HospitalInspections.org

Based on review of personnel files, policies and procedures and interview with staff, it was determined the facility failed to follow their Employee Health policy for 9 of 17 employees. This had the potential to affect all staff and patients.

Findings include:

Policy: Hepatitis B Vaccination Program
Reviewed/Revised 2-12

Purpose:
1. The Hepatitis B vaccine will be available to all employees.
2. Hepatitis B vaccine will be ordered through Bryce Hospital Pharmacy.
7. If an employee is considered at risk and refuses the vaccine, this refusal will be documented.

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Policy: Tuberculosis Screening of Hospital Employees

Purpose:
To promote early detection of employees' exposure to Tuberculosis and prevent spread of the disease.

Procedure:
...1. As part of the employment procedure, each new employee will be tuberculin tested using the two-step (test-retest) method, unless a previously significant reaction can be documented (10 mm (millimeter) or greater). The results of the tuberculin testing will be recorded in the employee's health record.

Employee health records were reviewed on 8/14/13. Nine of seventeen contract and/or hospital employees had no documentation of being offered the Hepatitis B vaccine.

One of seventeen contract and/or hospital employees had no documentation of results of Tuberculosis screening.

An interview conducted on 8/14/13 at 12:15 PM with Employee Identifier # 1, Hospital Director, confirmed the above findings.

Based on record review, tour of the facility,review of policies and procedures and an interview, the hospital failed to:

1. Provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency

2. The patient environment was maintained to prevent opportunities for self injury and assure patient dignity.

3. Ensure modifications to the patient's treatment plan were documented to meet the increased needs of the patient.

This had the potential to affect all patients in the facility.

Findings include:

Refer to A 118, A 144 and A 166.

Based on observation and interview with agency administrative staff, it was determined the hospital did not make available to the patient or to the patient's representative the phone number to the State Agency for filing a grievance. This had the potential to affect all patients within the hospital.

Findings include:

A tour of the hospital and administrative buildings on 8/12/13 at 11:00 AM failed to reveal any posting of the state hotline number to file a grievance.

In an interview on 8/12/13 at 3:30 PM with Employee Identifier # 1, the Facility Director, stated she was not aware of the need for the state hotline number to be posted.

Based on review of medical records, observations,facility policies and procedures, and interview, it was determined the facility failed to ensure:

1. Medical Record (MR) # 1 was assessed and the careplan updated to prevent future falls.

2. The patient environment was maintained to prevent opportunities for self injury and assure patient dignity.


This affected MR # 1 and units C, D, E, F toured and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Fall Assessment, Planning and Implementation # NP 5.3.0

Definition: A "fall" is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force...

Purpose:

A. To identify patients who are at risk for falling

B. To initiate fall reduction strategies for all patients

C. To implement a fall reduction plan individually designed for patients at risk

D. To modify plans to protect the patient, reduce future falls and decrease the severity of injuries resulting from falls.

Procedure:

D. The following assessments forms will be placed in the medical record behind the Fall Assessment Tab:

3. BH-2266 Special Fall Review Form

E. Initiate applicable interventions.

I. A review of the patient's fall reduction plan will be held at scheduled treatment team planning conferences and/or as deemed necessary to determine if the plan needs modification, such as the recommendation made at the Special Fall Review Meeting.

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Bryce Hospital Information Handbook

page 45

Prohibited Items/Contraband

The Administration of Bryce Hospital asks that all visitors abide by the Visitation and Safety Policy...

The items listed below are permitted with staff supervision and treatment team approval...

4. Hair care products

These items will be secured at the nursing station and provided to the patient with staff supervision and treatment team approval...

Medical record findings:

1. Medical Record (MR) # 1 was admitted to the facility 10/29/12 with diagnoses including Schizoaffective Disorder and a history of Perforated Sigmoid Colon.

Review of the Incidents With Patient/Client Involvement between 5/1/13 to 7/31/13 revealed MR # 1 had fallen on the following dates: 5/1/13, 5/11/13, 6/22/13, 7/9/13, 7/10/13, 7/11/13, and 7/30/13.

Review of the Special Fall Review Form dated 7/12/13 with a follow up meeting dated 7/26/13 revealed documentation the patient had not had a fall since 7/9/13.

An interview was conducted on 8/14/13 at 12:30 PM with Employee Identifier (EI) # 2, Director of Nurses who verified the Special Fall Review Form dated 7/12/13 with a follow up meeting dated 7/26/13 was not accurate and did not include the falls from 7/10/13 and 7/11/13.

***** Environment

A tour was conducted on 8/12/13 at 10:15 AM on Ward C and the surveyor observed the following:

Activities Room - a large piece of the end of the table was broken off about 4 inches leaving jagged edges.

Room C 12 (Restraint Room) - Alcohol pad lying on the mattress, cracks all along the area between the wall and the floor, a strong urine smell, and the door was chipped away about 5 inches in diameter and no door handle.

