HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1. failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients requiring acute inpatient psychiatric care, who had been admitted for being a danger to self or others; and
2. failure to ensure patients did not have access to contraband items for 1 of 1 (#2) patients reviewed for access to contraband items out of a sample of 5 (#1-#5); and
3. failure to ensure the MHTs follow the hospital protocol and retrieved hygiene items (shampoo, lotion, deodorant, toothpaste and mouth rinse) from the patients after hygiene time for 4 (Rooms 123, 126, 128, 133) out of 25 patient rooms observed.


Findings:
1. Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients requiring acute inpatient psychiatric care

Review of the hospital policy titled, Environmental Risk Assessment, revealed in part, The scope of this policy affects all facility area including: patient bedrooms, bathrooms, patient common areas as priority area and other environmental area affecting patients, staff and visitors... The potential risk are identified on the environmental risk assessment tool or instrument, including potential ligature risks...The Director of Plant Operations with other members of the Safety/Risk Management Committee including the Safety Officer provided an initial assessment of the building(s) to identify potential hazards/risk to patients, staff and visitors. Ligature assessment guide, bedroom furniture attached to wall or the floor, is the plumbing under the sink enclosed to prevent looping, are the toilets fitted with a locking lid if they are the tank type.

The observations were conducted on 4/25/2022 between 10:00 a.m. and 12:15 p.m.

An observation was conducted in the cafeteria. The cafeteria had a handrail around the perimeter of the room. A long flexible piece of metal was found in the gap between the handrail and the wall.

An observation was conducted of the following patient rooms with cracked or broken vent covering on the wall heating and air conditioner units (P-TAC system): Room 109, 115, 123, 125, 126, 134, 137 and the seclusion room on Unit 1. This provided a safety hazards due to the sharp edges of the plastic covering.

An observation was conducted of the following patients' bathrooms with a gap between the sink and shield covering the sink plumbing that was a ligature risk: Rooms 111, 113 and 121.

An observation was conducted of the following bathrooms with rusted, protruding, sharp bolts protruding from the bottom of the toilet that was a safety risk: Rooms 115 and 132.

An observation was conducted of the following bathrooms that had hinged toilet seats that presented numerous anchoring points and was a ligature risk: Rooms 101, 102, 103, 104/105, 106, 107, 108, 109, 110, 111, 113, 114, 115/116, 118,121, 122, 123,126, 128, 130, 132, and 134.

An observation was conducted of the bed in Room 133 being loosely secured to the floor.

An observation was conducted of the locking device in the door to Room 126 was not flush to the door and had sharp edges.

An observation was conducted of Room 124 of metal flashing being loosely secured to the floor of the shower and the bathroom floor resulting in access to the sharp edges of the metal flashing.

An observation was conducted of the patient outside area of Unit 2. There was an enclosed rat trap by the fence, a long tree limb hanging over the enclosed area and a picnic table that was not securely fastened to the ground with a broken table top. The wooden gate had wood splinters with sharp edges.

The following observations were confirmed by S2DON on 4/25/2022 between 10:00 and 12:15 p.m. and 04/26/2022 between 9:00 a.m. and 10:00 a.m.

2. Failure to ensure patients did not have access to contraband items.

Review of the hospital policy titled, Contraband, revealed in part, items from patient's bin may be signed out ... 4. Cigarettes per program policy.

An observation was conducted on 04/25/2022 at 11:00 a.m. of Patient #2 approaching S2DON and handing her a cigarette. Patient #2 apologized and reported last night he had forgotten to return the cigarette since it was behind his ear.

An interview was conducted with S2DON on 4/25/2022 at 11:00 a.m. She reported the cigarette was considered contraband and should had been collected from the patient last night after their smoke break.

3. Failure to ensure the MHTs followed the hospital's protocol and retrieved hygiene items (shampoo, lotion, deodorant and mouth rinse) after hygiene time.


Observations were conducted on 4/25/2022 between the times of 10:00 a.m. and 12:15 p.m. of the following rooms with hygiene products in the room.

An observation was conducted of Room 123 with shampoo and mouth rinse on the side of the sink.
An observation was conducted of Room 126 with mouth rinse, shampoo and lotion in the room.
An observation was conducted of Room 128 with toothpaste, lotion, deodorant and shampoo in the room.
An observation was conducted of Room 133 with shampoo in the shower.

An interview was conducted with S2DON on 04/25/2022 at 2:00 p.m. She reported the patients may have hygiene products at hygiene time and the MHTs are instructed to pick up the hygiene items after the patient has finished with the products.

Based on record review and interview, the hospital failed to identify after an adverse fire/smoke event on 04/20/2022, the fire department was not automatically notified by their contracted monitoring company the fire alarm was activated. Findings:

Review of the hospital policy titled, Performance Improvement Plan, revealed in part, The Performance Improvement Committee has chosen the Improve model developed by Ernst and Young as the performance improvement tool for system changes. I-Identify and define the problem, M- Measure impact on customers, P-Prioritize root causes, R- research and analyze root causes, O- Outline alternate solutions V-validate solutions will work E-Execute solutions and standardize.

