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Based on observation, interview, record review, and policy review the facility failed to:
-Provide adequate registered nurse (RN) supervision to identify suicidal risk factors, assess, re-assess, and implement individualized interventions to prevent suicide attempt (actions taken to self-harm) for one patient (#22) of one discharged patient reviewed, and one patient (#39) of two current patients reviewed on the behavioral health unit (BHU, an acute inpatient psychiatric unit for adults). (Refer to A395).
-Conduct a timely, thorough investigation and implement adequate treatment interventions to prevent the potential for harm to patients at risk of suicidal behavior after a patient attempted suicide. (Refer to A395).
-Ensure that an RN followed the facility's Nursing Structure Standards (nursing policies and procedures) to question a physician's order to discontinue a patient's (#39) higher level of supervision/observation, when the order was in direct conflict with the RN's nursing assessment that showed suicide risk. (Refer to A395).
-Ensure facility staff conducted patient observation rounds at unpredictable intervals for one (#39) of one current patient assessed at risk for suicide.
-Provide adequate staff oversight for one patient (#22) of one discharged patient that attempted suicide by hanging on the BHU, and for one patient (#39) of one current patient with suicidal behavior in an environment with looping/ligature hazards. (Refer to A395).

The BHU census was five. The total facility census was 22.

The cumulative effect of these systemic practices had the potential to place all patients in the BHU at risk for their health and safety, also known as immediate jeopardy (IJ).

As of the time of survey exit, the facility failed to provide an immediate action plan sufficient to abate the IJ. The IJ was unabated at the time of the survey exit.




31891

Based on observation, interview, record review, and policy review the facility failed to:
- Provide adequate registered nurse (RN) supervision to identify suicidal risk factors, assess, re-assess, and implement interventions to prevent suicide attempt (actions taken to self-harm) for one patient (#22) of one discharged patient reviewed, and one patient (#39) of two current patients reviewed on the behavioral health unit (BHU, an acute inpatient psychiatric unit for adults).
- Conduct a timely, thorough investigation and implement adequate treatment interventions to prevent the potential for harm to patients at risk of suicidal behavior.
- Ensure that the RN staff followed the facility's Nursing Structure Standards (nursing policies and procedures) to question a physician's order to discontinue a patient's (#39) higher level of supervision/observation, when the order was in direct conflict with the RN's nursing assessment that showed suicide risk.
- Ensure that facility staff conducted patient observation rounds at unpredictable 12 to18 minute intervals for one (#39) patient of one current patient with suicide risk.
-Provide increased staff oversight for one patient (#22) of one discharged patient that attempted suicide by hanging on the BHU, and for one patient (#39) of one current patient with suicidal behavior, in an environment with looping/ligature hazards. The BHU census was five. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Nursing Process," dated 05/28/13 showed that the RN staff collected data through interview, observation, and physical examination to assess and reassess the patient's status. The initial assessment was completed within eight hours of admission and reassessments were performed at least every shift. The RN staff validated the accuracy of the data collected and determined the significance of the information. The evaluation was written as a shift summation in the nurses' notes and the content included evaluative statements about the patient's response to treatment in relation to the patient's plan of care (treatment plan).

Record review of the facility's BHU policy titled, "Patient Observation," dated 05/28/13 showed that all patients were monitored a minimum of once every 12 to 18 minutes. The time of the observation and the location of the patient was documented on the rounds sheet (form). An increased degree of monitoring was applied to patients whose psychiatric condition was assessed as needing more intense external controls and/or intense frequency of staff contact.

Record review of the facility's BHU policy titled "Suicide," dated 05/28/13 showed that a patient was placed on suicide precautions by the physician on admission, or anytime during hospitalization, when a patient expressed ideas of self-harm or acted in self-destructive ways. The policy showed the charge RN may initiate suicide precautions with line of sight (staff assigned to keep patient in sight at all times) or one-to-one supervision (staff assigned to work with one patient, remaining in close proximity at all times), but the RN must contact the physician to obtain an order as soon as possible.

2. Record review of Patient #22's physician progress note dated 09/23/13, showed the patient was admitted to the BHU on 09/23/13 with a diagnosis of major depression (long periods of feeling worried or empty with a loss of interest in activities once enjoyed), severe with suicidal ideation (thoughts of suicide).

Record review of Patient #22's nurses' notes on 09/23/13 showed that she was admitted for anxiety and cutting behaviors. Her anxiety level was very high and she isolated herself to her room most of the day. She was hearing voices that told her to cut herself, and had frequent thoughts to self-harm. She stated she needed to cut herself to see blood and feel better. She tried to find objects to cut self and made an attempt with a window handle in her room (these can all be initial risk factors for future self-harm).

Record review of the Patient Observation Record (form that documents the status, time precaution level, and activity of the patient to be completed every 12-18 minutes) dated 09/24/13 at 2:14 PM, showed she was in her room.

