HospitalInspections.org

Based on observation, interview, and record review, the facility did not meet the Condition of Participation (CoP) for Patient Rights as follows:

The facility failed to ensure that two patients (Patient 6 and 23) had the right to receive care in a safe setting. (Refer to A0144).

The facility failed to ensure that the use of a restraint for one Patient (Patient 5) was in accordance with the order of a physician who was responsible for the care of the patient as specified under ?482.12(c) and authorized to order restraints by the hospital policy in accordance with State law. (Refer to A0168)

Based on observation, interview and record review, the facility failed to ensure 2 patients (Patient 6 and 23) had the right to receive care in a safe setting.

Findings:

1. On April 6, 2010, a review of the face sheet disclosed Patient 6 was admitted to the facility on December 19, 2009 with diagnoses of bipolar disorder and post trauma stress disorder. The patient was discharged on January 12, 2010.

The psychiatric history and evaluation reviewed disclosed the patient stated that she would kill herself if she had to go back to her group home. According to the psychiatric history and evaluation, the patient required the structure of the hospital setting in order to ensure her safety.

The facility occurrence report, dated December 31, 2009 at 7 p.m., was reviewed, disclosed the patient was found in the bathroom cutting her left forearm by using a broken metal piece from a small paint brush, the patient had several fresh, bleeding cuts during the art group session.

A review of the RN (Registered Nurse) Reassessment dated January 1, 2010 disclosed the patient had multiple superficial cuts on both arms.

During an interview with Employee 3 on April 6, 2010 at 4:05 p.m., she stated the patient went into the bathroom and cut herself during the art group session. According to Employee 3, the facility staff failed to develop a contraband search policy for art group session participants to ensure patients receive care in a safe setting.

2. During an initial tour, on April 5, 2010, at 10:30 a.m., Patient 23 was asleep and completely covered from head to toe with a blanket. Employee 16 stated Patient 23 was on 1:1 status because he had stabbed a psychiatric evaluator team member. The staff member assigned to Patient 23 was observed sitting at a table, out of "arms length" from the patient.

During an interview with Employee 17, on April 6, 2010, at 1:15 p.m., she stated Patient 23 was placed on a 1:1 for "impulsive behavior " as the patient stabbed a person prior to being admitted. She further stated Employee 16 informed her that the mental health workers were not to sit at arms length. Employee 17 reviewed the clinical record and was unable to find documentation in the medical record for the mental health worker (MHW) not to sit at arms length. Employee 17 further stated 1:1 status meant staff were to be at arms length from the patient. Employee 17 further stated the MHW did not follow the policy and procedure.

During an interview with Employee 2, on April 6, 2010, at 4:30 p.m., she reviewed the clinical record and stated there was no indication written on the physician's orders why Patient 23 was on 1:1 status. She further stated she was unaware what the physician meant " renew 1:1 at the clock."

During an interview on April 7, 2010, at 9:30 a.m., Employee 19 initially stated Patient 1 had assaultive behavior and was "guarded."

A review of the face sheet disclosed Patient 23 was admitted to the facility on April 2, 2010 with diagnoses of major depression affective disorder.

A review of the admission orders dated April 2, 2010, at 4 a.m., indicated "special precautions with every 15 minutes observations. "
A physician's order dated April 2, 2010, at 9:50 a.m., indicated place patient on 1:1 if approved by parents.
A physician's order dated April 3, 2010,(not timed) indicated " renew Patient 23's 1:1 status when order on April 3, 2010 expires."
Two physician's order dated April 4, 2010, at 12 noon and on April 5, 2010 indicated renewal of 1:1 status "at the clock."

An admission psychological history and evaluation dated April 2, 8:10 p.m. was reviewed and indicated Patient 23's chief complaint was extremely delusional, paranoid, disorganized, and was arrested and charged with felony assault in the past 24 hours. Patient 23 had a history of chronic paranoid schizophrenia.

A review of a psychiatric history and physical dated April 2, 2010 indicated Patient 23 had a long standing history of paranoid schizophrenia with a conservators. Diagnoses included chronic paranoid schizophrenia. Patient 23's weakness where described as impulsivity and lack of insight.

