HospitalInspections.org

Based on observation, interview, and record review the facility failed to ensure basic patient rights. The facility ' s procedures included an informal restriction of Patient #13 ' s visitation and telephone rights to only immediate family without a physician order or justification that it was therapeutically warranted. This restricted practice was not in accordance with the basic patient rights and facility policies.
Findings included:
Observation on 09/16/15 at 12:45 PM in the Living/Activity Room of the San Saba Unit revealed the Patients " Basic Rights " posted which included the " right to talk to friends and family outside the hospital. "
During an interview on 09/16/15 at 1:00 PM with Patient #13, who was a 14-year-old male, asked about his rights to visitation and telephone use. He was directed to the Patient Rights posting observed in the Living/Activity Room. Patient #13 stated that " no one can visit me except for immediate family " and that he could only receive or make phone calls to " immediate family. " Patient #13 was requesting to have phone contact with his " girlfriend. " Patient #13 stated during admission to the San Saba unit, the on-duty Charge RN told his parent that he could only visit and communicate with immediate family; and no one else was allowed. Patient #13 stated his parent filled out the approved patient contact list but only wrote immediate family; since his parent was told no one else could visit, and they " did not want to break the rules. "
During an interview on 09/16/15 at 1:40 PM with the San Saba Charge RN stated that the adolescent patients could make phone calls twice daily to people designated on their phone list; which was completed by the minor ' s parents and/or guardians. The Charge RN stated the adolescent patients could only visit and make phone calls to " family; " and " no friends. " The Charge RN state it is " not allowed " for the adolescent patients to make phone calls to " boyfriends and girlfriends. " The Charge RN stated the parents and guardians are " told up front to who is filling out the phone list to only put family; and that friends are not allowed. "
During an interview on 09/16/15 at 4:20 PM with the Director of Nursing (DON) for the adolescent and child units revealed that parents fill out the allowed contact phone/visitation list upon admission for the child. The DON stated the parents are " asked to keep/limit it to immediate family. " The DON indicated that parents can designate someone that is " directly involved in the patient ' s treatment, but they are asked not to put friends, girlfriends, and boyfriends. " The DON stated if the parents want a friend listed on the phone list then it was referred to the patient ' s Therapist, who may also talk to the Doctor for review. The DON stated it was reviewed on a " case by case basis. "
Record review of the Basic Rights for All Patients, dated 07/10/15 revealed " 9. You have the right to talk and write to people outside the hospital. You have the right to have visitors in private, make private phone calls, and send and receive sealed and uncensored mail. "
Record review of the facility ' s Patient Visitation Policy, undated, revealed the facility " patient's have the right to a visitation policy that will foster access and communication with family and friends. " All Patients shall have the right, subject to his or her consent, to receive the visitors, whom he or she designates, including, but not limited to:
1. A spouse, a domestic partner (including a same-sex domestic partner),
2. another family member,
3. or a friend

Further review revealed, " a physician may restrict patient visitors when determined to be in the best interest of the patient. This is accomplished by the physician writing and order to indicate restriction of specific visitors. Exception to these restrictions may be made when therapeutically warranted as determined by the treatment team. "

Based on observation, interview and record review the facility failed to follow the facility's policy on Medication Administration and Document and Medication Management. Observation of the medication cart drawers revealed an unwrapped Risperdal 0.25 mg in a soufflé cup.
The findings were:
Observations on 9/14/15 at 12:55 p.m. of the medication cart on the Navasota unit, revealed an unwrapped pill in a soufflé cup. The unwrapped medication pill was confirmed to be Risperdal 0.25 mg.
Interview with the facility Chief Nurse Officer (CNO) confirmed the unwrapped pill was Risperdal 0.25 mg. The CNO further stated the medication was from a patient who refused her medication. The CNO confirmed the medication should not have been left in the medication cart and should have been disposed of according to policy.
Record review of the facility policy titled Medication Administration and Document and Medication Management, last reviewed on March 2015, states in part, " F. Refused medication shall be disposed of in the red " sharps " container. "

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, and safe environment for the well-being of patients. Specifically, observations of the facility revealed the following:

1. An unsanitary and unsafe environment with trash, debris, and cigarette butts; throughout the grounds of the facility.
2. Unsanitary patient bathrooms with dirty walls, flooring with blackened substances around the toilet bases, and rust visibly present.
3. The patient bathrooms in the units designated for children and adolescents were not provided with hand soap and/or a sanitizing agent for the patients to complete necessary hand washing.
4. The walls had peeling paint, peeling plaster, graffiti, and smeared substances.
5. The laminate flooring was worn through multiple layers to the core throughout living areas causing discoloration. There were broken or chipped pieces of laminate in seclusion rooms.

These deficient practices placed the patients' health and safety at risk.

Refer to A 0701 for specific evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Physical Environment.

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, and safe environment for the well-being of patients. Specifically, observations of the facility revealed the following:

1. An unsanitary and unsafe environment with trash, debris, and cigarette butts; throughout the grounds of the facility.
2. Unsanitary patient bathrooms with dirty walls, flooring with blackened substances around the toilet bases, and rust visibly present.
3. The patient bathrooms in the units designated for children and adolescents were not provided with hand soap and/or a sanitizing agent for the patients to complete necessary hand washing.
4. The walls had peeling paint, peeling plaster, graffiti, and smeared substances.
5. The laminate flooring was worn through multiple layers to the core throughout living areas causing discoloration. There were broken or chipped pieces of laminate in seclusion rooms.

These deficient practices placed the patients' health and safety at risk.

