HospitalInspections.org

Based on observations and staff interviews, it was determined the facility failed to ensure all patients were in a secure and safe environment.

This had the potential to affect all patients admitted to the geriatric behavioral hospital.

Findings include:

During a tour of the facility on 9/14/21 at 9:00 AM, the surveyor observed paper towel dispensers in each patient bathroom, a total of 12, that were not ligature resistant. Employee Identifier # 1, Administrator, who was present on the tour, confirmed the dispensers were not ligature resistant.

Based on review of facility policies and procedures, medical record (MR) reviews and staff interviews, it was determined the facility failed to ensure:

1. Staff documented 15 minute patient observations as directed per the facility policy.

2. Staff completed admission nursing assessment and suicide risk assessment per policy.

2. Staff documented wound care and measurements per policy.

3. Staff documented bed alarm checks as ordered.

4. Fasting blood glucose was obtained daily as ordered by the physician.

These deficient practices affected 6 of 7 active records reviewed and did include Patient Identifier (PI) # 3, PI # 6, PI # 8, PI # 2, PI # 4, PI # 7, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Special Precautions
Policy Number: None listed
Date Revised: 12/2020

Policy:

All patients entering the program are assessed for their degree of risk behaviors during the admission process...

Staff monitoring is instituted to prevent patients from harming themselves or others...

Procedure:

1. Precautions:
...d. 15 minute checks by staff include the following precautions:
1. Elopement
...3. Suicide/ Self-injury
...6. Assault
7. Sexually inappropriate

2. Description of Precaution Levels
...b. 15 minute checks
...2. Staff will observe the patient every 15 minutes until precaution is discontinued by a physician's order.

Facility Policy: Suicide Potential Rating Scale
Policy Number: None listed
Revised Date: 8/2021

...Policy:
On admission the nursing staff will complete the Suicide Potential Rating Scale Form or at the time, physician may order. The form is used to identify risk of a patient that has suicidal thoughts and/or plan. The form will help identify causative factors and plan treatment.

...Procedure:
1. The nursing staff shall assess the patient for thoughts of suicide, self-harm, history of self-harm or thoughts. When identified, the nurse should complete the suicide potential rating scale.
2. The nurse shall complete the suicide assessment tool.
3. The nurse shall notify MD (Medical Doctor) of score...
4. When suicide precautions ordered, the nurse notes the time and precaution sheet is started for 15-minute checks...

Facility Policy: Wound Care
Policy Number: None listed
Revised Date: None listed
Version: 2.0

Purpose:
1. To identify "at risk" patients and implement preventative care to reduce the risk of pressure injury development, and
2. To maintain skin integrity and promote wound healing using a systematic approach and monitoring process.

Policy:
To provide a consistent process for accurate and complete documentation of wound assessments and treatments.

Procedure:
1. Admission Skin Assessment
a. A thorough inspection of the patient's skin must be accomplished within the first 24 hours of admission/ readmission to the facility.
b. Documentation of findings on the admission note should include any alterations in skin integrity...
d. Notification to the physician and the family or responsible party must be completed timely...
e. Obtain orders and implement treatments for wound care as appropriate.

...5. Pressure Injury Documentation
a. Once a pressure injury is identified, an assessment must be documented. This must reflect that Physician and family were notified and what treatment/ interventions were initiated.
b. The Weekly Wound Progress Note must be initiated by the nurse. The Date of Onset and the location must be documented. This will be completed weekly and PRN (as needed).
c. Pressure injuries must be assessed and measured weekly.
...e. Weekly documentation is to be recorded on a Weekly Wound Progress Note...


1. PI # 3 was admitted to the facility on 8/26/21 with diagnoses including Dementia with Behavioral Disturbance and Anxiety.

Review of the Order Detail Reports dated 8/26/21 revealed orders for Assault Precautions, ADL (Activities of Daily Living) Precautions and Fall Precautions.

Review of the Client Observation Detail report dated 8/27/21 from 12:00 AM to 1:00 AM revealed the 15 minute check for 12:00 AM, 12:15 AM, and 12:30 AM were all documented at 1:01 and 1:02 AM which was 61 minutes later, 46 minutes later, and 32 minutes later respectively.

Review of the Client Observation Detail report dated 8/27/21 from 3:45 AM to 4:00 AM revealed the 15 minute checks for 3:45 AM, 4:00 AM were both documented at 4:43 AM which was 58 minutes later and 43 minutes later respectively.

Review of the Client Observation Detail report dated 8/27/21 from 5:30 AM to 5:45 AM revealed the 15 minute checks for 5:30 AM and 5:45 AM, were both documented at 6:29 AM which was 59 minutes later and 44 minutes later respectively.

Review of the Client Observation Detail report dated 8/27/21 from 8:15 PM to 10:44 PM revealed the 15 minute checks for 8:15 PM, 8:30 PM, 8:45 PM, 9:00 PM, 9:15 PM, 9:30 PM, 9:45 PM and 10:00 PM were all documented at 10:43 and 10:44 PM which was 2 hours and 28 minutes later, 2 hours and 13 minutes later, 1 hours and 58 minutes later, 1 hour and 43 minutes later, 1 hour and 28 minutes later, 1 hour and 13 minutes later, 59 minutes later, and 44 minutes later respectively.

Review of the Client Observation Detail report dated 8/28/21 at 7:00 AM revealed the 7:00 AM check was documented at 7:40 AM which was 40 minutes later.

An interview conducted on 9/16/21 at 10:00 AM with Employee Identifier (EI) # 1, Administrator confirmed the 15 minute checks were not completed as ordered and per the facility policy.

2. PI # 6 was admitted to the facility on 9/9/21 with diagnoses including Dementia with Behavioral Disturbance.

Review of the Order Detail Reports dated 9/9/21 revealed orders for Assault Precautions, Fall Precautions, ADL Precautions and Elopement Precautions.

Review of the Client Observation Detail report dated 9/10/21 at 5:15 AM revealed the 15 minute check for 5:15 AM was documented at 5:58 AM which was 43 minutes later.

Review of the Client Observation Detail report dated 9/10/21 at 5:15 PM revealed the 15 minute check for 5:15 PM was documented at 5:57 PM which was 42 minutes later.