A review of a psychosocial assessment dated April 5, 2010 indicated current risks factors where assaultive behavior and elopement/AWOL risk. Patient 23 had been very paranoid and had been isolated since admission.

A review of a psychology progress note dated April 2, 2010 indicated the physician had ordered "1:1 for extra support." Additional psychology notes, dated April 4, 5, and 6, 2010, indicated Patient 23 was disorganized, confused, paranoid, delusional, and continued to exhibit "disorganized thinking" and behavior secondary to schizophrenia. There was no documentation of the above physician notification for Patient 23.

A review of a facility's policy and procedure regarding Level of Observation/Special Precautions revised on October 2009 indicated procedure of 1:1 status meant staff will stay within approximately one arm's length of the patient on 1:1 observation. Furthermore, the staff will notify the physician for the continuation of the 1:1 observation or provide an order for a different level of observation.

Based on interview and record review, the facility failed to ensure the use of restraints for Patient 5 in accordance with the order of a physician who was responsible for the care of the patient as specified under ?482.12(c) and authorized to order restraint per the hospital policy in accordance with State law.

Findings:

On April 7, 2010, a review of the face sheet disclosed Patient 5 was admitted to the Mariah East unit of the facility on December 28, 2009 with diagnosis of bipolar disorder. The patient was discharged on January 5, 2010.

A review of the seclusion and restraint debriefing record, dated January 5, 2010, disclosed the facility staff had applied "Hand held restraint" on the patient from 3:45 p.m. to 3:50 p.m. on January 5, 2010. The "seclusion/restraint physician order and assessment" was reviewed and disclosed a telephone order was obtained on January 5, 2010 at 3:47 p.m. and countersigned by the physician on January 6, 2010 at 10 a.m.

An interview with Employee 2 on April 7, 2010 at 1:40 p.m., as well as a review of the facility's restraint policies, revealed there was no policy and procedure developed for "hand held restraint." According to Employee 3, facility staff were not allowed to use hand held restraints per facility policy.

Based on interview and record review, the facility failed to maintain accurate, complete individual medical records for Patients 4.

Findings:

On April 6, 2010, a review of the history and physical dated on September 16, 2010, under "History of present illness", disclosed Patient 4 had deafness for 3 years. However, further review of the history and physical, under"Cranial nerves", disclosed, "Cranial nerve VIII: hearing is normal.", which was contradicted to the patient's history of deafness.

During an interview with Physician 1 on April 8, 2010 at 8:58 a.m., he stated the history and physical for Patient 4, completed by Physician 2, was not accurate.

Based on interview and record review, the facility failed to ensure the medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission for Patient 13.

Findings:

A review of Patient 13's Admission Sheet disclosed the patient was admitted to the facility on October 7, 2009 at 7:15 p.m. with diagnosis of mood disorder.

However, a review of the clinical record disclosed the psychiatric history and evaluation was not completed by Physician 2 until October 9, 2009 at 00:24 a.m., which was 29 hours after the admission.

During an interview with Physician 1 on April 8, 2010 at 8:50 a.m., he stated the the psychiatric history and evaluation should be completed within 24 hours after admission.

Based on observation and interview, the facility did not meet the Condition of Participation (CoP) for Physical Environment as follows:


The facility failed to maintain the physical plant and the overall hospital environment in a manner such that the safety and well-being of patients was assured. (Refer to A 0701).

The facility failed to maintain the interior finish of rooms with a flame spread rating of Class A or Class B (Refer to K015).

The facility failed to ensure that one hour fire rated construction was provided to hazardous use areas (Refer to K029).

The facility failed to ensure that fire drills were held under varying conditions, at least quarterly, on each shift (Refer to K050).

The facility failed to acilitate the fire alarm system, by automatic detection, when one smoke detector failed to activate the fire alarm system (Refer to K051).

The facility failed to maintain the fire alarm system in accordance with NFPA 72 by obstructing a manual fire alarm box from view (Refer to K052).

The facility failed to ensure that all the fire sprinklers were maintained in optimal condition at all times (Refer to K062).

The facility failed to ensure that all smoking areas included the provision for metal containers with self-closing cover devices (Refer to K066).

