HospitalInspections.org

Based on document review, the facility does not ensure all personnel meet all applicable personnel health requirements in accordance with State law for 4 of 10 clinical staff in the area of rubella immunization (Staff # 7, 13, 15 and 16).

Findings Include:

Review of policy "Employee Health Maintenance " last revised 3/07 revealed all employees are required to have a completed history and physical including rubella.

Review on 8/10/11 of personnel/credential files for Staff # 7, 12, 14 and 15 revealed no evidence of immunization against rubella.

This finding was verified with Staff #16 on 8/10/11.


Based on document review, the facility does not ensure all personnel meet all applicable personnel health requirements in accordance with State law for 5 of 10 clinical staff in the area of annual health reassessment and tuberculosis testing (Staff # 5, 8, 10, 14 and 15).

Findings Include:

Review of policy "Employee Health Maintenance " last revised 3/07 revealed the health status of all employees is reassessed annually and tuberculosis skin testing is performed based on the outcome of the TB risk assessment to ensure freedom from health impairments that may pose a significant risk or interfere with performance of duties.

Review on 8/10/11 of personnel/credential files for Staff # 10, 14 and 15 revealed no evidence of a current health assessment.

Review on 8/10/11 of personnel/credential files for Staff # 8, 10 and 15 revealed no evidence of annual tuberculosis testing, nor was there any evidence of an assessment/treatment of previous positive tuberculosis testing results for Staff #5 and 15.

This finding was verified with Staff #16 on 8/10/11.


Based on document review, the facility does not ensure all personnel meet all applicable personnel requirements in accordance with State law for 4 of 5 clinical staff in the area of performance evaluations (Staff # 10-13).

Findings Include:

Review on 8/11/11 of policy "Continuous Quality Improvement Guidelines for Assuring the Competency of Non-Physician Clinical Staff " last reviewed 4/07 revealed each employee will receive an annual performance appraisal to determine current competence.

Review on 8/11/11 of policy "Probation & Annual Performance Appraisals" last revised 6/98 revealed performance appraisals are conducted annually.

Review on 8/10/11 of personnel/credential files for Staff # 10-13 revealed no evidence of annual performance evaluations.

This finding was verified with Staff #1 and 17 on 8/10/11.

Based on document review and medical record review, the facility does not ensure adherence to policies and procedures related to the appraisal of emergencies, initial treatment and referral to a higher level of care.

Findings Include:

Review on 8/11/11 of policy entitled "Use of Emergency Transport Form" last revised 5/05 revealed it is the facility's policy to complete an Inter-Institutional Transfer Record when transporting a patient to another hospital. The form is sent with the patient to the facility they are transferred to.

Review on 8/10/11 of patient medical records revealed the following:

- Patient # 4: Review of the medical record revealed the patient was transported to an area hospital emergency department on 1/2/11. No evidence of an Inter-Institutional Transfer Record was found in the medical record.
- Patient # 23: Review of the Inter-Institutional Transfer Records dated 2/11/11 revealed no evidence to indicate the patient's family or guardian was notified of the transfer to an acute care hospital.

Based on medical record review, the facility failed to ensure ongoing assessment and monitoring of patient conditions during the use of restraint for 1 of 3 patients (Patient # 24).

Findings Include:

Review on 8/11/11 of policy "Use of Seclusion for Behavior" and " Use of Restraint for Behavior Management" revised 3/08 revealed while in restraint, the patient is assessed every 15 minutes for symptoms of impaired circulation and findings documented, an intake and output record is maintained and range of motion is done. For seclusion, once every 30 minutes for children and once every 60 minutes for adults- Vital signs are taken and physical/psychological needs are assessed. The Restraint and Seclusion flowsheet is completed while the patient remains in seclusion/restraints. Upon release, the patient's RN conducts an in-person evaluation of the patient and writes a progress note that includes a description of the patient's response to the seclusion and/or restraint.

Review on 8/11/11 of the Restraint and Seclusion Flowsheet for 5/19/11 revealed Patient # 24 was in a 5 point restraint from 2:00 PM to 3:00 PM. There was no evidence in the medical record to indicate assessment of circulation, fluids/toileting needs and vital signs were obtained in accordance with facility policy.

Review on 8/11/11 of the Restraint and Seclusion Flowsheet for 5/23/11 revealed Patient # 24 was in a 5 point restraint from 5:41 PM to 6:11 PM. Vital signs were attempted but not obtained due to the patient's violent behavior of spitting and biting.There was no evidence in the medical record to indicate assessment of circulation, fluids/toileting and vital signs were obtained after release to ensure the health and safety of this patient.