Review of the Client Observation Detail report dated 9/11/21 at 7:00 AM revealed the 7:00 AM check was documented at 7:44 AM which was 44 minutes later,

Review of the Client Observation Detail report dated 9/11/21 from 7:45 AM to 8:00 AM revealed the 7:45 AM and 8:00 AM checks were both documented at 8:32 AM which was 47 minutes later and 32 minutes later respectively.

Review of the Client Observation Detail report dated 9/11/21 at 10:45 AM revealed the 10:45 AM check was documented at 11:28 AM which was 43 minutes later.

Review of the Client Observation Detail report dated 9/11/21 from 12:15 PM to 12:30 PM revealed the 12:15 PM and 12:30 PM checks were both documented at 1:08 PM which was 53 minutes later and 38 minutes later respectively.

Review of the Client Observation Detail report dated 9/11/21 from 1:00 PM to 1:15 PM revealed the 1:00 PM and 1:15 PM checks were both documented at 1:55 PM which was 55 minutes and 40 minutes respectively.

An interview conducted on 9/16/21 at 10:00 AM with EI # 1 confirmed the 15 minute checks were not completed as ordered and per the facility policy.

3. PI # 8 was admitted to the facility on 9/8/21 with diagnoses including Major Neurocognitive Disorder Due to Alzheimer's Disease, Possible.

Review of the Client Doctor Orders dated 9/8/21 revealed orders for Assault Precautions, Fall Precautions and ADL Precautions.

Review of the Client Observation Detail report dated 9/8/21 from 3:15 PM to 4:00 PM revealed the 15 minute checks for 3:15 PM, 3:30 PM, 3:45 PM and 4:00 PM were all documented at 4:31 PM which was 1 hour and 16 minutes later, 61 minutes later, 46 minutes later and 31 minutes later respectively.

Review of the Client Observation Detail report dated 9/8/21 from 8:15 PM to 8:30 PM revealed the 15 minute checks for 8:15 PM was documented at 9:09 PM and the 8:30 PM check was documented at 9:10 PM which was 54 minutes later and 40 minutes later respectively.

An interview conducted on 9/16/21 at 10:00 AM with EI # 1 confirmed the 15 minute checks were not completed as ordered and per the facility policy.



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4. PI # 2 was admitted to the facility on 8/31/21 with diagnoses including Major Depression, Recurrent Severe.

Review of the physician's orders dated 8/31/21, included Assault Precautions, and "Every 12 hours ensure bed alarm is in place and functioning properly Q (every) shift. Replace as indicated."

Review of the initial Nursing Assessment/ Presenting Symptoms, dated 8/31/21, revealed an incomplete assessment with no medical history, skin assessment, ADL needs assessment, or suicide risk assessment per policy. The summary was listed as "...draft status." The MR was reviewed on 9/15/21, which was 15 days later.

Review of the Client Observation Details dated 9/9/21 revealed the 2:30 AM check was documented at 3:04 AM, which was 34 minutes later.

Review of the 9/9/21, 8:30 AM check, revealed the documentation was at 9:00 AM, which was 30 minutes later.

Review of the 9/9/21, 11:00 AM check, revealed the documentation was at 11:33 AM, which was 33 minutes later.

Review of the 9/9/21, 5:15 PM check, revealed the documentation was at 5:49 PM, which was 34 minutes later.

Review of the 9/9/21, 10:30 PM check, revealed the documentation was at 11:06 PM, which was 36 minutes later.

Review of the Client Observation Details dated 9/10/21, 2:45 AM check, revealed the documentation was at 3:26 AM, which was 41 minutes later.

Review of the 9/10/21, 5:15 AM check, revealed the documentation was at 5:58 AM, which was 43 minutes later.

Review of the documentation of every 12 hours bed alarm checks, revealed there was none documented for either shift on 9/6/21, 9/7/21, 9/8/21, 9/11/21, or 9/12/21, which was 5 days out of 14 days reviewed.

An interview was conducted on 9/16/21 with EI # 3, Risk Manager, who confirmed staff failed to document every 15 minutes per policy, and failed to document bed alarm checks as ordered.

5. PI # 4 was admitted to the facility on 9/8/21 with diagnoses including Major Neurocognitive Disorder due to Alzheimer's Disease with Behavioral Disturbances.

Admission physician's orders dated 9/8/21 included suicide precautions.

Review of the initial Nursing Assessment/ Presenting Symptoms, dated 9/8/21 at 7:33 PM revealed the nurse documented a Stage II or > (greater) wound, with location, "open area on sacrum." For the statement, "Impaired Skin Integrity Treatment Plan/ Wound Care protocol indicated," the Skilled Nurse answered, "Yes." There was no documentation the physician was notified of the wound, per policy.

Review of the Weekly Skin Integrity Tool, dated 9/8/21 revealed a measurement of 1 cm (centimeter) x 1 cm. There was no depth measurement.

Review of the Client Observation Details dated 9/8/21 revealed the checks for 11:15 AM, 11:30 AM, and 11:45 AM, were all documented at 12:28 AM, which was 73 minutes later, 58 minutes later, and 43 minutes later, respectively.

Review of the 9/8/21, 3:45 PM check, revealed the documentation was at 4:32 PM, which was 47 minutes later.

Review of the 9/8/21, 4:00 PM check, revealed the documentation was at 4:33 PM, which was 33 minutes later.

Review of the 9/8/21, 7:45 PM check, revealed the documentation was at 8:16 PM, which was 31 minutes later.

Review of the 9/8/21, 8:30 PM and 8:45 PM checks, revealed the documentation was at 9:39 PM, which was 69 minutes later and 54 minutes later, respectively.

Review of the Client Observation Details dated 9/9/21, 8:30 AM check, revealed the documentation was at 9:01 AM, which was 31 minutes later.

Review of the 9/9/21, 11:00 AM check, revealed the documentation was at 11:56 AM, which was 56 minutes later.

Review of the 9/9/21, 7:15 PM check, revealed the documentation was at 7:50 PM, which was 35 minutes later.

Review of the 9/9/21, 10:30 PM check, revealed the documentation was at 11:07 PM, which was 37 minutes later.

Further review of the MR revealed the following wound care order dated 9/9/21 at 4:50 PM, "Clean area on sacrum with wound cleanser, pat dry, cover with foam dressing, and secure with tape. Change dressing every 3 days and prn (as needed) if soiled. Watch for signs of infection."

