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23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS

Tag No.: A0115

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Patient's Rights as evidenced by failure to ensure all patients received care in a safe setting. This deficient practice was evidenced by:
1) Record review and interview revealed the hospital failed to ensure the hospital's direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills or CPI when it identified that out of a total of 201 employees on the active roster, 112 employees were delinquent in CPI certification; furthermore, the hospital failed to implement an effective plan of correction to increase compliance regarding staff competency (See findings under A-200);
2) Record review and interview revealed, the hospital failed to ensure the direct care staff were educated, trainned and demonstrated knowledge including the periodic recertification related to CPR (cardiopulmonary resuscitation) when it identified that out of a total of 201 employees on the active roster, 111 employees were delinquent in CPR certification; furthermore, the hospital failed to implement an effective plan of correction to increase compliance regarding staff competency (See findings under A-206); and,
3) Observation of the hospital's Glucometer Calibration and Control Logs on multiple patient units revealed no documentation of quality controls being performed (See findings under A-144).

An Immediate Jeopardy was identified on 03/29/2023 at 4:25 p.m. and reported to S1CEO, S4RN, S5RN and S7RM. The Immediate Jeopardy situation was the result of the hospital failing to ensure there was enough direct care staff trained in CPI and CPR scheduled to ensure the safety of all current and future admits.

On 03/30/2023 at 10:05 a.m., S4RN presented the plan for lifting the immediacy of the IJ which included the assurance that all direct care staff working with patients were current in CPI and CPR The hospital conducted trainings related to CPI and CPR beginning 03/29/2023 through 03/30/2029. A review and reconciliation through verification of the daily nursing staffing schedule for 03/30/2023 day and night shifts revealed all direct care staff assigned to the patient units and the admission department were current in CPI and CPR certification.

On 03/30/2023 at 4:10 p.m. the IJ was removed; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by no signed consent for treatment or signed patient rights information form for 1(#3) of 2 (#3 and #4) patients sampled from the Intensive Outpatient Program (IOP). .
Findings:

A review of facility policy titled "Client Rights" revealed, in part: Department: Behavioral IOP - Policy: A "Clients Rights" statements are provided for each client upon admission and posted in a prominent place in the program. If the client is unable to read, the statement will be read to them by a staff member. Procedure, in part: The signed "Client Rights" form is part of the client's record.

A review of Patient #3's medical record revealed, in part, that patient was admitted on 12/05/2023. Further review failed to reveal evidence of a signed consent for treatment. Continued review failed to reveal evidence of a signed document indicating Patient #4 was informed of their patient rights.

In an interview on 03/28/2023 at 4:03 p.m. S6DC confirmed there was no evidence of a signed consent for treatment. S6DC further confimed there was no evidence of a signed document that Patient #3 was informed of their patient rights.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

40548




48051




Based on observations, record reviews and interviews, the hospital failed meet the requirements for the Condition of Participation for Patient's Rights as evidenced by failure to ensure all patients received care in a safe setting. This deficient practice was evidenced by:
1) The presence of toilet paper dispensers secured to the walls in the hall bathrooms of units a, b, c, d, e and f presenting ligature risks;
2) The presence of telephone cords longer than 3 feet located in the patient care areas of units a, b, c, d, e and f. presenting ligature risks;
3) The presence of many fluorescent lights under the exterior breezeway connecting the buildings missing light covers and missing bulbs with open electrical bulb sockets;
4) The presence of plastic liners in large garbage cans accessible to patients on units a, b, c, d, e and f. presenting a risk of harm to self or others;
5) The presence of a mattress with a covering that was accessible by a zipper in room h;
6) Observation of the hospital's Glucometer Calibration and Control Logs on multiple patient units revealed no documentation of quality controls being performed; and,
7) The presence of partitions in disrepair between the bathroom commodes in the short hall of building c and the short hall of building e presenting ligature risks.
Findings:

Review of the policy and procedure titled, "Patient Rights, Responsibility and Advocacy" effective 01/02/2013 and most recently revised on 06/13/2022 revealed, in part, safety is a responsibility of staff and patients working as a team to provide a safe, therapeutic environment.

1) The presence of toilet paper dispensers secured to the walls in the hall bathrooms of units a, b, c, d, e and f presenting ligature risks;

An observation on 03/27/2023 at 1:40 p.m. revealed toilet paper holders on the long and short halls of unit a presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 2:28 p.m. revealed toilet paper holders on the long and short halls of unit b presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 2:50 p.m. revealed toilet paper holders on the long and short halls of unit c presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 3:12 p.m. revealed toilet paper holders on the long and short halls of unit d presenting ligature risks to patients and this observation was verified by S13Main; and
An observation on 03/27/2023 at 4:10 p.m. revealed toilet paper holders on the long and short halls of unit e presenting ligature risks to patients and this observation was verified by S13Main.


