HospitalInspections.org

Based on interview, record review and observation the facility failed to meet the Condition of Participation (COP) for patient's rights by failing to comply with the requirements as evidenced by the following:

Patient Rights: Care in a Safe Setting - Refer to 0144

Based on record review and interview the facility failed to maintain a process for a patient or his/her representative to make informed decisions regarding his/her treatment or medication management for 4 (P1, P2, P8, P10) of 10 (P1-P10) patient records reviewed. This failed practice can lead to patients receiving treatment and/or medications without their consent and can lead to patient harm.

The findings are:
A. Record review of facility's policy titled, "Patient/Resident Rights" dated 05/01/18 confirms, on section titled "Procedures:" confirms, "On admission, each patient/resident is informed of his/her rights and responsibilities and of the rules and regulations governing patient/resident conduct and responsibilities orally and in writing: The receipt of which will be acknowledged by the patient's/resident's signature or legal guardian/power of attorney's signature.

B. Record review of P1 medical chart date of admission 03/18/22 shows patient's name typed in on facility's "Consent for Medical Treatment" with no signature from patient or his/her representative. On 03/18/22 on Admission Nurse's note states, "Patient was cooperative and responsive, gave consent for Psychiatric and medical treatment." No mention of why no patient signature for consent was given.

C. Record review of P2 medical chart date of admission 03/03/2022 shows patient's name typed in on facility's "Consent for Psychiatric Medications" with no signature from patient or his/her representative. On 03/03/22 on Admission Nurse's notes states, "Patient's son/guardian Ad Litem [as appointed by law], provided verbal consent for [facility] to move forward with appropriate medical and psychiatric treatment." There is no mention of type of medication the consent was obtained, nor that there is a Black Box Warning (a warning required by the Food and Drug Administration for certain medications that carry serious safety risks), nor that the patient is high risk for safety risks.

D. Record review of P8 medical chart date of admission 04/05/2022 shows patient's name typed in on facility's "Consent for Psychiatric Medications" with no signature from patient or his/her representative. On 04/05/2021 on Admission Nurse's note states, "Obtained verbal consent to treat patient per wife". There is no mention of type of medication the consent was obtained, nor that there is a Black Box Warning (a warning required by the Food and Drug Administration for certain medications that carry serious safety risks), nor that the patient is high risk for safety risks.

E. Record review of P10 medical chart date of admission 04/26/2022 shows patient's name typed in on facility's "Consent for Psychiatric Medications" with no signature from patient or his/her representative. On 04/26/2022 on Admission Nurse's note states, "Provided verbal consent for (Facility Name) to move forward with appropriate medical and psychiatric treatment as indicated". No mention of why no patient signature for consent was given. Nor type of medication the consent was obtained.

E. On 06/17/22 at 11:00 am during interview with Staff S2 (Director of Quality) who confirmed, "We [facility] were unable to locate the any signed consent for treatment for P1."

F. On 06/16/22 at 9:30 am during an interview with S2 (Chief Nursing Officer) when asked about the consent process and missing signatures stated, "Nurses do not know how to access the form, but we are training them now ... The signatures can all be on an iPad, it's a tech issue."



46429

Based on record review, observation and interview the facility failed to maintain the patient's right to receive care in a safe setting in reference to fall risk management for all patients receiving treatment in this facility. This failed practice can lead to increase in patient falls and patient harm for all patients by the facility not having a system in place to physically identify residents at risk and are likely to be at risk of serious harm or death related to falls.

The findings are:

A. Record review of facility's policy titled; "Fall Prevention" revision dated 02/01/20 confirms:

1. Section labeled "Policy" #2 "Patients will be assessed upon admission utilizing the Fall Risk Assessment section of the Nursing Assessment. All patients are placed on a standard fall prevention protocol regardless of the fall risk score. For patients with a Fall Risk score of 19 or greater, the [facility] will implement high risk fall prevention strategies and alerts.

2. Section labeled "Procedures:" #2 "The following actions are initiated:
a. For patients with a fall Risk score of 19 or above, fall precautions are implemented based on the patient's individual needs and plan of care such as:
1) Bed in low position unless bolted to the floor.
2) Call light within reach/Emergency Communication system.
3)Non-slip socks or footwear for ambulation.
4)Assistance as needed for personal care and toileting.

3. Section #3 The [facility] will indicate patients at high risk for falls through a standardized approach, such as:
a. ID(identification) band marking or specific color.
b. Colored "falling star" affixed to the exterior of the patient's room.
c. Noted on staff communication tool."

B. Record review of facility's "Facility Incident Detail Report" dated 2021 confirms, "Year to date for January through November 2021, Number of Falls: 327, Number of falls with Injury: 113, Number of falls with Injury Reported to the State of NM: 6"

C. Record review of facility's "Facility Incident Detail Report" for 2022 confirms "Facility has had 184 patient falls and 96 resulted in injury to patient from 01/01/22 to 06/17/22."