Review of the eMAR (electronic Medication Administration Record) revealed the nurse documented, "Nurse Administered" on 9/9/21 at 4:59 PM for the wound care order. There was no documentation by the nurse what wound care was performed, or how the patient tolerated the wound care.

Further review of the eMAR revealed the nurse documented, "Nurse Administered" on 9/13/21 at 3:33 PM for the wound care order, which was 4 days later, and not 3 as ordered. There was no documentation by the nurse what wound care was performed, or how the patient tolerated the wound care.

The surveyor requested documentation of additional wound measurements, and none was provided.

An interview was conducted on 9/15/21 at 3:30 PM with EI # 2, Director of Nursing, who confirmed staff failed to document every 15 minute observation precautions as ordered, and no specific wound care and measurements were documented.



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6. PI # 7 was admitted on 9/3/21 with diagnoses including Dementia with Behavioral Disturbances, Hypertension, and Diabetes Mellitus.

Review of the physician's order dated 9/4/21 revealed Assault Precautions and Accucheck (fingerstick blood glucose) "check fasting blood sugar every day."

Review of the MR revealed the following blood glucose (BG) results:
9/8/21 - patient refused
9/9/21 - 154
9/10/21 - 134
9/12/21 - 172
9/14/21 - 190
9/15/21 - 174.
There was no documentation the BG was obtained on 9/5/21, 9/6/21, 9/7/21, 9/11/21, and 9/13/21 as ordered by the physician.

Review of the Client Observation Details dated 9/13/21 revealed the 10:30 AM check was documented at 11:04 AM, which was 34 minutes later.

Review of the 9/13/21, 10:45 AM check, revealed the documentation was at 11:04 AM, 19 minutes later.

Review of the 9/13/21, 11:00 AM check, revealed the documentation was at 11:04 AM, which was the same time the 2 previous observations were documented.

Review of the Client Observation Details dated 9/14/21 revealed the 12:00 AM check was documentation at 12:54 AM, 54 minutes later.

Review of the 9/14/21, 12:15 AM check, revealed the documentation was at 12:57 AM, 42 minutes later.

Review of the 9/14/21, 12:30 AM check, revealed the documentation was at 12:57 AM, 27 minutes later.

Review of the 9/14/21, 12:45 AM check, revealed the documentation was at 12:57 AM, which was the same time the 3 previous observations were documented.

Review of the 9/14/21, 3:15 AM check, revealed the documentation was at 3:49 AM, 34 minutes later.

Review of the 9/14/21, 3:30 AM check, revealed the documentation was at 3:50 AM, 20 minutes later.

The staff failed to document patient observations every 15 minutes as directed per facility policy.

An interview conducted on 9/16/21 at 12:00 PM with EI # 2 confirmed the staff failed to obtain a BG daily as ordered and failed to document 15 minute patient observations according to policy.

8. An observation of the facility video surveillance was conducted on 9/15/21 at 2:00 PM with EI # 2 and EI # 3 to observe staff conducting 15 minute patient observations. On 9/5/21 at 12:19 AM, staff was observed completing room checks with a flashlight. The next room check was observed at 1:12 AM which was 53 minutes later. At 1:24 AM a patient was observed exiting his/her room, crossed the hall and entered a patient room, exited that room at 1:32 AM, went down the hall toward the exit door, entered another patient room at 1:34 AM, came out and went back to his/her room at 1:36 AM and exited his/her room again and stood in the hall. At 1:50 AM, a staff member came down the hall and stood by the patient, then escorted him/her back into his/her room. This was 38 minutes from the last room check and 26 minutes the patient had been observed wandering out of his/her room.

The staff failed to complete patient observations every 15 minutes.

All video times and events were verified by EI # 3 during the surveillence observation, and EI # 3 confirmed 15 minute observations were expected for all patients.

Based on observations, review of facility policy and procedure, Discontinued Narcotic Control Records, medical records, Consultant Pharmacist Responsibilities, Consultant Pharmacist Quarterly Report, Ampharm Inspection Checklist and interviews it was determined the facility failed to demonstrate pharmaceutical services were provided in an organized manner with a drug storage area under competent supervision.

Findings include:

See A 0491 and A 0492 for findings.

Based on observations, review of facility policy and procedure, Discontinued Narcotic Control Records, medical records (MR), Consultant Pharmacist Responsibilities, Consultant Pharmacist Quarterly Report, Ampharm Inspection Checklist and interviews it was determined the facility failed to demonstrate supervision and coordination of all pharmacy services and ensure:

1. The medical staff and/or the consulting pharmacy staff developed, implemented, and periodically reviewed the policies and procedures governing the provision of pharmaceutical services.

2. Policies and procedures were in place for tracking and control of narcotic medications when patients were discharged.

3. Medications were not kept on the medication cart after patients were discharged from the facility.

4. Records for tracking expired and discontinued medications were maintained.

5. Discontinued Narcotic Control Records included the signature of two nurses.

6. Expired and discontinued medications were stored in a manner to prevent diversion.

This deficient practice affected 2 of 6 discharged records reviewed including Patient Identifier (PI) # 1, PI # 12 and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Disposal of Medications
Policy Number: None
Effective: 10/2020

Policy

Unity Psychiatric Care will dispose of all medications properly and in accordance with all state and federal guidelines.

Procedure

1. All unused controlled substances will be destroyed on site by the pharmacy consultant and a member of the nursing staff.

3. Non-controlled substances will be collected by pharmacy contractor for appropriate destruction.

Senior Care Consultant Group
Pharmacist Consultant Responsibilities

The consultant pharmacist shall be responsible for the general supervision of the facility's pharmaceutical services which include the following:

1. Monthly reviews of the medication regimen of each facility patient...

2. Supervision of the disposition of all controlled substances and the maintenance of such reports...

3. Being a member and participant of the Pharmaceutical Services and Quality Assurance committees.

...8. General supervision of the facility's procedures for the control and accountability for all drugs and biologicals...

Appendix A

Baseline Consultant Pharmacist MRR (medication regimen review) services will include:

Monthly random drug storage area reviews including controlled drug audits on two carts and reports.