The facility failed to ensure that window treatments complied with applicable flame resistance standards (Refer to K074).

The facility failed to ensure that fire extinguishers were properly secured and installed (Refer to K130).

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

Findings:

Mariah West

There were stain ceiling tiles located over the receptionist sliding glass door.

Mariah East

On 4/7/2010, at 10:25 a.m., the evaluator observed a hole in the ceiling located near patient room 427. The woman's restroom was dirty, the bathtub caulking was worn and cracked, the toilet base caulk was cracked and unclean, and the handwash sink faucet had an aerator.

Second Floor West

The Nurse Station air vent had an accumulation of lint, the icemaker water filter was not dated. Per interview with the Maintenance Supervisor the filter should have a date of installation/last changed.

The floor covering, located near room 252 was damaged and cracked. Patient room 257 had a two inch by five inch cracked over the electrical outlet.

Kitchen

On April 8, 2010, at 11:35 a.m., the evaluator observed that the ice maker filter was dated June 30, 2009. Per interview with the kitchen supervisor, he stated that the filter should be changed every six months.



16281


On April 5, 2010 at 9:55 a.m., during a tour of the kitchen, the evaluator observed the following food items stored, in the walk-in refrigerator 5 and reach in refrigerator 6, which were not dated:

One bin of chopped cauliflower
One opened jug of blue cheese dressing
One opened container of macaroni salad
One opened jug of buttermilk dressing
One opened container of sour cream
One bowl of chopped boiled eggs
One bowl of tuna salad
One bowl of cole slaw
One container of beets
One container of olives
One container of sliced onions

At 10:07 a.m., there were boxes of food stored on the floor in the walk in freezer. The food items included:

Five boxes of bread
One box of ribs
One box of ice cream

Between 10:07 a.m. and 10:25 a.m., there was an ice ball next to the fan and an accumulation of ice on the ceiling and on the floor of the walk in freezer.

Reach in chest freezer 3 did not have a thermometer. The chest was used to store vegetables.

There was an accumulation of leaves and debris under the storage rack located next to the walk in freezer.

There was an accumulation of food and debris at the space behind the grill line and the wall.

There was an accumulation of dust and grease on the hood behind the grill.

There was an accumulation of dried food on the slicing blade, knife hub, knife guard and carriage tray of a meat slicer stored in the pantry.

At 10:25 a.m., there were dented cans at the canned food racks in the pantry, including:

One 6 pound can of tomato sauce
One 6 pound can of apricots
One 6 pound can of sliced pineapple

Between 10:25 a.m. and 10:38 a.m., there was a puddle of water on the floor between reach in refrigerator 11 and a food preparation table. Closer observation revealed a leak at the kitchen ceiling.

At 10:38 a.m., raw shelled eggs were stored directly over an open bag of sun dried tomatoes in reach in refrigerator 11.

At 10:43 a.m., a food preparation sink's drain pipe was directly connected to the sewer drain pipe eliminating the indirect drainage of discharge liquid through an air gap into a floor sink or other approved type of receptor. During an interview, Employee 12 stated the sink was used to rinse lettuce. At 11:05 a.m., there was a colander of pasta in the sink.

Between 10:43 a.m. and 11:05 a.m., the drain line of the reach in display refrigerator was draining directly into a floor sink, eliminating the indirect drainage of discharge liquid through an air gap into the floor sink.

The kitchen flooring was dirty and worn through in different areas, including a 1 1/2 foot by 6 inch section of flooring missing in front of reach in refrigerator 10.

There was an oil covered spoon, a knife with pieces of lettuce on it and a dirty electrical fuse puller stored among clean knives in a utensil storage drawer. The fuse puller was not designed or constructed as a kitchen utensil, and was not smooth and easily cleanable. During an interview, Employee 12 stated the fuse puller was used to remove the lids off of buckets in the kitchen.

There was a broken light shield at the wall mounted fluorescent lamp by the dishwasher.

