Patient #48 was admitted to the hospital on 7/29/10 with a diagnosis of a postoperative lumbar wound. Review of the patient's electronic record identified that the patient's lumbar wound was surgically debrided on 7/30/10 and although the operative report was dictated on 7/30/10 and transcribed on 7/31/10, the physician had not signed/authenticated the report as of 9/7/10. The medical record also indicated that the history and physical dated 7/29/10 also lacked the physician's signature. Physician orders dated 8/3/10 directed that the patient be discharged and noted that the discharge summary had been dictated. Although nursing progress notes identified that the patient was discharged to home on 8/3/10 at 7 PM the patient's record lacked a physician's discharge summary. Interview with the Director of Medical Records on 9/7/10 at 11:22 AM noted that incomplete records for physician's can be visualized by the physician when the physician signs onto the computer. Review of the hospital's Medical Records Completion policy identified that the physician was responsible for timely completion of medical records. A complete record indicated that all required contents and signatures are present. The person responsible for ordering, providing or evaluating services furnished must authenticate all entries.
3. In addition, hospital documentation dated 7/1/09 from the Chief Medical Officer (CMO) identified that effective with this communication, the hospital's completion protocol process which ends with physician suspension for delinquent records is on hold. The Medical Records Committee meeting minutes dated 6/23/10 for the delinquent medical records review identified that February had 40%, March had 30% and April had 31% for an average medical record delinquency rate of 32%. The minutes also identified that physician orders not signed within 48 hours increased the numbers for June by 20%. Although the follow up action noted by the Medical Records Committee indicated an action to monitor the impact of unsigned orders on the hospital's overall delinquent account, the action did not include methods to improve the overall delinquency rate. Medical Executive Committee (MEC) meeting minutes dated 7/7/10 identified that the MEC had reviewed the minutes of the Medical Records Committee dated 6/23/10. Interview with the Director of Medical Records on 9/7/10 at 11:22 AM noted that the transitional phase of medical record access was difficult and therefore the physician suspension process for delinquent medical records was eliminated August 2009. The Director of Medical Records further noted that a weekly letter was sent to physicians to inform them of delinquent records and after 30 days the delinquency would be handled on a peer to peer basis by the CMO.

Based on clinical record reviews and interviews with facility personnel for one sampled patient (Patient #54), the facility failed to ensure that a consent to treat was completed on admission.

The findings include:

Patient #54 was admitted to the hospital on 9/8/10 after transferring from another hospital for neonatal intensive care. Review of the initial consent failed to identify that the parents had consented to treatment when the patient was admitted. Upon surveyor inquiry on 9/8/10, the consent form was signed by the parents on 9/9/10. Interview with the Nurse Manager on 9/8/10 identified that the consent form should have been signed by the parents when the patient had arrived from another hospital.

Based on medical record reviews, a tour of the medical records department, review of hospital policies/documentation and interviews for one patients (Patient #48) the hospital failed to ensure that the physician had completed a discharge summary. The findings include:

Patient #48 was admitted to the hospital on 7/29/10 with a diagnosis of a postoperative lumbar wound. Physician orders dated 8/3/10 directed that the patient be discharged and noted that the discharge summary had been dictated. Although nursing progress notes identified that the patient was discharged to home on 8/3/10 at 7 PM the patient's record lacked a physician's discharge summary. Interview with the Director of Medical Records on 9/7/10 at 11:22 AM noted that a weekly letter was sent to physicians to inform them of delinquent records. Review of the hospital's Rules and Regulations indicated that a dictated discharge summary was required for all patient stays that include an inpatient or observation admission to the hospital. All medical records will be completed within thirty (30) days of patient discharge.

Based on a tour of the dietary department, review of hospital documentation/policies and interviews dietary staff, the hospital failed to provide adequate sanitization of dishwashed items and/or consistently monitor sanitization of the pot sink. The findings include:

A tour of the dietary kitchen conducted on 9/7/10 by Building and Fire Safety Staff identified that a temperature of 180 degrees Fahrenheit or greater was not reached during the dishwasher sanitization cycle for one observation. A tour of the kitchen was also conducted on 9/7/10 at 11:20 AM with the Director of Food and Nutrition Services and the sign posted on the dishwasher identified that the sanitization cycle must reach a final rinse temperature of 180 degrees Fahrenheit. Although a temperature of greater than 180 degrees Fahrenheit was observed on 9/7/10 at 11:27 AM during the dishwasher sanitization cycle, the dishwasher temperature log noted multiple prior recordings when the dishwasher temperature had not reached 180 degrees Fahrenheit. The dishwasher temperature logs from 8/1/10 to 9/7/10 indicated two undated, untimed temperature labels for each day and 11 recorded labels ranged from plum to black in color. Interview with the Director of Food and Nutrition on 9/7/10 at 11:45 AM noted that the temperature test strips were randomly conducted twice daily, should change color (to orange) and that maybe the readings were wrong. The temperature test strip container directed to place a test strip label on a dry item and if the label turned bright orange, the temperature had reached 180 degrees, brown denoted 170 degrees and plum denoted 160 degrees. The temperature test strip container also directed to remove the temperature label when finished, sign, date and place in the dishwasher temperature log book.