Record review of Patient #22's nurses' note dated 09/24/13, timed 3:34 PM, showed that at approximately 2:30 PM, the patient was found in her room crying and stated that she tried to hang herself and called for help but no one heard her. She complained of neck pain and had a red mark on her neck. The RN staff failed to contact the physician to obtain orders for suicide precautions and/or an increased level of observation/supervision after the patient's suicide attempt. The RN staff also failed to evaluate the behaviors and institute interventions to address the patient's suicidal thoughts and behaviors.

Record review of Patient #22's physician progress note dated 09/25/13, dictated at 3:56 PM, showed the patient had acute anxiety, felt suicidal and used a bed sheet as a noose over the bathroom door to hang herself after the physician's visit on 09/24/13. The patient kicked the chair away, then saw faces of her children in her mind's eye and regretted the attempt. She tried to call for help but said no one heard her. She was able to retrieve the chair with her feet, support her weight on the chair, and get out of the sheet.

3. During an interview on 10/23/13 at approximately 2:30 PM Staff QQ, Certified Nurse Assistant (CNA) stated that:
- On the day of Patient #22's attempted suicide she had conducted rounds (12 to 18 minute observation checks) on the BHU.
- She typically started her rounds to observe the patient in room 151 and continued rounds with patients by room number and continued her rounds in the same consecutive order until she reached the last patient room. (The pattern of patient observation rounds allowed patients to predict the estimated time of the subsequent rounds, leaving them at potential risk between rounds).
- She had just completed rounds on all patients when Staff YY, licensed practical nurse (LPN), informed her that Patient #22 attempted to hang herself.
- Since the suicide attempt, the facility had not changed any of the patient supervision or treatment processes.

The RN staff failed to evaluate the patient observaton rounds procedure and implement interventions for the safety of all patients on BHU.

4. During an interview on 10/24/13 at 1:40 PM, Staff JJ, CNA, stated the following:
- The 15-minute observation rounds were completed the same way each time she did them. Staff JJ started her rounding at one patient's room and continued through to end of her assignment consistently (this made the rounding predictable to the patients).
- The only knowledge of the incident involving Patient #22, was that she, Staff JJ, was re-assigned to the BHU after the incident because the BHT originally assigned was in orientation and not qualified to supervise the patient.
- Patient #22 told Staff JJ that she felt like no one would care if she was "here" or not (verbalizing hopelessness) after the incident.

5. During an interview on 10/23/13 at 9:50 AM, Staff HH, RN, stated that:
- She arrived to work at 1:30 PM and received a report that Patient #22 was readmitted after making suicidal statements, was showing anxiety, and had no precaution for the suicide risk.
- At approximately 2:30 PM Patient #22 walked up to the nurses' station, wringing her hands with anxiety, and Staff HH directed the LPN to escort the patient back to her room.
- The LPN requested Staff HH come to Patient #22's room and found a bed sheet draped over the top hinge of the bathroom door and the sheet had a knot at one end.
- Patient was sitting on her bed rocking back and forth stating she needed help and that she tried to hang herself.
- Patient #22 had a red horizontal mark on her neck and complained of pain.

The RN staff failed to obtain orders for suicide precautions and evaluate the need for additional interventions for patient's suicide risk and attempt at suicide.

6. During an interview on 10/23/13 at 11:15 AM, Staff II, RN, and Nurse Educator stated that:
- Patient #22 had frequent hospitalizations for suicidal thoughts and behaviors.
- Staff II was with Staff W, Physician while meeting with Patient #22 on 09/24/13, approximately two hours before the suicide attempt. She was watching Patient #22 closely during the session as the patient was displaying anxiety, had urges to hurt herself, and was looking for something to cut herself. She stated that during the session she did not assess Patient #22 as a suicidal risk.
- She met with Patient #22 on 09/24/13 after the event and the patient told her that she fashioned a noose (sheet tied into a hanging device) around her neck, pushed the chair away, saw her kids faces in her mind, tried to call for help and no one heard her, had difficulty getting chair back but got the chair back, beared her weight on the chair, released herself from the noose, and reported the incident to staff.
- Staff II and other RN staff considered one-to-one supervision for Patient #22 after the suicide attempt but they decided to use line of sight observation to avoid increasing the patient's anxiety.

7. During a record review of a document titled "Root Cause Analysis and Action Plan in Response to a Sentinel (adverse) Event" (an evaluation process to determine the underlying causes of an adverse event and take actions to reduce the likelihood of reoccurrence), dated 09/24/13, showed that the investigation was incomplete and had not addressed all of the factors involved. The facility had not conducted a thorough investigation of the attempted suicide.

8. During an interview on 10/24/13 at 1:30 PM (30 days after the attempt of suicide), Staff F, BHU RN nurse manager, stated that no changes to processes had been implemented to prevent similar future suicide attempts. Staff F stated that the investigation of this incident had not been completed as of this date (30 days later) because of other duty involvements.

