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Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for geriatric psychiatric patients admitted for being a danger to self or others. Findings:

On 11/16/2020 at 10:30 a.m. an observation was made of the hospital's patient care area with S4RN. There were 8 double occupancy patient rooms located down a single hallway in view of the nurse's station.

The following ligature and safety risks were observed:

1) Patients' rooms #1- #8: Observed patient beds were noted to be adjustable, metal-framed, hospital-type beds with 4 open-framed ¼ side rails (2 - 1/4 rails per each side of the bed). The beds also had headboards and footboards. The beds provided multiple potential ligature points. There were a total of 16 hospital-type beds located in rooms #1- #8. S4RN, present during the observation, indicated patients' rooms were locked during the day, but indicated patients were allowed to go to their rooms unattended to lay down or for quiet time, unattended by staff, if they were on every 15 minute observations.

An interview was conducted with S2DON on 11/16/2020 at 12:30 p.m. She reported the facility was receiving admissions from nursing homes with a high percentage of patients being total care patients. She further stated the metal beds had the ability to raise the head of the bed which she felt were better for the total care type of patients the facility was admitting from the nursing homes.

2) Patients' bathrooms in rooms #1- #8 : Observed toilets in the patients' bathrooms with an opening between the toilet and the wall that provided a potential ligature point. There were a total of 8 toilets with the opening between the wall and the toilet.

3) An observation conducted of Room 205 on 11/16/2020 at 10:40 a.m. revealed 3 brackets secured to the foot of the bed (bed closest to the door) with 6 non-tamper resistant screws (2 screws per bracket). S4RN, present during the observation, confirmed the screws were non-tamper resistant.

4) An observation of the outside smoking area used by the patients was conducted on 11/17/2020 at 2:00 p.m. The outside smoking area was surrounded by a wood fence. Four wooden boards at the top of the fence were no longer nailed in on one side. Further observation revealed one unsecured wooden fence board was propped up in the corner of the fence. S3ADON, present for the observation, confirmed the referenced findings.

An interview was conducted with S2DON on 11/17/2020 at 2:30 p.m. She reported the patients had not been going outside lately due to Covid positive cases in the unit and she was unaware the fence was damaged.






30984

Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services by failing to include all hospital services in the QAPI program. This deficient practice was evidenced by failing to include laboratory services, pharmacy services, radiology services, and linens, which were provided by contract or agreement, in the hospital's QAPI program.

Findings:

Review of the facility's quality improvement indicators for 2020 revealed contracted services were not included in the QAPI program.

An interview was conducted with S2DON on 11/17/2020 at 3:30 p.m. S2DON verified the contracted services such as pharmacy, laboratory, radiology, and linen were not included in the hospital's QAPI program for 2020.

38777



Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was established. This deficient practice was evidenced by the hospital's:
1) failure to ensure expired nutritional supplements were unavailable for patient use.
2) failure to ensure single use normal saline was discarded after use and not available for patient use.
3) failure to ensure all patient mattresses were maintained in a condition that allowed for proper cleaning.
4) failure to ensure expired IV catheters were not available for patient use.
Findings:

1) An observation was made of the medication room on 11/16/2020 at 10:45 a.m. and an expired box of 32 individually packaged Juven therapeutic nutrition supplements was found. The expiration date on the packages was listed as September 1, 2020. S3ADON confirmed the nutrition powder supplement was expired.

2) An observation was made of the medication room on 11/16/2020 at 11:00 a.m. and an opened single use 100 ml Normal Saline bottle with an expiration date of 10/11/2020 and an opened single use 250 ml Normal saline bottle with an expiration date of 10/31/2020 were found. S3ADON confirmed the normal saline bottle was expired and was for single use only.

3) An observation on 11/16/2020 at 11:00 a.m. of room 208 revealed the underside of the mattress was ripped from side to side exposing the foam mattress. S4RN verified the mattress cover was torn exposing the foam mattress which could not be properly cleaned.

4) An observation on 11/16/2020 at 11:30 a.m. revealed a basket with IV supplies stored in the medication room. The basket contained 8- 20 Ga. IV Catheters with an expiration date of 10/2019. S3ADON confirmed the catheters were expired and should not be available for patient use.

30984


Based on record reviews and interview, the hospital failed to ensure the methodology of gross testing of Cranial Nerves II-XII, during the neurological examination, was documented in each patient's admission History and Physical. This deficient practice was evidenced by failure to include the methodology used for gross testing of Cranial Nerves II-XII for 4 (#2, #6, #7, #8) of 5 (#2, #3, #6, #7, #8) sampled patient records reviewed for History and Physicals from a total sample of 9 patients.

Findings:

Patient #2
Review of Patient #2's (current patient) History and Physical assessment conducted on 11/03/2020 by S6MD revealed the patient's cranial nerve function was documented as Cranial Nerves II-XII intact. Further review revealed no documented evidence of the methodology used to assess the patient's cranial nerve function.

Patient #6
Review of Patient #6's History and Physical assessment conducted on 10/14/2020 by S6MD revealed the patient's cranial nerve function was documented as Cranial Nerves II-XII intact. Further review revealed no documented evidence of the methodology used to assess the patient's cranial nerve function.

