HospitalInspections.org

Based on medical record review, review of facility policies and procedures, and interviews with administrative staff, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure the notice of rights requirements are met. (Refer to Tag A 116, Tag A 118, Tag A 132)

2. The facility failed to ensure all patients are informed of their rights. (Refer to Tag A 117)

3. The facility failed to ensure that patients have the right to receive care in a safe setting. (Refer to Tag A 144)

Based on 2 of 2 medical records reviewed and staff interview on 8/28/19, it was determined that the facility failed to ensure that the patient or when appropriate, the patient's representative, are informed of the patient rights in advance of discontinuing patient care.

Findings include:

Reference: Facility policy titled, "Important Message from Medicare" states, "... Procedure ... Discharge
1. No more than two (2) calendar days and no less than 4 hours before anticipated discharge the Social Service Department or designee will: a. Provide the Medicare beneficiary or their designated Proxy with a follow up copy of the signed "Important Message from Medicare". At that time the Social Services Department or designee will document in the medical record the date and time the "Important Letter from Medicare" was provided to the beneficiary or designated Proxy ...
2. The signed IM will be maintained in the patient's Medical Record."

1. Patient #17 was admitted to the facility on 7/28/19 and discharged on 8/9/19. The medical record contained a signed admission Important Message (IM) form. There was no evidence that the IM patient notification form was provided to the patient or their designated proxy prior to discharge.

2. Patient #18 was admitted to the facility on 7/8/19 and discharged on 7/26/19. The medical record contained a signed admission IM form. There was no evidence that the IM patient notification form was provided to the patient or their designated proxy prior to discharge.

3. Interview with Staff #15 on 8/28/19 at 11:45 AM confirmed that patients were not being provided the IM patient notification form prior to discharge.

Based on observation and staff interview, it was determined that the facility failed to ensure all patients are provided with privacy.

Findings include:

1. On 8/26/19, during a tour of the facility, the following was observed:

a. At 11:50 AM, Patient #9 was observed ambulating in the hallway wearing a patient gown that was open in the back, exposing the patient's back and underwear.

b. At 12:15 PM, Patient #10 was observed walking the hallway with Staff #18 wearing a patient gown that was open in the back, exposing the patient's back and diaper.

2. The above findings were confirmed by Staff #1, Staff #2, Staff #3 and Staff #8.

A. Based on observation and staff interview, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

1. During a tour of the facility on 8/26/19, in the presence of Staff #4, in Room #2, the bed was noted to have a bed alarm with a cord, approximately six (6) feet long which poses a ligature risk.

a. Staff #4 stated that the these bed alarms should be removed during the day and only used at night for fall risk patients.

b. Staff #4 confirmed that the long cord is a ligature risk.


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2. On 8/28/19 at 2:00 PM in the presence of Staff #1, during a tour of the facility, the following unmitigated ligature risks were identified in the patients bedrooms:

a. Two (2) patient beds, one (1) located in Patient Bedroom #1 and one (1) located in Patient Bedroom #12 were constructed of Poly Vinyl Chloride (PVC) piping. These beds have gaps at the head and foot that can be utilized as ligature points. These beds are light enough that if placed on their side would expose the tubular sides which could also be utilized as ligature points.

b. Twenty-seven (27) beds were traditional hospital beds that provided ligature points in the following areas:

(i) Manual hand cranks for adjustments

(ii) Head and Foot Boards

(iii) Open areas along the frame

c. The dresser drawers in Patient Rooms #1, #2, #12, and #16 can slide out providing ligature points.

d. In all of the patient rooms, the bathroom doors were constructed in a way that allows for the creation of a ligature point when the doors are in a closed position.

3. During an interview on 8/28/19, Staff #1 confirmed the following:

a. The hospital does not conduct environmental risk assessments of the patient care areas.

b. The hospital does not have any policies and procedures to address environmental risk assessments.

c. The hospital does not educate patient care staff in the identification of potential ligature points.

On 9/9/19 after supervisory review, the following Immediate Jeopardy (IJ) was identified:

The facility failed to ensure that a safe environment was maintained to prevent patient self harm.

The facility was notified of the IJ and a copy of the IJ Template was provided. An IJ Removal Plan was accepted on 9/12/19.

On 9/16/19, an onsite revisit was conducted. The Removal Plan for the IJ was implemented and the IJ was removed.


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B. Based on observation, medical record review, document review, and staff interview, it was determined that the facility failed to ensure implementation of their Falls Prevention Program to facilitate the provision of care in a safe setting.

Findings include:

Reference: Facility Document titled, "Falls Prevention Program; Fall Risk" states, "... on admission, the Edmondson Fall Risk Assessment is performed to determine the fall risk; if fall score is 89 or above, the patient will receive initial fall precautions to include a yellow or a red star placed on the patient's door, a fall risk bracelet, and fall risk stickers placed on MAR [Medication Administration Record], TAR [Treatment Administration Record], and Psych Aide Care Kardex, and "FP" [Fall Precautions] placed next to the patient's name on the white board to indicate fall precautions ... Initial Fall Precautions: Yellow Star- Fall Score 90-120. Red Star- Fall Score 121 or Higher ..."

1. On 8/26/19, upon interview, Staff #2 confirmed that in addition to a facility falls policy and procedure, a falls prevention program has been implemented as a means to prevent falls. Staff #2 stated that the nurse will complete a falls risk assessment on admission. Patients identified as a high fall risk will have FP [falls precaution] placed next to their name on the the whiteboard behind the nursing station. These patients will also have a large yellow or red colored star placed above their door, depending on their fall score. A smaller color coded star sticker will be placed next to the individual name of the patient outside their doorway. Low to moderate risk fall risk patients will receive yellow star stickers and high fall risk patients will receive red star stickers. A yellow bracelet will also be placed on the patient's wrist labeled Fall Risk. The patient will also be provided non-skid socks.

2. On 8/27/19, the "Psychiatric Fall Risk Assessment" flow sheets in seven (7) medical records were reviewed.

a. Five (5) out of seven (7) medical records, (#8, #9, #13, #21, #22) revealed that the patients had a fall risk score above 89. A fall risk score above 89 identifies those patients as moderate to high fall risk. The following fall risk interventions were not implemented:

(i) The nursing documentation on 8/23/19 on the Psychiatric Fall Risk Assessment identified a score for Patient #8 as ninety (90). The 8/26/19 documented fall score was ninety-four (94). Patient #8 did not have a yellow bracelet on his/her wrist labeled Fall Risk. There was no color coded star above the patient door nor next to the patient name outside the patient doorway to communicate moderate to high risk.

(ii) The nursing documentation on 8/16/19 on the Psychiatric Fall Risk Assessment identified a score for Patient #9 as ninety-eight (98). The 8/21/19 documented fall score was one hundred ten (110). Patient #9 did not have a yellow bracelet on his/her wrist labeled Fall Risk.

(iii) The nursing documentation on 8/19/19 on the Psychiatric Fall Risk Assessment identified a score for Patient #13 as one hundred thirteen (113). Patient #13 did not have a yellow bracelet on is/her wrist labeled Fall Risk.

(iv) The nursing documentation on 7/31/19 on the Psychiatric Fall Risk Assessment identified a score for Patient #21 as one hundred three (103). On 8/1/19, 8/7/19, and 8/14/19, the score was one hundred nine (109). Patient #21 did not have a yellow bracelet on his/her wrist labeled Fall Risk.