1. A tour was conducted of the medication room on 9/14/21 at 9:15 AM. The surveyor observed 2 metal locked boxes mounted to the wall and 2 large, uncovered cardboard boxes underneath the locked boxes. The open cardboard boxes were 3/4 full of discarded medications.

The surveyor requested tracking records for removal of discontinued medications from the facility. Employee Identifier (EI) # 1, Administrator, confirmed there was a contract in place with a 3rd party for removal of expired or discontinued medications but no tracking record was provided.

2. PI # 1 was admitted on 6/30/21 with diagnoses including Lewy-Body Dementia and Dysautonomia with Orthostatic Hypotension. PI # 1 expired at the facility on 8/31/21.

Review of the Discontinued Narcotic Control Records (DNCR) on 9/16/21 revealed 3 sheets which listed the Date, Time, 2 spaces for Nurses, Rx (prescription) Number, Resident's Name, Medication, and Med Count. EI # 3, Risk Manager, confirmed these sheets documented when patient medications were removed from the medication cart and placed in the locked Narcotic Destruction box located in the medication room.

The DNCR included the following entries for PI # 1:

9/8/21 at 7:00 PM, Ativan 2 mg/ml (milligrams per milliliter) - 10 (vials)

9/12/21 at 9:15 PM, Lorazepam 0.5 mg - 13 tabs (tablets)

9/16/21 at 10:25 AM, Ativan 1 mg - 11 tabs

9/16/21 at 10:30 AM, Ativan 2 mg/ml - 8 vials

9/16/21 at 10:30 AM, Lorazepam 0.5 mg - 13 tabs

9/16/21 at 10:30 AM, Lorazepam 1 mg - 17 tabs

9/16/21 at 10:30 AM, Lorazepam 0.5 mg - 5 tabs

Further review of the DNCR entries dated 9/12/21 revealed only one nurse signature and not two, and the date was incomplete with no year documented.

An interview conducted 9/16/21 at 11:00 AM with EI # 3, Risk Manager, confirmed the DNCRs are completed when the medications are removed from the medication cart and placed in the locked narcotic disposal box in the medication room. EI # 3 further confirmed PI # 1 expired on 8/31/21 and the medications listed should have already been removed from the medication cart, 2 nurses are required to witness and sign the DNCR and the date should include the year.

The surveyor requested the policy for removing discontinued medications from the med cart and no policy was provided.

3. PI # 12 was admitted 8/12/21 with diagnoses including Major Depression Recurrent Severe with Psychosis and Dementia with Behavioral Disturbance. PI # 12 was discharged 9/9/21.

Review of the DNCRs on 9/16/21 revealed the following entries for PI # 12:

9/12 at 9:15 PM, Morphine concentrate - 22 ml

9/12 at 9:15 PM, Oxycontin 10 mg - 15 tabs

9/12 at 9:15 PM, Gabapentin 100 mg - 13 tabs

9/12 at 9:15 PM, Morphine concentrate - 30 ml (unopened)

9/13/21 at 7:30 AM, Oxycontin - 2

9/16/21 at 10:30 AM, Klonopin - 10 tabs

9/16/21 at 10:30 AM, Clonazepam - 29 tabs

9/16/21 at 10:30 AM, Hydrocodone 10/325 - 28 tabs

9/16/21 at 10:30 AM, Clonazepam 0.5 mg - 27 1/2 tabs

9/16/21 at 10:30 AM Hydrocodone 5/300 mg - 2 tabs

Further review of the DNCR entries dated 9/12 revealed only one nurse signature and not two, and the date was incomplete with no year documented. Three entries dated 9/13/21 at 7:30 AM and 9/16/ 21 at 10:30 AM failed to include the medication dosage.

An interview conducted 9/16/21 at 11:00 AM with EI # 3, confirmed PI # 12 was discharged 9/9/21 and the medications listed should have already been removed from the medication cart. EI # 3 further confirmed 2 nurses are required to witness and sign the DNCR and the date and medication dosage should be complete.

4. Review of the Consultant Pharmacist Quarterly Report dated September, 2021 revealed the following documentation:

Medication Rooms:

There is a clearly defined area (basket, box, etc) for items being returned to the pharmacy. Please make sure the pharmacy driver picks these items up daily.

Expired and discontinued meds should be removed daily.

Medication Carts:

Expired and discontinued medications should be removed daily.

Non-Controlled Drug Destruction:

All unit dosed drugs should be returned to the pharmacy for possible credit when possible. All other drugs should be discharged with the patient upon attending physician's order or disposed of in the facility; disposition should be documented on the proper drug disposition form and witnessed by two nurses.

Notes:

Narcotic Destruction not completed with DON (Director of Nursing), will follow up next month...

Review of the Ampharm Inspection Checklist completed by EI # 8, Consulting Pharmacist, dated 9/13/21 revealed documentation expired or discontinued medications were removed from the medication cart.

An interview conducted 9/21/21 at 1:00 PM with EI # 8 confirmed when checking the medication cart on monthly visits there was no process for ensuring discharged patients medications had been removed from the medication cart. EI # 8 further confirmed he/she had no role in pharmacy policy development or review for Unity Psychiatric Care. When asked about the process for the open cardboard boxes of medications in the medication room, EI # 8 stated "that is a question for Ampharm. I believe that is picked up by a 3rd party." EI # 8 was asked to describe his participation in Quality Assessment Performance Improvement committee. EI # 8 confirmed he had not attended the meetings but provided reports to DON.

The consulting pharmacist failed to demonstrate responsibility for developing, supervising, and coordinating all the activities of the pharmacy services and minimize the potential for medication errors or diversion.

Based on observation, review of the Pharmacy Services Agreement, Discontinued Narcotic Control Records, Consultant Pharmacist Responsibilities, and interviews it was determined the facility failed to ensure the consulting pharmacist provided supervision of the facility's pharmaceutical services to include:

1. Procedures for the control and accountability for all drugs and biologicals throughout the facility.

2. Policies and procedures were in place for tracking and control of narcotic medications when patients were discharged.

3. Policy and procedure was in place to ensure medications were not kept on the medication cart after patients were discharged from the facility.

4. Ensuring expired and discontinued medications were removed from the facility and records maintained.

5. Discontinued Narcotic Control Records included the signature of two nurses.

6. Providing and conducting in-service education for the facility professional staff annually.

This deficient practice had the potential to affect all patients served by the facility.

