HospitalInspections.org

Based on observation, patient interview and staff interview the facility staff failed to ensure the privacy of one patient, Patient #10 by ensuring the blinds in the window of the patient's room could be lowered.

The Findings Include:

During the initial tour of the hospital with the Director of Nursing (DON) on 9/13/11 on Unit # 7B the room of Patient #10 was observed. The blinds in the window were only lowered approximately 2/3 way down and could not be accessed by the patients in the room. People walking by the room on the outside of the building could be observed through the window.

Patient #10 stated, "We have to change our clothes in here (the patient's room) and people are always walking by our room. The blinds do not lower or close all the way." Patient #10 stated, "I have told the staff before that the blinds didn't work." Patient #10 stated, "I don't remember who I told."

The Director of Plant Operations (DPO) was interviewed on 9/16/11. The DPO stated, "I never received a work order to fix the blinds." The DPO stated, "The administrative staff make rounds through each building every week to assess what needs to be repaired."

Based on observations, medical record review, family interview, staff interviews and policy review the facility failed to ensure adequate nursing staff were available to maintain staff to patient ratio as prescribed, care as prescribed and the safety of patients. (See Tag 392).

Based on observations, medical record review and staff interview the nursing staff failed to ensure physician ordered calorie count and timed toileting were performed for one of eighteen patients (Patient #2). (See tag 395).

Based on observations, medical record review, staff interview and policy review the facility staff failed to update and implement care plans for five of eighteen patients in the survey sample (Patients #1, #2, and #9 and Patients #5 and 7). (See tag 396).

Based on medical record reviews and staff interview nursing staff failed to administer physician ordered medications as prescribed for three of eighteen patients in the survey sample. (Patients #1, #3, and #9). (See tag 404).

Based on observations, medical record review, family interview, staff interviews and policy review the facility failed to ensure adequate nursing staff were available to maintain staff to patient ratio as prescribed, care as prescribed and the safety of patients.

The findings included:

An observation was conducted on September 13, 2011 at 10:18 a.m. with Staff #1, the Director of Nursing (DON) and Staff #11, a Registered Nurse (RN) Unit Coordinator during the initial tour of the facility's neurobehavioral unit. The observation revealed a contraband item, a wire hanger visible on opening a patient's closet. Protruding from the top shelf of the closet was the curved top of a wire hanger, on removing the wire hanger it had been straighten with a loop re-shaped at the opposite end. The surveyor asked if patients were allowed to have wire hangers; Staff #1 stated, "No. Wire hangers are not allowed on the unit. No, hangers are allowed on the unit."

An interview was conducted on September 13, 2011 at 4:35 p.m. with the parent and family of Patient #2. Patient #2's family had verbalized concerns to the facility staff and the surveyor. Patient #2's family listed their concerns related to Patient #2's safety, grooming, and finding the patient in bed incontinent of bowel and bladder. Patient #2's family verbalized that staff had re-directed a male patient three times regarding entering Patient#2's room, however the male patient entered a fourth time and as reported by the family physically struck one of Patient #2's family members.

An observation was conducted on September 14, 2011 from 9:48 a.m. through 12:31 p.m. within the neurobehavioral unit in the presence of Staff #1. Patient #2 was escorted to school at 9:28 a.m. however returned to the unit at 9:48 a.m. Patient #2 was tearful and displayed agitated behaviors (loud noises, pulling at objects and pushing on the door). Staff redirected the patient by offering television programming; during the two hours and forty-three minutes of observation the staff did not attempt to toilet Patient #2.

Review of Patient #2's medical record revealed the patient was to be "timed toileted".

An interview was conducted on September 14, 2011 at 2:08 p.m. with Staff #1 and Staff #28 (the RN Charge Nurse). Staff #28 stated "Timed toileting as I understand it means toileting every two hours."

An observation was conducted on September 16, 2011 at 9:00 a.m. to 9:11 a.m. on the neurobehavioral unit, with Staff #1. The observation revealed four patients on the unit and one staff (Staff # 28, RN Charge Nurse). During the observation two patients with Prader-Willi Syndrome (an eating disorder characterized by insatiable hunger) wandered about the unit, one patient was at the nurse's station performing his nebulizer treatment and the fourth patient, who needed to eat alone was eating breakfast at a table. As Staff #28 assisted one of the four patients; one patient with Prader-Willi Syndrome grabbed food from the fourth patient's plate, which escalated the disorder on the unit.

