HospitalInspections.org

Based on review of facility documents, policies and procedures, medical records (MR), observations and interview with staff (EMP), it was determined the Governing Body failed to ensure the Patient Rights Condition of Participation was met (A-0115), failed to ensure allegations of sexual abuse were reported as grievances (A-0121), failed to ensure a safe setting (A-0144), failed to ensure established policy was followed for reporting allegations of sexual abuse (A-0145), failed to ensure incident report severity was properly documented (A-0145), failed to ensure staff were properly trained (A-0200), failed to ensure quality data was collected, tracked and analyzed (A-0273), failed to establish a budget for the quality program (A-0315), failed to ensure staff completed mandatory training (A-0397, ) failed to provide a safe physical environment (A-700), failed to maintain the annual tuberculosis prevention program (A-0745) and failed to report patient death to Organ Procurement (A-0886).


Findings include:

1. Review on September 12, 2018, of facility document "Governing Body Bylaws of Haven Behavioral Hospital of Philadelphia" approval date February 2018, revealed "Purposes. The principle purposes of the governing board are to recommend Hospital policy to the Member, to implement Hospital policy approved by the Member, to promote performance improvement and quality patient care at Hospital, to organize and oversee management and planning of Hospital ... "



Cross Reference with:
482.12 Governing Body
482.13 Patient Rights
482.13(a)(2)(i) Patient Rights: Grievance Procedures
482.13 (c)(2) The patient has a right to receive care in a safe setting
482.13(c)(3) Patient Rights: Free from Abuse/harassment
482.13(f)(2)(ii) Patient Rights: Restraint or Seclusion
482.21(a), (b)(1),(b)(2)(i),(b)(3) Data Collection & Analysis
482.21(e)(4) Providing Adequate Resources
482.41 Physical Environment
482.42(a) Infection Control Officer
482.45(a)(1) OPO Agreement
482.45(a)(5) Staff Education

Based on review of facility policy and procedures, review of facility documents, review of medical records and interview with staff (EMP), it was determined the facility failed to meet the Patient Rights Condition of Participation by failing to ensure an allegation of sexual abuse was reported as grievance (A-0121), failing to ensure a safe setting (A-0144), failing to ensure established policy was followed for reporting sexual events (A-0145), failing to ensure incident report severity was properly documented (A-0145), failing to ensure staff were properly trained (A-0200) and failed to ensure a safe physical environment (0700).


An Immediate Jeopardy was identified on October 9, 2018, at 12:50 PM for failure to immediately report and investigate one (1) patient reported allegation of sexual abuse and one (1) suspicious behavior, by the same alleged employee, that involved a different patient April 13, 2018. The facility was made aware of the April 13, 2018, suspicious behavior April 30, 2018, from an employee witness statement submitted to the Risk Manager. There was no documentation the facility fully reported or investigated these allegations and did not provide re-education for staff related to reporting abuse or incidents.


The facility submitted an action plan that included terminating the employee named in both events, provided immediate and ongoing education of all staff employed that included the facility's abuse reporting policy, harassment policy and incident reporting policy, immediately re-verifying criminal background checks for all employees and securing the two (2) entrances to the building and the 5th floor behavioral health unit until the terminated employee's keys were recovered (security measures included notifying building security and circulating a picture of the terminated employee). The action plan was approved by the Department of Health and the Immediate Jeopardy was abated at 9:30 PM on October 9, 2018.


An Immediate Jeopardy was identified October 10, 2018, at 12:30 PM for the facility's failure to follow the action plan that was submitted and approved by the Department of Health on October 9, 2018, at 9:30 PM. The facility failed to secure access to the building and 5th floor patient behavioral health unit as outlined in the action plan dated October 9, 2018. The facility failed to notify building security to restrict access of the terminated employee. The facility determined these steps would prevent them to comply with all Federal and State equal opportunity and anti-discrimination employment laws. Additionally, the facility was unable to successfully contact the employee to terminate employment.


The facility submitted an action plan that included following the facility's standard protocol for the for termination of an employee. The standard protocol included withholding amounts allowable bylaw from final pay due, holding personal property, challenging unemployment claims and refusal to consider rehire in the future. The action plan was approved by the Department of Health and the Immediate Jeopardy was abated on October 10, 2018, at 6:30PM.