Findings include:

Pharmacy Services Agreement: Ampharm, Inc.
Effective Date: May 1, 2012

A. Pharmacy Services - Consulting

1. The pharmacy shall be responsible for the general supervision of Hospital's pharmaceutical services. More specifically, these services shall include:

a. General supervision of Hospital's procedures for the control and accountability for all drugs and biologicals throughout Hospital...

b. Supervision of the records and disposition of all controlled drugs and the maintenance of such records in sufficient detail so as to allow an accurate reconciliation.

...e. Recommendations, plans for implementation, and continuing assessment through dated, signed reports, which are given to and retained by the Hospital for follow-up action and evaluation of performance.

...g. Being an active member of Hospital's pharmacy and therapeutics and infection control committees.

h. Providing and conducting programs of in-service education for professional staff of Hospital which would enhance the effectiveness of the pharmaceutical service.

Senior Care Consultant Group
Pharmacist Consultant Responsibilities

The consultant pharmacist shall be responsible for the general supervision of the facility's pharmaceutical services which include the following:

1. Monthly reviews of the medication regimen of each facility patient...

2. Supervision of the disposition of all controlled substances and the maintenance of such reports...

3. Being a member and participant of the Pharmaceutical Services and Quality Assurance committees.

...7. All other responsibilities required of a qualified consultant pharmacist as set forth in federal or state law...

8. General supervision of the facility's procedures for the control and accountability for all drugs and biologicals...

Appendix A

Baseline Consultant Pharmacist MRR (medication regimen review) services will include:

Monthly random drug storage area reviews including controlled drug audits on two carts and reports.

Quarterly meeting attendance

One annual in-service

1. A tour was conducted of the medication room on 9/14/21 at 9:15 AM. The surveyor observed 2 metal locked boxes mounted to the wall and 2 large, uncovered cardboard boxes underneath the locked boxes. The open cardboard boxes were 3/4 full of discarded medications.

The surveyor requested tracking records for removal of discontinued medications from the facility. Employee Identifier (EI) # 1, Administrator, confirmed there was a contract in place with a 3rd party for removal of expired or discontinued medications but no tracking record of medications removed from the facility was provided.

2. The surveyor requested controlled medication tracking records for 2 discharged patients, Patient Identifier (PI) # 1 and PI # 12.

Review of the Discontinued Narcotic Control Records (DNCR) on 9/16/21 revealed 3 sheets which listed the Date, Time, 2 spaces for Nurses, Rx (prescription) Number, Resident's Name, Medication, and Med Count. EI # 3, Risk Manager, confirmed these sheets documented when patient medications were removed from the medication cart and placed in the locked Narcotic Destruction box located in the medication room.

a. The DNCR included the following entries for PI # 1 who expired on 8/31/21:

9/8/21 at 7:00 PM, Ativan 2 mg/ml (milligrams per milliliter) - 10 (vials)

9/12 at 9:15 PM, Lorazepam 0.5 mg - 13 tabs (tablets)

9/16/21 at 10:25 AM, Ativan 1 mg - 11 tabs

9/16/21 at 10:30 AM, Ativan 2 mg/ml - 8 vials

9/16/21 at 10:30 AM, Lorazepam 0.5 mg - 13 tabs

9/16/21 at 10:30 AM, Lorazepam 1 mg - 17 tabs

9/16/21 at 10:30 AM, Lorazepam 0.5 mg - 5 tabs

Further review of the DNCR entries dated 9/12 revealed only one nurse signature and not two, and the date was incomplete with no year documented.

b. Review of the DNCRs on 9/16/21 revealed the following entries for PI # 12 who was discharged on 9/9/21:

9/12 at 9:15 PM, Morphine concentrate - 22 ml

9/12 at 9:15 PM, Oxycontin 10 mg - 15 tabs

9/12 at 9:15 PM, Gabapentin 100 mg - 13 tabs

9/12 at 9:15 PM, Morphine concentrate - 30 ml (unopened)

9/13/21 at 7:30 AM, Oxycontin - 2

9/16/21 at 10:30 AM, Klonopin - 10 tabs

9/16/21 at 10:30 AM, Clonazepam - 29 tabs

9/16/21 at 10:30 AM, Hydrocodone 10/325 - 28 tabs

9/16/21 at 10:30 AM, Clonazepam 0.5 mg - 27 1/2 tabs

9/16/21 at 10:30 AM Hydrocodone 5/300 mg - 2 tabs

Further review of the DNCR revealed entries dated 9/12 had only one nurse signature and not two, and the date was incomplete with no year documented. Three of the entries failed to include the medication dosage.

The surveyor requested the policy for removing medications from the med cart upon patient discharge and no policy was provided.

A phone interview was conducted on 9/21/21 at 1:00 PM with Employee Identifier (EI) # 8, Unity Consulting Pharmacist, EI # 1, Administrator, and EI # 2, Director of Nursing (DON). EI # 8 was asked to give an overview of his responsibilities at the facility and how much time he spent at the facility. EI # 8 stated each quarter he completes chart reviews for medication interactions, appropriate diagnoses and so forth. EI # 8 stated he is on-site approximately 45 minutes to an hour each month. He checks the medication room, med cart and re-stocks the IStat medication dispenser. EI # 8 stated the narcotics are destroyed using Drug Buster and both he and the DON do that together and sign the DNCR form. EI # 8 was asked to describe his process for checking the medication cart when on-site. EI # 8 stated he checks for outdated medications, checks the MAR (medication administration record), looks for discontinued medications, and has a list of things. The surveyor informed EI # 8 of the results of the audit of controlled medications for 2 discharged patients (PI # 1 and #12) and asked EI # 8 what the policy was for removing medication from the medication cart upon discharge. EI # 8 stated the policy would be to remove the meds off the cart immediately, also if a medication had been changed or discontinued the medications should be removed immediately. When asked why the medications for PI # 1 and # 12 were removed from medication cart on 3 different dates EI # 8 stated medications should be pulled from the cart at the same time. EI # 8 was asked to describe his role in policy development, supervision and implementation - he stated that was a question for Ampharm - "I am more of a compliance piece - I follow the policy (Ampharm) but have no role in developing the policies for Unity. If I see a problem I will get with the DON." EI # 8 was asked if he checked for discharged patients medications remaining on the med cart during his inspection and he stated no, but he could certainly start doing that. EI # 8 was asked what is the process for the large, open box of expired medications in the med room. The response was "that would be a question for Ampharm - I believe that is picked up by a third party." EI # 8 was asked if he had completed an annual inservice for the staff and he stated no, not this year.

