HospitalInspections.org

Based on document review, observation and interview the facility failed to ensure compliance with 2001 AIA guidelines plan approval for 6 of 10 patients (P1, P2, P3, P6, P7 and P8).

Findings include;

1. 440 IAC 1.5-3-8 Physical plant; maintenance and environmental services Authority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4 Affected: IC 12-25 Sec. 8. (a) The private mental health institution shall be constructed, arranged, and maintained to ensure the safety of the consumer and to provide facilities for services authorized under the private mental health institution license as follows: (1) The plant operations and maintenance service, equipment maintenance, and environmental service shall meet the following requirements: (A) Be staffed to meet the scope of the services provided. (B) Be under the direction of a person or persons qualified by education, training, or experience. (2) The facility shall have a designated safety officer to assume responsibility for the safety program. (3) The facility shall have a physical plant and equipment that meet the statutory requirements and regulatory provisions of the rules of the fire prevention and building safety commission, including 675 IAC 22, Indiana fire codes, and 675 IAC 13, Indiana building codes. (b) The condition of the physical plant and the overall environment shall be developed and maintained in such a manner that the safety and well-being of consumers are assured as follows: (1) No condition in the facility or on the grounds shall be maintained that may be conducive to the harborage or breeding of: (A) insects; (B) rodents; or (C) other vermin. (2) No condition shall be created or maintained that may result in a hazard to: (A) consumers; (B) employees; or (C) the public. (3) The facility shall have a plan for emergency fuel and water supply. (4) Provision shall be made for the periodic inspection, preventive maintenance, and repair of the physical plant and equipment by qualified personnel as follows: (A) Operation, maintenance, and spare parts manuals shall be available, along with training or instruction of the appropriate personnel, in the maintenance and operation of the fixed and movable equipment. (B) Operational and maintenance control records shall be: (i) established; (ii) retained; (iii) analyzed periodically; and (iv) readily available on the premises. (C) Maintenance and repairs shall be carried out in accordance with applicable codes, rules, standards, and requirements of: (i) local jurisdictions; (ii) the fire prevention and building safety commission; and (iii) the Indiana state department of health. (5) The food service of the private mental health institution shall comply with the administrative rules of the Indiana state department of health contained in 410 IAC 7-24. (c) A facility shall comply with the following provisions regarding new construction, a renovation, or an addition to the facility: (1) The standards contained in the 2001 edition of the national "Guideline for Construction and Equipment of Private Mental Health Institution and Medical Facilities" (Guidelines) shall apply to all facilities covered by this rule, except as provided in subdivision (2). (2) Codes and rules adopted by the fire prevention and building safety commission that pertain to building requirements, fire safety, and access for individuals with disabilities shall: (A) apply to all facilities covered by this rule; and (B) take precedence over the requirements of the Guidelines on those topics.

2. The facility was plan approved utilizing the 2001 AIA guidelines which states under 11.2 General Psychiatric Nursing Unit: 11.2.A Patient Rooms: Each patient room shall meet the following standard: 11.2.A1. Maximum room capacity shall be two patients.

3. P1's medical record was reviewed and indicated the patient was 45 y/o (year/old) admitted to H1 from 4/22/24-4/26/24. The MR documentation indicated H1 was at capacity at the time of P1's admission and the patient was admitted to a cot 4/22/24 , room # 217, Bed C (added as 3rd patient to room).

4. P2's medical record was reviewed and indicated the patient was 37 y/o (year/old) admitted to H1 from 4/22/24-4/27/24. the MR documentation indicated H1 was at capacity at the time of P2's admission and the patient was admitted to a cot 4/22/24, room # 336, Bed C (added as 3rd patient to room).

5. P3's medical record was reviewed and indicated the patient was 30 y/o (year/old) admitted to H1 from 3/6/24-3/27/24. The MR documentation indicated H1 was at capacity at the time of P3's admission and the patient was admitted to a cot on 3/6/24, willows unit, no room number (added as 3rd patient to room).

6. P6's medical record was reviewed and indicated the patient was 27 y/o (year/old) admitted to H1 from 1/22/24-1/27/24. The MR documentation indicated H1 was at capacity at the time of P6's admission and the patient was admitted to a cot 1/22/24, room #217, Bed C (added as 3rd patient to room).

7. P7's medical record was reviewed and indicated the patient was 26 y/o (year/old) admitted to H1 from 1/21/24-1/28/24. The MR documentation indicated H1 was at capacity at the time of P7's admission and the patient was admitted to a cot 1/24/24, room #217, Bed C (added as 3rd patient to room).

8. P8's medical record was reviewed and indicated the patient was 32 y/o (year/old) admitted to H1 from 1/3/24-1/8/24. The MR documentation indicated H1 was at capacity at the time of P8's admission and the patient was admitted to a cot 1/3/24, room #213, Bed C (added as 3rd patient to room).