Findings included:

Observations conducted in the facility on 09/14/15 from 11:50 AM to 2:30 PM; with the Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Director of Clinical Services, and the Environmental Services Manager present revealed the following:

1.) Brazos (inpatient unit for adolescent females)-

a. Living/Activity Room area had paint peeling off of the walls and the cement structure poles. The community hall sink for handwashing had peeling paint all around the sink and wall areas.

b. The Seclusion room used for Brazos and San Saba had written, " Fuck These Hoes " on one wall, " Fuck Them " and " Bitch " on another wall. The laminate flooring was peeling up in an area of approximately 1 inch by 4 inches; exposing the underlayment flooring. The plexi-type glass window for viewing patients had a crack on the corner that went all the way through; causing a jagged sharp edge.

c. Room 509 ' s bathroom had the wood peeling off of the toilet and the toilet base needed cleaning and/or re-caulking. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

d. Room 505 sheets were dirty on the bed and full of debris. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

e. The door leading into the Group room had the letters written in cursive-style, " Xautes. "

2. Navasota (inpatient unit for adolescent females)-

a. The Living/Activity Room laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black coloration throughout the flooring where the laminate had worn off of completely from the wood. There was peeling paint on the wall around the phone area. One of the chairs in the living room had a handwritten phone number on the chair. The community hall sink for handwashing had peeling paint all around the sink and wall areas.

b. The Group Room contained 19 chairs that were all dirty with hair, trash, dirt, and debris.
There were multiple chairs that had different drawings including one with a pentagram, a dirty full hand print, and marks from pencils, crayons, and markers.

c. The Seclusion Room had writing on the wall, " Stupid Bitch, I ain ' t Fucking with you. " The laminate flooring was peeling up in the corner with an area of approximately 1 inch by 4 inches (triangular shaped); exposing the underlayment flooring.

d. The female adolescent patients were outside on the covered patio, with one patient sitting out in the yard with a half-eaten apple discarded onto the yard and left. There were numerous amounts of discarded cigarette butts observed in the yard, on the wooden deck, and in the cracks by the walls.

e. Room 604 ' s bathroom toilet base was dirty with a blackened substance on the tile. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. There were two large plastic bags of garbage, and one plastic bag of dirty lines discarded on to the ground on the end side of the unit by the parking lot.

3. San Jacinto (inpatient unit for children)-

a. The seclusion room used for San Jacinto and Navasota units, had writing on the walls that contained a written name, " John " , multiple sets of initials including " JMK; " and Bitch in crayon/marker.

b. The Group Room had " Anthony " etched in the entry door.

c. The Living/Activity room had peeling paint on the wall all around the phone area. There were 3 fabric chairs that were torn on the edges; exposing the stuffing.

d. The outside courtyard of the unit had 2 picnic benches with peeling paint. One picnic bench contained large oversized screws underneath with metal edges that were sharp.

e. Room 618 ' s bathroom toilet wood covering had wood peeling off and splintering. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. Room 617 ' s bathroom flooring was dirty, discolored, and smelled of urine. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. There was a toothbrush lying on the bathroom counter with the bristles touching the counter.

g. Room 616 ' s bathroom porcelain sink was chipped. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

h. Room 612 ' s toilet base was dirty. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The Patient ' s clothing was on the floor in the bedroom and not in the available open shelving.

4. Guadalupe (inpatient unit for acute adults)-

a. The Living/Activity room laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black colorations throughout the flooring where the laminate had worn off of completely from the wood. There was missing pieces of wooden trim/baseboard. There was peeling paint on the wall. The living room chairs had tears on the edges exposing the inner stuffing. The community hall sink for handwashing had peeling paint and plaster around the sink and wall areas. The wall behind the hall sink was discolored and stained.

b. The outside covered patio had discarded cigarette butts that littered all around on the ground.
Room 816 had used discarded towels lying on the floor and in the sink area.
Room 815 ' s bathroom toilet seat and wooden cover had peeling paint.
Room 813 ' s baseboards were dirty with yellowed stains.

5. Rio (inpatient acute male/female adults)-

a. The community sink in the Living/Activity room had peeling paint and brown and yellow like substances present around the sink.

b. Room 808 had trash and debris on the floor and the bathroom had feces-like brown/black matter on the floor underneath the toilet. The toilet paper was lying directly on the floor.

c. Room 805 ' s metal door edging was rusted on the bottom of the frame.

6. Colorado (inpatient acute adult)-

a. The outside covered patio was used as the smoking area with a metal table containing half smoked cigarettes discarded on the table. The wooden deck had discarded cigarette butts that littered throughout the courtyard area.

b. Room 904 and Room 901 ' s bathroom toilet base had a black substance around the base on the tile.

c. Room 902 ' s bathroom toilet base chipped and caulking separated from flooring with black substance on tile.

d. Room 906 ' s bathroom wall had peeling paint with plaster, and the mirror in the bathroom was peeling.

e. The walls outside of rooms 904 and 905 had multiple large markings on the walls around the areas where the plastic name plates were placed.

7. Sabine (Acute Intensive Psychiatric Unit)-

a. The Seclusion room used for Colorado and Sabine had writing on the walls; " Shit Face was written on the metal door way, " " Dog Shit Hard, " " God World, " and " Lost in a state " was written on the wall with multiple arrow signs. The floor was dirty, discolored, and contained debris including a dead cricket.

b. Room 916 ' s porcelain sink was chipped multiple times.

c. Room 913 ' s bathroom wall near the sink had peeling paint and plaster that was falling off from the wall. There were two open bars of soap that were lying directly on the sink counter top.