Based on observation and interview, it was determined the facility failed to ensure policies and procedures were developed regarding the safety and location of mobile xrays.

This had the potenital to affect all persons served by the facility.

Findings include:

During a tour of the facility on 9/14/21 at 10:20 AM, the surveyor observed an xray technician, employed by a mobile imaging company, enter the facility with a mobile xray machine, and proceed to the dining room. The technician performed a CXR (chest xray) on a patient sitting in the dining room. Also present in the room were 10 other patients and 2 employees.

The surveyor requested a policy and procedure regarding mobile imaging safety and locations for xrays. None was received.

An interview was conducted on 9/15/21 at 2:00 PM with Employee Identifier (EI) # 2, Director of Nursing, and EI # 3, Risk Manager. During the interview, video surveillance was reviewed which confirmed the technician's actions. EI # 2 further confirmed there was no policy and procedure regarding safety and locations for xrays.

Based on facility policy, observations and interviews, it was determined the hospital failed to ensure food was stored and served in a safe and sanitary manner. This had the potential to negatively affect all patients.

Findings include:

Facility Policy: Dietary Food Service
Date Revised 9/2021

Policy:

Food shall be stored promptly by the designated staff after delivery.

Procedure:

Perishable Items:
7. Leftover foods are stored in appropriate containers so that the interior temperature of the food chills quickly to less than or equal to 41 degrees Fahrenheit. They are covered, labeled, and dated...

Non-Perishable Items:
4. Staple items...should be stored in clean, closed containers and labeled.
5. All stored items should have an expiration date or a purchase/delivery date.

On 9/14/21 at 10:00 AM, the surveyor performed a tour of the snack room with Employee Identifier EI # 7, RN (Registered Nurse). During the tour, the surveyor observed the following:

Unrefrigerated shelf foods: One 32 ounce plastic box of re-packaged dry cereal, 1/2 full and without a label indicating contents, date opened or expiration date . One 31 ounce Goldfish Cracker carton opened with no label indicating the date when the container was opened or expiration date.

Refrigerated foods: Two 16 ounce containers of Cheese spread opened without a label indicating when the Cheese spread was opened or the expiration date. One 8 ounce container of Chicken Salad spread opened without a label indicating when the Chicken Salad spread was opened or the expiration date. Three 1 pint containers of 2% milk with an expiration date of 9/13/21. One pitcher of Orange drink with no label of contents or expiration date. One 62 ounce opened container of Southern Sweet Tea without a label indicating when the tea was opened or the expiration date.

An interview conducted on 9/14/21 at 10:00 AM with EI # 7, RN confirmed the food items were not labeled and dated correctly and/or expired.

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

Findings include:

Refer to Life Safety Code violations, and A 724

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

1. Expired supplies were not available for patient use.

2. Bulk containers of liquid were not stored above sterile patient supplies.

3. Wheelchairs were in good repair.

4. Sharps containers were disposed of in the appropriate biohazard container for removal from the facility.

5. Contaminated sharps, soiled linen and trash was disposed of in a manner to prevent possible injury to staff and not mixed together in the soiled linen container.

6. The laundry room was clean and free from dust.

7. The facility developed and implemented a policy for the disposal of contaminated sharps containers that included the process of removal from the point of use to storage in the appropriate biohazard container.

8. Refrigerator and freezer temperatures were monitored in the pharmacy, nourishment room, and exam room per policy.

Findings include:

Facility Policy: Equipment/Supply Storage
Effective Date: 8/2021

Purpose:

To provide guidelines on storage of equipment and supplies.

Procedure:

2. Supplies and equipment shall be stored in a manner to prevent contamination. Supplies shall be stored in dust free condition. Dust covers and storage cabinets shall be utilized...

4. Heavy items and liquids shall not be stored above eye-level. Heavy bulk containers shall be placed on lower shelves...

6. Rotate all supply stock to promote use of longest held stock first. This will assure that products are not retained past their expiration date (safe use) date. Expired supplies must be removed from stock immediately and disposed of in the appropriate manner.

Facility Policy: Packaging Infectious Waste
Effective: 10/2020

Policy:

It is the policy of Unity Psychiatric Care to promptly package waste to prevent leakage or possible injuty to staff. Also, to protect waste handlers and the public from exposure.

Procedure:

1. Contaminated sharps must be directly placed in leak proof, rigid, and puncture resistant containers which must be tightly sealed.

2. All containers must be labeled infectious waste.

Facility Policy: Houskeeping - Routine Cleaning and Disinfection

Policy:

It is the policy of Unity Psychiatric Care to establish policies, procedures, and guidelines to provide a clean and sanitary environment for patients, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection (HAI).

Procedure:

1. The Administrator is responsible for compliance...

2. If there is a spill, trash, or other small housekeeping problem, the staff member identifying the issue should immediately remedy the problem...

General weekly cleaning...

...Biohazard waste which is located/bagged in "biohazard" red bags in the soiled utility room will be disposed of by a contract provider. Housekeeping will follow CDC (Centers for Disease Control) guidelines when handling all waste products.

Facility Policy: Monitoring Refrigerator/ Freezer
Policy Number: None listed
Date Revised: 10/2019

Policy:

Unity Psychiatric Care monitors the temperature to ensure adequate refrigeration of all foods, medication and laboratory specimens. The charge nurse will be responsible for ensuring that this be completed at least daily...

Procedure:

1. The charge nurse will assign a staff to monitor and document refrigerator temperatures on the Refrigerator/ Freezer Temperature Log nightly...

A facility tour was conducted 9/14/21 at 9:30 AM with Employee Identifier (EI) # 6, Maintenance Supervisor. In the soiled utility room the surveyor observed a full sharps container on the countertop, a small biohazard container under the sink with no red liner and a large square, metal biohazard box with no red liner. Upon closer inspection of the small container, the surveyor observed soiled gloves and other discarded items. EI # 6 confirmed the biohazard containers should have red liners and the sharps containers were to be placed in the square metal container.