9. During an interview on 10/24/13 at 8:55 AM, Staff W, Physician, stated that an RN (did not recall who) contacted her about Patient #22's attempted suicide by hanging on 09/24/13 and staff had placed her on one-to-one supervision. Staff W acknowledged the intervention by stating okay, and she thought one-to-one supervision was implemented. The physician stated that the RN staff failed to write telephone orders for one-to-one supervision. Staff W also stated that the adverse event (suicide attempt) was a wake-up call to nursing staff to the importance of not being complacent with patient observation and supervision.

10. Record review of Patient #22's nurses' notes from 09/25/13 to 10/01/13 showed that:
- The patient continued to have periods of severe anxiety and depressed mood;
- Continued to have suicidal thoughts;
- Scratched at old wounds on hands and arms on multiple occasions;
- Continued to have voices telling or insisting she harm herself;
- Tried to harm herself by hitting her head on a wall;
- Planned to hang herself as soon as she got a chance; and
- On 10/01/13 she was found sitting on the floor in her room with a sheet and pillow.

The RN staff failed to complete an assessment for suicide risk on 10/01/13. The RN staff failed to contact the physician to obtain orders for suicide precautions and/or an increased level of observation/supervision for Patient #22's suicidal thoughts and behaviors.

11. During an interview on 10/23/13 at 1:17 PM Staff OO, RN stated that:
- The RN staff failed to address Patient #22's safety concerns such as increasing her level of supervision.
- The point of the unit is to keep patients safe until they go home.
- The entire team needs to improve and not [think] "Oh well, it's just ...(patient's name) again." The team needed to figure out what to do differently to better treat Patient #22.
-"If staff do not pay attention to the patient, something (adverse) will eventually happen."

The RN staff failed to evaluate Patient #22's suicide risk and institute interventions for her safety needs, before or after the suicide attempt.

12. During an interview on 10/23/13 at 2:20 PM Staff PP, LPN stated that since the suicide attempt, the facility had not changed any of the patient supervision or treatment processes.

13. Record review of the facility's policy titled "Nursing Responsibilities to the Medical Staff," dated 05/28/13 showed that nursing staff was responsible for questioning orders when they were in conflict with existing standards. Nursing staff was responsible for communicating clearly and promptly with the medical staff to keep them informed about the patient's status, change in condition, and response to therapy.

14. Record review of Patient #39's Psychiatric Evaluation dated 10/22/13 showed patient was admitted to the BHU on 10/19/13 following a suicide attempt. He overdosed on a combination of alcohol and several different medications. He then used a box cutter and made severe lacerations (cuts) in both forearms that required emergency treatment with sutures and bandages. The physician's examination showed a diagnosis of major depressive disorder with severe suicidal gesture. There was no order for suicide precautions or an increased level of observation/supervision.

15. Record review of Patient #39's Sad Persons Scale (a nursing screening tool that measures suicide risk) dated 10/19/13, showed a score of eight out of a 10 point scale. The form's guidelines for action for a score of eight showed that patient was to be placed on line of sight with patient observation documented every one to 18 minutes (12 to 18 in policy) and the nurse was to conduct rounds every hour.

Record review of Patient #39's observation rounds forms dated from 10/19/13 to 10/23/13 showed no line of sight observations, and the majority of the entries were documented were at 15 minute intervals (predicable time intervals). The nursing staff failed to conduct the additional consistent hourly rounding as indicated in the Sad Persons Scale guidelines.

Record review of Patient #39's of nurses note dated 10/21/13, showed that the patient was depressed with less facial affect (emotional expression), he had suicidal ideations, and no suicide precautions. The RN documented that the patient was not assessed as needing an increased level of supervision even though the patient exhibited suicidal ideations.

Record review of the BHU nursing report sheet (a form used to provide patient information from one nurse to another, provided a line listing of patients including their diagnosis, behavior and precautions) dated 10/23/13 showed Patient #39 was admitted with a diagnosis of depression with suicide attempt and Staff OO, RN, had documented on the report sheet that Patient #39 had suicidal ideations. The RN staff failed to evaluate the need for additional interventions for Patient #39's suicide risk until surveyor inquiry on 10/23/13.

Record review of Patient #39's nurses' note on 10/23/13 at 5:25 PM showed the patient had intermittent suicidal ideations with anxiety and flat affect (the absence of or near absence of an emotional response, also known as a symptom of depression).

Record review of Patient #39's Sad Person's Scale form on 10/23/13 showed a score of seven out of a 10 point scale. The form's guidelines for scores from six to eight showed actions included placement on line of sight observation, observations documented every one to 18 minutes (two to 18 minutes in policy), completion of a suicidality assessment every four hours, and hourly rounding by the nurse.