There was a wiping towel and a knife in a container of sanitizer solution on a food preparation table. Closer observation revealed the solution was turbid and had pieces of food in it. Employee 12 tested the concentration of sanitizer in the solution by dipping a sanitizer test strips into the solution and comparing the strip to the color chart on the container of the test strips. The test strip indicated the concentration was 50 ppm. During an interview, Employee 12 stated the solution should have had a sanitizer concentration of 200 ppm.

At 11:08 a.m., the surfaces of three range hoods and one double deck oven were spray painted. The surfaces were not smooth and easily cleanable. The spray painted surfaces were also not resistant to conditions that could adulterate food such as chipping, peeling, crazing, scratching and scoring. Closer observation revealed the paint was scratched, peeling and flaking. During an interview, one of the kitchen staff members stated he had spray painted the surfaces many years ago.

There was slime accumulated in the nozzle of the ice tea dispenser.

At 11:33 a.m. there was slime built up at the surface area next to the nozzles of the juice dispenser.

There was a garbage bin outside the kitchen that was not covered.

MARIAH WEST

On April 5, 2010 at 1:34 p.m., during a tour of Mariah West, an acute psychiatric unit, the evaluator observed three loose toilets. The toilets were located in the bathroom across from room 404, the bathroom between rooms 405 and 407, and the bathroom of room 408. The toilet between rooms 405 and 407 had a loosened nut at one of the anchor bolts.

Between 1:34 p.m. and 2:25 p.m., there were screws protruding from inside corner brackets used to secure furniture to the floor. Two of the screws were at the brackets securing a night stand in room 408. Another screw was at a bracket securing a bed in room 404.

Two toilet stall metal supports had sections cut away from the top of the stalls. The cut supports were loose and had sharp edges. On April 8, 2010 at 10:53 a.m., during an interview, Employee 1 stated he did not know why the sections of the supports had been cut away.

There were standard type bathroom sink faucet fixtures to which a noose would not slip off with the weight of a person. On April 8, 2010 at 10:53 a.m., during an interview, Employee 1 stated there were "safer faucet fixtures" and that he would "push to have the faucets changed out."

There was a cover loosely fastened to an electrical conduit body by use of electrical tape that was unraveling. Closer observation revealed the fasteners were missing and the cover was separated from the conduit body, exposing the electrical wires within. The conduit body was located at the Mariah West activity yard next to the perimeter fence. During an interview, Employee 10 stated the conduit body was part of the electrical conduit that went from the emergency power source (EPS) generator to the Mariah West structure.

There was a piece of coving separated from the wall at the base of the shower entrance in room 408.

There was mold on the shower room ceiling of room 408.

There was a loose shower door in room 408. Closer observation revealed there was a missing fastener at the base of the door.

There was an accumulation of dust and trash at narrow areas between furnishing in rooms 405 and 408. On April 8, 2010 at 10:25 a.m., during an interview, Employee 11 stated housekeeping was suppose to clean and remove the trash daily from the narrow areas between furnishing.

At 2:25 p.m., there was an approximately 1 1/2 foot diameter culvert at the Mariah West secured activity yard. There was no barrier to prevent entry into the culvert. The culvert was 368 feet long and ran underground below Mariah West and its perimeter fence, campus roads and grounds. The other opening of the culvert was located at a storm water drainage dry creek bed. The end of the culvert at the creek bed had a rebar barrier at the opening. During an interview, Employee 1 stated that a patient could fit through the pipe and there should be a grate at the culvert because the drain goes out to the creek located by the Briar structure.


MARIAH EAST

On April 5, 2010 between 2:25 p.m. and 2:44 p.m., during a tour of Mariah East, an acute psychiatric unit, the evaluator observed a linen cover was torn so that it no longer covered the clean linen stored in the clean linen room.

There were standard type bathroom sink faucet fixtures to which a noose would not slip off with the weight of a person. On April 8, 2010 at 10:53 a.m., during an interview, Employee 1 stated there were "safer" faucet fixtures and that he would "push to have the faucets changed out."

At 2:44 p.m., there was a splintered door jamb at the door frame assembly of room 422.

There was worn flooring at the doorway of room 422.