A tour was conducted on 8/12/13 at 10:45 AM on Ward D and the surveyor observed the following:

Room D 30 - There were 13 bottles of hair care products on the patient's shelf and 2 brushes which were unsecured and accessible to patients.

A tour was conducted on 8/12/13 at 11:15 AM on Ward E and the surveyor observed:

The water fountain in the common area had one side pulled away with jagged metal exposed. The surveyor asked Employee Identifier (EI) # 5, Director of Risk Management, what was the plan for fixing the water fountain and EI # 12, Mental Health Worker stated, "I called it in Saturday" (8/10/13 which was 2 days before the survey began).

Room 34 - the outer portion of the door was peeling away leaving jagged edges.



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During a tour of the distinct unit C on 8/12/13 at 10:15 AM, the surveyor observed two rooms with the bathroom doors locked under repair. The rooms, C 26 and C 28 were occupied by two male patients to each room.

The surveyor returned to the C unit 8/14/13 at 8:30 AM, to evaluate the progress of the repairs. Rooms C 26 and C 28 continued to have locked bathroom doors. C 26 still had the same tools in the floor that were present 8/12/13.

In an interview on 8/14/13 at 8:45 AM with EI # 4, Registered Nurse (RN), the surveyor asked what these patients were doing for a bathroom and shower. EI # 4 responded they used the bathroom between the restraint and seclusion room off the group room and shower in another patient room.

Documentation presented to the surveyor 8/14/13 at 8:50 AM from the maintenance department confirmed the bathroom repairs were not completed. The documentation provided indicated the repairs started 8/8/13. The patients had been without private toileting facilities and a shower for 6 days.

During a tour of ward F on 8/12/13, the surveyor observed Room F24 had an isolation sign on the door VRE (Vancomycin Resistant Enterococcus). The room contained an electric hospital bed with full side rails. The electrical cord had not been shortened to protect this patient or any other patient who might enter the room from potential for harm. The bathroom had a soiled glove lying on the floor. The surveyor questioned the need for the side rails and it was explained the patient is on 15 minutes checks and will call if needed. When asked how the patient was to call, staff stated just holler.

These hazards provided an unsafe environment for psychologically compromised patients with a potential for injurious behavior toward themselves and others.

Based on review of medical records, policy and procedures and interview it was determined the facility failed to ensure the patient's treatment plan was updated to meet the increased needs of the patient requiring PRN (as needed) medications to control behaviors in 4 of 9 medical records reviewed and had the potential to affect all patients served by this facility. This affected Medical Record (MR) # 3, # 6, # 7 and #8.

Facility Policy Number 430-5
Title: Recipient Restraint and Seclusion

I. Recipients of the Alabama Department of Mental Health psychiatric facilities have the right to be free of restraint and seclusion. Restraint and seclusion are safety procedures of last resort and not therapeutic interventions.

II. Definitions

2. Restraint:

b. Use of medication that is not a standard treatment for the recipient's medical or psychiatric condition and is used to control behavior or restrict the recipient's freedom of movement.

III. Standards

7. The alternative treatment intervention shall be documented in the medical record.

13. The use of restraint or seclusion must be in accordance with a written modification to the recipient's plan of care.


Facility Policy Number 430-5.1
Title: Patient Seclusion and Restraint

IX. Documentation Qualified Registered Nurse

1. Documentation of each restraint will include, but is not limited to the following:
a. Title progress note Face -to Face Assessment.
d. Alternative interventions attempted before restraint. If alternative interventions were not attempted due to sudden onset of the behavior, this will be documented as well. Some possible interventions include:
i. The de-escalation techniques identified by the patient
ii. verbal intervention/redirecting
iii. alternate constructive activities.

Medical Record (MR) findings:

1. MR # 7 was admitted to the facility 2/14/13 with an Axis I diagnosis of Schizoaffective Disorder with Self Injurious Behaviors.

MR # 7 had an increase in the use of psychotropic medications to control his behaviors from 7/14/13 through 8/11/13.

The progress note dated 7/14/13 at 3:30 PM, by the MHW (Mental Health Worker) documented, " 1:1 constant observation. Start note pt (patient) was received in quiet room sitting down in chair with eyes open breathing normal. Pt says he is hearing voices and crying..."

MR # 7 received Ativan 2 mg (milligrams) and Haldol 5 mg IM (intramuscular) at 6:35 PM on 7/14/13 for complaint of hearing voices.

Prior interventions documented, " Pt went to quiet room/ pt went to his room."

MR # 7 received Ativan 2 mg and Haldol 5 mg IM at 12:00 PM on 7/16/13 for hollering, crying and threatening to hurt himself.

Prior interventions documented, " Spending time. Continued to escalate."

There was no mention of a problem requiring a PRN in the 7/16/13 progress note.