Record review of Patient #39's nurses' note dated 10/23/13, timed 10:36 PM, showed that at 8:30 PM, Staff ZZ, RN, received a verbal order from the physician to discontinue line of sight observation for Patient #39. Then, at 9:00 PM, Staff ZZ completed a suicidality assessment tool (nursing assessment tool used to determine suicide risk) that showed Patient #39 expressed suicidal thoughts, significant hopelessness, and isolation from others with little or no social interaction. Staff failed to question the physician's order to discontinue the precautions, even though this order was in direct conflict with the Sad Person's scale score of seven and the RN's suicidality assessment that showed the patient at suicide risk.

16. Record review of a written statement, in relation to the facility's root cause analysis, by Staff HH and dated 10/24/13, showed that she had all patients reassessed for suicide risk on the evening of 10/23/13 and one patient had a suicide risk score requiring line of sight observation. Even though the patient was assessed at risk Staff HH documented that the physician was contacted and the line of sight order was discontinued.
The RN failed to assess Patient #39's risk and question the physician's order to discontinue the precautions, when the order was in direct conflict with the Sad Person's scale score of seven and the RN's suicidality assessment. Both assessment tools showed suicide risk for Patient #39.

17. Observation and concurrent interview with Staff HH on 10/23/13 at 10:40 AM, showed that:
- The BHU had a capacity of 10 patients and a current census of five. No patients were on suicide precautions. The unit consisted of 10 private rooms each with their own bathroom. The doors to the bathrooms were wood with three hinges and were looping hazards. Staff HH stated that a few years ago the hinges on the bathroom doors were discussed as a suicide risk but it had not been discussed since.
- Each patient room had two knobs on the sink and two louver-style ceiling vents that were looping hazards.
-Staff HH stated she had not assessed the risk with the faucet handles (environmental factors) or the looping hazards in the ceiling.
-Staff HH stated that observation rounds were to be conducted at 12 to 18 minute intervals.
-Concurrent observation of Patient #39's observation rounds form showed the majority of the observations were conducted consistently at 15 minute intervals, and not staggered.
Failure to conduct patient observation rounds at staggered intervals for patients at risk of suicide, coupled with the environmental risk factors, increase the opportunity for suicide.

The facility did not provide increased staff oversight for suicidal patients in rooms with environmental hazards. Facility staff failed to proactively identify the overall system failure that contributed to Patient #22's suicide attempt and Patient #39's potential for harm, and failed to develop a systemic resolution.











12450

Based on interview, record review and policy review (Structure Standards), the facility failed to develop comprehensive, individualized care plans for four current patients (#13, #3, #5, and #39) and for four discharged patients (#14, #15, #16, and #22) out of ten patients' care plans reviewed. This had the potential to affect all patients admitted to the facility. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Care Planning," dated 05/28/13, showed that:
- The patient care problems must be addressed comprehensively in all three domains of physical, psychosocial, and cognitive need.
- Problems must be prioritized.
- Preplanned care is individualized and modified for the unique needs of patients .
- The management of the problems requires plans with predetermined outcomes and interventions reflecting best practice.
- Some care planning must be spontaneous and is a result of collaborative interaction among the interdisciplinary team.
- Daily outcome evaluation is the basis for documentation, and modification.
- Registered Nurses (RNs) are encouraged, and expected, to utilize all available resources in planning patient care.

2. Record review of current Patient #13's nursing admission assessment, dated 10/16/13, showed that the patient was admitted, to the Swing Bed unit (a special unit that receives reimbursement based on skilled care required), on that date with a diagnosis of congestive heart failure (condition whereby the heart does not pump adequately).

Record review of Patient #13's recreational therapy assessment dated 10/18/13, showed the patient enjoyed dominoes, country music and solitaire (a card game). The patient also found choices, family, news and snacks very important to her routine.

Record review of the patient's care plan on 10/22/13, dated 10/16/13, showed the facility failed to incorporate the recreational therapy assessment into the care plan. The patient's care plan showed no problem, goal and/or interventions for recreational therapy.

3. During an interview on 10/22/13 at 11:42 AM, Staff F, RN Manager, stated that there was no recreational therapy care plan for this patient.

4. During an interview on 10/22/13 at 2:00 PM, Staff T, Patient Care Coordinator (PCC), stated that the recreational therapy assessment should drive the care plan, and be utilized to provide care.

5. During an interview on 10/23/13 at 9:02 AM, Staff EE, Recreational Therapist, stated that she compiled the assessment information and sent it on to the PCC who was responsible for entering the information into the patient's care plan. Staff EE stated that she did not make entries into the care plan.

6. Record review of current Patient #3's History and Physical (H & P) dated 10/21/13, showed the patient was admitted on 10/20/13 with problems of chronic bronchitis (a persistent disorder that blocked airflow and causes difficulty breathing, dyspnea (difficulty breathing), and diabetes (a disease that causes the inability of the body to break down glucose (sugar) and can cause multiple medical problems)

Record review of current Patient #3's care plan dated 10/20/13, showed no problem and care planning for diabetes.