9. In an interview on 5/6/24 at approximately 2:30 pm with A1 (Quality Director) confirmed cots are for both over-flow admissions, bed blocks, and/or bed holds. Cots are not utilized for any other reasons. H1 does not currently have a policy stating three patients can be roomed together.

10. Facility tour on 5/6/24 at approximately 2:30 pm with A1 (Quality Director) this writer observed over-flow patient cots were blue plastic, canoe shaped cots/sleds, without wheels or legs, able to be placed on the floor and are able be donned with a thick foam mattress.

10. H1 facility unit blueprints indicated the patient sleeping area for each unit is 5016 square feet in total and can house up to forty-two patients. Rooms are designed with two patient beds.

Based on document review and interview, nursing staff failed to complete documentation of the Over-Capacity Emergency Admissions Checklist for 10 of 10 medical records reviewed. (P1, P2, P3, P4, P5, P6, P7, P8, P9, and P10)

Findings Include:

1. The facility policy titled, "Wait List & Over Capacity Admission Policy for IP, PHP, & IOP", PolicyStat ID 15562647, last revised 05/2024, indicated under Procedures: Those Assessed as Required Inpatient Services: When patients are assessed and the Psychiatric Medical Provider determines the patient requires inpatient admission to the Hospital and there is not an inpatient bed available, the Assessment Department will begin to locate alternative placement for the patient. However, if the alternative arrangements cannot be secured for the patient, the patient shall be admitted to the hospital utilizing the Over-Capacity Emergency Admissions Checklist. This process is as follows:
1. Documentation reflecting capacity status of the Hospital at time of decision.
2. Documentation reflecting efforts to accommodate patient with local option.
3. Documentation reflecting the On-Call Psychiatric Medical Provider recommends or agrees that the patient's condition warrants admission despite the limited capacity at the Hospital.
4. Documentation that the Director of Nursing or designee is notified to discuss census and acuity to determine need for additional staffing.
5. Documentation that the patient will be accommodated in a manner that will ensure safety, privacy, access to bathroom facilities and all other essentials including a comfortable, safe bed option.
6. Documentation reflecting that the AOC or designee has spoken with the patient/and or family to explain the situation and obtains their understanding and approval. This should include:
a. that the arrangement states that the patient will not occupy a patient room for the night,
b. the details of the patient's accommodation,
c. assurance that all patient safety and privacy rights will be in compliance throughout the accommodation time,
d. both patient and or guardian/family will have access to AOC/Patient Advocate for questions or concerns.
7. Documentation that the Hospital CEO or their designee has been notified and agrees to alternative accommodation.
Upon completion of all above steps, the patient may be admitted to the Facility. Recommended that status be reevaluated every shift in attempt to move patient to common accommodations as quickly and safely as possible.

2. Review of P1's medical record (MR) indicated he/she was admitted to H1 on 4/22/24, H1 was at capacity at the time of P1's admission, H1 staff attempted but were unable to place P1 at three other locations. P1's MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission.

3. Review of P2's MR indicated he/she was admitted to H1 on 4/22/24. H1 was at capacity at the time of P2's admission, P2 rejected H1's staff notification of finding other placement him/her. P2 requested to remain at H1. P2's MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission.

4. Review of P3's MR indicated he/she was admitted to H1 on 3/6/24, H1 was at capacity at the time of P3's admission. P3's MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission.

5. Review of P4's MR indicated he/she was admitted to H1 on 3/2/24. H1 was at capacity at the time of P4's admission. P4's MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission.

6. Review of P5's MR indicated he/she was admitted to H1 on 2/21/24. H1 was at capacity at the time of P5's admission. P5's MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission.

7. Review of P6's MR indicated he/she was admitted to H1 on 1/22/24. H1 was at capacity at the time of P6's admission. P6's MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission.

8. Review of P7's MR indicated he/she was admitted to H1 on 1/24/24. H1 was at capacity at the time of P7's admission. H1 staff attempted but were unable to place P7 at two other locations. P7's MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission.

9. Review of P8's MR indicated he/she was admitted to H1 on 1/16/24. H1 was at capacity at the time of P8's admission. H1 staff attempted but were unable to place P8 at two other locations. P8's MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission.

10. Review of P9's MR indicated he/she was admitted to H1 on 12/6/23. H1 was at capacity at the time of P9's admission. P9's MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission.

11. Review of P10's MR indicated he/she was admitted to H1 on 12/5/23. H1 was at capacity at the time of P10's admission. H1 staff attempted but were unable to place P10 at two other locations. P10 declined to be sent out for medical clearance required by another facility to facilitate alternative placement. P10's MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission.

12. In an interview on 5/6/24 at approximately 3:00 pm with staff member A2 (Chief Executive Officer) confirmed Over-Capacity Emergency Admission Checklists were not completed per facility policy and should have been.