HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged, by the Governing Body for 3 of 3 (S8Rad, S9Rad, S10Rad) radiologists' credentialing files reviewed for credentialing and privileging.

Findings:
Review of Medical Staff and Professional Staff By-laws revealed in part, membership on the staff of this hospital is privilege that shall be granted only to professionally qualified and currently competent practitioners (including those Practitioners under contract with the Hospital) who:
a ) Continuously meet the qualifications, standards, and requirements set forth in these Bylaws and Hospital policies;
b) Are professionally qualified to provide quality health care, treatment, and services which need to be provided at facilities within the Hospital as such need is determined to exist from time to time by the Board; and
c) Comply with the provisions of these Bylaws and Hospital policies.
Appointment to and subsequent membership on the Staff shall confer on the Member only such Clinical Responsibilities, Prerogatives, and other rights as have been granted by the Board and/or Medical Executive Committee (MEC) in accordance with these Bylaws.

Review of Patient #R3's radiology report revealed he had an x-ray of his left foot on 02/19/2020 and the report was read by S10Rad.

Review of Patient #R4 radiology report revealed he had an x-ray of his right tibia/fibula on 02/16/2020 and the report was read by S8Rad.

Review of Patient #R5 radiology report revealed he had an x-ray of his right foot on 11/14/2019 and the report was read by S9Rad.

An interview was conducted with S7Dir on 03/03/2020 at 3:00 p.m. S7Dir confirmed the telemedicine radiologists with Company "A" had not been credentialed and approved by the Medical Executive Committee of the hospital.

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 patients were observed by MHTs in accordance with physician orders and hospital policy for 2 (#R7, #R9) of 3 (#2, #R7, #R9) patients observed on 1:1 level of supervision.
2. failure to ensure patients did not have unsupervised access to contraband items/items to be used with staff supervision only (per hospital policy) for 4 (#4, #R1, #R6, #R8) of 4 patients observed in the dayroom, unattended by staff; and
3. 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.

Findings:

1. Failure to ensure patients on 1:1 level of supervision were observed by MHTs in accordance with physician orders and hospital policy.

Review of the hospital policy titled, "Level of Observation", revealed in part: One - to - One (1:1 Observation) is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient ( i.e. one staff member to one patient). The staff member assigned to 1:1 cannot be assigned any other patients or tasks during that period. Close proximity is to be maintained in that the staff member must never be separated from the assigned patient by a barrier such as a closed door or window. An order may specify the proximity to be maintained (e.g. at arm's length). The assigned member must maintain direct visual observation of the patient at all times, including when using the bathroom and/or shower. As it is crucial for the staff member assigned 1:1 observation to be attentive at all times, it is advisable that a staff member never be assigned 1:1 for more than 2 hours without being relieved for a period of not less than 30 minutes.

On 03/04/2020 at 12:24 p.m. S17MHT was observed walking with her assigned 1:1 level of observation patient (Patient #R7- on Elopement Precautions) walking behind her, following her, and not remaining within her direct line of sight. Further observation revealed S17MHT then walked into the glass enclosed nurses station, closed the door, and left Patient #R7 outside of the nurses' station. S17MHT was noted to be facing forward, looking down toward the desk, while Patient #R7 (on elopement precautions) remained to her right, outside of the nurses' station, with the door closed. The observation ended at 12:29 p.m. (a total of 6 minutes). No other staff members were noted to be watching the patient.

On 03/04/2020 at 12:31 p.m. S5MHT was observed standing in the doorway of his assigned patient's room (Patient #R9 -on Homicidal Ideation Precautions), facing the hallway. S5MHT reported he was assigned Patient #R9 and confirmed the patient was on 1:1 level of observation. S5MHT indicated Patient #R9 was in his room using the restroom. S5MHT failed to maintain visual observation of Patient #R9 while he was using the restroom. The duration of the observation was from 12:31 p.m. - 12:38 p.m. (a total of 7 minutes).

In an interview on 03/04/2020 at 12:45 p.m. with S3ClinEduc, she verified S5MHT and S17MHT should have maintained direct visual observation of their assigned 1:1 level of observation patients at all times. S3ClinEduc confirmed MHTs should not have their assigned 1:1 patients walking behind them. She also confirmed S17MHT should not have been separated physically, by the closed door to the nurses' station, from Patient #R7. S3ClinEduc verified 1:1 level of supervision should also be maintained, by the patient's assigned staff, when the patients were using the restroom.


2. Failure to ensure patients did not have unsupervised access to contraband items/items to be used with staff supervision only (per hospital policy).