D. Record review of facility's "Performance Improvement Plan(PIP)" dated 04/01/20 states, "Identified issue: Prevent patient's from falling. Monitor patient fall/incidents and any trends. PIP will be continued for 12 months, and data reviewed during Quality Assurance Performance Improvement (QAPI) quarterly." Facility's "Performance Improvement Plan: Falls Prevention/Reduction", not dated, confirms, "Identified Issue: Prevent patients from falling: Monitor patient fall/incidents and trends. PIP will be continued for 12 months and data reviewed during QAPI quarterly. PIP was not updated in 2021 due to COVID-19 Pandemic challenges."

E. Record review of facility's "Quality Assurance Performance Improvement (QAPI) Minutes" dated 12/30/21 confirms:
Page 12 section XI. Risk Management
d. Total Falls: b. Falls Task force Committee was placed on hold due to EMR (electronic medical record) training, transition, and COVID-19. Root cause need to be identified. Need to be proactive.
Page 20 XXIV "Performance Improvement Projects"
c. Falls PIP-Ongoing a. Falls Taskforce Committee will be updating the "Falls PIP",
d. Falls Committee to resume, now that the EMR has been implemented."
This document provides conflicting information about the status of the Falls Committee.

F. Record review of facility's "Quality Assurance Performance Improvement: Focus Fall Review, Meeting Minutes" dated 08/07/20, 08/14/20, 11/25/20 reviewed falls. From 11/25/20 through 02/28/22 meeting minutes do not indicate falls were reviewed or discussed.

G. On 06/14/22 at 9:30 am observation during facility tour of patient treatment units, the following was observed:
1. [Name of Unit] had 29 patients today, No 'falling stars' noted on doorways. No fall risk wrist bands identified.
2. [Name of Unit] 32 patients today, No 'falling stars' noted on doorways. No fall risk wrist bands identified.

H. On 06/16/2022 at 10:05 am during interview with S(staff)17 (Contracted Registered Nurse) who confirmed, "[For patients on fall risk] we check medical history, age, what type of medications the patient is taking, how are they walking or using a walker. The patient wears a red band to identify them as a high fall risk. "

I. On 06/16/2022 at 10:45 am during interview with S18 (Registered Nurse) who confirmed, "[For patients on fall risk] we check age, medical history, medications patients are taking. Walking on their own or using a walker. No wristband is used to identify high fall risk patients."

J. On 06/16/2022 at 2:21 pm during interview with S20 (Mental HealthTech) who confirmed, "For patients on fall risk, in the morning during shift change the night shift will inform day staff [of patients on fall risk]. The Q-15 (15-Minute Patient Safety Check) sheet is in red and that indicates patient is high fall risk."

K. On 06/16/22 at 9:30 am during interview with S3 (Director of Nursing) who confirmed, Question 1: Do you guys have a falling star or leaf program? Answer: No. Question 2: How do you identify patients that are high risk for falls? Answer: Should have fall bracelet, could be a different color. Fall Sticker on patient's paper chart.

Based on record review and interview the facility failed to establish and maintain a QAPI Program (Quality Assurance Performance Improvement) to monitor and implement policies and procedures to ensure that the needs and concerns of the facility are given due consideration and are addressed for all patients receiving treatment in this facility. This failed practice can lead to lack of guidance through policies and procedures for patient care and can lead to patient harm.

The findings are:

A. Record review of facility's QAPI procedure for updating policies (by email from S(staff)2 (Director of Quality)) dated 06/24/22 confirmed, We [Facility Name] does not have a written policy; we [Facility Name] have a process for updating/changing policies as follows:
1. Consultant Review & discussion
2. Legal team review
3. Governing Board Committee reviews
a. Decline / Adoption approval
b. Plan for implementation of changes. Policies are reviewed annually and as needed, if a situation arises that promotes review.

B. Record review of facility's policy titled; "Documentation of Patient Care" last revision dated 02/01/2020 confirms this policy has not been updated since the implementation of Electronic Medical Record (EMR) System in the summer of 2020.


C. On 06/16/22 at 9:35 am during interview with S(staff) 3 (Director of Nursing) who confirmed, "WellSky (facility EMR system name) was started in Summer 2020, I am not sure when the policy was updated."

Based on interview and record review the facility failed to meet the Condition of Participation (COP) for nursing services by failing to comply with the requirements as evidenced by the following:

Nursing Care Plan: Refer to 0396
Patient Care Assignments: Refer to 0397

Based on record review and interview the facility failed to initiate a care plan for a COVID (acute disease capable of progressing to severe symptoms and in some cases death) positive patient, which would have likely identified a trend of decline and led to reporting the change of condition to the Medical Practitioner, for 1 (Patient (P)3) of 10 (P1 - P10) patients reviewed. This deficient practice led to patient harm by allowing a declining patient not to receive necessary higher level of care which resulted in death.