Cross Reference with:
482.12 Governing Body
482.13(a)(2)(i) Patient Rights: Grievance Procedures
482.13 (c)(2) The patient has a right to receive care in a safe setting
482.13(c)(3) Patient Rights: Free from Abuse/harassment
482.13(f)(2)(ii) Patient Rights: Restraint or Seclusion
482.41 Physical Environment

Based on review of facility policies and procedures, review of facility document, review of personnel files and interview with staff (EMP), it was determined the facility failed to ensure annual mandatory training was completed in two of eight personnel files reviewed (PF3, PF7).

Findings include:

Review on September 12, 2018, of facility policy and procedures "Mandatory Training," approved August 2018 revealed " ... Procedure: 1. All employees of Haven are to receive annual training in specific areas identified each year in an effort to meet Federal and State regulations."

Review on September 12, 2018, of facility document "Student and Group Transcript Report" revealed it contained annual mandatory training that included "" ... Patient Rights- Abuse Reporting - Restraints, Code of Conduct ... ".

Review on September 12, 2018, of PF3 revealed no documentation of completed annual Mandatory Education for this direct care staff since May 2015.

Review on September 12, 2018, of PF7 revealed no documentation of completed annual Mandatory Education for this direct care staff since March 2017.

Interview with EMP4 on September 12, 2018, at 3:15 PM confirmed there was no documentation for current annual Mandatory Education for the direct care staff in PF3 and PF7.

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Based on review of facility policies and procedures, review of personnel files and interview with staff (EMP), it was determined the facility failed to ensure annual performance reviews were completed in three of eight personnel files reviewed (PF3, PF5, PF7).

Findings include:

Review on September 12, 2018, of facility policy and procedures "Performance Review and Salary Adjustments," approved January 2018 revealed, "Policy: Haven evaluates each employee's performance at least once annually ... the supervisor will complete a Performance Review and meet with the employee to discuss in detail ... Staff members are advised that their signature on the Performance Review does not mean that the necessarily agree with the content and perspective of the supervisor. Their signature confirms that the staff member has received the feedback from the Performance Review ...".

1) Review on September 12, 2018, of PF3 revealed the date of hire was April 2015. Continued review of PF3 revealed the "2016-2017 Performance Evaluation" was signed by the supervisor on May 2, 2018, and by the CEO on July 17, 2018. Further review of the document revealed it did not contain the employee's signature.

Interview with EMP4 on September 12, 2018, at 3:15 PM confirmed the 2016-2017 Performance Evaluation in PF3 did not contain the employee's signature. Further interview with EMP4 confirmed the employee in PF3 was not yet given the annual Performance Evaluation.

2) Review on September 12 2018, of PF5 revealed the date of hire was January 2014 and the current annual Performance Evaluation was dated 2015.

3) Review on September 12, 2018, of PF7 revealed the date of hire was October 2013 and the current annual Performance Evaluation was dated April 2015.

Interview with EMP4 on September 12, 2018, at 4:30 PM confirmed the above most current annual Performance Evaluation dates for PF5 and PF7.

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Based on review of facility policy and procedure and interview with staff (EMP), it was determined the facility failed to ensure patient care in a safe setting by staff failing to comply to facility's code of conduct.

Review on October 11, 2018, of facility's, "Employee Handbook," dated July 2015, revealed, " ... Our Code of Conduct ... our primary responsibility is to our patients by providing ethical and patient-centric behavioral healthcare services ... it is also our responsibility to treat each other with dignity and professional respect ...."

Interview conducted on October 10, 2018, at 12:05 PM with EMP3 confirmed staff disagreements or arguments occur at Nurse's Station at times. Further confirmed staff are immediately redirected to a private room to resolve their differences.

Interviews conducted on October 11, 2018 between 11:57 AM and 12:17 PM with EMP9, EMP10, EMP11, EMP12 confirmed staff disagreements and arguments have occurred at Nurse's station. Further confirmed staff involved in disagreements and arguments at Nurse's Station are immediately redirected to a private room to resolve their differences.

Interviews conducted on October 11, 2018 between 1:50 PM and 2:16 PM with PT1, PT2, PT3 and PT4, confirmed observing staff engaging in disagreements at times at the Nurse's Station.

