HospitalInspections.org

Based on review of clinical records, policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined the Governing Body failed to ensure the hospital functioned in a manner for the provision of quality care in a safe environment as evidenced by:

(A-0065): The hospital accepted transfers of patients without an accepting provider and without available inpatient beds at the time the patients were accepted. The patients had been assessed by Emergency Department (ED) physicians and evaluated by Behavioral Health professionals at the referring hospitals who determined the patients required inpatient psychiatric services. The patients were evaluated by a behavioral health staff member after their arrival to St. Luke's and then admitted by a provider to their observation/stabilization unit which is a lower level of care. (Patients #19 and #35)

(A-0115): Patient Rights Condition of Participation: The hospital failed to ensure the rights for each patient were protected and promoted as evidenced by the hospital's:

(A-0144): 1. Failure to ensure that a one to one (1:1) observation of a patient had a staff member present with one (1) of one (1) patient at all times as ordered by the physician for a patient who had required multiple interventions due to aggressive behaviors putting the patient, staff, and other patients in a potential unsafe environment; and 2. Failure to ensure there were no items of furniture in inpatient units that could be used by a patient(s) to harm themselves or others;

(A-0160): Failure to identify the use of chemical restraints as evidence by one of one record review where events of chemical restraints were administered during restraint/seclusion and hospital personnel failed to recognize, document and assess them as chemical restraints. (Patient #21) ;

(A-0168): 1. Failure to ensure provider orders were obtained for the use of restraints on Patients #21 and #52; and 2. Failure to ensure provider orders were obtained as soon as possible for the restraints used on Patient #21. the use of the restraints were in accordance with an order from a physician or other credentialed Licensed Independent Practitioner (LIP). (Patients #21 and #52);

(A-0174): Failure to ensure for 2 of 2 records reviewed of patients who were restrained and/or placed in seclusion, the hospital failed to ensure the restraints and/or seclusion were discontinued at the earliest possible time as evidenced by patients left in the restraints/seclusion after criteria was met to release them. (Patients #3 and #21);

(A-0385): Nursing Services Condition of Participation. The hospital failed to provide organized nursing services 24-hours per day to assess the individual needs of each patient and deliver and supervise the care required in accordance with physician orders, policies and procedures and nursing standards of care as evidenced by: A-0392: Failure to ensure each unit was staffed with the number and types of personnel required to meet the needs of each patient as evidenced by documented events of events of Code Gray (individuals with episodes of danger to self or others requiring de-escalation and/or restraint), and incidents of patient self-harm, and/or assault between patients that may have been prevented if staff with the appropriate knowledge and skill were at the levels required to support the patient census, acuity and patient need.

(A-0386): The Director of Nursing failed to ensure that AIMS (Abnormal Involuntary Movement Scale) was completed on all patients as indicated.

(A-0392): The hospital failure to ensure each unit was staffed with the number and types of personnel required to meet the needs of each patient as evidenced by documented events of events of Code Gray (individuals with episodes of danger to self or others requiring de-escalation and/or restraint), and incidents of patient self-harm, and/or assault between patients that may have been prevented if staff with the appropriate knowledge and skill were at the levels required to support the patient census, acuity and patient need;

(A-0395): Failure to require a registered nurse: 1. Ensure that patients ordered 1:1 observation were constantly monitored and directly observed at all times as required by the hospital policy and procedure in 1 of 1 patients reviewed (Patient #3); and 2. Directed and monitored the observations of patients by the assigned staff member on the child/adolescent unit on 09/07/2021. (Patients #24, #45, #46 #47, #48, #49 #50, and #51).

(A-0405): Failure to ensure hospital policies and accepted standards of practice were followed for medication preparation and administration as evidenced by nursing personnel not preparing and administering medications one patient at a time and storing the prepared medications in a secured location to prevent medications from being misplaced or accessed by unauthorized individuals.

(A-0618) Food and Dietetic Services Condition. The hospital failed to provide organized dietary services to meet the nutritional needs of the patients as evidenced by:

(A-0620): Failure to ensure that:
1. the person in charge of dietary provided services to the hospital that met the patient's nutritional needs as evidenced by alternative menus not being available to patients, supplemental nutritional snacks being available to patients, and documentation of meals being broad and not specific to evaluate if the nutritional needs were being met;
2. the person in charge of dietary services was appointed by the Governing Board. The deficient practice poses a potential risk to the health and safety of the patients, when the minimum standards are not met regarding daily management of the dietary services; and .

(A-0629): that equivalent meal replacements are available to patients

(A-1620) Special Medical Record Requirement Condition of Participation: The hospital failed to meet the Condition of Participation for Special Medical Record Requirements that required the medical record maintained by a psychiatric hospital to contain the degree and intensity of the treatment provided to the patients as evidenced by:

(A1644) Failure to require that the medical record documentation each patient have an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities deficient practice poses a risk to the health and safety of the patients and staff, when the hospital does not have an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities and the responsibilities of each member of the treatment team in 8 of 8 records reviewed for individualized comprehensive treatment plans.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of clinical records, hospital documents, and staff interviews, for two of two clinical records reviewed of patients who were accepted in transfer from other hospitals, it was determined the hospital accepted the transfers of the patients without an accepting provider and without available inpatient beds at the time the patients were accepted. The patients had been assessed by Emergency Department (ED) physicians and evaluated by Behavioral Health professionals at the referring hospitals who determined the patients required inpatient psychiatric services. The patients were evaluated by a behavioral health staff member after their arrival to St. Luke's and then admitted by a provider to their observation/stabilization unit which is a lower level of care. (Patients #19 and #35)

Findings include:

The hospital's 2021 Plan for the Provision of Patient Care included: "The Observation Services for Children & Adolescents (OSCA) Program - serves children ages 5 through 17 years of age. The program provides observation services for eligible children. OSCA provides a safe and therapeutic environment to assess mental health status with plan to de-escalate the crisis or develop a plan to do so within 23.59 hours. Complimented by Inpatient, the patient may transition from crisis to home or another level of care here or in the community...The OSCA Program also functions as a safe haven for...youth who may be victim of domestic minor sex trafficking...."

The Governing Board meeting minutes dated 03/03/21 included: "Working on a plan to route patients through OSCA (Observation Services for Children & Adolescents) before going inpatient...Need to get our program running well before we face any competition." Documentation in the Governing Board meeting Minutes dated 05/05/2021 included: "...The whole reason for OSCA is to relieve the emergency room from holding behavioral patients." There was no documentation in the Governing Board Meeting minutes between the period of July 2020 to June 2021 that addressed patients being accepted in transfer for inpatient services without available beds and then being admitted to the OSCA Unit which is a lower level of care.


The Medical Executive Committee General Session meeting minutes dated 05/25/2021 included: "...complaints received the last week of April. Concerns with OSCA bringing in patients and putting on lower level of care...Will need to change status before 23.5 (sic) hours. Will need to provide services while on Obs unit...."

Patient #19:

Patient #19 was transferred from an acute care hospital in the community to St. Luke's Behavioral Health Center on 08/21/2021 for inpatient admission.. Documentation in the acute care hospital's Emergency Department (ED) record revealed the adolescent presented there after an intentional overdose. A psychosocial assessment was performed at that hospital and it was determined the patient required "inpatient psychiatric treatment for safety and stabilization." The documentation also included: "...spoke with (staff name) at St. Luke's...(staff name) confirmed available beds and will call nursing for report...." The time of the patient's arrival to St. Luke's Behavioral Health Center was on or around 3:49 p.m. A Mental Health Evaluation was performed at 5:05 p.m.. The name of the staff who completed the evaluation was not on the evaluation, however, the electronic medical record showed the author to be a "Mental Health Provider." The reason for the evaluation was documented on the form as "OSCA eval." The evaluation identified the patient's presentation and history as documented in the psychosocial evaluation at the acute care hospital. The Mental Health Provider's documentation included: "patient denied current suicidal ideations. However patient has history of suicide attempts...Suicide Risk Level High...Intervention...Patient will be receive (sic) an evaluation while on the children and adolescent unit...Treatment Plan...Patient will receive an evaluation while on the children and adolescent unit." The evaluation was reviewed with the on-call provider who provided orders to admit the patient to the OSCA unit. The patient was taken to the OSCA Unit at 8:53 p.m. A Psychiatry Consultation was performed by a Nurse Practitioner (NP) on 08/22/2021 at 11 a.m. on the OSCA Unit. The NP's Assessment and Plan was " Admit to a level 1 inpatient psychiatric facility for further assessment and evaluation, medication stabilization, and appropriate referrals upon discharge. The patient remained on the OSCA unit until 08/23/2021 at 1:29 p.m., a period of over forty hours. The patient was then placed in an "overcapacity bed/room" which is a portable bed placed in a group therapy room. The room serves as a group room during the day and then the patient's room to sleep in a night. The patient remained in the "overcapacity room" until a licensed bed became available on 08/24/2021 at 8:30 p.m., a period of over 24 hours.

A review of the census, staffing sheets, and Supervisor Reports for 08/21/2021 revealed there were no inpatient beds available on the Child and Adolescent Units in which to admit Patient #19. There was also documentation in the census, staffing sheets and Supervisor Reports that staffing was inadequate on the CAS unit on 08/23/2021 and 08/24/2021.

Patient #35:

Patient #35, an adolescent) was transferred from an acute care hospital on 08/29/2021 for inpatient admission to St. Luke's Behavioral Health Center. Documentation in the ED record from the transferring hospital included: "...Will set up direct admission to St. Luke's. Holding here for flight risk...received call from (name) that pt has a bed at St. Luke's Bhx hospital (sic)...." The patient arrived at St. Luke's at 2:43 p.m. A Mental Health Evaluation was performed by a Mental Health Counselor which was staffed with the on-call NP who ordered the patient to be admitted to the OSCA Unit. The patient was transferred to the OSCA Unit at 5:20 p.m. A Psychiatry Consultation was performed at 8 a.m. on 08/30/2021, and the NP wrote admission orders for inpatient treatment. The patient remained in the OSCA Unit until 08/31/2021 at 9:52 p.m. when she was transferred to an over-capacity bed on the CAS Unit.

A review of census, staffing sheets, and Supervisor Reports for 08/29/2021 revealed there were no child/adolescent inpatient beds available in which to admit Patient #35.

There was no documentation in Patient #19 or Patient #35's clinical records that the requests from the sending hospitals were reviewed with a St. Luke's provider prior to acceptance to the hospital and no documentation that the referring hospitals were notified by St. Luke's that they did not have any available inpatient beds and that the patients would be evaluated and admitted to a lower level of care and held there until a bed became available.

Observations of the OSCA Unit on different times during the survey revealed an open room containing reclining chairs OSCA patients were admitted to and where they received meals and slept. On one day of observations, the patient ages ranged between six years and 17 years. Some patients were OSCA patients and some were inpatients waiting for an inpatient bed to become available.