The findings are:

A. Record review of P3 face sheet shows an admission date of 10/19/2021 at 19:20 (7:20 pm) and a discharge date of 11/06/2021 8:34 am. Discharge reason is 'Expired'. Admitting Diagnosis indicates the following:
Bipolar Disorder
Suicidal ideations
Adjustment disorder with mixed anxiety and depressed mood
Insomnia
Type 2 diabetes mellitus
Heart failure, unspecified
Gastro-esophageal reflux disease without esophagitis
Unspecified osteoarthritis
Unspecified asthma
Dyspnea (difficulty breathing)

B. Record review of P3 Psychiatric Evaluation dated 10/20/2021. States 'Covid-19 status upon admission: Negative'.

C. Record review of P3 "All Orders" show the following respiratory medications prescribed: Albuterol Sulfate (relaxes muscles in the lungs and increases air flow): Administer via inhalation every four hours as needed for acute asthma attack. Budenoside (reduces inflammation in the lungs to help breathe better): Administer via inhalation twice daily for severe chronic obstructive pulmonary disease.

D. Record review of P3 Covid 19 Testing dated 10/25/2021 states that patient tested positive for COVID 19.

E. Record review of P3 Plan of Care and Master Treatment Plan shows a care plan for COPD (Chronic Obstructive Pulmonary Disease) initiated on 10/19/2021. COPD Care Plan was then reviewed by the Interdisciplinary Team on 11/2/2021. There is no evidence of a Positive COVID Diagnosis Care Plan initiated or reviewed after patient was diagnosed on 10/25/2021.

F. Record review of P3 Nurse Note dated:
1. 10/28/2021 states 'patient awake and reporting SOB [shortness of breath], patient provided with nebulizer albuterol treatment'.
2. 10/29/2021 states 'patient refused one meal and Neb [nebulizer, Albuterol] treatment given as needed'.
3. 10/30/2021 at 03:53 (3:53 am) states 'patient can become SOB [short of breath] when speaking'
4. 10/30/2021 at 16:40 (4:40 pm) states 'patient reports feeling SOB, breathing treatments given per order & PRN (as needed). O2 (oxygen) at 2 liters per min via nasal cannula ... signs and symptoms suggestive of covid19 infection'.
5. 10/31/2021 at 03:56 (3:56 am) states 'poor sleep, disrupted, asking for breathing treatment, provided her with one and she rips off mask and throws on floor also rips off oxygen ... will endorse to day nurse to obtain order for PRN oxygen and NEBS'.
6. 10/31/2021 at 15:26 (3:26 pm) states 'patient energy level is poor. O2 at 2 liters per min via Nasal Cannula, as needed and at night'.
7. 11/1/2021 at 01:36 (1:36 am) states 'poor sleep, disrupted, asking for breathing treatment, provided her with one and she rips off mask and throws on floor also rips off oxygen ...will endorse to day nurse to obtain order for PRN oxygen and NEBS'.
8. 11/1/2021 at 13:32 (1:32pm) states 'Abdominal breathing [sign of difficulty breathing] noted'.
9. 11/02/2021 at 22:54 (10:54 pm) states 'poor sleep, disrupted, asking for breathing treatment, provided her with one and she rips off mask and throws on floor also rips off oxygen ...will endorse to day nurse to obtain order for PRN oxygen and NEBS'.
10. 11/02/2021 at 10:58 (10:58 am) states 'Positive productive cough with whitish, thick sputum noted'.
11. 11/02/2021 at 23:09 (11:09 pm) states 'Patient complained of cough. Notified [provider] and ordered and provided Guaifenesin (relieves chest congestion from mucus) 100 mg/ml in dropper'
12. 11/03/2021 at 16:57 (4:57 pm) states 'continues to take off O2 [oxygen]. Does not let techs help her with care'
13. 11/04/2021 at 00:52 (12:52 am) states 'SPO2 (amount of oxygen in the blood) 93% on 4 lpm (liters per minute)' What am I updating here??
14. 11/05/2021 at 01:46 (1:46 pm) states 'O2 SATs (amount of oxygen in the blood) were taken. Patient at 75%. NC [nasal cannula] replaced O2 SAT 91%. Patient has to be continually reminded to keep oxygen on. Patient requested PRN [as needed medication] Albuterol for tightness in her chest.
15. 11/05/2021 at 16:13 (4:13 pm) states 'She continues to take off her O2'.
16. 11/05/2021 at 23:23 (11:23 pm) states 'Pt was asleep and snoring. Nurse tried to arouse pt to take medications. Unable to arouse pt ... unable to give meds.'
17. 11/06/2021 at 01:39 (1:39 am) states 'Patient awoke and was screaming and scooting around on the floor. Patient not wearing oxygen. Nurse and techs helped patient back onto mattress ... Pt given medications that was not given earlier in the evening due to inability to arouse pt from sleep.'
18. 11/06/2021 at 11:08 (11:08 am) states 'At exactly 0750 (7:50 am) this nurse passed through her room to make sure that the nasal cannula was on, this nurse found the patient collapsed. Patient not responding to her name, no chest movements, eyes fixed and dilated, pulse not felt ... Patient dead at 0834 [08:34am]'

G. Record review of P3 Discharge Summary completed by Staff S27, Medical Director, states 'The patient was COVID positive and she has many comorbidities including allergic rhinitis, chronic obstructive pulmonary disease, shortness of breath ... congestive heart failure ... It seems that this combination with the Covid positive may have affected the patient tremendously and sometimes she was taken of the oxygen off and on.'