Cross Reference:
482.12 Governing Body
482.13 Patient Rights
482.13(a)(2)(i) Patient Rights: Grievance Procedures
482.13(c)(3) Patient Rights: Free from Abuse/harassment
482.13(f)(2)(ii) Patient Rights: Restraint or Seclusion

Based on a review of facility policy, facility documents and staff interview (EMP), it was determined facility staff failed to follow approved reporting requirements for allegations sexual assault and suspected sexual assault for two of two medical records. (MR1and MR12).

Findings include:

Review of the Department's file for Haven Behavioral Hospital of Philadelphia, from March 1, 2018 to October 18, 2018, revealed no documented evidence the facility reported suspected allegations of sexual assault for MR1 and MR12.


1. Review on September 12, 2018, of facility policy "Abuse Reporting," approved August 2017, revealed "Policy: 1. Patients have the right to be free from mental, physical, sexual and verbal abuse ... It is the policy of this hospital to protect patients from real or perceived abuse ... from anyone including staff members ... 2.3 Sexual Abuse ... Procedure: 1.0 Management of Suspected abuse ... 1.1 In cases of suspected sexual assault ... will be given priority and will be investigated thoroughly. Suspicions must be reported to the CEO immediately ... 1.3 All cases of suspected abuse/neglect must be reported to authorities. All persons (including an employee, a volunteer or another person) associated with the hospital, who reasonable cause a person to believe that the physical or mental welfare of a patient of the hospital, who is receiving medical services, has been, is or will be adversely affected by abuse or neglect by any person shall. As soon as possible, report the information supporting that belief to the Department of Health ...2.0 The Hospital CEO or designee, shall be notified immediately prior to making a report, with no delay in reporting ..."


Review on September 12, 2018, at 3:00 PM of facility document "Timeline of Events " revealed MR1 contacted OTH1and reported [they] were " molested. " Further review revealed staff did not immediately report the suspected sexual assault to the CEO until 72 hours after the patient made the allegations. " ... 4/28/2018, [charge nurse] texted [DON] at 3:33 AM stating that she needed to talk to her about something but did not specify. 4/28/2018, At 8:19 AM [DON] responded by saying she could stop by the hospital if needed. [Charge Nurse] stated that she would meet with [DON] on Monday (April 30, 3028). The [DON] made contact with [Nurse Manager] on April 29, 2018, at 6:19 PM to notify her of the incident. 4/29/18, at 6:35 PM Risk Manager and CEO received call from [Nurse Manager] notifying them of the incident. 4/29/18 at 6:40 PM BHT (PF3) notified that he would be taken off the schedule due to a pending investigation ... "

Interview with EMP3 on September 11, 2018, at 11:00 AM confirmed they were the DON (Director of Nursing) on-call April 28, 2018. Further interview with EMP3 confirmed on April 30, 2018, was when OTH1 disclosed MR1 ' s specific allegations of sexual assault. EMP3 confirmed they contacted OTH3 (Nurse Manager at the time) April 30, 2018 and reported the allegations. EMP3 confirmed OTH3 informed her to contact EMP5 and EMP1 April 30, 2018, " sometime in the morning. " Continued interview with EMP3 confirmed PF3 (the employee named in the allegation) remained on-duty and provided patient care the night the allegation was reported to the charge OTH1: April 28, 2018, from 11:00 PM to 7:00 AM and April 29, 2018, 11:00 PM to 7:00 AM. Further interview with EMP3 confirmed PF3 was notified on April 30, 2018, that he was removed from the schedule pending an investigation into the allegations of sexual assault.

At the time of the interview with EMP3 the facility document " Time Line of Events " was reviewed and discrepancies were identified regarding when PF3 was suspended from duty. EMP3 confirmed PF3 was on the schedule and worked April 29, 2018, 11:00 PM to April 30, 2018, 7:00 AM.

Interview on September 12, 2018, at approximately 3:00 PM with EMP5 confirmed they documented the events on the timeline from interviews with the staff. EMP5 was not able to provide information why there were discrepancies regarding the time PF3 was suspended from duty.


Interview on September 11, 2018, at 2:00 PM with EMP1 confirmed they were notified of the allegations of sexual assault April 30, 2018 and removed the employee from the schedule immediately pending further investigation. Further interview with EMP1 confirmed allegations of sexual assault were not reported until 72 hours after the allegations were reported to the charge nurse.


2) This was the 2nd allegation of possible sexual assault that involved PF3 and the information was documented in the witness statement submitted by OTH1 on April 30, 2018.


