HospitalInspections.org

Based on observation, document review, and interview, the facility did not ensure that patients were afforded their rights to privacy and respectful care. This finding was noted for Patient #s 1, 2 and 3.

Findings include:

On tour of inpatient, Unit 063 on 04/26/17 at 10:25 AM, it was observed that Patient #1 did not have curtains on the wall-to-wall window in her room.

During interview with Patient #1 on 04/26/17 at 10:40 AM, the patient complained of a lack of curtains on the window for the past year and reported that she has no privacy and is unable to sleep during the day.

During interview with Staff G, Chief Nursing Officer on 4/28/17 at 11:00 AM, the staff reported that as part of the corrective measures to an incident of 3/1/16, all curtains in the facility were replaced on 5/1/16 with a Velcro type material that easily breaks away if weight is applied.

Staff members A, Unit Psychiatrist; Staff B, Chief of Service and Staff G during interviews on 4/26/17 between 10:00 AM and 1:00 PM were unable to state why Patient #1, who is on 1:1 observation twenty-four hours a day, did not have a curtain in her room since hospital wide replacement of curtains were made in May 2016.


During the observation of medication administration on 4/25/17 between 11:00 AM and 12:15 PM, the following was observed:
it was noted that two patients received their finger-stick glucose checks and injections of insulin in the open hall, in view of other patients and staff.

At 11:19 AM, Staff D, Registered Nurse (RN) performed a finger-stick glucose check on Patient #2 in the open hallway, in view of the other patients and staff.
At 11:32 AM, Staff D also performed a finger-stick glucose check in the hallway on Patient #3.

At 12:00 PM, Staff E, Registered Nurse, administered an injection of insulin subcutaneously to Patient #2 in the hallway without a privacy screen. The patient lifted her upper clothing exposing her abdomen to receive the injection. At 12:11 PM, Staff E administered an injection of insulin to Patient #3 in his abdomen, while he was in the hallway, without a privacy screen.

Based on observation and interview the facility failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

The presence of ligature (looping) hazards pose a potential for patient harm.

Findings include:

During tours of inpatient units on 4/24, 4/25 and 4/26/2017 between 10:00 AM and 4:00 PM, numerous ligature (looping) hazards were found in buildings 2, 6 and 7, were psychiatric patients resides.

See Tag A701.

Based on observation and interview, the facility failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.
The presence of ligature hazards pose a potential for patient harm.

Findings include:

During tours of the building on 4/24, 4/25 and 4/26/2017 between 10:00 AM and 4:00 PM, numerous ligature (looping) hazards were found in buildings 2, 6 and 7, where psychiatric patients resides.

In Building 7, the bathroom adjacent to patient room 208 was equipped with a standard electric hand dryer. The square top of the dryer extended approximately 6 inches from the wall, and a there was an approximate quarter inch gap between the dryer and the wall. These features would allow a ligature to be looped around or behind the dryer.

In the same bathroom, the towel hook was observed to be of a type that has the potential to create a ligature point. Similar hooks were found throughout buildings 2, 6 and 7.

The handrails in the patient shower in the rest room adjacent to room 208 had gaps in the caulking that seals the handrail to the wall, leaving a looping point between the handrail and the wall.

Door knobs on all patient and patient bathroom doors throughout the facility were standard round, turn style knobs. These protrude from the door to create a ligature point.

Faucets on the sinks in patient rooms 404 and 428 were of the conventional two-handled type. The handles and faucets are looping points. Similar faucets were found in numerous patient bathrooms in buildings 2, 6 and 7.

In Building 2, patient room 226 was equipped with a disused fan coil unit that previously served the room's heating system. A metal panel on the front of the unit had an approximate half inch gap behind it, creating a ligature point.

In building 6, room 829 was equipped with a bed that had legs, rather than a solid non-loopable base.