The Clinical Manager of the Intake and Assessment Department reported during a tour of the unit on 08/23/2021 that all calls and written requests from other hospitals to transfer a patient to St. Luke's Behavioral Health Center comes through the Intake and Assessment Department. The Clinical Manager stated the requests for transfers in are reviewed by a Registered Nurse who make the decision on whether or not to accept a patient. The Clinical Manager stated the requests for transfer are not reviewed with a provider prior to accepting the transfer unless there is a concern and they don't always have an accepting provider. After the patient arrives, an evaluation is performed and then the provider is consulted. There were no hospital policies and procedures that addressed the practice of accepting transfers from other hospitals without physician authorization and without available inpatient beds and/or without available staff.

Staff #54 was asked during an interview on 08/25/2021 if requests from other hospitals to transfer a patient to St. Luke's was reviewed with a physician who accepted the patient prior to transfer, and the staff responded, "No."

In summary, the hospital accepted the transfers of the patients without an accepting provider and without available inpatient beds at the time the patients were accepted. The patients had been assessed by Emergency Department (ED) physicians and evaluated by Behavioral Health professionals at the referring hospitals who determined the patients required inpatient psychiatric services. The patients were evaluated by a behavioral health staff member after their arrival to St. Luke's and then admitted by a provider to their observation/stabilization unit which is a lower level of care. Patient #35 remained in the OSCA unit for over 48 hours and was placed in an "overcapacity bed" (group room on the unit) for over 24 hours before being placed in a licensed inpatient bed. Patient #19 remained in the OSCA unit for over 40 hours and then placed in an "overcapacity bed" where she remained for over 24 hours before being placed in a licensed bed.

Based on clinical record reviews, document reviews and staff interviews, it was determined each patient's rights were not protected and promoted as evidenced by the hospital's:

(A-0144):

1. Employee #50 was assigned to Patient #3, who was on a one to one (1:1) observation assingment. Employee #50 was observed 2 of 2 times, during video review, leaving the patient care area/unit, and leaving Patient #3 unattended without ensuring another staff member was present and monitoring the patient.

2. Furniture that could easily be moved or thrown were located in a patient room, patient milieu, and the patio.

3. Failure to ensure security staff received initial hospital life safety training, emergency preparedness training, and infection control training.

(A-0160):

Failure to identify the use of chemical restraints as evidence by one of one record review where events of chemical restraints were administered during restraint/seclusion and hospital personnel failed to recognize, document and assess them as chemical restraints. (Patient #21) ;

(A-0168): Failure to ensure the use of the restraints were in accordance with an order from a physician or other credentialed Licensed Independent Practitioner (LIP). (Patients #21 and #52);

(A-0174)

Failure to ensure for 2 of 2 records reviewed of patients who were restrained and/or placed in seclusion, the hospital failed to ensure the restraints and/or seclusion were discontinued at the earliest possible time as evidenced by the patients left in the restraints/seclusion after criteria was met to release them. (Patients #3 and #21);

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of policies and procedures, documents, video review, medical records, and interview, the hospital failed to ensure the patient care environment was safe as evidenced by:

1. Employee #50 was assigned to Patient #3, who was on a one to one (1:1) observation assignment. Employee #50 was observed 2 of 2 times, during video review, leaving the patient care area/unit, and leaving Patient #3 unattended without ensuring another staff member was present and monitoring the patient.

2. Furniture that could easily be moved or thrown were located in a patient room, patient milieu, and the patio.

3. Failure to ensure security staff received initial hospital life safety training, emergency preparedness training, and infection control training.

These deficient practices pose a potential risk of safety and harm to patients and/or staff during violent acts.

Findings include:

1.
Policy titled "Observation of Patients on Inpatient Psychiatric Units" revealed: " ...One to one (1:1) Observation: Assignment of a qualified staff member to remain with the patient and maintain an unobstructed view of the patient at all times to prevent harm to the patient or others. The ordering licensed independent practitioner (LIP) may indicate the proximity to the patient at which the one to one (1:1) observation is conducted, if necessary) ...C. One to one (1:1) Observation 1. Patients will be placed on one to one (1:1) observation when they are at imminent risk of harm to themselves or others ...3. The Registered Nurse Role ...d. The RN will obtain an order from the LIP ...H. The RN supervises the qualified staff member observing the patient ...j. The RN documents at least every two hours on the status of the patient on one to one (1:1) observation. 4. The Patient Observer Role ...b. Maintains unobstructed view of patient at all times ...The patient may never be out of the Patient Observer's sight ...."

Policy titled "Patient's Rights and Responsibilities" revealed: " ...Policy ...All hospital staff, medical staff members and contracted agency staff performing patient care activities will observe all patient rights ...Receive considerate and respectful care provided in a safe environment ...."

Document titled "Daily Patient Assignment Sheet" dated 09/05/2121, 1900 - 0730, CAS (Child and Adolescent Unit), revealed that Employee #50 Behavioral Health Technician (BHT) was assigned to provide 1:1 observation for Patient #3 in Room #286. Employee #51 was the Registered Nurse (RN) on the unit.

The surveyor conducted video review on 09/08/2021 with Employee #2. The video review covered the time frame from 09/05/2021, 11:00 p.m. (2300), through 09/06/2021, 2:02 a.m. (0202) on the CAS Unit, including Room #286. No other employee, including Employee #51, the RN responsible for the care of patients on the unit, entered Room #286 during the video review. Video review revealed there was no employee providing 1:1 coverage during the following times:

12:21 a.m. (0021) Employee #50 exited patient room #286 and exited the unit
12:26 a.m. (0026) Employee #50 returned to the unit
12:27 a.m. (0027) Employee #50 entered patient room #286
12:41 a.m. (0041) Employee #50 exited patient room #286 and exited the unit
12:56 a.m. (0056) Employee #50 returned to the unit
12:58 a.m. (0058) Employee #50 entered patient room #286

Medical record for Patient #3 dated 09/05/2021, (0910), revealed provider order to nurse, continue one to one times 24 hours for danger to self (DTS). Patient #3 had multiple documented events requiring a physical hold, restraint, and/or seclusion for being violent, fighting, kicking/pounding and shouting throughout the patient's hospitalization.

Medical record for Patient #3 dated 09/06/2021, 0000 - 2345, revealed that the Special Precautions Monitoring Q 15 Min Checks, confirmed special needs as a 1:1. At 0045, Employee #50 BHT documented that Patient #3 was in his/her room, appears asleep, and respirations regular.

Employee #2 confirmed during an interview conducted on 09/08/2021, that video review confirmed that Employee #50 appeared to be on a 1:1 patient assignment, left the patient's room and the unit on two (2) occasions and no other employee entered patient room #286 during that time. Employee #2 confirmed Employee #50's name and that s/he was listed on the Daily Patient Assignment Sheet as a 1:1 assignment for Room #286.

In summary Employee #50 left the patient room two separate times and was out of site of the patient in room #286 where Patient #3 was located and ordered to be on 1:1 observation. The first time was for six minutes and the second time for 17 minutes. There was no video evidence to show that another employee was in direct observation of Patient #3 during these absences by Employee #50.

2.
Policy titled "Patient's Rights and Responsibilities" revealed: " ...Patient Rights ...Receive considerate and respectful care provided in a safe environment ...."

Document titled "2021 Infection Control Program, Goals, Objectives & Risk Assessment" revealed that Environmental and Safety Rounds are performed monthly.

Medical record for Patient #21, dated 08/08/2021, revealed: "...Psych Progress Note...Shortly after the interview the patient became highly agitated with a peer and began tossing furniture around the unit...."

Tour conducted on 08/23/2021, with Employee #12, included a tour of units AP2 and AP3. Observations on tour revealed: On AP3 there were 10 non-weighted chairs in the milieu, 9 non-weighted chairs on the patio, and 2 non-weighted chair in Room 224. On AP2 there were 5 non-weighted chairs in the milieu, 1 non-weighted chair in Room 244, and 1 non-weighted chair in the patient's shower.

Employee #1 confirmed during an interview conducted on 08/23/2021, that the facility does a large risk assessment for the environment annually and rounding is completed between the yearly rounding. Additionally, after an adverse event or a near miss, a risk assessment is completed.

Employee #2 and Employee #11 confirmed during a combined interview on 08/23/2021, that the plastic non-weighted chairs should be removed. Employee #2 revealed that the staff should be reeducated on not using non-weighted chairs and that the hospital had no specific policy related to the use of non-weighted chairs.

3.
Policy titled "Mandatory Education and Discipline for Failure to Completed Education '' revealed: "...Policy Each member of the workforce is required to complete certain mandatory training...Procedure...1. All Steward Health Care workforce members will receive general mandatory education and training during their initial orientation and on an annual basis thereafter on specific regulatory and/or safety topics that are relevant to their job duties and required of all workforce members ...."

Document titled "SLBHC Contractors/Vendor Orientation" revealed that the orientation for contractors and vendors did not include life safety, emergency preparedness, or infection control.

Employee file reviews conducted on 09/01/2021, and 09/02/2021, revealed that the facility failed to provide any training to contract security personnel on the facilities policies or procedures before allowing them to perform their duties. The facility did show proof of MOAB training, however there was no documented evidence for subjects such as life safety, emergency preparedness, infection control, and licensing requirements.

Employee #46 acknowledged during an interview conducted on 09/01/2021, that s/he was unable to answer any questions regarding infection control, life safety, and emergency preparedness.

Employee #29 acknowledged during an interview conducted on 09/01/2021, that the security officers were not getting new employee orientation.

Employee #11 acknowledged during an interview conducted on 09/01/2021, that s/he gives employee's basic training, however s/he does not document the training.

Based on review of medical records, policies and procedures, and staff interviews, it was determined the hospital failed to identify the use of chemical restraints as evidence by one of one record review where events of chemical restraints were administered during restraint/seclusion and hospital personnel failed to recognize, document and assess them as chemical restraints. (Patient #21)

Findings include:

The hospital's policy and procedure titled "Restraint and Seclusion" included the following definitions:

"Chemical restraint: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's movements and is not a standard treatment or dosage for the patient's condition."

"Emergency Medication: A psychoactive medication that is used to treat the sudden onset of signs and symptoms of mental illness in a psychiatric emergency with the expectation of improving their level of functioning so that they can more actively participate in their treatment. Chemical restraints are prohibited."

"Psychiatric Emergency: A situation in which, in the opinion of the LIP, it is immediately necessary to administer medication to ameliorate the signs and symptoms of a patient's mental illness; allowing the patient to improve their level of functioning so that they can more actively participate in their treatment and environment around them, and to prevent:
1. Imminent probably death or substantial bodily harm to the patient because the patient: a. is threatening or attempting to commit suicide or serious bodily harm; or b. is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or
2. Imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits; or
3. Loss of level of functioning...."

Patient #21, an adolescent, was an inpatient at the time of the survey. Nursing documentation dated 07/25/2021 at 12:19 p.m. revealed the patient was placed in a physical hold at 10:45 a.m. when he tried to push himself through a crevice on an outdoor balcony to fall over. The patient was then placed in seclusion and a physician ordered the one time administration of Benadryl 50 mg intramuscularly (IM) which was given. The order did not include an indication for use. Documentation in the Seclusion and Restraint Individual Reporting Form identified seclusion and personal restraint as the types of restraints used. There was a section in the packet for "Medication Used as Restraint" which had "N/A" handwritten in.