In addition, the three-compartment pot sink was also observed in use on 9/7/10 at 11:20 AM. The sanitizing sink was tested by the Director of Food and Nutrition at this time and noted that the test strip recorded a sanitization level of greater than 200 parts per million (ppm). Review of the Final Rinse Sanitizer Daily Log for the pot sink directed that the sanitization level be monitored and recorded for 9AM, 2PM and 5:30 PM daily and the level should read 200ppm. The log further identified that the sink's sanitization level was not documented for 53 of 210 occasions and this included 12 days when all three timed tests were not recorded. Interview with the Operations Manager on 9/7/10 at 2PM indicated that the dietary staff assigned to the pot sink area was responsible to monitor/record pot sink sanitization levels. Although the Supervisor Check List directed to check room service tray temperatures and log as well as other staff monitoring duties, the list did not direct the supervisor to monitor sanitization testing.

Based on a tour of the hospital, the facility failed to ensure that the Behavioral Health Unit was designed and maintained in such a manner as to promote the safety and well being of patients.

On 08/09/10 at 08:30 AM, upon a tour of the Behavioral Health Unit while accompanied by the Behavioral Health Unit Director and the Interim Director of Engineering the following was observed:

a. That the resident rooms within the Behavioral Health Unit (Pond 4) had non-tamper proof screws and fasteners, curtains that had washers/weights within them, shower curtains & rod assemblies that do not break away, anchor point-free toilet paper dispensers, grab rails, faucet and shower controls, non-institutional style sprinkler heads, door handles, under sink piping and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.

b. That the behavioral rooms within the Emergency Department had non-tamper proof screws and fasteners, non-institutional style sprinkler heads, open ceiling/wall HVAC registers & grilles, door handles, and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.

c. That the bathroom within the Emergency Department that is designated for use by behavioral patients had non-tamper proof screws and fasteners, non-institutional style sprinkler heads, and door hinges that posed a potential hanging hazard and was not designed to a psychiatric institutional standard and that such had been identified on a risk based analysis conducted by the facility prior to this inspection with no date for abatement of these hazards.

Based on review of facility documentation, review of facility policies, staff interviews, and observation, the facility failed to ensure that water was tested in accordance with facility policy and/or manufacturers directions. The finding includes the following:

a. On 09/08/10 at 9:45 AM the surveyor observed a staff nurse obtain a water sample from the port located after the RO machine to test for chlorine/chloramine levels. The nurse proceeded to fill the sample tube and add the prepared reagent, however, failed to allow the the sample to develop for three minutes prior to interpreting the result. Review of the policy posted on the wall in the water treatment room directed that water should have been obtained from the port after the carbon tank. Review of the manufacturer's directions for testing water directed that the test sample should develop for three (3) minutes prior to reading the result. Subsequent to this observation the facility provided the Department with an immediate action plan that included reeducation of all dialysis staff on proper testing procedures of water.

Based on clinical record reviews, interviews with staff, observation, and review of policies, the hospital failed to maintain a sanitary hospital environment, and failed to ensure that staff followed proper infection control practices. The findings include:

A tour of the hospital ' s off-campus care center was conducted with the Patient Care Service Director and Nursing Manager on 9/7/10 at 10:10 AM. The patient care area had 3 laryngoscope trays with outdated batteries dating to 6/7/10. A clean commode was observed to be stored in the dirty utility room. And an open bottle of a skin/wound-cleansing agent was observed in a patient care area. The bottle was outdated from 8/15/10.

Based on tour of the facility, review of the clinical record, review of facility policy and interviews with hospital personnel for one patient (Patient #22) , the facility failed to ensure that a post-operative anesthesia evaluation was performed.

The findings include:

Patient #22 was admitted to the hospital on 4/24/10 for delivery of a baby. Review of clinical record identified that the patient had an emergency C-Section due to failure to progress. Review of the anesthesia record dated 4/24/10 identified that at 5:15am, the patient had an epidural inserted and delivered the baby at 10:37am. Review of the clinical record failed to identify that a post anesthesia evaluation was completed. Interview with the Director of Anesthesia on 10/6/10 identified that the clinical record failed to reflect that an post-anesthesia evaluation was completed.




19952

Based on tour of the facility, review of the clinical record, review of facility policy and interviews with hospital personnel for one patient (Patient #41) who had surgery, documentation and interviews failed to reflect that a post operative anesthesia evaluation was performed.

Patient #41 was admitted to the hospital on 9/7/10 and underwent bilateral breast revision. Review of the clinical record identified that the patient underwent general anesthesia. Review of the anesthesia record dated 9/7/10 and interview with the PACU (post-anesthesia care unit) manager failed to reflect that an anesthesia post-operative evaluation was completed.