HospitalInspections.org

Based on facility observations, review of the policy and procedures, medical records (MR), and staff interviews, it was determined the facility failed to provide a safe and ligature risk free environment for geriatric psychiatric patients admitted to the Senior Behavioral Care Unit (SBCU) and patients presenting to the Emergency Department (ED) at risk for self-harm. This had the potential to affect all patients admitted to the SBCU and ED.

Findings include:

Please refer to tag A-0144 for findings.

Based on facility observations, review of the policy and procedures, medical records (MR), and staff interviews it was determined the facility failed to:

1. Ensure a safe environment was provided for patients presenting to the ED (Emergency Department) at risk for self-harm.

2. Ensure the geropsychiatric (Geropsych) unit was free from environmental risks which included ligature risks.

These deficient practices affected ED Patient Identifier's (PI) # 9, # 3 and # 7, which was 3 of 3 patients who presented to ED identified at risk for self-harm and all patients admitted to the Geropsch unit and had the potential to negatively affect all at risk patients.

Findings include:

Policy: Suicide Assessment and Preventions
Policy # 9004
Department: Patient Care Services
Reviewed: 05/22/2018

Purpose:

To outline the process for the timely assessment and reassessment of patient's suicide risk and to provide guidelines for safety interventions.

Policy:

...to create an environment of care that will foster the accurate identification and successful management of patients who are at increased risk of suicide or self destructive behaviors. Patients at risk for suicide requires intensive support, close observation, and frequent re-assessment and application of protective measures for their emotional and physical well be at all times. The scope for this plan begins with any patient presenting to our hospital for treatment.

Procedures:

A. Assessment of Suicide Risk:

Initial suicide risk assessments must be performed by members of the clinical staff as part of assessment on all patients.

...The initial suicide risk assessment will include specific factors including:

Presence of suicidal ideation at the time of the assessment
Intent to perform self-harm at the time of assessment
Presence of a plan to carry out the self-harm or attempt suicide...How, When, Where
Previous suicide attempts
Date
Methods used to cause self-harm
How often the thoughts of self-harm and/or suicide occur
Any contributing factors. i.e. death of a family member...job loss, financial hardships, etc.

B. Reassessment of Suicide Risk:

A Registered Nurse (RN) or Licensed Practical Nurse must reassess the risk of self-harm or suicide at least every 12 hours for any patient...on suicide precautions who exhibits a sudden or significant change in mental status.

The assessment should be documented in the Suicide Risk Re-assessment Form...All patients should be re-assessed for risk of self-harm or suicide prior to discharge. If positive findings, the Attending (physician) should be notified immediately prior to discharging the patient.

If the patient is being discharged to a psychiatric facility, then the ideation of self-harm or suicide may still be present.

Documentation of reassessments:

Nursing: Suicide Risk Re-Assessment Form
Physician: Progress Notes

Patient Monitoring:

All patients at risk or self-harm on the Med/Surg Unit will be observed 1:1 at all times....At risk in the ICU (intensive care unit) will be observed via Line of Site observation or 1:1 observation, whichever the Attending Physican's deems more appropriate.

D. Suicide Precautions:

Suicide Precautions will be ordered by the Attending Physican
Staff will document patient behaviors at minimum of every 15 minutes...notify the charge nurse for...suicidal statements or actions...Attempts to gain access to dangerous items such as sharps, cleaning agents, medications...access to contraband

Staff are to maintain a safe and therapeutic environment for patients at risk for self-harm or suicide by implementing the following...

Perform a thorough search of the patient's clothing, personal articles, room and belonging to ensure that any times (things) which might be used in a self-harmful way are confiscated...Remove all potential ligatures (shoelaces, belts, oxygen tubing...suction tubing)...sharps...

E. Safety and Environmental Checks:

Staff are to be continually aware of the environment and immediately correct or report any identified risk, damage, missing linens or any other change in the environment to the Charge Nurse.

Levels of Observation:

Line of Sight: A level of observation wherein the patient remains in staff view at all times...not be video monitoring.
One to One (1:1): Consists of one to one staff observation with a patient never farther away than arm's length. The patient remains within arm's of a staff member at all times.

1. On 5/21/19 at 10:30 AM, a tour of the ED was conducted with Employee Identifier (EI) # 10, ED/ICU Manager. The surveyor asked EI # 10 how the facility ensured patients presenting to the ED who were identified at risk for self-harm were kept safe? EI # 10 responded the patient would be admitted to the trauma room.

The surveyor observed 3 trauma bays thorough an adjoining window at nurses desk. The surveyor then asked EI # 10 how the trauma room was safe with emergency equipment and monitoring equipment (with cords) medical supplies? EI # 10 reported at risk patients have 1:1 monitoring by an ED Nurse or other facility staff while in the ED. The survyeor asked if the 1:1 monitoring was documented medical record? EI # 10 responded, it should be.

1. ED PI # 9 presented to the ED on 2/14/19 and was triaged at 2:46 PM with chief complaint SI( Suicidal Ideation). The ED RN documented patient was found in the woods with three guns.

Review of the 2/14/19 RN Triage Intervention documentation revealed presents with SI with a plan.

Further review of the ED RN Triage Intervention documentation failed to reveal a complete suicide risk assessment was documented which included documentation of past suicide attempt (s) and the frequency of thoughts of self-harm.

Review of the 2/14/19 ER Nurses Notes revealed documentation beginning at 3:00 PM the patient was in line of sight of nurses station. There was no documentation the patient belongings were searched for dangerous items.

Review of 2/14/19 ED physician documentation revealed orders at 3:06 PM for lab testing and chest x ray.

There were no orders for suicide precautions documented.