Based on medical record review and documentation review, nursing staff do not ensure supervision and evaluation of care for each patient is provided.

Findings Include:

Review on 8/11/11 of policy "Fall Risk Assessment and Prevention (Falling Star)" effective 5/06 revealed on admission all adult patients will be assessed by a registered nurse using the Fall Risk Assessment Tool. Scores ranging from 25 and above would initiate the falls prevention program and implementation of the pre-printed treatment plan. The pre-printed treatment plan must be individualized to reduce the risk of injury.

Review on 8/10/11 of the medical record for Patient #3 revealed the initial intake assessment completed on 7/13/11 identified safety and fall precautions due to age of 83 years and increased behavioral issues/ changes due to dementia. Review of progress notes dated 7/14/11 revealed the patient fell coming out of her room. There was no evidence the patient was re-assessed for fall risk until 7/17/11 when the patient was scored as 65 or "high risk" on the Fall Risk Assessment tool.

Review on 8/10/11 of the medical record for Patient #23 revealed on 2/12/11 the patient was transferred to an area hospital for a possible overdose. There was no evidence in the medical record to indicate nursing staff performed an assessment of the patient or documented a description of the events that occurred prior to the transfer.

Based on medical record review and document review, the facility does not ensure nursing staff develop and keep current the plan of care for 8 of 24 patients (Patient # 1, 2, 3, 5, 7, 8 19, and 21).

Findings Include:

Review on 8/10/11 of the medical record for Patient #1 revealed the Treatment Plan dated 4/25/11 lists obesity and hypertension under Axis III. The multidisciplinary treatment plan for medical issues and the problem statement had no entries for medical issues. There was no evidence of a plan of care to address the medical conditions of obesity and hypertension while the patient was hospitalized.

Review on 8/10/11 of the medical record for Patient #2 revealed the treatment plan lists osteoarthritis, hypertension, urinary tract infection (UTI) and chronic pain syndrome under Axis III. Review of the Multidisciplinary Treatment Plan for medical issues revealed skin breakdown listed as a problem. Review of progress notes and physician orders dated 6/18/11 revealed the patient was transferred to an area hospital emergency department for hematuria and diagnosed with a urinary tract infection. There was no evidence of a plan of care to address the medical conditions of urinary tract infection, osteoarthritis, hypertension or chronic pain.

Review on 8/10/11 of the medical record for Patient #3 revealed the initial intake assessment completed on 7/13/11 identified safety and fall risk issues. Although the patient sustained a fall on 7/14/11 and received a score of 65 or "high risk" on the 7/17/11 Fall Risk Assessment, no evidence of a fall prevention plan of care was found in the record.

Review on 8/10/11 of the medical record for Patient #5 revealed a history of dementia, type II diabetes, obesity, dyslipidemia, total thyroidectomy, hypertension and coronary artery disease. Review of the treatment plan for admission dated 2/23/11 revealed diabetes, hypertension, thyroidectomy, dyslipidemia and coronary artery disease are listed under Axis III. The multidisciplinary treatment plan for medical issues and the problem statement only includes hypertension in the treatment plan despite an order for fasting and 4 PM fingersticks. A multidisciplinary treatment plan "review" dated 3/1/11 identifies the current medical problem status as being stable despite elevated blood glucose readings throughout the hospitalization. Recommendations were to monitor vital signs daily, monitor fingerstick's per order, administer medications and labs per order and to monitor diet. Dementia and obesity were not documented on the initial treatment plan and there is no evidence of a formal plan of care for any of the identified medical problems other than hypertension. On 3/16/11 the patient was transferred to an area hospital emergency department and admitted overnight for observation due to chest pain. Review of the treatment plan initial review for admission date 3/17/11 revealed hypothyroidism, CABG and left mastectomy are listed under Axis III. The multidisciplinary treatment plan for medical issues only includes hypertension despite other identified medical issues and hospitalization for chest pain on 3/16/11.

Review on 8/9/11 of the medical record for Patient #7 revealed the patient had been refusing to eat/drink for approximately 5 days. This "hunger strike" was not addressed in the nursing plan of care.

This finding was verified with Staff #1 on 8/9/11 at 10 AM.

Review on 8/8/11 of the medical record for Patient # 8 revealed a medical diagnosis of cardiac disease, hypertension and carotid blockage. There is no evidence these problems were adressed in the nursing care plan.

This finding was verified with Staff # 1 on 8/9/11 at 2:30 PM.

Based on record review and document review, the facility does not ensure all entries in the medical record are dated, timed and legible.