Review on September 12, 2018, of MR12 revealed the patient was admitted to the facility on March 29, 2018, for response to internal stimuli, depression, suicidal ideation, yelling and screaming. The patient was treated and discharged May 8, 2018. Continued review of MR12 revealed no documented evidence of an incident or suspicious incident involving an unwanted sexual event.

Review on September 11, 2018, of facility document, employee witness statement for OTH1 dated April 30, 2018, revealed " ... Side note: the reason this incident caught my immediate attention was because this is not the first suspicious behavior I experienced between the BHT and another patient (MR12). The first incident was brought to my manager's attention on April 18th.


Interview on October 9, 2018, at 2:30 PM with OTH1 confirmed on April 13, 2018, [they] were the RN in charge of the unit. OTH1 confirmed EMP7 and OTH2, from Admissions, were on duty that night. OTH1 confirmed PF3 was on the floor (monitoring) patients and EMP7 was performing patient safety rounds every 15 minutes. OTH1 confirmed they were looking for PF3 and found PF3 in the room of MR12, room 5017. OTH1 confirmed the door was locked and [they] had to use keys to enter the room. OTH1 confirmed PF3 was providing incontinent care to MR12. OTH1 confirmed PF3 was in room 5017 longer than expected to provide incontinent care. OTH1 confirmed she requested OTH2 to look in MR12 ' s room to confirm if PF3 was still providing incontinent care. OTH2 confirmed PF3 was still providing care. OTH1 confirmed during patient safety rounds EMP7 had to unlock the door to room 5017 to check on MR12 for safety. Room 5017 was directly across from the nurse ' s station and OTH1 confirmed that is where observation occurred. OTH1 confirmed [they] reported this event to EMP3, but she did not submit an incident report because she was afraid of how PF3 would react. OTH1 described him as a larger person and she was afraid that he would become angry.


Review of facility document on October 16, 2018, of EMP3's written witness statement for the event that allegedly occurred on April 13, 2018, revealed " On 4/18/18, I met with OTH1 in my office at the end of her shift. OTH1 informed me that she had trouble locating PF3 when she needed his assistance and that she had attempted to call on the walkie with no response. OTH1 state that after a few minutes of not finding anyone, she began looking in patient's rooms. Upon entering the room of [MR12] OTH1 observed PF3 providing care for that patient. MR12 was usually a 2 assist, Hoyer lift patient. OTH1 reported PF3 was wearing gloves, holding a diaper, patient was uncovered, and bathroom light was on. Patient was talking and moaning. OTH1 asked PF3 to finish what he was doing and come out to help when done. She reported leaving door slightly ajar and going back to the nurse ' s station. OTH1 reported that PF3 was in there another 10 minutes ... I asked OTH1 did she think PF3 was sleeping ... she said no. I asked her if she thought something inappropriate was going on and she said it didn ' t ' t appear that way, but she would let me know if she saw or heard anything else.

Interview on October 11, 2018, at 12:00 PM with EMP3 confirmed EMP1 requested EMP3 write a statement regarding a reported concern OTH1 had with PF3 the night of April 13, 2018. EMP3 confirmed the statement was written prior to speaking with the surveyor. Further interview confirmed OTH1 did not mention concerns of abuse or assault.


_____________


Based on review of facility documents, facility policy and interview with staff (EMP) it was determined the facility failed to follow their approved policy for incident classification of reporting sexual assault. (MR1)

Findings include:

Review on September 12, 2018, of facility policy "Incident Reporting" approved January 2018, revealed ''Policy: Any incident, unusual occurrence, variance, hazard or theft, involving patients, visitors or staff is to be reported timely and in the approved format ..."


Review on September 12, 2018, of facility document "Incident Reporting Definitions, version 1.2 (2017)" revealed "Incident Reporting Event; Sexual Event- patient/staff ... Event Definition-Includes any actual or alleged or inappropriate sexual contact between staff and current patients ... Severity Number: Class 1- Any allegation of sexual familiarity between staff and patient (including kissing, flirtation, fondling, touching of breast or other private parts or any other sexual activity or behavior by a staff member ... Class 2- Any intentional exposure of genitals and breasts, kissing, fondling, touching of breasts or other private parts, or any other sexual activity ... "

Review on September 12, 2018, of physician document " Medical Progress Note" dated April 30, 2018, revealed "Interval History ... [patient] is seen and examined by request this morning as the patient reported inappropriate sexual incident that occurred on the night of April 27th to the 28th. The patient states that a male aide, entered [the patient's] room after [they] went to sleep at night and stated that [behavioral health technician (BHT)] needed to do a skin check. [patient] reports that BHT then proceeded with no gloves on [their] hands and started on [the patient's] calves working [their] way up to [the patient's] knees and then [BHT] told me to spread my legs, 'I have to check there' The patient became tearful ... and says BHT took 2 or 3 fingers and touched inside of the [patient's] labia. The patient tells me BHT said you have some redness and discharge ... patient reports there was no vaginal penetration ..."