7. Record review of current Patient #5's H &P dated 10/21/12, showed the patient was admitted to the medical surgical unit on 10/20/13 for problems of failure to thrive, vomiting, malnutrition, and depression.

Record review of Patient #5's nurses' notes from 10/20/13 to 10/22/13 showed multiple notes with patient needs for pain management and a nurses' note that her psychiatrist would be visiting her in the hospital.

Record review of Patient #5's care plan showed no individualized care planning for pain management or depression.

8. Record review of discharged Patient #14's H & P dated 06/18/13, showed the patient was admitted to the Swing Bed unit on that date with problems of right leg pain, swelling and infection.

Record review of Patient #14's recreational therapy assessment dated 06/18/13, showed the patient enjoyed reading, puzzles, television, walking outside, and UNO (a card game). The patient also found choices, family, and activities with groups very important to her routine.

Record review of the patient's care plan dated 06/18/13, showed the facility failed to incorporate the recreational therapy assessment into the care plan. The patient's care plan showed no problem, goal and/or interventions for recreational therapy.

9. Record review of discharged Patient #15's H & P dated 07/02/13, showed the patient was admitted to the Swing Bed unit on that date with a diagnosis of pneumonia (an infection in the lungs). The patient was moderately mentally retarded.

Record review of Patient #15's recreational therapy assessment dated 07/08/13, showed the patient enjoyed music, activities with groups, snacks and choices. The assessment showed the patient needed activities that were diversional.

Record review of the patient's care plan dated 07/02/13, showed the facility failed to incorporate the recreational therapy assessment into the care plan. The patient's care plan showed no problem, goal and/or interventions for recreational therapy.

10. Record review of discharged Patient #16's H & P dated 08/21/13, showed the patient was admitted to the Swing Bed unit on that date with a diagnosis of abdominal abscess (draining wound).

Record review of Patient #16's recreational therapy assessment dated 08/22/13, showed the patient enjoyed reading, choices, religious services, family, news, and outside activities. The patient also found puzzles, gardening, and the local paper very important to her routine.

Record review of the patient's care plan dated 08/21/13, showed the facility failed to incorporate the recreational therapy assessment into the care plan. The patient's care plan showed no problem, goal and/or interventions for recreational therapy.

11. Record review of the facility's policy titled, "Treatment Plans" for the BHU showed that:
- Each patient had a written individualized Interdisciplinary Treatment Plan (ITP) based on assessments of his/her clinical needs and strengths.
- The admitting nurse entered the problems observed and the problems reported by the treating psychiatrist, in the ITP on the problem list.
- The nurse in collaboration with the social worker initiated an initial ITP that was based on at least an assessment of the patient's presenting problems, emotional status, behavioral status, and physical health.
- Appropriate therapeutic efforts began immediately when the initial ITP was developed.
- A multidisciplinary team conference was held biweekly during which a comprehensive, individualized ITP was developed, evaluated, and/or updated.

12. Record review of current Patient #39's Psychiatric Evaluation dated 10/22/13 showed patient was admitted to the facility on 10/19/13 following a suicide attempt by drug overdose. He then used a box cutter and made severe lacerations (cuts) in both forearms that required emergency treatment with sutures and bandages. The physician's examination showed a diagnosis of major depressive disorder with severe suicidal gesture.

Record review on 10/23/13 of Patient #39's ITP dated 10/19/13 showed a problem of depression with suicide attempt but there were no nursing objectives or interventions for patient's suicide risk. The RN staff failed to evaluate the behaviors and institute interventions in the patient's ITP to address the patient's suicidal thoughts and behaviors.

13. Record review of discharged Patient #22's physician progress note dated 09/23/13, showed the patient was admitted to the BHU on 09/23/13 with a diagnosis of major depression (long periods of felling worried or empty with a loss of interest in activities once enjoyed), severe with suicidal ideation.

Record review of Patient #22's nurses' notes on 09/23/13 showed that she was readmitted to the facility for anxiety and cutting behaviors. Her anxiety level was very high and she isolated herself to her room most of the day. She heard voices that told her to cut herself and had frequent thoughts to self-harm. She stated she needed to cut herself to see blood and feel better. She tried to find objects to cut self and made an attempt with a window handle in her room (these can all be initial risk factors for future self-harm).

Record review of Patient #22's ITP dated 09/23/13 showed that even though the patient had problems of depression, suicidal ideation, anxiety, and auditory hallucinations, the RN staff failed to evaluate the behaviors and update, develop and document goals and interventions in the ITP to address suicide risks, and other self-harm.

Record review of Patient #22's nurses' notes dated 09/24/13, timed 3:34 PM, showed that at approximately 2:30 PM, the patient stated that she tried to hang herself. The RN staff failed to evaluate the behaviors and institute interventions in the patient's ITP to address the patient's suicide attempt.