(v) The nursing documentation on 8/10/19 on the Psychiatric Fall Risk Assessment identified a score for Patient #22 as one hundred four (104). On 8/24/19, the score was one hundred seven (107). On 8/25/19, the score was one hundred seven (107). Patient #22 did not have a yellow bracelet on his/her wrist labeled Fall Risk.

3. The above findings were confirmed by Staff #2.

A. Based on document review and staff interview conducted on 8/26/19, it was determined that the facility failed to ensure that the medical staff enforces its bylaws.

Findings include:

Reference #1: Medical Staff Bylaws Section 7.9 states, "... The Pharmacy and Therapeutics Committee is chaired by an active Medial Staff Member appointed by the Medical Director in consultation with the Medical Executive Committee. Its Membership includes, The Pharmacy Consultants, Director of Nursing, a representative of Food & Nutrition and Director of Quality Assurance."

Reference #2: Facility policy titled "Pharmacy Organization: Pharmacy and Therapeutics Committee" states, "Policy: 1. The facility will establish a Pharmacy and Therapeutics Committee. The Committee is a multidisciplinary committee that will consist of at least the following five persons: Facility Administrator, Consultant Pharmacist, Provider Pharmacy Representative, Director of Nursing Service and the Medical Director."

1. The members of the Pharmacy and Therapeutics Committee that are required in the Medical Staff Bylaws are not the same members required in the facility policy.

2. The Pharmacy and Therapeutics Committee meeting minutes, dated 2/11/19, 4/1/19, and 6/20/19 lacked evidence that a physician chaired the Committee. All three meetings were called to order by the Director of Nursing.

3. The Pharmacy and Therapeutics Committee meetings, dated 2/11/19, 4/1/19, and 6/20/19 lacked evidence that the Medical Director or any other member of the medical staff had attended the meetings.

4. The Pharmacy and Therapeutics Committee meetings, dated 2/11/19, 4/1/19, and 6/20/19 lacked evidence that a representative of Food & Nutrition had attended the meetings.

5. The Pharmacy and Therapeutics Committee meetings, dated 2/11/19, 4/1/19, and 6/20/19 lacked evidence that a facility administrator had attended the meetings.

6. These findings were confirmed by Staff #25.


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B. Based on review of 2 of 4 medical records, document review, and staff interview on 8/27/19, it was determined that the facility failed to ensure that patients are seen by the treating physician in accordance with its medical by-laws.

Findings include:

Reference: Facility policy, "Medical By-Laws- Physician Documentation: Assessments, Orders, Progress Notes ..." states, "... Procedures & Specifications: Psychiatry ... Routine Visits: Consistent with N.J.A.C. Hospital Licensing Standards 8:43 G-16.6(f), "Every acute care patient shall receive a visit by a clinical practitioner every day unless there is a clinical basis to justify the patient not receiving such a visit that is documented in the medical record by the practitioner. In all cases a patient shall receive a visit by a practitioner at least once every two days." If this criterion is not met, the clinician will provide a progress note specifying the reason(s) for said variance to include a description of the efforts make toward satisfaction of these requirements."

1. Medical Record #1 indicated that the patient was admitted to the facility on 3/29/19 and discharged on 4/6/19. The medical record lacked documentation of psychiatric progress notes for 4/2/19 and 4/3/19.

2. Medical Record #2 indicated that the patient was admitted to the facility on 4/12/19 and discharged on 4/21/19. The medical record lacked documentation of psychiatric progress notes for 4/15/19, 4/17/19 and 4/18/19.

3. There was no evidence in the progress notes of a reason for the patient not to be seen daily.

4. The above was confirmed by Staff #8.

Based on medical record review, staff interview, and review of facility documentation, it was determined that the facility failed to have an organized nursing service.

Findings include:

1. The facility failed to ensure staffing for assistive personnel was in accordance with the facility staffing plan. (Refer to Tag A 392)

2. The facility failed to ensure that nursing staff are assessing, coordinating, documenting, and evaluating the care of each patient. (Refer Tag A 395)

3. The facility failed to ensure that treatment plans are developed and implemted. (Refer to Tag A 396)

4. The facility failed to ensure that medications are administered in accordance with prescriber's order and documented in accordance with facility policy. (Refer to Tag A 405)

Based on document review and staff interview, it was determined that the facility failed to ensure that the number of personnel providing nursing care is in accordance with its Staffing Grid.

Findings include:

Reference: Facility Staffing Grid states, "Staffing Patterns to determine number of CNAs [certified nursing assistants] for all shifts. To use the grid below, you take the total daily census and subtract the number of patients on 1:1 observation for the shift. That number will determine the baseline number of staff needed. Then you add one staff for each patient on 1:1 observation. That number is the total number of staff required for the shift.
The 1:6 ratio would be for 7-3:30 & 3-11:30:
Patients after removing 1:1- 19-24--Number of CNA staff 4
Patients after removing 1:1- 25-50--Number of CNA staff 5

The 1:8 ratio would be for 11-7/30 [sic]:
Patients after removing 1:1- 17-24--Number of CNA staff 3
Patients after removing 1:1- 25-30--Number of CNA staff 4"

1. Review of a two weeks staffing pattern for CNA coverage revealed the following:

a. 8/4/19 Day shift (7:00 AM- 3:30 PM)-
Census thirty (30). One (1) patient was on a 1:1 observation. The number of CNAs was five (5). This was one (1) below the required number.

b. 8/4/19 Evening shift (3:00 PM-11:30 PM)-
Census thirty (30). One (1) patient was on a 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

c. 8/4/19 Night shift (11:00 PM-7:30 AM)-
Census thirty (30). Two (2) patients were on a 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

d. 8/6/19 Evening shift-
Census thirty (30). One (1) patient was on a 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

e. 8/6/19 Night shift-
Census thirty (30). Two (2) patients were on a 1:1 observation. The number of CNAs was five (5). This was one (1) below the required number.

f. 8/7/19 Evening shift-
Census thirty (30). Two (2) patients were on 1:1 observation. The number of CNAs was four (4). This was three (3) below the required number.

g. 8/7/19 Night shift-
Census thirty (30). Two (2) patients were on 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

h. 8/8/19 Night shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was four (4). This was one (1) below the required number.

i. 8/9/19 Evening shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was five (5). This was one (1) below the required number.

j. 8/9/19 Night shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was four (4). This was one (1) below the required number.

k. 8/11/19 Day shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was five (5). This was one (1)below the required number.

l. 8/11/19 Night shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was four (4). This was one (1) below the required number.

m. 8/12/19 Day shift-
Census thirty (30). One (1) patient was on 1:1 observation. The number of CNAs was five (5). This was one (1)below the required number.

n. 8/12/19 Evening shift-
Census thirty (30). Three (3) patients were on 1:1 observation. The number of CNAs was seven (7). This was one (1) below the required number.

o. 8/12/19 Night shift-
Census thirty (30). Three (3) patients were on 1:1 observation. The number of CNAs was five (5). This was two (2) below the required number.

p. 8/13/19 Day shift-
Census thirty (30). Three (3) patients were on 1:1 observation. The number of CNAs was seven (7). This was one (1) below the required number.