Also in the soiled utility room, there was a large, round, plastic red container with a lid, labeled "soiled linen." The surveyor lifted the lid and observed the container was full to the top. On top were several paper bags of trash and visible under the paper bags was a full sharps container. The container was malodorous. EI # 6 confirmed the sharps container and trash should not be in the soiled linen container.

An observation in the medication room was conducted 9/14/21 at 10:45 AM with EI # 9, Licensed Practical Nurse. A sharps container was mounted to the wall beside the door. EI # 9 was asked who was responsible for removing the sharps container and to describe the process. EI # 9 stated the nurses are responsible for removing them, they are sealed and taken to the soiled utility room and placed in the metal biohazard can.

An inspection of the supply room was conducted on 9/15/21 at 7:45 AM and revealed the following:

In a metal rolling cart the surveyor observed 5 DermaView Dressings expired 6/1/2021, 1 Xeroform gauze dressing expired 9/2020, 1 pack of Iodine Swabs expired 5/11/21, an open and unlabeled bottle of DermaKlenz wound cleanser and 1 bottle of Antifungal powder prescribed for a patient no longer at the facility.

On the open, wired shelving unit there were 2 gallon jugs of liquid hand sanitizer and 1 unlabeled gallon jug containing a blue liquid substance, on the shelf at eye-level and directly over sterile patient supplies.

Also on the shelving units there were 5 Skin Staple Remover kits expired 8/30/21 and 1 that expired 6/30/21 and 5 boxes of PEN (for finger stick device) needles expired 7/25/2020.

An inspection of the equipment storage area on 9/15/21 at 9:00 AM with EI # 6 revealed a black wheelchair with holes, tears and rusty metal rivets in the seat. EI # 6 confirmed the wheelchair was in disrepair and stated "I don't think that even belongs to us."

Inspection of the laundry room on 9/15/21 at 9:15 AM with EI # 6, revealed a layer of dust on the window sill and on the connection cords for the automatic laundry detergent dispenser. EI # 6 was asked how often the laundry room was cleaned and the answer was "at least once a month."

The surveyor requested the facility policy for handling contaminated sharps when removed from point of use and no policy was provided.

An interview and observation of the supply room was conducted on 9/15/21 at 2:20 PM with EI # 2, Director of Nursing, and EI # 3, Risk Manager, who confirmed the expired supplies, storage of liquids above sterile patient supplies and the wheelchair in disrepair. EI # 3 returned to the soiled utility room with the surveyor and observed the sharps container on the counter, the small biohazard container with no red liner containing contaminated gloves, and the soiled linen container which also contained a full sharps container, trash and was malodorous.

The surveyor returned to the soiled utility room on 9/16/21 at 10:45 AM and the full sharps container remained on the counter and the soiled linen can remained full of mixed contents including a full sharps container, trash, and was malodorous.



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2. During a tour of the facility on 9/14/21 at 10:03 AM, the following expired items were observed in the Exam Room:

18- packets of Povidine Iodine Swabs, expired (exp) 5/11/21.
2- Introcan Safety needles, 20 g (gauge) x 1" (inch), exp 4/2021.
6- Sterile saline wipes, exp 6/2021.
1- 7.5 oz (ounce) bottle PeriGiene Antiseptic (For perineal use), exp 12/20.
1- pack of 100 cotton tipped applicators, opened 5/3/19, and spilled all in drawer.
8- red top lab tubes, exp 6/30/21.
1- red top lab tubes, exp 2/29/20.

Also in the exam room was a large set of floor scales, with the capacity to weigh a person in a wheelchair. On the scales was a sticker indicating the next calibration (not preventive maintenance) was due on 2/20/21, which was 7 months earlier.

A refrigerator was present in the exam room for storing lab specimens. The temperature log on the refrigerator door, labeled "Sept 2021" (September), contained the following documentation:

9/1/21- no temperature
9/3/21- no temperature
9/5/21- no temperature
9/7/21- no temperature
9/9/21- no temperature
9/11/21- no temperature
9/12/21- no temperature

The freezer temperature log on the refrigerator door was missing the same dates. The temperatures documented for the freezer, on the September 2021 log, ranged from 32 degrees to 40 degrees, and not 10 degrees Fahrenheit or colder, as listed on the form. There was no corrective action documented on the form, as directed for temperature readings above 10 degrees.

EI # 2, Director of Nursing, who was also present during the tour, confirmed the expired supplies, past due calibration of the scales, and the missing temperatures.

3. The surveyor requested copies of the August 2021 temperature logs for the medication room and the nutrition room and the following was received:

The medication room temperature log was missing temperatures for the following dates:

8/7/21, 8/12/21, 8/21/21, 8/22/21, and 8/26/21.

The nutrition room refrigerator log was missing temperatures for the following dates:

8/4/21, 8/11/21, 8/12/21, 8/14/21, 8/18/21, 8/19/21, 8/20/21, 8/22/21, 8/24/21, 8/26/21, 8/27/21, 8/28/21, and 8/31/21.

The nutrition room freezer log was missing temperatures for the following dates:

8/4/21, 8/10/21, 8/11/21, 8/12/21, 8/14/1, 8/18/21, 8/19/21, 8/20/21, 8/22/21, 8/24/21, 8/28/21, and 8/31/21.

An interview was conducted 9/16/21 at 1:45 PM with EI # 2, who confirmed the missing dates.

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

1. Staff followed policy for Covid Screening of visitors and contracted personnel.

2. Staff cleaned reusable equipment.

This affected 2 Unsampled Patients and had the potential to affect all persons served by the facility.

Findings include:

Facility Policy: Coronavirus 2019 (Covid-19) Response Plan and Facility Protocol
Policy Number: None listed
Date Revised: August 16, 2021

...XII. Management of Visitor Access and Movement Within the Facility

Essential visitors include, but is not limited to, State Surveyors... EMS (Emergency Management Services)... Xray...staff.

...Points of entry into the facility will be limited to one in order to minimize movement in and out of the facility.

Screening of visitors: As with staff members, visitors may also inadvertently foster spread of infections in the facility.

