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Based on record review, observation and interview, the hospital failed to ensure patients' care in a safe setting as evidenced by failing to:

A. Lock the soiled utilityroom door containing potentially hazardous cleaning chemicals, two full sharps containers, one mop with a handle, two brooms with handles, and multiple plastic bags.

B. Lock the door to the restraint ante room and the cabinet in the ante room containing four sets of patient restraints and two sets of restraint keys.

C. Mitigate the ligature risk of flat surfaced wall mounted shelves located at the bedside measuring approximately 12 inches wide by 18 inches long and 36 inches off the floor.

Findings:

A. A review of the hospital's policy Environment of Care, Subject OSHA/Hazardous Chemical Communication Program revealed in part:

Beacon Behavioral Hospital ensures that the hazardous chemicals used by the hospital are stored securely, evaluated, and that information concerning their hazards is communicated to staff within appropriate departments.

Beacon Behavioral Hospital ensures that hazardous chemicals are stored in a safe manner to prevent injury to patients, visitors and staff.

Storage areas are kept locked and are inaccessible to patients, visitors and unauthorized staff.

A review of the Spartan Chemical Company Material Safety Data Sheets for the following chemicals revealed in part:

a. Clean on the Go NABC Concentrate:
Causes eye irritation: symptoms may include pain, redness, swelling and possible tissue damage.
Causes skin irritation: Symptoms may include pain, redness and swelling.
Breathing product mist may cause respiratory irritation: Symptoms may include coughing and difficulty breathing.

b. Clean on the Go Clean by Peroxy Corrosive
Causes irreversible eye damage: Symptoms may include pain, redness, swelling of the conjunctiva and tissue damage.
Harmful to skin: Causes kin irritation with symptoms of pain, redness and possible chemical burns. Harmful if absorbed through the skin.
Harmful if swallowed: Symptoms may include nausea, vomiting, pain and diarrhea.
Do not get in eyes, on skin or clothing. Do not taste or swallow. Avoid inhalation of spray mist. Wash thoroughly with soap and water after handling.

c. DMQ Damp Mop Neutral Disinfectant Cleaner
Eye contact: pain, redness, swelling of the conjunctiva and tissue damage. Eye contact may cause permanent damage.
Skin contact: pain, redness, and cracking of the skin.
Inhalation: nasal discomfort and coughing.
Ingestion: pain, nausea, vomiting and diarrhea.

On 10/1/18 at 10:26 AM with S1CEO an observation of the soiled utility room revealed the door was not locked and accessible to residents. The room contained multiple safety risk to include:
a. One mop with handle which could be used as a weapon;
b. Two brooms with handles which could be used as a weapon;
c. Biohazard material to include two full sharps containers;
d. Cleaning chemicals specifically: Clean on the Go NABC Concentrate, Clean on the Go by Peroxy, and DMQ Damp Mop Neutral Disinfectant Cleaner;
e. Multiple plastic bags.

On 10/1/18 at 11:00 AM the soiled utility room door was observed to be unlocked again with the same safety risk noted for all patients and staff.

In an interview on 10/1/18 at 11:00 A.M. S1CEO verified the door was unlocked again with the same safety risk on both occasions.

B. On 10/1/ 18 at 10:45 A.M. with S1CEO and observation of the restraint ante room revealed the door and the cabinet were unlocked. Further observation revealed the cabinet in the ante room containing four sets of patient restraints and two sets of restraint keys was unlocked and accessible to all patients.

In an interview on 10/1/18 at 10:45 A.M, S1CEO verified the door and the cabinet are to remained locked at all times and it was a safety risk.

C. On 10/1/ 18 at 10:45 A.M. with S1CEO and observation of 18 of 18 patient rooms revealed
a flat surfaced wall mounted shelves located at the bedside of 18 of 18 beds measuring approximately 12 inches by 18 inches and 36 inches off the floor, which creates a ligature risk.

In an interview on 10/1/18 at 11:50 A.M. S1CEO verified the bedside shelves creates a potential ligature risk.

Based on record review and interview, the hospital failed to accurately measure, track and take actions aimed at performance improvement through the QAPI program activities for Health Information Management by failing to accurately measure, track and take action to ensure the completion of delinquent records greater than 30 days.

Findings:

Review of the hospital's Performance Improvement Indicators for Medical Records for the month of September 2018 revealed the tracked indicator "All telephone orders are authenticated within 30 days with signature, date, and time within 10 days" percent complete "12%".