Further observations on 09/16/15 from 12:05 PM to 1:40 PM in the San Saba and Brazos units revealed the following:

8. San Saba (inpatient adolescent males)-

a. The Group Room walls had large areas of peeling paint. The brown paint had peeled exposing the egg shell color beneath. The group room had a painted mural that had been vandalized with known written elements associated with gang graffiti which included cryptic-type writing. Written words included: " FREE KAMS, FREE ZINO, SPAZ ATW, FREE ARKS, JOE " and other types of symbols and letters. The number 13 was written by the electrical outlet. The floors were dirty with trash and debris present. There were multiple chairs that were dirty in the seating.

b. The Seclusion room had the number 13 written on the wall and a drawn pentagram on the bottom of the wall by window.

c. The Living/Activity room had peeling paint on the walls. The brown paint was peeled; exposing large areas of an egg shell color behind for peeled paint. There was peeling paint all around the phone area. The laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black colorations throughout the flooring where the laminate had worn off of completely from the wood. There were multiple fabric chairs with torn edges exposing the inside stuffing material.

d. Room 518 ' s bathroom porcelain sink was chipped and the wooden toilet cover was chipped. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

e. Room 517 ' s bathroom had writing on the wall behind the toilet, " Fuck You Bitch. " There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. Room 516 had 5 beds present for patients. On the walls of the bedroom and bathroom were written elements associated with gang graffiti which included: the number 13 multiple times; multiple words, names, letters/initials that were written cryptic-like that had been crossed out or scribbled through. There was written; " 13 LK " including a drawn crown. There were multiple crowns drawn over letters/initials. There were multiple large pentagrams (a five-pointed star that is formed by drawing a continuous line in five straight segments, often used as a mystic and magical symbol) drawn on the bedroom wall. There was a large silhouette female drawing on the wall above the shelving area with crayon that included breasts, an outlined vagina with the perception/appearance of a male penis penetrating the vagina. The paint and plaster was peeling away from the wall by the bedroom window and there was multicolored wording written on the wall in sentence form that was unintelligible. There was a large pentagram drawn on the bathroom wall with another smaller one on the wall next to the toilet. The porcelain sink contained multiple chips. There was rust-like substance on the caulking present. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The bedroom door edges contained writing and peeling paint.

g. Room 515 ' s bathroom toilet base needed cleaned and/or re-caulked. There was a brown substance around the toilet base. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

h. Room 514 had an outlined drawing in the shape of a male penis and scrotum on the wall. The toilet base needed cleaned and/or re-caulked. There was a brown/yellow substance around the toilet base. The bathroom sink had rusted around the caulked area. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

i. Room 513 ' s bathroom wall had multiple fecal/brown spots on the wall. The toilet base needed cleaned and/or re-caulked. The bathroom sink was rusted. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

j. Room 512 ' s bathroom sink had rust like substance around the caulking. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

k. Room 511 ' s bathroom sink was rusted. The toilet base needed cleaned and/or re-caulked. There was a brown substance around the base of the toilet. The wooden back of the toilet cover was peeling. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The bedroom wall had cryptic-type writing on the walls. The door way to the room had large writing, " PARLIEKCA. "

l. Room 510 ' s bathroom had writing on the wall, " Red Flag, " and the porcelain sink was chipped. The lower wall by the sink had peeling plaster and paint. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

Observation in San Saba on 09/16/15 at 12:55 PM revealed multiple adolescent male inpatients came out from the group room and went down the hallway to the bedroom areas; and into the bathrooms. All the bedroom doors remained open while Licensed Therapist-A monitored the hallway. The Charge Registered Nurse (RN) was in the living room/activity area. Further observations revealed Patient #13 went into the bathroom in his bedroom #518. The bedroom door remained open, and the bathroom door was shut. Surveyor heard the toilet flush and Patient #13 immediately walked out of the bathroom. Another Patient (#14) went into his bathroom in his bedroom. Surveyor heard the toilet flush and Patient #14 immediately walked out of the bathroom. The Mental Health Tech (MHT) directed all the Patients ' to line up so they could leave the unit to Specialized Therapeutic Services. The Patients left the unit; including Patient #13 and #14 without any staff redirection to complete Hand Washing following toileting from the Licensed Therapist, Charge RN, and MHT.

During an interview on 09/16/15 at 1:00 PM with Patient #13 revealed he was a 14-year-old adolescent who had been an inpatient for psychiatric services. Patient #13 confirmed he did not complete handwashing after toileting; and further stated there was no soap available for use in his bathroom. Patient #13 stated he had soap in his hygiene supply box that was locked up. Patient #13 stated he would have to ask staff to get his hygiene supply box to access the soap; if they were not busy. Patient #13 stated there was a community hand washing sink but it was on the other side of the unit and he would have to ask staff to unlock and/or allow him to enter the other side of the unit in order to utilize that community sink.

During an interview on 09/16/15 at 1:10 PM with the San Saba Charge RN confirmed all the bathrooms in the Patients ' bedrooms did not contain hand soap. Charge RN stated the Patients ' could use the community sink located on the other side of the unit in the Living/Activity area for handwashing with soap. Charge RN stated that the Patients ' use to keep their hygiene soap, bars of soap, in the bathroom for handwashing; but they would clog up the toilets with the soap, so they are kept locked in their hygiene box in a closet. Charge RN confirmed that she had not directed the Patient ' s; including Patient #13 and #14 to wash their hands following toileting.

During an interview on 09/16/15 at 1:50 PM with MHT-A stated that Patients ' are advised not to keep their bars of soap in their bathroom. MHT-A stated that he was supposed to direct Patients ' over to the community sink to wash their hands where soap was available; if they forget. MHT-A confirmed that Patients ' were supposed to wash their hands following a restroom break.