The patient was put in seclusion and four-point restraints on 08/08/2021 at 8:55 a.m. The patient was also give IM injection(s) of Benadryl 50 mg; Haldol 5 mg; and Ativan 2 mg at that time. Documentation in the restraint packet identified seclusion and mechanical as the types of restraints used. There was a line drawn across the section for Medication Used as Restraint and the IM injections were not listed.

The patient was put in seclusion again on 08/08/2021 at 4:50 p.m.; 08/12/2021 at 4:25 p.m.; and 08/13/2021 at 5:10 p.m. and given an IM injection of Benadryl 50 mg and Haldol 50 mg. The patient was given Thorazine 100 mg IM on 08/17/2021 while in seclusion. The medications were not identified as chemical restraints in the Seclusion and Restraint Individual Reporting Forms.

Haldol and Thorazine are antipsychotic medications and Ativan is an anxiolytic medication and not a part of Patient 21's scheduled treatment.

The Chief Nursing Officer (Staff #3), a Nurse Manager (Staff #52), the Risk Manager (Staff #2) and the Quality Director (Staff #29) stated during separate interviews that the hospital did not consider the use of "prn" (as needed) medications as chemical restraints.

Based on clinical record reviews, review of hospital policies and procedures, and staff interview, it was determined for 2 of 3 patients with documentation of being restrained, the hospital failed to ensure the use of the restraints were in accordance with an order from a physician or other credentialed Licensed Independent Practitioner (LIP). (Patients #21 and #52)

Findings include:

The Restraint and Seclusion policy and procedure included: "...All mechanical and personal restraint or seclusion use requires the order of an LIP...If an LIP is not present when an emergency justifying restraint or seclusion occurs, a Registered Nurse can initiate mechanical and/or personal restraints or seclusion. The Registered Nurse must immediately notify an LIP...."

Patient #21:

Patient #21's clinical record included a nurse's note dated 07/29/2021 at 6:46 p.m. which included: "...Pt then decided to head towards an exit and busted through the door (using his shoulder) and ran out the hallway. A nurse and a BHT ran after him. Pt was caught by the ramp and was escorted back to the unit and walk (sic) into the seclusion room...." A Psych Progress Note dated 07/30/2021 included: "Yesterday the patient became highly agitated during visitation and attempted to elope from the unit. Staff reports they had to place him in a hold but he did come back willing to the unit...." There was no documentation in the record that a physician was notified and order obtained for the physical hold. There was no documentation of how long the patient was held or that a face to face assessment was performed.

Patient #21 was placed in seclusion on 08/08/2021 at 8:55 a.m. The order for seclusion was not obtained until 08/13/2021 at 6:14 p.m., five days after the episode. The patient was physically held and then placed in seclusion on 08/25/2021. Provider orders for the restraints were not obtained until 08/29/2021, four days later after the episode. Staff #52 acknowledged during the record review that provider orders were not obtained for several days..


Patient #52:

Observation on 08/31/2021, of Patient #52 was laying on the floor and two (2) BHT's (Behavioral Health Technicians) were observed picking Patient #52 up under each arm and carrying the patient to his/her room. The patient was unable to walk, due to his/her feet being elevated off the floor.

Employee #41 (RN) confirmed during an interview conducted on 08/31/2021, that the observation of Patient #52 being picked up under his/her arms was not considered a hold.

Employee #3 (Chief Nursing Officer) confirmed during an interview and video review conducted on 09/01/2021, that if staff put hands on a patient, it would be considered a hold. Employee #3 would expect to see that the doctor was called and that an order was obtained.

Employee #2 (Risk Manager) confirmed during an interview and medical record review conducted on 09/01/2021, that there was no order in Patient #52's medical record for the observed hold on 08/31/2021.

Based on review of hospital policies and procedures, clinical records, and staff interviews, it was determined for 2 of 2 records reviewed of patients who were restrained and/or placed in seclusion, the hospital failed to ensure the restraints and/or seclusion were discontinued at the earliest possible time as evidenced by the patients left in the restraints/seclusion after criteria was met to release them. (Patients #3 and #21). This deficient practice poses the risk of physical and/or emotional harm to patients when they are restrained/secluded without justification.

Findings include:

The Policy titled "Restraint and Seclusion" (Policy No.: RMCO) revealed: " ...The use of restraint and seclusion must be in accordance with a written modification to the patient's plan of care and in accordance with the order of a Licensed Independent Practitioner...Chemical Restraint: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's movements and is not standard treatment or dosage for the patient's conditions...If the individual appears to fall asleep while in mechanical restraint or seclusion, the registered nurse shall assess the individual to determine if the individual is asleep. If the individual is determined to be asleep, the registered nurse shall assess and instruct an authorized staff member to immediately release the individual from restraint or unlock the seclusion room door. Authorized staff members shall maintain constant face-to-face observation until the individual is awake and re-evaluated by the registered nurse. 6. The registered nurse shall re-assess the individual upon awakening, 7. If the individual exhibits emergency behaviors requiring restrain or seclusion upon awakening, the registered nurse shall obtain a new LIP order...5. When a mechanical restraint or seclusion has been initiated, and the unsafe situation ends, a staff member shall contact a LIP or a registered nurse. The LIP or registered nurse must evaluate the individual for release based on a determination as to whether the unsafe situation has been resolved...."

Patient #3:
Review of patient #3's medical record conducted on 09/01/2021, and 09/02/2021, revealed "...08/13/2021, a Physical Hold starting at 1910 and ending at 1917 and Seclusion starting at 1910 and ending at 2105...." The Seclusion and Restraint Monitoring entries revealed:

1932 "Seclusion observed on 1:1 basis; Quiet; calming down, Afraid to come out because s/he will be attacked"
1947: "Seclusion observed on 1:1 basis; Quiet; calming down, Afraid to come out because s/he will be attacked"
2002: "Seclusion observed on 1:1 basis; Quiet; calming down, Sleeping in the seclusion room..."
2017: "Seclusion observed on 1:1 basis; Quiet; calming down, Sleeping in the seclusion room..."
2032: "Seclusion observed on 1:1 basis; Quiet; calming down, Sleeping in the seclusion room..."
2047: "Seclusion observed on 1:1 basis; Quiet; calming down, Sleeping in the seclusion room..."
2105: "Seclusion observed on 1:1 basis; Quiet calming down, Sleeping in the seclusion room guided pt to his/her room..."

Patient #3 was kept in seclusion for over an hour after the assessment documentation revealed the patient was quiet, calming down, and sleeping. There was no documentation to indicate a need for the patient to remain in seclusion.

Review of patient #3's medical record conducted on 09/01/2021, and 09/02/2021, revealed on "...08/16/2021, a Physical Hold starting at 2035 and ending at 2036 and Seclusion starting at 2036 and ending at 2156...." The Seclusion and Restraint Monitoring entries revealed:

2035: "Physical Hold; Seclusion; Violent Shouting; Kicking/Pounding; Verbally Abusive; Attempting to Hit Others..."
2036: "Seclusion Agitated; Loud; Violent; Shouting; Kicking/Pounding..."
2048: "Seclusion; Agitated; Loud; Violent; shouting; Kicking/Pounding..."
2105: "Seclusion; Shouting; Fluids Offered..."
2120: "Seclusion; Loud; Fluids Offered; ..."
2135: "Seclusion; Quiet; Fluids Offered; ..."
2145: "Quiet"

Patient #3 was maintained in seclusion after the assessment revealed the patient was quiet.

Review of patient #3's medical record conducted on 09/01/2021, and 09/02/2021, revealed on "...08/18/2021, a Physical Hold starting at 1900 and ending at 1902 and Seclusion starting at 1903 and ending at 2003...." The Seclusion and Restraint Monitoring entries revealed:

1902: "Seclusion; Agitated; Loud; Violent; Fighting Restraints; Shouting; Kicking/Pounding; Attempting to Hit Others..."
1917: "Seclusion; Agitated; Loud; Shots..."
1930: "Seclusion; Quiet; Asleep; Shots..."
1945: "Seclusion; Quiet; Calming down; Calm taking to BHT..."
2000: "Seclusion; Quiet; Asleep; Sleeping, lying down..."
2003: "Released from Seclusion..."

Review of patient #3's medical record conducted on 09/01/2021, and 09/02/2021, revealed on "...08/21/2021, a Physical Hold starting at 1615 and ending at 1620 and Seclusion starting at 1620 and ending at 1700...." The Seclusion and Restraint Monitoring entries revealed:

1615: "Physical Hold; Agitated; Loud; Violent; Fighting Restraints; Shouting; Kicking/Pounding; Verbally Abusive; Attempting to Hit Others; Verbally Threatening; Not Responsive to Verbal limits..."
1630: "Seclusion; Quiet; Calming Down..."
1645: "Seclusion; Quiet; Calming Down..."
1700: "Pt. calm, maintain control; following directions..."

Employee #36 and Employee #52 confirmed during separate interviews conducted on 09/01/2021, and on 09/02/2021, that the patient #3 met release criteria prior to the patient being released from seclusion episodes on 08/13/2021, 08/18/2021 and on 08/21/2021.

Patient #21:

Patient #21, an adolescent patient, was placed into the seclusion room on the unit and mechanical restraints applied to all four extremities (4-point restraints) on 08/08/2021, at 8:55 a.m. The 4-point restraints were removed at 9:52 a.m. when the patient was observed sleeping, however, the patient remained in seclusion. The patient was observed being agitated, kicking/pounding, violent, and agitated at 10:15 a.m. and 10:20 a.m. The patient was documented to be sleeping between 10:35 a.m. and 12:20 p.m. and was quiet between 12:35 p.m. and 12:50 p.m. The patient was released from seclusion at 12:55 p.m. almost two hours after the patient was observed sleeping at 10:35 a.m.

Patient #21 was placed into seclusion again on 08/13/2021, at 5:17 p.m. Documentation in the Seclusion and Restraint Monitoring Form revealed the patient was "quiet" between 5:42 p.m. and 6:30 p.m., however, the patient was not released from seclusion until 6:30 p.m. a period of almost one hour. Nursing documentation at 7:37 p.m. included: "Vitals taken. B/P low due to patient not having dinner yet, fluids given and BP WNL...."


43475

Based on review of clinical records, policies and procedures and staff interviews, it was determined the hospital failed to monitor the effectiveness of the process of restraint and seclusion as evidenced by the quality program tracking only numbers of episodes and failure to include chemical restraints.

Findings include:

The 2021 Steward Health Quality and Patient Safety Plan - St. Luke's Behavioral Health Addendum included: "Data is collected to monitor the stability of processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement. Data collection is used to identify and prioritize improvement initiatives. In addition, collected data is used to: "Establish performance baseline...Describe dimensions of performance relevant to functions, processes, and outcomes...Identify areas for more focused data collection; and Sustain improvement..."