MR # 7 received Ativan 2 mg and Haldol 5 mg IM at 1:15 (neither PM nor AM were marked) on 7/28/13 for crying, stating he wanted to be on 1:1.

Prior interventions documented, " Unable to redirect, PRN given as ordered."

There was no mention of a problem requiring a PRN in the 7/28/13 progress note.

MR # 7 received Ativan 2 mg and Haldol 5 mg IM at 5:31 PM on 7/29/13 for patient hearing voices.

Prior interventions documented, " Per patient request."

MR # 7 received Geodon 20 mg IM on 8/3/13 at 4:30 PM for pt crying and stating," I want to go to hospital."

Prior interventions documented, " Tried redirect to quiet him."

There was no mention of a problem requiring a PRN in the 8/3/13 progress note.

MR # 7 received Geodon 20 mg IM on 8/5/13 at 5:25 PM for pt was becoming agitated and stated to RN (Registered Nurse), " I want to hurt myself."


MR # 7 received Geodon 20 mg IM on 8/6/13 at 12:00 PM for crying, tore a hole in his bag.

Prior interventions documented, " Unable to redirect."

MR # 7 received Geodon 20 mg IM on 8/6/13 at 5:25 PM for pt ripped colostomy pouch away from abdomen and started digging in ostomy with fingers.

Prior interventions documented, " Unable to redirect."

MR # 7 received Geodon 20 mg IM on 8/10/13 at 3:50 PM for complaint of nervousness and anxious.

Prior interventions documented, " Pt unable to tell writer why he is nervous and anxious. Writer attempted to calm pt down. Pt crying and requesting PRN."

MR # 7 received Geodon 20 mg IM on 8/11/13 at 12:15 PM for crying, uncooperative, refuses to take medication.

Prior interventions documented, " Pt in his bed room. Would not verbalize any problems he is having, just crying and unable to redirect."

The patient received 10 PRN medications for behaviors in 29 days. The staff failed to document specific alternative interventions attempted before medicating the patient.

The facility failed to modify the treatment plan to include the increase in use of PRN medications for behaviors.

The physician was made aware of the use of the PRN medications on 7 of the 10 doses by a copy of the shift report being provided to the physician on daily rounds.

In an interview 8/14/13 at 1:00 PM with Employee Identifier (EI) # 2, the Director of Nursing (DON), confirmed the above findings.

2. MR # 3 was admitted to the facility 1/2/13 with an Axis I diagnosis of Paranoid Schizophrenia.

MR # 3 had an increase in the use of medications to control his behaviors from 6/22/13 through 8/9/13.

The patient hit a co-patient on back of head 6/22/13 reportedly due to voices telling him to hit someone. This was the first assault since 4/16/13.

MR # 3 received Droperidol 10 mg IM on 6/22/13 at 7:00 PM for assaultive behavior.

MR # 3 received Droperidol 10 mg IM on 7/2/13 at 7:30 PM for assaultive behavior. MR # 3 swung at staff in the courtyard, staff intervened and escorted patient back to the ward, received PRN and asked to sit in quiet room to calm down. Five minutes later patient ran out of the quiet room and hit co-patient, staff intervened and escorted MR # 3 back to the quiet room.

MR # 3 received Droperidol 10 mg IM on 7/12/13 at 5:25 PM for assaultive behavior and at 8:50 PM.

The RN note dated 7/12/13 at 6:05 PM documented, " Patient observed hitting a co-patient unprovoked. Patient states he heard voices that told him to hit someone. He was re-directed and voluntarily went into quiet room.

Later while in the medication line he attacked another patient, was re-directed and voluntarily went into the quiet room. After a few moments a commotion was heard in the quiet room, another patient was found in the quiet room hitting MR # 3. MR # 3 sustained a hematoma to left temple." The patient required over night hospitalization for observation related to the hematoma.

MR # 3 received Droperidol 10 mg IM on 7/12/13 at 9:00 AM for assaultive behavior.

An order was received 7/30/13 at 9:00 AM to place patient in 4 point leather restraints for up to 4 hours (9:00 AM - 1:00 PM). The patient remained in restraints from 9:00 AM until 11:50 AM, the first time on 7/30/13.

MR # 3 received Droperidol 10 mg IM on 7/30/13 at 1:40 PM for assaultive behavior.

At approximately 1:40 PM staff reported to writer that MR # 3 had started the same behavior again. He was fighting and hitting staff and patients. Manual hold done with second observer PRN given and patient placed in 4 point restraints. The patient was released from restraints the second time at 3:25 PM.

The progress notes documented by the Mental Health Worker at 9:50 PM on 7/30/13, " Reported to ward staff at approx (approximately) 9:10 PM that pt just received a PRN for aggressive behavior, he went after... and .... Writer assessed pt. Pt denies any injuries, pt sitting in quiet room with light off at his request."

MR # 3 received Droperidol 10 mg IM on 8/1/13 at 6:40 AM for assaultive behavior.