q. 8/13/19 Night shift-
Census thirty (30). Two (2) patients were on 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

r. 8/14/19 Day shift-
Census twenty-eight (28). Two (2) patients were on 1:1 observation. The number of CNAs was six (6). This was one (1) below the required number.

s. 8/14/19 Night shift-
Census twenty-eight (28). Two (2) patients were on 1:1 observation. The number of CNAs was four (4). This was two (2) below the required number.

t. 8/15/19 Night shift-
Census twenty-seven (27). Two (2) patients were on 1:1 observation. The number of CNAs was five (5). This was one (1) below the required number.

u. 8/16/19 Day shift-
Census twenty-nine (29). Two (2) patients were on 1:1 observation. The number of CNAs was six (6). This was one (1) below the required number.

v. 8/16/19 Evening shift-
Census twenty-nine (29). Three (3) patients were on 1:1 observation. The number of CNAs was six (6). This was two (2) below the required number.

w. 8/16/19 Night shift-
Census twenty-nine (29). Three (3) patients were on 1:1 observation. The number of CNAs was three (3). This was four (4) below the required number.

x. 8/17/19 Day shift-
Census twenty-eight (28). Three (3) patients were on 1:1 observation. The number of CNAs was five (5). This was three (3) below the required number.

y. 8/17/19 Evening shift-
Census twenty-eight (28). Three (3) patients were on 1:1 observation. The number of CNAs was three (3). This was four (4) below the required number.

2. Upon request, Staff #2 was unable to provide a nursing staffing plan or a policy to include a method for assessing the unit's additional nursing needs for each shift. He/she indicated that the licensed staffing number was integrated in the CNA staffing grid.

Based on document review and staff interview, it was determined that the facility failed to ensure that the registered nurse evaluates the nursing care for each patient.

Finding includes:

Reference #1: Facility policy "Incidents and Occurrences" states, "... Procedures ... 6. Any incident of head injury or suspected head injury must generate neurological checks."

1. The medical record of Patient #1 revealed the following:

a. The patient sustained an unobserved fall on 3/31/19 at 7:50 PM. As per the Incident Report Checklist, one of the nursing interventions was "Neuro checks initiated." There was no neurological flow sheet available for that timeframe.

b. The patient sustained an unobserved fall on 3/31/19 at 10:15 PM. Neuro checks were initiated. The Neurological Flow Sheet stated: "Vital Signs and Neurological Checks: q [every] 15 minutes x1 hour; q 30 minutes x1 hour; q 1 hour x4 hours; q 8 hours x 48 hours."

c. The Neurological Flow Sheet revealed that vital signs and neurological checks were initiated on 3/31/19 at 10:15 PM and were not completed as follows:

(i) 3/31/19 at 10:45 PM (q 15 checks)

(ii) 3/31/19 at 11:30 PM (q 30 checks)

(iii) 4/1/19 at 12:00 AM (q 30 checks)

(iv) 4/1/19 at 1:00 AM, 2:00 AM, 3:00 AM, and 4:00 AM (q 1 hour checks)

(v) 4/2/19 at 4:00 AM (q 8 hour checks x 48 hours)

(vi) 4/3/19 at 4:00 AM (q 8 hour checks x 48 hours)

d. The patient sustained an observed fall on 4/5/19 at 10:45 PM. Neuro checks were initiated at that time. The Neurological Flow Sheet revealed that vital signs and neurological checks were not performed on 4/6/19 at 12:00 AM and 12:30 AM (q 30 checks) and from 1:30 AM to 4:30 AM (q 1 hour checks).

e. The above was confirmed by Staff #8.

2. The medical record of Patient #2 revealed the following:

a. A physician order dated 4/12/19 at 9:30 PM stated, "FBS [finger stick blood sugar] bid [twice daily] x 3 days AC [before meals] -then show MD," and on
4/17/19 at 8:00 AM, "FBS bid daily x 2 days - show MD"

(i) The Blood Glucose Record sheet revealed that blood sugar glucose finger testing was not performed on 4/13/19 and on 4/17/19 at 4:30 PM.

(ii) The above was confirmed by Staff #8.

b. A physician order dated 4/12/19 at 3:48 PM stated, "... 9. CMP [comprehensive metabolic panel], CBC [complete blood count] with diff [differential], B-12, folate, RPR [rapid plasma reagin], Vitamin D, Magnesium, TSH [thyroid stimulating hormone], Hbg [hemoglobin] A1C, VPA [valproic acid] level x 4 days." On 4/13/19, a physician order stated, "Add ammonia (NH3) level to lab ..." On 4/15/19 the physician lab order states, VPA level 4/18/19, RPR, TSH, Lyme titer, B12 folate."

(i) A laboratory (lab) form provided by Staff #2 revealed that on 4/17/19, the patient refused labs and that the laboratory technician informed the facility. There was no evidence in the nursing notes that the laboratory orders were carried out or refused. There was no evidence in the Psychiatric Physician/APN notes of awareness of laboratory refusal. The only documentation was by the Medical Physician on 4/19/19 that labs were refused.


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Reference #2: Facility policy titled "Multidisciplinary Progress Notes" states: "... Procedure: 1. The licensed nursing staff on all shifts shall document daily observation of each patient's progress on the Psychiatric Nursing Flowsheet. ..."

1. Upon interview, Staff #2 confirmed that the facility has three (3) scheduled nursing shifts: 11:00 PM - 7:00 AM, 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM.

2. The "Psychiatric Nursing Flowsheet" in four (4) out of 4 medical records lacked documentation of daily observation of each patient's progress by licensed nursing staff on the following dates and shifts:

a. Medical Record #9, admission date 8/16/19:

- 8/17/19 (11:00 PM - 7:00 AM) and (3:00 PM - 11:00 PM)

- 8/18/19 (11:00 PM - 7:00 AM), (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

- 8/21/19 (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

- 8/23/19 (3:00 PM - 11:00 PM)

- 8/24/19 (11:00 PM - 7:00 AM) and (7:00 AM - 3:00 PM)

- 8/25/19 (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

b. Medical Record #11, admission date 7/16/19:

- 8/15/19 (3:00 PM - 11:00 PM)

- 8/16/19 (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

- 8/17/19 (11:00 PM - 7:00 AM) and (7:00 AM - 3:00 PM)

- 8/18/19 (7:00 AM - 3:00 PM)

- 8/22/19 (3:00 PM - 11:00 PM)

- 8/23/19 (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

c. Medical Record #13, admission date 8/19/19:

- 8/20/19 (7:00 AM - 3:00 PM)

- 8/21/19 (7:00 AM - 3:00 PM)

- 8/23/19 (3:00 PM - 11:00 PM)

- 8/24/19 (11:00 PM - 7:00 AM) and (7:00 AM - 3:00 PM)

- 8/25/19 (7:00 AM - 3:00 PM) and (3:00 PM - 11:00 PM)

d. Medical Record #14, admission date 8/14/19:

- 8/16/19 (3:00 PM - 11:00 PM)

- 8/17/19 (11:00 PM - 7:00 AM)

- 8/18/19 (7:00 AM - 3:00 PM)

- 8/22/19 (7:00 AM - 3:00 PM)

3. The above findings were confirmed by Staff #1, Staff #2, Staff #3 and Staff #8.

A. Based on document review, it was determined that the facility failed to ensure that the patient nursing care plan is implemented.