...All essential visitors are required to sign in the Visitation Log at the receptionist desk. If the visitor answers yes to any of the screening questions, visitation will not be allowed. The visitor will be screened for:

Travel outside of the United States within the prior 30 days;
Anyone in their immediate family or residence with a fever or symptoms of COVID- 19;
Contact (within 6 feet) with an individual confirmed positive for COVID-19 within the prior 30 days;
The presence of active signs and symptoms of respiratory or COVID-19 illness.

In addition to screening questions, a temperature check will be performed. Access will be denied for readings that exceed 99.4 degrees.

Facility Policy: Housekeeping Routine Cleaning and Disinfection
Policy Number: None listed
Date Approved: 11/2020

Policy:

It is the policy of Unity Psychiatric Care to establish policies, procedures and guidelines to provide a clean and sanitary environment for patients, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infections (HAI).

Procedure:

...2. If there is a spill... or other small housekeeping problem, the staff member identifying the issue should immediately remedy the problem...

On each day of the survey, conducted on 9/14/21 to 9/16/21, all four surveyors (1 Federal surveyor and 3 State surveyors) entered the main entrance at the front of the building. Staff failed to conduct screening questionnaires and check the temperatures of the surveyors on all three days.

On 9/14/21 at 10:20 AM the surveyors observed an xray technician enter the building, pushing a portable xray machine. Staff offered the technician a face mask, but failed to ask the screening questions or check the technician's temperature, per policy. The technician continued in to the dining room, where 10 patients and 2 employees were present, and performed a CXR (Chest Xray) on a patient.

During medication pass observations in the dining room, conducted on 9/15/21 at 9:00 AM with Employee Identifier (EI) # 5, RN (Registered Nurse), the surveyor observed EI # 5 retrieve a pair of scissors from the medication cart, and take them to a table where Unsampled Patient (UP) # 1 was sitting. EI # 5 used the scissors to open the individual medication packets. After the patient consumed the medication, EI # 5 headed toward the sink, and on the way, dropped the scissors on the floor. EI # 5 picked up the scissors and put them in her/his uniform pocket. Then washed her/his hands at the sink, and went back to the medication cart to prepare UP # 2's medications. The RN then took the contaminated scissors from her/his uniform pocket, and placed them in a drawer on the medication cart, without first cleaning the scissors. EI # 5 then prepared UP # 2's medication, retrieved the scissors from the drawer, and proceeded to the table where UP # 2 was sitting. EI # 5 used the scissors to open UP # 2's medication packets. Following medication administration, EI # 5 returned the scissors to the drawer on the medication cart.

During the medication preparation, UP # 3 wandered up to the medication cart, and reached for a bottle of eye drops. EI # 5 took the bottle and put in her uniform pocket. UP # 3 then walked around to the side of the cart, and reached his/her bare hands in a cup containing small unwrapped wooden spoons, used to administer medications. After touching several spoons with his bare hands, UP # 3 selected one and walked away.

During video review, on 9/15/21 at 2:00 PM, with EI #2, Director of Nursing, and EI # 3, Risk Manager, the technician's actions were confirmed.

On 9/15/21 at 3:00 PM the surveyor reviewed the visitor sign in log in the administrative area. There was no signature by the Xray technician.

An interview was conducted on 9/16/21 at 11:00 PM with EI # 1, Administrator, and EI # 2, who confirmed staff failed to screen surveyors and xray technician for Covid-19, staff should have cleaned the scissors before returning to cart, and remainder of wooden spoons should have been discarded following contamination.

Based on facility policy, review of medical records (MR) and interviews it was determined the facility failed to ensure an individualized treatment plan was developed to include need for Accucheck (fingerstick blood sugar) daily and wound care. This affected 1 of 1 active records reviewed with fingerstick blood sugars ordered, and 1 of 1 active records reviewed with a wound, including Patient Identifiers (PI) # 7, and PI # 4, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Treatment Plan
Policy Number: None listed
Date Revised: 12/2020

Policy:

Each patient will have an individual comprehensive treatment plan that will be based on an inventory of the patient's strengths and disabilities...

Procedure:

...4. The treatment plan should include:
a. Both physical and mental problems that are actively being treated.
b. Treatment goals which are measurable...
c. Methods and individualized approaches of treatment.
...e. Specific interventions addressing each goal.
f. How each goal is accomplished.

...6. The interdisciplinary treatment team meets weekly to review and accept changes to the master treatment plan.

7...
a. After completion of the nursing assessment a master problem list will be developed detailing specific problems identified.
b. Problems and modalities identified from each assessment will be added to the treatment plan...

1. PI # 7 was admitted on 9/3/21 with diagnoses including Dementia with Behavioral Disturbances, Hypertension, and Diabetes Mellitus.

Review of the physicians's order dated 9/4/21 revealed Accucheck "check fasting blood sugar every day."

Review of the Treatment Plan initiated on 9/4/21 and updated on 9/6/21 and 9/14/21 revealed the treatment team failed to include diabetes as a problem with the daily fasting blood glucose intervention as ordered. There were no patient goals for the glucose result or an acceptable range for PI # 7.

Review of the MR revealed the following blood glucose results:
9/8/21 - refused
9/9/21 - 154
9/10/21 - 134
9/12/21 - 172
9/14/21 - 190
9/15/21 - 174

An interview conducted on 9/16/21 at 12:00 PM with Employee Identifier (EI) # 2, Director of Nursing, confirmed the treatment team failed to include diabetes management and blood glucose assessment in the treatment plan for PI # 7.



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2. PI # 4 was admitted to the facility on 9/8/21 with diagnoses including Major Neurocognitive Disorder due to Alzheimer's Disease with Behavioral Disturbances.

Review of the physician's order dated 9/9/21 revealed the following wound care, "Clean area on sacrum with wound cleanser, pat dry, cover with foam dressing, and secure with tape. Change dressing every 3 days and prn if soiled. Watch for signs of infection."

Review of the Treatment Plan initiated on 9/9/21, and updated on 9/10/21 and 9/13/21, revealed the treatment team failed to include the patient's wound as a problem with interventions as ordered.

An interview was conducted on 9/16/21 at 1:48 PM with EI # 3, Risk Manager, who confirmed staff failed to include the patient's wound and wound management in the Treatment Plan.