During an interview on 09/16/15 at 4:20 PM with the Director of Nursing (DON) for the adolescent and child units confirmed the Patient bathrooms in the adolescent and child units did not contain soap containers; or soap available in the bathrooms for at least 4 years that she had been employed at the facility. The DON stated they were removed because the psychiatric Patients ' were " self-harming " with the soap dishes. The DON stated there was a community sink on one side of the unit and confirmed that Patients ' from the other side of the unit would have to have the door opened to allow access to the sink.

During an interview on 09/16/15 at 4:35 PM with the Infection Control RN revealed that part of the infection control plan and monitoring included " look for cross-contamination. " The Infection Control RN stated the facility was preparing for the upcoming flu and upper respiratory infection (URI) season approaching. The Infection Control RN stated it was important that staff and patients practice good hand hygiene procedures. The Infection Control RN stated there were flyers and posters for the appropriate hand washing procedures; and confirmed this included using soap when washing hands. The Infection Control RN stated the adolescent and child units had their " own individual bars of soap in their hygiene boxes " and they could ask staff for access to their hygiene boxes. The Infection Control RN stated she had not recently monitored the child/adolescent units for hand hygiene or infection control concerns. The Infection Control RN confirmed that she only monitored hand washing for the nurses during medication pass.

During an interview on 09/16/15 with the Environmental Services Manager (ESM) confirmed the above findings during observations of the physical plant and facility. The ESM stated he documented the findings also; so that he could follow-up. The ESM stated there was an Environmental Round Policy and attached Checklist; but that he had only been in this position for 3 months, and had not had an opportunity to complete a full Environmental Rounds using the Checklist. The ESM stated the facility staff were supposed to put maintenance requests in the facility ' s computerized maintenance system, " DUDE. " The ESM confirmed he was aware of the peeling paint throughout the facility ' s units and had a bid to hire that out for contracting. The ESM stated the work should begin this next week. The ESM confirmed he was aware of the laminate flooring wearing down and they were currently working on repairing the flooring in the Nurses ' station of Colorado. The ESM stated the internal maintenance staff was supposed to paint over the graffiti areas internally once notified through the facility ' s work order request, DUDE. The ESM stated the facility contracted out with a landscaping company that maintained the grounds keeping; once a week, and was supposed to pick up trash and debris on the patio ' s. The ESM stated the discarded cigarette butts were supposed to be picked up by housekeeping and maintenance. The ESM stated he had a bid/contract for replacement of 72 sinks. The ESM stated that he had a bid/contract to " clean the grout and old caulking out " from around the toilets in the patient bathrooms. The ESM stated housekeeping was to ensure the walls and floors were clean. The ESM stated he was trying to find a safe cleaning solvent to clean the writing and drawings on the chairs that had been marked on in the living and group rooms.

Review of the facility ' s Infection Control Plan effective 01/01/15 revealed, " Surveillance for healthcare-associated infections includes; Monitoring hand washing in patient care settings. " Goals included, " Identify and prevent the occurrences of healthcare associated infections by pursuing sound infection control practices such as aseptic technique, standard precautions, and other isolation as needed and appropriate. " The first Infection Control Indicators for 2015 was, " Hand Hygiene. " The monthly action plan for hand hygiene only included monitoring nurses on medication pass hand hygiene. There was no monitoring or plan designated for the inpatients. The facility ' s policy references resources and support from the Center for Disease Control (CDC).

Review of the Infection Control Education provided and reviewed with Patient ' s upon admission revealed the following for Handwashing: "Wash your hands thoroughly with warm water, rubbing your hands for at least 15 seconds; make sure you scrub between your fingers and around your wrists. Rinse your hands, and then dry them with a clean towel. Use the towel to turn the water faucet off. You should wash your hands whenever they are visibly dirty, before you eat, before and after touching your mouth, nose or eyes and after contact with any body fluid. " The procedures did not include the use of soap and/or a sanitizing agent. The procedures also did not include for patients to wash their hands following toileting or smoking.

Review of the Personal Hygiene and Grooming Policy, last reviewed January 2015, revealed 7. " Nursing staff will function as a resource in directing patient education programs regarding health and hygiene. 8. Staff will give verbal prompts, suggestions, information and directives regarding personal hygiene and grooming practices (i.e, need for more frequent hair washing, change inappropriate clothing, regular teeth brushing, use of deodorant, etc.) as needed for individual patients. 14. Soap and Shampoo are provided by [the facility]. "

Review of the Housekeeper ' s Position Description, last revised 07/01/07 revealed housekeeping was to maintain a clean and safe environment for all staff, patients, and visitors. Daily cleans and disinfects all areas of the hospital. Ensures all trash and soiled lines is picked up twice a day. To give good quality customer service to all patients, staff and visitors.

Review of the Infection Control RN ' s June 2015 " Infection Control/Environmental Survey " revealed documentation for " hand soap is present, in a container with patient name on it " as " - " meaning " 0 " for San Saba unit.

Review of the Housekeeping ' s Daily Unit Cleaning Checklist revealed daily cleaning included the following:
Patient Rooms- Soil and debris must be removed from floor. Mop clean baseboards.
Restrooms- Clean floors and refill soap/ sanitizer/ towel
Walls-Wipe down as needed when dirty or soiled
Floors- Soil and debris must be removed from floor

Review of the Environmental Rounds Policy, last reviewed 01/15/15 revealed the facility would conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks. Procedures included; 1. As part of an ongoing environment of care program, the Safety Officer shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety, fire safety, hazardous conditions, exposure to hazardous materials and wastes, security, utilities, medical equipment and staff knowledge.