Findings include:

1. The medical record of Patient #1 indicated an initial Nursing Plan Of Care dated 3/28/19 which states,
"Problem: Risk for suicide related to depression ... Staff Interventions: Nursing will assess the patient's suicidal potential by asking the patient if he/she has a plan for suicide and evaluate the need for suicide precautions every shift.
Problem: Risk for skin breakdown related to incontinence ... Staff Interventions: Nursing: Perform skin assessment twice weekly and PRN ... Ensure adequate food and fluid intake every meal and snack."

a. Review of the Psychiatric Nursing Flowsheet from 3/29/19, evening shift, through 4/5/19, evening shift (total of 16 shifts) failed to indicate if the patient had a plan for suicide.

b. Review of the Psychiatric Nursing Flowsheet from 3/29/19 evening shift, through 4/5/19, evening shift (total of 16 shifts) failed to indicate in the Intake section of the flowsheet what percentage the patient consumed at meals/snacks, how much he/she drank in a shift, or if the the meals were refused.

2. The medical record of Patient #2 indicated an initial Nursing Plan of Care dated 4/12/19 which states, "Problem:
Impaired skin integrity related to decubs to hips, redness to sacrum ... Staff Interventions: Nursing ... Ensure adequate food and fluid consumption and document amounts throughout day ..."

a. The intake section of the Psychiatric Nursing Flowsheet from 4/14/19 to 4/20/19, revealed the following:

(i) The 11:00 PM to 7:00 AM shift (6 shifts), lacked evidence of any meals/beverage or snack consumed by the patient.

(ii) The 7:00 AM to 3:00 PM shift (5 shifts), indicated "completed meals/beverage," however, it failed to indicate the percentage of food/snacks and fluid consumption. On 4/16/19, the patient refused breakfast and completed the rest of the meal/beverage. However, the form failed to indicate the percentage of food/snack and total shift fluid consumption.

(iii) The 3:00 PM to 11:00 PM shift (3 shifts), indicated "completed meals/beverage," however, it failed to indicate the percentage of food/snack and fluid consumed by the patient; 2 shifts lacked evidence of any meals/snacks/beverage consumed by the patient.


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B. Based on medical record review, observation, and staff interview, it was determined that the facility failed to ensure that a patient nursing care plan for contact precautions is developed.

Findings include:

1. Review of Medical Record #6 indicated the patient had a diagnosis of Extended Spectrum Beta-Lactamases (ESBL).

2. During a tour of the unit, a red sign stating "STOP! Please see Nurse before entering" was observed outside of Patient #6's room, Room #3.

3. Staff #4 stated during interview that the sign is to trigger staff and/or visitors to go to the nurse's station prior to entering the room. The nurse will the look at the Care Cardex file then instruct staff/visitors on what needs to be done.

4. The Care Cardex file for Patient #6 stated "Contact Precautions - Patient Placement, Private room if possible. Ensure that patients are physically separated (i.e., >[more than] 3 feet apart) from each other...Personal Protective Equipment (PPE), Don [put on] gown upon entry into the room or cubicle and observe hand hygiene before leaving the patient-care environment. Hand Hygiene ... Avoid unnecessary touching of surfaces in close proximity to the patient... Perform Hand Hygiene... After removing gloves... Patient Transport, Limit transport and movement of patients outside of the room to medially-necessary purposes."

5. There was no evidence of a nursing care plan addressing contact precautions for Patient #6.

6. Staff #4 confirmed the above findings.

A. Based on observation, document review, and staff interview, it was determined that the facility failed to ensure implementation of policies and procedures addressing medication administration.

Findings include:

Reference: Facility policy titled "Administration of Medication" states, "...8. The following time schedule is used for administration of medication in Buttonwood Behavioral Health Hospital unless other wise specified by the prescriber's order. QD/OD ...daily at 9am...BID [twice daily] 9am & 5pm ... QID [four times a day] 9am, 1pm, 5pm & 9pm ...."

1. Medications with an administration time of 9:00 AM were administered during a medication pass observation conducted on 8/26/19 from 10:30 AM until 12:00 PM.

a. The following medications, with an administration time of 9:00 AM, were administered to Patient #23 at 10:30 AM:

(i) Lisinopril 5 mg (milligrams)

(ii) Diltiazem ER 120 mg

(iii) Eliquis 5 mg

(iv) Furosemide 20 mg

(v) Clozaril 25 mg

(vi) Metformin 500 mg

(vii) Lamotrigine 150 mg

(viii) Clonazapine 0.5 mg

(ix) Breo Ellipta 100/25 inhaler

b. Toprol XL, with an administration time of 7:00 AM, was administered to Patient #23 at 10:30 AM.

c. The following medications, with an administration time of 9:00 AM, were administered to Patient #26 at 11:00 AM:

(i) Thiamine 100 mg

(ii) Quetiapine 50 mg

(iii) Enteric coated aspirin 81 mg

d. The following medications, with an administration time of 9:00 AM, were administered to Patient #25 from 11:25 AM until 11:55 AM:

(i) Raniditine 150 mg

(ii) Colace 100 mg

(iii) Tamsulosin 0.4 mg

(iv) Vitamin C 250 mg

(v) Lisinopril 5 mg

(vi) Brimonidine 0.2% ophthalmic solution

2. Staff #16 stated that medications scheduled for 9:00 AM should be administered by 10:00 AM.


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B. Based on review of two (2) medical records, review of policy and procedure, and staff interview, it was determined that the facility failed to ensure that medications are administered in accordance with physician orders and that missed or refused medication is communicated to the physician in accordance with its policy.

Findings include:

Reference: Facility policy, "Medication Administration" states, "... Procedure: ... 3. All medications are ordered by a physician or advanced practice nurse on the physicians' order form ... 17. Medications that are not given/refused are to be recorded with the nurse's initials and circled. Document the reason on the back of the MAR [medication administration record]. This information is to be further documented in a Multidisciplinary Progress Note in the medical record. Notify the physician or any missed or refused medication."

1. The medical record of Patient #2 revealed the following:

a. Physician orders dated 4/13/19 state, "Diltiazem 60 mg [milligram] po [by mouth] twice daily HTN [hypertension]" and "Metoprolol Suc [succinate] ER [extended release] 25 mg po at 5 pm HTN."

(i) The medication administration record indicated that Metoprolol 25 mg at 5:00 PM was not administered on 4/14/19, 4/15, 4/18, 4/19 and 4/20/19 due to low blood pressure.

(ii) The medication administration record indicated that Diltiazem 60 mg at 9:00 AM was not administered on 4/14/19 and 4/18/19 due to low blood pressure.

(iii) The medication administration record indicated that Diltiazem 60 mg at 5:00 PM was not administered on 4/13/19, 4/14 and 4/15/19 due to low blood pressure.

There was no evidence that the medications not administered were documented in a Multidisciplinary Progress Note or that the physician was notified.

(iv) The medication administration record indicated that Diltiazem 60 mg was held on 4/13 at 5:00 PM but Metropolol 25 mg was given.

(v) The medication administration record indicated that Metropolol 25 mg was held at 5:00 PM on 4/18, 4/19 and 4/20 yet Diltiazem 60 mg were administered on the same day and time.

There was no evidence that the physician was contacted regarding which medication should be held or given.