An interview was conducted on September 16, 2011 during the observation with Staff #1. When asked about the staff to patient acuity/ratio; Staff #1 verified the unit during the observation consisted of one patient who required a 1:2 ratio; two patients that required a 1:3 ratio and one patient that required a 1:4 ratio. Staff #1 verified the unit was not adequately staffed for the prescribed/required number of staff to patients. Staff #1 stated, "That's a problem when you have a mix of kids (patients) on a unit... chronic illness, brain injury... and they go to different classes." Staff #1 reported there was not a coordination of staff to ensure that the adequate number of staff was maintained a certain times of the day. When asked if the Unit Coordinator was available to assist; Staff #1 stated, "If the staff call her." When asked about the likelihood that staff would involve the Unit Coordinator, Staff #1, "They probably wouldn't call until the situation was out of control." The surveyor questioned the safety of the unit, Staff #1 nor Staff #28 called the Unit Coordinator or other staff to the unit in order to achieve the required staff to patient ratio.

The review of the facility's policy titled "Hospital Policy on Searches by Staff Involving Patients/Residents" read: "...Contraband is defined as any item which is prohibited by hospital policy for a patient/resident to posses ...At any time during hospitalization patient's clothing, belongings or room may be searched by staff. Searches are to be conducted in such a manner as to protect the Constitutional and Statutory rights of a patient to privacy and dignity and freedom from unreasonable search and seizure while still ensuring the protection and safety of all patients, visitors and staff ..."

The review of the facility's policy titled "Nursing Services Policy and Procedure for Unit and Patient Room Searches" read: "1. A safe, therapeutic environment will be maintained on each patient unit. 2. Harmful items, illegal substances, contraband, or stolen articles will not be present on the unit, in a patient's room or in patient's possession ... 8. Unsafe items: weapons, glass, sharp objects, ... Outcome Standards: 14. The patient rooms and units shall be free of any unsafe contraband ... 15. Patients and the environment shall remain safe ..."



25746


During observations on Unit 7A on 9/15/11 Patient #13 was observed calling out to the Director of Plant Operations who was on the way out of a door that leads to the outside. Patient #13 then approached Staff member #6 and asking if she could speak with her. Staff member #6 stated, "I will talk to you in a minute, I am giving report." Patient #13 approached a 2nd staff member and asked if she could talk to her. The 2nd staff member stated she was in report. Patient #13 approached a 3rd staff member who did not respond to her. Patient #13 again approached Staff member #6 who stated, "I told you I was in report and I will talk to you when I am done." Patient #13 then approached the Director of Risk Management and told her the door the Director Plant Operations had gone through did not close. The Director Risk Management was told by the surveyor the above observations. The Director of Risk Management thanked Patient #13.

Based on observations, medical record review and staff interview the nursing staff failed to ensure physician ordered calorie count and timed toileting were performed for one of eighteen patients (Patient #2)

The findings included:

1. Observations were conducted on the neurobehavioral unit during meal times on September 14, 2011 and September 15, 2011 for the breakfast and lunch meals. The observations revealed Patient #2 would become agitated displaying the following behaviors: making loud noises, pulling at objects and attempting to get inside the unit kitchen area or pushing on the kitchen door. The observations were conducted in the presence of Staff #1. Staff #1 reported Patient #2 had Prader-Willi Syndrome, a disorder that included insatiable hunger and developmental delays. Staff #1 stated, "[Patient #2's name] has aggressive behaviors and tantrums related to food. The problem with Prader-Willi children is family members tend to give in to the behaviors and the children become morbidly obese."

Review of Patient #2's medical record revealed a physician's admission order dated "07/21/11" to place Patient #2 on "Wt (weight) Management Protocol ..." A subsequent physician's order directed nursing staff to maintain a "calorie count." A physician's order dated "8/8/11" read: "Cal (calorie) ct (count) sheets need to be completed (underlined) every shift." A physician's order dated 8/23/2011 read: "Place copy of completed (underlined) calorie count sheet each day (underlined) in MD (Medical Doctor) folder for review. Do not leave out any foods eaten."