H. Record review of P3 Medical Practitioner visits shows an admission assessment on 10/19/2021 note states 'Non face-to-face note'. A History and Physical dated 10/20/2021. A Progress Note dated 10/31/2021. There are no other Medical Practitioner visits identified.

I. On 06/16/2022 at 9:30 am in an interview with S3, Chief Nursing Officer, when asked "When a patient shows a medical decline and continues to be non-compliant with the oxygen, What is the care expectation at that point?" S3 response was "That's a change of condition and the doctor should have been notified."

J. Record review of Nursing Policies and Procedures. Subject: Physician and Other Communication/Change in Condition. Complete revision: 7/1/2016. States the following:
a. "Item 3. Notify the physician of the change of medical condition."
b. Under the "Physician Communication Grid" it states to notify the physician that treatment is required within 1 hour if "acute onset or with chest pain, change in VS [vital signs], labored breathing, Oxygen saturation <95%"
c. It then states to notify physician that treatment is required within 4 hours if "gradual onset of SOB [shortness of breath], oxygen saturation 95%".

K. Record review of policy labeled: "Behavioral Health Services Clinical Policies and Procedures" Title: Medical Record Documentation. Revision: 2/1/2020. Under 'Plan of Treatment' Item 3. "Treatment plan reviews are conducted at least weekly or when any major change in the patient's condition occurs."

Based on record reviews and interviews, the facility failed to ensure that assigned personnel was competent and qualified to monitor and/or care for 10 (P1, P2, P16, P18, P19-P24) of 24 (P1-P24) patients reviewed. This deficient practice to ensure staff had proper qualifications can likely cause injury, serious harm, or death to all patients.

The findings are:

Findings for P1:

A. Record review of 6 Q15 (15 Minute Check/1:1 Observation Check Sheet) for Patient (P) P1 dated Friday 03/18/22 at 0030 (12:30 am) - Wednesday 03/23/22 at 0600 (6:00 am) shows 6 of 6 records were incomplete (date not filled out correctly, suicide risk level not done, illegible staff names that had completed sheet and Q15 check initials did not match staff initials or names on form).

B. Record review of P1's Q15 checks dated 03/21/22-03/23/22 from 1800-0600 (6:00 pm - 6:00 am) revealed patient in dining room/bedroom, eating/quiet/sleeping, safe from ligature (a thing used for tying or binding something tightly).
a) At 1800 (6 pm) patient was in the dining room, quiet, safe from ligature.

C. Record review of P1 - Investigation of video recordings from 5:57 pm on 03/22/22 through 6:34 am on 03/23/22.
a) On 03/22/22 at 6:03 pm, patient is seen in the doorway of his room.
b) Patient was last seen at doorway of room at 7:26 pm on 03/22/22.
c) From 5:57 pm on 03/22/22 to 6:34 am on 03/23/22 patient was checked on by staff a total of 9 times.
d) Medical Health Tech (MHT) assigned to patient room for Q15 checks, checked on patient 4 times. On 03/22/22 at 7:13 pm (3 minutes(m) and 46 seconds(s)), on 03/22/22 at 9:54 pm (49 (s)), on 03/22/22 at 11:38 pm (47 (s)) and on 03/23/22 at 12:42 am (8 (s)) for a total of 5 minutes and 30 seconds.
e) Second MHT checked on patient 2 times on 3/22/22 at 10:28 pm (6 (s)) and 10:55 pm (9 (s)), for a total of 15 seconds.
f) Nurse checked on patient 1 time on 03/23/22 at 1:49 am for a total of 12 seconds.
g) On 03/23/22 staff entered room of patient at 1:49 am and no documentation of timeline or of staff entering the room again until 4:58 am.

h) Third MHT was collecting trash out of patient's room and was in room on 03/23/22 at 4:58 am (25 (s)) and on 03/23/22 at 4:59 am (45 (s)) for a total of 1 minute and 8 seconds.
i) At 6:09 am on 03/23/22, "patient was found deceased by nurses."
j) At 6:12 am on 03/23/22, "additional nurses arrive with emergency cart but stay in hallway. Scene appears very chaotic with a total of 15 staff members in the hallway."

D. Record review of P1's medical chart on 6/17/22 revealed, patient was listed as full code. (Full Code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR).

E. On 07/05/22 at 3:15 pm during an interview with Staff (S)30, Mental Health Technician (MHT). S38 was asked what kind of training had been received on Code blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient especially when in cardiac arrest or respiratory distress or failure; also: the attempt to resuscitate the patient.) staff stated. "Honestly, there was not training on code blue. It was kind of more hands on. I just kind of knew from my other employment." When asked about recollection of the evening of 03/22/22, S30 stated, "I was on unit 200. I had room 200 - 206. The man (S31, MHT) that was supposed to be training me had the middle of the unit [S31 assigned area]. He pulled up the wow (computer on wheels), threw on his hoodie and passed out for at least 2 hours when he was supposed to be training me. Every time I walked by, he would see me, and I would give him a little nod and he would wake up." [S30 was not assigned to P1]

