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Based on review of facility documents, observation and interview, the facility failed to ensure patients received care in a safe setting.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part, "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility Housekeeper staff position description stated in part, "Position purpose: According to established procedures, performs a variety of environmental services duties to maintain the facility in a clean, safe, and sanitary condition ...
Key Responsibilities:
· Comply with all Administrative, Clinical, and Human Resources policies and procedures ...
· Adheres to departmental policies and procedures.
· Adhere to appropriate infection control and established safety procedures ...
Performance standards: Environment of Care and Safety
· ...Utilize appropriate sanitation supplies and equipment to maintain cleanliness and safe condition."

Facility document titled, "Basic Rights for All Patients" stated in part,
"3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

During a tour of the facility on 09/19/16 at 1:50 PM the following infection control issue were noted:
· In the TV room a floor tile was observed with a large chip present (2 X 4 inches), the uneven surface prevents effective cleaning of the floor and poses a trip hazzard to patients.
· In the exam room of the adult unit on the second floor, there was cracked laminate observed on the side of the sink cabinet, preventing effective cleaning of this surface.
· In the TV room of the psychiatric intensive care unit (PICU) a large 1.5 x 3 foot area of the wall was observed with uneven peeled paint on the wall, preventing effective cleaning of this surface.
· In the PICU pantry a rusted and chipped area (1 X 3 inches) was observed on the left side of the sink. Rust cannot be effectively cleaned. The chipped area provided a vector for pest and dirt to enter the area where food is prepared. The cabinet also had several areas with exposed particle board, preventing effective cleaning.
· In the dining room/large treatment room on the second floor, approximately 3-4 dead insects (which appeared to be cockroaches) were observed between a cabinet and the wall.
· In the dining room/large treatment room and pantry room, dark droplet stains were observed on the walls, indicating these areas had not been effectively cleaned.
Third floor dayroom:
· Layer of dust along window sill
· Layer of dust on dry erase board
· Layer of dust on the fire alarm
· Visible dirt along base boards
Third floor medication room:
· Layer of dust on top of the refrigerator
· Black layer of dust all along ceiling trimming
· Four holes in corner ceiling tile with black dust
Main third floor hallway:
· Black layer of dust all along ceiling trimming
· One stained ceiling tile
· Community meeting room window sill with layer of dust
· Visible dust and dirt on vent
Dining Room:
· Four live gnats around the entrance and coffee cart
· Visible dirt and a sticky substance on coffee cart
Patient room 309:
· Dirt build-up under toilet in restroom
· Layer of dust on both call lights
· Layer of dust on top of book shelf and desk
· Dead cricket in vanity light
Laundry room on third floor with visible dust on call light box.

During a tour of the 2nd floor on the afternoon of 9-19-16, the following observations were made:
· The baseboard under the sink located in the small television room appeared to be rotted and crumbled when touched with the toe of a shoe.
· An end table between 2 couches held a used Styrofoam cup and 4-5 wadded up, paper, hand towels.
· Several areas of a dark, tacky substance was stuck to the top of the wooden, trash can cover.
· A tour of the laundry room on the 2nd floor revealed a sign on the wall that stated " Please sanitize washer between each patient use with 1 cup clorox to 1 small drum/load water. "

An additional sign provided from the 3rd floor laundry room read " Sanitize washing machine between each patient use with 1 clorox tablet to 1 small drum/load of water. "

Facility policy IC-1400 titled " Laundry " states the following:
" Policy:
...
B. Patient Clothing and Laundry
...
g. Staff will disinfect the washing machine after each patient use. The tub and exterior surfaces may be wiped out with hospital approved disinfectant wipes. For gross contamination a full cycle will be run with bleach. "

In an interview with staff #28, the staff was asked to explain the procedure for cleaning the interior of the washing machine between loads of clothing for different patients. The staff escorted the surveyor to the housekeeping closet and indicated that the interior of the washing machine was sprayed with " Tilex " or wiped out with a " Cavicide " wipe. The staff stated that one of the two (Tilex or Cavicide) was used, " unless it ' s a really bad load. " When asked what the process for cleaning the washing machine interior would be if they had just washed " a really bad load " , the staff indicated a product in the laundry room called " Oxiclean Power Pak " and stated that an empty load would be run using hot water and a pak/pod of the " Oxiclean " product. Examination of the ingredient labels for each of the three products revealed that only the " Tilex " contained sodium hypochlorite, the active ingredient in bleach.

