HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. Findings:

An observation was conducted on 07/26/2021 at 11:00 a.m. of the patients' bathrooms. A ligature risk was observed on all the patients' bathroom between the base of the toilet and the wall There was an opening between the toilet base and the wall which posed a safety risk and provided an anchoring point. The toilet seats lifted in all the patient's bathrooms and provided numerous anchoring points. There were 9 patients' bathrooms in the facility. S1COO confirmed the observation on 07/26/2021 at 11:00 a.m.

An observation was conducted of patient room 24, bed "b" on 07/26/2021 at 11:10 a.m. The bed had a mattress with a zipper in the mattress cover which could be used to hide contraband and posed a safety risk.

An interview was conducted with S1COO and S2DON on 07/26/2021 at 11:10 a.m. They reported the mattress should not had been in the patient's room.

On 07/27/2021 at 1:15 p.m. an observation was conducted of the hall shower room, hall bathtub room and the hall bathroom. All three rooms had deadbolts on the outside of the door that had to be opened by the staff with a key. The inside of the 3 rooms had a turn bar to lock the rooms from the inside. An observation was conducted on 07/27/2021 at 1:15 p.m.with S1COO, S2DON and the surveyors demonstrating if a patient was inside the room and held the bar, the staff member on the outside of the door would be unable to open the door. This posed a safety risk because the patient would be able to barricaide their selves in the rooms. S1COO and S2DON confirmed the observation on 07/27/2021 at 1:15 p.m.

Based on record review and interview the hospital failed to assure all nursing staff received training and demonstrated competency for use of restraints and seclusion. This failure is evidenced by no documentation of orientation training for use of restraints and seclusion in 1(S8LPN) of 2(S6LPN, S8LPN) agency nurse personnel files reviewed.
Findings:

Review of S8LPN's personnel file revealed no training and demonstrated competency for restraints and seclusion prior to providing direct patient care.

In interview on 07/28/2021 at 9:35 a.m., S3HR confirmed S8LPN was an agency nurse. She also confirmed that S8LPN had not received the required hospital orientation which included restraint and seclusion training and the training had not been provided by her agency.

Based on record review and interview, the hospital failed to provide appropriate supervision of contract staff. This deficiency is evidenced by failure of the hospital to provide orientation to hospital policies and procedures in 1(S8LPN) of 2 (S6LPN, S8LPN) agency nurses personnel files reviewed for proper training and licensure.
Findings:

Review of the personnel file for S8LPN revealed no evidence of orientation to the facility's policies and procedures before beginning direct patient care.

In interview on 07/28/2021 at 9:35 a.m., S3HR verified S8LPN was a contract nurse and had not received orientation to the hospital's policies and procedures before beginning direct patient care.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of the patients during radiological procedures performed in the hospital.

Findings:

Review of the Nursing policy titled, Radiology Services, revealed in part, 4. X-ray contracted provider will perform the services ordered on-site in the patiet room. Staff will not accompany patient in the room during x-ray.

Review of the hospital's policy for radiology services failed to address the safety precautions for the patient during radiology procedures.

An interview was conducted with S1COO on 07/28/2021 at 10:00 a.m. confirming the policy failed to address the safety issues for the patient.

Based on record review, observations, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards. This deficient practice was evidenced by having an unsanitary environment and/or having furniture and equipment that was unable to be disinfected. Findings:

Review of the hospital policy titled, Infection Control Inspections, revealed in part, the hospital will take steps to ensure that the environment of care is clean and free of infection control risks.

Review of the hospital policy titled, Infection Control Housekeeping Department, revealed in part, b. Furniture, ledges, telephones, exposed parts of beds and nightstands are disinfected using an approved disinfectant and appropriate wait time for disinfecting.

A tour of the facility was conducted on 07/26/2021 at 11:00 a.m. Wooden nightstands were in between the patient's beds. The nightstands were unable to be disinfected due to the porous nature of the wood. There were 9 nightstands in the facility made of wood. In the seclusion room there was a wooden restraint bed that could not be disinfected. Under the mattress of the wooden seclusion bed, a wedge was observed. The wedge had a brown substance smeared on its surface. An opened mustard pack was also observed under the mattress. The findings were confirmed by S1CCO on 07/26/2021 at 11:00 a.m.

An observation was conducted of the shower room on 07/27/2021 at 1:15 p.m. The shower room had 2 benches in the room with rust covering the legs of the benches. There were rusted screws in the handrails in the shower. Also a bariatric chair was in the shower with rusted wheel pieces. The observation was confirmed by S1COO on 07/27/2021 at 1:15 p.m.

Based on interview and record review, the hospital failed to ensure respiratory services were provided by personnel qualified to perform those services. This deficient practice was evidenced by no documented competencies for 4 (S2DON, S4RN, S5LPN, S6LPN) of 5 (S2DON, S4RN, S5LPN, S6LPN, S8LPN) personnel files reviewed for respiratory competencies, of listed personnel who, by their discipline would be in a position to provide respiratory services.

Findings:

Review of policy titled "Nasal Mask Ventilation (CPAP and BiPAP)" revealed in part, Nurses will provide non-invasive positive airway pressure to increase the transpulmonary pressure gradient and enhance lung expansion if the patient is prescribed to use this at home and brings their own equipment.

Review of policy titled "Pulse Oximetry" revealed in part, Nurses will monitor the adequacy of arterial oxyhemoglobin saturation as ordered by patient's physician.

Review of policy titled "Oxygen Administration", revealed in part, Oxygen administration will be administered only with a physician's order or in an emergency by a competent RN/LPN.

Review of policy titled "Nasopharyngeal and Oropharyngeal Suctioning" revealed in part, To perform nasopharyngeal or oropharyngeal suctioning by a competent registered nurse to patients in emergency situations only.

Review of personnel files for S2DON, S4RN, S5LPN, S6LPN revealed no respiratory competencies.

In an interview on 07/28/2021 at 9:47 a.m. S2DON confirmed respiratory competencies were not completed for the above stated respiratory policies.