Review on September 12, 2018, of facility document " Haven Philadelphia Incident Report " revealed an incident report was filed for MR1 on April 28, 2018 at 1:10 AM. Further review revealed the classification of the incident was "Category- Alleged Sexual event-patient /staff; Class2 ..."

Interview on September 12, 2018, with EMP3 at 11:00 AM confirmed the Incident Report was categorized as a Class 2 and not as a Class I that was defined as staff contact with patient.

cross reference with:
482.12 Governing Body
482.13 Patient Rights
482.13(a)(2)(i) Patient Rights: Grievance Procedures
482.13 (c)(2) The patient has a right to receive care in a safe setting
482.13(f)(2)(ii) Patient Rights: Restraint or Seclusion

Based on review of facility documents, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure documentation of demonstrated knowledge for the needs of the patient population for CPI (Nonviolent Crisis Intervention) training in two of eight personnel files reviewed (PF3, PF6).

Findings include:

Review on September 12, 2018, of facility document "Job Description for Registered Nurse (RN)" revealed, " ... Qualifications ... CPI ... ".

Review on September 12, 2018, of facility document "Job Description Behavioral Health Technician (BHT) revealed, " ... Certifications/Licenses ... CPI ... ".

Review on September 12, 2018, of PF3 revealed no documentation of current CPI training for this BHT.

Review on September 12, 2018, of PF6 revealed no documentation of current CPI training for this RN.

Interview with EMP4 on September 12, 2018, at 2:15 PM confirmed there was no documentation of current CPI training in PF3 and PF6.


Cross Reference with:
482.12 Governing Body
482.13 Patient Rights
482.13(a)(2)(i) Patient Rights: Grievance Procedures
482.13 (c)(2) The patient has a right to receive care in a safe setting
482.13(c)(3) Patient Rights: Free From Abuse/harassment

Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined that the facility failed to ensure the quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators for Utilization Management, Infection Control, Human Resources, Biomed and Pharmaceutical Services.

Findings include:

Review on September 12, 2018, of the facility's "Performance Improvement Plan", dated April 2018, revealed "Responsibility the Governing Board has the ultimate authority and responsibility for adopting an organization-wide plan to assess and improve the quality of care provided and to assure quality care ... Responsibility the Quality Council is responsible for the following: ... 2. Coordinate organization-wide performance improvement activities as designed i n the PI [performance improvement] Plan ... a. Ensure that patient care areas and organizational functions are included in the performance improvement process ... 4. ... Facilitation of facility-wide performance improvement activities ... 6. Review the results of all monitoring evaluation and performance improvement activities ..."

Review on September 11 and 12, 2018, of the Performance Improvement committee meeting minutes, dated September 2017 through August 2018, revealed there was no documented evidence of the review of quality assessment indicators for Utilization Management, Infection Control, Human Resources, Biomed and Pharmaceutical Services.

Interview with EMP5, on September 12, 2018, confirmed there was no documented evidence of the review of quality assessment indicators for Utilization Management, Infection Control, Human Resources, Biomed and Pharmaceutical Services in the Performance Improvement committee meeting minutes.



Cross Reference with:
482.12 Governing Body
482.21(e)(4) Providing Adequate Resources

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to establish a budget for quality assessment and performance improvement activities.

Findings include:

A request was made on September 11 and 12, 2018, to EMP5 for the facility's QAPI budget. None was provided.

Interview on September 12, 2018, with EMP5, at 3.42 PM, confirmed the facility did not establish a budget for quality assessment and performance improvement activities.


Cross Reference with:
482.12 Governing Body
482.21(a),(b)(1),(b)(2)(i),(b)(3) Data Collection & Analysis

Based on review of medical records (MR), review of facility documents and policies, and interview with staff (EMP), it was determined that the facility failed to provide documented evidence of daily administration of wound care treatment as ordered by physician for one of one medical records reviewed (MR10).