Review of the hospital policy titled,"Control of Contraband and Dress Code", revision: 03/21/208, revealed in part: Beacon Behavioral Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or are counter-therapeutic. Such items are considered "contraband." Additionally, clinical staff have identified some items of clothing (such as shirts containing metal spikes) and accessories (such as belts and steel - toed boots) present a safety risk. As a result, Beacon Behavioral Hospital has identified certain clothing as prohibited.
At Beacon Behavioral Hospital there are 3 categories of contraband: 1. Restricted: Items that are secured away from patient access but may be used by the patient with staff supervision and/or at scheduled times; 2. Prohibited: Items that are prohibited from the secure unit and/or patient access at all times; and 3. Illicit: Items that are not legally able to be possessed by the patient.
This hospital utilizes a number of methods for controlling the existence of contraband, including but not limited to: Checking and inventorying patient belongings on admission and when brought in during hospitalization; Ensuring patients don't have access to high-risk items; Checking patient rooms daily; and Obtaining orders to search a patient's room if there is reason to believe that a high-risk item may be present.
A patient admitted to an acute, psychiatric inpatient setting may be (potentially) impulsive, impressionable, self-destructive, violent, and sexually promiscuous. Additionally he/she may have thought disturbances (hallucinations and delusions), a tendency to abuse substances, poor judgement, and cognitive impairment. As a result, it is crucial to the physical and emotional safety of all patients, that the inpatient environment be free of items that pose an obvious threat. Maintaining a safe environment is the responsibility of all staff members.
Contraband: 1. Restricted items: This category includes items a patient will be permitted to access during hospitalization, on a limited basis or with supervision. Items may be secured in a designated locked room or in the nurses' station. Included in this category are: a. Toiletries: toothpaste, toothbrush, deodorant (stick or roll-on), shampoo, conditioner, hairbrush, and comb.
2. Prohibited items: This includes any items patients will not be permitted to access at any time while on the unit. These items include: sharp objects - cans, tacks, pieces of wire, nails and screws, plastic bags, cords, strings, rope, aerosols and spray cans, and alcohol based hand sanitizer.
Procedure: 8.Once a day, during security rounds, a staff member will check each patient room and commons area for contraband. This is different from conducting a thorough search, which requires a prescriber's order.

Review of the Red Cross Comprehensive Guide to First Aid and CPR, choking is defined as occurring when the airway is partially or completely blocked by a foreign object, by swelling in the mouth or throat, or by fluids (vomit or blood). Further review revealed plastic bags were included in the list of objects that presented a choking risk if swallowed.

Observation Dayroom A:
An observation was conducted on 03/02/2020 at 12:55 p.m. of Patient #4 in Dayroom A on the telephone with no staff members present in the dayroom. The telephone had a long bungee cord attached to the receiver of the phone ( potential ligature risk). Patient #R1 was also in Dayroom A, seated in a wheelchair, at a table, with no staff members present, observing the patients. Also observed in the dayroom was a large outdoor trash can with a plastic liner in the trash can. An unlocked cabinet was observed to contain packets of plastic eating utensils that were available to the unsupervised patients at the time of the observation. Aerosol spray cans of chemicals and 2 partially used bottles alcohol based hand sanitizer were noted to be unsecured in the dayroom and available to patients.

Review of Patient #4's medical record, navigated by S3ClinEduc, revealed the patient was admitted on 02/24/2020, with homicidal ideations toward her 3-week old infant. Further review of the medical record revealed she was currently on aggression precautions and q 15 minute observations.

Review of the current nursing report sheet, dated 03/03/2020, revealed Patient #R1 was on aggression precautions and q 15 minute observations.

An interview was conducted with S4PlantOps on 03/02/2020 at 1:00 p.m. He reported the patients should not be in the dayroom unsupervised.

On 03/04/2020 at 12:15 p.m. an observation was made of the large commons area - Dayroom A . Three patients ( Patient #R1, #R6, and #R8) were observed seated in the room, unattended by a staff member. Patients #R1 and #R8 were completing their lunches. Further observation revealed Patient #R1 had a pile of small, soft, thin plastic bags (potential choking hazard) on the table in front of her. Patient #R8's styrofoam meal box also had food items contained in the same plastic bags ( a total of 3 of them). The room was also observed to have a telephone with a long cord, a television with exposed wires/cords and bracket (all potential ligature risks). A packet of plastic dinnerware (can be broken and used for cutting/self-harm/harm of others) was also noted on one of the tables.

Review of the nursing report/assignment sheet revealed Patient #R1 was on aggression precautions with q 15 minute observations, Patient #R6 was on fall precautions with q 15 minute observations, and Patient #R8 was on Suicidal Ideation Precautions with q 15 minute observations.

In an interview on 03/04/2020 at 9:10 a.m. with S8DM, she confirmed plastic utensils were used by patients for meals and should have been secured in a locked cabinet to prevent unsupervised patient access. She indicated MHT staff were supposed to ensure patients did not have possession of the utensils after meal service and to make sure the utensils were secured after each meal.

In an interview on 03/04/2020 at 12:30 p.m. with S3ClinEduc, she confirmed the plastic bags should not have been in the patients' meal boxes and the plastic utensils should not have been available to the patients unsupervised. S3ClinEduc also confirmed there was no staff present, supervising the patients in the room with identified safety risks, at the time of the observation.


3. Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for being a danger to self or others.

Review of the hospital's policy for Monitoring Conditions in the Environment, revealed in part, the hospital conducts environmental tours every six month in patient care areas to evaluate the effectiveness of previous implemented activities intended to minimize or eliminate environment risk in the environment. The hospital conducts annual environment tours in non-patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in environment. The hospital uses its tours to identify environmental deficiencies, hazards, and unsafe practices.

Review of the hospital's policy defining Aggression/Violent Behavior Precautions revealed in part: Aggression/violent behavior precautions are ordered when a patient, by behavior, verbalization, history, or by report presents a risk of violence towards others, regardless of the specific type of risk (i.e. fighting, homicide, sexual assault). The determination for ordering these precautions may be made based on verbal threats, threatening behavior, reports, or history. The following components of Aggression/Violent Behavior Precautions ...Sharp restriction-staff members are prohibited from providing those sharp items typically allowed for patient use with supervision and/or with time restrictions (e.g. razors, etc.) 10 feet Parameter- the patient is required to remain in a minimum of 10 feet away from individuals that are identified as potential victims up to and including all peers.