MR # 3 received Droperidol 10 mg IM on 8/2/13 at 9:07 AM for assaultive behavior.

MR # 3 received Droperidol 10 mg IM on 8/9/13 at 5:15 PM for assaultive behavior.

MR # 3 was placed in 4 point leather restraints at 6:30 PM on 8/9/13 after attacking staff, PRN not effective.

MR # 3 received Droperidol 10 mg IM on 8/9/13 at 9:12 PM for continue aggression, remains in restraints.

Physician called, notified pt still in restraints. Physician ordered Ativan 2 mg IM now. Pt released from restraints at 10:15 PM.

The patient received 11 PRN's between 6/22/13 and 8/9/13. MR # 3 required 4 point restraints 3 times between 6/22/13 and 8/9/13.

There was no documentation of interventions prior to medication being administered or being placed in restraints. On 7/15/13 a Patient Crisis Intervention Plan was documented by the treatment team and included the patient's input. The plan for intervention for the behavioral problem of assaultive and aggressive behavior towards co-patients and staff included the following:
1. redirection
2. talk to a staff member
3. sit on porch or quiet room
4. recreational activities to divert his attention
5. refer to the ward nurse to assess the need of PRN ( if applicable).

The planned interventions were not documented prior to use of restraint. There was no documentation if alternative interventions were not attempted due to sudden onset of the behavior.

In an interview with EI # 1, the Facility Director, on 8/14/13 at 12:20 PM, the above information was confirmed.

3. MR # 6 was admitted to the facility 5/17/12 with an Axis I diagnosis of Impulse Control Disorder and Mood Disorder.

The patient returned to the facility after a failed temporary placement visit on 5/28/13.

On 6/12/13 at 4:30 PM, the patient had an altercation with another patient exiting the telephone booth.

The psychotropic PRN form dated 6/16/13 documented, " Requested PRN for agitation." Ativan 2 mg and Haldol 5 mg IM administered.

Prior interventions documented, " Patient has been very hyper today, trying to come in med ( medication) room, demanding...asked patient what was going on and she said she is getting agitated."

On 6/21/13 at 8:15 PM, the patient was involved in an altercation with co-patient suddenly attacking co-patient. Ativan 2 mg and Haldol 5 mg IM administered for agitation.

The form had no prior interventions documented. The only prior interventions documented was, "Unsuccessful."

The psychotropic PRN form dated 7/2/13 documented, " Requested PRN for agitation." Ativan 2 mg and Haldol 5 mg IM administered.

The prior interventions documented area was blank.

The psychotropic PRN form dated 7/19/13 documented, " Complained of anxiousness requested PRN." Ativan 2 mg and Haldol 5 mg IM administered.

The prior interventions documented area was blank.

The patient received 4 PRN medications for behaviors in 29 days. The staff failed to document specific alternative interventions attempted before medicating the patient.

The facility failed to modify the treatment plan to include the increase in use of PRN medications for behaviors.

In an interview with EI # 1 on 8/14/13 at 12:25 PM, confirmed the above information and they would work on educating the staff.




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4. MR # 8 was admitted to the facility on 9/10/12 with diagnoses including Schizoaffective Disorder and Dementia with Behavioral Problems.

Review of the Master Service Plan Part B revealed an objective indicated 9/18/12 which stated, Pt (patient) has no periods of agitation x 2 weeks". Target dates included 10/18/12, 12/8/12, 2/10/13, 4/10/13, 6/10/13, 8/10/13 and 10/30/13.

The interventions included, "adjust psychotropic medications to stabilize moods & agitation. Add mood stabilizer".

Review of the medical record revealed the following Rational For Psychotropic PRN administration:

6/1/13 3:00 PM:

Describe Behavior Requiring PRN: patient hollering out; cursing and kicking.

Prior Intervention used and patient response: unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

6/7/13 8:15 AM:

Describe Behavior Requiring PRN: patient agitated and attempting to fight sitter.

Prior Intervention used and patient response: re-direction unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

6/8/13 12:00 PM:

Describe Behavior Requiring PRN: screaming, threating staff.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

6/14/13 10:30 AM:

Describe Behavior Requiring PRN: patient loud; cursing and combative.

Prior Intervention used and patient response: redirection ineffective.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

6/27/13 12:00 PM:

Describe Behavior Requiring PRN: patient attempting to roll over sitter with the wheelchair and combative.

Prior Intervention used and patient response: unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7/2/13 3:10 PM:

Describe Behavior Requiring PRN: patient hollering out, cursing and disruptive in the ward.

Prior Intervention used and patient response: unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7/19/13 2:50 AM:

Describe Behavior Requiring PRN: yelling, trying to climb out of bed, and trying to hit staff.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7/20/13 2:30 AM:

Describe Behavior Requiring PRN: yelling trying to climb out of bed.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

Review of the progress notes dated 7/19/13 at 11:35 PM and 7/20/13 at 7:00 AM revealed no documentation of the above behavior or any redirection needed.

