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Based on interview and document review, the Community Behavioral Health Hospital failed to ensure policies and procedures were developed and implemented related to the provision of a written notice that a doctor of medicine or doctor of osteopathy (MD / DO) was not present at the hospital 24 hours a day, seven days a week, at the beginning of all inpatient admissions. This affects all patients admitted to the hospital.


Findings Include:


During an interview on 9-10-15 at 10:15 a.m. with the administrator and registered nurse (RN)-A, the administrator stated the hospital did not have a written policy or procedure in place to notify patients there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. RN-A stated during the admission process, patients were informed verbally there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. RN-A verified patients did not sign a written acknowledgment form stating they understood that a MD/DO may not be present at all times services were furnished to the patient.

Based on interview and document review, the Community Behavioral Health Hospital (CBHH) failed to have a prompt medical record retrieval system. This had the potential to affect all patients readmitted to the hospital.

Findings include:

On 9/11/15, at 8:25 a.m. the administrative secretary stated it took approximately a week to retrieve the paper portion of a patient's medical record if it was stored in the medical record storage facility in St. Paul, Minnesota.

On 9/11/15, at 10:10 a.m. registered nurse (RN)-A (hospital nursing supervisor) stated when a patient was transferred to another state operated facility the patient's medical record was sent in its entirety with the patient or to the receiving facility. The medical record then was stored at the last facility the patient was discharged. RN-A confirmed if a patient was readmitted to the CBHH and they had been discharged from a different state operated facility, it would take approximately three days to retrieve the paper medical record from the other facility. The paper record contained legal documents, observations sheets, restraint flow sheets, nursing documentation, consents, consults etc. RN-A verified none of these documents were scanned into the electronic medical record system.

The Storage, Retention and Destruction policy dated 8/1/01, indicated the record retrieval system would accommodate both scheduled and demand-based requests. In addition, each facility would develop an effective process for requesting medical records.

Based on observation, interview and document review, the Community Behavioral Health Hospital (CBHH) failed to ensure eye drop bottles were labeled appropriately for 1 of 1 patient (P2) who received eye drop medication.

Findings include:

On 9/9/15, at 8:13 a.m. licensed practical nurse (LPN)-A retrieved P2's eye drop bottle of Timolol Maleate (glaucoma medication) from the locked cupboard in the medication room. The bottle of Timolol Maleate lacked a patient label which would have indicated dosage and dispensing information along with a date when the eye drop bottle had been opened. LPN-A proceeded to administer the eye drops.

On 9/9/15, at 9:00 a.m. LPN-A confirmed P2's eye drop medication bottle had not had a patient label attached, nor dated when it had been opened. LPN-A verified P2's eye drop medication bottle should have had a patient label on it and should have been dated when opened.

On 9/9/15, at 9:48 a.m. registered nurse (RN)-B confirmed eye drop bottles should be labeled and dated when opened.

On 9/9/15, at 3:30 p.m. the consulting pharmacist stated the best practice was to document a when opened date on multi dose bottles.

The Medication Administration, General Information policy dated 3/9/15, indicated any multi-dose container must be labeled with the expiration date and staff initial on the container the date when it was opened.

The Pharmacy Infection Control and Sanitation policy dated 7/7/15, indicated all multi-dose vials would be labeled with the "do not use beyond date", which was 28 days from the time it was first opened unless otherwise exempt.

The Medication Storage, Dispensing Medications and Labeling Requirements policy dated 7/7/15, indicated all medications dispensed should be labeled at a minimum with the following information:

- Name of client
- Name of drug
- Route of administration when necessary
- Strength of drug
- Expiration date
- Date dispensed

The American Society of Ophthalmic Registered Nurses (ASORN) recommended ophthalmic bottles or tubes be labeled with the date and time they were originally opened, and the expiration date should not exceed 28 days once opened.

Based on interview and document review, the Community Behavioral Health Hospital (CBHH) failed to have emergency water and natural gas policies that included specific criteria for the emergency provision of water and gas sources in the event of a disruption of water and natural gas supply. This had to the potential to affect all patients admitted to the hospital.


Findings include:


The Minnesota Department of Human Services State Operated Services-CBHH [Community Behavioral Health Hospital] Alexandria Scope and Resources last reviewed 12/14/14, indicated the hospital was to contact Blue Eye Development for loss of heat. In the "Backup Systems/Contingency Plans" (the hospital's emergency plan) read, in the event of loss of heat, "During the heating season keep doors closed to conserve heat. Dress warm. Evacuate to Douglas County Hospital."


In the "Backup Systems/Contingency Plans" (the hospital's emergency plan) only listed "contact city" in the event of loss of water. The plan failed to address the amount of non-potable and potable water required in the event of loss of water and failed to address a plan in the event of a disruption in supply (e.g. disruption to the entire surrounding community).


During interview on 9/10/15, at 11:45 a.m. the administrator confirmed the hospital did not have policies and procedures in place for obtaining emergency gas and water. The administrator stated the hospital plan would be to evacuate the building.

Based on observation, interview and document review, the Community Behavioral Health Hospital (CBHH) failed to ensure the hospital owned exercise equipment; Pro-form 910 E (elliptical machine), Matrix Recumbent Bike and the NordicTrack C900 (treadmill) were on a preventive maintenance program. This practice had the potential to effect all patients who utilized the exercise equipment. In addition, the CBHH failed to maintain the ice machine in good working repair. Also, the CBHH failed to ensure the medication room distribution window was constructed to promote a safe environment for patients and staff. This had the potential to affect all staff and patients at the hospital.