Observations of the inpatient unit on 03/02/2020 from 12:25 p.m. - 12:45 p.m. revealed the following:
1. Hallway of "L" hall:
a. non-tamper proof screws in bulletin board
b. elbow hinge on door in alcove with double doors (located across from the social services office), unable to be visualized by looking down the hall - potential ligature anchor point;
c. plastic bag noted in trash can in seclusion room

2. Small commons area/group room, located beside the conference room:
a. non-tamperproof screws noted in the sink cabinet, window frame in the door (entry door), in the wooden bookcase, in the bracket securing the television to the wall.;
b. gooseneck faucet and sink knobs - potential ligature anchor point;
c. bracket for television - potential ligature anchor point;
d. flanged handles of metal cabinet - potential ligature anchor point;
e. elbow hinge on door - potential ligature anchor point;
f. television cords accessible to patients - potential ligature risk; and
g. broken/cracked plastic front covering of air conditioning unit - potentially used for self harm, could expose wires inside of unit.

S2DON, present during the observation, confirmed patients could be present in the room unattended if they were on q 15 minute observation level. S2DON also confirmed the above referenced safety risks and pointed them out to S4PlantOps who was also present during the observation.

3. Room L- 101:
a. non- tamperproof screws protruding from the name plate and dry erase board.
b. 2 - nails, approximately 1 1/2 inches long protruding from wall where a painting had been removed. The nails were easily removed from the sheetrock wall by the surveyor - potential use for self harm or for harm of others.
c. toilet not flush with the wall, base of toilet exposed- potential ligature anchor point.

4. Room L - 109:
a. hairbrush with hair in it noted under the mattress in a room that was deemed clean and ready for a new patient.
b. toilet not flush with the wall, base of toilet exposed- potential ligature anchor point.

5. Room L- 108: deodorant under mattress - considered restricted item to be used only with staff present.

6. Room L - 106: deodorant- considered restricted items to be used only with staff present.

7. Room S - 14
a. Outside enclosure securing air conditioning unit broken, pieces missing exposing parts of the unit - potentially used for elopement- access to the outside.;
b. Right side of plastic covering of the air conditioning unit (inside facing part of the unit), cracked and could be lifted.

S7Dir, present during the observation, confirmed the outside enclosure securing the air conditioning was unit broken, with pieces missing, exposing parts of the unit. S7Dir also confirmed patient elopements have occurred when patients pushed air conditioning units out of the wall and eloped through the opening to the outside.

8. Room S- 16: toothbrush and toothpaste in room - considered restricted items to be used under staff supervision.

9. Room S-20: enclosure box for cords of air conditioning unit cracked , allowing potential patient access.

10. Room S- 22: non - tamper proof screws in head of bed.

11. Toilets observed in all patient rooms were noted to have bases exposed and were not flush to the wall, providing access for potential ligature anchor.

S2DON, present during the observations, confirmed the safety issues noted above. S2DON also confirmed patients on q 15 minute observation level could be in their rooms unattended by staff for 15 minutes at a time ( in- between q 15 minute observation documentation intervals).

12. An observation of the inpatient unit on 03/02/2020 between 11:00 a.m. and 1:25 p.m. revealed non tamper proof screws in the door hinges and latch plates for the following rooms: patient belongings room, L103, L104 and L108. The observation also revealed non tamper proof screws in the Dry Erase Board for rooms: L103, L106 and L110. S4PlantOps, present during the observation, verified the above findings.


Observation Dayroom A:
An observation was conducted on 03/02/2020 at 12:55 p.m. of Patient #4 in Dayroom A on the telephone with no staff members present in the dayroom. The telephone had a long bungee cord attached to the receiver of the phone ( potential ligature risk). Patient #R1 was also in Dayroom A, seated in a wheelchair, at a table, with no staff members present, observing the patients. During the observation the surveyor pushed on a door on the back wall of the dayroom and the door opened and revealed a hallway with numerous doors. One of the doors had an elbow hinge at the top of the door, which was a potential ligature risk. A second door had two handles on the door, both of which could used as a ligature anchor point. There was no camera in this hallway and the hallway could not be viewed from Dayroom A due to the door located between the dayroom and the hallway.
Further observation revealed a wall mounted TV with an exposed extension cord hanging behind a wooden shelving unit that was secured to the wall with metal L brackets leaving a gap which could be used as a ligature point. The room also contained 7 heavy wood framed chairs with open wooden arm rest that could be used as a ligature point.

Review of Patient #4's medical record, navigated by S3ClinEduc, revealed the patient was admitted on 02/24/2020, with homicidal ideations toward her 3-week old infant. Further review of the medical record revealed she was currently on aggression precautions and q 15 minute observations.

Review of the current nursing report sheet, dated 03/03/2020, revealed Patient #R1 was on aggression precautions and q 15 minute observations.

An interview was conducted with S4PlantOps on 03/02/2020 at 1:00 p.m. He reported the patients should not be in the dayroom unsupervised, or on the phone, and the door between Dayroom A and the hallway should be locked.










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Based on observation, record review, and interview, the hospital failed to ensure clear expectations for patient safety and quality of care were established and addressed through the hospital's QAPI program. This deficient practice was evidenced by failure of the hospital to identify and mitigate safety risks observed in the patient environment, and failure to address the unsanitary environmental conditions and environmental disrepair as issues to be addressed through the hospital's QAPI program.

Findings:

Safety risks in the environment:

Observations of the inpatient unit on 03/02/2020 from 12:25 p.m. - 12:45 p.m. revealed there were non-tamper proof screws and nails located throughout the hospital, elbow hinges, faucets/knobs/closet handles, toilet bases not flush with the walls - all potential ligature anchor points, that were accessible to the patients. Television cords were accessible to patients in commons areas and patients were observed in the rooms without staff being present. Also observed was a broken outside enclosure used to secure an air conditioning unit and half of it was missing. The broken enclosure could potentially allow the air conditioning unit to be pushed out and the opening could be used for elopement/access to the outside.