Review of the ER Nurse Note dated 2/14/19 failed to reveal documentation of the patient behaviors from 4:16 PM until 5:00 PM, which was 45 minutes and from 9:48 PM until 11:02 PM, which was 64 minutes. Staff failed to document patient behaviors every 15 minutes.

The patient was transferred to a local psychiatric unit at 11:02 PM.

There was no documentation the patient was on 1:1 while in the ED and no documentation staff performed a suicide risk re-assessment at discharge.

In an interview on 5/23/19 at 11:35 AM, EI # 10 confirmed the suicide risk assessment was not complete, there was no order for suicide precautions, there was no documentation the patient belongings were searched, patient behaviors was not documented every 15 minutes, there was no documentation the patient was on 1:1 for SI and no documentation a suicide risk assessment was performed at discharge.

2. ED PI # 3 presented to the ED on 1/7/19 and was triaged at 7:15 PM with the chief complaint SI, Bipolar, and Depression.

Review of the RN Triage Interventions dated 1/7/19 at 7:15 PM revealed the following suicide risk assessment documentation: Thoughts suicide; yes, Plan to carry out suicide, no. There was no documentation for previous suicide attempt, method used or frequency of thoughts of harm to self. The Suicide risk assessment documentation was not complete.

Record review revealed the ED physician examined ED PI # 3 on 1/7/19 (Time first examined was not documented). The ED physician documented positive for suicidal ideations without a plan and with recent mood change. Lab tests, x-ray, EKG (electrocardiogram) and Ativan 2 mg were ordered by the physician (no time the tests and Ativan were ordered documented). There were no physician orders for suicide precautions documented.

Review of the 1/7/19 RN ER Note documentation revealed beginning at 7:30 PM to 9:05 PM the patient was in line of sight of nurses station and family at bedside.

Further review of the 1/7/19 RN ER Note documentation revealed at 9:25 PM, Mental Health was at the bedside speaking with the patient.

Further review of physician documentation revealed orders to admit to ICU at 9:30 PM.

Review of the ED RN documentation at 9:55 PM revealed Mental Health requested the patient be admitted to ICU until a bed was available at a local psychiatric unit the next day. At 10:50 PM, the ER RN documented the patient was admitted to ICU and personal belongings sent with the patient.

There was no documentation the patient was placed on 1:1 while in the ED. There was no documentation the patient belongs had been searched for dangerous items or contraband. There was no documentation a suicide re-assessment was performed before discharge to the ICU.

In an interview on 5/23/19 at 11:20 AM, EI # 10, confirmed the ED staff failed to follow the facility suicide assessment and preventions policy.

3. ED PI # 7 presented to the ED on 2/26/19 and was triaged at 9:25 PM with chief complaint SI.

Review of the 2/26/19 9:25 PM RN Triage Intervention documentation and suicide risk assessment revealed complaints of depression with SI, with a possible plan and no previous suicide attempt.

Further review of the ER Nurses Notes revealed documentation every 15 minutes beginning 9:30 PM to 11:30 PM that the patient was resting on stretcher with no acute distress.

Review of ED physician documentation revealed at 10:30 PM, Mental Health was consulted and would to evaluate the next morning. There were physician orders for lab testing, EKG and chest x ray (no time ordered was documented). There were no orders for suicide precautions documented.

Review of the 2/27/19 ER Nurse Notes documentation beginning 12:00 AM to 8:30 AM revealed patient resting on stretcher/in bed, no acute distress noted and/ or no complaints voiced. At 8:30 AM, the RN documented, "Mental Health here for evaluation." At 9:15, AM the RN documented the patient was eating breakfast, no distress noted.

There was no documentation staff performed a suicide risk re-assessment at least every 12 hours, which was at 9:25 AM on 2/27/19.

There were no patient behaviors documented 2/27/19 from 1:30 PM to 2:05 PM, which was 35 minutes.

At 2:45 PM, the ED RN documented no available bed at named psychiatric unit. At 3:30 PM, the ED RN documented admission order received, patient admitted to ICU until bed available.

There was no documentation the patient was on 1:1 while in the ED. There was no documentation patient belongs had been searched for dangerous items or contraband. There was no documentation a suicide re-assessment was performed every 12 hours and before discharge to the ICU.

In an interview on 5/23/19 at 11:28 AM, EI # 10 confirmed the above findings.


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2. During a tour of the Senior Behavioral Care Unit (SBCU) on 5/21/19 at 10:31 AM, the following observations were made:

1. Bathroom grab bars in the patient rooms were a ligature risk, able to be used for hanging/strangulation.

2. Uncovered Oxygen Meter in patient room 242, not in use for a patient, was a ligature risk, able to be used for hanging/strangulation.

3. Furniture which included night stands and chairs were not secured in all patient rooms.

4. Cabinet in patient room 234 with approximately 6" wooden rectangular handles, including 6 handles on the top cabinets, 6 handles on the bottom cabinets, and 3 handles on the bottom drawers, were a ligature risk, able to be used for handing/strangulation.

5. Shower heads and faucets in patient rooms 230, 231, 232, 234, and 240 were a ligature risk, able to be used for hanging/strangulation.

6. Sink faucets in the patient's rooms/bathrooms were a ligature risk, able to be used for hanging/strangulation.

7. Ceramic square towel rod holder, without the rod, secured to the top 1/3 of the shower wall in patient rooms 230, 231, and 232 were a ligature risk, able to be used for hanging/strangulation.

During the tour of the SBCU on 5/21/19 at 10:31 AM, an interview with Employee Identifier (EI) # 2, Assistant Chief Nursing Officer/Director of SBCU, was conducted. EI # 2 confirmed the above findings prior to the end of the tour.