2) The presence of telephone cords longer than 3 feet located in the patient care areas of units a, b, c, d, e and f. presenting ligature risks;

An observation on 03/27/2023 at 1:35 p.m. revealed a telephone cord in excess of 3 feet in length in the dayroom of unit a connected to a landline presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 2:20 p.m. revealed a telephone cord in excess of 3 feet in length connected to a landline on unit b presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 2:45 p.m. revealed a telephone cord in excess of 3 feet in length connected to a landline on unit c presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 3:05 p.m. revealed a telephone cord in excess of 3 feet in length connected to a landline on unit d presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 3:55 p.m. revealed a telephone cord in excess of 3 feet in length connected to a landline on unit e presenting ligature risks to patients and this observation was verified by S13Main;
An observation on 03/27/2023 at 3:58 p.m. revealed a large padlock in the hall of unit f on the fire extinguisher closet presenting a danger to patients and was verified by S5RN;
An observation on 03/27/2023 at 4:15 p.m. revealed a telephone cord in excess of 3 feet in length connected to a landline on unit f presenting ligature risks to patients and this observation was verified by S13Main.

3) The presence of many fluorescent lights under the exterior breezeway connecting the buildings missing light covers and missing bulbs with open electrical bulb sockets.
On 03/29/2023 at 8:10 a.m. a tour of Unit a and Unit b with S5RN and S1CEO revealed multiple light fixtures under the breezeway connecting the builds with missing light covers, exposed fluorescent bulbs, missing fluorescent bulbs and exposed open bulb sockets. It was noted that some lights were functioning.
In an interview on 03/29/2023 at 8:10 a.m. S5RN and S1CEO verified the above findings and stated the electricity was connecting to all the light fixtures. They also verified the lights could be a safety issue if a resident were to jump and grab the bulbs and or open fixtures with electricity.

4) The presence of plastic liners in large garbage cans accessible to patients on units a, b, c, d, e and f. presenting a risk of harm to self or others;

An observation on 03/27/2023 at 2:25 p.m. revealed a large plastic trash bag at the outside of door of unit a and a large garbage can with a plastic liner on the inside of the door of unit a presenting a potential risk to patients and staff; this was verified by S13Main;
An observation on 03/27/2023 at 2:54 p.m. revealed a large plastic trash can on the inside of the entry door to unit b presenting a potnetial risk to patients and staff; this was verified by S13Main;
An observation on 03/27/2023 at 3:07 p.m. revealed a large plastic trash can with a plastic liner on unit c where patients had access presenting a potential risk to patients and staff members and this was verified by S13Main;
An observation on 03/27/2023 at 3:55 p.m. revealed a large plastic trash can with a plastic liner on unit d where patients had access presenting a potential risk to patients and staff members and this was verified by S5RN;
An observation on 03/27/2023 at 4:01 p.m. revealed a large plastic trash can with a plastic liner on unit e where patients had access presenting a potential risk to patients and staff members and this was verified by S13Main;
An observation on 03/27/2023 at 4:23 p.m. revealed a large plastic trash can with a plastic liner on unit f where patients had access presenting a potential risk to patients and staff members and this was verified by S13Main/

5) The presence of a mattress with a plastic covering that was accessible by a zipper in Patient Room h;
An observation on 03/27/2023 at 2:55 p.m. of room h revealed a mattress with a covering that can be removed and/or replaced by a zipper access. Further observation revealed the zipper cover could be accessed for hidden storage or removed and used for potential self-harm or harm to others.

In an interview on 03/27/2023 at 2:55 p.m., S13Main verified the presence of the mattress and stated it should not be on the unit and would be immediately removed.

6) Observation of the hospital's Glucometer Calibration and Control Logs on multiple patient units revealed no documentation of quality controls being performed; and,

Review of the hospital's Policy #: NS-404, Section D, Item 1, revealed, in part, Control Test frequency is performed daily prior to the night medication pass, by the medication nurse, for each day that the glucometer is in use. If no diabetic patient was on the unit, document "No Active Diabetic on Unit."

Review of Unit a-e Glucometer Calibration and Control Log revealed the following missing documentation for either a Control Test performed or the entry, "No Active Diabetic on Unit," on the first 26 days of this month (March, 2023).
Unit a: failed to reveal documentation on March 1,3-6,9,10,12-15,18,19,23,24 of 2023;
Unit b: failed to reveal documentation on March 1,6,10,15,20,24 of 2023;
Unit c: failed to reveal documentation on March 1,4,6,9-11,15,19,20,22-24 of 2023;
Unit d: failed to reveal documentation on March 1,2,4-6,8-10,16 of 2023;
Unit e: failed to reveal documentation on March 1-3,6-8,11-13,16,17,21,22,25,26 of 2023.


7) The presence of partitions in disrepair between the bathroom commodes in the short hall of building c and the short hall of building e presenting ligature risks.