14. During an interview on 10/23/13 at 1:17 PM Staff OO, RN stated that:
- The RN staff should have addressed safety in the objective section of Patient #22's ITP.
- The RN staff failed to address Patient #22's safety needs such as increasing her level of supervision.
- The treatment team, including the RN staff, failed to update the ITP.
- Had the treatment team updated objectives, interventions, and evaluated Patient #22's progress toward each goal, the staff would have focused their attention on her needs.



29117

Based on interview, record review and policy review the facility failed to have the radiology equipment inspected by a qualified medical physicist on at least an annual basis. This deficient practice has the potential to affect all patients who receive a radiology procedure. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Radiology Equipment Inspections, Records" dated 05/13, showed all ionizing producing devices (devices which produce x-rays which penetrate the body to study bones, organs, etc. inside the body and to diagnose and treat certain disorders) are inspected by a qualified physicist in accordance with State regulations.

2. Record review of the physicist inspection reports, conducted on the morning of 10/22/13, showed a physicist had conducted an inspection of the radiology equipment on 06/04/12 and had not conducted another inspection of the equipment until 09/25/13.

3. During an interview on 10/23/13 at 9:10 AM, Staff W, Radiology Manager, stated that the radiology equipment had not been inspection on an annual basis as the physicist was late.

Based on observation, interview, record review and policy review the facility failed to:
-Follow their policy for hand hygiene (use hand sanitizer or wash with soap and water) for two patients (#1 and #3) of eight patients observed and follow their policy for hand hygiene with glove use for four patients (#12, # 4, #19, and #41) of five patients observed.
-Ensure a cleanable surface, free from tears (open areas) and adhesive residue in two of three Operating Room (OR) areas observed. They were OR #1 and the Cesarean (C) Section OR. The torn mattresses and adhesive residue allowed for potential bacteria growth by not being a cleanable surface and had the potential to affect all patients receiving care in these patient areas.
-Accurately measure cleaning solutions in three of three areas observed that clean instruments and endoscopes (an instrument that can be introduced into the body to give a view of its internal parts). They were the Obstetrical (OB, unit for childbirth and caring for and treating woman in or in connection with childbirth) Unit, Gastrointestinal (GI) lab, and the Central Sterile (unit where instruments were sterilized) areas.
-Ensure nursing equipment was cleaned daily by nursing staff.
This had the potential to affect all patients receiving care in the facility. The facility census was 22.

Findings included:

1. Record review of the facility's policy (Structure Standards) titled, "Standard Precautions for Employee Protection," dated 05/28/13, showed direction for facility staff to perform hand hygiene under the following conditions:
- After the removal of any personal protective apparel;
- Before "clean" and aseptic (totally clean, free from bacteria) procedures;
- Before and after all patient contact procedures;
- Immediately after soiling with blood or body fluids;
- If hands will be moving from a contaminated-body site to a clean-body site during patient care;
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;
- After removing gloves.

2. Observation on 10/21/13 at approximately 3:45 PM showed Staff J, Licensed Practical Nurse, (LPN) left Patient #3's room and failed to perform hand hygiene.

3. During an interview on 10/21/13 at approximately 4:00 PM Staff J, stated that she was unaware she failed to perform hand hygiene after leaving Patient #3's room. Staff J stated that staff were to perform hand hygiene after leaving a patient's room.

4. Observation on 10/21/13 at 1:10 PM showed Staff AA, Certified Registered Nurse Anesthetist (CRNA) prepared to inject an Epidural (a space around the spinal cord) medication into Patient #12 and failed to perform hand hygiene before putting on sterile gloves. Staff AA completed the procedure and removed gloves and failed to perform hand hygiene.

5. During an interview on 10/21/13 at 1:35 PM Staff AA stated that the facility policy directed staff to perform hand hygiene before putting on and after removal of gloves.

6. During an interview on 10/23/13 at approximately 9:30 AM, Staff D, Infection Control Nurse, stated that anesthesia (drugs given to reduce sensitivity to pain prior to surgery) was not an area in which she currently conducted hand hygiene surveillance.

7. Observation and concurrent interview on 10/21/13 at 3:15 PM, showed Staff H, Registered Nurse (RN), drew up medications into two syringes, entered Patient #1's room, hanged an Intravenous (IV-a needle inserted into the vein to administer fluids and medication) solution bag and tubing, and administered two IV medications. Staff H failed to perform hand hygiene prior to entering or when leaving the patient's room. Staff H stated that he knew he had messed up.

8. Observation on 10/22/13 at 1:30 PM, showed Staff CCC, RN, failed to perform hand hygiene between glove changes while doing a wound dressing change on Patient #41.

9. Observation on 10/21/13 at 2:30 PM, showed Staff I, RN, prepared to start an IV line on Patient #4 and failed to perform hand hygiene before putting on gloves. She then used a cell phone and failed to perform hand hygiene and apply a new pair of gloves before she initiated the procedure.

10. During an interview on 10/21/13 at 2:40 PM, Staff I, RN, stated that she did not know why she didn't perform hand hygiene, she didn't think of it. She stated that staff were to perform hand hygiene when entering and leaving the room, and before and after glove placement. She also stated that she should have performed hand hygiene and put on new gloves before performing an invasive procedure.