F. On 07/05/22 at 3:40 pm during an interview with S25, Licensed Practical Nurse (LPN) when asked about recollection of the morning of 03/23/22, S25 stated, "I heard a blood curdling scream from one of the nurses and ran down the hall. It was a shock to everybody that he had expired. A lot of people there are not emergency room or urgent care people. It was very graphic. Like something out of a horror movie, modeled blue, the eyes, it wasn't like the eyes were closed and peaceful. The body was turning When you're a nurse for 20 years, I knew he was gone for a long time." [S25 was not assigned to P1]

G. Record review of facility policy titled; "Do Not Resuscitate (DNR) Department of Health Hospital Standards" dated 02/01/20 states under "Policy" "Hospital staff will follow the patient's Advance Directive in accordance with the applicable law and regulation and assure that patients' rights are respected when decisions are made to withhold resuscitative services." "Procedures" "12. Code Status Identification. The Case Manager/Social Worker or Nursing Designee will ensure the bracelet/necklace or other identification such as a sticker on the chart or color-coded bracelets (green and red as distinguished below). The Case Manager/Social Worker or Nursing Designee will also ensure that a patient's code status is prominently and clearly displayed in patient's medical record and on the patient. * FULL CODE. To signify a patient is FULL CODE and should be resuscitated, the Facility will prominently note the file by placing a green sticker on the inside cover of the patient's medical record. Absent any appropriate DNR Order/Identifier, Hospital staff will respond to medical emergencies with CPR measures and a FULL CODE will be instituted."

H. Record review of facility policy titled; "Code Blue" dated 02/01/22 states under "Policy" "An emergency department is not maintained on the campus of the Hospital; however, the Hospital ensures that the emergency medical needs of the individuals are met 24 hours per day, 7 days per week. All patient care staff will maintain current CPR certification. All patient care providers will receive education on Code Blue and Code Blue activation. Staff competency on Code Blue and Code Blue activation will be completed on orientation, annually and as needed." "Purpose:" "To assure optimal patient care during a medical crisis, respiratory distress, respiratory arrest or cardiac arrest, including referral or transfer of the individual when deemed necessary." Procedures" "1. Announce Code Blue. 2. The staff person trained in CPR (cardiopulmonary resuscitation) and first aid, who first responds to the emergency will evaluate the patient's condition. 3. Direct care staff finding the patient in distress or arrest will initiate the Basic Life Support protocols. 5. Only staff members with current certification in CPR may perform cardiopulmonary resuscitation. Disposable mouthpieces or Ambu bags are available for administration of CPR. 8. The charge RN will manage the Code Blue until a physician arrives."

Findings for P2:

I. Record review of 25 Q15 checks dated Thursday 2/02/22 at 1800 (6 pm) - Monday 2/28/22 at 2245 (10:45 pm) for P2 revealed records were incomplete, (day of the week information not completed. suicide risk level not completed, multiple Q15 checks not completed and illegible staff names. Q15 check initials do not match staff initials or names on form. Some of the Q15 check were completed but were not initialed by staff).

Findings for P16:

J. Record review of 15 Q15 checks dated Thursday 6/10/22 at 1700 (5 pm) - Friday 6/25/22 at 1045 (10:45 am) for P16 revealed records were incomplete, (suicide risk level not completed, multiple Q15 checks not completed, illegible staff names, Q15 check initials do not match staff initials on form, Q15 check done and not initialed by staff).

Findings for P19:

K. Record review of 1 Q15 check dated Wednesday 6/15/22 at 2330 (11:30 pm) - Thursday 6/16/22 at 2315 (11:15 pm) for P19 revealed record was incomplete, (suicide risk level not completed, record, multiple Q15 checks not completed, illegible staff names, Q15 check initials do not match staff initials or names on form.

Findings for P20:

L. Record review of 1 Q15 check dated Wednesday 6/15/22 at 2330 (11:30 pm) - Thursday 6/16/22 at 2315 (11:15 pm) for P20 revealed record was incomplete, (suicide risk level not completed, multiple Q15 checks not completed, illegible staff names, Q15 check initials do not match staff initials or names on form).

Findings for P21:

M. Record review of 1 Q15 check dated Wednesday 6/15/22 at 2330 (11:30 pm) - Thursday 6/16/22 at 2315 (11:15 pm) for P21 revealed record was incomplete, (suicide risk level not completed, multiple Q15 checks not completed, illegible staff names, Q15 check initials do not match staff initials or names on form).

Findings for P22:

N. Record review of 1 Q15 check dated Wednesday 6/15/22 at 2330 (11:30 pm) - Thursday 6/16/22 at 2315 (11:15 pm) for P22 revealed (suicide risk level not completed, multiple Q15 checks not completed, illegible staff names, Q15 check initials do not match staff initials or names on form).

Findings for P23:

O. Record review of 16 Q15 checks dated Wednesday 02/09/23 at 2330 (11:30 pm) - Wednesday 02/22/22 at 1115 (11:15 am) for P23 revealed (day of the week information not completed, suicide risk level not completed, multiple Q15 checks not complete, illegible staff names, Q15 check initials do not match staff initials or names on form, Q15 check done and not initialed by staff).