An observation on 03/27/2023 at 2:25 p.m. revealed the bathroom in the short hall of building c had a partition between the commodes that was approximately 5 ft. tall creating a ligature risk. Continued observations revealed pieces of wood on each side of the commodes, opposite the partition creating a ligature risk.

In an interview on 03/27/2023 at 2:40 p.m., S13Main reported that the doors had been removed but the framework for the doors remained. S13Main confirmed the framework was a ligature risk.

Observations on 03/27/2023 at 3:00 p.m. revealed the bathroom in the short hall of building e had a partition between the commodes that was approximately 5 ft. tall creating a ligature risk. Further observations revealed pieces of wood on each side of the commodes, opposite the partition creating a ligature risk.

In an interview on 03/27/2023 at 3:00 p.m., S13Main reported that the doors were removed but the framework for the doors remained. S13Main confirmed the framework was a ligature risk.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0200

Based on record review and interview, the hospital failed to ensure the hospital's direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills or CPI when it identified that out of a total of 201 employees on the active roster, 112 employees were delinquent in CPI certification; furthermore, the hospital failed to implement an effective plan of correction to increase compliance regarding staff competency.
Findings:

Review of the active list of employees provided by the hospital revealed 33 Registered Nurses, 15 Licensed Practical Nurses, and 153 Mental Health Technicians.

Review of the January 23, 2023 Performance and Improvement monthly meeting revealed under Education and Training, CPI delinquent 94.

Review of the February 20, 2023 Performance and Improvement monthly meeting revealed under Education and Training, "no data submitted to the Risk Management department".

Review of the March 20, 2023 Performance and Improvement monthly meeting revealed, in part, Section 1. Education and Training with # of delinquent CPI - 112 employees. Further review revealed delinquent CPI numbers will improve in March now that all information has been entered into the system. Continue to report patterns and trends.

In an interview on 03/29/2033 at 10:50 a.m., S7RM verified that the number of delinquencies regarding CPI was "most likely correct".

Review of the nursing staff schedule provided and verified by S3COO for 03/29/2023 revealed the hospital's account of staff members who were certified in CPI as follows (some staff were not included in the accounting and were excluded from the total numbers): 2 of the 12 RNs without CPI, 1 of the 3 LPNs without CPI and 12 of the 47 MHTs working without CPI.

In an interview on 03/29/23 at 10:15 a.m. S2DON indicated there were no QAPI indicators to assess/evaluate the effectiveness and frequency of compliance with the schedules to ensure improved health outcomes.

In an interview on 03/29/2023 at 10:10 a.m. S2DON indicated she worked the unit to fill in and did not have CPI while working on the unit with patients.

An Immediate Jeopardy was identified on 03/29/2023 at 4:25 p.m. and reported to S1CEO, S4RN, S5RN and S7RM. The Immediate Jeopardy situation was the result of the hospital failing to ensure there was enough direct care staff trained in CPI and CPR scheduled to ensure the safety of all current and future admits.

On 03/30/2023 at 10:05 a.m., S4RN presented the plan for lifting the immediacy of the IJ which included the assurance that all direct care staff working with patients were current in CPI or removed from the schedule.

Review and reconciliation through verification of the daily nursing staffing schedule for 03/30/2023 day and night shifts revealed all direct care staff assigned to the patient units and admission were current in CPI certification and those who were not, removed from the schedule.

On 03/30/2023 at 4:10 p.m. the IJ was removed; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0206

Based on record review and interview, the hospital failed to ensure the hospital's direct care staff had the education, training and demonstrated knowledge including the periodic recertification related to CPR (cardiopulmonary resuscitation) when it identified that out of a total of 201 employees on the active roster, 111 employees were delinquent in CPR certification; furthermore, the hospital failed to implement an effective plan of correction to increase compliance regarding staff competency.
Findings:

Review of the policy and procedure titled, "Staff Training and Development" revealed, in part, "mandatory and required training for all personal who is in direct patient care: CPR".

Review of the active list of employees provided by the hospital revealed 33 Registered Nurses, 15 Licensed Practical Nurses, and 153 Mental Health Technicians.

Review of the January 23, 2023 Performance and Improvement monthly meeting revealed under Education and Training, CPR delinquent 50.

Review of the February 20, 2023 Performance and Improvement monthly meeting revealed under Education and Training, "no data submitted to the Risk Management department".

Review of the March 20, 2023 Performance and Improvement monthly meeting revealed, in part, Section 1. Education and Training with # Delinquent CPR - 111. Further review revealed delinquent CPR will improve in March now that all information has been entered into the system. Continue to report patterns and trends.

In an interview on 03/29/2033 at 10:50 a.m., S7RM verified that the number of delinquencies regarding CPR was "the number of staff without CPR may need to be updated".

Review of the nursing staff schedule provided and verified by S3COO for 03/29/2023 revealed the hospital's account of staff members who were certified in CPR and CPI as follows (some staff were not included in the accounting and were excluded from the total numbers): 3 of the 12 RNs without CPR, 2 of the 3 LPNs without CPR, 9 of the 47 MHTs working without CPR.