S2DON, present during the observations, confirmed patients could be present in their rooms/commons area rooms unattended if they were on q 15 minute observation level. S2DON also confirmed the above referenced safety risks and pointed them out to S4PlantOps who was also present during the observation. S7Dir confirmed the broken air conditioner enclosure could present an opening to the outside for elopement.

Observation Dayroom A:
An observation was conducted on 03/02/2020 at 12:55 p.m. of Patient #4 in Dayroom A on the telephone with no staff members present in the dayroom. The telephone had a long bungee cord attached to the receiver of the phone ( potential ligature risk). Patient #R1 was also in Dayroom A, seated in a wheelchair, at a table, with no staff members present to observe the patients. During the observation the surveyor pushed on a door on the back wall of the dayroom and the door opened and revealed a hallway with numerous doors. One of the doors had an elbow hinge at the top of the door, which was a potential ligature risk. A second door had two handles on the door, both of which could used as a ligature anchor point. There was no camera in this hallway and the hallway could not be viewed from Dayroom A due to the door located between the dayroom and the hallway. Also observed in the dayroom was a large outdoor trash can with a plastic liner in the trash can. An unlocked cabinet was observed to contain packets of plastic eating utensils that were available to the unsupervised patients at the time of the observation. Aerosol spray cans of chemicals and 2 partially used bottles alcohol based hand sanitizer were noted to be unsecured in the dayroom and available to patients. Further observation revealed a wall mounted TV with an exposed extension cord hanging behind a wooden shelving unit that was secured to the wall with metal L brackets leaving a gap which could be used as a ligature point. The room also contained 7 heavy wood framed chairs with open wooden arm rest that could be used as a ligature point.

An interview was conducted with S4PlantOps on 03/02/2020 at 1:00 p.m. He reported the patients should not be in the dayroom unsupervised, or on the phone, and the door between Dayroom A and the hallway should be locked.

On 03/04/2020 at 12:15 p.m. an observation was made of the large commons area - Dayroom A . Three patients ( Patient #R1, #R6, and #R8) were observed seated in the room, unattended by a staff member. Patients #R1 and #R8 were completing their lunches. Further observation revealed Patient #R1 had a pile of small, soft, thin plastic bags (potential choking hazard) on the table in front of her. Patient #R8's styrofoam meal box also had food items contained in the same plastic bags ( a total of 3 of them). The room was also observed to have a telephone with a long cord, a television with exposed wires/cords and bracket (all potential ligature risks). A packet of plastic dinnerware (can be broken and used for cutting/self-harm/harm of others) was also noted on one of the tables.

In an interview on 03/04/2020 at 9:10 a.m. with S8DM, she confirmed plastic utensils were used by patients for meals and should have been secured in a locked cabinet to prevent unsupervised patient access. She indicated MHT staff were supposed to ensure patients did not have possession of the utensils after meal service and to make sure the utensils were secured after each meal.

In an interview on 03/04/2020 at 12:30 p.m. with S3ClinEduc, she confirmed the plastic bags should not have been in the patients' meal boxes and the plastic utensils should not have been available to the patients unsupervised. S3ClinEduc also confirmed there was no staff present, supervising the patients in the room with identified safety risks, at the time of the observation.

Physical environment unsanitary and not maintained in good repair:

On 03/02/2020 between 11:00 a.m. and 1:25 p.m. a tour of the hospital revealed multiple findings of hair on the floors in the patient bedrooms and bathroom floors, hair in the sink, hairbrushes with hair in them found under mattresses in rooms deemed clean and ready for a new patient, hair in the sink in the shower room, dust and hair on bedframes, floor tiles in the hallway noted to have hair and stains, and the clean linen closet floor was also noted to be covered in dust and hair. A dirty mop bucket was observed in a "clean" patient room. In an interview on 03/02/2020 at 1:30 p.m.S4PlantOps verified the above findings.

In an interview on 03/03/2020 at 8:40 a.m. S4PlantOPs stated the lawn personnel bring their push mower in through the attached nursing home and into the hospital hallway near the large dayroom on B Hall. They then roll the mower to the small court yards on the left and right. S4PlantOps further stated after cutting the grass in those areas the mower is rolled through the large day room into the large court yard. Lastly, S4PlantOps stated he frequently comes to work to find grass in the hospital from the wheels of the mower.

On 03/03/2020 at 3:00 p.m. an observation of the outside dryer vent revealed it was nearly clogged with lint buildup with approximately a 2-inch hole for airflow. The buildup of lint creates a potential fire hazard. In an interview on 03/03/2020 at 3:00 p.m. with S7Dir and S2DON, they confirmed the above referenced findings.

Environmental Disrepair
Observations conducted on 03/02/2020 from 12:30 p.m. - 12:50 p.m. revealed the following issues with disrepair observed in the hospital:
a. Room S - 5: Crack on the front of the air conditioner case that had sharp edges and could be a safety issue.
b. Room S - 7: Sink in the patient bathroom not working.
c. Room S - 8: Cracked tiles noted in patient bathroom.
d. Numerous broken and scuffed baseboards noted throughout the facility in the hallways, commons areas, and inpatient areas.
e. Grayish-Black colored stains (reportedly wax buildup) noted on floors throughout the hospital, located in hallways, patient rooms/bathrooms, and in commons areas.
f. Room L - 101: floor tile missing by the head of the bed, rust colored stains on the floor and baseboards.
g. Room L - 109: plexiglass window covering cracked;
h. Room L - 103: Sheetrock wall covering torn (where a receptacle had previously been located); bathroom light not working; unknown yellowish, raised substance splattered on the wall below the patient belongings shelving.
i. Room S - 13: Plexiglass at base of window broken with shards coming out when the surveyor touched the broken edge.
The above referenced observations were confirmed by S2DON, S4PlantOps, and S7Dir who had accompanied the surveyors during the observations.

