HospitalInspections.org

Based on observation, staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure the rights of each patient is protected.

Findings include:

1. The facility failed to ensure patients receive care in a safe setting. (Refer to Tag A-144)

2. The facility failed to ensure a physician's order was documented and a face to face evaluation was conducted by a physician or licensed independent practitioner for a patient placed in seclusion, in accordance with facility policy. (Refer to Tag A-168)

Based on observation and staff interview, it was determined the facility failed to ensure ligature and safety risks are mitigated in environments where patients are at risk for self-harm.

Findings include:

1. During a tour of the B Wing on 2/8/22, the following was observed:

a. At 11:05 AM, in Bathroom B237A, two (2) metal hooks were attached to the shower curtain.

b. At 11:10 AM, in Bathroom B225A, eight (8) metal hooks were attached to the shower curtain.

2. Upon interview, Staff #3 confirmed the metal hooks could be used as a source to inflict self harm or harm to others.

3. Upon interview on 2/8/22 at 1:00 PM, Staff #13 indicated the metal hooks were removed immediately and staff were educated on the risks the metal hooks posed.

N.J.A.C. 8:43G-4.1(a)

Based on staff interview, review of one (1) of two (2) medical records (#19) of a patient in seclusion, and review of facility documents, it was determined the facility failed to ensure a physician's order was documented, and a face to face evaluation was conducted by a physician or licensed independent practitioner (LIP) for a patient placed in seclusion.

Findings include:

Reference: Facility policy titled, "Mechanical Restraint and Seclusion in Inpatient Services and Emergency Services" states, "... 11. The use of restraint or seclusion must be in accordance with the order of a medical provider/physician or other licensed independent practitioner who is responsible for the care of the patient... c. Qualified staff must obtain an order from the licensed independent practitioner as soon as possible but no longer than one hour following the application of restraint or seclusion... f. The licensed, independent practitioner designee... evaluates the individual in restraint or seclusion face to face within one hour of the initiation of restraint or seclusion. ... ."

1. Review of Medical Record #19, on 2/10/22, revealed the patient was placed in seclusion on 12/17/21 at 6:30 PM. Seclusion time ended at 9:00 PM.

a. Review of the "Restraint/Seclusion Provider Order Form" indicated that an order for "Personal Restraint (<15 minutes)" was written on 12/18/21 at 3:10 AM.

b. Review of the "Restraint/Seclusion Provider Face to Face Note" indicated that a face to face evaluation was documented on 12/18/21 at 3:13 AM.

c. There was no evidence of a physician's order or face to face evaluation within one hour, for the patient's placement in seclusion, initiated on 12/17/21 at 6:30 PM and ended at 9:00 PM.

2. Upon interview, Staff #3 stated that the physician or resident should have documented that he/she was in to see the patient on the date and time of the event.

3. The above findings were confirmed with Staff #1, Staff #2, and Staff #3.

N.J.A.C. 8:43 G-4.1(a)19

Based on observation, staff interview, and review of nationally recognized infection control guidelines, it was determined the facility failed to ensure parenteral fluids are prepared in accordance with acceptable standards of practice.

Findings include:

Reference: The Centers for Disease Control and Prevention (CDC), FAQs (frequently asked questions) regarding Safe Practices for Medical Injections, https://www.cdc.gov/injectionsafety/providers/provider_faqs_med-prep.html, states, " ... Medications should be drawn up in a designated clean medication preparation area that is not adjacent to potential sources of contamination, including sinks or other water sources. Water can splash or spread as droplets more than a meter from a sink... ."

1. Upon interview on 2/8/22, Staff #19 confirmed the facility follows CDC guidelines.

2. During a tour of the Acute Psychiatric Services Unit on 2/9/22 at 11:10 AM, in the presence of Staff #3, Staff #20, and Staff #22, Staff #22 stated that parenteral medications are prepared on the countertop immediately adjacent to the sink in the medication room.

3. This finding was confirmed by Staff #3 on 2/9/22 at 11:10 AM.

N.J.A.C. 8:43 G-14.1(d)(iii)

A. Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure policies and procedures that address the disposal of Controlled Dangerous Substances (CDS) in accordance with Drug Enforcement Administration (DEA) regulations, are developed and implemented.

Findings include:

Reference #1: Drug Enforcement Administration regulation 21 CFR 1317.90 Methods of Destruction, https://www.deadiversion.usdoj.gov/21cfr/cfr/1317/subpart_c.htm, states, "... (a) All controlled substances to be destroyed by a registrant, or caused to be destroyed by a registrant, pursuant to 1317.95(c), shall be destroyed in compliance with applicable Federal, State, tribal, and local laws and regulations and shall be rendered non-retrievable... ."