In an interview on 03/29/2023 at 10:10 a.m. S2DON indicated she worked the unit to fill in and did not have CPR while working on the unit with patients.

An Immediate Jeopardy was identified on 03/29/2023 at 4:25 p.m. and reported to S1CEO, S4RN, S5RN and S7RM. The Immediate Jeopardy situation was the result of the hospital failing to ensure there was enough direct care staff trained in CPI and CPR scheduled to ensure the safety of all current and future admits.

On 03/30/2023 at 10:05 a.m., S4RN presented the plan for lifting the immediacy of the IJ which included the assurance that all direct care staff working with patients were current in CPR or removed from the schedule.

Review and reconciliation through verification of the daily nursing staffing schedule for 03/30/2023 day and night shifts revealed all direct care staff assigned to the patient units and admission were current in CPR certification and those who were not, removed from the schedule.

On 03/30/2023 at 4:10 p.m. the IJ was removed; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.

QUALITY IMPROVEMENT ACTIVITIES

Tag No.: A0283

Based on record review and interview, the hospital failed to ensure the QAPI program focused on indicators related to improved health outcomes and the prevention and reduction of medical errors when it identified that out of a total of 201 employees on the active roster, 112 employees were delinquent in CPI certification, 111 employees were delinquent in CPR certification and the hospital failed to implement an effective plan of correction to increase compliance regarding staff competency.
Findings:

Review of the QAPI Plan revealed, in part, the charge of the performance improvement team is to: 1. Identify, monitor and analyze performance; 2. Share the findings of analyses and make recommendations on possible performance improvement initiatives to the leadership team; and, 3. Collect, analyze and report accurate and consistent data to support performance improvement goals. Performance Measurement is the process of regularly assessing the results produced by the program. It involves identifying processes, systems and outcomes that are integral to the performance of the service delivery system, selecting indicators of these processes, systems aand outcomes, and analyzing information related to these indicators on a regular basis. CCQI involves taking action as needed based on the results of the data analysis and the opportunities for performance they identify.

Review of the active list of employees provided by the hospital revealed 33 Registered Nurses, 15 Licensed Practical Nurses, and 153 Mental Health Technicians.

Review of the January 23, 2023 Performance and Improvement monthly meeting revealed under Education and Training, CPR delinquent 50; CPI delinquent 94.

Review of the February 20, 2023 Performance and Improvement monthly meeting revealed under Education and Training, "no data submitted to the Risk Management department".

Review of the March 20, 2023 Performance and Improvement monthly meeting revealed, in part, Section 1. Education and Training with # of delinquent CPI - 112 employees; # Delinquent CPR - 111. Further review revealed delinquent CPR and CPI #s will improve in March now that all information has been entered into the system. Continue to report patterns and trends.

In an interview on 03/29/2033 at 10:50 a.m., S7RM verified that the number of delinquencies regarding CPI was "most likely correct, however, the number of staff without CPR may need to be updated".

Review of the nursing staff schedule provided and verified by S3COO for 03/29/2023 revealed the hospital's account of staff members who were certified in CPR and CPI as follows (some staff were not included in the accounting and were excluded from the total numbers): 3 of the 12 RNs without CPR, 2 of the 3 LPNs without CPR, 9 of the 47 MHTs working without CPR; 2 of the 12 RNs without CPI, 1 of the 3 LPNs without CPI and 12 of the 47 MHTs working without CPI.

In an interview on 03/29/23 at 10:15 a.m. S2DON indicated there were no QAPI indicators to assess/evaluate the effectiveness and frequency of compliance with the schedules to ensure improved health outcomes.

In an interview on 03/29/2023 at 10:10 a.m. S2DON indicated she worked the unit to fill in and did not have CPR while working on the unit with patients.

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on observation and interview, the hospital failed to properly file and store patient records in a manner to protect them from fire damage as evidenced by storing paper medical records on open shelving without an overhead sprinkler system or other protection from fire.
Findings:

An observation of the medical records department on 03/28/2023 at 2:30 p.m. revealedthere were 7 open shelves approximately 11 feet long with 7 open shelves within a room in the medical records department. The shelves contained paper medical records. Further observation revealed the room failed to contain sprinklers in the ceiling and the door was blocked open by a desk with boxes of medical records stored on top of the desk. Further observation of the medical records department revealed approximately 102 cardboard boxes containing prior patient medical records stored in the open room without sprinklers in the ceiling or other protection from fire.

In an interview on 03/28/2023 at 2:40 p.m. S9DHID indicated the records were being purged to be stored offsite and only parts of the records were scanned prior to boxing the records. S9DHID also indicated the staff started purging the boxed records about a year ago, and also verified the door to the room with the movable shelves was blocked open as noted above.