Review of the hospital policy titled, Code Red Fire Emergency Plan, revealed in part, Dial 911 and report the fire to the fire department. (Our fire alarm system should do this automatically), however this second notification should be made in the event of a system failure.

An interview was conducted with S1Adm and S2DON on 4/25/2022 at 11:15 a.m. They reported on 04/20/2022 a patient barricaded his self in a room and stuffed toilet paper in the P-TAC system and created a smoke event. The staff called 911, the fire alarm sounded and the fire department arrived at the hospital along with EMS.

Review of the Contractor A's activity report for 04/20/2022 failed to show the fire department was automatically notified by the alarm system. Contractor A is a contractor that monitors the system that automatically notifies the fire department when an alarm is activated.

An interview was conducted with S1Adm on 04/26/2022 at 2:00 p.m. She reported Contractor A's system should have automatically notified the fire department when the alarm sounded. She further reported she was not aware the fire department was not notified by Contractor A's monitoring system.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.
Findings

The following observation were made between 04/25/2022 between 10:00 a.m. and 12:15 p.m.

Patient Room 109
When the light was turned on in the bathroom area, the light was observed to flash like a strobe light.

Patient Room 113
The room was observed to have approximately 2 feet of missing baseboards. The wall air conditioner unit had tape around the edges of the unit.

Patient Room 115
The plastic covering over the air condition wall unit was observed to have a crack in the cover.

Patient Room 121
Broken floor tiles were observed and tape was observed around the edges of the air conditioner unit. Peeling paint was observed on the ceiling.

Room 123
Light switch plate cover was observed to be cracked. Peeling paint was observed in the bathroom.

Room 124
Rust was observed on the light fixtures. Peeling paint was observed on the wall in the bathroom.

Patient Room 126
5 loose floor tiles were observed on the floor and peeling paint was observed in the bathroom.

Room 127
The light switch cover was observed to be warped on both ends. In the bathroom, the toilet bowl was observed to have peeling white paint inside of the bowl of the toilet.

Patient Room 128
The light switch cover plate was observed to be cracked.

Patient Room 129
The wallpaper in the bathroom was observed to be pulled from the wall and had a black substance on the adhesive side of the wallpaper. Other areas of the wallpaper was bubbled up and wasn't flush to the wall.

Patient Room 131
An observation was made of a large 1.5 foot by 1 foot hole in the sheet rock of the room. The wallpaper in the bathroom was bubble up in places and not flush to the wall.

Patient Room 132
An observation in bathroom was made of black spots dotting the ceiling.

Patient Room 133
The wallpaper in the bathroom was observed to be bubbled and not flush to the wall and the toilet bowl had peeling white paint inside of the bowl. The wall air conditioner unit had tape around the edges.


Patient Room 134
The wall air condition unit was observed to have a broken vent and the sheet rock in the bathroom was coming off the wall by the sink.

Patient Room 135
The paper towel holder was observed to be loosely secured on the wall and the wall air conditioner had vents which were broken.

Patient Room 137
Broken floor tile was observed close to bathroom entrance. The air conditioner unit had vents broken on the unit.

In the seclusion room on Unit 1 the light was observed not to be working. In the bathroom located off the seclusion room the wall and ceiling had black spots and the shower stall wall was separating from the wall.

In the hallway on Unit 1, the wallpaper was observed to be coming off the wall and the wallpaper had large gaps where it was no longer adhering to the wall.

The fencing around the property was observed to have missing planks.

An interview was conducted with S1Adm on 04/25/2022 at 1:30 p.m. She reported she was recently hired at the facility and when she arrived she had recognized the facility was in need of maintenance.

.


.

Based on observations and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established. This deficient practice was evidenced by the hospital's failure to maintain a sanitary environment. Findings:

These observations were made on 04/25/2022 between 10:00 a.m. and 12:15 p.m.

Patient rooms

The shower curtains in all the patient's bathrooms were stained. Reddish brown stains were noted at the bottom edges of the shower curtains.

The patient rooms' floors were dirty with dried liquid spills and darkened areas on the floor. Most of the patient rooms were littered with used towels and trash in different degrees. The wall air conditioner unit's vents were covered with a gray substance in the patients' room.

Cafeteria
A wooden table was observed in the cafeteria area. The table had part of a cardboard box stuck to the table and numerous dried liquid spills. The air vent in the ceiling was caked with a gray substance.

Patient Room 133
The bathroom vent was covered with a gray substance.

Patient Room 134
The bedside table was made of wood without a finish making the bedside table porous and unable to be disinfected appropriately.

The mattresses in Room 111, 113, and 134 had holes in the mattress covering making them unable to be disinfected properly.

An interview was conducted with S2DON and S1Adm during the time of the observations and confirmed the above infection control findings.

Based on record review and interview, the hospital failed to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirement, 90 day after implementation of CMS Omnibus Covid -19 Health Care Staff Vaccination Regulations. This deficient practice is evidenced by the hospital compliance rate being 84.87% of the hospital staff being either vaccinated or having an exemption. Findings:

Review of the hospital's current vaccine compliance spreadsheet for Covid-19 vaccines revealed an overall compliance rate of 84.87%

An interview was conducted with S1Administrator on 04/27/2022 at 11:00 a.m. She reported the 84.87% compliance rate included vaccinated and exempted employees.