Reference #2: The Federal Register, Vol. 79, No. 174, September 9, 2014 Rules and Regulations, https://www.deadiversion.usdoj.gov/fed_regs/rules/2014/2014-20926.pdf, states, " ... Non-Retrievable Destruction Standard... the DEA (Drug Enforcement Administration) indicated that incineration and chemical digestion are some examples of current technology that may be utilized to achieve the non-retrievable standard. The preamble of the NPRM states that sewering (disposal by flushing down a toilet or sink) and landfill disposal (mixing controlled substances with undesirable items such as kitty litter or coffee grounds and depositing in a garbage collection) are examples of current methods of disposal that do not meet the non-retrievable standard."

1. During a facility tour on 2/9/22, it was identified that the facility lacked a method to dispose of CDS that would render the medication "non-retrievable."

2. During an interview on 2/9/22 at 10:37 AM in the pharmacy, Staff #3 and Staff #20 stated that damaged or expired CDS or partial doses of CDS are discarded in the red sharps container.

3. During an interview on 2/9/22 at 11:21 AM, in the Acute Psychiatric Service Unit in the presence of Staff #20, Staff #22 stated that partial doses of CDS are discarded in the red sharps container.

4. During an interview on 2/9/22 at 12:05 PM, in the Child/Adolescent Inpatient Unit in the presence of Staff #20, Staff #24 stated that partial doses of CDS are discarded in the red sharps container.

5. Review of facility policy titled, "Narcotic and Controlled Drugs" on 2/10/22 states, "... 4.1 Distribution of Controlled Substances, 4.1.1 Nursing... All wasted doses must be placed in the red bags or sharp containers... ." This disposal method does not render the CDS non-retrievable as required by DEA regulations.

6. During an interview on 2/10/22 at 11:05 AM, Staff #20 confirmed the above findings.

N.J.A.C. 8:43 G-23.2(a)(5)

B. Based on staff interview, review of CDC guidelines, and review of facility documents, it was determined the facility failed to ensure policies and procedures that address temperature monitoring of refrigerators used to store medications and vaccines, are developed and implemented.

Findings include:

Reference: The Centers for Disease Control and Prevention (CDC), Vaccine Storage and Handling Toolkit (September 2021) states," ... Check and record storage unit minimum and maximum temperatures at the start of each workday. If your TMD [temperature monitoring device] does not read min/max temperatures, then check and record the current temperature a minimum of 2 times per workday (at the start and end of the workday). Record... Minimum/maximum temperature - Date - Time - Name of person who checked and recorded the temperature - Any actions taken if a temperature excursion occurred... If a reading is missed, leave a blank entry in the log."

1. During a tour of the pharmacy on 2/9/22 at 10:46 AM, in the presence of Staff #3, Staff #20 and Staff #21, six (6) boxes of Flucelvax Quadravalent, containing ten (10) prefilled syringes of flu vaccine, were found stored in the pharmacy medication refrigerator.

2. Upon interview on 2/9/22 at 10:50 AM, Staff #20 stated that the medication refrigerator and freezer temperatures are monitored and documented twice daily on days that the pharmacy is open. Staff #20 confirmed that while the facility had a refrigerator thermometer with a data logger, the facility lacked a process to monitor and document the refrigerator and freezer temperatures on days the pharmacy is closed.

a. Staff #20 indicated the pharmacy is closed on Sundays and holidays.

3. Review of the pharmacy's Medication Refrigerator Temperature Logs, dated 8/1/21 to 1/31/22, lacked documentation of the refrigerator temperature on the following dates:

a. In August 2021, the refrigerator temperature was not documented on: 8/1, 8/8, 8/15, 8/22, or 8/31.

b. In September 2021, the refrigerator temperature was not documented on: 9/5, 9/6, 9/12, 9/19, or 9/26.

c. In October 2021, the refrigerator temperature was not documented on: 10/3, 10/10, 10/17, 10/24, and 10/31.

d. In November 2021, the refrigerator temperature was not documented on: 11/7, 11/14, 11/21, 11/25, 11/26, or 11/28.

e. In December 2021, the refrigerator temperature was not documented on: 12/5, 12/12, 12/19, 12/24, 12/25, 12/26, or 12/31.

f. In January 2022, the refrigerator temperature was not documented on: 1/1, 1/2, 1/9, 1/16, 1/17, 1/23, or 1/30.

4. Review of facility policy titled, "Medication and Specimen Refrigerator and Freezer Monitoring and Use of Temperature Logs" on 2/10/22, indicated the policy fails to include the need to monitor and document the refrigerator/freezer temperatures, twice daily, of units containing vaccines, in accordance with the reference above.

5. During an interview on 2/10/22 at 11:15 AM, Staff #20 confirmed the above findings.

N.J.A.C. 8:43 G-23.2(a)(5)

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure compliance of the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines."

Findings include:

Reference #1: The Program Director's Job Description states, "ESSENTIAL DUTIES AND RESPONSIBILITIES include the following... 1. Provides administrative and clinical direction for program. ... j. Promotes a safe, functional and supportive environment so that quality and safety are preserved. ... 8. Keeps abreast of all pertinent federal, state and [Name of facility] regulations, laws and policies as they presently exist and as they change or are modified."

Reference #2: N.J.A.C. #8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #3: N.J.A.C. 8:24-6.5(j) states, "The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is non-functional or no longer used, and litter."