Findings Include:

Medical record review on 8/10/11 revealed the following entries lack dates and times:
-Patient #2: The medical note dated 6/15/11 is not timed.
-Patient #3: The medical note dated 7/14/11 is not timed.
-Patient #23: The medical note dated 2/11/11 and the progress note dated 2/13/11 are not timed.

Medical record review on 8/10/11 revealed the following illegible entries:
-Patient #3: The Intake Assessment form for Psychiatry, page 11 is signed off by the unit nurse but the date is illegible.The medical note dated 7/14/11 is not timed. The dates on the 24 hour Observation Flowsheet and the 1:1 Worksheet is "written over" by staff. The date could be either 7/28/11 or 7/29/11.
-Patient #2: The target date for the medical problem of skin breakdown listed on the Multidisciplinary Treatment plan is "written over" by staff and illegible.
-Patient #7: The blood pressure was "written over" and illegible on the medication administration record dated 8/8/11 at 12 PM.
-Patient #23: The restraint and seclusion flowsheet dated 5/19/11 has three entries for prn medication dosages for Ativan and Haldol. The second entry is "written over" and illegible.

Based on medical record review and interview, physician orders were not authenticated in 2 of 24 medical records (Patients #9 and 20).

Medical record review on 8/10/11 revealed Patient #9 and 20 had been admitted to the facility on 8/5/11. As of 8/10/11 the physician orders had not been authenticated.

This finding was verified with Staff # 23 on 8/10/11 at 2 PM.

Based on document review, the facility does not ensure verbal orders are verified utilizing "read back" by nursing staff and authenticated within 24 hours by the prescribing practitioner consistent with facility policy.

Findings Include:

Review on 8/11/11 of policy "Physician Orders/Telephone Orders" effective 2/91 revealed when a registered nurse documents a telephone order given by a physician on the order sheet "verbal order read back to physician (VORB) is written beneath the order. All telephone orders are co-signed by the physician within 24 hours of the given order.

Review on 8/11/11 of telephone physician order for Patient # 3 dated 7/28/11 at 9:20 AM revealed no evidence of a read back verification by nursing or authentication of the order by the physician.

Review on 8/11/11 of physician order for Patient # 4 dated 1/2/11 at 9:35 AM revealed a telephone order order was not authenticated by a physician.

Review on 8/11/11 of physician order for Patient # 5 dated 3/16/11 at 8:40 AM revealed a telephone order that was not authenticated by the physician until 5/2/11. There is no evidence of a read back verification by nursing.

Review on 8/10/11 of physician order for Patient # 21 revealed verbal orders were given by the physician on 8/5/11. There was no evidence the physician authenticated the orders.

Review on 8/11/11 of physician order for Patient # 24 dated 5/18/11 at 7:45 AM and 5/18/11 at 9:05 PM revealed a telephone order was received. There is no evidence of a read back verification by nursing or that the order was authenticated by a physician. A telephone order on 5/18/11 at 9:40 AM revealed no evidence of a read back verification by nursing staff.

Based on observation, the facility does not ensure that outdated, mislabeled or otherwise unusable drugs and biologicals are not available for patient use.

Findings Include:

Observation on 8/8/11 at 10:00 AM of the general psychiatric patient unit medication room revealed the following:
-2 bottles of Fluphenazine Hydrochloride 2.5 mg/ml were opened but not dated and/or initialed when opened.
-1 bottle of Chlorpromazine Hcl 25 mg/ml expired 6/11.

These findings were verified with Staff #3 on 8/8/11.

Based on medical record review, the facility did not meet the nutritional needs of 1 of 24 patients (Patient #4).

Findings Include:

Review on 8/11/11 of the medical record for Patient # 4 revealed the following:

The Multidisciplinary Treatment plan cover sheet for the initial review for admission date 12/29/10 is not completed as it does not list any conditions under Axis I-V. The problem statement sheet indicates the patient has an eating disorder and needs an eating disorder clinic referral upon discharge. No evidence was found to indicate the multidisciplinary team developed a care plan to address the nutritional needs of the patient. No evidence was found to indicate a referral to an eating disorder clinic was ordered/obtained upon discharge.

The initial nutritional assessment dated 12/30/11 revealed a history of bulimia. A nutritional status of level I- moderate/severely compromised nutritional status with a referral to a dietitian for assessment is indicated within 3 to 5 days. Review of progress note dated 1/2/10 revealed the patient had been vomiting and purging for 24 hours and lost consciousness. The patient was transferred to an area hospital for medical evaluation. No evidence was found in the medical record of nutritional follow up.

Based on observation the facility did not maintain the building.

Findings Include:

Observation during the tour on 8/9/11 at 11:00 AM revealed deterioration of the loading dock surface and structure. Reinforcement rod is protruding through eroded concrete causing safety and operational hazards.