The hospital's safety indicators included "Seclusion/Restraint Usage" including the appropriateness of physician orders for seclusion/restraints. Documentation in the Performance Improvement Committee meeting minutes dated May 20, 2021, June 17, 2021, and July 15, 2021 revealed the numbers of physical holds, mechanical restraints, and seclusion were reported. There was no documentation that referenced the appropriateness of physician orders. There was also no documentation that the data collected showed patients were released from restraints/seclusion when criteria was met nor was there documentation that data was collected on the use of chemical restraints.

Patients #3 and #21 had documented episodes of physical holds, mechanical restraints and/or seclusion. Documentation in the reporting forms revealed the patients were not released from restraints/seclusion when they met criteria such as non-violent, calm, asleep. (Refer to Tag A160 for specific details).

Documentation in the Seclusion and Restraint Individual Reporting Forms for Patient #21 revealed the patient received intramuscular injections of medications, including antipsychotic, not used as a standard treatment for the patient's condition. The medications were not identified and documented as chemical restraints. In addition, there was also documentation that physician orders for restraints/seclusion were not obtained for four and five days after the two of the episodes.

The Risk Manager and the Quality Director acknowledged during interviews that data was collected on the number of episodes of physical holds, mechanical restraints, and/or seclusion.

Based on policy and procedure review, hospital documents, and staff interview, it was determined the hospital failed to follow up on a corrective action plan developed as a result of a quality review of concerns identified during a Code Blue after a patient attempted suicide.

Findings include:

The hospital's quality review of a patient attempted suicide in June 2021. The patient ripped the hem off of her top, tied it around her neck, and was unresponsive when found by staff. The quality review identified emergency supplies including appropriate scissors to cut off the piece of cloth from around the patient's neck and oxygen tubing were not readily available and emergency equipment and supplies were stored in different areas. The corrective actions included tackle boxes containing sheers, oxygen tubing and other emergency supplies would be kept together in one place on each unit and next to the AED (automated external defibrillator) and oxygen tanks. Plastic breakable locks were to be placed on the tackle boxes and inspected by pharmacy monthly to verify Registered Nurses were checking and verifying the integrity of the lock and expiration dates.

Observations on Adult Services Units 4 and 5 with personnel #38 conducted on 09/08/2021, revealed one red emergency tackle box, inside each of the medication rooms. The label attached to the tackle boxes stated sheers were located inside the red emergency tackle boxes. Upon examination the tackle boxes contained bandage scissors and not medical sheers scissors.

Personnel #47 confirmed during an interview conducted 09/08/2021, that the emergency tackle boxes contained bandage scissors.

Personnel #1 and Personnel #38 confirmed during an interview conducted 09/08/2021, that the emergency tackle boxes contained bandage scissors and not medical sheers scissors.

The Quality Director acknowledged there was no documentation or audit to ensure the corrective action was implemented, effective, and sustained.

Based on review of clinical records, review of hospital policies and procedures, review of daily nurse staffing records, hospital documents, and staff interviews, it was determined the hospital failed to provide organized nursing services 24-hours per day to assess the individual needs of each patient and deliver and supervise the care required in accordance with physician orders, policies and procedures and nursing standards of care as evidenced by:

A-0386: The Director of Nursing failed to ensure that AIMS (Abnormal Involuntary Movement Scale) was completed on all patients as indicated.

A-0392: The hospital failed to ensure each unit was staffed with the number and types of personnel required to meet the needs of each patient as evidenced by documented events of events of Code Gray (individuals with episodes of danger to self or others requiring de-escalation and/or restraint), and incidents of patient self-harm, and/or assault between patients that may have been prevented if staff with the appropriate knowledge and skill were at the levels required to support the patient census, acuity and patient need.

A-0395: Failure to require a registered nurse: 1. Ensure that patients ordered 1:1 observation were constantly monitored and directly observed at all times as required by the hospital policy and procedure in 1 of 1 patients reviewed (Patient #3); and 2. Directed and monitored the observations of patients by the assigned staff member on the child/adolescent unit on 09/07/2021. (Patients #24, #45, #46 #47, #48, #49 #50, and #51).

A-0405: Failure to ensure hospital policies and accepted standards of practice were followed for medication preparation and administration as evidenced by nursing personnel not preparing and administering medications one patient at a time and storing the prepared medications in a secured location to prevent medications from being misplaced or accessed by unauthorized individuals.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of the facility's polices/procedures, medical records, and interviews, it was determined that the Director of Nursing failed to ensure that AIMS (Abnormal Involuntary Movement Scale) was completed on all patients as indicated. This deficient practice poses a risk to the health and safety of the patients and staff, when the hospital does not adhere to the policies and procedures of the hospital.

Findings Include:

Review of policy titled, "AIMS TESTING" (Policy No. AP2 9), revealed: "...All patients admitted to St. Luke's Behavioral Health Center Inpatient will have AIMS (Abnormal Involuntary Movement Scale) completed...."

Review of medical records, and staff interview, the Department determined the administrator failed to ensure that 25 out of 27 sampled patients received an Abnormal Involuntary Movement Scale (AIMS) test.

Employee #2 and Employee #29 confirmed during an interview conducted on August 30, 2021, that the patients are not receiving AIMS (Abnormal Involuntary Movement Scale) testing as required per the policies and procedures of the hospital. "We dropped the ball on this when we revised the workload. We didn't include it on the flowsheet for the nurses."

There was no documented evidence of an implementation plan for the registered nurses to complete the AIMS Testing as required by the hospital policy.

Based on review of hospital policy/procedure, Nursing's July 2021 and August 2021 work schedule and hospital documents, it was determined that the hospital failed to ensure that each unit was staffed with the number of personnel and the types of required personnel to provide nursing care to all patients as needed as evidenced by:

the unit shifts that were identified as not having the number of personnel required to meet the staffing requirements had events of Code Grays (where individuals are becoming uncontrollable and require deescalation and/or restraint), patient self-harm, and/or assault between patients that may have been prevented if staff with the appropriate knowledge and skill were at the levels required to support the patient census, acuity and patient needs.

This deficient practice poses a risk to the health and safety of patients and staff, when the hospital does not have the number and type of personnel that are required to meet the needs of the patients.

Findings include:

The hospital policy titled "Inpatient Staffing/Acuity Plan and Patient Acuity Tool Guidelines" requires that " ...Each unit will have sufficient staff to maintain a safe and therapeutic environment. The total number of staff is determined by the number and acuity of patients ...On the day and evening shifts the maximum patient to registered nurse (RN) ratio is 15:1 ...On the day and evening shift the maximum patient to Behavioral Health Technician (BHT) is 15:1 on the adult units and 10:1 for children and adolescent units ...On the 11-7 shift, the staffing matrix is followed with the maximum patient to RN ratio of 15:1 with a minimum of one (1) RN on the unit at all times ...The maximum patient to BHT ratio is 18:1 ...Acuity levels are assigned an approximate time allowance to help determine staffing needs and may be used as a guideline for making assignments ...Patient care assignments will be made taking into consideration the acuity and nursing care needs of the patients and will not be made based on geographic room locations of patients on any unit ...." The policy listed the Acuity Based Guidelines for each shift for each unit.

Review of the Staffing Schedule, Shift Assignment Sheets and House Supervisor Reports for the month of July 2021 revealed that thirty-nine (39) of sixty-two (62) shifts were short staffed at least one (1) staff member based on census and the acuity matrix. Of those 62 total shifts, there were thirty-four (34) shifts that were short staffed at least 1 staff member when the hospital was overcapacity in census one (1) to four (4) beds. Further review of the House Supervisor Report revealed units were utilizing orientees as core staff when the units were understaffed, often occurring while the hospital was admitting patients to overcapacity beds.

A review of the House Supervisor Report revealed on 07/06/21 day shift, the facility had 3 overcapacity beds and unit AP5 had an acuity of 78 requiring 3 RN's, however 2 core staff RN's worked with the unit utilizing 1 RN orientee as the third (3rd) core staff member.

Additionally, on 07/26/21 day shift Unit AP1 had an acuity of 70 requiring 3 RN's, however 2 core RN's worked and utilized 1 RN orientee as core staff. Further review for that day revealed on Unit CAS day shift had acuity of 54 requiring 2 RN's, however 1 RN worked with 2 RN orientees who were utilized as core staff. Further review of the House Supervisor Report revealed thirty-one (31) shifts in July where staff were floated between units to cover for shortage of staff.

Review of the House Supervisor Report for 07/04/21 night shift revealed on the CAS unit had a census of 26 with 2 patients in overcapacity and an acuity of 60. According to the staffing matrix 2 RNs and 4 BHTs were required for the night shift. The House Supervisor Report revealed the unit had the following in staff scheduled: 2 RNs for 12 hours and 3 BHTs for 12 hours and 1 BHT for 8 hours, with no BHT scheduled for the remaining 4 hours. A note on the House Supervisor Report revealed that the patients were given box dinners with water bottles and 2 patients had put the caps to the water bottles in their mouths. Subsequently, 1 patient swallowed a bottle cap and was transferred to the emergency room with a BHT from the unit. Another patient, it was noted, had swallowed a coin which resulted in a Code Gray (Disruptive Patient/Person) and the patient was transferred to the emergency department (ED) with another of the BHTs.

Review of the House Supervisor Report for 07/06/21 night shift revealed the AP3 unit with a beginning census of 19 and an acuity of 58. The staffing matrix required the unit to have 2 RNs and 2 BHTs for the night shift. Per hospital policy, the patient to nurse ratio for night shift is 15:1. Further review of the House Supervisor Report revealed that 1 RN was floated from AP3 to the CAS unit at 2335, leaving the AP3 unit with 1 RN and 2 BHTs for 19 patients. Further review of the House Supervisor Report revealed on CAS unit the census was 25 including 1 overcapacity patient with an acuity of 62. The staffing matrix required 2 RNs and 4 BHTs. The House Supervisor Report revealed there were 2 Code Grays that night on the unit, involving the same patient in which the patient was physically assaulting staff. The patient injured one of the RNS, which resulted in the RN going home and an RN from AP3 was floated to CAS to replace the injured RN. Police were called to the second Code Gray.

Review of the House Supervisor Report for 07/12/21 revealed on CAS unit day shift the census was 23 patients with an acuity of 51. The staffing matrix required 3 RNs and 4 BHTs. The House Supervisor Report revealed 2 RNs and 2 BHTs worked that shift. Further review revealed there was 1 Code Gray on the unit that shift in which a patient became combative and assaulted 6 staff members which resulted in the police being called and the patient being taken into police custody off the unit.

Review of the House Supervisor Report for 07/20/21 AP5 unit day shift revealed a census of 24 and an acuity of 75. The staffing matrix required 3 RNs and 5 BHTs. The House Supervisor Report revealed the unit had 3 RNs and 4 BHTs working that shift. Further review of the House Supervisor Report revealed a Code Gray occurred on the unit in which a patient physically assaulted another patient resulting in the patient being transferred to the ED and the other patient was arrested by the police.

