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Based on document review and interview, it was determined that for 2 of 3 inpatient behavioral health units/BHUs (Child and Adult) reviewed, the Hospital failed to ensure that care was provided in a safe setting, by ensuring the completion of environmental rounds and contraband checks twice daily (Day/Evening Shifts) for all clinical areas of the unit.

Findings include:

1. The Hospital's policy titled, "Environmental Rounds" (dated 2/18/2022), was reviewed on 10/4/2022 and required, "[Hospital] will conduct regular environmental tours of all areas of the organization... intended to minimize or eliminate environment of care risks... As part of an ongoing environment of care program, the Safety Officer shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety... hazardous conditions... An Environmental Tour Team will be utilized in conducting the tours and documentation of the inspections... The Team should consist of representatives from the following departments: ... Nursing (for clinical areas)..."

2. The Hospital's policy titled, "Contraband Clothing and Belonging Search" (dated 12/1999), was reviewed on 10/5/2022 and required, "...During Environmental Rounds, the Behavioral Health Technicians will check rooms for contraband..."

3. During a tour of the Child Behavioral Health Unit (consists of 2 wings North and South) on 10/4/2022, at approximately 10:45 AM, the "Environmental Rounds" binder was reviewed for 1/1/2022-10/4/2022 and included "Child Unit Patient Safety/Environmental Rounds" sheets for only the following 11 dates/shifts/wings: 4/17/2022 (Day AM/South only); 4/21/2022 (Day/South only); 5/3/2022 (Day/Both North and South); 5/25/2022 (Day/South only); 8/3/2022 (Day/South only); 8/9/2022 (Day/Both North & South); 8/10/2022 (Day/Both North & South); 8/23/2022 (Day/South only); 8/25/2022 (Day/Both North & South); 9/12/2022 (Day/South only); and 10/4/2022 (Day/South only). Some sheets lacked documentation of whether patient mattresses were lifted to check for contraband and whether common areas were assessed for damage. There were no rounds documented for the evening (PM) shifts. The log book contained round sheets from 2020 and 2021; however, lacked documentation of any environmental rounds completed for the remaining 266 days of the current year of 2022 (Missing all of January through March, June, and July).

4. The Adult BHU Environmental Rounding sheets from 9/1/2022-10/5/2022 were reviewed on 10/5/2022 and lacked documentation of whether patient mattresses were lifted to check for contraband and/or whether common areas were assessed for damage on the following dates/shifts: 9/5/2022 PM shift; 9/6/2022 PM shift; 9/7/2022 AM shift; 9/10/2022 PM shift; 9/25/2022 PM shift; 9/26/2022 PM shift; 9/30/2022 unknown shift; and 10/1/2022 PM shift.

5. Interviews were conducted during the tour on 10/4/2022 with the Child BHU Nursing Staff (including Registered Nurses E#8 and E#9, Behavioral Health Technician/BHT E#10, Program Specialist E#11, and Unit Secretary/BHT E#12). All staff stated that environmental rounds are completed twice a day, once on the day shift (7a-3p) and evening shift (3p-11p). Staff stated that rounds are conducted to check the patient rooms and common areas (i.e. hallways, dayrooms, group rooms, quiet rooms) for damage and contraband. Staff stated that they put the rounding sheets in the binder labeled "Environmental Rounds." Staff did not know where the rest of the rounding sheets from 2022 were located.

6. An interview was conducted with the Manager of the Adult BHU (E#14) on 10/5/2022, at approximately 10:30 AM. E#14 reviewed the rounding sheets and stated that staff were inconsistent with documentation of the rounds. Some staff were only documenting if contraband or damage was found; however, there was no indication that each room was checked and mattresses were lifted to check for contraband. E#14 stated that staff will be re-educated to ensure that they document that each room was checked for damage and contraband.

7. An interview was conducted with the Director of Nursing (E#2) on 10/4/2022, at approximately 1:10 PM, and again on 10/5/2022, at approximately 9:40 AM. E#2 stated they were not able to locate the missing sheets. E#2 stated that staff reported they are doing the rounds twice a day but may be placing them in the wrong place. E#2 stated that they are working on educating the staff to place the sheets in a universal location.

Based on document review and interview, it was determined that for 1 of 3 behavioral health units (Child BHU) reviewed, the Hospital failed to ensure that narcotic medication counts were supervised by two qualified nursing personnel during shift change, as required.

Findings include:

1. The Hospital's policy titled, "Medication Administration" (revised 2/2019), was reviewed on 10/4/2022 and required, "...A narcotics count is completed at the end of each shift..."

2. The Child BHU Controlled Substances Daily Records from 9/25/2022-10/4/2022 were reviewed on 10/4/2022 and indicated that counts were not conducted on the following dates/shift changes: 9/25/2022 7AM shift change; 9/26/2022 7AM shift change; on 9/27/2022 no counts were done; 9/29/2022 3PM shift change was missing counts for the emergency boxes/supplies; and 9/30/2022 7AM and 3PM shift changes. The records also lacked a co-signature of another nurse to verify the counts on the following dates/times: 9/26/2022 at 3:40 PM and 11:00 PM; 9/28/2022 at 11:00 PM; 9/29/2022 at 7:00 AM; 9/30/2022 at 11:00 PM; 10/2/2022 at 7:00 AM; 10/3/2022 at 11:00 PM; and 10/4/2022 at 7:00 AM.

3. An interview was conducted with Registered Nurses (E#8 and E#9) on 10/4/2022, at approximately 10:30 AM. Both E#8 and E#9 stated that counts are conducted at each shift change with two nurses present to verify the counts. E#8 stated that shift changes typically occur at 7AM, 3PM, and 11PM. Both E#8 and E#9 stated that two nurses must verify the count together and sign off on the count record. E#9 stated that the night nurse last night did the count at the shift change at 11:00 PM but left before E#9 could have her do the count with E#9 this morning. E#9 had mistakenly signed off the count at 11:00 PM instead of the count done this morning at 7:00 AM. E#9 stated that she did the count at 7:00 AM by herself this morning.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on October 4, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on October 4, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.