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Based on clinical record review, staff interview and facility document review the facility staff failed to follow their policy regarding the use of restraints for one patient, Patient #14.

The findings include:

Patient #14 was admitted to the facility on 9/2/10 with a diagnosis of Diabetes and Behavioral Disturbance who resided on Unit 7B. A review of Patient #14's clinical record was conducted on 10/26/11. The review revealed Patient #14 had been restrained on 10/2/11 and was taken to the time out room on Unit 9.

The Director of Nursing explained Unit 9 was the Residential Treatment Center. The Resident Treatment Center is not licensed under the hospital license issued by the State of Virginia.

A review of the facility policy related to the use of restraints does not identify the use of the Residential Treatment Center.

Based on clinical record review, staff interviews and facility policy review, the facility staff failed to ensure physician orders for medications (heparin and TPN) were clarified by the physician prior to administration for 2 of 20 patients, Patient #5 and #20.

The findings include:

1. Patient #5 was admitted to the facility on 10/19/11 with the diagnoses of Conversion Pain Syndrome, Reflex Sympathetic Dystrophy, Hysterical Blindness and Anxeity Disorder. Patient #5 had a Port-a-cath, which she had since August 2010. During the review of the clinical record the following were noted:
? admission a physician order dated 10/19/11 "T.O. (telephone order) flush port-a-cath "c" with a line above it (with) 3cc-5cc when available and heparin when available and monthly thearafter".
? MAR (medication administration record): Flush Port-a-cath with 3cc-5cc of heparin when available and monthly thereafter, dated 10/19/11. The MAR indicated the flush was done on 10/20/11 at 2305 hours. There was no indication of what amount of heparin was used.




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2. Patient #20 was admitted to the adolescent psychiatry hospital on March 19, 2010, with the diagnoses of post traumatic stress syndrome and pernicious vomiting. A peripherally inserted central catheter (PICC) was located in the arm of Patient #20. Due to Patient #20's vomiting, a special intravenous medication containing sugar, protein, and fats along with electrolytes to deliver nutrients called total parental nutrition (TPN) was administered.

Physician's orders for TPN on admission for Patient #20 stated continue with previous TPN formulation. The registered nurse failed to clarify the medications and the formulas for the type of TPN to be administered with either the Pharmacist or Patient #20's physician upon admission to the hospital. The Surveyor revived the clinical record of Patient #20 and found no orders for the specific composition of the TPN, on October 26, 2011. The TPN physician's order failed to list the composition or the dosage of the TPN, and the registered nurse failed to obtain a physician's order for the composition of the TPN for Patient #20.

The Pharmacist verified during interview, that a copy of the TPN order should had been placed in Patient #20's chart for the registered nurses to verify that they were hanging the right dosage of TPN. This interview occurred in the conference room on October 26, 2011, at 12:06 p.m.

Based on medical record review, staff interview and facility policy review the facility failed to maintain physician's orders for restraint and seclusion of patients on their medical record for six of thirteen restrained/secluded patients in the survey sample. (Patient #6, #9, #10, #11, #12, and #15)

The findings include:

Review of the medical records did not reveal physician's orders on the patient's chart for documented occurrences of restraint, seclusion, or restraint to seclusion incidents:
? Patient #6- one incident,
? Patient #9- two incidents,
? Patient #10- two incidents,
? Patient #11- three incidents,
? Patient #12- twenty-three (23) incidents, and
? Patient #15-one incident.

An interview was conducted on 10/25/2011 at 11:23 a.m. with Staff #4, the Director of Nursing. Staff #4 was asked to review Patient #6's medical record related to nursing documentation, which recorded an incident of restraining the patient. Review of the record did not reveal a physician's order for the patient's restraint. Staff #4 stated "An order should be on the chart." Staff #4 reported the facility utilized a restraint/ seclusion packet, which included the verbal order for restraints/seclusion received from the physician, an every 15 minute nursing assessment, documented assessment every five minutes by the staff observing the patient, the unit manager's checklist, a physician's attestation related to notification, and staff debriefing. Staff #4 reported the restraint/seclusion packets were reviewed by administration prior to returning the information to the unit for filing in the patient's medical record. Staff #4 verbally acknowledged the restrained/secluded patient would not have documentation of a physician's order on their medical record during the administrative process.