Based on review of the facility restraint log documentation, medical records (MR), the Restraint and Seclusion policy and procedure and staff interviews, it was determined the staff failed to follow their own policy for restraint use and complete staff debriefing and update the Treatment Plan after use of restraints. This affected Patient Identifier (PI) # 13, 1 of 1 Geropsych (Geropsychiatric) restraint records reviewed and had the potential to negatively affect all patients in restraint/seclusion at the facility.

Findings include:

Policy Title: Restraint and Seclusion
Department: SBCU (Senior Behavioral Care Unit)
Reviewed: 09/21/2017

...Purpose:

To establish guidelines for the safe, effective use if ...restraints in accordance to state, CMS (Centers for Medicare Services) ...ensure the protection of the patient's rights...physical and psychological well being...

A. Restraint is any manual method , physical or mechanical...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

D. Orders:

3. The order shall specify the method of restraint...

E. Restraint...shall only be used for the protection of the patient, staff me,members...

G. Only qualified...trained staff members...may initiate a restraint...

P. The treatment team reviews alternative strategies relative to behaviors that require the use of restraint...If restraint recurs, the treatment ream will consult the medical director...Written modification to the patient's plan of care occurs with any restraint...usage.

Documentation:

...Debriefing with the staff....is documented and placed in the patient's medical record...


1. PI # 13 was admitted to the Geropsych unit on 4/17/19 with diagnoses including Schizo-affective Disorder.

MR review revealed a physician order dated 4/18/19 at 4:24 PM, to hold patient to prevent staff injury.

Review of the facility restraint log documentation revealed on 4/18/19 PI # 13 was in a "hold" restraint from 4:26 PM to 5:38 PM, that was initiated by the RN (Registered Nurse) with a face to face completed at 5:40 PM.

Record review revealed at 4:10 PM on 4/18/19 Nursing Assessment documentation the patient's mood was unpredictable, stood in front of staff in a confrontational manner. At 4:20 PM, the patient jumped and charged towards staff, pushed staff and pulled staff's hair and the nurse responded with CPI (crisis prevention intervention). At 4:22 PM, the nurse documented, patient resting in bed eyes closed, stood up quickly and charged the nurse who was 1:1 (one staff to one patient) attempting to redirect behavior and again the nurse used CPI to free self. At 4:29 PM, the nurse documented physician notified, order received to hold (patient) to prevent injury and give Thorazine 100 mg (milligram) now. At 4:52 PM the nurse documented unit manager notified of aggressive behavior, bed removed from room, mattress on floor and Thorazine 100 mg IM (intramuscularly) given. At 5:00 PM, the nurse documented able to take vitals signs, remains awake with even breathing no attempts of aggression. At 5:38 PM, face to face evaluation completed, awake, pulling covers over face, breathing even and unlabored, remains one to one observations.

Record review failed to include staff documentation for debriefing after the use of restraints.

Review of the Interdisciplinary Treatment Plan revealed a problem list with psychotic symptoms and fall risk dated 4/17/19 and altered skin integrity dated 4/24/19. There was no update which included the use of a physical restraint on 4/18/19.

In an interview on 5/23/19 at 10:18 AM, Employee Identifier # 2, Assistant Chief Nursing Officer, Director of SBCU confirmed the aforementioned findings.

Based on review of medical records (MR), policy and procedure, published resources, and interview, it was determined the facility failed to ensure the staff:

1. Orders were written for wound care.

2. Performed wound assessments per the facility policy.

3. Performed assessment and reassessment of pain per the facility policy.

4. Performed patient positioning to prevent pressure ulcer development.

This affected Patient Identifier (PI) # 4, PI # 5, PI # 2 and PI # 1, 4 of 6 records reviewed with wounds, and had the potential to affect all patients treated at the hospital.

Findings include:

Policy: Wound Staging and Documentation
Policy Number: 9196
Revised: 8/7/18

Purpose: To provide consistent wound care protocols to assess, maintain, and promote skin integrity.

Definitions:
Staging of Pressure Ulcers is done by Registered Nurse (RN)...

Procedure:
...a. Wounds should be undressed and cleaned.
...c. Institute nursing interventions to include...appropriate product selection based on...exudates, presence of infection, and MMH (Mizell Memorial Hospital) product availability.
...e. Implement required Wound Care treatment...

...4. Interim Patient Interventions in lieu of a Physician Order
a. Orders not received within 4 hours of patient arrival...will default to wound care protocols...
b. The nurse will initiate such protocols...

Policy: Pain Assessment, Reassessment and Management
Policy Number: 9013
Revised: 8/2/11

Policy:
MMH shall respect and support the patient's right to optimal pain assessment and management... The organization will also address the appropriateness and effectiveness of pain management.

Procedure:
It is the responsibility of all clinical staff to screen all patients for the presence or absence of pain.
If the screening assessment reveals pain is present in the patient...conduct an indepth clinical assessment of the pain...including the intensity and quality (i.e. character, frequency, location and duration of pain), and responses to treatment.
...The patient will undergo reassessment of pain...within 60 minutes after every pain control mechanism employed by patient care providers. Pain control mechanisms include, but are not limited to:
Medications administered for the control or relief of pain...

Documentation:
On each patient's MAR (Medication Administration Record) the nurse is to document the pain scale pre-medication and reassess within 60 minutes post-medication with documentation supporting the reassessment on the MAR.

Resource:

Fundamentals in Nursing, 6th Edition
Authors: Patricia Potter and Anne Griffin Potter

Chapter 47, Skin Integrity and Wound Care

Page; 1515.

Positioning interventions are designed to reduce pressure and shearing force to the skin... The immobilized client's position should be changed according to activity level, perceptual ability, and daily routines (Braden 2001)... The Agency for Health Care Policy and Research) (AHCPR) guidelines (1992a) recommend that a written turning and positioning schedule be utilized. Clients should be repositioned at least every 2 hours.