An interview was conducted on September 15, 2011 with Staff #15, a Behavioral Counselor (BC) in the presence of Staff #1, the Director of Nursing. Staff #15 reported the "MD folder" was located within the "Kardex" binder. Review of the MD folder revealed laboratory reports but did not contain Patient #2's calorie count sheets. Staff #15 reported the calorie count sheets were attached to the daily "Blue Sheets", which staff recorded patient's activities, behaviors and every fifteen minute checks. Staff #15 reported the sheets were turned in at night. Staff #1 asked Staff #20, a Registered Dietitian (RD) where the calorie count sheets were located. Staff #20 reported Patient #2 was followed by a different RD (Staff #24). A request was made for Patient #2's calorie count sheets for the months of August, 2011 through September 14, 2011.

On September 16, 2011 Patient #2's calorie count sheet were made available. Less than thirty calorie count sheets were provided for the requested time period, of the sheets provided the last date was September 5, 2011: seventeen (17) of the sheets were blank with nothing recorded, six (6) sheets were incomplete with only one or two meals recorded for the day and six (6) dates within the time periods were missing.

An interview was conducted on September 16, 2011 at 9:35 a.m. with Staff #24. Staff #24 reported awareness of the incomplete calorie count sheets for Patient #2. Staff #24 stated, "I have addressed the issue with nursing and [Staff #1's name]."

An interview was conducted on September 16, 2011 at 11:18 a.m. with Staff #1, Staff #3, the Administrator and Staff #2, Risk Manager. Patient #2's calorie count sheets were reviewed; Staff #1 verified nursing staff had not followed the physician's order to complete calorie count sheets for every day, which detailed all foods Patient #2 had eaten.

2. Review of Patient #2's medical record revealed physician's admission orders, which included "Timed toileting, enc (encourage) Pt (Patient) to request." Review of Patient #2's treatment plan included "Timed toileting, while awake."

An interview was conducted on September 14, 2011 at 2:08 p.m. with Staff #1 and Staff #28 (the RN Charge Nurse). Staff #28 stated "Timed toileting as I understand it, means toileting every two hours." A request was made to review the documented toileting schedule for Patient #2. Staff #28 retrieved Patient #2's Blue Sheet and reported the toileting schedule is not attached. When questioned by Staff #28, Staff #14, a Behavioral Counselor (BC) stated, "We haven't been filling out a toileting sheet for [Patient #2's name]." A request was made for the facility's policy for timed toileting.

An interview was conducted on September 15, 2011 at 2:05 p.m. with Staff #1. Staff #1 reported the facility did not have a policy, procedure or best practice information to guide staff's performance related to timed toileting or a standard for how timed toileting was defined.

A review of Patient #2's daily nursing documentation and interview was conducted on September 16, 2011 at 9:00 a.m. with Staff #1. Calculation of Patient #2's documented episodes of urinary and bowel incontinence for the day and afternoon shifts only, since the physician's order read "while awake", were completed for the month of August 2011 and for September 1 through 14, 2011. The documentation revealed Patient #2 experienced during August, 2011; one hundred-twenty four (124) episodes of urinary incontinence and twenty-two (22) episodes of bowel incontinence on the day and afternoon nursing shifts. For the time period of September 1 to 14, 2011 the nursing documentation was incomplete or non-descriptive of the number of incontinence episodes; from the documented data Patient #2 had experienced sixty (60) episodes of urinary incontinence and eight (8) episodes of bowel incontinence during the day and afternoon nursing shifts. Staff #1 reported "doubts" that staff were performing timed toileting and stated "She (Patient #2) should not be incontinence that many times." Staff #1 verbally acknowledged nursing staff had not been completing a toileting schedule sheet for Patient #2 and had not been following the physician's orders.