Review of the facility ' s Work Order Summary List from 08/16/15 to 09/14/15 revealed the following documented work order requests that were outstanding:
08/21/15 Brazos Unit Room 507- Drywall " wall has been removed from behind toilet. "
08/25/15 Brazos Unit Room 503- " please remove Formica due to piece missing. "
09/07/15 San Saba Unit Community Room 510, " Day room multiple walls need painting. Boys pulling paint off and throwing it at each other. "

Further review of the facility ' s Work Order Summary List for 09/15/15; following the survey entrance revealed the following requests for 09/15/15:
San Saba Unit, bathroom 511 " tagging. "
San Saba Unit, bathroom and bedroom 514 " tagging in bathroom and bedroom. "
Brazos Unit, bedroom 508 " graffiti on walls in room and bedroom, profanity. "
San Saba Unit, bedroom 516 " Graffiti in bedroom and bathroom. "
San Saba Unit, bedroom 517 " paint peeling in the bedroom-Graffiti in bathroom. "
Brazos Unit, bedroom 505, " graffiti on walls in room. "
Brazos Unit, bedroom 506, " graffiti on walls in room. "
San Saba/Brazos Unit, Community Room " Peeling paint in both day areas and group room."
Brazos Unit/San Saba Community Room 111, " peeling of paint on the poles in day area, walls, and nurses station. "
San Saba Unit, Isolation Room, Seclusion Room " Window to seclusion room cracked. "
San Saba Unit, Isolation Room, " Graffiti, tagging in seclusion room. "
Navasota Unit, Community Room, " peeled paint on wall by patient telephone on right hand side. "

Review of the facility ' s Smoking Policy, last reviewed 03/13/15, revealed that all smoking material, including matches and cigarette butts, must be disposed of in the provided waste containers in the designated smoking areas.

Review of the CDC website on 09/25/15 at revealed, " Hand hygiene is one of the most important ways to prevent the spread of infections. " Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
1. Handwashing- refers to washing hands with plain soap and water. Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts.
2. Antiseptic handwash- refers to washing hands with water and soap or other detergents containing an antiseptic agent.
3. Alcohol-based handrub- refers to the alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms.

Further review revealed easy access to hand hygiene supplies is essential for acceptance and use of products. Handwashing procedures included; " When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.

Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following:

1. An unsanitary environment with trash, debris, and cigarette butts; throughout the grounds of the facility.
2. Unsanitary patient bathrooms with dirty walls, flooring with blackened substances around the toilet bases, and rust visibly present.
3. The patient bathrooms in the units designated for children and adolescents were not provided with hand soap and/or a sanitizing agent for the patients to complete necessary hand washing.
4. The walls had peeling paint, peeling plaster, graffiti, and smeared substances.
5. The laminate flooring was worn through multiple layers to the core throughout living areas causing discoloration. There were broken or chipped pieces of laminate in seclusion rooms.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

Findings included:

Observations conducted in the facility on 09/14/15 from 11:50 AM to 2:30 PM; with the Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Director of Clinical Services, and the Environmental Services Manager present revealed the following:

1.) Brazos (inpatient unit for adolescent females)-

a. Living/Activity Room area had paint peeling off of the walls and the cement structure poles. The community hall sink for handwashing had peeling paint all around the sink and wall areas.

b. The Seclusion room used for Brazos and San Saba had written, " Fuck These Hoes " on one wall, " Fuck Them " and " Bitch " on another wall. The laminate flooring was peeling up in an area of approximately 1 inch by 4 inches; exposing the underlayment flooring. The plexi-type glass window for viewing patients had a crack on the corner that went all the way through; causing a jagged sharp edge.

c. Room 509 ' s bathroom had the wood peeling off of the toilet and the toilet base needed cleaning and/or re-caulking. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

d. Room 505 sheets were dirty on the bed and full of debris. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

e. The door leading into the Group room had the letters written in cursive-style, " Xautes. "

2. Navasota (inpatient unit for adolescent females)-

a. The Living/Activity Room laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black coloration throughout the flooring where the laminate had worn off of completely from the wood. There was peeling paint on the wall around the phone area. One of the chairs in the living room had a handwritten phone number on the chair. The community hall sink for handwashing had peeling paint all around the sink and wall areas.

b. The Group Room contained 19 chairs that were all dirty with hair, trash, dirt, and debris.
There were multiple chairs that had different drawings including one with a pentagram, a dirty full hand print, and marks from pencils, crayons, and markers.

c. The Seclusion Room had writing on the wall, " Stupid Bitch, I ain ' t Fucking with you. " The laminate flooring was peeling up in the corner with an area of approximately 1 inch by 4 inches (triangular shaped); exposing the underlayment flooring.

d. The female adolescent patients were outside on the covered patio, with one patient sitting out in the yard with a half-eaten apple discarded onto the yard and left. There were numerous amounts of discarded cigarette butts observed in the yard, on the wooden deck, and in the cracks by the walls.

e. Room 604 ' s bathroom toilet base was dirty with a blackened substance on the tile. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. There were two large plastic bags of garbage, and one plastic bag of dirty lines discarded on to the ground on the end side of the unit by the parking lot.