Findings include:

Review on October 11, 2018, of facility policy, " ... Documentation Protocol," dated January 2018, revealed, " ... Policy: ... Staff are to document accurately our [sic] services provided, patient interactions and all ...."

Review on October 11, 2018, of facility policy, " ... Nursing Reassessment Forms," dated January 2017, revealed, " ... BIRP [Behavior Intervention Response Plan] Note should reflect all interventions provided to address patient ' s active problems ...."

Review on October 10, 2018, of MR10's, "Practitioner Order," dated August 18, 2018, revealed, " ... cleanse L [left] leg ulcer BID [twice a day] with soap and water, dry and apply triple ABT[antibiotic] sterile dressing ...."

Review on October 10, 2018, of MR10's, "Practitioner Order," dated August 20, 2018, revealed, " ... d/c [discontinue current L [left] leg wound tx [treatment] cleanse L [left] leg wound with NSS[Normal Sterile Saline] apply calcium alginate qd [daily] and cover with CDD [clean, dry dressing] daily and prn [as needed].

Review on October 10, 2018, of MR10's, "Medical Progress Note," dated August 22, 2018, revealed, " ... Assessment and Plan: 1. Left lower extremity ulceration with cellulitis ... wound also has increased drainage. There is just a regular dressing with no medication. I wonder if they have started the calcium alginate. I will need to discuss this with nursing ... We will need to monitor this closely and continue wound care ...."

Review on October 10, 2018, of MR10's, "Medical Progress Note," dated August 29, 2018, revealed, " ... Assessment and Plan: ... The patient does have increased drainage and there is a lot of moisture trapped under the dressings ... I did order calcium alginate, which has not been applied yet, but will be started now and we need to order a nonstick dressing. We will need to monitor closely at high risk of further skin breakdown if that type of moisture continues."

Review on October 10, 2018, of MR10's, "Nursing Reassessment," dated "August 18, 2018," "August 19, 2018," "August 20, 2018," "August 21, 2018," August 22, 2018," "August 24, 2018," "August 25, 2018," "August 27, 2018," "August 28, 2018," "August 30, 2018," "September 3, 2018," "September 4, 2018," "September 5, 2018," "September 7, 2018," "September 8, 2018," "September 9, 2018," "and September 10, 2018," revealed, no documented evidence of daily administration of wound care treatment as ordered by physician."

Interview on October 10, 2018, at 12:05 PM, with EMP3 confirmed there is no documented evidence of daily administration of wound care treatment as ordered by physician for patient related to MR10.

Limbert, Wendy J.
Based on observation, policy and procedure review and interview with staff (EMP) it was determined the facility failed to ensure a safe environment was provided for patients admitted Haven Behavioral Hospital.


Findings includes:

Review on September 12, 2018, of facility documents "Safety Management Plan," approved February 2018, revealed "Purpose: ... The scope of the Safety Management Plan defines the processes which the Hospital utilizes to provide our patients, staff and visitors with a physical environment free of hazards and manages activities proactively through risk assessment to reduce the risk of injuries to patients, staff and other individuals coming to the hospital ... the goals of Hospital's Safety Management Plan include the following: maintain a safe environment and conditions for patients, staff and visitors ... The safety committee shall include representation from administration and supervisory staff from clinical and support services ... written minutes of each meeting shall be retained ... the risk Management Program is carried out by using Risk Assessments ..."

Review on September 12, 2018, of facility document "Environmental Safety Risk Assessment, Inpatient Behavioral Health Settings," date March 2018, revealed the following identified risks: "Location: Client Activity Areas: Ceilings: prefer solid gypsum board ceilings: not compliant-moderate risk severity. Additional actions - secure clips ... Door closures mounted on the outside: not compliant-moderate risk severity. No additional actions documented ... Furniture: heavy, no loopable points: Compliant-low risk severity. No additional actions documented .. Artwork: securely mounted, flush to wall: Compliant-low risk severity. No additional actions documented ... Appliances: all cooking appliances should be key operated with lock-out switches; Compliant. No additional actions documented ... Location: Hallways: prefer solid gypsum board ceilings: not compliant-moderate risk severity. No additional actions documented ... No wall or ceiling mounted hardware brackets or thermostats: Compliant-low risk severity. No additional actions documented ... all exit signs and emergency light fixtures are flush mounted or are ceiling hung: Compliant-low risk severity. No additional actions. "

