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Based on observation and interview, it was determined the facility failed to protect patient's rights in that patients did not receive care in a safe environment in that ligature risks were present in two of two (Adult and Geriatric) Psychiatric Units as follows:
1) Protruding doorknobs were present.
2) Door hinges were protruding out from the walls.
3) Door closers were exposed.
4) Electrical sockets next to patient beds were not locked.
5) Ceiling tiles were not secured in a manner to not allow the tiles to be lifted up.
6) Sinks did not include ligature risk-free faucet heads.
7) Fire and exit signs were hanging directly from the ceiling.
8) Patient toilets were not securely attached to the walls.
9) Door closers were not placed to avoid ligature risk.
The failed practices did not ensure the patients could not inflict harm upon themselves. The failed practice had the likelihood to affect all patients admitted to the Adult and Geriatric Psychiatric Units.
See A-0144 for details.

Based on observation and interview, it was determined the facility failed to protect patient's rights in that patients did not receive care in a safe environment in that ligature risks were present in two of two (Adult and Geriatric) Psychiatric Units as follows:
1) Protruding doorknobs were present.
2) Door hinges were protruding out from the walls.
3) Door closers were exposed.
4) Electrical sockets next to patient beds were not locked.
5) Ceiling tiles were not secured in a manner to not allow the tiles to be lifted up.
6) Sinks did not include ligature risk-free faucet heads.
7) Fire and exit signs were hanging directly from the ceiling.
8) Patient toilets were not securely attached to the walls.
9) Door closers were not placed to avoid ligature risk.
The failed practices did not ensure the patients could not inflict harm upon themselves. The failed practice had the likelihood to affect all patients admitted to the Adult and Geriatric Psychiatric Units. Findings follow.

A. Observation of all rooms on the Adult Psychiatric Unit on 4/5/2023 from 9:15 AM to 9:45 AM showed that the facility failed to ensure that:
1) Protruding doorknobs were not present.
2) Door hinges were not protruding from the door frames.
3) Door closers were not exposed.
4) Electrical sockets next to patient beds were locked.
5) Ceiling tiles were secured in a manner to not allow the tiles to be lifted up.
6) Sinks had ligature risk-free faucet heads.
7) Fire and exit signs were not hanging directly from the ceiling.
8) Patient toilets were securely attached to the walls.
9) All door closers were placed to avoid ligature risk.

B. The findings in A were verified in an interview with the Maintenance Supervisor on 4/5/2023 at 9:50 AM.

C. Observation of the Geriatric Psychiatric unit on 4/5/2023 from 10:00 AM to 10:47 AM showed that the facility failed to ensure:
1) Fire and exit signs were not hanging directly from the ceiling.
2) The latching mechanism placed on the back of the fire doors were placed at least 12 inches from the floor.
3) Hands soap dispensers were attached to the walls as to avoid ligature risk.
4) Patient toilets were securely attached to the walls.
5) Ceiling tiles were secured in a manner to not allow the tiles to be lifted up.
6) All door closers were placed to avoid ligature risk.

D. The findings in C were verified by the Maintenance supervisor on 4/5/2023 at 10:58 AM

Based on review of DEA (Drug Enforcement Administration) Regulations, observation, and interview, it was determined the facility failed to receive a Controlled Substance properly in that there was no official transfer paperwork (DEA Form 222) for a Controlled Substance stored in one of one Narcotic Vault. By storing a Controlled Substance that was not legally transferred to them, the facility was not in compliance of DEA Regulations. This failed practice had the likelihood to affect all patients treated at the hospital. Findings follow:

A. Review of DEA Regulations, Chapter II, Part 1305, Section 1305.03, "Distributions requiring a DEA Form 222," current as of 01/17/2023, showed a DEA Form 222 is required for each distribution of a Schedule I or Schedule II controlled substance.

B. During a tour of the Pharmacy on 04/05/2023, from 9:00 AM until 10:22 AM, observation showed a 40 ml (milliliter) Hydromorphone 10 mg (milligram)/ ml filled pain pump for implantation, stored in the Narcotic Vault. Hydromorphone is a Schedule II Controlled Substance.

C. During an interview on 04/05/2023 at 9:32 AM, The Executive Director was asked if there was a DEA Form 222 showing the Hydromorphone had been legally transferred from the original DEA Registrant to their facility. The Executive Director stated the Hydromorphone pump that was in their possession, did not get transferred to them using a DEA Form 222.