The above was verified in an interview with the chief nursing officer on the afternoon of 9/19/16.

Based on a review of documentation and interview, the facility failed to ensure that the physician orders for restraint or seclusion cannot be written as a standing order or on an as needed basis (PRN).

Findings included:

Facility based policy PC-127 last review date 03/18/2016 entitled "Emergency Intervention (Restraint and Seclusion)" stated in part,
"3.1.1 The physician orders are not written as standing or PRN orders ...
3.2 The physician's order for use of restraint or seclusion will be recorded in the medical record and include the following:
3.2.1 Reasons for using restraint/seclusion, including specific behaviors and safety issues; ...
3.3.1 A physician's order is required for each separate restraint and seclusion episode that is not considered one continuous episode, i.e. a patient at some time later is determined to require the use of restraint or seclusion to ensure his/her safety or the safety of others."

Review of medical records revealed the 1 of 4 patients (#4) with restraint/seclusion episodes had documentation issues.
* Patient #4 had a physician order on 10/05/15 at 1845 stating, "May hold for safety of staff and patient ". Documentation on the "Restraint/Seclusion/Emergency Medication Record" indicated the patient had 2 separate personal restraints on 10/05/15. First personal restraint was from 1815-1830. Second personal restraint was from 1831-1845. There was only one order for a personal restraint. The other personal restraint episode requires a separate order and documentation of the event.
* Patient #4 had a physician order on 10/11/15 at 1120 to "OK for personal hold X 3 and seclusion-aggressive". Documentation on the "Restraint/Seclusion/Emergency Medication Record" indicated the patient had 3 separate personal restraints on 10/11/15. First personal restraint was from 1114-1115. Second personal restraint was from 1118-1119. Third personal restraint was from 1126-1127. There was only one order for a personal restraint. The other 2 personal restraint episodes require separate orders and documentation of the events.

According to facility policy the separate personal restraints required separate orders with documentation of each separate episode.


The above findings were confirmed in an interview on 09/21/16 with staff members # 11 and 27.

Based on a review of documentation and interviews the facility failed to ensure the use of seclusion was discontinued at the earliest possible time, regardless of the length of time identified in a physician's order.

Findings included:

Facility based policy PC-127 last review date 03/18/2016 entitled "Emergency Intervention (Restraint and Seclusion)" stated in part,
"4.5 The patient shall be assessed every 15 minutes while in restraint/seclusion by the RN/assigned trained staff ...The assessment includes: ...
4.5.5 Readiness for discontinuation of restraint/seclusion ...
4.11 Staff shall assist the patient to meet the behavioral criteria for release. Use of restraint/seclusion shall be terminated as soon as criteria for release has been met evaluated by the RN or physician ...
8.0 Discontinuation of Restraint/Seclusion: Although the restraint/seclusion order is written for a maximum time period, the goal is to discontinue restraint or seclusion as soon as the patient meets the behavioral criteria for release ...
8.3 Behavioral criteria for discontinuation of restraint or seclusion may include, but is not limited to:
8.3.1 Absence of self-injurious behavior
8.3.2 Absence of aggression/violent/threatening behavior ..."

Review of medical records revealed that 1 of 4 patients (# 4) with restraint/seclusion episodes had documentation issues.

Patient #4 was in seclusion from 1355-1432 on 10/05/15. Documentation on the "Restraint/Seclusion/Emergency Medication Record" indicated the patient was exhibiting release behavior from 1410-1425 and was not released from the restraint until 1432. The behavior codes indicated the following:
* At 1410 the behavior codes were: quiet, sitting/lying, mat present, and attempting to open doors.
* At 1416 the behavior codes were: calm, quiet, sitting/lying, given exit criteria, and mat present.
* At 1425 the behavior codes were: quiet, sitting/lying, mat present, and calm.