2. The above was confirmed by Staff #8.

3. The medical record of Patient #1 revealed the following:

a. The Physician's Orders form stated:
"3/30/19 2:30 pm Ativan 0.5 mg po q 8HRS PRN [every 8 hours as needed] Severe Anxiety
Ativan 0.5 mg IM [intramuscular] q 8 HRS PRN if PO [by mouth] refused"

b. The Multidisciplinary Progress Notes PRN Medication Only indicated that on 3/31/19 at 6:15 PM, Ativan 0.5 mg IM was administered for "Agitation/Aggression to Self or Others: Yelling"

c. The Multidisciplinary Progress Notes PRN Medication Only indicated that on 4/5/19 at 1:30 PM Ativan 0.5 mg. IM was administered for "Agitation/Aggression to Self or Others: Yelling"

d. There was no evidence that the patient was offered oral medication prior to the IM injection. The indication for the administration of Ativan was for severe anxiety and not agitation.

4. The above was confirmed by Staff #8.

Based on document review and staff interview conducted on 8/29/19, it was determined that the facility failed to ensure that the Pharmacy Policy and Procedure Manual is reviewed and approved yearly.

Findings include:

1. The "Certification of Policy and Procedure Manual Approval" form, located at the front of the Pharmacy Policy and Procedure Manual provided for review, lacked an effective date and signatures of Pharmacy and Therapeutics Committee members. "Must be signed upon distribution and renewed annually" was printed on the top of the sheet.

2. Staff #25 failed to provide evidence, such as Pharmacy and Therapeutics Committee meeting minutes, that indicated that the manual had been reviewed and approved within the past year.

Based on observation, staff interview, and review of manufacturer's instructions for use, it was determined that the facility failed to ensure that unusable drugs are not available for patient use.

Findings include:

Reference: "Aqua Care Sterile Water" Manufacturer's Instructions for use states: "Indications: ... Warning: ... No antimicrobial or other substance has been added. Caution: ... Use only if ... seal is intact. ..."

1. On 8/26/19 at 10:35 AM, during a tour of "Exam Room A," in the presence of Staff #2, a cabinet located below the sink, contained a half-empty bottle of "Aqua Care Sterile Water" with a non-intact seal.

2. Staff #2 explained that the sterile water is used by nursing personnel for dressing changes on patients.

3. The above finding was confirmed by Staff #1, Staff #2, Staff #3 and Staff #8.

Based on observation, document review and staff interview, it was determined that the facility failed to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24).

Findings include:

Reference #1: N.J.A.C. #8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #2: N.J.A.C. 8:24-6.5(j) states, "The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is non-functional or no longer used, and litter."

Reference #3: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #4: N.J.A.C. 8:24-6.2(n) states, "Requirements for the protection of outer openings shall include the following: 1. Except as specified in (n) 2 and 3 below, outer openings of a retail food establishment shall be protected against the entry of insects and rodents by: (i) Filling or closing holes and other gaps along floors, walls and ceilings; (ii) Closed, tight-fitting windows; and iii. Solid self-closing, tight-fitting doors."

Reference #5: N.J.A.C. 8:24-4.11(f) states, "...Knives, forks, and spoons that are not prewrapped shall be presented so that only handles are touched by employees..."

Reference #6: The facility policy titled, "All food items must be labeled and dated", states. "...PROCEDURE: 1. All food items must be labeled with either a manufacturer label or handwritten label. ..."

Reference #7: N.J.A.C. 8:24-6.5(f) states, "After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies."

Reference #8: 'Food Services Director/Account Manager' job description states, "Manages the dining services in a single site according to Healthcare Services Group (HCSG) policies and procedures, and federal/state requirements."

1. On 6/27/19 at 10:15 AM, a tour of the kitchen was completed in the presence of Staff #5 and Staff #7, and the following observations were made:

a. The floors at the kitchen entrance [a five (5) foot area] had sticky residue. (Refer to Reference #1 and #8)

b. The two (2) ceiling tiles in the dish washing room had visible brown yellow stains and were dislocated from the frame holding the tiles in place.
(Refer to Reference #3 and #8)

c. The "cooks" four (4) door refrigerator, had gaskets with gray brown residue. All 4 doors had gaskets that were peeling off and were torn in several places. (Refer to Reference #3 and #8)

d. The Produce Box #6 was not in use. Staff #7 stated that it had broken down and needed repair. Produce Box #6 had visibly torn gaskets with gray-black residue.
(Refer to Reference #2, #3 and #8)

e. Two (2) storage bins containing rice and flour were unlabeled. (Refer to Reference #6 and #8)

f. The utility closet had two (2) mops and one (1) broom on the floor.
(Refer to Reference #7 and #8)

g. The loading dock entrance door had visible gaps at the sweep of the door allowing for insect and/or rodent entry. (Refer to Reference #4 and #8)

2. On 6/27/19 at 2:00 PM, in the presence of Staff #5, the following observations were made:

a. Staff #8 was providing snacks to the patients in the social room. Staff #8 was holding the unwrapped plastic-ware (spoon) from the bowl of the spoon. (Refer to Reference #5)

Based on observation and staff interview, it was determined that the facility failed to provide a safe setting that is appropriate for the special needs of the patient population.

Findings include:

1. The facility failed to ensure a safe environment that is appropriate for the special needs of the patient population. (Refer to Tag A 701)

Based on observation and staff interview, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety of the patients.

Findings include:

1. On 8/28/19 at 2:00 PM, in the presence of Staff #1, the following safety concerns were identified during a tour of the facility:

a. Two (2) patient beds, one (1) located in Patient Bedroom #1 and one (1) located in Patient Bedroom #12 were constructed of Poly Vinyl Chloride (PVC) piping. These beds are light weight and could be picked up and thrown or used to cause harm to patients or staff. These beds are light enough that if placed on its side would expose the tubular sides which could also be utilized as ligature points.

b. The PVC bed was fastened together with non-tamper-resistant screws.

c. The PVC piping at the head and foot create gaps that can be utilized as ligature points.

d. Twenty-seven (27) beds were traditional hospital beds that provided ligature points in the following areas:

(i) Manual hand cranks for adjustments

(ii) Head and Foot Boards

(iii) Open areas along the frame

e. The dresser drawers in Patient Room #1, #2, #12, and #16 slide out providing ligature points.

f. In all of the patient rooms, the bathroom doors were constructed in a way that allows for the creation of a ligature point when the doors are in a closed position.

g. During an interview on 8/28/19, Staff #1 confirmed that c, d, and e above were unmitigated ligature risks.

h. Staff #1 also confirmed that no environmental risk assessment has ever been conducted to determine what environmental risks exist.

2. During a tour of the facility on 8/28/19 at 2:10 PM, in the presence of Staff #1, all patient bedroom windows in the facility were found to be covered with a film that prevents the patients from seeing natural light, weather, and the outside environment.

3. On 9/9/19, after supervisory review, the following Immediate Jeopardy (IJ) was identified:

a. The facility failed to ensure that a safe environment was maintained to prevent patient self harm.

The facility was notified of the IJ and a copy of the IJ Template was provided. An IJ Removal Plan was accepted on 9/12/19.

On 9/16/19, an onsite revisit was conducted. The Removal Plan for the IJ was implemented and the IJ was removed.

Based on observation and staff interview, it was determined that the facility failed to ensure that the medication room and other areas are clean and maintained.

Findings include:

1. On 8/27/19 at 10:00 AM, in the presence of Staff #24, the following was observed in the medication room:

a. Horizontal and vertical surfaces throughout the room and medication cart had evidence of spills and residue.