According to Lippincott Manual of Nursing Practice " Eighth edition, Chapter 2, page 17:
" The Standards of Professional Nursing Practice: 1. The standards of professional nursing practice include standards of care and standards of professional performance. 2. The standards of care for professional nursing include assessment, diagnosis, outcome identification, planning, implementation, and evaluation ... Common Departures from the Standards of Nursing Care: Claims most frequently made against professional nurses include failure to make the appropriate assessments, follow physician orders, follow appropriate nursing measures, communicate information about the patient, follow facility policy and procedures, document appropriate information in the medical record ... "

Based on observations, medical record review, staff interview and policy review the facility staff failed to update and implement care plans for five of eighteen patients in the survey sample (Patients #1, #2, and #9 and Patients #5 and 7)

The findings included:

1. Review of Patient #1's medical record revealed the physician's admission orders included program treatment protocols for "Anger Management" and "Impulse Control." On August 20, 2011 a physician's order placed Patient #1 on "Sexually Provocative Behaviors (SPB) Precautions." Patient #1's treatment plan dated "08/23/2011" documented that Patient #1 had a "Risk for Injury." Review of Patient #1's "Kardex" on September 14, 2011 did not reveal it had been updated to include the patient's SPB precautions. The "Kardex" contains patient information, which should be shared between nursing shifts.

Observations conducted on September 13, 2011 at 10:18, while touring the neurobehavioral unit revealed Patient #1 had access to a wire hanger, which had been reshaped. During the observation, Staff #1, the Director of Nursing, reported that wire hangers were not allowed on the units related to the potential for harm. The nursing staff had failed to ensure Patient #1's risk for injury and the risk to other patients as documented in his care/treatment plan had been implemented.

An interview was conducted on September 15, 2011 at 11:02 a.m. with Staff #1 and Staff #7, a Registered Nurse. Staff #7 stated, "[Patient #1's name] had not been out on pass since admission." Staff #7 and Staff #1 reported staff had been unable to determine how Patient #1 obtained a wire hanger. Staff #1 reported the "Kardex" should reflect the patient's treatment plan and should be updated to reflect changes in the patient's care. Staff #1 stated, "We are working on a more efficient way of handing off patients between nursing shifts and the Kardex is supposed to be used at that time." Staff #1 reported that staff from different units float to the neurobehavioral unit and the "Kardex" was a way for that staff to obtain a quick overview of the plan of care for that patient. Staff #1 stated, "[Patient #1's name]'s SPB precautions should have been documented, it's important to his care and well being." Staff #1 verbally verified that nursing staff had failed to implement Patient #1's plan of care related to impulse control and risk for self injury and injury of other patients.

2. Review of Patient #2's medical record revealed physician's admission orders, which included "Timed toileting, enc (encourage) Pt (Patient) to request" and "Assist with ADL's (activities of daily living)." A review of Patient #2's occupational therapy evaluation read: "[Patient #2's name] does not perform any hygiene task." Review of Patient #2's treatment plan included "Assist with ADLs and dressing" and "Timed toileting, while awake."

Observations conducted on September 13, 2011 during initial tour of the neurobehavioral unit revealed Patient #2's hair had not been groomed. Observations conducted September 14, 15, and 16, 2011 on the neurobehavioral unit during preparations by staff to escort patients to school in the mornings revealed Patient #2's hair had not been groomed.

An observation was conducted on September 14, 2011 from 9:48 a.m. through 12:31 p.m. within the neurobehavioral unit in the presence of Staff #1. Patient #2 was escorted to school at 9:28 a.m. however returned to the unit at 9:48 a.m. by staff. Staff redirected the patient by offering television programming; during the two hours and forty-three minutes of observation the staff did not attempt to toilet Patient #2.

An observation was conducted on September 14, 2011 at 2:25 p.m. while Patient #2's family performed combing and braiding of the patient's hair. Patient #2 sat quietly watching television while her family performed the task of grooming her hair.

An interview was conducted on September 13, 2011 at 4:48 p.m. with Staff #29, Registered Nurse, Supervisor. Staff #29 reported Patient #2's hair was not combed every day.

An interview was conducted on September 14, 2011 at 2:08 p.m. with Staff #1 and Staff #28 (the RN Charge Nurse). Staff #28 stated "Timed toileting as I understand it, means toileting every two hours."

An interview was conducted on September 14, 2011 at 4:10 p.m. during the end of the day wrap up with Staff #1 and Staff #3, the Administrator. Staff #1 and Staff #3 reported their expectations for grooming patient's hair: "It should be done every day."