1. PI # 4 was admitted to the facility on 5/3/19 with diagnosis of Major Depression, Severe.

Review of the SBCU (Senior Behavior Care Unit) Skin Assessment dated 5/4/19 revealed documentation of an abrasion to the right elbow with a wound dressing in place. There was no documentation of the type of wound dressing.

Review of the MR revealed no documentation of a wound assessment, wound measurements, physician wound care orders or wound protocol initiated by the nurse.

Review of the Verbal/Phone/Protocol Orders dated 5/8/19 revealed a physician order for Zanaflex 4 mg (milligrams) as needed (PRN) every 6 hours.

Review of the MAR revealed Zanaflex was administered on 5/9/19 at 4:49 PM for muscle spasms to the left leg. There was no documentation of a pain score.

Review of the Patient Progress Notes documentation on 5/9/19 at 4:52 PM revealed "patient c/o (compliant/of) muscle spasms to left leg. PRN Zanaflex administered..." There was no documentation of a pain score.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain until 5/9/19 at 7:40 PM, which was over 3 hours after Zanaflex was administered.

Review of the MAR revealed Zanaflex was administered on 5/12/19 at 8:27 PM for muscle spasms to the left leg. There was no documentation of a pain score.

Review of the Patient Progress Notes documentation on 5/12/19 at 8:30 PM revealed "pt (patient) requested and received prn Zanaflex as ordered for muscle spasms." There was no documentation of a pain score.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain on 5/12/19 through midnight.

An interview was conducted on 5/22/19 at 8:35 AM with Employee Identifier # 2, Assistant Chief Nursing Officer/Director of SBCU who confirmed the above findings.

2. PI # 5 was admitted to the facility on 5/14/19 with diagnosis of Psychosis due to Organic Brain Disorder.

Review of the Medication Reconciliation Report dated 5/14/18 at 5:45 PM revealed a physician's order for Percocet 10 mg - 325 mg 1 tablet every 6 hours prn.

Review of the SBCU Admission Assessment dated 5/14/19 at 5:30 PM revealed documentation of a patient pain score of "9-10" on a Faces 1-10 scale with documentation of "what helps pain? Medication." There was no documentation of the location of the patient's pain, assessment for administration of pain medication, or documentation Percocet was administered for the patient's pain.

Review of the Patient Progress Notes documentation on 5/14/19 at 8:00 PM revealed the next pain assessment was completed, which was over 2 hours after patient compliant of pain at a "9-10".

Review of the Patient Progress Notes documentation on 5/14/19 at 11:00 PM revealed the patient was holding left leg and stating "My leg is hurting me real bad" with a pain score of "9."

Review of the MAR revealed Percocet was administered on 5/14/19 at 11:09 PM.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain until 5/15/19 at 9:52 AM, which was over 10 hours after Percocet was administered.

Review of the Patient Progress Notes documentation on 5/15/19 at 9:59 PM revealed "pt complaints of back pain and medication nurse...instructed to give pt Percocet..." There was no documentation of a pain score.

Review of the MAR revealed Percocet was administered on 5/15/19 at 10:16 AM. There was no documentation of a pain score.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain until 5/15/19 at 7:55 PM, which was over 9 hours after Percocet was administered.

Review of the Patient Progress Notes documentation on 5/16/19 at 8:45 PM revealed patient was "Lying in bed with eyes closed, sleeping..."

Review of the MAR revealed Percocet was administered on 5/16/19 at 8:51 PM. There was no documentation of a pain location, pain assessment or pain score.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain until 5/17/19 at 7:50 PM, which was over 22 hours after Percocet was administered.

Review of the Patient Progress Notes documentation on 5/20/19 from 4-6 AM revealed no nursing documentation of a pain assessment.

Review of the MAR revealed Percocet was administered on 5/20/19 at 5:19 AM. There was no documentation of a pain location, pain assessment or pain score.

Further review of the Patient Progress Notes revealed no documentation of a reassessment of pain until 5/20/19 at 7:20 AM, which was over 2 hours after Percocet was administered.

Review of the SBCU Skin Assessment dated 5/20/19 revealed documentation of a new wound to the "Right Ankle." There was no documentation of the Right Ankle wound type or wound measurements for the Right Ankle wound.

Review of the MAR dated 5/20/19 at 4:30 PM revealed a wound care order to "Clean (with) soap and water, pat dry, apply CA (calcium) alginate, telfa, wrap with kling, q (every) 72 hours and prn." There was no documentation on the wound location to provide the wound care.

Further review of the MAR dated 5/20/19 revealed documentation the wound care was provided at 4:45 PM.

Review of the MR revealed no documentation of the wound location wound care was performed to or the actual wound care performed.

An interview was conducted on 5/21/19 at 2:15 PM with Employee Identifier (EI) # 2, who confirmed the above findings and identified the MAR wound care order on 5/20/19 was for the Right Ankle wound and the wound care documented as provided at 4:45 PM was to the Right Ankle wound.


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3. PI # 2 was admitted to the facility on 5/18/19 with diagnoses including, Hyperkalemia and Multidrug Resistant Urinary Tract Infection.

Review of the Admission Nursing Assessment dated 5/18/19 at 6:35 PM revealed, "Wound Assessment Site A: Wound Color: White ... Description: quarter size wound beefy in middle with white edges". There was no documentation of the location and type of wound, wound measurements, physician wound care orders or wound protocol initiated by the nurse.

Review of the Daily Shift Assessment dated 5/18/19 at 7:30 PM and 5/20/19 at 8:20 AM revealed, "Wound Assessment Site A: Wound Color: White ... Description: coccyx". There was no documentation of the stage of the wound, wound measurements, physician wound care orders or wound protocol initiated by the nurse.