An interview was conducted on 10/26/2011 at 4:40 p.m. with Staff #26 the Administrator; Staff #4; Staff #5, the Risk Manager/Director of Health Information Management; Staff #27, Corporate Director of Clinical Services; Staff #9, the Assistant Director of Nursing, Staff #12, the Director of Residential Services. The staff was made aware of the findings. Staff #26 and Staff #5 reported a physician's order needed to remain on the patient's medical record whenever a restraint /seclusion occurred.

Review of the facility's policy and procedure titled "Hospital Policy on Restrictive Procedures" read: "Authorization: 24. Restraint or seclusion shall be used in emergency situations only and require an order from a physician ..."

Based on medical record review, staff interview and facility policy review the facility failed to ensure verbal orders for restraint/seclusion had been signed within twenty-four (24) hours of the occurrence for five of thirteen patients restrained/secluded in the survey sample. (Patients #3, #6, #11, #13 and #15)

The finding included:

Review of the medical records for Patients #3, #6, #11, #13 and #15 revealed the verbal order given by the physician for the patient's restraint/seclusion had not been signed by the physician within the required twenty-four hour timeframe.

An interview was conducted on October 25, 2011 at 11:23 a.m. with Staff #4, the Director of Nursing. Staff #4 reviewed Patient #6's medical record and stated "[Name of Patient] was restrained on 9/10 (2011) at 9:20 in the morning the doctor should have signed it by the next day no later than 9:20 in the morning. That signature looks like it was signed in the PM on the eleventh it was late."

An interview was conducted on October 25, 2011 at 2:50 with Staff #5, the Director of Risk and Health Information Management. Staff #5 reviewed Patient #11's medical record and verbally acknowledged
Patient #11 had been placed in restraint at 7:05 a.m. on October 17, 2011. Staff #5 reported the verbal order had been obtained at 9:00 a.m. on October 17, 2011 "but the physician did not sign the order until October 19th at 9:00 in the morning over forty-eight (48) hours after the implementation."

An interview was conducted on October 26, 2011 at 2:23 p.m. with Staff #4 and Staff #5. Staff #4 and Staff #5 were asked to review the restraint/seclusion orders for Patients #3, #6, #11, #13 and #15. Staff #5 verified the dated and timed physician's signature had not been obtained within twenty-four hours of the dated and timed verbal order.

Review of the facility's policy and procedure titled "Hospital Policy on Restrictive Procedures" read: "Authorization: 24. (E) The physician shall authenticate verbal/telephone orders for restrictive procedures as soon as possible up to or within twenty four hours of the implementation."

Based on observation, staff interview and facility documentation the facility failed to maintain a safe and sanitary environment for the well-being of the patients.

The findings included:

1. The tour of the admission/exam room, the pharmacy, the gym, the weight room, the physical therapy and occupational therapy units, and the patient units 6 A and 6 B occurred on October 24, 2011 between the hours of 10:45 AM and 13:45 AM, by two surveyors and the Director of Standards and Regulatory Compliance, the Director of Admissions and the Director of Resident Services.

The admission/exam room was noted to have a dirty tiled floor, with a torn space on the wall. The staff bathroom outside the admission/exam room contained a yellowish toilet seat that had the original color of white.

The Director of Admissions verified during interview, on October 24, 2011, at 12:10 p.m., that these areas needed corrections.

Physical therapy unit had torn mats, with the large bright blue mats on the work table, with a small tear in the main area. The speech therapy area contained a 1/4 inch tear in the exam mat and the underside contained 1/4 to 1/2 cup of grains of rice under the mat. Four ceiling tiles were noted to be wet and discolored with brown stains. The intake air vent was wet and gray with dust. Four steel bars used to assist with ambulation did not contain end caps with sharp edges on the ends.

Intake vents were noted to be dirty and dusty with stained ceiling tiles and the light fixture falling from the ceiling in the bathroom of the occupational therapy room. No paper towels were noted in the dispenser by the sink in this area.