Observation during the tour on 8/11/11 at 11:00 AM revealed deterioration of the Transformer Room exterior door. The bottom of the door does not seal the opening to prevent water from entering the room.

Observation during the tour on 8/9/11 at 2:30 PM revealed vertical surfaces of refrigerators and kitchen cabinets had accumulations of grease and grime.

These findings were verified with Staff # 4 on 8/9/11.

Based on observation and interview the facility did not maintain the facility in compliance with NFPA 101.

Observation during the tour on 8/11/11 between the hours of 10:30 AM and 2:00 PM revealed the following:
-Several storage rooms (Room #422, 424, and 425) were filled with unused equipment and furnishings creating a safety and fire hazard. Items include but are not limited to construction equipment, hospital equipment, painting tarps, ceiling tiles and miscellaneous items.
-Medical records storage room # B 3 has records stored in an unsafe manner creating a possible fire hazard.

These findings were verified with Staff # 4 on 8/11/11.

Based on observation the facility did not maintain the facility in compliance with NFPA 101.

Findings Include:

Observation during the tour on 8/11/11 between the hours of 10:30 AM and 2:00 PM revealed roller latches were identified on 18 patient room doors on the second and third floor (Room #'s 201, 213, 215, 216, 218, 219, 231, 246, 247, 249,313, 315, 316,318, 335, 346, 347, and 349.)

These findings were verified with Staff # 4 on 8/11/11.

Based on observation and interview the facility did not ensure patient safety related to the building's hot water system.

Findings Include:

Observation during the tour on 8/8/11 at 10:30 AM revealed the hot water in the patient restroom (Room 208) was at a temperature that was dangerous to patients and staff.

Interview with Staff # 4 on 8/8/11 revealed the hot water was set at 122 degrees.

Based on observation the facility did not maintain supplies from possible contamination and ensure an acceptable level of safety and quality.

Findings Include:

Observation during the tour on 8/8/11 at 2:15 PM revealed clean linen sheets stored on a metal shelf less than 1 inch above the floor in the clean linen room.

Five twenty-gallon bags of clean mop heads were stored on the floor in the soiled linen room.

These findings were verified with Staff # 4 on 8/11/11.


Observation on 8/8/11 at 10:00 AM of the general psychiatric patient unit medication room revealed one bottle each of Accu-check level 1 and 2 test solution open and undated.

This finding was verified with Staff #3 on 8/8/11.

Observation on 8/8/11 at 10:30 AM of the geriatric unit medication room revealed one bottle each of Accu-check level 1 and 2 test solution open and undated.

This finding was verified with Staff # 1 on 8/8/11.

Observation on 8/8/11 at 10:50 AM of the children's psychiatric unit medication room revealed one bottle of sterile water opened but not dated or initialed.

Observation on 8/8/11 at 1:35 PM of the ETC unit revealed the following:
- In the recovery room file cabinet: 1 bottle each of the Accu-check level 1 and level 2 test solution was opened but not dated or initialed when opened.
- In room 447: 4 22 gauge IV stylets expired 6/2010 and 1 Yankauer suction catheter packaging was opened and attached to the suction machine.

These findings were verified with Staff #9 on 8/8/11.

Based on document review and interview, the infection control officer did not implement policies governing control of communicable diseases, specifically tuberculosis.

Findings Include:

Review of the Infection Control policy and procedure manual on 8/9-10/11 revealed a policy #7.05.23 TUBERCULOSIS:TB. (no revision date) Section -Control Measures: Negative pressure room.

Interview with Staff #4 on 8/9/11 at 9 AM revealed the facility does not have any negative pressure rooms.

Review of the Infection Control policy and procedure manual revealed a policy entitled Tuberculosis (TB) Control Plan reviewed 12/09.

Interview with Staff # 16 on 8/10/11 revealed the above noted policy is not current. The current policy is entitled "Screening Patients for Tuberculosis During Admission" dated 2/12/07. Review of the Infection Control policy and procedure manual revealed no evidence of this policy in the manual.

Based on medical record and document review and interview, the hospital did not have a discharge plan evaluation in the patient medical record in 1 of 1 discharge medical records (Patient #11).


Medical record review on 8/8/11 at 2 PM revealed documentation in the progress notes from the discharge planner for this homeless patient. Based on the documentation in the medical record it was unclear how the anticipated discharge plan would be complete and safe.

Interview with Staff # 24 on 8/10/11 revealed the discharge plan was adequate, but much of the exchange of information between the patient and Staff # 24 went undocumented in the medical record. Therefore the discharge appeared less than adequate based on documentation.

These findings were verified with Staff # 24 on 8/10/11.