Reference #4: Facility policy titled, "Food Handling/Preparation: Food Storage" states, "... Procedure...7. Foods must be stored in their original containers with sell by/use by dates clearly visible; those with closer expiration dates shall be stored in the front, farther dates in the rear, supporting a system of 'first in -first out' food use."

1. During a tour of the outpatient Cherry Hill location on 2/8/22, in the Food Staging area, the following was observed:

a. Corroded surfaces on the bottom of the table legs of four (4) metal work tables.

b. The floor was visibly dirty with brown stains throughout the kitchen area.

c. The mobile food warmer was visibly dirty with debris on each shelf. The mobile food warmer contained an aluminum tray with dried rice.

d. A thirty-two (32) ounce container of 'Quick Oats' had an expiration date of 1/29/22.

2. During an interview on 2/9/22 at 1:30 PM, Staff #8 stated that the Food Staging area at the Cherry Hill location had not been used for over two (2) years and he/she was unsure of when the kitchen floor and equipment located in the area was last cleaned.

3. During a tour of the main kitchen at 10:10 AM on 2/9/22, in the presence of Staff #18, the following was observed:

a. Cheese wrapped in plastic wrap with a label that stated: "Prep (preparation) Date 11/16/21... Use through 11/22/21."

b. Four (4) packages of pork/ham with a label that stated: "Prep Date 10/12/21... Use through 10/15/21."

4. During an interview at 11:15 AM, Staff #18 confirmed the expired food items should have been discarded.

N.J.A.C. 8:43G-10.6(q)

Based on staff interview, review of one (1) of one (1) medical record (#5) of a patient transferred to another level of care, and review of facility policy and procedure, it was determined the facility failed to ensure hand-off communication is documented between discharge from an inpatient hospitalization and transfer to outpatient services.

Findings include:

Reference: Facility policy titled, "Transfer/Hand-Off Communication Among Providers" states, "... Policy: A. Transfers between [facility name] Levels of Care/Programs... 2) The sending service provider will contact the receiving service provider in advance of transfer to provide hand-off communication. Their discussion will include: sender's contact information, treatment summary including events leading to the current episode of care and response to treatment, assessment/severity of symptoms, allergy list, medication reconciliation, laboratory tests, and aftercare recommendations as applicable. ... a. The sending service provider will document the above discussion in a Coordination of Care (COC) progress note. ... ."

1. Review of Medical Record #5 on 2/10/22 at 10:47 AM revealed the following:

a. On 11/22/21, Patient #5 was discharged from an adult inpatient unit. A Coordination of Care Note states, "[Patient name] has an appt [appointment] via telehealth with the [named] outpatient office on 12/3/21 at 2PM."

b. The medical record lacks documentation in a Coordination of Care Note of a discussion between the sending service provider and the receiving service provider that indicates the patient's current episode of care, response to treatment, and aftercare recommendations.

2. The above findings were confirmed with Staff #3 and Staff #16 at 11:15 AM.

N.J.A.C 8:43G-11.5 (c)

Based on staff interview, it was determined the facility failed to ensure a written agreement with an Organ Procurement Organization.

Findings include:

1. On February 10, 2022 at 11:45 AM, Staff #13 confirmed the facility did not have a written agreement with an organ procurement organization.

Based on staff interview, review of one (1) of one (1) medical record (#5) of a patient transferred to another level of care, and review of facility policy and procedure, it was determined the facility failed to ensure an outreach letter is sent to patients for missed outpatient appointments.

Findings include:

Reference: Facility policy titled, "Non-Attendance of Treatment and Non-Adherence to Treatment Recommendations - Outpatient Services" states, "... Procedure A. Non-attendance: After an individual fails to show for a scheduled individual, family, or pharmacological management appointment, or cancels with less then 24 hours notice, the following will occur: Outreach is attempted by staff via phone contact during the missed appointment time. This attempt will be documented in the EMR (electronic medical record). If no answer, a letter is sent advising the consumer that their case will be closed in 7 days if an appointment is not made/or no contact."

1. Review of Medical Record #5 on 2/10/22 at 10:47 AM revealed the following:

a. On 11/22/21, Patient #5 was discharged from an adult inpatient unit. A Coordination of Care Note states, "[Patient name] has an appt [appointment] via telehealth with the [named] outpatient office on 12/3/21 at 2PM."

(i) On 12/3/21, Staff #44 documented in the "Misc Data Progress Note" that Patient #5 did not answer the phone when called for his/her scheduled intake appointment.

(ii) On 12/7/21, Staff #45 documented in the "Care Management Progress Note" that he/she "phoned the client to see if they would like to continue coming here for treatment, there was no answer. I could not leave a voice message due to lack of release and client not being clearly identified on the answering machine. A 7 day outreach letter will be requested."

(iii) There was no evidence in the medical record of an outreach letter sent to the patient.

2. The above findings were confirmed with Staff #16 at 1:30 PM.

N.J.A.C. 8:43G-5.2(a)