Review of the Daily Shift Assessment dated 5/19/19 at 12:18 PM revealed, "Wound Assessment Site A: Wound Color: White ... Description: dressing dry and intact". There was no documentation of the type of wound dressing. There was no documentation of the stage of the wound, wound measurements, physician wound care orders or wound protocol initiated by the nurse as directed per the facility policy and procedure.

Review of the Daily Shift Assessment dated 5/19/19 at 10:20 PM revealed, "Skin Assessment: ... pressure injury coccyx ... Wound Color: White ... Description: pressure injury". There was no documentation of the stage of the wound, wound measurements, physician wound care orders or wound protocol initiated by the nurse as directed per the facility policy and procedure.

Review of the Daily Shift Assessment dated 5/20/19 at 10:10 PM revealed, "Musculoskeletal: ... right upper arm wrapped in gauze and secured w/ (with) tape... Wound Assessment Site A: Description: patient states a "burn" - wrapped in gauze. Wound Assessment Site B: Description: coccyx". There was no documentation of the stage of the wound, wound measurements, physician wound care orders or wound protocol initiated by the nurse as directed per the facility policy and procedure.

An interview was conducted on 5/21/19 at 2:15 PM with EI # 5, Medical/Surgical Nurse Manager, who verified the aforementioned findings.


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4. PI # 1 was admitted to the facility on 5/19/19 with diagnoses including Urinary Tract Infection, weakness, decreased mobility, and decubitus ulcer.

Review of initial Physical Assessment dated 05/19/19 at 6:00 PM revealed no documentation of staging of decubitus ulcer to buttocks.

Review of "Admission Nursing Assessment" dated 5/19/19 at 6:00 PM revealed that on "Braden Scale for Predicting Pressure Sore Risk" PI # 1 scored a 12 indicating that he was at high risk for developing pressure sores

Observation of medication pass on 5/22/19 at 9:15 AM the surveyor observed EI # 13 Licensed Practical Nurse applying cream to PI # 1 buttocks. When PI # 1 was rolled to his/her side the surveyor observed multiple skin creases on patient's back and buttocks, indicating that the patient had been in the same position for an extended period of time. The patient also had a foam dressing over an existing Decubitus ulcer to the sacral area.

Upon exiting the room an "Hourly Rounding Log" dated 5/22/19 was observed taped to the patient's door. The log indicated that the patient had been in position "3" (supine) at 7 AM, 8 AM, and 9 AM.

Review of the "Hourly Rounding Log" in the MR dated 5/21/19 revealed the following:
7:00 AM - supine
8:00 AM - supine
9:00 AM - supine
10:00 AM - supine
11:00 AM - supine
12:00 PM - supine
1:00 PM - supine
2:00 PM - supine
3:00 PM - right side
4:00 PM - right side
5:00 PM - supine
6:00 PM - supine
7:00 PM - supine
8:00 PM - supine
9:00 PM - supine
10:00 PM - right side
11:00 PM - supine
12:00 AM - supine
1:00 AM - supine
2:00 AM - supine
3:00 AM - supine
4:00 AM - supine
5:00 AM - supine
6:00 AM - supine

Review of the care plan "impaired skin integrity related to immobility" dated 5/22/19 at 9:28 AM revealed documentation of "staff will implement turning and other preventable measures."

An interview was conducted with EI # 5, Med/Surg Manager, on 5/22/19 at 11:45 AM EI # 5 who confirmed the above findings and verbally indicated that according to the Braden Scale of 12 that PI # 1 was placed on a turn schedule. EI # 5 provided a copy of the care plan indicating that "staff will implement turning and other preventable measures."

EI # 5 further verified that proper positioning to prevent pressure ulcers was not done per care plan.

Further review of initial Physical Assessment dated 5/19/19 at 6:00 PM revealed no documentation of staging of decubitus ulcer to buttocks.

An interview was conducted with EI # 5, Med/Surg Manager, on 5/22/19 at 11:15 AM EI # 5 stated that wound care staging was to be done by wound care nurse or nursing supervisor. EI # 5 was unable to provide documentation of wound staging by wound care nurse or nursing supervisor.

Based on review of medical records (MR), facility policy and procedure and staff interviews, it was determined the staff failed to ensure the initial treatment plan was developed within the required timeframe and all assessments were completed prior to the Treatment Plan Meeting including the psychiatric evaluation, the psychosocial assessment and recreational /activity assessment. This affected PI # 13, 1 of 4 Geropsych records reviewed and had the potential to negatively affect all patients admitted to the Geropsych unit.

Findings include:

Policy Title: Treatment Team Protocol
Department: SBCU (Senior Behavior Care Unit)
Reviewed Date: 09/19/2017

Policy/Procedure:

The Treatment Team is a meeting of the Program Director, Attending Physician and members of the interdisciplinary treatment team for the purpose of developing an individualized treatment plan. The first team meeting occurs no later than three (3) days after admission...

Procedure:

A. Initial Treatment Team Meeting

1. Occurrence: The initial team meeting will occur within 3 days of admission.
2. Participants...include the Attending Physician, Program Director, Unit Nurse Manager and may attend (s).... Recreational /Activitiy Therapist and Social Worker (SW)...

Each team member participating...is responsible for having completed and documented their assessment. The Social Worker or Case Manager should have reviewed the...medical record prior to the meetings and be prepared to present a...summary of the primary problems...

The Program Director...in consultation with other members of the treatment team, develop a proposed master treatment plan...

1. PI # 13 was admitted to the Geropsych unit on 4/17/19 with diagnoses including Schizo-affective Disorder.

Record review revealed the medical history and physical and psychosocial assessment was completed on 4/18/19 and the psychiatric evaluation and recreational/activity assessment was completed on 4/19/19.