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2. During a tour of the Quiet Room on 8/26/19 at 11:36 AM, the following was observed:

a. Upon entering, a strong offensive odor was emanating from the room.

b. Brown splatters and stains, identified by Staff #18 as feces, were noted on the walls, bed linen, floor, bathroom floor and toilet.

c. Upon interview with Staff #20, Patient #10 was discharged from the Quiet Room at 7:00 AM on the same day.

d. Upon interview with Staff #18, the Quiet Room was cleaned by the housekeeping staff prior to our observation and was ready for the next patient.

e. The above findings were confirmed by Staff #3, Staff #4, and Staff #18.


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3. On 8/26/19 at 10:30 AM, in the presence of Staff #1, the following was observed:

a. The walls throughout the Dining Room were chipped exposing a porous surface that cannot be properly cleaned.

b. The wall in the Exam Room had an approximate one "1" inch hole in the wall exposing a porous surface that cannot be properly cleaned.

Based on observation, staff interview, and facility document review, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings include:

1. The facility failed to provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases, and failed to implement nationally recognized infection control guidelines. (Refer to Tag A 749)

Based on staff interviews and document review, it was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) is designated to oversee the facility's Infection Control Program.

Findings include:

1. During the entrance conference, Staff #1 and Staff #2 confirmed that the facility's ICP was Staff #4.

a. Review of the personnel file for Staff #4, failed to show evidence that Staff #4 was the designated ICP.

b. Review of personnel file for Staff #4, failed to show evidence that Staff #4 was qualified as an ICP.

2. Staff #3 confirmed the above findings.

A. Based on observation, staff interviews, review of facility policy and procedure, and review of facility documents, it was determined that the facility failed to ensure blood splatter in the patient unit corridor, is removed in accordance to manufacturer's instructions and the facility's standard precautions policy, to avoid sources and transmission of infections and communicable diseases.

Findings include:

Reference #1: Facility policy titled, "Standard Precautions" states, "9. Blood Spills - or other body fluids should be removed and the area decontaminated using the facility approved blood spill kit. ... The manufacturer's directions shall be followed... . The disinfectant should be EPA registered... ."

Reference #2: The EZ Clean-Up Kit manufacturer's instructions for use states, "...1. Put on Disposable Gloves and Appropriate protective clothing. 2. Sprinkle Red-Z over spilled area. Allow liquid to congeal for safer handling and transport. 3. Remove gelled material with scoop & scrapper. Carefully place in Red Biohazard Bag. 4. Disinfect contaminated surface area with Disinfectant Solution and wipe up with towel [disposable towel included in kit]. Place all contaminated materials (including gloves) in Red Biohazard Bag. Seal and dispose of bag as required by local, State and Federal regulations for infected solid waste. 6. Wipe hands with Antimicrobial Hand Wipe. Wash with soap and running water as soon as possible."

1. During a tour of the facility on 8/26/19 at 11:42 AM, a bright red liquid splatter was observed in the patient unit hallway, spanning the length of 24 feet.

a. Staff #4 confirmed the bright red liquid splatter was blood.

b. Facility staff failed to restrict the contaminated area. Traffic in the area increased, as patients were going to the dining area for lunch, and walking through the contaminated area. Facility staff were observed pushing patients in wheel chairs through the blood spill. Other patients were observed walking and or being assisted by facility staff to the dining room walking through the contaminated area. Some patients were wearing only socks or were in their bare feet. The blood contamination spread an additional thirty (30) feet, totaling fifty five (55) feet.

c. The measurements were confirmed by Staff #23.

2. Staff #11 and Staff #12 were observed wiping the blood off the floor, with lint free reusable cloth towels. Then spraying an unidentified solution, in an unlabeled bottle and wiping it off. This was in the presence of Staff #4, the infection control preventionist/Educator.

a. Staff #12 failed to place the contaminated cloth towels used to clean up the blood in a red biohazard bag. The cloth towels were placed in a clear plastic bag, and disposed in a regular waste receptacle.

b. At 12:18 PM, this surveyor asked Staff #4 for a blood spill kit. At 12:27 PM Staff #4 presented this surveyor with an EZ Clean-Up (blood spill) Kit. This surveyor questioned why the staff were not using the EZ Clean-Up (blood spill) Kit to clean up the blood. Staff #4 didn't answer the surveyor's question, and proceeded to hand the EZ Clean-Up (blood spill) Kit to Staff #11 and Staff #12.

c. Staff #11 and Staff #12 were unfamiliar with the EZ Clean-Up (blood spill) Kit. They opened the kit and were reading the manufacturer's instructions.

d. At 12:48 PM, Staff #4 approached Staff #11 and Staff #12 and instructed them to spill the contents of the package on the blood.

e. At 12:50 PM, Staff #4 requested several blood spill kits to be brought over to the contaminated site.

f. At 12:59 PM, facility staff was observed placing a "Wet Paint" sign on the one end of the blood spill.

(i) At 1:01 PM, a patient was observed knocking down the sign. Staff #12 proceeded to pick up the sign, folded it and placed it in the cleaning cart. During this time facility staff and patients continued to walk through the blood spill.

g. Upon interview Staff #11 and Staff #12 stated they had never been educated on the use of EZ Clean-Up (blood spill) Kit.

h. Upon interview Staff #11 and Staff #12 were unaware of the name of the solution in the unlabeled bottles and were unaware of the contact time.

i. Staff #11 and Staff #12 failed to don (put on) personal protective equipment (PPE) while cleaning up the blood spill.

j. After cleaning the blood spill, Staff #11 and Staff #12 failed to perform hand hygiene after removing their gloves.

k. Upon several requests for an approved list of disinfectants, the facility was unable to provide one.

l. Staff # stated on 8/26/19 at 2:09 PM that the blood came from a cut that Patient #24 obltained on her/his right hand.

m. On 8/26/19 at 2:24 PM, Patient #24 was observed with a fresh dressing on her/his right hand.

At 3:45 PM, this finding resulted in an Immediate Jeopardy (IJ). The facility was made aware of the IJ and a copy of the IJ Template was provided.

On 8/27/19, an acceptable removal plan was received, accepted and verified and the IJ was removed.

B. Based on observation, staff interview, review of facility policy and procedure, and review of infection control guidelines, it was determined that the facility failed to ensure implementation of hand hygiene in accordance with nationally recognized guidelines.

Findings include:

Reference #1: Facility policy titled "Contact Precautions" states, II Gloves and Hand Hygiene... A. Hand hygiene should be completed prior to donning gloves... C. Gloves should be changed after having contact with infective material... D. Gloves should be removed before leaving the patient's room and hand hygiene should be performed immediately."

Reference #2: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee [HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, "Recommendations: 1. Indications for Handwashing and Hand antisepsis ... C. Decontaminate hands before having direct contact with patients. ... E. Decontaminate hands before inserting ... peripheral vascular catheters, or other invasive devices ... F. Decontaminate hands after contact with a patient's intact skin ... G. Decontaminate hands after contact with ... a patient's nonintact skin ... I. Decontaminate hands after contact with inanimate objects ... in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves."

1. During a tour of the facility on 8/26/19, the following was observed:

a. Staff #9 was observed changing the bed linens in the room (Room #3) of Patient #6 who has a diagnosis of Extended Spectrum Beta-Lactamase (ESBL).