3. San Jacinto (inpatient unit for children)-

a. The seclusion room used for San Jacinto and Navasota units, had writing on the walls that contained a written name, " John " , multiple sets of initials including " JMK; " and Bitch in crayon/marker.

b. The Group Room had " Anthony " etched in the entry door.

c. The Living/Activity room had peeling paint on the wall all around the phone area. There were 3 fabric chairs that were torn on the edges; exposing the stuffing.

d. The outside courtyard of the unit had 2 picnic benches with peeling paint. One picnic bench contained large oversized screws underneath with metal edges that were sharp.

e. Room 618 ' s bathroom toilet wood covering had wood peeling off and splintering. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. Room 617 ' s bathroom flooring was dirty, discolored, and smelled of urine. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. There was a toothbrush lying on the bathroom counter with the bristles touching the counter.

g. Room 616 ' s bathroom porcelain sink was chipped. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

h. Room 612 ' s toilet base was dirty. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The Patient ' s clothing was on the floor in the bedroom and not in the available open shelving.

4. Guadalupe (inpatient unit for acute adults)-

a. The Living/Activity room laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black colorations throughout the flooring where the laminate had worn off of completely from the wood. There was missing pieces of wooden trim/baseboard. There was peeling paint on the wall. The living room chairs had tears on the edges exposing the inner stuffing. The community hall sink for handwashing had peeling paint and plaster around the sink and wall areas. The wall behind the hall sink was discolored and stained.

b. The outside covered patio had discarded cigarette butts that littered all around on the ground.
Room 816 had used discarded towels lying on the floor and in the sink area.
Room 815 ' s bathroom toilet seat and wooden cover had peeling paint.
Room 813 ' s baseboards were dirty with yellowed stains.

5. Rio (inpatient acute male/female adults)-

a. The community sink in the Living/Activity room had peeling paint and brown and yellow like substances present around the sink.

b. Room 808 had trash and debris on the floor and the bathroom had feces-like brown/black matter on the floor underneath the toilet. The toilet paper was lying directly on the floor.

c. Room 805 ' s metal door edging was rusted on the bottom of the frame.

6. Colorado (inpatient acute adult)-

a. The outside covered patio was used as the smoking area with a metal table containing half smoked cigarettes discarded on the table. The wooden deck had discarded cigarette butts that littered throughout the courtyard area.

b. Room 904 and Room 901 ' s bathroom toilet base had a black substance around the base on the tile.

c. Room 902 ' s bathroom toilet base chipped and caulking separated from flooring with black substance on tile.

d. Room 906 ' s bathroom wall had peeling paint with plaster, and the mirror in the bathroom was peeling.

e. The walls outside of rooms 904 and 905 had multiple large markings on the walls around the areas where the plastic name plates were placed.

7. Sabine (Acute Intensive Psychiatric Unit)-

a. The Seclusion room used for Colorado and Sabine had writing on the walls; " Shit Face was written on the metal door way, " " Dog Shit Hard, " " God World, " and " Lost in a state " was written on the wall with multiple arrow signs. The floor was dirty, discolored, and contained debris including a dead cricket.

b. Room 916 ' s porcelain sink was chipped multiple times.

c. Room 913 ' s bathroom wall near the sink had peeling paint and plaster that was falling off from the wall. There were two open bars of soap that were lying directly on the sink counter top.

Further observations on 09/16/15 from 12:05 PM to 1:40 PM in the San Saba and Brazos units revealed the following:

8. San Saba (inpatient adolescent males)-

a. The Group Room walls had large areas of peeling paint. The brown paint had peeled exposing the egg shell color beneath. The group room had a painted mural that had been vandalized with known written elements associated with gang graffiti which included cryptic-type writing. Written words included: " FREE KAMS, FREE ZINO, SPAZ ATW, FREE ARKS, JOE " and other types of symbols and letters. The number 13 was written by the electrical outlet. The floors were dirty with trash and debris present. There were multiple chairs that were dirty in the seating.

b. The Seclusion room had the number 13 written on the wall and a drawn pentagram on the bottom of the wall by window.

c. The Living/Activity room had peeling paint on the walls. The brown paint was peeled; exposing large areas of an egg shell color behind for peeled paint. There was peeling paint all around the phone area. The laminate flooring had worn down many layers to the core throughout the whole living room area leaving patches of white and black colorations throughout the flooring where the laminate had worn off of completely from the wood. There were multiple fabric chairs with torn edges exposing the inside stuffing material.

d. Room 518 ' s bathroom porcelain sink was chipped and the wooden toilet cover was chipped. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

e. Room 517 ' s bathroom had writing on the wall behind the toilet, " Fuck You Bitch. " There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

f. Room 516 had 5 beds present for patients. On the walls of the bedroom and bathroom were written elements associated with gang graffiti which included: the number 13 multiple times; multiple words, names, letters/initials that were written cryptic-like that had been crossed out or scribbled through. There was written; " 13 LK " including a drawn crown. There were multiple crowns drawn over letters/initials. There were multiple large pentagrams (a five-pointed star that is formed by drawing a continuous line in five straight segments, often used as a mystic and magical symbol) drawn on the bedroom wall. There was a large silhouette female drawing on the wall above the shelving area with crayon that included breasts, an outlined vagina with the perception/appearance of a male penis penetrating the vagina. The paint and plaster was peeling away from the wall by the bedroom window and there was multicolored wording written on the wall in sentence form that was unintelligible. There was a large pentagram drawn on the bathroom wall with another smaller one on the wall next to the toilet. The porcelain sink contained multiple chips. There was rust-like substance on the caulking present. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The bedroom door edges contained writing and peeling paint.