There was an accumulation of dust and trash in the narrow area between the furnishing and a wall in rooms 422. On April 8, 2010 at 10:25 a.m., during an interview, Employee 11 stated housekeeping is suppose to clean and remove the trash daily from the narrow areas between furnishing and walls.

Between 2:44 p.m. and 3:28 p.m., there was bulging and loose flooring in the bathroom between rooms 424 and 425.

There was an open lawn sprinkler system control box exposing wiring inside. Closer observation revealed the hinges of the box were bent and rusted impeding the lid from closing to secure the wires inside. The control box was located at the Mariah East activity yard next to the perimeter fence.


LAS ENCINAS SCHOOL

On April 5, 2010 between 2:44 p.m. and 3:28 p.m., during a tour of Las Encinas School, an on campus school attended by Mariah East patients, the evaluator observed an exposed sink drain pipe to which a noose would not slip off with the weight of a person. The drain pipe was located in the student bathroom.

There was a standard type sink faucet fixture in the student bathroom to which a noose would not slip off with the weight of a person.

There were accessible electrical receptacles in the student bathroom.

There was a broken electrical receptacle next to a desk in the classroom.

On April 8, 2010 at 9:10 a.m., during an interview, ST 1 stated the students use the student bathroom located in the school. He also stated that if the student is on a one to one observation the bathroom door was left ajar, otherwise the door was closed when the student was in the bathroom.

At 10:53 a.m., during an interview, Employee 1 stated he was not aware there was an accessible drain pipe and electrical receptacles in the school bathroom and that because the majority of the patients who attend the school are on "holds," he would have expected there to be no electrical receptacles and a barrier to the drain pipe in the school bathroom. He also stated there were "safer faucet fixtures" and that he would "push to have the faucets changed out."

CHEROKEE

On April 5, 2010 at 3:28 p.m., during a tour of Cherokee, an acute psychiatric unit, the evaluator observed there were standard type bathroom sink faucet fixtures to which a noose would not slip off with the weight of a person. On April 8, 2010 at 10:53 a.m., during an interview, Employee 1 stated there were "safer faucet fixtures" and that he would "push to have the faucets changed out."

MAIN BUILDING - Basement

On April 6, 2010, between 1:42 p.m. and 3:11 p.m., during a tour of the main building, the evaluator observed live adult American cockroaches in the basement water heater room. Further observation revealed food left uncovered in the basement employee room.

There was a wall clock and lamp connected to the electrical service by use of spliced wire and a wire connector at the pharmacy.

Based on observations, interviews, and review of records, the facility did not meet the Condition of Participation (CoP) for Infection Control as follows:

The facility failed to ensure communal containers used for dispensing liquids to patients were clean and sanitary. (See "Findings" below)

The facility failed to develop and implement policies to ensure early identification of, and treatment for, infectious diseases in two patients (Patients 26 and 27) who may require isolation, or other special considerations for the safety and protection of all patients and personnel. The facility failed to design and implement a plan for the management of an uncooperative patient (26) who refused to permit the facility to obtain microbiological cultures needed for a laboratory test; and failed to establish a definitive plan for the evaluation, and subsequent management, of a patient (27) who reportedly had an epidemiologically-significant contagious disease. (Refer to A0748)

The facility failed to identify, investigate and monitor for possible communicable diseases in one patient (Patient 25) to ensure other patients and personnel remained safe from potential contamination. (Refer to A0749)

Based on observations, interviews, and review of records, the facility failed to ensure communal water pitchers remained clean and sanitary prior to dispensing water to patients.

Findings:

On 4/7/10, during the medication observation at 11:55 a.m., in the adult locked unit, a plastic water pitcher was observed sitting on a counter where medications were prepared in the medication room.

Employee 11 explained that the pitcher was used to carry water to the patients when they dispensed medications, "We take the medications to them, so we have water on hand if they need it."

A few minutes later, close examination revealed the lid of the water pitcher was covered with dust, and the spout of the pitcher appeared to have a layer of dusty calcium deposits. When the lid was lifted, a mold-like substance was noted inside the container walls, in the connecting grooves of the sides and bottom of the pitcher, as well in the lid itself.

At 12:05 p.m., Employee 11 inspected the pitcher and declared, "That looks like mold to me. That shouldn't be like that."