7/21/13 10:00 AM:

Describe Behavior Requiring PRN: hitting walls and windows.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

Review of the progress notes dated 7/21/13 between 7:10 AM and 1:00 PM revealed no documentation of redirection needed.

7/22/13 10:20 AM:

Describe Behavior Requiring PRN: patient aggressive, 1:1 sitter reports patient attempting to hit her several times.

Prior Intervention used and patient response: unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7/24/13 8:35 AM:

Describe Behavior Requiring PRN: patient agitated and aggressive toward 1:1, 1:1 sitter reports patient attempting to hit her several times.

Prior Intervention used and patient response: unsuccessful redirection.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7/27/13 11:30 PM

Describe Behavior Requiring PRN: agitated, attempting to get out of bed, screaming.

Prior Intervention used and patient response: Redirection short lived...

Patient was given Ativan 2 mg and Haldol 5 mg IM.

Review of the progress notes dated 7/27/13 at 11:00 PM revealed no documentation of the above behavior or any redirection needed.

7/30/13 4:00 AM:

Describe Behavior Requiring PRN: trying to climb out of bed and yelling.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

Review of the progress notes dated 7/29/13 at 11:35 PM and 7/30/13 7:05 AM revealed no documentation of the above behavior or any redirection needed.

7/31/13 7:15 AM:

Describe Behavior Requiring PRN: attacking staff.

Prior Intervention used and patient response: staff attempted to redirect patient and were unsuccessful.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

Review of the progress notes dated 7/31/13 at 7:00 AM and 7/31/13 3:00 PM revealed no documentation of redirection needed.

8/1/13 12:15 AM:

Describe Behavior Requiring PRN:yelling and trying to climb out of bed.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

8/4/13 8:15 PM:

Describe Behavior Requiring PRN: striking out at sitter, banging on the walls and yelling.

Prior Intervention used and patient response: unable to redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.


Further review of the Psychotropic PRN documentation revealed the patient was given Ativan 2 mg and Haldol 5 mg IM on 7/4/13 at 9:10 AM, 7/26/13 at 4:55 PM, and 7/30/13 at 12:50 PM.


An interview was conducted on 8/14/13 at 12:45 PM with EI # 11, Clinical Director (Medical Doctor) who stated the patient's psychotropic medications were not adjusted because the source of the patient's agitation was Dementia. The surveyor asked why the Treatment Plan continued with adjustment of psychotropic medications and the response was, "we need to change the intervention".

Based on review of the hospital dietary contract and policies and procedures, observations and interviews, it was determined the hospital failed to ensure:

1. Food temperatures were monitored and maintained at safe levels.

2. Prepared foods items were maintained in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Policy:
The production area is responsible for proper panning and timely delivery of food at the proper temperature to tray line area.

Procedures:
....Check temperatures of foods before delivery to tray line, including back up pans...

Contract: Master Outsources Services Agreement 11/01/11
...21. Food Temperatures
Production temperatures:

a. Temperatures of all hot foods must be at least 140 degrees Fahrenheit (F) but no greater than 180 degrees F prior to distribution to points of service.

...Temperatures are to be taken and immediately documented by the supplier's personnel:

1. Upon delivery at each service location at each meal,

2. Prior to initiation of service, and

3. At the mid-point of the service period.

On 8/12/13 at 10:15 AM, prepared hot and cold pans and containers of food were observed to arrive at the Admissions building dietary department on two rolling carts. The temperatures of the food items were not checked at that time.

The steam table with four sections for hot food items had not been prepared for use at this time.

A large metal pan of strawberry mixture was observed to be covered with saran wrap. Four small pint size containers with lids wrapped in saran wrap of pureed food were observed on top of the saran wrap which covered the strawberry mixture. The saran wrap had separated from two corners of the strawberry mixture pan exposing over half of the contents to air. The four containers were sitting directly in the strawberry mixture.

Employee Identifier (EI) # 7, Dietary Aide, was observed removing the strawberry covered saran wrap from the four containers and disposed in the trash. The four containers with lids were then placed near the tray line service area. EI # 7 removed the saran wrap from the large pan of strawberry mixture, replaced with new saran wrap and placed the pan in the tray line service area to serve to patients.

A large pan of chopped steamed yellow squash covered with saran wrap was observed on the cart with a large pan of braised pork tips mixture, one pan of wheat dinner rolls and one pan of cornbread placed directly on top. Two corners of the saran wrap on the yellow squash had separated exposing over half of the contents to air. EI # 7 then transferred the squash from the large pan to a smaller metal pan, covered the contents with new saran wrap and placed it in the tray line service area to serve to the patients.

At 10:55 AM EI # 3, Director of Nutritional Services, intervened and instructed EI # 7 to remove the squash and strawberry mixture from the tray line service area.