11. Observation on 10/22/13 at 9:40 AM, showed Staff S, Lab technician, failed to perform hand hygiene before putting on gloves to draw blood on Patient #19. She completed the procedure and failed to perform hand hygiene after she removed the gloves.

12. During an interview on 10/22/13 at 9:50 AM, Staff S stated that she knew the policy was to use hand hygiene when entering and leaving a patient's room, and before and after using gloves to draw blood. She stated that she typically performed hand hygiene when she left the lab and when she returned to the lab. She stated that she was unaware of the number of inanimate objects she touched inbetween the lab and the patient, and the potential for cross contamination.

13. Record review of the facility's policy titled, "Room Safety Inspection Procedure," approved 01/13, showed facility staff direction to check mattresses for tears and report all tears to the charge nurse.

14. Record review of the facility e-mail showed an article titled, "Medical Bed Mattresses: FDA Safety Communication-damaged or Worn Covers Pose Risk of Contamination and Infection," sent on 04/19/13 to Staff B, Corporate Compliance Officer. On 04/22/13 this same article was sent by e-mail to Staff D, Infection Control Officer; Staff GG, Director Plant Operations and Grounds; Staff AAA, Vice President Risk Management and Hospital Services; and Staff BBB, Director of Materials Management.

15. Observation with concurrent interview on 10/23/13 at 9:25 AM of OR #1 showed a mattress on the OR table with four separate tears. Two of the tears were approximately one inch long by one inch wide. One of the tears was approximately two inches long by two inches wide. One of tears was approximately three inches long by one inch wide. Staff MM, Assistant Director of the OR confirmed these findings.

16. Observation with concurrent interview on 10/23/13 at 10:40 AM in the C-section OR showed a mattress on the OR table with multiple areas of adhesive residue that ranged in size from approximately pin point to one inch long by a half inch wide. The smaller mattress for the head of the OR table showed ten tears ranging from approximately pin point openings to one inch long by a fourth inch wide. Staff MM confirmed these findings. Tears and adhesive residue allow bacterial growth because it becomes a non-cleanable surface.

17. During an interview on 10/23/13 at 11:40 AM Staff D, Infection Control Nurse, stated that mattresses with open areas or adhesive needed to be replaced and facility staff should follow manufacture guidelines for facility cleaning agents.

18. Record review of the facility's policy titled, "Instruments: Care and Cleaning," dated 05/28/13, showed direction for facility staff to use hospital-approved warm enzyme (removes blood and body fluids) cleansing solution or detergent and to avoid harsh abrasives (cleansers that may may damage the steel or plating).

Record review of the facility's policy titled, "Steps for Cleaning and Processing of Instruments and Supplies," dated 05/28/13, showed facility staff direction that cleanliness is essential for proper sterilization.

19. During an interview on 10/21/13 at 2:15 PM Staff K, RN stated that to clean instruments in OB she used a basin and filled it approximately half full of water and added one squirt of cleaning agent. Staff K stated that she failed to measure the water or the cleaning agent.

20. Record review of the manufacturer's guidelines showed instructions to mix one ounce of cleaning agent to one gallon of water to clean the instruments.

21. During an interview on 10/23/13 at 11:00 AM Staff SS, LPN stated that she filled the sink approximately a third full of water and added three squirts of cleaning agent to clean endoscopes. Staff SS stated that she failed to measure the water or the cleaning agent.

22. Record review of the manufacturer's guidelines showed instructions to mix one ounce of cleaning agent to one gallon of water to clean the endoscopes in the GI lab.

23. During an interview on 10/23/13 at 12:08 PM Staff NN, Instrument Technician in the Central Sterile department, stated that to clean surgical instruments the instruments were placed by the OR staff into a basin of water with ten squirts of cleaning agent added. Staff NN stated that she was the one who added the water and cleaning agent to the basin and she failed to measure the water or the cleaning agent.

24. Record review of the manufacturer's guidelines showed instructions to mix one ounce of cleaning agent to one gallon of water to clean the surgical instruments.

25. During an interview on 10/23/13 at approximately 12:15 PM Staff NN, stated that she cleaned the autoclave (a strong pressured steam-heated vessel for sterilization of surgical equipment) with a solution of water and a cleaning agent. Staff NN stated that she failed to measure the water and the cleaning agent. Staff NN stated that she was unable to confirm the manufacturer's guidelines for the mixture of water to cleaning agent because she threw the bottle away after she cleaned the autoclave and had not yet obtained a new bottle.

26. During an interview on 10/23/13 at approximately 12:25 PM Staff MM, Assistant Director of the OR, stated that staff should follow manufacture guidelines when mixing cleaning agents.

27. Record review of the facility's policy titled,"Routine Equipment-Equipment Cleaning," dated 05/28/13, showed direction for staff to use unit specific equipment cleaning procedures.

