HospitalInspections.org

Based on observation and staff interview the facility did not provide or maintain a safe environment for psychiatric hospital patient rooms. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients within the identified rooms.

FINDINGS INCLUDE:

1. On 03/24/2014 at 3:20 pm, observation revealed on the 1st floor in the Orange Zone-SC, Tub Rooms 1152 & 1170, the facility failed to adequately minimize or prevent the incidence of suicide. Fully exposed ceiling mounted sprinkler heads were installed and accessible by inpatients.

2. On 03/24/2014 at 3:23 pm, observation revealed on the 1st floor in the Orange Zone-SC, Interview Room 1162, the facility failed to adequately minimize or prevent the incidence of suicide. Fully exposed ceiling mounted sprinkler heads were installed and accessible by inpatients.

3. On 03/24/2014 at 3:59 pm, observation revealed on the 1st floor in the Orange Zone-SC, Units A & B Inpatient Activity area, the facility failed to adequately minimize or prevent the incidence of suicide. Fully exposed ceiling mounted sprinkler heads were installed and accessible by inpatients. This area is used by mental health inpatients 24 hours per day and 7 days per week.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).

Based on MR review and Medical Staff Bylaws, the facility failed to ensure all medical record entries are timed and dated in 8 of 30 medical records reviewed (Pt #18, 24, 25, 26, 27, 28, 31, 32). This could potentially effect all patients receiving treatment at this hospital.

Findings include:

Review on 3/24/14 beginning at 12:45 PM of Medical Staff Bylaw, Rules and Regulations dated 2007 states, "All medical record entries must be legible, complete, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided."

Per MR review on 3/25/14 and 3/26/14 beginning at 9:00 am, no documentation of time and/or date of the History and Physical Examination and/or Psychiatric Evaluations for Pt #18, 24, 25, 26, 27, 28, 31, 32.

The above findings were confirmed with Admin A on 3/26/14 beginning at 11:00 am.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41- Condition of Participation: Physical Environment IS NOT MET. This deficiency has the ability to affect 20 in-patients currently in the hospital.

Findings Include:

It was observed that the facility had the following life safety deficiencies. K-12: Building Structural Members, K-20: Shafts and Fire Separations, K-27: Smoke Barrier Doors, K-29: Hazardous Spaces, K-33: Stairwell Enclosures, K-45: Egress Lighting, K-46: Emergency Lighting, K-50: Fire Drills, K-56: Sprinkler Systems, K-62: Sprinkler Maintenance, K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observation and staff interview the facility failed to ensure the hospital environment is maintained to ensure patient safety in 3 of 4 patient room observations (Pt # 4, 6,16) and 2 of 3 treatment areas (Occupational Therapy (OT) room, Nursing Unit B). This could potentially effect all patients receiving treatment at this facility.

Findings include:

Per MR review on 3/25/13 at 10:10 AM, Pt. # 16 resides in room 151, which contains an electric bed with a cord and Pt. # 16 was admitted on 15 minute for suicidal behavior. The electrical cord provides the potential for strangulation for a suicidal patient.


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During tour of Nursing Unit B on 3/24/2014 at 10:35 AM observed discolored ceiling tiles above the tables where patients eat. Per interview with Nursing Supervisor B at the time observation, the facility has had problems with the roof leaking.
Per MR review on 3/25/2014 at 9:30 AM Pt # 6 resides in room 140, which contains an electric bed with a cord and Pt # 6 is on 15 minute checks for suicidal behavior. The cord provides the potential for strangulation for a suicidal patient.
Per MR review on 3/25/2014 at 10:15 AM Pt # 4 resides in room 141, which contains an electric bed with a cord and Pt # 4 is on 15 minute checks for suicidal behavior. The cord provides the potential for strangulation for a suicidal patient.
During tour of OT room on 3/24/2014 at 11:20 am accompanied by OT Supervisor C, observed grab bars in the OT room bathroom without guards to prevent injury by hanging. Per interview at the time of discovery with OT Supervisor C, patients use this bathroom unsupervised.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41(b) Standard: Safety from Fire IS NOT MET. This deficiency has the ability to affect 20 in-patients currently in the hospital.

Findings Include:

It was observed that the facility had the following life safety deficiencies. K-12: Building Structural Members, K-20: Shafts and Fire Separations, K-27: Smoke Barrier Doors, K-29: Hazardous Spaces, K-33: Stairwell Enclosures, K-45: Egress Lighting, K-46: Emergency Lighting, K-50: Fire Drills, K-56: Sprinkler Systems, K-62: Sprinkler Maintenance, K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observation and staff interview the facility failed to ensure staff maintain a sanitary environment in 2 of 3 patient areas observed (Occupational Therapy (OT) room, Inpatient Treatment Area "B" and 3 of 3 interviews (A, B, D). This could potentially effect all patient's receiving treatment at this hospital.

Findings Include:

Per tour of "B" patient area on 3/24/14 at 10:40 AM, noted a round coffee table located in the common area, the laminate covering was missing in several areas exposing a porous wood surface which can not be disinfected allowing for potential cross contamination.

Per interview with Nursing Supervisor B on 3/24/14 at 10:40 AM, B stated that the patients are picking off the laminate making the surface an uncleanable area.


32670

Per tour of OT room on 3/24/2014 at 11:15 am accompanied by OT Supervisor C, noted dirt and debris in cabinets containing OT supplies and cabinet under the sink. Per interview with OT Supervisor C at the time of the findings, the cabinets need cleaning and old supplies need to be removed.
Per interview with Housekeeping Supervisor D on 3/24/14 at 12:15 PM, housekeeping does not clean inside locked cabinets on the nursing unit.
Per interview with Administer A on 3/25/2014 at 3:35 PM, housekeeping should be cleaning inside cabinets and asking staff to unlock the cabinet if needed.