Review of the Medical Staff By-Laws revealed in part: 8. All clinical entries and summaries in the patient's medical record shall be accurately signed, dated, and timed. 16. An attending medical staff member will be considered delinquent in completion of his medical records if the records are not completed, written or dictated within the periods specified in these rules. An attending medical staff member will automatically be suspended in the form of withdrawal of his admitting privileges 5 days after he is given a warning of delinquency for failure to complete medical records. If the medical record is incomplete 5 days after the warning is given, a written notice shall be sent to the attending medical staff member, notifying him that his admitting or other privileges shall be suspended immediately and that he shall remain suspended until all of his delinquent records have been completed.

A review of the Committee of the Whole Meeting Minutes held 9/6/18 for July 2018 revealed "All telephone orders are authenticated within 30 days with signature, date, and time within 10 days" percent complete "0". Action: Review with S8MD and S7MD and all LIPs. Further review failed to reveal any action taken related to the timely completion of the medical records.

In an interview on 10/2/2018 at 3:00P.M. S3HIM verified she audits 100% of the patient records. She also verified she was not sure if any action was taken based on the findings beside speaking with the physicians.

In an interview on 10/3/18 at 8:40 A.M. S5VP Operations and S1CEO verified they was not effective process in place for identifying delinquent medical records. They also verified they were not following the By-Laws because no action had been taken on any physician or licensed practitioner as it relates to delinquent medical records.

Based on record review and interview the hospital failed to ensure the clinical record system was maintained in accordance with written policies and procedures as evidenced by failure to develop and implement a process for identification of incomplete medical records and their completion.
Findings:

Review of the hospital's policy titled Medical Records, revised 03/21/2018 revealed in part: Medical records must be completed within 30 days after the patient is discharged. "Timely documentation in the medical record". Beacon Behavioral hospital requires that prescriber's orders in the medical records are authenticated within 10 days of the order being issued, per state law.

Review of the Medical Staff ByLaws revealed in part: 8. All clinical entries and summaries in the patient's medical record shall be accurately signed, dated, and timed. 16. An attending medical staff member will be considered delinquent in completion of his medical records if the records are not completed, written or dictated within the periods specified in these rules. An attending medical staff member will automatically be suspended in the form of withdrawal of his admitting privileges 5 days after he is given a warning of delinquency for failure to complete medical records. If the medical record is incomplete 5 days after the warning is given, a written notice shall be sent to the attending medical staff member, notifying him that his admitting or other privileges shall be suspended immediately and that he shall remain suspended until all of his delinquent records have been completed.

Interview on 10/02/18 at 1:20 p.m. with S3HIM reported that there were no delinquent medical records past 30 days.

Further investigation revealed that S4Quality had QA indicators and was tracking 5 of 61 records for QA that were delinquent for timed and/or authenticated phone orders.

Interview on 10/02/18 at 4:20 p.m. with S3HIM and S4Quality now confirmed there were some delinquent records but the system was not able to give an accurate number and description of what was incomplete in the medical records and she was unable to populate any accurate list of how many and/or what was delinquent in the record. Further interview with S3HIM revealed the hospital had a contract with S6RHIT and that she was contracted to give oversight to the medical records department.

Interview on 10/03/18 at 8:40 a.m. with S5VP Operations reported that there was no process for determining if any record is delinquent. He reported that the hospital has only one indicator for medical records, and that is verbal/telephone orders that are not verified within 10 days. S5VP Operations further reported that there are a total of over 111 medical records that are incomplete for verbal/telephone orders not authenticated. He stated that S6RHIT was the contracted Director of HIM and a request to interview her was made at that time.

Review of the hospital's contract with S6RHIT confirmed that she was contracted as Medical Records Manager and was responsible for review of policies and procedures related to health information system. Provide training and orientation to health information personnel. Establish a process for systematically reviewing documentation on an ongoing basis for both quality and quantity of documentation.

Interview on 10/03/18 at 9:05 a.m. with S6RHIT confirmed that she was contracted for consultation of the medical records and was not Director. S6RHIT further stated that she usually comes to the hospital every 3 to 6 months to assist S3HIM to streamline the process for scanning of open charts. S6RHIT further stated that she was unaware of any delinquent medical records past 30 days for the hospital. She was unable to confirm if the hospital had a process for determining the number of delinquent records and/or what part of the record was delinquent.

Interview on 10/03/18 at 11:05 with S5VP Operations stated that he was unaware there was a system problem with the medical records until now.

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a radiologist. This deficient practice was evidenced by failure of the hospital to appoint a radiologist to supervise/direct the hospital's contracted radiological services. Findings:

Review of the hospital's contracted services revealed a contract with hospital (a) and an area mobile x-ray service.