Review of the Interdisciplinary Treatment Plan revealed a problem list which included psychotic symptoms and fall risk dated 4/17/19 and altered skin integrity dated 4/24/19, which was 6 days after the admission date.

Review of the Treatment Team participants signatures revealed the date the physician's signed the plan was not legible, the RN signature was dated 4/17/19, the SW 4/18/19, the AT/RT (activity therapist/recreational therapist) on 4/18/19 and "Other" LBSW (licensed bachelor social worker) dated 4/23/19.

Further review of the Treatment Plan revealed problem 1, Psychotic Symptoms, was to be assessed by the physician 3 times a week. The physician signed and dated the intervention on 4/27/19 which was 7 days after the admission date.

There was no date documented when the initial meeting of Treatment Team occurred. An update to the Interdisciplinary Treatment Plan Review was completed on 5/1/19.

In an interview on 5/23/19 at 10:18 AM, Employee Identifier (EI) # 2, Assistant Chief Nursing Officer, Director of SBCU confirmed the physician signature was not legible and the Interdisciplinary Team Meeting was held on 4/17/19, which was the day of admission. The physician's history and physical, psychiatric exam, psychosocial assessment and recreational/activity assessment would have not been completed at the time the 4/17/19 initial treatment team meeting was completed.

Based on observation, review of facility procedure and interview, it was determined the facility failed to ensure staff prepared medications from a multiple dose vial in the Outpatient Therapy Department as directed per the facility policy. This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Use of Multiple Dose Vials (MDVs)
Reference Number: 7047
Revised: 7/20/12

Procedure:

... A new, sterile needle and syringe shall be used each time medication is drawn from the vial.

A tour of the Outpatient Therapy Department was conducted on 5/22/19 at 10:15 AM with Employee Identifier (EI) # 6, Physical Therapist Assistant (PTA), in the locked storage room. The surveyor observed a MDV of Dexamethasone Sodium Phosphate 120 mg (milligrams) / 30 ml (milliliters) opened and dated with one (1) syringe lying next to the MDV. The surveyor asked EI # 6, "What is that syringe used for?" EI # 6, stated, "We use that syringe to draw up the Dexamethasone with". The surveyor then asked, "You use that syringe each time you draw up the medication?" EI # 6 replied, "Yes". There were no other syringes in the storage room.

At 10:20 AM EI # 7, Physical Therapist, Rehab (Rehabilitation) Director, entered the storage room and verified the aforementioned findings.

An interview was conducted on 5/23/19 at 7:43 AM with EI # 2, Assistant Chief Nursing Officer, who verified the staff failed to follow the facility procedure for preparation of medication with the use of new syringe and needle for each withdrawal from a MDV.

Based on review of medical records (MR), policy and interviews, it was determined the facility failed to ensure staff provided care to patients receiving blood transfusions according to their own policy. This affected 1 of 1 blood transfusions records reviewed and included Patient Identifier (PI) # 3 and had the potential to affect all patients admitted to the who required a blood transfusion.

Findings including:

Policy: Reference # 9106
Subject: Blood/Blood Component-Transfusion
Revised: 04/16/18

Purpose:

To ensure...safe administration of blood and/or blood components.

Policy:

...safe transfusion occur when blood is is issued for transfusion at the patient's bedside when blood is administered.

...Care During Transfusions:

1. Most life-threatening complication occur in the first 5-15 minutes; therefore the RN (Registered Nurse) should remain with the patient for the initial 15 minutes of the infusion...
2. Vital signs, including temperatures, are to be obtained prior to initiation of transfusion, at 5 minutes, 15 minutes...then every hour until transfusion is complete...

1. PI # 3 was admitted to the facility on 5/14/19 with diagnoses including Acute Kidney Disease and Rhabdomyolysis.

Record review revealed a physician's order dated 5/19/19 at 5:42 AM to type and cross to transfuse 3 units PRBC (packed red blood cells).

Record review revealed unit one of the PRBC transfusion was initiated at 11:15 AM. The next vital signs were documented 15 minutes later at 11:30 AM. The RN failed to perform and document PI # 3's vital signs at 11:20 AM, which was 5 minutes after the transfusion began. At 1:15 PM, the first unit of PRBC's had transfused.

Record review revealed the second unit of PRBC's was initiated at 1:45 PM with vital signs documented. At 2:00 PM, the RN documented the first 15 minute reassessment that included vital signs. There were no vital signs documented at 1:50 PM, which was 5 minutes after the second unit of PRBC's infusion began. The second unit transfusion was complete at 3:45 PM.

Record review revealed the third unit of PRBC's infusion began at 4:00 PM and vitals signs were documented. The next vital signs was documented at 4:15 PM, which was 15 minutes after the transfusion was initiated. The staff failed to perform and document PI # 3's vital signs 5 minutes after transfusion initiation.

In an interview on 5/23/19 at 11:05 AM, Employee Identifier # 10, Emergency Department/Intensive Care Unit Manager, confirmed staff failed to follow the facility policy for completion and documentation of vitals signs during blood transfusions.

Based on observations, facility policies and procedures, and interviews, it was determined the hospital failed to ensure:

1. Food was stored in a safe and sanitary manner.

2. The dishwashing machine temperature was checked during each use.

3. The concentration of chemical or hot water (temperature) was monitored and documented in the 3 compartment sink.

4. Staff monitored and documented food temperatures for meal service.

This had the potential to negatively affect all patients in this facility.

Findings include:

Facility Policy: Stock Storage
Dietary: page 178-179

Policy:

Food shall be stored on shelves in areas which provide the best preservation and be stored at a proper temperature for appropriate lengths of time.

Purpose:

To protect quality of food ...