In buildings 2, 6 and 7, many fire sprinkler heads were non-concealed. The facility did not provide manufacturer's specifications indicating the sprinkler heads would break away if a weight was suspended from them.

Water fountains in the corridors of buildings 2, 6 and 7 are of the standard type with standard spigots. Both the spigots and the shape of the fountains present a looping hazard. The vent grills under the water fountains have slots which can also be used to tie off a ligature.

The common seating areas in buildings 2, 6 and 7 are equipped with refrigerators that have standard door handles with a gap between the handle and the door that may be looped. Cabinets in these areas are also equipped with standard door handles as well as metal padlocks.

In corridors throughout buildings 2, 6 and 7, the tamper resistant covers on the thermostats were square metal boxes, protruding approximately 4 inches from the wall. These protrutions creates a ligature point.

In buildings 2, 6 and 7, exit doors leading out the patient units had grab style door handles with large gaps between the handle and the door.

Failure to eliminate ligature hazards from a facility housing psychiatric patients may result in injury to patients who wish to harm themselves

These findings were verified by Staff X (OMH Life Safety Manager), Staff Y (Deputy Director of Facilities) and Staff Z (Maintenance Supervisor) at the times of observation.

During tours of buildings 2, 6 and 7 on 4/23, 4/25 and 4/26/2017, between 10:00 AM and 4:00 PM, it was observed that all dining chairs in the buildings' dining areas were cafeteria style chairs, and were not secured to the floor or to the dining table.

Failure to remove items such as unsecured dining chairs, which can be used by patients to cause bodily harm, may result in injury to patients and staff.

These findings were verified by Staff X (OMH Life Safety Manager), Staff Y (Deputy Director of Facilities) and Staff Z (Maintenance Supervisor) at the time of observation.

Based on observation and interview, in 2 (two) of 2 (two) observations, nursing staff did not ensure that appropriate infection control measures were implemented during a glucose monitoring procedure (Patient #s 2 and 3).


Findings include:

During observation of blood glucose monitoring procedure on 4/25/17 at 11:18 AM, Staff D, a Registered Nurse, after performing finger-stick for Patient #2, placed the lancet (a pricking needle used to obtain drops of blood for testing) on the counter top before disposing the lancet in a sharps container. After the completion of finger stick for Patient #2, Staff D, wearing the same gloves, touched the disinfectant wipes and then proceeded to clean the glucometer with the wipes. Staff D then touched the surrounding area and articles on the medication cart, documented the patient's glucose result in the Medication Administration Record and then carried a binder and a bunch of keys back to the medication room before washing her hand.

Similarly, on 4/25/17 at 11:34 AM, Staff D, after completion of finger-stick for Patient #3, documented the glucose result in the Medication Administration Record and then touched several items before performing hand hygiene.

During interview with Staff F, Nurse Manager on 4/25/17 at 11:45 AM, staff acknowledged the findings.

Based on record review, interview, and policy review, the facility failed to provide psychosocial assessments that rendered conclusions and recommendations for the anticipated social worker's role in treatment for 16 of 16 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A 14, A15, and A16). This failure results in a lack of documented conclusions and recommendations for professional social work treatment services and has the potential for the treatment team not to have available the current baseline social functioning of the patient, to be used in establishing goals and interventions for the patient.

Findings include:

A. Record Reviews

1. The Core (Psychosocial) Evaluation dated 3/2/17 for Patient A1 recommended no social work treatment interventions.

2. The Core Evaluation dated 4/24/17 for Patient A2 recommended no social work treatment interventions.

3. The Core Evaluation dated 1/27/17 for Patient A3 recommended no social work treatment interventions.

4. The Core Evaluation dated 4/7/17 for Patient A4 recommended no social work treatment interventions.

5. The Core Evaluation dated 11/17/16 for Patient A5 recommended no social work treatment interventions.

6. The Core Evaluation dated 3/13/17 for Patient A6 recommended no social work treatment interventions.

7. The Core Evaluation dated 1/4/17 for Patient A7 recommended no social work treatment interventions.

8. The Core Evaluation dated 3/17/17 for Patient A8 recommended no social work treatment interventions.

9. The Core Evaluation dated 1/19/17 for Patient A9 recommended no social work treatment interventions.

10. The Core Evaluation dated 2/10/17 for Patient A10 recommended no social work treatment interventions.

11. The Core Evaluation dated 4/15/16 for Patient A11 recommended no social work treatment interventions.

12. The Core Evaluation dated 2/27/17 for Patient A12 recommended no social work treatment interventions.

13. The Core Evaluation dated 1/7/17 for Patient A13 recommended no social work treatment interventions.

14. The Core Evaluation dated 4/5/17 for Patient A14 recommended no social work interventions.

15. The Core Evaluation dated 4/3/17 for Patient A15 recommended no social work interventions.

16. The Core Evaluation 1/8/17 for Patient A16 recommended no social work interventions.

B. Interviews

1. In an interview on 4/24/17 at 2:40 pm, SW1 confirmed the Core Evaluation for patient A5 had no social work treatment interventions.

2. In an interview on 4/25/17 at 3:15 pm, the Acting Social Work Director stated that the Core Evaluation is the psychosocial evaluation. She also explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete the Core Evaluation. Therefore, only those Core Evaluations completed by a Social Worker include the social work interventions. The Social Work Director corroborated the surveyor's findings regarding the Core Evaluations for Patients A1, A2, A3, A4, A5 A6, A7, A8, A9, A10, A11, A12, A13, A14 , A15, A16 and the absence of social work treatment methodology recommendations.

C. Policy Review

1. The facility's "Policy and Procedure" titled, "Psychosocial Assessment (Core History, Core Evaluation I and II) dated 12/10" stated on page 1 under Core Evaluation, Part 1: "The patient strengths are then considered and the Recommendations for treatment modalities and the clinical rationale for these recommendations are made. Also included are the need for additional evaluations, the anticipated residential setting, a listing of support agencies and resources and anticipated aftercare services."

2.The facility's "Hospital Plan of Patient Care" dated 2017, stated on page 7, "IP [Inpatient] units have professional social work treatment services which provides conclusions and recommendations for use in the treatment plan that are specified and appropriate, social work treatment modalities, and documentation."

Based on record review, interview, and policy review, the facility failed to provide a Social Work Director (SWD) who monitored and evaluated the quality and appropriateness of social services. This resulted in:

A. Psychosocial assessments lacking conclusions and recommendations for the social worker's role in treatment.

1 The Core (Psychosocial) Evaluation dated 3/2/17 for Patient A1 recommended no social work treatment interventions.

2. The Core Evaluation dated 4/24/17 for Patient A2 recommended no social work treatment interventions.

3. The Core Evaluation dated 1/27/17 for Patient A3 recommended no social work treatment interventions.

4. The Core Evaluation dated 4/7/17 for Patient A4 recommended no social work treatment interventions.

5. The Core Evaluation dated 11/17/16 for Patient A5 recommended no social work treatment interventions.

6. The Core Evaluation dated 3/13/17 for Patient A6 recommended no social work treatment interventions.

7. The Core Evaluation dated 1/4/17 for Patient A7 recommended no social work treatment interventions.

8. The Core Evaluation dated 3/17/17 for Patient A8 recommended no social work treatment interventions.

9. The Core Evaluation dated 1/19/17 for Patient A9 recommended no social work treatment interventions.

10. The Core Evaluation dated 2/10/17 for Patient A10 recommended no social work treatment interventions.

11. The Core Evaluation dated 4/15/16 for Patient A11 recommended no social work treatment interventions.

12. The Core Evaluation dated 2/27/17 for Patient A12 recommended no social work treatment interventions.

13. The Core Evaluation dated 1/7/17 for Patient A13 recommended no social work treatment interventions.

14. The Core Evaluation dated 4/5/17 for Patient A14 recommended no social work interventions.

15. The Core Evaluation dated 4/3/17 for Patient A15 recommended no social work interventions.

16. The Core Evaluation 1/8/17 for Patient A16 recommended no social work interventions.

B. Interviews

1. In an interview on 4/24/17 at 2:40 pm, SW1 confirmed the Core Evaluation for patient A5 had no social work treatment interventions.