Findings for P24:

P. Record review of 1 Q15 checks dated Sunday 6/05/22 at 2330 (11:30 pm) - Monday 6/06/22 at 2315 (11:15 pm) for P24 revealed record was incomplete (suicide risk level not completed, multiple Q15 checks not completed record, show illegible staff names. Per form instructions, staff is to initial and print name on form. Q15 check initials do not match staff initials or names on form).

Findings for P18:

Q. Record review of 1 Q15 check dated Wednesday 1/19/22 at 2330 (11:30pm) - Thursday 1/20/22 at 2315 (11:15 pm) for P18 revealed record was incomplete (missing suicide risk level, Q15 minute checks not done, illegible staff names). Record revealed only one Q15 had been completed at 1915 (7:15 pm) on 01/20/22. Stating patient in dining room, quiet and safe from ligature.

R. Record review of 5-day summary dated 02/03/22, done for internal investigation of elopement revealed, "On January 20, 2022, at approximately 19:15 pm, patient was found walking outside the secure building by staff family member." During the course of the investigation, it was discovered by the Chief Nursing Officer and unit manager, Mental Health Tech (MHT) S28 responsible for the Q15 safety checks for rooms [8 rooms assigned to MHT] had failed to appropriately complete the rounds.

S. Record review of Nursing note dated 01/21/22 at 0125 (1:25 am) revealed, "at 1925 (7:25 pm) hours P18 was brought back to the facility by a stranger after she was picked up from the street following her escape from the facility." "Asked her who helped her out of the facility since all doors were securely closed, she laughed and said I pushed all the doors by myself."

T. Record review of Patient /Resident Incident/Accident Investigation Worksheet dated 01/21/22 at 1925 (7:25 pm) by S36, Registered Nurse, states, "Patient eloped at around 1925 (7:25 pm) from the facility. Was brought back by a stranger who picked her up from the street. She clearly told the stranger that she had escaped from the facility."

U. On 06/16/22 at 10:05 am during an interview with S17, Registered Nurse, when asked What the process for an Elopement was and had S17 received any training. S17 stated. "Have not received training on elopement. The process would be to inform staff, the medical provider, call the family, and the police."


V. On 06/16/22 at 10:35 am during an interview with S24, Mental Health Technician, when asked "Do you know what a code pink (the alert that a patient is unaccounted for) is?" Staff answered, "I do not."

W. On 06/16/22 at 3:04 pm during an interview with S26, Registered Nurse, when S26 was asked, what kind of training S26 had with elopement. S26 stated. "So, the training, I didn't receive any about elopement. I asked and they told me about we can inform the police and inform the supervisor."

X. Record review of facility policy titled, "Patient Monitoring - Frequency Of" dated 02/01/20 states under "Procedures" "1. Patient monitoring will occur at a minimum of every 15 minutes."

Y. Record review of facility policy titled; "Elopement" dated 02/01/20 states under "Procedures" "4. If the patient cannot be located on the unit and Hospital security is notified, a designated staff member will announce a CODE PINK via the overhead page system."


46429

Based on observation, interview, and record review, the facility failed to maintain an ongoing program that would prevent mishandling of patient's blood tissue samples for 1 (Patient (P) #14) of 1 (Patient (P) #14) patient blood sample observed in the supply room, to be sent to a laboratory for complete and accurate testing. This failed practice is likely to lead to poor treatment and delayed progression and increase the risk of injury to patients because of inaccurate blood testing results.

The findings are:

A. On 06/14/2022 at 9:45 am, during tour of one of the facility's unit, in the IDF (name of room) supply room where patient blood sample collections are stored and sent to a laboratory for testing the following was observed:
1. One (1) Vacuette (brand name) blood collection tube lavender cap in a styrofoam (white soft insulation) holder for blood collection tubes filled with blood (approximately 2 ml (measurement)) and a label on the tube with Patient (P) #14's name and date of birth.

B. On 06/14/2022 at 9:50 am, during an interview, Staff (S) #3 CNO (Chief Nursing Officer) confirmed the blood collection tube should not have been in the styrofoam holder and the blood sample was collected from the patient on Sunday 06/11/2022. S#3 confirmed when patient blood samples are collected on a weekend should be sent to lab by Monday of the following week. S #3 confirmed because the blood tube was spun (small samples of the patient's blood are taken and spun in a centrifuge (device that uses centrifugal force to separate various components of a fluid), allowing platelets (bone marrow) and blood plasma (clear liquid portion of the blood) to be isolated from other blood components)) by a staff member and it should not have been, unable to use the blood sample and S#3 discarded the tube.

C. Record Review of Manual: Behavioral Health Services Clinical Policies and Procedures, Section: B, under section Policy, "To have information available to appropriate personnel who might collect a venous blood specimen from a patient for laboratory analysis." under section Purpose:, "To outline policies and procedures for the appropriate collection of venous blood specimens from patients for laboratory analysis. List of commonly used blood tubes, colors, additives and laboratory use., Lavender- EDTA (ethylenediaminetetra-acetate); removes calcium to prevent blood from clotting; fluoride inhibits glycol's and stabilizes test values, Hematology testing.