Procedure:

1. Staple items to be stored in the storeroom on shelves with original label, or in a labeled container.

...7. Storage temperatures and maximum length of storage will adhere to the guidelines which follow:

Food Item/Maximum Storage

Dairy Products:
Cheese: 7 days (tightly covered)

Frozen Products:
Poultry: 6-12 months (original container)

Meat:
Cold cuts: 6 days (moisture proof wrap)

Vegetable (fresh):

Leafy: 7 days unwashed
Potatoes, onions, ...: 7-30 days (dry, in ventilated bag or container).

Facility Policy: Temperature Documentation
Dietary: page 25

Policy:

The Dietitian/Consultant shall be available to develop and implement a system for temperature documentation of equipment and food and shall monitor its use.

Purpose:

1. To ensure that food is held and served at safe temperatures.

2. To assist in developing in each employee an awareness of proper temperature maintenance.

Procedure:

1. A notebook for "Temperature Documentation" is used to document equipment and food temperatures ... Dish Machine Temperature Log, Equipment Temperature Log and Food Temperature Log Forms.

Facility Policy: Monitoring Food Temperatures for Meal Service
Dietary: page 32

Policy:

Food temperatures will be monitored daily to prevent foodborne illness.

Procedure:

Food temperatures will be taken and recorded for all hot and cold foods prior to placement on the serving line. (see ... Food Temperature Log).

Facility Policy: Pot and Pan Handling
Dietary: page 166

Policy:

Procedures guaranteeing safe and sanitary handling of pots and pans shall be followed.

Procedure:

4. The 3-compartment pot and pan sink will have each compartment cleaned before use ... The concentration of chemical or hot water will be tested before cleaning pots and pans.

A tour of the dietary department was conducted on 5/21/19 at 10:35 AM with Employee Identifier (EI) # 3, Dietary Manager. EI # 3 walked the surveyor into the dish washing machine area. The surveyor asked EI # 3, "When does the staff monitored the temperature of the dish washer"? EI # 3 replied, "Daily". The surveyor requested the temperature logs for the dish washer. EI # 3 stated, I know we check it, but we don't log it. There was no temperature logs provided for the dish washer.

At 10:45 AM observations in the food service areas revealed the following:

Salad Refrigerator: 2 large open containers with a moderate amount liquid substance. The surveyor asked EI # 3 what was in the containers. EI # 3 replied, "They catch water dripping from condensation". The surveyor asked, "How long has it been that way?" EI # 3 stated, "Months". The facility failed to protect the quality of the food in the salad refrigerator.

Dessert Refrigerator (sign on the refrigerator read - "Cover, Label, Date"):
30 Jello bowls
6 Jello cups
3 Fruit bowls
9 Fruit cups
11 Banana pudding cups
1 pack Unwrapped Cheese - opened and not tightly covered

There was no label or date on the above food items as directed per the facility policy.

Dry Storage
Basic Muffin Mix: 2 boxes opened, not closed, not covered and not dated.
Penne Pasta: large bag opened and not dated.

Sitting on a Cabinet
1 Container of Oreo Cookies
1 Container of Chocolate Chips
1 Container of Peanut Topping
1 Container of Malted Milk Balls
1 Container of M&M's
1 Container of Reese's Pieces

The above containers failed to be labeled and dated per the facility policy:

Walk in Cooler:
Mozzarella Cheese x (times) 2 bags in large baggies not labeled or dated
Asparagus: lying in the bottom of the drawer (brown in color). Not covered or labeled.
Purple Onions: 2 halves in a large baggie not stored in a ventilated bag or container as directed per the facility policy.
Fruit Dip: 1 large container not labeled or dated
Cheese: 2 packs opened, not tightly covered, labeled or dated.

Walk in Freezer
2- 8 piece cut chicken in large baggies not labeled or dated
Egg Patties: opened and not dated
Donuts: large bag opened and not labeled or dated
M&M Cookie Dough: opened and not labeled or dated
1 bag chicken breast: opened and not labeled or dated
1 bag Pepperoni: opened, not labeled or dated or stored in a moisture proof bag as directed per the facility policy.

A review of the May 2019 Patient Menu Temperature Logs at 12:07 PM revealed there was no documentation of the food temperature checks on the following dates and times:

Supper: 5/1/19, 5/4/19, 5/5/19, 5/6/19, 5/7/19, 5/14/19 and 5/19/19
Lunch: 5/3/19 and 5/16/19
Breakfast, Lunch and Supper: 5/8/19

Further review of the May 2019 Patient Menu Temperature Logs at 12:07 PM revealed incomplete documentation of all hot and/or cold food item temperature checks on the following dates and times:

Lunch: 5/1/19, 5/4/19, 5/5/19 and 5/6/19
Breakfast and Supper: 5/9/19
Lunch and Supper: 5/10/19
Breakfast, Lunch and Supper: 5/13/19, 5/14/19, 5/15/19 and 5/16/19
Breakfast and Lunch: 5/19/19

The facility failed to ensure staff monitored and documented food temperatures for food service to prevent foodborne illness.

An interview was conducted on 5/23/19 at 8:35 AM with EI # 4, Registered Dietitian, who verified the aforementioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on facility observation, review of the facility policy and procedure, and interview with staff it was determined that the facility failed to ensure that equipment malfunction was properly reported and maintained. This had the potential to affect all patients undergoing surgery and all patients with whom reusable sterile instruments are used.

Findings include:

Policy: Reporting Equipment Malfunction
Effective: 10/17/11
Last Reviewed 6/21/18

Policy: When equipment malfunctions, the following procedure will be followed.

Procedure:

Equipment malfunctions-Patient Care Equipment:

When a malfunction is evident, the following steps shall be taken:

Double check procedure techniques to ascertain whether there is a true malfunction or a procedural error.
If the malfunction continues to occur, complete a Maintenance Request Form and remove the equipment from service-notify Plant Operations.

