HospitalInspections.org

Based on a tour of the inpatient psychiatric units on 11/12/13, and a review of hospital documentation on 11/13/13 it was identified that the facility was not maintained in such a manner as to promote the safety and well-being of patients. The findings include:

a. The facility bathrooms and sleeping rooms had faucet controls, sprinkler heads, door handles, shower curtain mounting brackets and door hinges that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.

b. The Adult Unit had a wall locker in the corridor and in the lounge B area were patients could be unsupervised and both were equipped with hasp lock sets that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.
c. The Adult Unit lounge B had window latch that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.

Based on review of staffing, hospital policies and procedures, and interviews for all patient units, the hospital failed to ensure that a Registered Nurse (RN), was present on each unit during morning report (7:00 AM through 7:30 AM). The findings include:

Interview with the Director of Nursing on 11/13/13 at 8:30 AM identified that all 11:00 PM to 7:00 AM Registered Nurses (RN) attended the morning report from 7:00 AM to 7:30 AM along with the RN's and Mental Health Workers (MHW) assigned to the 7:00 AM to 3:00 PM Shift. The MHWs from the 11:00 PM to 7:00 AM shift remained on the patient units during morning report. Additionally, daily team meetings for the Child/Adolescent Units took place off the unit.

Observation of the Child/Adolescent meeting area with Unit Manager #1 on 11/14/13 at 10:45 AM identified that the meetings were conducted in the patient dining room next to the cafeteria which required entering and exiting 3 locked doors to move between the unit and the dining room and lacked visual access to the units.

Review of the hospital Standard of Practice for Assessment included, in part, that the patient will be assessed by the RN and re-assessed continuously throughout the hospitalization.

The Condition of Participation for Physical Environment has not been met.

Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the hospital failed to ensure that the physical environment was maintained in such a manner as to promote the safety and well-being of patients.
Multiple ligature points were identified throughout the facility that included faucet controls, sprinkler heads, door handles, shower curtain mounting brackets, door hinges, wall lockers with hasp locks, and a window latch in lounge B. The hospital failed to mitigate and/or eliminate hazards identified by the hospital's environmental risk assessment conducted in September of 2013. Patients were not afforded a safe area behind a closed door to protect them from the effects of fire, patients had no ability to self-evacuate in the event that staff members were overcome by a fire, and failed to meet life safety codes to include: lack of smoke barriers, lack of stairway treads and solid landing surfaces, lack of doors with self-closing mechanisims, lack of battery backup emergency lights, lack of smoke and fire detector testing, multiple non-sprinkled areas, and lack of annual staff training on emergency plans and procedures. The cumulative life safety failures resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.



Please refer to A 701, A 709, A 714, K25, K34, K38, K46, K50, K52, K54, K62, K67, K130, and K154.

Based on a tour of the inpatient psychiatric units on 11/12/13, and a review of hospital documentation on 11/13/13 it was identified that the facility was not maintained in such a manner as to promote the safety and well-being of patients. The findings include:

a. The facility bathrooms and sleeping rooms had faucet controls, sprinkler heads, door handles, shower curtain mounting brackets and door hinges that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.

b. The Adult Unit had a wall locker in the corridor and in the lounge B area were patients could be unsupervised and both were equipped with hasp lock sets that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.
c. The Adult Unit lounge B had window latch that could be utilized as a ligature point and were not designed to a psychiatric/ institutional standard.


d. The Joshua Center activity room floor lacked a floor finish and was debris laden.
e. The facility failed to conduct a comprehensive environment of care risk based assessment of all patient care and sleeping areas. A risk assessment was conducted by the facility in September of 2013. The plan failed to identify any short term and or long term goals to mitigate and/or eliminate hazards. The documentation produced for review was an excel spread sheet with 32 items and only 4 corrected.

f. During tour of the Child/Adolescent Behavioral Health Unit with Unit Manager #1 on 11/12/13 at 9:30 AM and tour with Unit Manager #1 and the Director of Plant Operations on 11/14/13 at 10:45 AM identified one of two Seclusion Rooms were observed to have dust and debris in the corner of the room as well as multiple marks on the walls and ceiling. The Plant Operations Manager identified that the rooms were to be mopped daily and the walls to be cleaned as needed per staff request.

g. Please reference the following Life Safety Code findings: K25, K34, K38, K46, K50, K52, K54, K62, K67, K130, and K154.




27691

Based on a tour of the inpatient psychiatric units on 11/12/13, and a review of hospital documentation on 11/13/13, the hospital failed to ensure that the life safety from fire requirements are met as required i.e.
Please reference the following Life Safety Code K Tags on the 2567- K25, 34, 38, 46, 50, 52, 54, 62, 67, 130, and 154

Based on review of hospital documentation, review of policies, and staff interview, the hospital failed to have an effective policy to meet the needs of the patients and to protect them in the event of a fire.

On 11/13/13 during documentation review with the Director of Dietary and Support Services Regulation and subsequent interview it was identified that in the facility fire plan and during facility fire drills, patient were gathered in the hallway adjacent to a door way the farthest distance from the location of the fire emergency and prepared to be horizontally evacuated. The patients were not afforded a safe area behind a closed door to protect them from the effects of a fire and in the event of a staff member being overcome by a fire, the patients would have no ability to self-evacuate as this is a locked unit psychiatric hospital.

Based on interviews and review of hospital policy and procedure, the hospital failed to work cooperatively with the Organ Procurement Program (OPO) and/or provide education to the staff on donation issues in accordance with hospital policy. The findings include:

Review of a Memorandum of Agreement for Tissue Procurement between the Hospital and the OPO dated December 28, 1999 directed that the hospital would provide the following services: a. Notify the next of kin of the patient's prognosis/death. b. Identify and inform the OPO of all potential tissue donors. c. Establish, implement, maintain and have available policies and procedures for tissue donation. d. Complete all necessary death forms including time of death. e. Complete all necessary documentation prior to tissue procurement. f. Assist in obtaining release of the donor's body from the Medical Examiner if necessary.

Interview with the Director of Admissions and Care Management on 11/13/13 at 3:15 PM identified that an informational booklet was not available, however, if asked, he/she would access the policy and procedure and obtain an informational booklet on-line. Interview with the DNS on 11/13/13 at 3:30 PM identified that, as far as he/she was aware, informational booklets were not available and the OPO telephone number was not accessible. Interview with RN #4 on 11/14/13 at 11:15 AM identified that he/she was unaware of a special procedure to follow if a patient expired.


Review of of a hospital policy entitled Organ and Tissue Donation identified, in part, that the purpose of the policy was to identify the procedure whereby clients who have expired at the hospital may be a candidate for organ or tissue donation. The procedure included that the OPO would be notified within an hour of death and, if a client of the hospital requested information regarding anatomical gifts, they would be given a copy of a booklet provided by the OPO and informed that a OPO representative would be available to discuss issues upon request.