2. In an interview on 4/25/17 at 3:15 pm, the Acting Social Work Director stated that the Core Evaluation is the psychosocial evaluation. She also explained that the facility uses a primary therapist model in which a psychologist, social worker or nurse is assigned on a rotating basis to complete the Core Evaluation. Therefore, only those Core Evaluations completed by a Social Worker include the social work interventions. The Social Work Director corroborated the surveyor's findings regarding the Core Evaluations for Patients A1, A2, A3, A4, A5 A6, A7, A8 , A9, A10, A11, A12 , A13, A14 , A15, A16 and the absence of social work treatment methodology recommendations.

C. Policy Review

1. The facility's "Policy and Procedure" titled, "Psychosocial Assessment (Core History, Core Evaluation I and II) dated 12/10" stated on page 1 under Core Evaluation, Part 1: "The patient strengths are then considered and the Recommendations for treatment modalities and the clinical rationale for these recommendations are made. Also included are the need for additional evaluations, the anticipated residential setting, a listing of support agencies and resources and anticipated aftercare services."

2. The facility's "Hospital Plan of Patient Care" dated 2017, stated on page 7, "IP units have professional social work treatment services which provides conclusions and recommendations for use in the treatment plan that are specified and appropriate , social work treatment modalities, and documentation."

Based on record review and interview, the facility failed to ensure that qualified rehabilitation (rehab) staff assessed the therapeutic activity needs of 8 of 16 adult sample patients (A1, A2, A9, A10, A13, A14, A15 and A16). In addition, all 10 of the patients on the Child and Adolescent Unit failed to receive a rehab/activity therapy assessment. (A5 and A6 plus 8 adolescent patients added to the sample to evaluate the scope of failure: (N1, N2, N3, N4, N5, N6, N7 and N8). Rehab staff were only assigned to the patient centralized mall and not on the Patient Care Units and were only available to the adolescents for one Arts and Craft Group on Sunday. Failure to identify the therapeutic activity needs of patients and failure to provide individualized therapeutic activities and rehab services has the potential to result in patients' rehab needs not being met which could result in longer hospitalization.

Findings Include:

A. Record Review

1. Record review for patients A1, A2, A9, A10, A13, A14, A15 and A16 revealed that all the rehab/activity therapy assessments (Core Evaluation Part 2) were completed by social workers instead of being completed by a qualified rehabilitation staff member.

2. Record review for Child and Adolescent patients (A5, A6, N1, N2, N3, N4, N5, N6, N7 and N8) revealed that there were no rehab/activity therapy assessments completed for any of these patients.

3. Review of the Individual Program Schedule for the Child and Adolescent Unit revealed that the only therapeutic activity group scheduled by rehab staff was an Arts and Craft group scheduled on Sundays from 3:00-4:00 p.m.

B. Interviews

1. In interview on 4/24/17 at 3:10 p.m., the Chief of Services for Children and Youth stated that there are no rehab/activity assessments conducted for the patients on the unit because they are in school. The Chief further stated that only educational and psychological assessments are done.

2. In interview on 4/25/17 at 12:45 p.m., the Director of Rehab Services stated that the Rehab staff did not assess all the patients. The Director further stated that the patients on the Child and Adolescent Unit did not get a rehab/activity assessment because they went to school during the day.

3. In interview on 4/16/17 at 10:15 a.m., the Chief of Services for Children and Youth acknowledged that there were no rehab/activity staff assigned to the Child and Adolescent Unit and that there was only one group a week offered by the rehab staff.