Review of the Staffing Schedule, Shift Assignment Sheets and House Supervisor Reports for the month of August 2021 revealed that forty-seven (47) of sixty-two (62) shifts were short staffed at least one (1) staff member based on census and the acuity matrix. Of those 62 total shifts, there were thirty (30) shifts that were short staffed at least 1 staff member when the hospital was overcapacity in census 1 to 3 beds. Further review of the House Supervisor Report revealed thirty-two (32) shifts in August where staff were floated between units to cover for shortages of staff. Further review of the House Supervisor Report revealed on 08/26/21 day shift the hospital was overcapacity 1 bed, and Unit AP1 had an acuity of 63 requiring 3 BHT's, however there were only 2 core staff BHT's from 1500-1900 hours with the unit utilizing the 1 BHT orientee as the third (3rd) core staff BHT.

Review of the House Supervisor Report for 08/02/21 revealed on CAS unit days the census was 20 patients with an acuity of 57. The staffing matrix indicated 3 RNs and 4 BHTs were required. The actual staffing was 2 RNs and 3 BHTs. Further review of the House Supervisor Report revealed the unit had 2 Code Grays in which there were altercations between patients.

Further review of the 08/02/21 House Supervisor Report for day shift revealed on unit AP5 a census of 23 patients with an acuity of 78. The staffing matrix required 3 RNs and 5 BHTs to be working. The House Supervisor Report revealed there were 2 RNs and 4 BHTs working that unit that shift. Further review of the House Supervisor Report revealed that there were 3 separate Code Grays on the unit. At 0806 a patient hit an RN; at 1130 a patient became violent and required restraint and seclusion; and at 1240 a patient became violent and required restraint and seclusion.

An interview was conducted on 08/23/21 with RN Employee #14 who stated shift assignments are usually done by dividing the unit in half and each nurse takes one half. "One nurse gets the top half of the unit and the other nurse gets the bottom half. Acuity isn't really considered, if it looks like the assignment is off balance we can adjust the assignments if needed."

An interview was conducted on 08/24/21 with RN Employee #26 who stated "there is no maximum patient to nurse ratio for each nurse to be assigned. There is no written guide regarding acuity and staffing that should be assigned to a unit. Total acuity is really considered when assigning staff for a unit."

An interview was conducted on 09/07/21 with Chief Nursing Officer (CNO, Employee #3) who acknowledged the hospital did not have enough RN and BHT staff and units worked short staffed. S/he further stated there are more deficiencies in the schedule with RN's than BHT's. S/he stated the hospital staffs according to the acuity matrix. S/he stated that orientees are not to be included in the acuity ratio or staffing. S/he further stated it may be necessary to float staff from one unit to another to cover staff shortages. S/he further stated that the hospital will continue admitting patients into overcapacity despite having no beds or staff to accommodate because "that's how it has always been done."

40528

Based on review of hospital policies and procedures, documents, video review, medical records and staff interviews, it was determined the responsible registered nurse failed to:

1. Ensure individuals assigned to provide continued observation as ordered by a provider as evidenced by 1 of 1 patient (Patient #3) observed during a video review was continually monitored. This deficient practice has the potential to cause harm to the patient, staff, or other patients.

2. Direct and monitor the observations of patients by the assigned staff member on the child/adolescent unit on 09/07/2021 (Patients #24, #45, #46 #47, #48, #49 #50, and #51). This deficient practice poses the risk of harm to patients if safety checks are not performed to ensure their safety and well-being.

Findings include:

1.
Policy titled "Observation of Patients on Inpatient Psychiatric Units" revealed: " ...One to one (1:1) Observation: Assignment of a qualified staff member to remain with the patient and maintain an unobstructed view of the patient at all times to prevent harm to the patient or others. The ordering licensed independent practitioner (LIP) may indicate the proximity to the patient at which the one to one (1:1) observation is conducted, if necessary) ...C. One to one (1:1) Observation 1. Patients will be placed on one to one (1:1) observation when they are at imminent risk of harm to themselves or others ...3. The Registered Nurse Role ...d. The RN will obtain an order from the LIP ...g. The RN retains full responsibility for the provision and/or delegation of all direct care. h. The RN supervises the qualified staff member observing the patient ...j. The RN documents at least every two hours on the status of the patient on one to one (1:1) observation. 4. The Patient Observer Role ...b. Maintains unobstructed view of patient at all times ...The patient may never be out of the Patient Observer's sight ...."

Policy titled "Patient's Rights and Responsibilities" revealed: " ...Policy ...All hospital staff, medical staff members and contracted agency staff performing patient care activities will observe all patient rights ...Receive considerate and respectful care provided in a safe environment ...."

Document titled "Daily Patient Assignment Sheet" dated 09/05/2121, 1900 - 0730, CAS (Child and Adolescent Unit), revealed that Employee #50 Behavioral Health Technician (BHT) was assigned to provide 1:1 observation for Patient #3 in Room #286. Employee #51 was the Registered Nurse (RN) on the unit.

The surveyor conducted video review on 09/08/2021 with Employee #2. The video review covered the time frame from 09/05/2021, 11:00 p.m. (2300), through 09/06/2021, 2:02 a.m. (0202) on the CAS Unit, including Room #286. No other employee, including Employee #51, the RN responsible for the care of patients on the unit, entered Room #286 during the video review. Video review revealed there was no employee providing 1:1 coverage during the following times:

12:21 a.m. (0021) Employee #50 exited patient room #286 and exited the unit
12:26 a.m. (0026) Employee #50 returned to the unit
12:27 a.m. (0027) Employee #50 entered patient room #286
12:41 a.m. (0041) Employee #50 exited patient room #286 and exited the unit
12:56 a.m. (0056) Employee #50 returned to the unit
12:58 a.m. (0058) Employee #50 entered patient room #286

Medical record for Patient #3 dated 09/05/2021, (0910), revealed provider order to nurse, continue one to one times 24 hours for danger to self (DTS). Patient #3 had documented multiple events requiring physical hold, restraint, and/or seclusion for being violent, fighting, kicking/pounding and shouting throughout the patient's hospitalization.

Medical record for Patient #3 dated 09/06/2021, 0000 - 2345, revealed that the Special Precautions Monitoring Q15 Min Checks, confirmed special needs as a 1:1. At 0045, Employee #50 BHT documented that Patient #3 was in his/her room, appears asleep, and respirations regular.

Employee #2 confirmed during an interview conducted on 09/08/2021, that video review confirmed that Employee #50 appeared to be on a 1:1 patient assignment, left the patient's room and the unit on two (2) occasions and no other employee entered patient room #286 during that time. Employee #2 confirmed Employee #50's name and that s/he was listed on the Daily Patient Assignment Sheet as a 1:1 assignment for Room #286.

2.
The hospital's policy and procedure titled "Observation of Patients on Inpatient Psychiatric Units" included: "Policy...The patients served on the Steward Health Care inpatient psychiatric units are experiencing intensive subjective distress and/or have a sever function impairment related to psychiatric illness. As such there is a significant risk of harm to the patient and/or to others. The inpatient psychiatric units provide a highly supervised and regulated environment that affords protection to patients and staff while providing for patient choice and responsibility...Procedure...B. Frequent Observation (Safety Checks)...1. All patients will receive safety checks at minimum intervals of every 15 minutes throughout their stay...The charge nurse is responsible for ensuring that a qualified staff member is assigned to conduct safety checks throughout the entire shift...The qualified staff member conducting checks will remain in the milieu during this assignment to safety checks...During their assignment to safety checks, the qualified staff member will continuously round on all unabated ligature and safety risks on the unit to ensure that patients are not accessing these for self-harm. During their assignment to safety checks, the qualified staff member will not undertake other assignments other than patient safety checks and ligature/safety rounds...During their assignment to safety checks, the qualified staff member will actively round throughout the unit, visualize each patient at 15-minute intervals or as ordered by the patient's LIP (Licensed Independent Practitioner), ensure the patient's safety, and confirm the presence of life signs...Safety checks will be documented on the unit safety checks sheet which will include the date, the patient's name, the patient's room number, 15-minute time blocks, the patient's whereabouts, a key to the location abbreviations, and the qualified staff member's initials and signature...."

The patient observation sheets were requested for review during observations of the child/adolescent unit on 09/07/2021 at 8:30 a.m. Staff #53 was identified to be assigned to the every fifteen minute patient observation checks, however, another staff member reported,\ Staff #53 had left the unit to take out the trash and had not turned the sheets over to another staff member on the unit. Staff #53 returned to the unit at 8:31 a.m. and retrieved the clipboard with the observation sheets. There was no documentation that observations were made of Patients #24, #45, #46, #47, #48, #49, #50, and #51 at 8 a.m. and 8:15 a.m. which was acknowledged by Staff #2 and Staff #53.

Based on review of hospital policies/procedures, observations and staff interviews, it was determined the hospital failed to ensure staff follow hospital policy and accepted standards of practice for medication preparation and administration by not preparing and administrating medications one patient at a time and maintaining medications once prepared for administration in a secured location.

This deficient practice poses a risk for patients to receive the wrong medication and increases the risk of medication errors in the patient population and medication being misplaced and/or being accessed by individuals who are not authorized to have access to medications.

Findings include:

Review of hospital policy titled "Medication Administration: Medication Management" requires that " ...Medications are prepared for one patient at a time ...Medications are accessed from the automated dispensing machine or secure storage area ...."

Review of hospital policy titled "Medication Security and Storage: Medication Management" requires that " ...Medications should be stored in automated dispensing machines (ADMs), when possible ...Medication and medication-containing carts, boxes, and alike must be maintained secured and under the control of authorized personnel when actively providing, or preparing to provide, patient care ...."

Review of hospital policy titled "Hand Hygiene" requires that " ...Hand hygiene is indicated before and after patient contact ...."

Observation on 8/23/21 on Unit AP3 revealed Employee # 17 opening a cupboard labeled "Empty Charts" and removing a paper cup which contained medication packets. S/he then proceeded to scan a patient armband through the medication administration window in the nurse's station. S/he then scanned the medication in the paper cup and gave the medication to the patient. S/he then retrieved another paper cup containing medication packets and proceeded to scan the armband of the next patient in line at the medication window. S/he did not perform hand hygiene before beginning the medication administration or in between each patient. The cupboard was not locked.

Observation on 8/23/21 on Unit AP1 revealed at nurse's station two (2) medication bins on counter containing multiple medications both for external and internal use. Further examination revealed these medications were for multiple patients and staff were giving patients medications from these bins. The medication bins were not secured.

Observation was conducted on 9/7/21 on Unit AP5 revealed a staff nurse removing all medications from the ADM for patients for that scheduled time and placing them in individual cups.

An interview was conducted on 8/23/21 with Employee #17 who stated s/he pulls the medications from the ADM for all patients that have medications for a scheduled time. S/he places each patient's medications in an individual cup that is labeled with their name and then keeps the medications in the cupboard at the nurse's station.

An interview was conducted on 8/23/21 with Employee #16 who stated medications should be removed from the ADM 1 patient at a time and given to patient before retrieving another patient's medication. S/he stated however, when there are multiple patients with multiple medications at the same time it is common practice to pull all the medications at one time and put in the labeled cups. S/he stated otherwise it takes too long to go into medication room, retrieve the medications from the ADM and then give to the patient. S/he stated medications would then be given late if they didn't pull all at one time.