An interview was conducted on September 15, 2011 9:50 a.m. with Staff #1 and Staff #15, a Behavioral Counselor (BC). Staff #15 reported that Patient #2 did not resist the grooming of her hair. Staff #15 reported the patient's hair was thick and took time to groom. Staff #15 reported that when Patient #2 had been on a different unit the staffing for the unit had been one staff for every two patients and more assistance could be provided. Staff #1 reviewed Patient #2's medical record and reported Patient #2 remained on 1:2 staffing ratio. Staff #1 reported the same assistance that had been provided on the other unit should have been provided on the patient's current unit.

A review of Patient #2's daily nursing documentation and interview was conducted on September 16, 2011 at 9:00 a.m. with Staff #1. The surveyor calculated Patient #2's documented episodes of urinary and bowel incontinence for the day and afternoon shifts only, the night shift episodes of incontinence was not included related to the physician's order "while awake." The calculations were completed for the month of August 2011 and for September 1 through 14, 2011. The nursing documentation revealed Patient #2 experienced during the month of August, 2011; one hundred-twenty four (124) episodes of urinary incontinence and twenty-two (22) episodes of bowel incontinence on the day and afternoon nursing shifts. For the time period of September 1 to 14, 2011 the nursing documentation was incomplete (nothing recorded) or non-descriptive of the specific number of incontinence episodes (Incontinent recorded); from the documented data Patient #2 had experienced sixty (60) episodes of urinary incontinence and eight episodes of bowel incontinence during the day and afternoon nursing shifts. Staff #1 reported "doubts" that staff were performing timed toileting and stated "She (Patient #2) should not be incontinence that many times."

3. Review of Patient #9's medical record revealed a physician's order dated August 20, 2011, which placed the patient on "Sexually Provocative Behaviors (SPB) Precautions." A physician's order dated August 23, 2011 read: "renew SPB..." A Physician's order dated August 28, 2011 read: "SPB is a protocol which stands until discontinued & (and) doesn't need q (every) 3 day evaluation and renewal."

Review of the nursing documentation from August 23, 2011 through the patient's discharge on September 6, 2011 revealed:
? On 8/23/11; 8/29/11; 8/30/11 and 9/2/11 nursing failed to indicate assessment of Patient #9's SPB precautions on the day and afternoon shifts.
? On 8/25/11; 8/27/11; 8/28/11; 9/3/11; 9/4/11; 9/5/11 and 9/6/11 nursing failed to indicate assessment of Patient #9's SPB precautions on all three shifts.
? On 8/24/11 and 9/2/11 the documentation could not be determined. Staff #1 verified the inability to determine what had been documented.

Review of the "Nursing Plan of Care" dated "08/31/11" did not document Patient #9 had been places on SPB precautions.

An interview was conducted on September 16, 2011 at 9:20 a.m. with Staff #1. Staff #1 reviewed the nursing care plan dated August 31, 2011 and reported Patient #9's SPB precautions had not been addressed. Staff #1 stated, "It (SPB precautions) should have been included." Staff #1 reviewed Patient #9's medical record and stated "I see no order to discontinue [Patient #9' name]'s SPB precautions ..." Staff #1 reported nursing should have documented on each shift that Patient #9's SPB had been assessed.

An interview was conducted on September 16, 2011 at 11:10 a.m. with Staff #1 and Staff #2, Risk Manager. Staff #1, Staff #2 and the surveyor reviewed Patient #9's medical record and nursing documentation for August 23, 2011 through September 6, 2011. Staff #1 and Staff #2 verified for twenty-seven (27) shifts staff failed to indicate assessment of Patient #9's SPB precautions. The question was posed if the staff during those shifts did not realize Patient #9 was on SPB precautions how was the safety of the other patients maintained; Staff #1 and Staff #2 could not provide information other than there had been no reported incidents of sexual abuse.

Review of the facility's policy titled "Nursing Service Policy and Procedure on Transcription of Physician's Orders" read: "1. To insure [sic] correct transcription of physician's orders. To insure [sic]prompt initiation of therapies, treatments and test ... 4. To facilitate communication ... Restrictions/Precautions ... in the Restrictions/Precautions section of the Kardex ..."

Review of the facility's policy titled "Nursing Service Guidelines on Performing Twenty-four Hour Nightly Chart Checks" read: "Purpose: To ensure accurate transcription of all physicians' orders ... 7. Review and update the Kardex ..."