The Director of Rehabilitation verified that the following areas needed correction for the safety and welfare of the patients and staff. This interview occurred in the occupational therapy room, on October 24, 2011, at 12:20 p.m.

Tour of the gym revealed a 1/2- 3/4 inch gap from the closed back door at the threshold, the floor was dusty with dead bugs, and dust bunnies in all four corners, with the intake air vent dirty.

An odor of sweat/urine was noted upon the entrance to the gym which was identified by the Surveyors as coming from the linen basket upon arrival to the gym. Big chunks of torn carpet was noted on the floor which has the potential for the staff/patients to fall. Dirty intake vents were noted in the ceiling.

The Directors of Standards, Admissions and Resident Services verified that the environment of the gym and weight room needed improvement. These interviews occurred in the weight room, on October 24, 2011, at 12:45 p.m.

Patient unit 6 A revealed broken blinds in patient rooms #101, #103 and #108. The patients were unable to raise the blinds up or down which prevented privacy. Uncovered electrical outlets were noted in patients rooms #105 and #106. Electrical outlets that are uncovered has the potential to cause harm to the adolescent boys in unit 6 A. A reddish stain was noted on the floor tile from a pair of red underwear on the floor behind the door of patient room #103. A toilet seat was missing on the toilet for the boys bathroom on unit 6 A.

Inspection of the custodian room of unit 6 B revealed a dirty gray colored drain that had not been rinsed past discarding the dirty water from mopping. Dust had collected on the intake vent on unit 6 B in the Quiet Room. A quarter to fifty cents size torn carpet was noted in the day room of unit 6 B. A dirty intake vent with water stains was revealed in the women's bathroom of unit 6 B. The faucet to the sink in the dayroom was loose at the base on patient unit 6 B. Room #9, on patient unit 6 B, contained a missing faucet handle on the sink.

The Directors of Standards, Admissions and Resident Services verified that the environment of units 6 A, 6 B and the custodian room needed improvements to protect the special needs of the adolescent psychiatric diagnoses of patient unit 6 A and 6 B. These interviews occurred on patient unit 6 B, on October 24, 2011, at 1:40 p.m.


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2. Observations and staff interviews were conducted on October 24, 2011 from 12:00 p.m. to 1:11 p.m. during the initial tour of the facility with Staff #4, the Director of Nursing, Staff #27, the Corporate Director of Clinical Services, and Staff #6, Director of Support Services revealed the following unsafe practices:
? Unit 7 B Room 408 a portable cylinder of oxygen had been positioned next to two other portable oxygen cylinders. The portable oxygen cylinder was not secured in an oxygen tank carrier. Staff #4 stated "Oxygen tank should always be secured in a carrier." Staff #4 directed the unit staff to place the oxygen cylinder in a carrier or remove the cylinder to the storage area.

? Unit 7 B Restroom II: the floor tile next to the shower was not intact and elevated from the surrounding floor tile. The area of tile presented both a trip hazard and potential injury issue. On the floor next to the paper towel hanger was a broken and sharp piece of wood. Staff #6 observed the broken and elevated floor tile next to the shower and acknowledged the potential for injury. Staff #5 and Staff #6 were asked to identify the broken, sharp wooden object on the floor. Staff #6 picked the item up and identified the object as a "toothpick". Staff #5 retrieved the item from Staff #6 and stated "It looks like a broken piece of the wooden handle of a swab of some type." Staff #5 verified the wooden item was sharp on one end and prepared to throw the item in the restroom trash. Staff #27, redirected Staff #5 to dispose of the item in the sharps container within the nurses' station.

? Unit 7 B Room 403 within the closet the bottom drawer had been broken and had rough and jagged edges. The patient stated "I have gotten splinters in my fingers from that drawer."

? Unit 7 A Room 302 the wooden front and handle area of the closet had been broken. The split wood was jagged, rough and presented a potential for injury. Staff #5 and #6 observed the findings and verbally acknowledged the potential dangers to the patients.

Based on observations, staff interviews and facility document review the facility staff failed to follow their infection control plan for identifying, reporting and preventing the spread of infection.