Observation on 03/03/2020 at 8:00 a.m.
Floor tiles in front of the shower room on Hallway A had numerous brownish colored stains on them. When the floor tiles were stepped on by the surveyor, water seeped from between the tiles and a small amount of water pooled on the floor. S1Adm, present with the surveyors at the time of the observation, confirmed the stained tile and water seepage and indicated there had been a shower leak in the past. She confirmed there was water coming up from beneath the tiles when they were stepped on.

Review of Committee of the Whole meeting minutes, presented by S1Adm, dated 02/27/2020, revealed environment of care walk-throughs were conducted by the safety officer on 12/13/2019, 01/06/2020, and 02/04/2020 with no physical environment findings documented on the corresponding dates. Further review revealed the section titled, "Action Plan" had a notation of n/a in the column.

Review of the hospital's QAPI plan revealed no documented evidence that the above referenced safety/unsanitary environment and environmental disrepair issues were identified as problems to be addressed in the QAPI plan.

In an interview on 03/04/2020 at 12:50 p.m. with S1Adm, she confirmed the above referenced issues related to environmental safety risks/unsanitary environment and environmental disrepair were not identified as problems to be addressed in the QAPI plan. She reported environmental rounds were conducted by staff but there were no administrative rounds conducted. She indicated apparently the environmental rounds being conducted were not sufficient.

Based on observations, record review, and interviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1. failure to ensure a patient assessment was completed and documented before transfer of 1 (#8) of 1 (#8) patient reviewed for patient transfer from the hospital;

2. failure to ensure telephone orders were documented as read back prior to initiating the orders for 3 (R10, R11, R12) of 3 (R10, R11, R12) patients reviewed for telephone orders;

3. failure of the RN to perform accurate skin assessments as evidenced by the nurses failure to document an abscess under the right axilla of a patient (Patient #4), who was receiving Bactrim for the infection and failure to assess a patient's lacerated, sutured lip (Patient #3) for the day and night shift of 03/02/2020 for 2 (#3, #4) of 7 (Patient #1-#7) patients reviewed for skin assessments from a total patient sample of 9 (#1-#9);

4. failure to reassess a patient's blood pressure before discharge after a low reading was previously obtained
for 1(#7) out of 2 (#6, #7) patients reviewed for discharge out of a total sample of 9 (#1- #9); and

5. failure of the RN to clarify whether a PRN dose of Catapres should have been administered for a patient's elevated blood pressure when there were no parameters ordered for 1 (#2) of 2 ( #2, #3) sampled patients reviewed for PRN blood pressure medication orders from a total patient sample of 9 (#1 -#9).

Findings:

1. Failure to ensure a patient assessment was completed and documented before transfer from the hospital.

On 03/04/2020 at 12:20 p.m. a review of Patient #8's medical record revealed S27 PsychNP documented the treatment plan as; "The patient is being sent to Tulane Hospital ED for evaluation of current change in status to rule out medical cause."
Further review of the medical record failed to reveal a physical assessment by the medical staff nor the nursing staff prior to the transfer to Hospital B.

In an interview on 03/04/2020 at 12:35 p.m. S2DON reviewed Patient#8's medical record and confirmed there was no documented physical assessment prior to Patient #8's transfer to Hospital B for medical evaluation.

2. Failure to ensure telephone orders were documented as read back prior to initiating the orders.

A review of hospital policy titled Nursing Service, Receiving and Transcribing Prescribers Orders reveals in part:
Telephone and Verbal Orders
2. The nurse reads the order back to the prescriber to ensure accuracy.

On 03/04/2020 at 12:20 p.m. a review Patient R10's medical record revealed a telephone order was documented on 11/04/2019 at 1:58 a.m. for Haloperidol Solution 5mg/ml 1 milliliter PRN-Q6H taken by S19RN. Further review revealed S19RN documented the telephone order was not read back to the prescriber.

On 03/04/2020 at 12:22 p.m. a review of Patient R11's medical record revealed a telephone order was documented on 11/01/2019 at 6:35 p.m. for Ativan Solution 2 mg/ 1ml dose 1milligram PRN-Q6H taken by S20RN. Further review revealed S20RN documented the telephone order was not read back to the prescriber.

On 03/04/2020 at 12:24 p.m. a review of Patient R12's medical record revealed a telephone order was documented on 12/08/2019 at 12:30 p.m. for Catapress Tablet 0.1 mg PRN Q 12H taken by S22RN. Further review revealed S22RN documented the telephone order was not read back to the prescriber.

On 03/04/2020 at 12:24 p.m. in an interview S2DON verified the above findings.

3. Failure to perform accurate skin assessments.

Patient #4
Review of Patient #4's EMR, navigated by S3ClinEduc, revealed the patient was admitted on 02/24/2020. With further review of the medical narrative note by S29FNP, dated 02/26/2020, revealed in part, abscess right axilla, nondraining, start Bactrim DS 1 po BID X 7 days. Monitor and defer to PCP on DC.