An interview was conducted on 9/7/21 with the Chief Nursing Officer (CNO, Employee #3) who stated the nurses should be preparing and administering patient medications one patient at a time. S/he further stated that it is too time consuming to prepare the medications 1 patient at a time. S/he stated all medications are removed from the ADM at same time but the nurse will prepare each patient medication one patient at a time. The nurse will then put the prepared medication in a labeled cup or bag for each patient. S/he stated the medications should be kept in the locked medication room and the nurse should be going to the medication room and retrieving the medications for one patient at a time. S/he stated the medication should not be kept in the nurse's station because there are too many people that would have access to the medication if it was in the nurse's station.

Based on review policies and procedures, documents, and interviews, it was determined the hospital failed to ensure the medical staff approved the hospital's Formulary. This deficient practice poses a potential risk for patient safety when medications are not periodically reviewed based on emerging safety information and current guidelines for optimal use of the medications.

Findings include:

Policy titled "Formulary System" revealed: " ...E. Formulary Maintenance 1. Formulary maintenance is ongoing process on continual review and revision overseen by the corporate Pharmacy & Therapeutic Committee. 2. The corporate Pharmacy & Therapeutics Committee objectively appraises, evaluates, and selects medication for addition to or deletion from the formulary ...3. Annual Review of the Formulary by American Hospital Formulary Service (AHFS) Classifications ...Each year a calendar will be developed to ensure that the entire formulary is reviewed ...."

Documents titled "Pharmacy & Therapeutics Committee, 05/23/2019" revealed an Annual Safety/Efficacy Formulary Review for compounding formulas and the formulary.

Documents titled "Medical Executive Committee (MEC) Meeting Minutes, 02/23/2021, 03/23/2021, 04/27/2021, 05/25/2021, 06/22/2021, and 07/27/2021," revealed that there was no documented evidence of the Formulary being approved by the MEC.

Employee #2-Risk Manager confirmed during an interview conducted on 08/25/2021, the Formulary has not been approved by the medical staff.

Employee #29-Quality Director confirmed during an interview conducted on 08/30/2021, the Formulary was not listed in the MEC meeting minutes. The approval is in the P&T meeting minutes and P&T is part of the MEC Meeting. P&T approved the Formulary in 2019.

Employee #47-Pharmacist confirmed during an interview conducted on 09/02/2021, that the P&T and MEC meetings are held at the same time. Corporate P&T has broken the Formulary review down into sections that are reviewed per a monthly schedule. The hospital policy states that the Formulary is to be approved by P&T but not MEC or the Governing Board.

Based on review of clinical records, review of hospital policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide organized dietary services to meet the nutritional needs of the patients as evidenced by:

(Tag 0620): failed to ensure that:
1. the person in charge of dietary provided services to the hospital that met the patient's nurtritional needs as evidenced by alternative menus not being available to patients, supplemental nutritional snacks being available to patients, and documentation of meals being broad and not specific to evaluate if the nutritional needs were being met;

2. the person in charge of dietary services was appointed by the Governing Board. The deficient practice poses a potential risk to the health and safety of the patients, when the minimum standards are not met regarding daily management of the dietary services.

(Tag0629): that equivalent meal replacements are available to patients.

Based on review of documents, employee files, policies and procedures, and interviews, it was determined that the hospital failed to ensure that:

1. The person in charge of dietary provided services to the hospital that met the patient's nutritional needs as evidenced by alternative menus not being available to patients, supplemental nutritional snacks being available to patients, and documentation of meals being generalized and not specific to evaluate if the nutritional needs were being met;

2. The person in charge of dietary services was appointed by the Governing Board and is full-time. The deficient practice poses a potential risk to the health and safety of the patients, when the minimum standards are not met regarding daily management of the dietary services.

Findings include:

1.
Document titled "Amendment to Master Service Agreement (Contract)" revealed: " ...Employment Transition of Personnel. i. Upon full execution of this Amendment, Service Provider shall make offers of employment to the Management, clinical (i.e., dieticians) ...employed by Client immediately prior to this Amendment ...."

Document titled "Job Description - Director Food and Nutrition" revealed: " ...Summary: Direct the operation of Food & Nutrition Services...Essential Functions and Responsibilities: Evaluates, directs and manages the function and structure of food and nutrition services, ensuring that all client expectations and regulatory standards are being appropriately monitored and adhered to...Signature ...09/24/2020 ...."

Employee File Review completed for Employee #20-Dietician and Employee #31-Director of Food and Nutrition. Included in the job description located in the employee's file was a list of essential functions and one of these functions was the responsibility to direct and manage the function and structure of food and nutrition services.

Policy titled "Alternate Menu Items" revealed: " ...Policy: To increase patient satisfaction or to meet specific patient needs and allow more flexibility in meal planning, long stay patients or those with special food requirements may be offered items not specifically listed on the patient menu ...Procedure: I. There are a number of items that are "always available" to be prepared for individual patients. II. Cafeteria items available for that day may be ordered for patients if the diet order allows. III. Specially prepared items may be appropriate and available ...."

Employee #41-Registered Nurse (RN) confirmed during an interview conducted on 08/31/2021, that they do not have an equivalent meal replacement. Options offered are dry cereal, milk if it is available, juice, teddy grahams, or saltines. The staff can grab a sandwich from intake, however they do not always have them available.

Patient #27 confirmed during an interview conducted on 08/31/2021, that s/he the alternative that was provided was cereal as a meal replacement after dropping his/her tray.

Employee #48-Behavioral Health Technician (BHT) confirmed during an interview conducted on 09/07/2021, that there was no food available on the unit, including snacks. The only thing in the cupboards is condiments. Meal times have been pushed back. There are no meal replacements if a patient does not like the food. Sometimes they can get a sandwich from intake, however most of the time there are not any available. If there are not any sandwiches available, the patient either eats what is provided or they go hungry until the next meal.

Employee #20-Dietician and Employee #31-Director of Food and Nutrition confirmed during a combined interview on 09/07/2021, that the hospital has a non-select menu and is scheduled in advance. An alternative meal may be provided if dietary knows ahead of time and the item available would depend on the alternatives offered through their vendor. The meal entrée would be replaced with a sandwich, which would be the equivalent nutritional value. The only item on site are extra sandwiches. Sixteen (16) to Eighteen (18) sandwiches a day are sent to intake and are only stocked in intake for patients that are coming in and have missed a meal or in case a unit needs a sandwich. Employee #31-Director of Food and Nutrition acknowledged that the nursing staff do not have a copy of the alternative menu.

Surveyors conducted tours on 08/25/2021, of the cafeteria/kitchen area and cart cleaning area. The kitchen included a service line where meals were plated into styrofoam containers and then brought to the units. The select meals were brought in from another location, through the contracted service agency.

Surveyors conducted tours on 08/26/2021, of the kitchen area revealed that the facility had relocated their kitchen/cafeteria area to another location off the premises through a third party vendor.

Surveyors conducted tours on 09/07/2021, of all the units and there were no meal replacements available for patients.

Summary: Meals are brought over from another location through the contracted service agency, all requests must be made in advance for an alternative meal. There is not a cafeteria or cafeteria items available, as required in the hospital policy, to the patients after the meal has been delivered and the patient for some reason is not able to eat at the meal time or is hungry in between meals. The hospital personnel could not provide a plan to support the patient dietary needs outside of the routine menu items and the routine menu time.

2.
Document titled "Amendment to Master Service Agreement (Contract)" revealed: " ...Employment Transition of Personnel. i. Upon full execution of this Amendment, Service Provider shall make offers of employment to the Management, clinical (i.e., dieticians) ...employed by Client immediately prior to this Amendment ...."

Document titled "Job Description - Director Food and Nutrition" revealed: " ...Summary: Direct the operation of Food & Nutrition Services...Essential Functions and Responsibilities: Evaluates, directs and manages the function and structure of food and nutrition services, ensuring that all client expectations and regulatory standards are being appropriately monitored and adhered to...Signature ...09/24/2020 ...."

Documents titled "Governing Board Meeting Minutes" dated 07/01/2020, 09/02/2020, 11/11/2020, 02/03/2021, 03/03/2021, and 05/05/2021, revealed no evidence of the hospital's Director of Dietary being appointed to his/her position.

Employee File Review completed for Employee #31-Director of Food and Nutrition. Included in the job description located in the employee's file was a list of essential functions and one of these functions was the responsibility to direct and manage the function and structure of food and nutrition services.

Employee #31-Director of Food and Nutrition confirmed during an interview conducted on 08/25/2021, that s/he works four (4) hours at the hospital and works the other four (4) hours at the hospital's sister facility.

Employee #2-Risk Manager confirmed during an interview conducted on 08/26/2021, that Employee #31-Director of Food and Nutrition is a contracted part-time employee for the hospital.

Employee #29-Quality Director confirmed during an interview conducted on 08/30/2021, that the Director of Dietary was not approved by the Governing Body and s/he has been contracted since October of last year.

Employee #1-President confirmed during an interview conducted on 08/30/2021, that the Governing Board had not approved the Director of Dietary.

Based on review of policies and procedures, documents, medical records, and interviews, as evidenced by, the hospital not providing alternatives to the scheduled meals and/or providing nutritional in-between snacks for patients when an expression of hunger is expressed and approved for the patient based on the ordered diet. This deficient practice poses a potential risk to the patient's overall health.

Findings include:

Policy titled "Alternate Menu Items" revealed: " ...Policy: To increase patient satisfaction or to meet specific patient needs and allow more flexibility in meal planning, long stay patients or those with special food requirements may be offered items not specifically listed on the patient menu ...Procedure: I. There are a number of items that are "always available" to be prepared for individual patients. II. Cafeteria items available for that day may be ordered for patients if the diet order allows. III. Specially prepared items may be appropriate and available ...."

Document titled "Forecast Sheet-Alternative Menu, Sunday - Day 22" revealed alternatives: Breakfast - no alternative offered; Lunch - Tuna Sandwich, Turkey Dog, or Peanut Butter and Jelly; Dinner - Turkey Sandwich, Hamburger, or Peanut Butter and Jelly. None of the alternatives were listed as being ordered by the hospital or sent to the hospital.

Document titled "Job Description - Director Food and Nutrition" revealed: " ...Essential Functions and Responsibilities: Evaluates, directs and manages the function and structure of food and nutrition services, ensuring that all client expectations and regulatory standards are being appropriately monitored and adhered to ...."

Documents titled "Menu 2021 Week 1, Week 2, Week 3, and Week 4" revealed no food alternatives/substitutions listed.

Patient #27 confirmed during an interview conducted on 08/31/2021, that s/he has received cereal as a meal substitute.

Patient #26 confirmed during an interview conducted on 09/07/2021, that s/he is always hungry and has been at the facility for five (5) days. Patient #26 asks for snacks, is told that they don't have any, and that s/he will have to wait until the next meal. The meals are late and if you don't like what is on the tray you just do not get anything.