Employee 14 stated during an interview on 4/9/10, "Those water pitchers can't be cleaned properly. A new one should be brought out every day."

A review of facility-provided documents failed to produce a policy that addressed the handling of communal water pitchers.

Based on observation, interviews, and review of records, the facility failed to develop and implement procedures for the management of uncooperative patients who refused to permit the facility to obtain microbiological cultures needed to ensure early identification of, and treatment for, infectious diseases in patients who may require isolation, or other special considerations for the safety and protection of patients and personnel (Patient 26). The facility failed to implement infection control policies and procedures for the early identification of infectious diseases in patients who were admitted with possible infections or communicable diseases who also may require isolation, or other special considerations for the safety and protection of patients and personnel (Patient 27).

Findings:

1. To prevent the spread of infection to others within a healthcare facility, the Centers for Disease Control (CDC) recommends, in part, the following for patients infected with clostridium difficile toxin (c.diff): "Place patients with suspected or confirmed c.diff in private rooms. Implement an environmental cleaning and disinfection strategy. Dedicate equipment for use only by the infected (or suspected infected) patient whenever possible. Establish appropriate cleaning and disinfection (using an EPA-registered agent) of environmental items likely to be contaminated with organisms from feces and surfaces that are touched frequently." (CDC website, 2010)

Patient 26 was admitted for being severely depressed and unable to care for himself. The patient was given a physical check up and cleared for admission on 3/7/10.

On 3/15/10, a physician's progress note addressed an episode of diarrhea the patient experienced during the night. On that same day, the physician ordered laboratory tests of the patient's stool for occult blood (hidden to the naked eye), ova parasite, and clostridium difficile toxin.

Various nursing staff members who were familiar with Patient 26 disclosed during interviews they were not aware the physician wanted tests for the listed conditions and organisms. Although each acknowledged that the patient had diarrhea, none of the staff were cognizant to the possibility that Patient 26 could have c.diff., a disease marked by intractable diarrhea, and a high potential for spreading to others.

When no evidence that the tests were done could be found in Patient 26's record, a search through the facility's laboratory log book produced a pre-printed lab form. Although the patient's information was on the form, there was no indication which test(s) were intended; none of the tests on the list were checked off on the form, indicating it was ordered. On the bottom of the form was a list of dates from 3/15/10 through 4/8/10 with the notation "refused" written after each date.

On 4/8/10, at 3:30 p.m., Employee 2 divulged Patient 26 "always refused." She added, "That's why there is no record of the tests in the chart."

A random review of Nursing Daily Assessment forms, dated between 3/15/10 and 4/4/10, revealed documentation that Patient 26 was mostly consistent in "following staff direction."

Employee 2 declared on 4/9/10, at 1:15 p.m., even if Patient 26 did have c.diff, patients were "mostly self-care," and staff members seldom had to provide care that would put them in "such close contact" with them.

A physician's progress note, dated 3/19/10, contained the assessment, "...functionally impaired...patient requires assistance with ADLs (activities of daily living), grooming, and hygiene." Patient 26 remained impaired on 4/6/10, and, according to another physician's note: "...confused and somewhat disorganized...requires prompting as well as staff assistance for ADLs."

Although documentation reflected Patient 26's continued "refusal" to allow staff to obtain the specimens the doctor ordered on 3/15/10, there was no nursing note to indicate the physician had been notified of the patient's repeated refusals through 4/8/10.