CONTROLLED DRUGS KEPT LOCKED

Tag No.: A0503

Based on observation and interview the facility failed to store controlled substances locked within a secure area.
Findings:

An observation on 03/27/2023 at 2:05 p.m. revealed a medication room located in Building a with a medication refrigerator. Further observations revealed a "Lockbox" with 2 unopened vials of lorazepam that was unlocked.

In an interview on 03/27/2023 at 2:05 p.m., S12RN stated she forgot to lock the lockbox and then proceeded to lock the lockbox.

SCOPE AND FREQUENCY OF REVIEW

Tag No.: A0655

Based on record review and staff interview, the Hospital failed to ensure a Utilization Review Plan was effectively implemented as evidenced by failing to consistently conduct Utilization Review Committee meetings within the past 12 months, and failing to provide documentation of UR committee meeting minutes for the past 12 months. This deficient practice has the potential to impact any of the patients receiving care at the hospital.
Findings:

Review of the Utilization Review Plan effective 01/17/2013 and last revised on 01/17/2023 revealed, in part, the Utilization Management plan of the hospital is designed to provide an on-going , systematic process for measurement of the necessity, appropriateness and efficiency of the sue of its health care services, procedures and facilities. The Utilization Review Committee shall render review decisions and assist the attending physician, the clinical staff, and facility leadership with resolution of any identified problems or opportunities for improvement.

In an interview on 03/29/2023 at 1:30 p.m. S19UR indicated the UR department presents to the Medical Executive Committee which meets at 1:00 p.m. every 3rd Monday of the month.

Review of the Medical Executive Committee meeting minutes for the previous 12 months revealed, in part, the hospital failed to provide documented evidence of the meetings taking place March, 2022; April, 2022; June, 2022; July, 2022; August, 2022; October, 2022; December, 2022; January, 2023. Further review revealed no meeting minutes for the September 2022 MEC meeting and in November 2022, failure to document UR presenting to MEC..

In an interview on 03/28/2023 at 11:30 a.m., S7RM indicated there were no meeting minutes for 2022 Medical Executive Committee.

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on observation and interview, the hospital failed to maintain the overall hospital environment in such a manner that ensures the safety and well-being of patients. This deficient practice was evidenced by water stains on ceiling tiles located by the entry door of a sprinkler closet and water stains/ceiling tile buckling in the center room of the pharmacy, next to the squared, boxed shaped ceiling area.
Findings:

On 03/28/2023 at 2:15 p.m. a tour of the pharmacy revealed water stains on ceiling tiles located by entry door of a sprinkler closet and water stains/ceiling tile buckling in the center room of the pharmacy, next to the squared, boxed shaped ceiling area.

In an interview on 03/28/2023 at 2:15 p.m., S20Pharm confirmed the presence of these areas on the ceiling tiles. S20Pharm also stated that there has been an issue with a leaking roof around this boxed-in area in center of the pharmacy.

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on record review and interview, the hospital failed to ensure expired or open supplies were not available for patient use. This deficient practice had the potential to affect any patients who needed such supplies in the hospital.
Findings:

Review of the Medline EVENCARE G2 Glucose Control Solutions insert revealed, in part, the solutions were to be discarded 90 days after first opening or after manufactures expiration date. Review of the Medline EVENCARE G2 Glucose Monitoring System User's Guide revealed, in part, the vial cap of the test strip bottle should be immediately closed after each use.

Review of the hospital's Policy #: NS-404 read, in part, Section D, item 1, the control solution and test strips must NOT be expired. These items cannot be used beyond the expiration date or after 90 days of opening. a. the nurse on the unit must then monitor the expiration date to avoid use beyond this date.

An observation on 03/27/2023 at 2:25 p.m. of glucometer controls currently used on Patient Unit b failed to have an open date or beyond use date written on the bottle or the box where they were stored.

In an interview on 03/27/2023 at 2:25 p.m., S14RN confirmed the opened box of controls with no open date or beyond use date.

On 03/27/2023 at 3:35 p.m., an observation of the blood glucose test strips currently in use on Patient Unit d revealed the glucose test strip container top being left open next to the glucometer on the counter of the medication room. This deficient practice may expose the test strips to light and humidity affecting their ability to work properly.

In an interview on 03/27/2023 at 3:35 p.m., S16LPN confirmed the glucose test strip container was opened.

On 03/27/2023 at 4:20 p.m., an observation of glucose controls in use on Patient Unit e revealed two beyond use dates, 03/03/2023 and 03/23/2023, written on the box of the current controls.