Review of the Daily Nursing Flowsheets from 02/26/2020 (7 p.m-7a.m nursing shift) through 03/02/2020 (7 p.m.- 7a.m. nursing shift) for documentation of the appearance/description of the axilla abscess revealed no documentation of the abscess. This was a total of 11 nursing assessments that failed to reveal documentation of the abscess that the patient was being treated for with antibiotics.

An interview was conducted with S3ClinEduc on 03/03/2020 at 10:30 a.m. S3ClinEduc, with review of the EMR, was unable to locate a nursing assessment of the patient's right axilla abscess. She confirmed there should had been a skin assessment of the abscess.

Patient #3
Review of Patient #3's electronic medical record, navigated by S34Nav, revealed an admission date of 02/28/2020 with an admission diagnosis of Bipolar Disorder, Schizophrenia, and Hypertension.

Further review of Patient #3's electronic medical record revealed the patient was involved in an altercation on 03/01/2020 and sustained a lip laceration. Patient #3 was sent out to the emergency room on 03/01/2020 at 8:27 p.m. for closure of the lip laceration with stitches.

On 03/03/2020 at 10:00 a.m. Patient #3 was observed and the patient was noted to have a laceration in the middle of his bottom lip that was closed with stitches.

Review of nurses' notes for 3/02/2020 for the day and night shift revealed no assessment of the appearance of Patient #3's lip/stitches. S34Nav, who was navigating the patient's record during the review on 03/03/2020 confirmed there were no assessments of the patient's lacerated, stitched lip after comprehensively reviewing the patient's electronic medical record.

4. Failure to reassess a patient's blood pressure before discharge after a low reading was previously obtained.

Review of the Vital Sign Flow Sheet revealed in part, report abnormal findings to the charge nurse. <90mmHg/60mHg, > 140mmHg/90mmHg. Normal readings B/P Systolic (top number) 90 mmHg to 140mmHg, Dystolic (bottom number) 60mmHg-90mmHg.

Review of Patient #7's EMR, navigated by S3ClinEdu, revealed the patient was admitted on 09/17/2019 for Schizophrenia with psychosis. With further review of the EMR revealed the patient had a blood pressure documented as 87/64 mmHg on 09/26/19 at 10:35 p.m. Review of the nursing notes on 09/27/19 revealed the patient was discharged from the hospital on 09/27/19 at 9:30 a.m. There was no documentation of another blood pressure being obtained on the patient prior to discharge and there is no documentation of the physician being notified of the low blood pressure.

An interview was conducted with S3ClinEdu on 03/03/2020 at 11:15 a.m. She reported there were no other blood pressure obtained on the patient prior to being discharged home. She further stated there was no documentation the physician was notified or the nurse was aware of the blood pressure.

An interview was conducted with S2DON on 03/03/2020 at 1:00 p.m. She reported the patient should have had a blood pressure taken prior to being discharged from the hospital.

5. Failure of the RN to clarify whether a PRN dose of Catapres should have been administered for a patient's elevated blood pressure when there were no parameters ordered.

Review of Patient #2's physician's orders revealed an order for Catapres 0.1 mg, 1 tablet, as needed, every 12 hours for hypertension. Further review there were no ordered parameters for administration of the PRNCatapres.

Review of Patient #2's vital signs revealed the following:
02/21/2020 10:16 a.m. Blood Pressure 142 mm/Hg/104 mm/Hg
02/24/2020 10:30 a.m. Blood Pressure 142 mm/Hg/98 mm/Hg
02/26/2020 8:51 p.m. Blood Pressure 145 mm/Hg /93 mm/Hg
02/29/2020 8:00 p.m. Blood Pressure 145 mm/Hg /93 mm/Hg

Review of the hospital's parameters for blood pressure on the vital sign record form, presented by S3ClinEduc, revealed the following parameters for blood pressures: readings less than 90 mmHg/60 mmHg and greater than 140 mmHg/90 mmHg were considered outside of normal range.

In an interview on 03/03/2020 at 9:20 a.m. with S3ClinEduc, she reported when blood pressures fell out of the hospital's established parameters, the blood pressures should have been retaken and reported to the LPN. She reported the LPN, who is the medicine nurse, receives a copy of the vital sign sheets prior to administration of medications. She also indicated the physician should have been called due to the lack of ordered parameters to determine whether the PRN Catapres should have been given.

On 03/03/2020 at 9:25 a.m. S34Nav comprehensively reviewed Patient #2's electronic medical record, including review of contact notes and nurses' notes and there was no documented evidence of the nurse calling the physician and no evidence that the blood pressure had been retaken. Further review of the medication administration records revealed the PRN dose of Catapres had not been administered for the elevated blood pressure readings.



26351





30984

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff. This deficient practice is evidenced by failure to provide orientation and training to agency (contracted) nursing staff utilized to provide inpatient care for 3 ( S23RN, S24RN, S25LPN) of 3 (S23RN, S24RN, S25LPN) sampled agency nurses.

Findings:

Review of a list of contracted agency nurses, provided by S2DON, revealed S23RN, S24RN, and S25LPN had recently been utilized to provide coverage for patient care in the inpatient psychiatric hospital.

In an interview on 03/03/2020 at 10:12 a.m. with S3ClinEduc, she reported agency nurses, who were used to fulfill staffing needs, received training on the floor with the charge nurse when they worked. She confirmed they received no general hospital orientation and training.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications for 1 (R12) of 3 (R10, R11, R12) patient records reviewed for First Dose Review.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders: A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

On 03/04/2020 at 12:35 p.m. a review of the hospital policy Pharmaceutical Services, Review of First Dose revealed in part:
Policy:
In accordance with State and Federal regulations and laws, and standards of practice, and to ensure patient safety, Beacon Behavioral Hospital ensures that a pharmacist reviews all orders for medication not documented as having been previously administered to the patient. Such review is conducted 24 hours a day and is never omitted unless an urgent or emergent situation exists in which a delay of administration of the medication is likely to result in harm to the patient.