Findings Include:


PREVENTATIVE MAINTENANCE FOR EXERCISE EQUIPMENT

During an environmental tour on 9/9/15, at 10:30 a.m. the safety administrator (SA)-A stated the exercise equipment in the hospital was not on a preventative maintenance program. The SA-A stated the exercise equipment was cleaned after each patient use by staff and stated the staff inspected the safety of the exercise equipment when the machines were cleaned.


During an interview on 9/9/15, at 5:00 p.m. the administrator stated the exercise equipment was purchased in the 2013, fiscal year. The administrator also stated the exercise equipment was not on a preventive maintenance plan and verified there had been no preventative maintenance completed on the exercise equipment since it was placed in the hospital for patient use. In addition, the administrator stated the hospital did not have preventative maintenance policy and procedure.


ICE MACHINE


During an environmental tour on 9/10/15, at 11:30 a.m. rust spots were observed on the ice machine grate and duct tape was observed on a plastic strip on the front of the ice machine. The SA-A verified the duct tape and rust spots and stated he was unaware of either concern, but would look to see if a work order had been completed.


During an interview on 9/10/15, at 11:58 a.m. SA-A provided a copy of the work order placed for repair of the ice machine. SA-A verified the work order was dated 4/28/15, and read, "Ice machine mold has a crack on the front of it." The work order indicated an email was sent to the landlord regarding the need for repair on 4/28/15, at 11:30 a.m.


During an interview on 9/10/15, at 1:20 p.m. housekeeper (H)-A and registered nurse (RN)-A confirmed the work order for the ice machine was placed on 4/28/15, and confirmed the ice machine had not yet been repaired. RN-A stated the facility staff had been meeting monthly, however, the work orders were not being reviewed during the meetings to monitor for follow-up/completion.


During an interview on 9/10/15, at 5:00 p.m. the administrator verified the work order for the repair of the ice machine was dated 4/28/15, and stated the ice machine should have been repaired at that time. The administrator stated the work order should have been flagged out of the work order book for completion. The administrator stated the hospital did not have a policy and procedure for the completion of work orders.


32601


MEDICATION ROOM WINDOW

On 9/9/15, from 8:00 a.m. until 9:00 a.m. licensed practical nurse (LPN)-A was observed conducting the morning medication passes. LPN-A remained in the medication room as the patients approached through an open window in the wall on the one side of the medication room to receive their morning medications. The size of the medication room was approximately 10 feet by 10 feet.

On 9/9/15, at 3:02 p.m. RN-A (nursing supervisor) confirmed on the evening of 9/8/15, patient (P3) had reached over the ledge of the open medication window during medication pass time and exhibited very threatening behavior. RN-A stated a patient could easily get over the medication room window ledge and into the medication room because the window opening was so large, it was really unsafe.

-P3's progress note dated 9/8/15, indicated P3 had went up to the medication window and requested medications. P3 proceeded to threaten the nursing staff and flicked the medication cup and all the medications fell to the floor in the medication room. P3 leaned way over into the medication room and grabbed onto the counter refusing to allow the window to be closed. After a short period of time, P3 stood back and allowed the medication window to be closed.

On 9/9/15, at 3:51 p.m. LPN-B stated even though she did not feel threatened by P3 when he had attempted to get over the medication room window ledge; LPN-B stated she did change her practice and distributed the rest of the evening medications passes by bringing the medications to the patients and not having them approach the medication room window.

On 9/10/15, at 9:27 a.m. RN-A stated the request for a safer medication room window had been brought to the administrator in the past.

On 9/10/15, at 9:56 a.m. the administrator confirmed there had been another incident in the past where a patient had entered the medication room through the medication room window. This incident had been reviewed by the safety committee and the recommendations from the safety committee had been to redo the window to provide a safer environment for staff and patients. This request had went to the Board, however was not acted on due to budget constraints.

-Incident report dated 5/24/14, indicated P1 had jumped up in the medication window and was striking out at the medication nurse. P1 lunged into the medication room and was demanding medications. Hands on was done and P1 was placed in restraints.

On 9/10/15, at 4:00 p.m. the safety administrator (SA) provided the following measurements of the medication room window:

- The distance from the floor to the window sill/threshold was 3 feet 6 inches
- The window opening was approximately 2 feet 8 inches in width and 3 feet 2 inches high

On 9/10/15, at 5:00 p.m. the safety administrator (SA) confirmed the safety committee had recommended the medication room window be replaced to provide a safer area. SA stated the safety committee had been made aware that the window was not going to be addressed at this time due to budget constraints. SA was unaware of a future plan for replacing the medication room window.

The Safety Committee Meeting Minutes dated 6/24/14, indicated discussions related to the medication room window would take place with the next safety officer.

The Safety Committee Meeting Minutes dated 7/29/14, indicated a window insert was going to be installed in the medication room which would prevent patients from entering the medication room over the counter. It would have a talk hole and about a six inch opening at the bottom for passing medications. The glass would need to be tempered or secure rated.

The State Operated Services Governance Structure Meeting minutes dated 1/29/15, due to budgetary constraints, CBHH-Alexandra had not been able to update their medication window. This left staff vulnerable to the persons they support entering the room through the window. In addition, the majority of staff did not have access to the medication room; therefore, assistance in the event of an emergency was impeded. This would be the first issue addressed once funding became available.