Based on observation, review of policy and interview, it was determined the facility failed to ensure the contents of emergency supply kits/carts were checked each shift per the established policy in one (Geropsychiatric Psychiatric Unit) of two (Geropsychiatric and Adult Psychiatric Units) Emergency Crash Carts surveyed. The potential existed for the crash carts not to have medications/supplies present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications/procedures in an emergency. Findings follow:

A. A review of policy titled "Emergency Crash Carts" revised 02/18, showed the following:
1) The emergency drug supply shall be stored in sealed tray of each crash cart.
2) Patient care units were responsible for checking the integrity of the equipment on the cart and the seal on each shift.

B. Observation on 03/04/23 from 9:00 AM to 10:00 AM showed the Geropsychiatric Psychiatric Unit Emergency Crash Cart was not being checked each shift to ensure the lock was intact and ready for a patient emergency.

C. The findings of A and B were confirmed in an interview with the Assistant Chief Nursing Officer #2 on 03/04/23 at 10:15 AM.

Based on review of WRMC (White River Medical Center) Tray Audit reports, review of the Arkansas Rules for Hospitals and Related Institutions and interveiw, it was determined the Director of Food Services failed to perform daily management of dietary services to assure safe practices for food handling in that food temperatures on the patient trayline were not taken before and after every meal in 30 of 31 (03/01/23-03/31/23) days. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the tray line service. The failed practice had the likelihood to affect anyone receiving food from the dietary service. Findings follow:

A. Review of Arkansas Rules for Hospitals and Related Institutions showed temperatures of hot and cold foods on the patient trayline was to be taken at the beginning of each meal and at the end of each meal in which the trayline lasted longer than 15 minutes.
B. Review of policy titled, "Test Meals" showed that the procedure was "Test trays will be completed at least once per month. Additional test trays will be sent as needed based on complaints about cold food."
C. Review of WRMC Tray Audit forms for 03/01/23-03/31/23 showed trayline temperatures were only recorded once a month.
D. During an interveiw on 04/04/23 at 1:55 PM with Director of Environmental Services it was confirmed that the patient trays were only being checked for proper temperatures on a monthly basis.

Based on review of policy and procedures, observation, and interview, it was determined the facility failed to ensure an acceptable level of safety and quality in that two of two blanket warmers in the medical surgical unit on the fourth floor had no evidence of maintaining daily temperature logs. The failed practice did not ensure the blanket warmers were maintaining a safe temperature and had the likelihood to affect all patients who received a warm blanket on the fourth floor. Findings follow:

A. Review of policy dated revised on 06/01/2019 titled, "Warming of Fluids and Blankets for Patient Use", showed that blanket warming cabinets will not exceed 130 degrees Fahrenheit and showed that temperatures were set, maintained, and documented on daily logs.

B. Observation of the medical surgical unit on the fourth floor on 04/04/23 at 8:25 AM showed two of two blanket warmer cabinets did not have evidence of daily temperature logs or documentation. Warmer #1's digital temperature setting read 160 degrees Fahrenheit. Warmer #2 had no method for monitoring accurate temperature.

C. During an interview with Clinical Manager on 04/04/23 at 8:30 AM, Clinical Manager verified the findings in A and B.

Based on observation, policy review and interview, it was determined the facility failed to prevent and control hospital acquired infection in the satellite emergency room for two of two (room four and room seven) patients in that Registered Nurse (RN) #1 and #2 failed to perform hand hygiene while performing patient care. Failure to perform hand hygiene during patient care did not assure patients were free from possible transmission of infectious organisms and from healthcare personnel. The failed practice had the likelihood to affect all patients receiving care in the satellite emergency room. Findings follow:

A. Review of the facility's police titled, "Infection Prevention-Emergency Department," showed hand hygiene must be performed between each patient contact.
B. Review of the facility's policy titled "Hand Hygiene," showed to remove gloves after caring for a patient and to change gloves during patient care if moving from a contaminated body site to a clean body site. The use of gloves does not eliminate the need for hand hygiene.
C. The findings of A and B were confirmed in an interview with the Director of Nursing on 04/05/23 at 11:15 AM.
D. Observation of patient care on 04/03/23 showed (RN) #2 entered Room #7 without performing hand hygiene, escorted the patient to be weighed and re-entered the room without performing hand hygiene.
E. Observation of patient care on 04/03/23 from 1:00 PM to 2:00 PM showed RN #1 exited Room #4 with gloves on, went to central supply, came back with materials and re-entered the room without changing gloves or performing hand hygiene.