(i) Staff #3 doffed (removed) his/her gloves and placed them in his/her back pocket.

(ii) Staff #3 removed the soiled linen from the patient's room, walked through the corridor to the soiled utility room and opened the door, contaminating the door handle.

(iii) Staff #3 returned to Room #3, pulled the used gloves from his/her back pocket and donned (put on) them.

(iv) Staff #9 failed to perform hand hygiene and failed to put on clean gloves.

b. Staff #12 was observed cleaning Room #1. He/she failed to perform hand hygiene after exiting Room #1 and proceeding to clean Room #2.

c. Staff #10 was observed cleaning the Patient Treatment Room. He/she failed to perform hand hygiene after cleaning and exiting the Treatment Room.

d. Staff #11 was observed mopping the hallway. After completing the mopping, he/she doffed gloves and failed to perform hand hygiene.

2. The above was confirmed by Staff #4.

C. Based on observation, staff interview, medical record, and review of facility policies and procedures, it was determined that the facility failed to ensure their contact precautions policy is implemented.

Findings include:

Reference #1: Facility policy titled "Contact Precautions" states, "III. A. A gown should be donned prior to entering the room or patient's cubicle. B. The gown should be removed before leaving the patient's room... IV. Patient Outside the Room A. Activities of the patient may need to be limited... B. When the patient leaves the room, precautions should be maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment."

Reference #2: Facility policy titled, "Standard Precautions" states, "...10. Linen - ...Linen shall be bagged in an impervious bag or placed in a container lined with an impervious bag."

1. During a tour of the facility on 8/26/19 at 10:53 AM, a red sign stating "STOP! Please see Nurse before entering" was observed outside of Room #3.

a. Patient #6, who was admitted to Room #3, had a diagnosis of Extended Spectrum Beta-Lactamases (ESBL).

b. Staff #9, a Health Aide, was observed inside Room #3 changing the bed linens. Staff #9 was not wearing personal protective equipment (PPE).

c. Staff #9 was observed holding the bed linens in his/her gloved hands and taking the linen out of Room #3 without placing the linen in an impervious bag or in a container lined with an impervious bag.

d. Staff #4, stated during interview that the red "Stop" sign is to trigger staff and/or visitors to go to the nurse's station prior to entering the room. The nurse will review the Care Cardex file and instruct staff/visitors on what needs to be done.

e. The Care Cardex file for Patient #6 stated "Contact Precautions - Patient Placement, Private room if possible. Ensure that patients are physically separated (i.e., >[more than] 3 feet apart) from each other... Personal Protective Equipment (PPE), Don gown upon entry into the room or cubicle and observe hand hygiene before leaving the patient-care environment. Hand Hygiene ... Avoid unnecessary touching of surfaces in close proximity to the patient... Perform Hand Hygiene... After removing gloves... Patient Transport, Limit transport and movement of patients outside of the room to medially-necessary purposes."

f. On 8/26/19 at 1:50 PM, Patient #6 was observed walking in the hallway among other patients, less than three (3) feet away.

g. Upon interview on 8/26/19 at 2:00 PM, Staff #9, Health Aide, was unaware of what type of precautions Patient #6 was on.

h. On 8/27/19 at 12:50 PM, Patient #6 was observed walking in the hallway among other patients, less than three (3) feet away.

2. Observation and medical record review of Patient #7 indicated the following:

a. Patient #7 has a diagnosis of Methicillin-resistant Staphylococcus Aureus (MRSA) in a wound of the left knee.

b. The Comprehensive Treatment Plan dated 8/15/19 states, Problem Statement: History of MRSA LE [Left Extremity] wound.

c. Medical record review for Patient #7 states in the care plan section, "Staff Interventions: ...Nursing: Assign patient a private room, maintain contact precautions. Alert others using precautionary sign on patient's room."

d. Physician's Orders dated 8/16/19 state, Contact Precautions for MRSA LE wound.

e. On 8/26/19 at 12:00 PM Patient #7 was observed sitting in the hallway in her/his wheel chair, with a seeping wound on the left knee. Patient #7 was among other patients, less than three (3) feet away from other patients.

f. On 8/27/19 at 12:22 PM Patient #7 was observed having lunch in the dining room, sitting in her/his wheel chair. Patient #7 was among other patients, less than three (3) feet away.

3. Observation and medical record review of Patient #8 indicated the following:

a. Patient #8 has a diagnosis of Extended Spectrum Beta-Lactamases (ESBL) in the urine. Patient #8 also has a diagnosis of incontinence.

b. The Comprehensive Treatment Plan dated 8/13/19 states, Problem: Extended Spectrum Beta-Lactamases (ESBL) in the urine.

c. Medical record review for Patient #8 states in the care plan section, "Staff Interventions: ...Nursing: Assign patient a private room, maintain contact precautions. Alert others using precautionary sign on patient's room."

d. Physician's Orders dated 8/10/19 state, "Contact Precautions for ESBL Urine."

e. On 8/27/19 at 12:24 PM Patient #8 was observed having lunch in the dining room, sitting with other patients, less than three (3) feet away.


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D. Based on observation and staff interview, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases.

1. On 8/26/19 at 10:35 AM, during a tour of the unoccupied "Exam Room A", which Staff #2 stated was clean and ready for new admission assessments, dressing changes and breathing treatments for patients, the following was observed:

a. Three (3) plastic bags containing the respiratory equipment of patients currently admitted were observed atop of the patient exam table.

b. An uncovered, assistive walking device for patient use was located next to the patient exam table.

c. An open shelf area located under the patient exam table had two (2) opened cardboard boxes which contained multiple plastic suction canisters and multiple specimen containers stored in them.

2. The above findings were confirmed by Staff #1, Staff #2, Staff #3 and Staff #8.

Based on administrative staff interview, it was determined that the facility failed to have written policies related to the discharge planning process.

Findings include:

1. On 8/28/19, upon request Staff #2 and Staff #15 were unable to provide policies and procedures addressing a discharge planning process.

2. The facility failed to ensure that discharge planning was discussed with the patient or individual acting on his/her behalf. (Refer to Tag A 811)

Based on medical record review, policy and procedure review and staff interview, it was determined that the facility failed to ensure that discharge planning is discussed with the patient or individual acting on his/her behalf in 3 medical records reviewed.

Findings include:

Reference: Facility policy titled, "Comprehensive Treatment Planning" states, "... Procedures: ... 2. Discipline-specific timeframes for initially assessment completion: ... d. Social Services-before the first Treatment Team meeting ... 3. Within 96 hours of admission, the Interdisciplinary Comprehensive Treatment Team will convene a meeting with the patient to formulate an individual comprehensive treatment plan ... Progress Notes ... 3. Social Worker will complete "Attempted Visit/Documentation Supplement" forms, which will be filed ... The note will include interventions and modalities, reason for intervention, progress, interventions ..., patient's participation in groups, and attainment of goals."

1. On 8/28/19, the following records were reviewed and indicated the following:

a. Medical Record #17 - The patient was admitted to the facility on 7/28/19. The Comprehensive Treatment Plan dated 7/31/19 stated, "Problem # ... DIS 1 [discharge]." Short Term Goals by a social worker were developed. The following interventions were put in place: "Social Service: Engage pt. [patient] in discussions regarding mental health services options and personal preferences 1 x per week for 30 min. with input from providers and family members with consideration of functional needs and to remove any obstacle."