During an interview on 4/8/10, at 2:10 p.m., Employee 15 disclosed, "I don't even know why he (the doctor) wrote the order [for the tests]. He did not converse with nursing. And he did not ask for results. He usually would write a follow-up order, "Please get lab test done," or, "Please get results." However, he was "certain" nursing conveyed the issues to the doctor at least verbally. He could not explain the lack of documentation of a doctor's response, if a nurse had reported their inability to obtain samples for testing since 3/15/10 due to Patient 26's failure to cooperate with staff.
On 4/8/10, at 3:30 p.m., a laboratory report (with specimen collection date of 4/4/10), was received from the testing company. Labeled "Stool Final Report," it reported the results of the tests for white blood cells (WBC) and ova and parasites in stool were both negative.
The form also contained a notation, "Request Problem," and continued, "No specimen received, please resubmit." The form identified the test not completed due to lack of specimen was "C. difficile Toxins A+B, EIA."
There was no documentation that explained why the test for occult blood had not been done, as was ordered.
The policy and procedure entitled, "Infection Control" (policy IV-1), stipulated, "Any patient suspected...of having any communicable, contagious or infectious disease shall be placed in the appropriate type of precautions established by facility policies and procedures."
Infection Control policy number III-2 categorized standard precautions into two tiers, one of which was designated for patients "suspected to be infected with a highly transmissible or epidemiologically important pathogen." This tier, identified as "Transmission-Based Precautions," included "contact precautions," for protection from microorganisms that could be transmitted by direct contact, or contact with surfaces contaminated with the suspected or identified organism.
This policy further stipulated that even a "suspicion of... an important pathogen," could warrant appropriate precautions, "until a diagnosis could be confirmed or ruled out."
Moreover, the policy specifically stipulated that patients who had "diarrheal illness and were incontinent of stool, or had poor personal hygiene habits" were to be placed in a private room.
No determination had been made in the care plan about Patient 26's potential infectious disease, the unfinished tests, or the course of action they would take in the interim while waiting to ascertain the presence or absence of c.diff. in Patient 26.
2. Patient 27 voluntarily came into the facility from assigned housing quarters with reports of wanting to harm herself.
The Initial Nursing Assessment form, reviewed 4/9/10 in the clinical record, identified a wound on the right side of Patient 27's face, with a notation, "bacterial infection." There was no further mention of the wound by nursing, and the presence or absence of a dressing was not noted.
A History and Physical (H&P) summarized the presence of "erythematous brownish discolored area...with a lump on the right lateral orbit, questionable cellulitis, cannot rule out secondary to methicillin-resistant staphylococcus aureus (MRSA)infection...". The source of the injury or rationale for suspecting (MRSA) was not discussed in the record.
The H&P was followed by an order for an antibiotic, which contained the notation, "Dx (diagnosis) MRSA inactive right side of face."
Further review of the clinical record failed to yield information regarding the "inactive MRSA" diagnosis. Staff members who were interviewed could not provide evidence that the status of the MRSA was inactive, either confirmed by laboratory test results, or written test results from another facility.
Employee 12 did not know why Patient 27 was taking antibiotics, and had not been aware the patient may have had MRSA, inactive or otherwise.
Laboratory test results, produced 4/7/10, reported on a drug screen for Patient 27, a standard test for all new admissions. Under "Request Problem" was a notation that reported, "no specimen received, please resubmit." It listed the missing tests, including a complete blood count (CBC), which can provide a first-line indication of the presence of an infection.
No one followed up on Patient 27's reported "inactive MRSA"; no communication was documented; and no plan of care addressed the infection.
Infection control policies and procedures indicated that, at a minimum, the infection control officer (ICP) be notified and any recommendations made by the ICP must be implemented "until further evaluation."

Based on interview and review of records, the facility failed to assess, identify, and investigate for possible epidemiologically-significant disease in one patient (Patient 25), in order to take appropriate action to ensure other patients and personnel remained safe from potential contamination.


Findings:

During review of an open clinical record on 4/9/10, it was discovered Patient 25, a diabetic who was admitted for self-injurious behavior, came in with a lacerated wrist.

Nursing documented their assessment of the wound on the day the patient was admitted. The following afternoon, a physician's medical History and Physical identified the plan to place Patient 25 on an oral antibiotic, and to apply an antibiotic ointment to the left wrist wound.

Patient 25's medication administration record (MAR) contained documentation of the antibiotics ordered on 4/6/10. "Infected wound 'L' (left) wrist" was written in a section designated for notating the rationale for the physician's order.

Laboratory results of blood tests ordered on admission were reported on 4/7/10. Some of the tests produced findings that might indicate the presence of infection. There were no further tests, or any response to those test results.

Further review of Patient 25's clinical record failed to yield evidence of communication regarding the laboratory test results, or show any follow up on the patient's purported infection.