Review of the Governing Board meeting minutes dated 03/21/2018, revealed no physician had been appointed as director of the hospital's contracted radiological services.

Interview on 10/02/18 at 10:40 a.m. with S1CEO confirmed that there had been no appointments by the Governing Body for Director of the hospital's radiological services.

Based on observations, record reviews, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by multiple observations of breeches in infection control practices not in compliance with hospital policies and acceptable standards of infection control practices.
Findings:

Observations 10/01/18 during a hospital tour from 10:25 a.m. to 11:00 a.m. revealed the following:
-In the soiled utility room a large round rubber container, full with used linens that stacked approximately 2 feet above the top rim, with the rubber lid sitting on top of the soiled linen. S2DON, present for the observation verified the linen should have been enclosed in a bag, and another bag used for the rest, to ensure the soiled linen was contained and not open and exposed.
-Observation of a Patient "Tub Room" revealed a large bathroom with a toilet on one side of the room, and a bathtub on the other side of the room. Also located in the bathroom were wheelchairs, walkers, and a Geri-chair sitting beside the bathtub. Further observation revealed a shelving unit near the bathtub. The shelving unit contained 2 shelves of disposable adult briefs, then on other shelves were sanitary pads, fall pads (pads placed on the floor beside a bed to prevent injury in the event), and wheelchair parts. S2DON, present during the observation, verified the findings and reported she was not aware the clean supplies could not be stored in the patient bathroom. S2DON reported the bathroom was available for patient use and was sometimes used by patients for a tub bath, if a physician's order was received that this was permitted. The DON reported that when a patient wanted to use the tub room, the mobile equipment would be moved out of the room while the patient used it, then move back to the bathroom. She reported the clean supplies stored on the shelving unit were not removed during the room's use by patients.
-in a room identified by S2DON as a room used by patients as a quiet room, or for visitation, 2 of 4 straight-backed armless chairs were observed to have tears in the synthetic covering on the seats. Further review revealed a chair with padded seat and arms, with a large tear in the material covering the seat, leaving a large area of foam padding exposed. S2DON, present for the observation verified the tears in the chair coverings, and acknowledged the chairs could not be cleaned and disinfected between use.
-on the enclosed outdoor patio, used by patients for leisure and/or smoking a straight-backed chair was observed to have approximately 1/2 of the synthetic seat covering missing, leaving 1/2 of the seat's foam padding exposed. S2DON confirmed the findings and that this chair could not be cleaned and disinfected, and had good potential to become contaminated from use or exposure to the outdoor elements.
-in the medication room, a individual package of chocolate pudding was observed in the medication refrigeration, with medications present. Further observation of the room revealed a box of instant Cappuccino Mix stored on one of the lower shelves. S2DON, present for the observation, verified the findings, and reported that no food was to be stored in the medication refrigerator, and no food was to be stored in the medication room. She reported there was a room right down the hall that was specifically for food storage.

In an interview 10/02/18 at 1:30 p.m. S2DON reported she had completed Infection Control training for her role as Infection Control Officer recently and provided the training materials from her training course. Review of the documents included a frame, titled "Other Responsibilities of the ICO-MISC." revealed in part, "Clean Utility Room must be sanitary, clean linen carts must be covered." Further review of the training documentation revealed "IC Priorities-Nursing Unit : Refrigerators * Refrigerators are used as specified (i.e. medication refrigerators only contain meds ..."

Based on record review and interview, the hospital failed to ensure Respiratory Care Services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis. This deficient practice was evidenced by failure of the hospital's Governing Body to appoint, credential and privilege a physician to serve as Medical Director of Respiratory Services.

Findings:

On 10/1/18 at 1:00 P.M. a review of the Respiratory Contract revealed S7MD was identified as the Medical Director. Review of the contract failed to reveal that S7MD was identified as the Director of Respiratory Services.

Review of the hospital's organizational chart, presented as current by S1CEO, revealed no documented evidence of a physician director of the hospital's Respiratory Services.

In an interview on 10/1/18 at 1:30 P.M. S1CEO confirmed respiratory services was provided via contracted services. S1CEO also reported S7MD was Medical Director of Respiratory Services.

Review of S7MD's credentialing file revealed no documented evidence that S7MD had been appointed by the Hospital's Governing Body to serve as the Medical Director of Respiratory Services. Further review revealed no documented evidence S7MD had been credentialed and privileged to serve as Medical Director of Respiratory Services.

In an interview on 10/1/18 at 3:00 P.M. S1CEO confirmed there was no documentation of appointment of S7MD, by the hospital's Governing Body, to serve as Medical Director of Respiratory Services.