D. Record Review of Manual: Behavioral Health Services Clinical Policies and Procedures, Section: S, under section Purpose, "To provide guidelines for the appropriate collection, transportation, handling and processing of patient specimens for microbiological analysis and/or culture." Under section Procedures, 2. Transportation of Specimens to the Laboratory, "A. Specimens containing blood or body fluids will be placed in sealed biohazard bags for transport to the laboratory."

Based on record review, interview, and observation, the facility failed to maintain a system for monitoring of equipment brought in by staff for patient monitoring (oxygen monitor, blood pressure monitor) for all patients receiving treatment in this facility. This failed practice can lead to use of equipment that has not been calibrated (of an instrument's readings correlated with those of a standard) or monitored for quality and can lead to patient harm.

The findings are:

A. Record review of facility's policy titled, "Plant Operations Medical Equipment Plan-2022 original 01/20, revised 01/22. Confirmed on Page 4 section "F-G Inspection, Testing, Maintenance - The Central Supply (C/S) Manager and Safety Officer (SO) have overall responsibility for the strategy and inspection, testing and maintenance of the medical equipment in the medical equipment program. The equipment inspection, testing and maintenance schedule is assessed to minimize risks. Recommendations of the C/S Manager and SO are based on manufacturer's criteria, risk levels and current organizational experience. These recommendations are reviewed and approved by the SC. All medical equipment included in the program is inspected before initial use and is inspected, tested and maintained according to the approved strategy"

B. Record review of facility's "PM Work Order Report" dated 02/01/22 through 03/09/22 shows the facility has (2) Monitor, NIBP [robo-nurse trees] for the entire facility that are being monitored and receiving maintenance.

C. Record review of facility's "Active Equipment List" dated 06/16/22 shows 2 Monitor, NIBP [robo nurse] units each located in the nurse's station on each of 2 units. These units are checked semiannually last check in February 2022.

D. On 06/16/22 at 9:35 am during interview with S(staff) 3 (Director of Nursing) who confirmed, "There are some very expensive machines that have blood pressure and oximeters but if you don't plug it in it will not work. It has to be cleaned between patients and that takes time. We have portable O2 saturation machines and blood pressure cuffs (monitors). I don't care if they (staff) bring their own, but I will show them a drawer where there is plenty of equipment for them to use. Director of Plant Operations does a walk through every week and there is nothing that we might need that we can't get. If they can't find it ask for it. It is just the communication that needs to improve. I am trying to break the culture of being afraid of asking for supplies and information."

E. On 06/16/22 at 10:45 am during interview with S18 (Registered Nurse) who confirmed, "[For use of personal equipment] I worked on night shift, recently came to day shift (first week.) Staff carries own medical supply equipment, in a backpack and keeps it at the nurse's station in case of an emergency. Has used own pulse oximeter on patients before, has not been told cannot use own purchased. Has heard of other staff using own equipment. It has not been brought up to the facility. It was never said okay to bring your own.

F. On 06/16/22 at 11:30 am, during interview with S19 (Mental Health Tech) who confirmed, "[For use of personal patient monitoring equipment] I have bought pulse oximeter and blood pressure cuff and use them on patients. I am not aware of the facility's policy of using personal bought equipment."

G. On 06/16/22 at 2:21 pm during interview with S20 (MHT) who confirmed, "The facility has robot vital machines, but staff including me bring their own equipment. In training was told if have own equipment can bring it but need to disinfect after every patient."

H. On 06/16/22 at 11:50 am during interview with S21 (MHT) who confirmed, "I have access to equipment here at the facility, have purchased to use their own. The facility allows to bring own equipment to use for patient care.

I. On 06/16/22 at 1:45 pm during interview with S(staff) 2 (Director of Quality) who confirmed, "Staff are not using their own equipment, they are using the robot nurses and they need to plug them in. I think we have 3 or 4 robot nurses (3 were confirmed). If staff is bringing equipment, they are not being required to. I write what staff says when I investigate incidents, so if they are saying they are using their own equipment I write it. We are not too busy, we are not understaffed, we have sufficient FTE's (full time employees) to take care of the patients we have, we need to take care of patients and Covid is not going away so we have to change with the ways things are changing in the facility. The bar is not going to lower, the staff needs to step up, the facility has sufficient manual equipment for nurses to use, there is no need for staff to bring their own."

J. On 06/17/22 at 9:00 am during observation of patient treatment floors, observed (3) robot-nurse machines. One on each patient unit, none in the COVID-19 unit and (1) in patient admissions. There are a total of (29) patients on 100's unit to include (12) on COVID-19 section and (32) patients on the 200's unit. Each unit has (1) robo-nurse unit for use on all patients for the unit.

Based on observation, record review, and interview, the facility failed to ensure staff is completing refrigerator temperature logs specific to all patient blood samples collected to be sent to the lab and patient medications stored in a refrigerator. This failed practice is likely to affect all patients requiring lab work and is likely to increase inaccurate blood testing results and medications that require cold storage will expire quickly at room temperature, rendering them toxic (poisonous) or less effective (no result.)