According to documentation, the patient had met release criteria and should have been released earlier than the 1432 release time, per facility policy and regulations.

In an interview on 09/21/16, staff members #11 and 27 confirmed the above findings.

Based on a review of documentation the facility failed to ensure that emergency equipment was maintained to ensure an acceptable level of safety and quality.

Findings included:

Facility based policy PC-133 last review date 03/18/2016, entitled "Medical Equipment and Change in Condition" stated in part,

"Medical Emergency Equipment..
d. The House Supervisor is to perform inventory daily and AED quality checks daily."

Review of the "Emergency Medical Equipment Daily Checklist" on the 2nd floor for September 2016 revealed that checks of the emergency equipment including the AED were not completed on 9/10/16, 09/11/16, 09/12/16, 09/17/16, and 09/18/16.

By failing to perform these checks, the facility potentially could have compromised emergency equipment (including the AED) available in an emergency situation.

The above findings were confirmed in an interview on 09/21/16 with staff member #11 and 27.

Based on a review of facility policy and staff interview, the facility failed to maintain a current policy and procedure for reporting state notifiable conditions.

Findings were:

A review of the hospital Infection Prevention and Control Manual, last approved 7/22/16, revealed the following:
"Strategies and Methodology
Epidemiologically relevant data is used to plan, implement, and evaluate infection strategies ...For the year 2016, these strategies include, but are not limit to the following...
Identifying and reporting communicable or reportable diseases..."

Health care providers, hospitals, laboratories, schools, and others facilities are required to report patients who are suspected of having a notifiable condition. Review of the policies and procedures provided by the facility on 9/20/16 revealed no documented evidence of a current listing and policy related to these notifiable conditions (available at http://www.dshs.texas.gov/region2-3/Notifiable-Disease-Conditions/?terms=notifiable%20conditions%202016).

In an interview with the Director of Infection Control on the afternoon of 9/20/16, in the facility conference room, he stated the listing was not posted in the hospital. He said, "I'm aware of the notifiable conditions list. If we don't have a policy related to reporting notifiable conditions, we need one."

Based on a review of facility documentation and staff interview, the facility failed to update the patient treatment plan in a manner consistent with patient strengths and disabilities, needed alternative strategies, and facility policy.

Findings were:

Facility based policy PC-127 last review date 03/18/2016 entitled "Emergency Intervention (Restraint and Seclusion)" stated in part,
"11.0 Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint /seclusion were indicated, a review and modification of the treatment plan is indicated. Based upon consultation with the attending physician information gathered from the debriefing with the patient, and the face-to-face evaluation, the RN shall review and update the treatment plan within 8 hours. The updated treatment plan shall reflect:
11.1 The identification of an assessed problem associated with the use of restraint/seclusion, if problem has not been previously identified.
11.2 Goals related to prevention further use of restraint/seclusion
11.3 Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention assigned.
11.4 Review of plan with the patient..."
A review of the clinical record of Patient #3, admitted 11/25/15, revealed he experienced an episode of restraint or seclusion on the following dates: 11/25/15, 11/27/15, 11/29/15, 11/30/15, 12/2/15, 12/3/15, 12/4/15, 12/6/15, 12/10/15, 12/11/15 (twice), 12/18/15 and 12/20/15. Updates to the patient treatment plan were completed on 12/3/15, 12/9/15 and 12/15/15.

A review of the clinical record of Patient #4 revealed he experienced an episode of restraint or seclusion on the following dates: 9/9/15, 9/22/15, 9/25/15, 9/26/15, 9/28/15, 9/29/15, 9/30/15, 10/1/15 (twice), 10/2/15, 10/3/15, 10/5/15 (twice), 10/8/15, 10/10/15 and 10/11/15. Updates to the patient treatment plan were completed on 9/11/15, 9/18/15, 9/25/15, 10/2/15 and 10/9/15.

These findings were confirmed in an interview with the chief executive officer and other administrative staff on the afternoon of 9/21/16 in the facility conference room.