At 11:10 AM temperatures of food on the steam tray line were checked by EI # 8, Dietary aide, with the following results:

Beef tips 169 degree Fahrenheit (F)
Rice 182 degree F (this is 2 degrees higher than required temperature for hot food)
Squash 133 degree F (this is 7 degrees below the required temperature for hot food)
Pureed meat: 133 degree F (this is 7 degrees below the required temperature for hot food)
Gravy 131 degree F (this is 9 degrees below the required temperature for hot food)
Pureed rice 128 degree F (this is 12 degrees below the required temperature for hot food)

The temperature controls were turned up on the steam table, however the food temperatures on the squash, pureed meat, gravy and rice were not rechecked prior to the patients arriving at 11:45 AM for the meal.

The above findings were observed and verified by EI # 3 on 8/12/13 from 10:15 AM to 11:45 AM.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged, and maintained to ensure patient safety.

Findings include:

Refer to the Life Safety Code violations and A 724 for findings.

Based on observations and interviews it was determined the facility failed to:
1. Ensure the consumer rooms were clean, temperature appropriate and maintained.
2. Ensure furniture and fixtures were continually maintained.
3. Ensure showers and bathrooms were available to the patients.
4. Ensure rooms were free of potentially infectious materials.

This had the potential to affect all patients.

The findings include:

During observations of patient areas in the admission building distinct units with the Director of Risk Management, Employee Identifier # 5 on 8/12/13 at 10:15 AM, the surveyors identified the following areas of concern:

1. Shower stalls with breaks around the bottom of the walls.

2. Shower stalls with mold/mildew around the bottom of the walls and the hand rails.

3. Floor tile broken in bathrooms and around the edge of the walls.

4. Used paper towels on the floors and in the corners of rooms.

5. Dirty dried wash cloth on the bathroom floor in room C 29.

6. Medication room door covered with ply wood and a hasp lock securing the door on ward D.

7. The water fountain outside the activity room on ward E had the metal stripping pulled away from the fountain with jagged edges and presented a cutting hazard.

8. A bulletin board by the bed covered with a pink sticky substance (identified as poligrip) attaching bits of paper to the board.

9. Ward E restraint/seclusion room had two mattress stacked on the bed, a chair with masking tape covering holes in the bottom and a red wax appearing blob on the wall which EI # 5 could not identify.

10. Room F 24 had an isolation sign on the door VRE (Vancomycin Resistant Enterococcus) in the urine,contained an electric hospital bed with full side rails. The electrical cord had not been shortened to protect this patient or any other patient who might enter the room.

11. Ward C has air conditioner problems according to EI # 5. There were large industrial fans in rooms with patients that have 1:1 sitters and one large fan out in the hall.

12. Quiet room on ward C has two holes about the size of a quarter gouged out with screw heads visible, an electrical outlet metal box visible and uncovered in the far wall (a cutting hazard) and no door knob on the door. When asked the last time the room was used the hall nurse did not know. In review of records it was determined the quiet room on ward C was used 8/9/13 and an altercation between patients occurred in this room.

13. Ward C clean laundry room had clean sheets lying on the floor and EI # 5 picked the sheets up off the floor and placed them on the cart ready for patient use.

14. Multiple rooms smelled of urine.
The facility stated that they had just started working on the bathrooms last Friday, August 9, 2013 to regrout the showers.


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During a tour of Ward D on 8/12/13 at 10:45 AM the surveyor noted 2 used Band-Aids on the hand rail around the bathtub in room D 24.

The surveyor returned to room D 24 on 8/14/13 at 8:45 AM and noted the same 2 used Band-Aids on the hand rail around the bathtub.

Based on review of policies and procedures, observations and interview it was determined the facility failed to ensure:

1. The policy for ice handling was followed.

2. The policy for hand hygiene was followed.

This had the potential to affect all patients.

Findings include:


Facility Policy: Hand Hygiene # NP 7.2.0

Purpose:

To establish hand hygiene procedures that shall be followed by all Health Care Workers in the health-care setting. To reduce or eliminate microorganisms on the hands that have the potential to cause infection or antibiotic resistance.

Procedure:

I. Indications for hand washing ,hand antisepsis and decontamination are:

C. Decontaminate hands before having direct contact with patients.

F. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings.

I. Decontaminate hands before putting on gloves and after removing gloves.

Special Points:

A. Alcohol-based hand rubs will be available for use by Health Care Workers in the health-care setting.

A tour of the facility was conducted on 8/12/13 from 10:00 to 11:45 AM. On the tour the surveyor observed Employee Identifier (EI) # 10, Mental Health Worker take sheets off a patient's bed that were soiled with urine without gloves, carry them down the hall, place them in the soiled linen container, and go to the nurses station and begin charting in the medical record without hand hygiene.