25746


Based on a review of the clinical record, staff interview and observations the facility staff failed to ensure 2 patients, Patients #5 and #7 had their glasses in order to see correctly.

Patient #5 was a 16 year old admitted on 7/27/11 with the diagnosis of Cystic Fibrosis, Diabetes and Macular Hypoplasia (according to eNotes.com Macular hypoplasia, also known as fovea hypoplasia, is a rare medical condition involving the underdevelopment of the macula, a small area on the retina (the eye's internal surface) responsible for seeing in detail. Macular hypoplasia is often associated with albinism.).
Patient #5's initial Nursing Assessment dated 7/27/11 noted Patient #5 "needs and eye appointment."
A physician's order indicated on 8/19/11 Patient #5's glasses were to be fixed. On 8/31/11 a physician's order indicated Patient #5 was to have an eye exam. An interview with the Assistant Director of Nursing (ADON) was conducted on 9/14/11. The ADON stated, "We are waiting to see how the eye exam will be for." On 9/14/11 Patient #5 was asked if he had his glasses and he stated, "I am still waiting for an eye exam."
According to the University of Houston's University Eye Institute "Albinism is a hereditary deficiency of pigmentation, which may involve the entire body (complete albinism) or a part of the body (incomplete albinism). It is believed to be caused by an enzyme deficiency involving the metabolism of melanin during prenatal development and is typically inherited as an autosomal recessive trait. In complete albinism, there is usually lack of pigmentation in skin and hair, as well as in retinal & iris tissue. In ocular albinism, function may vary from normal to impaired and may involve the retina (especially the macula) and iris. Photophobia (sensitivity to light), nystagmus (irregular eye movements), and refractive error (near and far sightedness) are often present. If acuity is decreased, it commonly ranges between 20/70 and 20/200. The condition does not progress. The ocular symptoms of albinism are corrected with tinted or pinhole contact lenses, absorptive lenses, optical aids, and lowered illumination if needed."

Patient #7's clinical record was reviewed on 9/14/11 and the following was noted. Patient #7 was admitted to the facility on 4/13/11 with the diagnosis of Fetal Alcohol Syndrome and Post Traumatic Stress Disorder. Patient #7's History and Physical on 4/13/11 indicated she wore glasses but they had been lost. Patient #7's most recent complete Medication Administration Record indicated from 9/5-10/11 she complained of a head ache 9 times.
Staff member #16 was interviewed on 9/15/11 regarding the glasses for Patient #7. Staff member #7 stated, "Her (Patient #7's) mother indicated she would obtain glasses for her (Patient #7) when she (Patient #7) went on pass. She (Patient #7) has not earned a pass since she was admitted."

Based on medical record reviews and staff interview nursing staff failed to administer physician ordered medications as prescribed for three of eighteen patients in the survey sample. (Patients #1, #3, and #9)

The findings included:

1. Review of Patient #1's Medication Administration Record (MAR) for September, 2011 revealed: Clonidine 0.1 mg (milligram) prescribed by the physician to be given at "7 AM, 2 PM and 8 PM had not been documented as administered on September 6, 2011 at 2:00 p.m. Nursing did not document on the MAR or in the shift charting why the medication had not been administered and if the physician had been notified of the missed dose. [Clonidine is utilized for behavior control.]

2. Review of Patient #3's medical record revealed the patient had been admitted to the facility on September 7, 2011 with a diagnosis of seizure disorder. Review of Patient #3's MAR for September, 2011 revealed: Seroquel 300 mg one tablet, Depakote ER 500 mg two tablets, Depakote 250 mg one tablet and Keppra 500 mg one tablet had not been administered at 8:00 p.m. on September 8, 2011 per physician orders. [Depakote and Keppra are medications generally prescribed for seizure disorder and Seroquel is utilized for mood disorder.]