Employee #41-Registered Nurse (RN) confirmed during an interview conducted on 08/31/2021, that they do not have an equivalent meal replacement. Options offered are dry cereal, milk if it is available, juice, teddy grahams, or saltines. The staff can grab a sandwich from intake, however they do not always have them available.

Employee #2-Risk Manager confirmed during an interview conducted on 09/07/2021, an alternative meal would be available through their dietary contract and they would work with the staff. An alternative is not stocked on the unit, sandwiches are stocked in intake, but unsure of the number of sandwiches stocked.

Employee #48-Behavioral Health Technician (BHT) confirmed during an interview conducted on 09/07/2021, that there was no food available on the unit, including snacks. The only thing in the cupboards is condiments. Meal times have been pushed back. There are no meal replacements if a patient does not like the food. Sometimes they can get a sandwich from intake, however most of the time there are not any available. If there are not any sandwiches available, the patient either eats what is provided or they go hungry until the next meal.

Employee #20-Dietician and Employee #31-Director of Food and Nutrition confirmed during a combined interview on 09/07/2021, that the hospital has a non-select menu. An alternative meal may be provided if dietary knows ahead of time and the meal entrée would be replaced with an equivalent nutritional value sandwich. Sixteen (16) to Eighteen (18) sandwiches a day are sent to intake and are only stocked in intake for patients that are coming in and have missed a meal or in case a unit needs a sandwich. The nursing staff do not have a copy of the alternative menu.

Observation on tour on 09/07/2021, revealed that condiments, milk, juice, dry cereal, and teddy grahams were available on the units.

Based on review of hospital policies/procedures, contracts, documents, observations, and staff interviews, it was determined that the hospital failed to ensure:
1. expired supplies were discarded.
2. the meal preparation area was in a clean and sanitary environment.
3. the swimming pool was maintained in a clean and sanitary condition.

The deficient practice poses a risk to the health and safety of the patients.

Findings include:

1. Review of the hospital policy titled "Equipment/Supplies: Acquisition and Use" requires that " ...Expired Equipment: 1. Monthly rounds (Medication Room and Exam Room) will be conducted by nursing staff for any expired medical supplies and will notify central supply for replacement ...."

Observation on tour on 8/23/21 revealed on Unit AP-1 a gallon size Ziploc type storage bag containing expired lab collection tubes, a roll of paper tape, several packages of 2X2 gauze, several alcohol prep pads and a used lab collection tube containing a blood sample.

Observation on tour on 8/25/21 revealed in the laboratory room of the facility the following expired supplies:
134 Prevantics prep pads expiration 6/2021
3 Vacuette Blood transfer devices expiration 1/27/202
21 Prevantics prep pads expiration 3/2019
2 boxes of OFT (OuantiFeron-TB) kits expiration 7/31/2021
2- 21 gauge X 1 inch hypodermic needles expiration 11/2020
7 Grey top Lab tubes expiration 7/31/2021
1 red top serum vacutainer lab tube expiration 6/30/2021

An interview was conducted on 8/25/21 with Employee #32 who stated supplies are checked monthly for expiration and discarded. Employee #32 confirmed the expired supplies should have been found during the monthly expiration checks. Employee #32 stated there should be no expired supplies in the facility.

An interview was conducted on 8/25/21 with Employee #2 who acknowledged expired supplies had been found and stated there should be no expired supplies in the hospital.

2. Review of the hospital policy titled "Environmental Services: Infection Control" requires that " ...Housekeeping surfaces require regular cleaning and removal of soil and dust to ensure that the environment is maintained in a clean and sanitary condition ...."

Review of hospital policy titled "Infection Control Guidelines for Food and Nutrition Services" requires that " ...Food should be received and stored under conditions that maintain nutritional value and minimize the risk of contamination by microorganisms, insect, rodents, and toxic substances ...Records of food and equipment temperatures must be maintained ...Corrugated cardboard used to deliver products, should be removed as soon as possible because these boxes deteriorate or damage the product, the product may leak, or water damage may be present; any moisture rots the boxes, and these conditions allow for pest infestation and possible damage to the product ...Patient refrigerator temperatures are checked and documented daily ...The refrigerator temperature is maintained at or below 40 degrees Fahrenheit ...The freezer temperature is maintained at or below 0 degrees Fahrenheit ...Housekeeping Daily Responsibilities: Clean outside of dry food storage areas and refrigerators, clean entire pantry ...Food Service Daily Responsibilities: record refrigerator temperatures, react to temperature problems, rotate stock ...Cleaning, Sanitizing and Equipment Maintenance: All work surfaces and counters should be cleaned and sanitize daily and more frequently as needed ...All floor surfaces will be wet-mopped daily and as needed ...Mops and brooms should not be left in food preparation areas when not in immediate use ...."

Review of the hospital document titled "Amendment to Master Service Agreement Between Steward Health Care System LLC and Morrison Management Specialists, Inc" revealed that " ...The Client will ensure that the Departments (including the kitchen, if any) are in good, clean, sanitary, working condition, as of the beginning of Service Provider's Services. The Client will be responsible for all maintenance, repairs and replacements with respect to the Facilities, equipment and other items furnished by the Client for use in the Department (collectively, the "Property") ...Cleaning responsibilities will be as follows:
...Kitchen: Floors, walls, equipment, refrigerators and freezers -Service Provider
...Vents, ceiling, duct work, light replacement- Client
...Storage Areas for Program: Floors, walls, shelving - Service Provider
...Ceiling- Client
...Cafeteria: Serving line/equipment, serving line walls, serving line floors (kitchen side)- Service Provider
...Serving line floor (customer side), ceiling - Client
...Receiving Area for Program: pick up/spot mop - Service Provider
...Daily cleaning- Client ...
Service Provider will prepare meals at the kitchen of an offsite location and transport those meals to a designated area at St Luke's Behavioral Health Center in appropriate containers. Service Provider's personnel will then properly handle such meals and equipment, including, but not limited to, complying with health department regulations, maintaining appropriate temperatures, and following appropriate health and sanitation practices after the meals are delivered to each location ...."

Review of the document titled "Morrison Healthcare Food Services Job Description: Director of Food and Nutrition" requires that " ...Maintains a clean, sanitary working environment ...Follows facility and department infection control policies and procedures ...Maintains equipment within the department in working order by notifying maintenance of needed repairs ...."

Observation and tour of the food service area was conducted on 8/25/21. Observed during the tour was multiple cardboard boxes of food items on shelving units in the food preparation area. Also observed were multiple plastic storage bins containing food items with no expiration date on container or on the food items. Further observation revealed a table with a food scale and a roll of plastic wrap. Also observed on the table next to these items were cleaning supplies: Bang liquid spray cleanser, Dawn spray degreaser, J512- Sanitizer spray, 5 Clorox wipes bins, 2 boxes of face masks, a land line telephone, packages of self-adhesive labels and multiple ink pens. A table with a microwave placed on it was observed with a package of Lysol cleansing wipes next to it. Further observation revealed a shelving unit containing multiple boxes with Styrofoam food containers, bins of individual maple syrup containers and an open plastic bin with 2 re-useable string mop heads. Further observation revealed a missing panel on the refrigerator exposing the cooling elements which were encased in dust and debris. Additionally, it was observed the sink had calcium and mineral build up and deposits around the faucet. Further observation revealed the hot food warmer was dirty with built up dried food, dirt and debris.

Dried food bits/ crumbs, and debris were noted on the food serving tray line. It was also observed 4 stainless steel food transfer containers on wheels used to transport the meals from the food service area to the patient floors were dirty with dried food and debris were noted on the handles, along the doors and inside the containers. There was visible buildup of food bits and stains noted on the stainless-steel sheet pans used in the containers to hold the Styrofoam clamshells when transporting. It was observed directly next to the food service tray line was a rolling 50-gallon trash bin without a lid, a mop, and a broom. There was visible buildup of food bits, dirt, dust and debris throughout the entire food service area including floors, pipes, connections, shelves, bins and walls. Food items were stored in these areas, many without expiration dates noted on the storage containers.

Temperature logs were observed on the 2 refrigerators and 1 hot food warmer. The logs were noted to be incomplete with the "Hot Holding Log" missing temperatures from 8/1/21 to 8/9/21. It was also observed that the parameters for the temperatures for the Hot Holding Log were incorrect stating " ...Temperature standards: Refrigerator 41 degrees or below ..." One of the refrigerator logs was noted to be completely blank with no documentation present and the other refrigerator log was incomplete from 8/1/21 to 8/9/21. However, when a copy of the temperature logs was requested and the copies were received the logs had been completed.

The tour of the food service area continued into the area that was considered "dirty". This is the area where the food transfer/delivery containers come to after going to the patient units, where they are to be cleaned before next use. Once clean they go to the food service area to be ready for the next meal. There was 1 food transfer container in this area and it was noted to have dried food and debris on the handle, on the doors, along the sides and in the interior. Also observed was a tall plastic shelving unit that had metal sheet pans on the shelves. It was explained this shelving unit is what the food trays are transported in from the outside food vendor. The shelving unit was noted to be dirty with dried food spills, dried food bits and dust. Also observed in this area was a table with a cardboard box of Styrofoam drinking cups and next to the cups were containers of Lysol cleansing wipes and a tray with soiled cleaning cloths. Further observation of this area revealed a table with a 2.2-pound cardboard box of tortilla chips and next to this was a "Sani bucket" with a cleansing solution and a soiled cleaning cloth in it.

An interview was conducted on 8/25/21 with Employee #31 who stated the meals come from an offsite provider and the food is placed in the Styrofoam clamshells once it arrives to the hospital. S/he stated the food temperature is checked upon arrival to ensure it is at the proper temperature. However, s/he was unable to provide food temperature logs. S/he stated the food service area should be cleaned after every meal service. S/he stated it was the food service provider's responsibility to clean the food service area. Employee #31 acknowledged the cleaning supplies should not be next to food items or food serving equipment. S/he stated the stainless-steel food transfer containers are cleaned after each meal service. S/he acknowledged the food transfer containers were not clean. Employee #31 acknowledged the refrigerator with the missing panel over the cooling elements should had been reported to maintenance for repair. S/he acknowledged the cardboard boxes should be removed and the food items should be stored in containers with expiration dates. Employee #31 stated the food service staff should be cleaning equipment and mopping the floors at end of shift every day. Employee #31 acknowledged the food service area was not clean and the equipment was not clean.

An interview was conducted on 8/25/21 with Employee #11 who stated environmental services rounding should be doing oversight on the food service area but it wasn't being done. S/he further stated the food service provider staff should be cleaning the area daily.

An interview was conducted on 8/26/21 with Employee #19 who stated infection control rounding is done weekly and it should include the food service area. However, s/he stated infection control rounds had not been done on the food service area.