A tour of the facility was conducted on 8/12/13 from 10:00 to 11:45 AM. The surveyor did not see any Alcohol-based hand rubs available for staff to use.

An observation of wound care was conducted on 8/14/13 at 8:05 AM with Employee Identifier (EI) # 8, Registered Nurse. After wound care was performed EI # 8 was helping a patient get off the exam table. EI # 8 changed gloves twice without hand hygiene.


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Facility Policy: Ice Handling

Procedures:

Use a scoop to remove ice from the storage bin into the receptacle used for service. (A scoop should be designated for removing ice from the bin, and should not be used for other purposes.)

During a tour of the dietary department on 8/12/13 at 9:50 AM Employee Identifier # 6, Dietary Aide, was observed removing ice from the ice machine with a plastic pitcher and placing in two large ice tea receptacles for patient use. There was an ice scoop located in the area which should have been used for ice removal.

An interview conducted on 8/12/13 at 9:50 AM with Employee Identifier # 3, Director of Nutritional Services, confirmed the ice scoop should be used to remove ice.

Based on review of medical records and interview, it was determined the facility failed to revise a patient's treatment plan in 1 of 1 record reviewed of a patient who received 12 Psychotropic PRN's (as needed) in a one month period. This affected Medical Record (MR) # 8 and had the potential to negatively affect all patients served by this facility.

Findings include:


1. MR # 8 was admitted to the facility on 9/10/12 with diagnoses including Schizoaffective Disorder and Dementia with Behavioral Problems.

Review of the Master Service Plan Part B revealed an objective dated 9/18/12 which stated, "Pt (patient) has no periods of agitation x 2 weeks". Target dates included 10/18/12, 12/8/12, 2/10/13, 4/10/13, 6/10/13, 8/10/13 and 10/30/13.

The interventions stated, "adjust psychotropic medications to stabilize moods & agitation. Add mood stabilizer".

Review of the Psychotropic PRN documentation revealed the following:

1. 7/2/13 3:10 PM:

Describe Behavior Requiring PRN: patient hollering out, cursing and disruptive in the ward.

Patient was given Ativan 2 mg (milligrams) and Haldol 5 mg IM. (intramuscular)

2. 7/4/13 9:10 AM:

Describe Behavior Requiring PRN: patient agitated, disruptive on ward, cursing and hollering out.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

3. 7/19/13 2:50 AM:

Describe Behavior Requiring PRN: yelling, trying to climb out of bed, and trying to hit staff.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

4. 7/20/13 2:30 AM:

Describe Behavior Requiring PRN: yelling trying to climb out of bed.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

5. 7/21/13 10:00 AM:

Describe Behavior Requiring PRN: hitting walls and windows.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

6. 7/22/13 10:20 AM:

Describe Behavior Requiring PRN: patient aggressive, 1:1 sitter reports patient attempting to hit her several times.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

7. 7/24/13 8:35 AM:

Describe Behavior Requiring PRN: patient agitated and aggressive toward 1:1, 1:1 sitter reports patient attempting to hit her several times.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

8. 7/26/13 4:55 PM:

Describe Behavior Requiring PRN: severe agitation, striking 1:1 sitter, attempting to flee from 1:1 sitter.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

9. 7/27/13 11:30 PM

Describe Behavior Requiring PRN: agitated, attempting to get out of bed, screaming.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

10. 7/30/13 4:00 AM:

Describe Behavior Requiring PRN: trying to climb out of bed and yelling.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

11. 7/30/13 12:50 PM:

Describe Behavior Requiring PRN: patient kicking and hitting 1:1 sitter, spitting and unable to handle or redirect.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

12. 7/31/13 7:15 AM:

Describe Behavior Requiring PRN: attacking staff.

Patient was given Ativan 2 mg and Haldol 5 mg IM.

There was no documentation MR # 8 had an adjustment to the prescribed psychotropic medications in the month of July.

An interview was conducted on 8/14/13 at 12:45 PM with Employee Identifier (EI) # 11, Clinical Director (Medical Doctor) who stated the patient's psychotropic Medications were not adjusted because the source of the patient's agitation was Dementia and not the Schizoaffective Disorder. The surveyor asked why the Treatment Plan continued with adjustment of psychotropic medications for agitation and the response was, "we need to change the intervention".

Based on medical record (MR) reviews, observation, policy and procedures and interviews, it was determined the nurse failed to:

1. Document wound care as provided.

2. Follow their own policy for wound assessment and documentation on 4 of 4 patients with wounds.

3. Follow physician orders for oxygen.

4. Obtain orders for lab.


This affected medical record # 2, # 1, # 4, # 8 and #10 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Wound Dressings # NP: 8.32.1

VI. Documentation:

1. Document size of wound, drainage, type of dressing applied...and patient's behavior and tolerance.

Facility Policy: Pressure Ulcer Assessment and Care # NP 8.32.0

Purpose:

To identify patients that may be at high risk for developing pressure ulcers. To provide guidelines for the prevention and treatment of pressure ulcers.