g. Room 515 ' s bathroom toilet base needed cleaned and/or re-caulked. There was a brown substance around the toilet base. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

h. Room 514 had an outlined drawing in the shape of a male penis and scrotum on the wall. The toilet base needed cleaned and/or re-caulked. There was a brown/yellow substance around the toilet base. The bathroom sink had rusted around the caulked area. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

i. Room 513 ' s bathroom wall had multiple fecal/brown spots on the wall. The toilet base needed cleaned and/or re-caulked. The bathroom sink was rusted. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

j. Room 512 ' s bathroom sink had rust like substance around the caulking. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

k. Room 511 ' s bathroom sink was rusted. The toilet base needed cleaned and/or re-caulked. There was a brown substance around the base of the toilet. The wooden back of the toilet cover was peeling. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom. The bedroom wall had cryptic-type writing on the walls. The door way to the room had large writing, " PARLIEKCA. "

l. Room 510 ' s bathroom had writing on the wall, " Red Flag, " and the porcelain sink was chipped. The lower wall by the sink had peeling plaster and paint. There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.

Observation in San Saba on 09/16/15 at 12:55 PM revealed multiple adolescent male inpatients came out from the group room and went down the hallway to the bedroom areas; and into the bathrooms. All the bedroom doors remained open while Licensed Therapist-A monitored the hallway. The Charge Registered Nurse (RN) was in the living room/activity area. Further observations revealed Patient #13 went into the bathroom in his bedroom #518. The bedroom door remained open, and the bathroom door was shut. Surveyor heard the toilet flush and Patient #13 immediately walked out of the bathroom. Another Patient (#14) went into his bathroom in his bedroom. Surveyor heard the toilet flush and Patient #14 immediately walked out of the bathroom. The Mental Health Tech (MHT) directed all the Patients ' to line up so they could leave the unit to Specialized Therapeutic Services. The Patients left the unit; including Patient #13 and #14 without any staff redirection to complete Hand Washing following toileting from the Licensed Therapist, Charge RN, and MHT.

During an interview on 09/16/15 at 1:00 PM with Patient #13 revealed he was a 14-year-old adolescent who had been an inpatient for psychiatric services. Patient #13 confirmed he did not complete handwashing after toileting; and further stated there was no soap available for use in his bathroom. Patient #13 stated he had soap in his hygiene supply box that was locked up. Patient #13 stated he would have to ask staff to get his hygiene supply box to access the soap; if they were not busy. Patient #13 stated there was a community hand washing sink but it was on the other side of the unit and he would have to ask staff to unlock and/or allow him to enter the other side of the unit in order to utilize that community sink.

During an interview on 09/16/15 at 1:10 PM with the San Saba Charge RN confirmed all the bathrooms in the Patients ' bedrooms did not contain hand soap. Charge RN stated the Patients ' could use the community sink located on the other side of the unit in the Living/Activity area for handwashing with soap. Charge RN stated that the Patients ' use to keep their hygiene soap, bars of soap, in the bathroom for handwashing; but they would clog up the toilets with the soap, so they are kept locked in their hygiene box in a closet. Charge RN confirmed that she had not directed the Patient ' s; including Patient #13 and #14 to wash their hands following toileting.

During an interview on 09/16/15 at 1:50 PM with MHT-A stated that Patients ' are advised not to keep their bars of soap in their bathroom. MHT-A stated that he was supposed to direct Patients ' over to the community sink to wash their hands where soap was available; if they forget. MHT-A confirmed that Patients ' were supposed to wash their hands following a restroom break.

During an interview on 09/16/15 at 4:20 PM with the Director of Nursing (DON) for the adolescent and child units confirmed the Patient bathrooms in the adolescent and child units did not contain soap containers; or soap available in the bathrooms for at least 4 years that she had been employed at the facility. The DON stated they were removed because the psychiatric Patients ' were " self-harming " with the soap dishes. The DON stated there was a community sink on one side of the unit and confirmed that Patients ' from the other side of the unit would have to have the door opened to allow access to the sink.

During an interview on 09/16/15 at 4:35 PM with the Infection Control RN revealed that part of the infection control plan and monitoring included " look for cross-contamination. " The Infection Control RN stated the facility was preparing for the upcoming flu and upper respiratory infection (URI) season approaching. The Infection Control RN stated it was important that staff and patients practice good hand hygiene procedures. The Infection Control RN stated there were flyers and posters for the appropriate hand washing procedures; and confirmed this included using soap when washing hands. The Infection Control RN stated the adolescent and child units had their " own individual bars of soap in their hygiene boxes " and they could ask staff for access to their hygiene boxes. The Infection Control RN stated she had not recently monitored the child/adolescent units for hand hygiene or infection control concerns. The Infection Control RN confirmed that she only monitored hand washing for the nurses during medication pass.

During an interview on 09/16/15 with the Environmental Services Manager (ESM) confirmed the above findings during observations of the physical plant and facility. The ESM stated he documented the findings also; so that he could follow-up. The ESM stated there was an Environmental Round Policy and attached Checklist; but that he had only been in this position for 3 months, and had not had an opportunity to complete a full Environmental Rounds using the Checklist. The ESM stated the facility staff were supposed to put maintenance requests in the facility ' s computerized maintenance system, " DUDE. " The ESM confirmed he was aware of the peeling paint throughout the facility ' s units and had a bid to hire that out for contracting. The ESM stated the work should begin this next week. The ESM confirmed he was aware of the laminate flooring wearing down and they were currently working on repairing the flooring in the Nurses ' station of Colorado. The ESM stated the internal maintenance staff was supposed to paint over the graffiti areas internally once notified through the facility ' s work order request, DUDE. The ESM stated the facility contracted out with a landscaping company that maintained the grounds keeping; once a week, and was supposed to pick up trash and debris on the patio ' s. The ESM stated the discarded cigarette butts were supposed to be picked up by housekeeping and maintenance. The ESM stated he had a bid/contract for replacement of 72 sinks. The ESM stated that he had a bid/contract to " clean the grout and old caulking out " from around the toilets in the patient bathrooms. The ESM stated housekeeping was to ensure the walls and floors were clean. The ESM stated he was trying to find a safe cleaning solvent to clean the writing and drawings on the chairs that had been marked on in the living and group rooms.