3. Review of the hospital policy titled " Swimming Pool Safety" requires that " ...test the swimming pool and spa water on each day the patients use the swimming pool utilizing N-Diethyl-phenylenediamine test ...Record the results of the water quality tests in a log that includes each testing date and test result ...Coordinated cleaning and maintaining of pool/pool area ...complete red phone work order if pool is cloudy/green and therapeutic activity staff will close area until cleared by facilities ...if contamination with human waste occurs in the pool/ jacuzzi the therapeutic Activity staff will
A. Remove patients form pool/Jacuzzi
B. Remove as much of the contamination as possible
C. Contact the Facility Services Department and place a red phone work order
D. Close pool area for the remainder of the day until the facilities department can clean and balance chemical levels ...."

Review on 9/7/21 of the hospital document titled "Pool Log" revealed that for the months of July and August 2021, that the pool water quality tests were not done on a daily basis. Further review revealed no documentation in the log was noted after 8/10/21.

Review of the hospital document titled "Pool Maintenance Service Contract with Sierra Pools" revealed that " ...List of services provided to be by Sierra Pools: Sierra Pools' standard cleaning includes vacuuming as needed, netting all debris from water surface, brushing sides, steps, benches, floor, emptying skimmer baskets, checking and adding chemicals and backwashing when needed ...."

Review of hospital document titled "Eurofins Environment Testing America: Analytical Report" revealed that a sample of pool water was received on 7/15/21 for testing with a result of coliform fecal matter found in the pool water sample.

Observation on 8/23/21 of the outdoor pool revealed the pool water to be cloudy with a slight green tinge in color. The bottom of the pool and swimming lane lines were not visible.

Observation on 8/30/21 of the outdoor pool revealed the pool water to be cloudy. The bottom of the pool and the swimming lane lines were not visible.

Observation on 9/7/21 of the outdoor pool revealed the pool water to be cloudy. The bottom of the pool was not visible, however there was 1 swimming lane line partially visible.

An interview was conducted on 8/23/21 with Employee #11 who stated the pool was drained on 7/26/21 for feces contamination which was originally thought to be bird feces but testing showed it was human feces. S/he stated the pool service company takes care of the pool weekly. S/he stated the pool service company is relied on for total pool maintenance that the facilities department at hospital doesn't do any testing. S/he stated the Infection Control Officer is not involved with the pool and pool maintenance. S/he stated the pool was used almost daily from Memorial Day to Labor Day but it was closed once the human feces contamination had been discovered. S/he stated the pool was cloudy as the pool service company was still adjusting the chemicals since refilling the pool. S/he stated the pool was not acid washed after draining the pool for the feces contamination.

An interview was conducted on 8/26/21 with Employee #19 who stated Infection Control Rounds are done weekly in the hospital. Employee #19 stated infection control rounding had not included the pool. Employee #19 acknowledged the pool should be included in infection control rounding.

Based on review of policies and procedures, document, video review, and employee interviews, it was determined the hospital failed to ensure that staff followed COVID-19 policies and procedures, including wearing face shields, goggles, or eye protection when entering a patient room as evidenced by the night shift not following appropriate personal protective equipment when providing services to patients and participating in staff activities when required by the hospital policies and procedures. This deficient practice poses a potential health and safety risk to patients and staff when policies are not followed to decrease the risk of contracting or spreading an infection.

Findings include:

Policy titled "COVID 19 Psychiatry Service Interim Guidelines" revealed: " ...Definitions ...Enhanced Droplet Precautions: the use of an isolation mask with eye protection (goggles or face shield) when caring for select patient or patient populations ...II. Care Delivery A. Enhanced Droplet precautions will be implemented for all patients regardless of Covid-19 Status. 1. All Healthcare workers will wear surgical masks and eye protection when seeing all patients regardless of COVID-19 status ...."

Document titled "2021 Infection Control Program, Goals, Objectives & Risk Assessment" revealed that the targeted area of isolation activities and respiratory hygiene action plan is to monitor the use and compliance of Personal Protective Equipment (PPE) for all precaution patients and compliance by staff.

Video review of 09/04/2021, from 09:20 p.m. to 11:00 p.m., CAS (Child and Adolescent) Unit (280's) conducted on 09/07/2021, with Employee #29, revealed that two (2) Behavioral Health Technicians (BHTs) had their eye protection on backwards when entering patient rooms.

Video review of 09/05/2021, from 11:00 p.m. to 09/06/2021, 2:02 a.m., CAS Unit (260's) conducted on 09/08/2021, with Employee #2 revealed that three (3) BHTs on the unit were not wearing eye protection when entering a patient room, including a BHT on a one to one (1:1) patient assignment.

Employee #29 confirmed during an interview conducted on 09/07/2021, during video review, that two (2) BHTs were not wearing their eye protection appropriately.

Employee #2 confirmed during an interview conducted on 09/08/2021, during video review, that three (3) BHTs entering patient rooms, including a BHT on a one to one (1:1) assignment, were not wearing eye protection appropriately, or at all, when entering a patient room.

Based on review of the facility's polices/procedures, medical records, and interview, it was determined that the Administrator failed to meet the Condition of Participation for Special Medical Record Requirements that required the medical record maintained by a psychiatric hospital to contain the degree and intensity of the treatment provided to the patients as evidenced by:

(A1644) failure to require that the medical record documentation each patient have an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities deficient practice poses a risk to the health and safety of the patients and staff, when the hospital does not have an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities and the responsibilities of each member of the treatment team in 8 of 8 records reviewed for individualized comprehensive treatment plans.

The cumulative effect of this has the potential risk of the coordination and systematic treatment of the patient with a documentation process that demonstrates the individualized needs of the patient and who is monitoring evaluating and managing the implementation of the plan and the patient's progress.

Based on review of policy, medical records, and interview, the Department determined the administrator failed to require that the medical record documentation for each patient had an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities. This deficient practice poses a risk to the health and safety of the patients and staff, when the hospital does not have an individualized comprehensive treatment plan based on an inventory of the patient's strengthens and disabilities and the responsibilities of each member of the treatment team in 8 of 8 records reviewed for individualized comprehensive treatement plans.

Findings include:

Review of a policy titled, "The Inpatient Treatment Planning" (Policy No. CP38), revealed: " Each patient shall have an individualized treatment/discharge plan based on assessments of their clinical, physical, emotional, behavioral, and social needs; including consideration of age...plan shall include consideration of education and learning needs...when a patient has a significant change in condition or experience an event that affects treatment (such as seclusion/restraint etc.) with multidisciplinary input. Evidence of involvement in the MTP/ITDP will be documented in the team participation section of the treatment plan review...."

Patient #1
Patient #1 was admitted on July 09, 2021, with diagnoses that included [depression; and polysubstance abuse]. At the time of the survey, patient #1 was listed as discharged.

Review of patient #1's medical records, "Treatment Plan Goals", dated July 13, 2021, July 20, 2021, July 27 and August 03, 2020", revealed: "...by target date to attend 75% of groups to learn ways to manage DTS/impulsive high risk behaviors...." There were no revisions to the plan. The electronic documentation separated the goals, interventions, and patient responses in different areas of the record which did not allow a tracking of progress or confirmation of individualization of the plan based on the patients needs and progress through the course of the plan.

Patient #2
Patient #2 was admitted July 30, 2021, on an amended court order for treatment because of medication non-compliance.

Review of Patient #2's who was admitted on July 30, 2021, medical records "Treatment Plan Goals" dated August 18, 2021, revealed: "...By day 10, Pt to deny and not engage in sx of psychosis including paranoid thought and aggressive behaviors for five consecutive days...." There was no revision to the intervention. The electronic documentation separated the goals, interventions, and patient responses in different areas of the record which did not allow a tracking of progress or confirmation of individualization of the plan based on the patients needs and progress through the course of the plan. Additionally, the written responsibilities of each member of the treatment team is missing from the Master Treatment Plan dated August 18, 2021.

Paient #3
Patient #3 was admitted July 25, 2021, [Disruptive Mood Dysregulation].

Review of patient #3's medical records "Treatment Plan Goals" dated August 23, 2021", revealed: "...By target date, Pt will engage in 75% of groups daily to learn skills to manage DTS thoughts associated with following rules and directives..." Two groups were assigned on the plan, Cognitive Behavioral Therapy and Activity Therapy. No other groups or interventions were assigned to patient #3 on the Master Treatment Plan. The electronic documentation separated the goals, interventions, and patient responses in different areas of the record which did not allow a tracking of progress or confirmation of individualization of the plan based on the patients needs and progress through the course of the plan.

Patient #29; Patient #53; Patient #54; Patient #55
Review of Patient # 29, Patient #53, Patient #54, and Patient # 55's medical records "Treatment Plan" revealed the same goals and interventions throughout the course of treatment for the differing patients. For example "...attend 75% of groups...by target date will identify 3 skills...provide daily CBT/Roadmap to peace of mind..." are listed on all the individual Treatment Plans. Patient #29's Treatment plan dated August 19, 2021, has one staff assigned, a teacher.

Patient #37
Patient #37 was a current inpatient who had physician orders for blood sugar testing by fingersticks before each meal and at night with the administration of Insulin based on the blood sugar results. Documentation in the clinical record revealed the patient refused the fingersticks and insulin at times. For example, the patient refused the fingersticks and insulin twice on 08/30/2021 and once on 08/31, 09/01 and 09/02/2021. There was no documentation in the Treatment Plan that referenced this health concern or a plan to address it. This was acknowledged by Staff #2 during the record review.

Personnel #52 confirmed during an interview conducted on August 26, 2021, at 2:15 P.M., patient #3's Treatment Plan had no update following a significant change in condition (seclusion and or restraint) occurring on August 13, 2021, August 16, 2021, August 18, 2021 and August 21 2021.

Personnel # 52 confirmed during an interview conducted on August 26, 2021, at 2:15 P.M. that the responsibilities of each member of the treatment team is missing on the Master Treatment Plans reviewed.

Personnel #2 and Personnel #29 confirmed during an interview conducted on August 30, 2021, that the seclusion and restraint treatment plan interventions are not being transcribed to the Master Treatment Plans, and the written responsibilities of each member of the treatment team is missing from the Master Treatment Plans. Additionally, the separation in documentation did not allow a tracking of progress based on the patients needs and progress through the course of the plan.










16807

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures related to subsistence needs for staff and patients as evidenced by; there only being crackers and 1/2 days worth of water available at the hospital. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.

Findings include:

Observation during document review on August 24-25, 2021 revealed the emergency plan only provided crackers and 1/2 days worth of water. In conversation with hospital personnel on 08/24/2021 and 08/25/2021, it was revealed the facility needed 1,100 gallons of water and meals that could sustain 350 people for 96 hours per their plan.

A policy was requested that addressed the emergency plan for subsistence needs. The hospital was not able to provide a policy during the onsite survey.

Employee #1, #11 and #19 acknowledged, during the exit conference, the facility did not have enough food or water onsite to sustain the facility during an an emergency lasting longer than a few hours.

Based on review of the Emergency Plan, record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy, hospital needs and the hospital's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.

Findings include:

The facility's Emergency Plan related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center. Hospital personnel were unable to provide to the surveyor any additional documentation or policies that addressed the sharing of occupancy levels and/or facility needs.

Employee #1, #11 and #19 confirmed during the exit interview that the Emergency plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.