In an interview on 03/27/2023 at 4:20 p.m., S17LPN verified the dates written on the box and confirmed that both dates indicated the current solutions being used were expired.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

Based on record review and interview, the hospital failed to meet the Condition of Participation related to infection control as evidenced by:
1) Failure to ensure the glucometer was appropriately cleaned between patient-use per the manufacturer's guideline; (See findings in A-0747)
2) Failure to appoint an Infection Control Preventionist by the governing body; (See findings A-0748)
3) Failure to ensure patient mattress and pillows were free from cracks which prevented effective cleaning; (See findings A-0750)
4) Failure to ensure the pharmacy refrigerator was free from rust so it could effectively be cleaned and the pharmacy air ducts being free from the buildup of a brown substance blowing in the medication room. (See findings A-0750)
5) Failure to ensure a clean and sanitary environment in the bathrooms available for patient use. (See findings A-0750)
6) Failure to ensure a clean and sanitary environment in the kitchen where food is prepared for patient consumption. (See findings A-0750).

INFECTION CONTROL PROFESSIONAL

Tag No.: A0748

Based on record review and interview the hospital failed to appoint an Infection Control Director as evidenced by the hospital having no documentation of appointment by the governing body.
Findings:

A review of Governing Body minutes failed to reveal evidence that the governing body appointed an infection preventionist/infection control professional responsible for the infection prevention and control program.

In an interview on 03/30/2023 at 4:10 p.m., S7RM stated that they were the Infection Control Director by promotion and not by appointment of the governing body.

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on record review and interview, the hospital failed to employ methods for preventing and controlling the transmission of infections. This deficient practice was evidenced by failure to ensure the glucometer was appropriately cleaned between patient-use per the manufacturer's guidelines.
Findings:

Review of the Medline EVENCARE G2 Glucose Monitoring System User's Guide revealed, in part, cleaning instructions with disinfecting wipes listed in the manual or other EPA registered wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use.

Review of the hospital's Policy #: NS-4045, section H: Equipment Maintenance item #2 Disinfecting - clean unit with hospital approved disinfectant wipes prior to and after each use.

In an interview on 03/27/2023 at 2:08 p.m., S12RN on Unit a indicated that she cleans Unit a glucometer with alcohol or cleaning wipes between and after each patient use.

In an interview on 03/27/2023 at 2:25 p.m., S14RN on Unit b indicated that he cleaned the Unit b glucometer with alcohol between and after each patient use.

In an interview on 03/27/2023 at 3:11 p.m., S15LPN on Unit c indicataed that she cleaned the Unit c glucometer with alcohol between and after each patient use.

INFECTION CONTROL SURVEILLANCE, PREVENTION

Tag No.: A0750

48051

Based on observation and interview, the hospital failed to ensure the infection prevention and control program including maintaining a clean and sanitary environment to avoid sources and transmission of infection.
This deficient practice was evidenced by:
1) Failure to ensure patient mattress and pillows were free from cracks which prevented effective cleaning;
2) Failure to ensure the pharmacy refrigerator was free from rust so it could effectively be cleaned and the pharmacy air ducts being free from the buildup of a brown substance blowing in the medication room.
3) Failure to ensure a clean and sanitary environment in the bathrooms available for patient use.
4) Failure to ensure a clean and sanitary environment in the kitchen where food is prepared for patient consumption.
Findings:

1) Failure to ensure patient mattress and pillows were free from cracks which prevented effective cleaning;

A tour of the hospital on 03/27/2023 between 1:55 p.m. and 3:22 p.m. revealed: patient room g with 2 of the 3 mattresses with cracks on the outer coverings and 1 of 4 pillows with cracks on the outer covering; patient room i revealed one pillow with cracks on the outer covering; and patient room h revealed one pillow with cracking in outer covering.

On 03/27/2023 between 1:55 p.m. and 3:22 p.m. interviews with S5RN and S13Main confirmed the presence of cracks on the outer coverings of the above pillows and mattresses.

2) Failure to ensure the pharmacy refrigerator was free from rust so it could effectively be cleaned and the pharmacy air ducts being free from the buildup of a brown substance blowing in the medication room;

A tour of the hospital pharmacy on 03/28/2023 at 2:15 p.m. revealed rust on the medication refrigerator door and a brown substance covering the air-conditioner vents in the medication room.

In an interview on 03/28/2023 at 2:15 p.m., S20Pharm confirmed the presence of rust and commented that she may have made the rust worse by attempting to clean the front of the refrigerator and also stated she was not aware of housekeeping going into the medication room to clean the air ducts.

3) Failure to ensure a clean and sanitary environment in the bathrooms available for patient use;

Observations of the bathroom in building b on 03/27/2023 at 2:15 p.m. revealed the bathroom located on the North Hallway. Further observations revealed missing floor tile in showers with dirt and hair noted. Continued observations revealed a black mold-like substance on the tile walls and a reddish colored mold-like substance on the walls.

In an interview on 03/27/2023 at 2:15 p.m., S13Main confirmed the mold-like substance and the dirty showers. S13Main was unable to confirm the last time the showers were cleaned and stated that housekeeping should be cleaning the showers and bathrooms daily.

Observations of the bathroom in building c on 03/37/2023 at 2:25 p.m.revealed porous wooden pipe covers with grime-like substance creating a medium for bacteria that is an infection control risk.