The findings include:

1. During an initial tour of the facility on 10/24/11 with the Director of Nursing the following were noted:
Physical Therapy (PT) department:
had two large mats with torn areas, one in the main PT area with small tear and several areas were the blue vinyl cover was worn to the porous under side and one in the speech room with a 1-2 tear in that mat.
Ceiling tiles stained and one currently showing signs of being wet.
Air vents dirty with compacted dust and dirt
Occupational Therapy (OT) kitchen:
Air vents dirty with compacted dust and dirt and spider webs
No paper towel holder for paper towels
Corners in and around the cabinets dirty
Gym:
Doors leading to outside had no threshold leaving a 1/2 to 1 and 1/2 inch gap running along the bottom of the door which would allow insects and pest to enter. Dead insects were observed on the gym floor
Weight Room:
Air vents dirty with compacted dust and dirt
Seclusion Room on Unit 6:
Air and light vent dirty and dusty
Day area had torn chair covers and air vents dirty with compacted dust

The Infection Control nurse was interviewed on 10/25 and 26/11. She stated she does not make round of the entire facility. She stated the Unit Coordinators do daily rounds and fill out a surveillance check list of items, the Director of Plant Operations and Administrative staff fills out another surveillance check list with some of the same items and the Infection Control nurse fills out a third surveillance check list.

The Infection Control nurse stated she also monitored the Residential Treatment Center (RTC) as well as the 2 group homes the facility owns. In some of the reports presented by the Infection Control nurse the infection control percentage rates from each area were totaled together. It could not be determined what percentage belonged to the hospital.






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2. Observations and staff interviews were conducted on October 24, 2011 from 11:00 p.m. to 1:11 p.m. during the initial tour of the facility with Staff #4, the Director of Nursing, Staff #27, the Corporate Director of Clinical Services, and Staff #6, Director of Support Services revealed areas for potential spread of infection:
? Observations at 11:10 a.m. outside the Dietary department there were three carts with Styrofoam containers and re-sealable plastic bags with milk, yogurt and/or fruit cups. The re-sealable plastic bags with milk, yogurt and/or fruit cups were not on ice. Staff #5 explained the carts were prepared for food deliver to the patients that ate on the units. A tour was started of the dietary department with Staff #20, the Dietary Manager. Staff #20 reported the carts were prepared for the unit patients that did not come to the cafeteria and were generally available for pick up by unit staff by 11:00 a.m. At 11:35 the carts remained outside of the dietary department; Staff #20 was asked to take the food temperature of a selected milk and yogurt from one of the re-sealable plastic bags on one of the carts. Staff #20 used his thermometer reported the temperature of the milk as "52" degrees Fahrenheit and the yogurt was "50" degrees Fahrenheit. Staff #20 reported the milk and yogurt were above the recommended holding temperature for cold items. Staff #20 reported "Dairy products held at an elevated temperature could become a medium for bacteria growth."

? Unit 7 B Restroom II: the floor tile next to the shower was not intact and elevated from the surrounding floor tile. The floor tile at the base of the shower was split. The floor in Restroom II could not be cleaned or disinfected to prevent the spread of infection.

? Unit 7 A Girl's Restroom the floor tile was not intact under the sink, along the flash area next to the wall and at the base of the shower. The floor could not be cleaned or disinfected to prevent the spread of infection.

? Unit 7 A Room 305: the patient's CPAP (continuous positive airway pressure) equipment, mask, and mouth piece were on the floor. Staff # 28 the Unit Manager reported nursing staff were responsible to ensure the patient's respiratory equipment was stored in a manner to prevent contamination. Staff #28 stated "[Name of the Patient]'s equipment should not be on the floor."

Review of facility's policy titled "Nutritional Services Procedure on Maintenance of Serving Line Temperatures" read: "Meals being sent to the units for consumption are handled in the following manner: ... b. All cold food is held at a temperature < (less than or equal to) 41 degrees (Fahrenheit). Individual patient bags containing cold food is refrigerated and removed from refrigeration at the time that unit staff arrive to transport meals."