Review of the facility ' s Infection Control Plan effective 01/01/15 revealed, " Surveillance for healthcare-associated infections includes; Monitoring hand washing in patient care settings. " Goals included, " Identify and prevent the occurrences of healthcare associated infections by pursuing sound infection control practices such as aseptic technique, standard precautions, and other isolation as needed and appropriate. " The first Infection Control Indicators for 2015 was, " Hand Hygiene. " The monthly action plan for hand hygiene only included monitoring nurses on medication pass hand hygiene. There was no monitoring or plan designated for the inpatients. The facility ' s policy references resources and support from the Center for Disease Control (CDC).

Review of the Infection Control Education provided and reviewed with Patient ' s upon admission revealed the following for Handwashing: "Wash your hands thoroughly with warm water, rubbing your hands for at least 15 seconds; make sure you scrub between your fingers and around your wrists. Rinse your hands, and then dry them with a clean towel. Use the towel to turn the water faucet off. You should wash your hands whenever they are visibly dirty, before you eat, before and after touching your mouth, nose or eyes and after contact with any body fluid. " The procedures did not include the use of soap and/or a sanitizing agent. The procedures also did not include for patients to wash their hands following toileting or smoking.

Review of the Personal Hygiene and Grooming Policy, last reviewed January 2015, revealed 7. " Nursing staff will function as a resource in directing patient education programs regarding health and hygiene. 8. Staff will give verbal prompts, suggestions, information and directives regarding personal hygiene and grooming practices (i.e, need for more frequent hair washing, change inappropriate clothing, regular teeth brushing, use of deodorant, etc.) as needed for individual patients. 14. Soap and Shampoo are provided by [the facility]. "

Review of the Housekeeper ' s Position Description, last revised 07/01/07 revealed housekeeping was to maintain a clean and safe environment for all staff, patients, and visitors. Daily cleans and disinfects all areas of the hospital. Ensures all trash and soiled lines is picked up twice a day. To give good quality customer service to all patients, staff and visitors.

Review of the Infection Control RN ' s June 2015 " Infection Control/Environmental Survey " revealed documentation for " hand soap is present, in a container with patient name on it " as " - " meaning " 0 " for San Saba unit.

Review of the Housekeeping ' s Daily Unit Cleaning Checklist revealed daily cleaning included the following:
Patient Rooms- Soil and debris must be removed from floor. Mop clean baseboards.
Restrooms- Clean floors and refill soap/ sanitizer/ towel
Walls-Wipe down as needed when dirty or soiled
Floors- Soil and debris must be removed from floor

Review of the Environmental Rounds Policy, last reviewed 01/15/15 revealed the facility would conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks. Procedures included; 1. As part of an ongoing environment of care program, the Safety Officer shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety, fire safety, hazardous conditions, exposure to hazardous materials and wastes, security, utilities, medical equipment and staff knowledge.

Review of the facility ' s Work Order Summary List from 08/16/15 to 09/14/15 revealed the following documented work order requests that were outstanding:
08/21/15 Brazos Unit Room 507- Drywall " wall has been removed from behind toilet. "
08/25/15 Brazos Unit Room 503- " please remove Formica due to piece missing. "
09/07/15 San Saba Unit Community Room 510, " Day room multiple walls need painting. Boys pulling paint off and throwing it at each other. "

Further review of the facility ' s Work Order Summary List for 09/15/15; following the survey entrance revealed the following requests for 09/15/15:
San Saba Unit, bathroom 511 " tagging. "
San Saba Unit, bathroom and bedroom 514 " tagging in bathroom and bedroom. "
Brazos Unit, bedroom 508 " graffiti on walls in room and bedroom, profanity. "
San Saba Unit, bedroom 516 " Graffiti in bedroom and bathroom. "
San Saba Unit, bedroom 517 " paint peeling in the bedroom-Graffiti in bathroom. "
Brazos Unit, bedroom 505, " graffiti on walls in room. "
Brazos Unit, bedroom 506, " graffiti on walls in room. "
San Saba/Brazos Unit, Community Room " Peeling paint in both day areas and group room."
Brazos Unit/San Saba Community Room 111, " peeling of paint on the poles in day area, walls, and nurses station. "
San Saba Unit, Isolation Room, Seclusion Room " Window to seclusion room cracked. "
San Saba Unit, Isolation Room, " Graffiti, tagging in seclusion room. "
Navasota Unit, Community Room, " peeled paint on wall by patient telephone on right hand side. "

Review of the facility ' s Smoking Policy, last reviewed 03/13/15, revealed that all smoking material, including matches and cigarette butts, must be disposed of in the provided waste containers in the designated smoking areas.

Review of the CDC website on 09/25/15 at revealed, " Hand hygiene is one of the most important ways to prevent the spread of infections. " Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
1. Handwashing- refers to washing hands with plain soap and water. Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts.
2. Antiseptic handwash- refers to washing hands with water and soap or other detergents containing an antiseptic agent.
3. Alcohol-based handrub- refers to the alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms.

Further review revealed easy access to hand hygiene supplies is essential for acceptance and use of products. Handwashing procedures included; " When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.