In an interview on 03/27/2023 at 2:41 p.m., S13Main reported that the wooden pipe covers were in disrepair and were an infection control risk.

4) Failure to ensure a clean and sanitary environment in the kitchen where food is prepared for patient consumption.

Observation of the kitchen area 03/28/2023 at 8:30 a.m., revealed multiple cracked ceiling tiles. Further review revealed water stains noted on ceiling tiles above the food prep area.

In an interview on 03/28/2023 at 8:35 a.m., S11RDN stated the maintenance team have the cracked tiles and leaking area on their list for required repairs.

Neurological Examination

Tag No.: A1626

48051

Based on record review and interview, the hospital failed to complete a neurological examination that included all elements at the time of admissions. This deficient practice was evidenced by:
1) The hospital failed to ensure the Cranial Nerve Assessment was documented on 2(#1 and #2) of 2(#1and #2) medical records sampled for the Cranial Nerve Assessment documentation.
2) The hospital failed to ensure a Cranial Nerve Assessment was completed on 2 (#3 and #4) of 2 (#3 and #4) patients sampled for the Intensive Outpatient Program (IOP).
Findings:

1) The hospital failed to ensure the Cranial Nerve Assessment was documented on 2(#1 and #2) of 2(#1 and #2) medical records sampled for the Cranial Nerve Assessment documentation.

On 03/29/2023 at 10:30 a.m. a review of patient #1 and patient #2's medical record with S5RN failed to reveal a documented Cranial nerve assessment for Cranial nerves IV, Troclear Nerve and V, Abducens Nerve.

In an interview on 03/292023 at 10:30 a.m., S5RN verified the missing documentation.

2) The hospital failed to ensure a Cranial Nerve Assessment was completed on 2 (#3 and #4) of 2 (#3 and #4) patients sampled from the Intensive Outpatient Program (IOP).

A review of the facility policy titled "Admissions from Hospitals" revealed, in part: Department: Behavioral IOP
Policy and Procedure: - When clients are admitted to the Intensive Outpatient Programs from a Hospital or other treatment facility, the following information should be secured from the transferring facility/hospital, in part:
C. History and Physical

Review of medical records failed to reveal evidence of a cranial nerve assessment in 2 of 2 (#3 and #4) patients sampled for the Intensive Outpatient Program (IOP).

In an interview on 03/29/2023 at 12:00 p.m., S6DC stated he did not think a cranial nerve assessment was needed for admission to the IOP.

Psych Eval - Medical History

Tag No.: A1632

Based on record review and interview the facility failed to ensure each patient received a thorough history and physical examination as evidenced by having no documented History and Physical for 2 of 2 (#3 and #4) sampled patients admitted to the Intensive Outpatient Program.
Findings:

A review of the facility policy titled "Admissions from Hospitals" revealed, in part: Department: Behavioral IOP
Policy and Procedure: When clients are admitted to the Intensive Outpatient Programs from a Hospital or other treatment facility, the following information should be secured from the transferring facility/hospital, in part:
C. History & Physical

Review of Patient #3's medical record revealed patient #3 was admitted on 12/05/2023. Further review failed to reveal evidence of a history and physical upon admission.

Review of Patient #4's medical record revealed patient #4 was admitted on 03/23/2023. Further review failed to reveal evidence of a history and physical upon admission.

In an interview on 03/28/2023 at 4:00 p.m., S6DC stated there are no history and physicals to be found on the medical records of Patient #3 and Paitent #4, and he did not think one was needed.

Treatment Plan

Tag No.: A1640

Based on record review and interview the facility failed to ensure each patient had an individualized treatment plan with discharge planning as evidenced by having no documented treatment plans or discharge plans available in the medical records for 2 (#3 and #4) of 2 (#3 and #4) patients sampled from the Intensive Outpatient Program (IOP).
Findings:

Review of facility policy titled "Treatment Plans", revealed in part:
Department: Behavioral IOP
Policy, in part:
Each client will have a written, individualized; interdisciplinary treatment plan based on assessments of his/her clinical needs and strengths.
7. Specific criteria for discharge.

Review of facility policy titled "Documentation of the Treatment/Discharge/Continuing Care Planning Process", revealed in part:
Department: Behavioral IOP
Policy, in part:
The multi-disciplinary treatment team at the Outpatient Program shall develop a written, comprehensive Treatment Plan with specific goals and objectives necessary to address personal needs identified in the assessment process. The treatment plan shall be initiated as a component of the admissions process with continual development by the multi-disciplinary treatment team throughout the course of treatment. The process is under the super vision of the attending physician.

A review of facility policy titled "Discharge Planning", revealed, in part:
Department: Behavioral IOP
Procedure:
A. The clinician will evaluate potential discharge problems and will make recommendations for discharge planning within the social assessment within 3 days of admission.

A review of Patient #3's medical records revealed the patient was admitted on 12/05/2022. Further review failed to reveal evidence of a treatment plan or discharge planning.