Observation of the 5th floor patient care unit on September 12, 2018, from 9:45 AM to 11:15 AM revealed the following:

1. Dining Room-contained the following: lightweight patient chairs with loopable arms and lightweight moveable tables that could be used to barricade the doorway, wall mounted thermostat without tamper-proof cover, framed picture not flush-mounted to wall, piano with removable parts that could cause self-harm, metal and plastic Geri-chair table that could be used as a weapon or for self-harm, food warmer cart with long detachable cord and no lock-out mechanism that could be used as a barricade or weapon, coffee machine with removable parts that could be used as a weapon, radio with removable metal antenna that could be used for self-harm, kitchen cabinets with removable metal hardware that could be used for self-harm, 2 sets of 3 foot long suction tubing that could be used for self-harm, suction machine that could be used as a weapon, unlocked refrigerator freezer with removable wire metal shelving, wall clock not flush mounted to wall, kitchen door closer mounted on the outside of the door tht could be used as an attachment point, dropped ceiling with removable panels.
2. Community Room-contained cabinets with removable metal hardware that could be used for self-harm.
3. Treatment Room- door handle could be used as an attachment point.
4. Nurses Station- lightweight plastic hand sanitizer dispenser mounted near patient hallway that could be used as an instrument for self-harm, door height and locking mechanism would allow access to nurse ' s station.
5 Hallways- wall mounted thermostats were not protected with a tamper resistant cover, exit signs were not flush mounted to ceilings, wall art was not flush mounted to walls, loopable door handles were on the nurse manager's office, nurses ' station, treatment team room and janitor closet, fire doors had loopable crash bars and door closures.
6. Music room- 2 patients observed in room without staff observation, moveable light weight furniture that could be used as a barricade, cabinets with removable metal hardware that could be used for self-harm.
7. Meditation Room- moveable furniture that could be used to barricade door, loopable chairs.

Interview on September 12, 2018, at 11:30 PM with EMP6 confirmed the above findings.

cross reference with:
482.12 Governing Body

Based on review of facility policy and procedures, review of personnel files (PF) and interview with staff (EMP), it was determined the facility failed to ensure they followed they TB (Tuberculosis) Prevention Program for three of eight personnel files reviewed (PF3, PF6 PF7).

Findings include:

Review on September 12, 2018, of facility policy "TB Prevention Program," approved August 2018 revealed " ... Surveillance - TB Screening ... b. ... Annual TB testing is required for direct patient contact staff ... ".

Review on September 12, 2018, of PF3 revealed TB testing documentation for this direct patient contact staff was dated July 2015.

Review on September 12, 2018, of PF6 revealed TB testing documentation for this direct patient contact staff was dated August 2016.

Review on September 12, 2018, of PF7 revealed TB testing documentation for this direct patient contact staff was dated March 2015.

Interview with EMP4 on September 12, 2018, at 12:30 PM confirmed there was no documentation of annual TB testing for PF3, PF6 and PF7.


Cross Reference with:
482.12 Governing Body

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure a patient death was reported for one of one death medical records reviewed (MR17).

Findings include:

Review on October 10, 2018, of facility policy "Death-Natural Death of a Patient,' approved April 2018 revealed " ... the DON/Designee shall notify contracted organ donor procurement agency."

Review on October 10, 2018, of facility document "Protocol for Death on Unit - Steps to follow" revealed " ... Call Gift of Life regardless of organ donation status... ".

Review on October 10, 2018, of MR17 revealed the patient expired at the facility on June 13, 2018. Further review of MR17 revealed no documentation the Gift of Life was notified of the patient's death.

Interview with EMP1 on October 10, 2018, at 3:45 PM confirmed there was no documentation of Gift of Life notification for the patient's death in MR17.


Cross Reference:
482.12 Governing Body
482.45(a)(5) Staff Education

Based on interview with staff (EMP), it was determined the facility failed to ensure the education was provided to staff on OPO donation issues.

Findings include:

On October 10, 2018, surveyor made a request to EMP1 for education provided to staff for OPO donations. None was provided.

Interview with EMP1 on October 10, 2018, at 3:45 PM confirmed the facility had no documentation of staff education for OPO donations.


Cross Reference with:
482.12 Governing Body
482.45(a)(1) OPO Agreement