3. Review of Patient #9's medical record revealed nursing staff failed to administer the following medications:
? Hydrocortisone cream 2.5 % [for eczema] prescribed twice daily- both doses were not administered on August 6, 2011. Nursing listed the medication as not available on August 7 and 8, 2011; review of nursing documentation did not reveal the physician had been notified of the medication not being available. The 7:00 a.m. dose was not administered on August 9 and 12, 2011. The 8:00 p.m. dose on August 20, 2011 and the 7:00 a.m. dose for August 26, 2011 were not administered.
? Depakene 500 mg/10 ml (milligram/milliliter) 20 ml prescribed three times daily- the 8:00 p.m. dose on August 8, 2011 had not been administered. [Depakene is a seizure disorder medication.]
? Flovent HFA prescribed inhale two puffs was not administered at 7:00 a.m. on August 26, 2011

An interview was conducted on September 15, 2011 at 3:22 p.m. with Staff #1, the Director of Nursing. Staff #1 reviewed the MAR information. Staff #1 reported nursing staff were to document the reason why a medication was not administered. Staff #1 reported Patient #1, #3, and #9's medical records did not have documentation to support that the medications had been administered or a reason why the patients' medications had not been administered.

Based on observations, staff interview and medical record review the facility staff failed to ensure Sodium Bicarbonate specifically ordered for 1 patient, Patient #18 for medical emergencies was not expired.
The Findings Include:
During the initial tour of the facility on 9/13/11 the medication cart on 6A was inspected. The medication cart contained four 50 milliliter bottles of sodium bicarbonate with an expiration date of August 1, 2011. The sodium bicarbonate was labeled with Patient #18's name. The medication nurse stated, "I am going to call the pharmacy right now."
Patient #18 was a 16 year old admitted on 4/8/11 with the diagnosis of McArdle's Disease. McArdle's Disease as defined by www.ParkhurstExchange.com (Parkhurst provides clinical, medical news and travel publications to physicians and their patients and maintains a variety of related websites.)
"There is a reported risk of acute muscle damage, with certain general anaesthetics (usually muscle relaxants and inhaled anaesthetics), although in practice problems appear to be very rare. The anaesthetist should be made aware of the diagnosis of McArdle's disease, and may choose to avoid certain anaesthetic agents. Tourniquets should not be used during operative procedures in patients with McArdle's disease.
Myoglobinuria can have many causes, including traumatic (crush injury), metabolic (enzyme deficiencies, such as McArdle's disease), toxic (alcoholism, street drugs) or infectious. The acute episode is treated by rest, maintaining adequate urine flow with hydration and diuretics, alkalinization of urine with sodium bicarbonate, and staying alert to prevent and/or treat two common complications, namely acute renal failure and compartment syndromes. Your patient with exercise-induced myoglobinuria may require further evaluation to assess the possibility of muscle phosphorylase deficiency (McArdle's disease). In this condition, glycogen breakdown is inhibited, leading to pyruvate shortage and impaired energy output."
Muscular-Dystrophy.org stated, "Most people with McArdle's disease will develop myoglobinuria at some time in their lives. Myoglobinuria is a dark discoloration of the urine from a red- brown color (mild) to a brown-black color (severe). This is a warning sign for acute renal failure, which can occur if severe muscle damage has occurred. If this happens the kidneys stop producing urine because the draining tubules become blocked with the products of muscle breakdown.
If the episode of pain and contracture was not too severe myoglobinuria will be transient and lighter in color. After more severe episodes the muscles may be swollen and tender and there may be flu like symptoms. Minor symptoms are managed by increasing fluid intake to maintain a good urine output. More severe episodes will require an admission to hospital for intravenous fluids and if kidney failure occurs, a period of dialysis may be required. Kidney failure is almost always reversible, but expert treatment is required immediately to prevent complications during the acute stage. It is, therefore, very important to seek medical help early should any of these symptoms occur."

Based on observations, staff interview and clinical record review the facility staff failed to ensure the dietary supplements available for patient consumption was not expired.

The Findings Include:

Patient #5 was a 16 year old admitted on 7/27/11 with the diagnosis of Cystic Fibrosis, Diabetes and Macular Hypoplasia. Patient #5 was initially ordered Boost Plus dietary supplements with every meal and for snacks. Patient #5's Care Plan dated 8/17/11 indicated Patient #5's body mass index was 17.9 and that he had lost 1.2 pounds since his admission.