28. Observation on 10/22/13 at 8:34 AM, showed a piece of equipment on wheels used to take vital signs, and oxygen saturation level (a measure of oxygen in blood) taken into Patient #9's room. The LPN handled this equipment prior to administering medications to Patient #9. The equipment was then taken out and left in the hallway for other staff to use (this could cause cross-contamination from one nurse/patient to another).

29. During an interview on 10/22/13 at 9:37 AM, Staff P, Housekeeper, stated that she did not know what the schedule for cleaning the vital sign equipment was.

30. During an interview on 10/22/13 at 9:38 AM, Staff I, RN Charge Nurse, stated that various nursing equipment, including the vital sign equipment, was cleaned daily by the tech. If there was no tech assigned, the nurse was responsible to clean the equipment. This cleaning was to be documented on the Thermometers & Vital Signs Daily Cleaning Log by the tech. The charge nurse was responsible for monitoring the Log for completeness.

31. Review of the Thermometers & Vital Signs Daily Cleaning Log for 2013 showed many blank dates, nine from October 1 through 21, 2013. Facility staff failed to clean equipment that was handled by nursing staff, and used on multiple patients daily.



12450

Based on interview and record review the facility failed to meet the needs of one current patient (#13) and three discharged patients (#14, #15, and
#16) because they failed to complete the recreational therapy assessment in a timely fashion, or failed to conduct recreational therapy visits per the patient's assessed need for four of four Swing Bed (a specialized unit that receives reimbursement based on skilled care required) patients reviewed. This had the potential to affect all Swing Bed patients admitted to the facility. The current Swing Bed census was one. The facility census was 22.

Findings included:

1. Record review of an undated facility policy (Structure Standards) titled, "Multidisciplinary Team Assessment," showed the activities (recreational therapy) assessment was to be completed within three working days of admission.

2. During an interview on 10/22/13 at 9:02 AM, Staff EE, Recreational Therapist, stated that she had 24-hours to conduct an assessment on a new patient, or if the patient was admitted over the weekend, the next business day. Staff EE stated that her normal work hours (Monday through Friday) varied with the census, but worked approximately 15-minutes per day, or one hour per week on the Swing Bed unit.

3. Record review of current Patient #13's nursing admission assessment, dated 10/16/13, showed that the patient was admitted, to the Swing Bed unit, on that date with a diagnosis of congestive heart failure (condition whereby the heart does not pump adequately).

Record review of Patient #13's recreational therapy assessment dated 10/18/13, showed the patient enjoyed dominoes, country music and solitaire (a card game). The patient also found choices, family, news and snacks very important to her routine. The assessment showed the need for 15-minute recreational therapy visits five times weekly.

Record review of recreational therapy visit documentation from admission through 10/23/13 (five working days) showed facility staff failed to engage the patient in recreational therapy for three of four days.

4. Record review of discharged Patient #14's History and Physical (H & P) dated 06/18/13, showed the patient was admitted to the Swing Bed unit on that date with problems of right leg pain, swelling and infection.

Record review of Patient #14's recreational therapy assessment dated 06/18/13 (Tuesday), showed the patient enjoyed reading, puzzles, television, walking outside, and UNO (a card game). The patient also found choices, family, and activities with groups very important to her routine. The assessment showed the need for 15-minute recreational therapy visits three to four times weekly.

Record review of recreational therapy visit documentation from admission through 06/22/13 (three working days) showed facility staff failed to engage the patient in recreational therapy for three of four days.

5. Record review of discharged Patient #15's H & P dated 07/02/13, showed the patient was admitted to the Swing Bed unit on that date with a diagnosis of pneumonia. The patient was moderately mentally retarded.

Record review of Patient #15's recreational therapy assessment dated 07/08/13, six days after admission, showed the patient enjoyed music, activities with groups, snacks and choices. The assessment showed the patient needed activities that were diversional; however, failed to show the patient's limitations related to cognitive functioning. The assessment showed the need for 15-minute recreational therapy visits three to five times weekly. The recreational therapist failed to do the assessment within the allotted timeframe resulting in only one day to involve the patient in therapy before discharge.

Record review of recreational visit documentation from admission through discharge on 07/09/13 showed no visits by the recreational therapist during this patient's stay.

6. Record review of discharged Patient #16's H & P dated 08/21/13, showed the patient was admitted to the Swing Bed unit on that date with a diagnosis of abdominal abscess (draining wound).

Record review of Patient #16's recreational therapy assessment dated 08/22/13/13 (Thursday), showed the patient enjoyed reading, choices, religious services, family, news, and outside activities. The patient also found puzzles, gardening, and the local paper very important to her routine. The assessment showed the need for 15-minute, in room, recreational therapy visits five times weekly.

Record review of recreational visit documentation from admission through discharge on 08/30/13, or eight days, showed no visits (should have been seven visits) by the recreational therapist during this patient's stay.