On 03/04/2020 at 12:20 p.m. a review of Patient #R12's medical record revealed an order for Catapress Tablet 0.1mg PRN Q 12 hours written on 12/08/2019 at 12:30 p.m. with the Completion Action noted as "print".

A review of Patient R12's Medication Administration Record revealed Catapress Tablet 0.1 mg was administered on 12/8/2019 at 8:35 p.m. by S21LPN.

A review of the Medication Errors for the December 9, 2019 revealed a request from Gulfcoast Pharmaceutical Specialty stating, "We have no orders for the following profile overrides performed in the Med-Dispense." Further review revealed there was no order for Patient R12's Catapress (Clonidine) 0.1mg removed from the med dispense by S21LPN.

In an interview on 03/04/2020 at 12:30 p.m. S2DON verified because the patient order Completion Action was to "print", pharmacy had not received nor reviewed the medications noted above prior to administration of the first dose.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having opened, undated medications available for patient use.

Findings:

On 03/ 02/ 2020 at 1:25 p.m. a tour of the medication room revealed the following open, undated medications available for patient use:
a. 1 bottle Extra Action Cough Syrup 1 pint;
b. 1 bottle MiraLax;
c. 1 tube of Nystatin and Triamcinolone Acetonide Ointment 15 g;
d. 2 tubes of Hydrocortisone Cream 1%;
e. 2 tubes of Hydrocortisone Cream 2.5 %.

In an interview on 03/02/2020 at 1:25 p.m. S16LPN verified the above undated medications were available for patient use. She further stated all opened medications were to be dated once opened.

Based on observation, record review, and interview, the hospital failed to ensure facilities and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by:
1. failure of the hospital to ensure the external dryer vent duct was cleaned on a regular basis to prevent lint build up, which could result in a fire hazard; and
2. failure of the hospital to maintain the facilities in good repair.

Findings:

1.Failure to ensure the external dryer vent duct was cleaned.
On 03/03/2020 at 3:00 p.m. an observation of the outside dryer vent revealed it was nearly clogged with lint buildup with approximately a 2-inch hole for airflow. The buildup of lint creates a potential fire hazard.

In an interview on 03/03/2020 at 3:00 p.m. with S7Dir and S2DON, they confirmed the above referenced findings.

2. Failure to maintain facilities in good repair

Review of Committee of the Whole meeting minutes, presented by S1Adm, dated 02/27/2020, revealed environment of care walk-throughs were conducted by the safety officer on 12/13/2019, 01/06/2020, and 02/04/2020 with no physical environment findings documented on the corresponding dates. Further review revealed the section titled, "Action Plan" had a notation of n/a in the column.

Observations conducted on 03/02/2020 from 12:30 p.m. - 12:50 p.m. revealed the following:
a. Room S - 5: Crack on the front of the air conditioner case that had sharp edges and could be a safety issue.
b. Room S - 7: Sink in the patient bathroom not working.
c. Room S - 8: Cracked tiles noted in patient bathroom.
d. Numerous broken and scuffed baseboards noted throughout the facility in the hallways, commons areas, and inpatient areas.
e. Grayish-Black colored stains (reportedly wax buildup) noted on floors throughout the hospital, located in hallways, patient rooms/bathrooms, and in commons areas.
f. Room L - 101: Floor tile missing by the head of the bed, rust colored stains on the floor and baseboards.
g. Room L - 109: Plexiglass window covering cracked;
h. Room L - 103: Sheetrock wall covering torn (where a receptacle had previously been located); bathroom light not working; unknown yellowish, raised substance splattered on the wall below the patient belongings shelving.
i. Room S - 13: Plexiglass at base of window broken with shards coming out.
The above referenced observations were confirmed by S2DON, S4PlantOps, and S7Dir who had accompanied the surveyors during the observations.

Observation on 03/03/2020 at 8:00 a.m.
Floor tiles in front of the shower room on Hallway A had numerous brownish colored stains on them. When the floor tiles were stepped on by the surveyor, water seeped from between the tiles and a small amount of water pooled on the floor. S1Adm, present with the surveyors at the time of the observation, confirmed the stained tile and water seepage and indicated there had been a shower leak in the past. She confirmed there was water coming up from beneath the tiles when they were stepped on.

In an interview on 03/04/2020 at 12:50 p.m. with S1Adm, she reported environmental rounds were conducted by staff but there were no administrative rounds conducted. She indicated apparently the environmental rounds being conducted were not sufficient.





30984

Based on record review 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:

1) failure to maintain a sanitary environment;
2) failure to ensure expired lab specimen tubes were not readily available for patient use;
3) failure to ensure the medication and laboratory refrigerator temperature checks were documented;
4) failure to ensure the contracted law service was not pushing the ridding lawnmower through the hospital.
5) failure to ensure hospital employees were screened for tuberculosis for 7 out of 7 (S5MHT,S21MHT, S21LPN, S30MHT, S31SW,S32RecTher, and S33Dietician) employees reviewed for TB screenings.
Findings:


1) Failure to maintain a sanitary environment.