If this is an emergency:

Institute clinical emergency procedures required to ensure patient care is not compromised.
Notify Plant Operations Director or designee
Let them know equipment is malfunctioning and get an estimate of the time before repair can be completed and/or if replacement is available.
Check the Maintenance Request Form for the phone numbers for repair service or a possible electrical safety problem.

A tour of the Central Sterile Receiving room in the surgical department was conducted on 5/21/19 at 11:15 AM with Employee Identifier EI # 12, Surgery Manager.

During the tour the surveyor observed the washer/decontaminator was out of service. EI # 15 RN stated that the washer had been out of service for "a couple of months." EI # 15 RN stated there was no documentation of a Maintenance Request Form.

An interview was conducted on 5/23/19 at 11:25 AM with EI # 12, Surgery Manager, on 5/23/19 at 11:25 AM confirmed the above findings.




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Based on observations, review of facility policies and procedures, and interviews with the staff, it was determined the facility failed to ensure the staff:

1. Followed the facility policy and procedure for proper hand hygiene and gloving.

2. Followed the facility policy and procedure for handling sharps.

This did affect Patient Identifier (PI) # 5, and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: WHO (World Health Organization) Guidelines on Hand Hygiene in Health Care (used as the facility policy)
Date: May 2009

...Indications for hand hygiene
...D. Perform Hand Hygiene:
a. before and after touching the patient...
e. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient...

E. Before handling medication...

Policy: Hazardous Materials and Waste - Nursing Services
Revised: 06/04/18

Policy:
Charge Nurses, House Supervisors, and personnel shall exercise extreme care when handling hazardous materials and waste...

Sharps: (Objects capable of puncturing the skin, such as hypodermic needles, blades and suture needles).

Handling:

Personnel shall exercise extreme caution when handling sharps:
To prevent skin punctures...
Dispose of all sharps in red impervious plastic containers.

1. An observation was conducted on 5/22/19 at 9:00 AM with Employee Identifier (EI) # 8, Licensed Practical Nurse (LPN), to observe medication administration on PI # 5.

During the observation, EI # 8 failed to perform hand hygiene prior to preparation of Cordarone, cutting pill in half, for patient administration and use of the computer.

EI # 8 failed to discarded opened halved Cordarone pill when pill was spilled out, by EI # 8, onto the nursing station counter and failed to perform hand hygiene prior to placement of the opened halved Cordarone pill back in the medication cup.

EI # 8 failed to perform hand hygiene after the administration of the patient's medications prior to preparation of additional medications in the medication room.

An interview was conducted on 5/22/19 at 9:32 AM with EI # 2, Assistant Chief Nursing Officer/Director of Senior Behavioral Care Unit, who confirmed the above findings were against facility policy.



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2. A tour of Operating Room (OR) #2 was conducted on 5/21/19 at 11:15 AM with EI # 12, Surgery Manager.

During the tour a syringe of unknown liquid was observed laying unattended on top of anesthesia cart. The surveyor asked EI # 12 about the syringe he/she grabbed the syringe, uncapped the needle, hastily emptied the contents into the sharps container, then tossed the uncapped needle and syringe toward the sharps container. The tossed syringe and needle hit the side of sharps container and bounced back toward EI # 12 narrowly missing his/her foot.

An interview was conducted on 5/21/19 at 11:15 AM with EI # 12, confirmed that tossing syringe toward sharps container was against facility policy and procedure.

Based on observations, review of facility policy and procedure, and interview with staff, it was determined the facility failed to ensure that staff followed hospital policy for proper surgical attire.

This had the potential to affect all patients undergoing surgery at this facility.

Findings include:

Policy: Surgical Attire

Effective: 3/13/01
Reviewed: 05/2018

Purpose: To provide guidelines for attire worn by all personnel enter semi restricted and restricted areas of the surgical suite...

10. All personnel entering the restricted area of the operating room suite should wear high filtration masks, including the room in which the patient's surgical procedure is performed, the cores, and other designated areas, where open sterile supplies or scrubbed persons may be located. Masks should cover both mouth and nose and be secured in a manner that prevents venting.

Rationale: Face masks decrease the spread of contaminated droplets by filtration and alter the direction of dispersal from the upper respiratory tract during talking, coughing, and breathing.

An observation was conducted on 5/21/19 at 9:00 AM with EI # 12, OR supervisor, to observe a split thickness skin graft to the scalp on PI # 16.

During the observation EI (Employee Identifier) # 12, Operating Room Supervisor, was observed wearing a loosely tied surgical mask in such a manner that the mouth and chin was visible in close proximity of the surgery being performed. The mask was not secured in a manner that would prevent venting or provide filtration.

An interview was conducted on 5/21/19 at 11:25 AM with EI # 12 on 5/21/19 at 11:25 who confirmed that mask was not secured per facility policy.

Based on observation, review of facility policy and interview, it was determined the facility failed to ensure the staff monitored the temperature and cleaned the Paraffin Bath per facility policy in the Outpatient Therapy Department. This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Cleaning Paraffin Bath
Reference Number: 6011
Revised: 5/1/17

Policy: Cleaning of the unit is to be done once a month, or as needed when used excessively for that month.

During a tour of the Outpatient Therapy Department on 5/22/19 at 10:40 AM with Employee Identifier (EI) # 7, Physical Therapist, Rehabilitation Director, the surveyor observed a Paraffin Bath filled with Paraffin located in the Massage Therapy Room. The surveyor requested the cleaning and temperature logs for the Paraffin Bath. There were no cleaning logs or temperature logs provided.

An interview was conducted on 5/22/19 at 11:35 AM with EI # 7, who stated the staff should monitor the temperature of the Paraffin Bath when in use and should clean the Paraffin Bath monthly as directed per the facility policy.