The findings are:

A. On 06/14/2022 at 9:55 am, during tour of one of the facility's unit, observed in the IDF (name of room) supply room where blood samples collection from patients are stored and sent to a laboratory for testing the following was observed:
1. The refrigerator temperature log for storing for patient blood samples and medication was not complete with a staff members initials to be checked on 6 pm to 6 am shift for dates 06/12/2022 and 06/13/2022.

B. Record review of Behavioral Health Services Clinical Policies and Procedures, undated, revealed, Section: R, Title, "Refrigerator/Freezer Temperature Control", under section Purpose, "To facilitate and ensure accurate and continual documentation of all refrigerators and freezer temperatures throughout the Hospital, satellite areas and physician offices. Refrigerator and freezers should be maintained at the correct temperature to protect the food from spoiling or medication from losing it potential." Under section Policy, "The temperature of all refrigerators and freezers will be maintained within the appropriate temperature ranges indicated below and recorded on a log daily by the staff of the department."

C. Record review of Pharma-Mon (name of entity), undated, revealed, "For medical refrigerators, typical prescribed levels of the unit's temperature range between 2 C (Celsius) and 8 C (36 F (Fahrenheit) and 46 F. temperatures).)

D. Record review of Lab Refrigerator & Checklist Log dated Year 2022, Month June, under Current Temperature:, revealed: 12th - 13th no refrigerator temperature checks were completed.

E. On 06/14/2022 at 10:00 am, during an interview, Staff (S)#3 CNO (Chief Nursing Officer) confirmed the refrigerator temperature log was not initialed by a staff member verifying the temperature of the refrigerator had been checked for 06/12/2022, and 06/13/2022. S#3 confirmed the refrigerator temperature logs are completed by a staff member in the 6 pm to 6 am shift. S#3 confirmed the range of 68-77 is incorrect, the temperature for storing patient blood samples and patient medications on the Lab Refrigerator & Checklist Log should list as 36F- 46F and as per Pharma-Mon.

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program which would prevent, identify, and manage infections or communicable diseases by 4 (Staff (S)#9, S#10, S#12, and S#13) of 4 staff and 3 (Patient (P)#11, P#12, P#13) of 3 patients observed not wearing PPE (Personal Protective Equipment) per CDC (Centers for Disease Control and Prevention) guidelines and not disposing of used gowns properly. This failed practice places patients at risk for infections while receiving treatment and staff while providing patient care.

The findings are:

A. On 06/14/22 at 10:05 am, during observation at the nurse's station for non-COVID-19 (upper respiratory symptoms) unit (per facility administration for safety precautions have staff and patients wear a mask and a gown) the following was observed:
1. Staff (S) #10 (Mental Health Technician) walked into the nurse's station area without an N95, K95, or surgical mask (respiratory face covering)

2. S#9 (Activity Coordinator) was observed on 06/14/22 at 10:10 am, wearing a gown with the strap near the neck area untied walking with patients (P#11, P#12, P#13) down the hall towards the patient room area. Prior to entering the unit near the double doors the patients took off the gowns and handed the gowns to S#9 to be placed in the trash.

3. S#13 (Nurse Practitioner) was observed on 06/14/2022 at 10:25 am, standing near the open double door of the unit and speaking with another staff member only wearing a face mask and no other PPE (Personal Protective Equipment)

4. S#12 (Social Worker) was observed on 06/14/22 at 10:40 am, leaving a therapy session room without a gown, walking a patient down the hall. Once the patient entered the unit, S#12 stayed near the double doors talking with another staff member and entered the unit while holding the door.

B. On 06/14/22 at 11:05 am, during an interview, Staff (S)#6 (Registered Nurse Manager Dayshift) confirmed S#10 MHT was not wearing any type of mask.

C. On 06/14/22 at 11:10 am, during an interview, S#3 CNO (Chief Nursing Officer) confirmed all staff is required to wear an K95 or an N95 (respiratory face covering) at this moment due to having several COVID-19 patients in the past few days. S#3 confirmed when entering the unit behind the double doors staff are required to wear gowns.

D. On 06/15/22 at 8:40 am, during an interview S#2 (Director of Quality/Compliance), confirmed staff is required to wear an N95 or K95 (respiratory mask) in both the COVID-19 and non-COVID-19 units of the facility because there were a few patients that tested positive for COVID-19. S #2 confirmed staff is required to wear gowns when interacting with patients in sessions or group or entering the units even if speaking with other staff near the entrance to the units.

E. Record Review of Nursing Policies and Procedures, undated, revealed, under Subject: "Personal Protective Equipment: Infection Prevention and Control", under Policy: "Facility staff follow clinical practice standards in the selection, use, donning (putting on) and doffing (taking off) of personal equipment", under Procedures, Item 3. letter A. "Apply gown, being sure it covers all outer garment. Pull sleeves down to wrist. Tie securely at neck and waist." Under Item 7. Letter C. "Untie neck strings and untie back strings of gown. Allow gown to fall from shoulders, touch inside of gown only. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams, and fold inside out into a bundle, discard."