A review of Patient #4's medical records revealed the patient was admitted on 03/23/2023. Further review failed to reveal evidence of a treatment plan or discharge planning.

In an interview on 03/28/2023 at 4:00 p.m., S6DC confirmed there was no evidence of a treatment plan or discharge plan for Patient #3 and no evidence of a treatment plan or discharge plan for Patient #4.

Treatment Plan - Substantiated Diagnosis

Tag No.: A1641

Based on record review and interview the hospital failed to ensure a substantiated diagnoses as evidenced by failing to conduct a detailed Suicide Risk Assessment for 2 (#3 and #4) of 2 (#3 and #4) patients sampled from the Intensive Outpatient Program (IOP).
Findings:

A review of facility policy titled "Suicide Risk Assessment" revealed, in part:
Department: Behavioral IOP
Policy: The clinician or RN will conduct a detailed Suicide Risk Assessment of each client upon first day of admission and at discharge.
Purpose: To provide an in-depth assessment of a client's potential risk for Suicide/Self-Harm in order to determine the correct level of care and create a Safety Plan to prevent an incident of Suicide/self-harm.
Procedure: The assigned clinician or RN will conduct the Suicide Risk Assessment for each client upon the first day of admission then at discharge.
The Assessment will include, in part:
1. Identifying Problem Areas Causing Client Need for Treatment:
2. Nature of Suicidal Thinking:
a. Current Suicidal Ideation
b. Current Intent Rate on Scale of 1-10 (Pt. rating)-Subjective/Objective Signs.
Current Suicide Plan-When, Where, How
d. History of suicidiality-Ideation, Single attempt, Multiple Attempts, Precipitant, Nature of Iedation or Attempt, Outcome, Reaction.
3. A Rating Symptom Severeity on a Scale of 1010, where 10 is severe (Pt. Self-Report):
4. Additional Risk Factors.
5. Protective Factors:
6. Acute Risk Rating:
7. Intervention and Plan

A review of patient #3's medical records revealed a Primary DX Code O90.6 (Postpartum depression). Further review failed to reveal documented evidence of a detailed Suicide Risk Assessment as described in the policy and procedure.

A review of patient #4's medical records revealed a Primary DX Code R45.851 (Suicidal Ideations). Further review failed to reveal documented evidence of a detailed Suicide Risk Assessment as described in the policy and procedure.

In an interview on 03/29/2023 at 9:15 a.m., S6DC and S7RM both agreed the suicide risk assessments for Patient #3 and Patient #4 were not appropriately completed.

Personnel - Active Treatment

Tag No.: A1687

Based on observations, record review and interview the facility failed to provide adequate numbers of qualified professional, technical and consultative personnel to allow active treatment measures to occur. This deficient practice is evidenced by the facility not providing active treatment to the adolescent patients in building b.
Findings:

A review of building b's short side schedule for Mondays revealed the following, in part:
01:00-02:00 p.m. Schoolwork+
02:00-03:00 p.m. Group Therapy
03:00-03:30 p.m. Nursing Education

A review of building b's acute side schedule for Mondays revealed the following, in part:
01:00-02:00 p.m. Group Therapy
02:00-02:40 p.m. Media Lounge
02:50-03:30 p.m. Structured Outdoor Time

A review of the document titled "Nursing Rounds" revealed a form containing a checklist. The checklist revealed, in part:

Schedule posted and being followed.
Staff engaged with patients.

A review of the MHT orientation on expected competency and skills revealed, in part:
Address patients with respect
Ability to communicate and interact appropriately, while avoiding power struggles, with age group, including: Use of age appropriate limit setting, language, communication style.
Practices active listening and provides positive encouragement.
Understands the importance of adhering to the schedule.
Creating a Therapeutic Environment
Therapeutic Boundaries
Following the Program Schedule
Patient Abuse/Neglect
Motivate patients to participate in programming
Redirect patients
Follow the daily schedule
Bring patients to therapy groups

Observations of outdoor space on 03/27/2023 between 1:20 p.m. and 3:30 p.m. revealed a group of adolescent girls housed in building b sitting at a picnic table with 2 mental health technicians (MHT) seated at another table. Further observations failed to reveal observable or evident active treatment process occurring. Observations failed to reveal schoolwork occuring. Continued observations revealed a patient laying on her stomach in the cement walk way and another patient laying in the grass. Further observation revealed an MHT using a loud and harsh tone to tell the girls to get off the ground.

In an interview on 03/29/2023 at 10:15 a.m, S4RN and S18MHTS stated the MHTs should be engaged with the patients even at leisure time. S4RN and S18MHTS indicated the scheduled group therapy was delayed due to therapists working on discharges.

In an interview on 03/29/2023 at 10:30 a.m., S8DIT stated that therapy staff consists of 2 full time music therapists.
S8DIT reported that they do not employ enough therapists to have two therapists at a time in each unit and most of the day.