HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #11) clinical records reviewed regarding use of psychotropic medications, the Hospital failed to obtain a consent to ensure patient was making an informed decision regarding his care.

Findings include:

1. On 11/14/2022, the clinical record for Pt. #11 was reviewed. Pt. #11 was admitted to the Hospital on 10/25/2022 with a diagnosis of depression. The clinical record included a physician's order for risperidone (psychotropic medication): 11/4/2022, 1 mg/milligrams BID/two times a day; 11/6/2022, 1.5 mg BID; 11/9/2022, 2 mg BID; and 11/11/2022, 2.5 mg BID. Pt. #11 received risperidone on 11/4/2022, 11/6/2022, 11/9/2022, and from 11/11/2022 through 11/14/2022. Pt. #11's consent for psychotropic medication did not include risperidone. The clinical record also lacked documentation that explanation regarding the beneficial effects and consequences of risperidone were explained to Pt. #11.

2. On 11/15/2022, the Hospital's policy titled, "Psychoactive Medication Consent" (dated 3/17/2022) was reviewed and included, "... It is the policy of the facility to seek informed consent from the patient... for the psychoactive/psychotropic medications... Patients must consent to take psychotropic drugs unless otherwise stipulated by psychiatric crisis or legal order... Explanation must include... 2. The name of the medication and the beneficial effects on the patient's mental illness or condition... 3. The probable health and mental health consequences to the patient of not taking the medication... Documentation of informed consent: Evidence by a copy of the Consent for Psychoactive Medications..."

3. On 11/14 2022 at approximately 10:30 AM and on 11/15/2022 at approximately 2:09 PM, interviews were respectively conducted with E #2 (Charge Nurse) and E #1 (Director of Behavioral Health Unit). E #1 and E #2 stated that risperdone should be written on the psychoactive consent form. E #1 and E #2 could not provide documentation that Pt. #1 consented the use of risperidone or that explanation regarding the beneficial effects and consequences regarding the use of risperidone were explained to Pt. #1.

Based on observation, document review, and interview, it was determined that for 5 of 31 days in October 2022 (10/6/2022, 10/8/2022, 10/14/2022, 10/25/2022, and 10/31/2022) and 2 of 14 days in November 2022 (11/2/2022 and 11/10/2022), the Hospital failed to conduct safety environmental rounds, as required, to ensure patients received care in a safe setting.

Findings include:

1. On 11/14/2022 between 9:30 AM through 10:40 AM, an observational tour of the Hospital's behavioral health unit was conducted. The change of shift safety and environmental rounds from September 2022 thorough November 2022 were reviewed. The change of shift rounds were not conducted on the following dates: 10/6/2022, Day Shift (7:00 AM to 3:30 PM); 10/8/2022, Evening (3:00 PM to 11:30 PM) and Night Shifts (11:00 PM to 7:30 AM); 10/14/2022, Evening Shift; 10/25/2022, Day Shift; 10/31/2022, Night Shift; 11/2/2022, Night Shift, and 11/10/2022, Day Shift.

2. On 11/15/2022, the Hospital's policy titled, "Change of Shift Safety Rounds of Entire Patient Area" (undated) was reviewed and required, "Purpose: To provide a safe environment on the Mental Health Unit for patients and staff... Policy... 2. The Change of Shift Safety Rounds Log Book will be used to document safety rounds done. Rooms and patient care areas are to be checked off respectively once that area has been checked for contraband or safety hazards..."

3. On 11/15/2022 at approximately 1:00 PM, findings were discussed with E #1 (Director of Behavioral Health Unit). E #1 stated that the safety and environmental rounds should be done every shift. E #1 could not provide documentation that the safety rounds were conducted. On 11/17/2022 at approximately 9:30 AM, E # 14 (Director of Quality) verified that the behavioral health unit remained open and had patients daily in October and November 2022.

A. Based on observation, document review, and interview, it was determined that for 1 of 7 staff (E #13/Meal Clerk) observed in the dietary department, the Hospital failed to manage dietary services by ensuring that the staff followed hygienic practice of wearing hair restraints. This potentially affected any patient or staff receiving meals from the dietary department.

Findings include:

1. On 11/14/2022 between 11:30 AM through 12:15 PM, observational tour of the Hospital's food and dietary department was conducted. During the observation, E #13 was wearing a cap, but the hair was not completely covered and dangling at the back. Behind the tray line, E #13 was seen chopping cabbage.

2. On 11/15/2022, the Hospital's policy titled, "Personal Hygiene" (released on 6/2020) was reviewed and required, "... This policy establishes guidance for individuals handling food using good personal hygiene to minimize the risk of contaminating food, which may result in a foodborne illness... Policy... 4. Hair Restraints... b. Hair restraints must fully cover hair. Baseball hats or chef caps that do not fully cover hair are not allowed..."

3. On 11/14/2022 at approximately 11:30 AM, findings were discussed with E #3 (Culinary/Dietary Supervisor). E #3 stated that hair must be fully covered while inside the dietary department to prevent potential contamination of food.

B. Based on observation, document review and interview, it was determined that for 1 of 2 cold food storage refrigerators and 1 of 1 dry food storage area, the Hospital failed to manage the dietary services by ensuring that food items were labeled or that food items with beyond used by date were not available for consumption. This potentially affected any patient or staff receiving meals from the dietary department.

Findings include:

1. On 11/14/2022 between 11:30 AM through 12:15 PM, observational tour of the Hospital's food and dietary department was conducted:

- In one of the two cold food storage refrigerators, two packs of open ham and roast beef had no label of use by date.

- In the dry food storage area, there were two open bottles of apple cider vinegar that had a used by date of 8/6/2022, one open bottle of white vinegar with a use by date of 9/29/2022, one open bottle of Worcestershire sauce with a use by date of 8/15/2022, one open bottle of honey with a use by date of 11/9/2022, and one open bottle of sesame oil with a use by date of 11/9/2022.

2. On 11/15/2022, the Hospital's policy titled, "Food and Storage Supply" (released on 6/2022) was reviewed and required, "... The policy establishes guidelines for food and supplies in food preparation shall be stored in such a manner as to maintain safety and sanitation... Policy... 2. Labeling and rotating food supply. a. For food products that are opened and not completely used... the product should be labeled as to its contents and use by date... i. Follow recommendations when indicated on the product for storage time.

3. On 11/14/2022 at approximately 11:30 AM, findings were discussed with E #3(Culinary/Dietary Supervisor). E #3 stated that opened food items should be labeled. E #3 also said that food items that exceeded beyond use by date should have been discarded and not kept in the dry food storage area.