Review of the policy for Proper Cleaning of Patient Rooms- inpatient revealed in part, it is the policy of the hospital to have the Environment Service department (EVS) to clean each occupied patient rooms daily, considered "routine cleaning" and after a patient is discharged (prior to a new patient admission to the room), which is referred to as terminal cleaning. Procedure: A Routine Cleaning- ....mop/clean floors....clean walls with disinfectant solution soak dust mop head in solution, apply to frame and use to clean walls)..B. Terminal cleaning: Apply disinfectant according to manufacturer's recommendations; allow to work for 10 minutes.

1) Failure to maintain a sanitary environment.

On 03/02/2020 between 11:00 a.m. and 1:25 p.m. a tour of the facility revealed:
a. C Hall Day Room: base boards and a metal cart were dirty and dusty;
b. C Hall Day Room floor pads used for CPI Training covered in dust and hair;
c. Room L 108 floor at the head of the bed dirty with hair and food, also the bathroom floor was dirty with hair around the toilet;
d. Room L 101 a clean patient room with a dirty mop bucket in the bathroom; the air-conditioner unit filters dirty;
e. C Hall Shower Room floor dirty with hair in the sink;
f. Room L 104 bed frame dirty with dust and hair;
g. Room S103 shower room floor dirty, dusty and the metal frame was rusted;
h. Floor tiles in the hallway near Room S103 shower room were dirty and covered with a crusted substance;
i. Clean linen closet floor covered with dirt, dust, and hair.

In an interview on 03/02/2020 at 1:30 p.m.S4PlantOps verified the above findings.

In an interview on 03/03/2020 at 8:40 a.m. S4PlantOPs stated the lawn personnel bring their push mower in through the attached nursing home and into the hospital hallway near the large dayroom on B Hall. They then roll the mower to the small court yards on the left and right. S4PlantOps further stated after cutting the grass in those areas the mower is rolled through the large day room into the large court yard. Lastly, S4PlantOps stated he frequently comes to work to find grass in the hospital from the wheels of the mower.

In an interview on 03/03/2020 at 12:20 p.m. S5MHT, S11MHT and S12MHT verified they have witnessed the riding mower being pushed through the hospital to access all three inner courtyards.

On 03/03/2020 at 3:00 p.m. a tour of the patient laundry room revealed: used vinyl gloves on the floor between the washer and dryer, dust and lint on the floor, sink and shelving, approximately ¾ in lint on the window sill, a piece of wood on the floor, spilled laundry detergent on the floor and brown stains on the floor.

In an interview on 03/03/2020 at 3:00 p.m. S4PlantOps and S3ClinEduc confirmed the above findings.



2) Failure to ensure expired lab specimen tubes were not readily available for patient use.

On 03/02/2020 at 1:10 p.m. a tour of the supply closet revealed 7 expired purple lab tubes.

On 03/02/2020 at 1:10 p.m. in an interview S4PlantOps verified the expired lab tubes.


3) Failure to ensure the medication and laboratory refrigerator temperature checks were documented.

A review of the hospital policy titled Infection Control, Infection Prevention and Control Program last revised on 03/21/2018 states in part:
A temperature log will be maintained for each refrigerator. Documentation on the log will be daily in inpatient settings and on days of operation in outpatient settings. A staff member will record the temperature reading and, if it is outside the acceptable range (as dictated by LAC 51), will immediately notify a supervisor.

On 03/02/2020 at 1:15 p.m. a tour of the lab room failed to reveal documented temperatures for the lab specimen refrigerator on the following dates: November 26, 27 of 2019; December 11, 14, 15, 16, 19, 25, 26 and 30 of 2019; January 3, 4, 8, 11, 12, 13, 16, 17, 18, 19, 21, 24, 25, 26 and 27, of 2020 and February 5, 10, 14, 21, 22, 23, 24, 27 and 28, of 2020.

In an interview on 03/ 02/ 2020 at 1:15 p.m. S4PlantOps verified the missing temperatures and also that the staff are to document the temperatures daily.

On 03/ 02/ 2020 at 1:20 p.m. a tour of the medicine room failed to reveal documented temperatures for the medication refrigerator on January 3, 4, 11, 12, 13, 14, 16, 17, 18, 19, 21 and 27 and February 4, 5, 14, 24, 27 and 28 of 2020.

In an interview on 03/02/ 2020 at 1:20 p.m. S16LPN verified the above missing documented temperatures.

5. Failure of the hospital to screen employees for tuberculosis.

Review of the hospital's policy and procedure for Infection Prevention and Control Program revealed in part, to prevent the transmission of tuberculosis (TB) among hospital personnel and patients, all employees and contracted personnel must participate in TB screening process. TB screening is provided to all staff upon hire and annually thereafter.

Review of the following personnel records reviewed revealed no TB screening documentation annually: S5MHT, S21LPN, S26RN, S30MHT, S31SW, S32RecTher and S33Dietician.

An interview was conducted with S3ClinEduc on 03/04/2020 at 10:00 a.m. She reported she was unable to locate documentation of the annual TB screening for S5MHT, S21LPN, S26RN, S30MHT, S31SW, S32RecTher, and S33Dietician.


38777

Based on record reviews and interview, the hospital failed to ensure it worked cooperatively with the designated organ procurement organization, tissue bank, and eye bank in educating staff on donation issues as evidenced by failure to have documented evidence of staff education related to donation issues for 2 out of 2 (S21LPN, S26RN) of employee files reviewed for donation issues education.

Findings:

Review of the personnel files for S21LPN and S26RN revealed no education was documented in their personnel/education files on donation issues for organ procurement, tissue and eye bank.

An interview was conducted with S3ClinEduc on 03/04/2020 at 12:30 p.m. She confirmed she was unable to locate any training for donation issues for organ procurement, tissue and eye bank for the nurses at the hospital.