D. Any patient presenting with a pressure ulcer or a patient who develops a pressure ulcer will have the Ulcer Assessment and Documentation Form (BH-2256) implemented immediately.

III. Ulcer Assessment and Documentation Form (BH-2256) - to be updated at every dressing change or daily if no dressing change is done.

D. Section "D"

2. SIZE - Once every seven (7) days indicate the size of the ulcer using the Medirule Decubitus Measuring Device. Indicate size in centimeters.

Medical Record findings:

1. MR # 2 was admitted to the facility 8/28/12 with an Axis I diagnosis of Chronic Paranoid Schizophrenia.

The patient was hospitalized in an acute service facility from 7/6/13 through 7/11/13 due to a clot in his dialysis graft.

The 7/11/13 progress note on return from the acute hospitalization documented, " O2 (oxygen) in place on arrival. Patient noted with wound to coccyx, new orders received..."

On return to the facility 7/11/13 an order was obtained to cleanse wound to coccyx with normal saline, pat dry, dry area completely. Apply Duoderm every 3 days until healed.

The nurse documented wound care provided 7/13/13, 7/17/13, 7/20/13 and 7/23/13 on the medication administration record (MAR). The date of 7/26/13 was blank on the MAR and 7/29/13 a note to the back of the MAR stated coccyx site healed.

The nurse failed to document an assessment of the wound 7/11/13 on return to the facility and failed to document any assessment or description of the wound as care was provided.

There was no update to the patient's treatment plan to reflect the skin integrity problem during the treatment team meeting on 7/12/13.

The patient had an order for oxygen at 2L/min (2 liters per minute) PRN ( as needed) for dyspnea or O2 saturation level less than 90% per nasal Cannula (NC) effective in January 2013.

A Patient Transfer Form dated 1/13/13 included emergency care provided O2 3 L per NC. There was no order to increase the oxygen or a range to use when needed in the medical record.

A Patient Transfer Form dated 3/4/13 included emergency care provided, " C/O (complained of ) SOB (shortness of breath) on O2 at 2L/min/NC, O2 saturation upper 70's to low 80's, O2 increased to 4 L..."

There was no order to increase the oxygen or a range to use when needed in the medical record.

In an interview on 8/14/13 at 12:10 PM with Employee Identifier (EI) # 1, the Facility Director, confirmed all of the above information.



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2. MR # 1 was admitted to the facility 10/29/12 with diagnoses including Schizoaffective Disorder and a history of Perforated Sigmoid Colon.

Review of the physician's order dated 6/17/13 revealed orders for wound care as follows: Clean with saline, dry, apply zinc oxide to skin around the wound and double antibiotic ointment to the red area BID (twice a day) and PRN (as needed).

Review of the medical record on 8/13/13 revealed no documentation of the wound measurement to include length, width, or depth.

An observation of wound care was conducted on 8/14/13 at 8:05 AM with EI # 8, Registered Nurse. During observation of wound care EI # 8 did not measure the wound.

An interview was conducted on 8/14/13 at 12:30 PM with EI # 2, Director of Nurses. EI # 2 verified the above.

3. MR # 4 was admitted to the facility on 1/22/13 with diagnoses including Dementia with Behavioral Problems.

Review of the physician's order dated 6/24/13 revealed the following wound care orders:

Clean abrasion on the left leg, ankle and behind the knee with saline, dry and apply antibiotic ointment BID (twice a day). Clean behind the right knee with saline and cover with a dry dressing BID.

Review of the medical record on 8/13/13 revealed no documentation of the wound measurement to include length, width, or depth.

An interview was conducted on 8/14/13 at 12:30 PM with EI # 1, Hospital Director. EI # 1 verified the above.

4. MR # 8 was admitted to the facility on 9/10/12 with diagnoses including Schizoaffective Disorder and Dementia with Behavioral Problems.

Review of the physician's order dated 6/24/13 revealed the following wound care orders:

Wash left deltoid with water and peroxide times 1, then apply Polysporin Ointment BID times 3 days till healed.

Review of the medical record on 8/13/12 revealed no documentation of the wound measurement to include length, width, or depth.

An interview was conducted on 8/14/13 at 12:50 PM with EI # 1. EI # 1 verified the above.



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5. MR # 10 was admitted on 4/25/13 with diagnoses including Schizoaffective Disorder and a history of Cerebral Vascular Accident.

A review of the medical record revealed a lab report with results, dated 7/8/13, to include CMP (comprehensive metabolic panel), Lipids, Iron, Ferritin, Vitamin B12, Folate and Transferrin Saturation. Further review of the record revealed no physicians order for a venipuncture to obtain the labs.

An interview conducted on 8/14/13 at 12:50 PM with EI # 2 confirmed labs were obtained without a physicians order.