An observation on September 13, 2011 at 5:00 p.m. within Bldg. 7's nursing storage room revealed the following expired nutritional supplements were available for patient consumption: Twelve containers of Boost dated 05/23/2011; one container of Pedisur dated 1June 2011, seven containers of Peptumen Vanilla dated 4/28/11 and twenty-four containers of Osmolite dated 1 May 11. The observation was conducted in the presence of Staff #1 (the Director of Nursing). Staff #1 verified the dates and reported the nutritional supplement should have been thrown away by the expiration date.

Based on observations and staff interviews the staff failed to ensure the environment was kept clean and safe for patients, visitors and staff.

The Findings Include:

During the initial tour of the facility on 9/13/11 the following environment issues were noted:
Building #6A:
Medication cart had a noticeable amount of dust and dirt on all sides of the cart.
Building #6B:
Room 204 drawers were missing and broken
Metal coat hanger found
Room 203 pillows with holes
Room 206 drawers missing and not working
Vents had significant amount of dust in them
2 of 3 hand gel cleaners empty
Building #7A:
Room 307 torn mattress, drawer missing from chest of drawers
Room 305 torn mattress
Room 304 overhead light had numerous bugs in it
Medication cart dirty, dried pudding
Floor in girls bathroom had cracks at least 1/4 inch or larger
Building #7B:
Room 404 dirty feeding pump stand
Room 406 Blind will not lower, drawer broken, vent dirty
Bathroom #2 (farthest from nursing station) rusted broken face plate in back of toilet
Table in common area has broken jagged edges
Building #8:
Medication room had no working light
Room 505 vent dirty, broken metal door stop, broken jagged drawers, sharp exposed drawer guides
Seclusion/Time out room broken over head light nearest to door, screws backing out of cover on far light, vents dirty
Janitor closet water dripping on floor from pipe coming out of far wall.
Physical Therapy:
Vents dirty, ceiling tiles brown from water leaks
Gym:
Broken tiles on floor, broken over head light cover

The Director of Plant Operations was interviewed on 9/16/11 regarding repairs and renovations. He provided a work order summary list. The work order list indicated some maintenance issue were be deferred until renovations were completed for the specific unit.

Based on observations, staff interviews and documentation of work orders the facility staff failed to ensure potential infection control issues were prevented; opened pudding used to give medications to patients was stored in a cabinet, mats in seclusion room and physical therapy had holes making the surface porous and unable to disinfect, and replacement of refrigerator identified as unable to maintain a correct temperature. And failed to ensure expired items on the crash cart in building #6 were not available for use.

The Finding Include:

During the initial tour of the facility on 9/13/11 on Unit 6B an opened container of pudding was found in the cabinet over the medication cart. The medication nurse stated, "I opened it around 7 or 7:30 this morning to administer medications. I was saving it to use with the medications at noon. I should have thrown it away."

The vents in patient rooms, medication areas, linen areas, physical therapy, seclusion/time out rooms and common areas were all very dirty and covered in dust.

The mats in the seclusion room on unit 8 had tears. Three mats in the physical therapy department had tears.

The refrigerators for the storage of patient food on Unit 6B and 7A were identified as having problems maintaining an appropriate temperature. On 9/6/11 the refrigerator on 6B was identified as needing to be repaired because the temperature was greater than 41 degrees and on 9/6/11 it was recorded as 51 degrees.

The temperature in the refrigerator on 7A was identified on 8/18/11 and 9/6/11 as not maintaining the appropriate temperature and on 8/8/11 as having a foul odor. The Work Order Summary List notes on 8/18/11 "we will continue to monitored the temp for now.(Name of Administrator) has plans to purchase a new fridge for the unit."

The crash cart on building #6 had the following expired items:
1 peritoneal drain bag with an expiration date of 05/2004,
1 Ethilon 3-0 sutures with an expiration date of 7/11,
3 sets of Tenumo 25 gauge winged infusion sets with an expiration date of 8/2001
3 sets of 23 gauge winged infusion sets with expiration date of 8/2001
3 four way stopcocks expired 12/2010
6 needles 22 gauge 1 and 1/2 inches expired 8/2011
2 lock cannulas expired dates of 3/2011

Emergency Box on Unit #8 had the following expired items:
1 Cepto Seal IV kit expired 1/09
3 winged IV infusion sets expired 2/2008
9 Jelco IVs various sizes expired 2010
1 bag of 0.9% Sodium Chloride expired 8/2011
1 bag of 5% Dextrose expired 8/2011