Patient #7
Review of Patient #7's History and Physical assessment conducted on 11/08/2020 by S8MD revealed the patient's cranial nerve function was documented as Cranial Nerves II-XII intact. Further review revealed no documented evidence of the methodology used to assess the patient's cranial nerve function.

Patient #8
Review of Patient #8's History and Physical assessment conducted on 09/02/2020 by S9MD revealed the patient's cranial nerve function was documented as Cranial Nerves II-XII intact. Further review revealed no documented evidence of the methodology used to assess the patient's cranial nerve function.

In an interview on 11/17/2020 at 10:30 a.m. S10RN verified Patient #7 and Patient #8's medical record failed to reveal documented evidence of the methodology used to assess the patient's cranial nerve function.

In an interview on 11/18/2020 at 1:30 p.m. with S3ADON, she reported S6MD had explained when he assessed cranial nerves that were intact he documented Cranial Nerves II-XII intact. S3ADON also reported S6MD had further explained if the findings were abnormal he included a description of the abnormality and how he assessed the nerves involved. S3ADON confirmed the method used to assess cranial nerve function had been documented in the patients' medical record in the past and confirmed it was no longer documented.





38777

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that estimated memory functioning. This deficient practice was evidenced by failure to include supportive information related to how memory functioning was evaluated for 3 (#1, #2, #6) of 3 (#1, #2, #6) sampled patient records reviewed for memory functioning in the psychiatric evaluation from a total sample of 9 patients.

Findings:

Review of the hospital policy titled Master List of Standards revealed in part, psychiatric evaluation shall be: Each patient must receive a psychiatric evaluation that must...6) estimate intellectural functioning, memory functioning, and orientation.

Patient #1
Review of Patient #1's (current patient) psychiatric evaluation conducted and documented by S5NP on 10/30/2020 revealed the patient's recent and remote memory was documented as impaired. There was no documented evidence of the means used to determine memory functioning.

Patient #2
Review of Patient #2's (current patient) psychiatric evaluation conducted and documented by S5NP on 11/03/2020 revealed the patient's recent memory was documented as impaired and remote memory was documented as intact. There was no documented evidence of the means used to determine memory functioning.

Patient #6
Review of Patient #6's psychiatric evaluation conducted and documented by S5NP on 10/14/2020 revealed the patient's recent memory was documented as impaired and remote memory and immediate recall were documented as intact. There was no documented evidence of the means used to determine memory functioning.

In an interview on 11/17/2020 at 3:00 p.m. with S2DON, she confirmed there was no documented evidence of the method used to determine memory function in the above referenced patients' psychiatric evaluations.

30984


Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets. This deficient practice was evidenced by failure to include an inventory of the patient's assets in the psychiatric evaluation for 6 (#1, #2, #3, #6, #7, #8) of 6 (#1, #2, #3, #6, #7, #8) sampled patient records reviewed for psychiatric evaluations from a total sample of 9 patients.

Findings:

Review of the hospital policy titled Master List of Standards revealed in part, psychiatric evaluation shall be: Each patient must receive a psychiatric evaluation that must: ...7) include an inventory of the patient's assets.

Patient #1
Review of Patient #1's (current patient) psychiatric evaluation conducted and documented by S5NP on 10/30/2020 revealed there was no assessment of the patient's assets.

Patient #2
Review of Patient #2's (current patient) psychiatric evaluation conducted and documented by S5NP on 11/03/2020 revealed there was no assessment of the patient's assets.

Patient #3
Review of Patient #3's (current patient) psychiatric evaluation conducted and documented by S7MD on 10/24/2020 revealed there was no assessment of the patient's assets.

Patient #6
Review of Patient #6's psychiatric evaluation conducted and documented by S5NP on 10/14/2020 revealed there was no assessment of the patient's assets.

Patient #7
Review of Patient #7's (current patient) psychiatric evaluation conducted and documented by S11MD on 11/09/2020 revealed there was no assessment of the patient's assets.

Patient #8
Review of Patient #8's psychiatric evaluation conducted and documented by S11MD on 09/02/2020 revealed there was no assessment of the patient's assets.

In an interview on 11/17/2020 at 10:30 a.m. S10RN verified Patient #7 and Patient #8's psychiatric evaluations failed to contain a documented assessment of the patients' assets.

In an interview on 11/18/2020 at 1:30 p.m. with S2DON, she indicated she knew patients' assets were assessed in the psychosocial assessment by the social worker and had not realized assets were to be assessed by the psychiatrist/psychiatric mental health nurse practitioner in the psychiatric evaluation as well.





38777

Based on record review and interview, the hospital failed to have an available psychologist to provide psychological services to meet the needs of the patients. This deficient practice was evidenced by failure of the hospital to have a full-time, part-time or consulting psychologist to provide psychology services.

Findings:

Review of the hospital's policy titled Psychological Services revealed in part, when ordered by the psychiatrist, consulting psychologists will provide a full range of psychological services, including a complete battery of psychological tests, neuropsychological or other tests needed to assist in differential diagnosis, determine the treatment needs of the patient and develop an appropriate treatment plan.

An interview was conducted with S1Adm on 11/17/2020 at 12:00 p.m. S1Adm reported the facility no longer had a contracted psychologist for the facility due to the psychologist not renewing his contract in 2020.