(i) The Comprehensive Treatment Plan review/update, dated 8/7/19 stated, "Planning Safe Discharge."

(ii) There was no evidence in the medical record that a social worker met with the patient, as required in the referenced interventions of the comprehensive treatment plan, or that the patient refused. The patient was discharged on 8/9/19.

b. Medical Record #16 - The patient was admitted to the facility on 6/21/19. The Comprehensive Treatment Plan dated 6/25/19 stated, "Problem # ... DIS 1." Short Term Goals by a social worker were developed. The following interventions were put in place: "Social Service: Will engage pt. is [sic] weekly discussions for 30 min with patient to examine placement options and preferences in conjunction with family members and facility staff to complete placement transition and reduce obstacles."

(i) The Comprehensive Treatment Plan review/update, dated 7/2/19, lacked evidence of updates related to discharge plans.

(ii) There was no evidence in the medical record that a social worker met with the patient, as required in the referenced interventions of the comprehensive treatment plan, or that the patient refused. The patient was transferred to a general acute facility on 7/3/19.

c. Medical Record #18 - The patient was admitted on 7/8/19. The Comprehensive Treatment Plan dated 7/10/19 lacked evidence of a discharge plan. However, the Psychosocial Service Psychosocial Assessment dated 7/9/19 stated "discharge planning-cord [coordination] of care." The Short Term Goals by a social worker were developed. The following interventions were included: "Engage pt. [patient] in discussions for 30 minutes once a week re: residential placement options. Instruct family on aftercare plan & purpose."

(i) The Comprehensive Treatment Plan review/update, dated 7/17/19 and 7/24/19, lacked evidence of updates related to discharge plans.

(ii) There was no evidence in the medical record that a social worker met with the patient, as stated in the referenced interventions of the Psychosocial Assessment, or that the patient refused. The patient was discharged on 8/26/19.

d. The above was confirmed by Staff #15.

Based on record review and interview, the facility failed to formulate short-term goals that were relevant to the patients' psychiatric condition for six (6) of eeight (8) active sample patients (Patients 1, 2, 4, 5, 7, and 8). The goals, as stated, were difficult to measure and were not behaviorally measurable. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. In Patient 1's Master Treatment Plan (MTP), dated 8/10/19, the difficult to measure short-term goal for the Problem "Reported suicidal ideation as evidenced by statements that [s/he] no longer wants to live anymore, vomiting will help [her/him] end [her/his] life" was "[First name of patient] will have a decrease thoughts [s/he] wants to harm [her/himself] to one or less a day x (seven) 7days." This goal is not objectively measurable.

2. In Patient 2's MTP, dated 7/8/19, for the Problem "Depressed mood with vegetative disturbance as evidenced by thoughts feeling sad especially after home sold & [and] [s/he] placed in facility," the difficult to measure short-term goal was: "[First name of patient] will have (two) 2 or less episodes of sadness each shift x (seven) 7 days."

3. In Patient 4's MTP, dated 7/26/19, for the Problem "Dementia/mood related agitation, aggression as evidenced by requests to eat more, then aggressive when doesn't get[her/his] way" was: "[First name of patient] will show decrease in agitation and reframe [sic] from aggression daily for four (4) days, having two (2) or less episodes."

4. In Patient 5's MTP, dated 8/21/19, for the Problem "Physical aggression aeb [as evidenced by] striking other residents at facility", the difficult to measure short-term goal was: "Pt. will have a 50% reduction in aggressive behavior q shift x seven (7) days."

5. In Patient 7's MTP, dated 8/21/19, for the Problem "Aggression towards others as evidenced by hitting a peer," the difficult to measure short-term goal was: "Daily exhibiting appropriate, safe social interaction to two (2) or more each shift x 14 days." Appropriate and safe social interaction was not defined.

6. In Patient 8's MTP, dated 8/21 [sic], for the Problem "Risk for injurious behavior toward other r/t [related to] dementia with aggressive behaviors," the difficult to measure short-term goal was: "Pt will have a 50% reduction in aggressive behaviors x seven (7) days."


B. Interviews

1. In an interview on 8/27/19 at 8:30 a.m. with the Director of Nursing, the difficult to measure short-term goals were discussed. She did not dispute the findings.

2. In an interview on 8/27/19 around 9:35 a.m. with RN2, the difficult to measure short-term goals were discussed. She agreed with the findings.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8 ) the Master Treatment Plans (MTPs) failed to include interventions by nursing staff that were patient-specific. This failure resulted in statements that were either identical and/or routine discipline functions.

Findings include:

I. Record Review:

1. Patient 1: The Master Treatment Plan (MTP) dated 8/16/19 stated for the Problem "Reported suicidal ideation" the following nursing intervention: "Patient will be med compliant and compliant with follow-up care q (each) shift x seven (7) days."

2. Patient 2: MTP dated 7/19/19 stated for the Problem "Suicidal ideation, attempted to cut wrists" the following nursing intervention: "Patient will be monitored for S.I. (suicidal ideation) & encouraged to express feelings & contract for safety x (seven) 7 days."

3. Patient 3: MTP dated 8/16/19 stated for the Problem "Mood lability" the following nursing intervention: "Pt. (patient) will be med compliant & compliant with treatment recommendations q shift x seven (7) days."

4. Patient 4: MTP dated 7/26/19 stated for the Problem "Mood lability" the following nursing intervention: "Nursing staff provide encouraging words & emotional support each shift. Pt. will be med compliant & ... (illegible writing for both D.O.N. (Director of Nursing) and surveyor) q shift x seven (7) days."

5. Patient 5: MTP dated 7/11/19 stated for the Problem "exacerbation of psychotic process" the following nursing intervention: "Pt. will be monitored for psychosis reality orientation... (illegible for both D.O.N. and surveyor) as needed q shift x seven (7) days."

6. Patient 6: MTP dated 8/19/19 stated for the Problem "Recent Ambien overdose requiring ventilatory support" the following nursing intervention: "Pt. will be med compliant & monitored for side effects & effectiveness, q shift x seven (7) days."

7. Patient 7: MTP dated 8/21/19 stated for the Problem "Mood lability /vague paranoia" the following nursing intervention: "Pt. will be monitored for paranoia & reality orientation... (illegible for both D.O.N. and surveyor) as needed q shift x seven (7) days."

8. Patient 8: MTP dated 8/21/19 stated for the Problem "Dementia related agitation, intrusiveness" the following nursing intervention: "Pt. will be monitored for agitation & intrusiveness q shift x seven (7) days and as needed."

II. Staff Interview:

On 9/27/19 at noon, the Director of Nursing was asked to help the surveyor in the attempt to read the nursing interventions as described in Section I, above. She agreed at that time that the interventions were generic discipline tasks and not patient-specific.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) the Clinical Director failed to ensure that Master Treatment Plans contained goals that were behaviorally measurable as well as nursing interventions that were patient-specific and not generic discipline functions.

Findings include:

1. Master Treatment Plan goals: See B 121 for details.

2. Master Treatment Plans interventions: See B 122 for details.

Based on record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) the Director of Nursing failed to ensure that the treatment interventions by nursing staff on the Master Treatment Plans were patient-specific and not simply generic discipline functions. See B 121 for details.