HospitalInspections.org

Based on staff interviews, review of facility documents, and medical record reviews it was determined that the facility failed to have a Governing Body that is effective in carrying out its responsibilities for the conduct of the hospital.

Findings include:

1. The facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. (Cross refer Tag 0263).

2. The facility failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. (Cross refer Tag 0338).

3. The facility failed to have a Utilization Review Committee comprised of at least two (2) doctors of medicine or osteopathy who do not have a relationship with facility patients. (Cross refer Tag 0652).

4. On 9/10/15, Staff #2 provided documentation of the members of the facility's Governing Body. The form identified two (2) member names.

a. There was no evidence of Governing Body Meeting Minutes.

b. Staff #2 confirmed in interview on 9/10/15 at 1:00 PM that there are no Governing Body Meeting minutes.

Based on review of two (2) medical records, and review of facility policy and procedure, it was determined that the facility failed to ensure that the physician documentation policies were implemented for Patient #2.

Findings include:

Reference #1: Facility policy, 'Physician Documentation: Assessments, Orders, Progress Notes ... ' states, "Routine Follow-Up & Continuing Care: Physicians and APN [advance psychiatric nurse] will: ... Provide continual monitoring, assessment, and treatment of additional medical/psychiatric issues that arise during the course of hospitalization."

Reference #2: Facility policy, 'Assessment of Patients after an Incident' states, "... Procedure: ... The nurse practitioner or physician will document the patient assessment in the medical record."

1. The Multidisciplinary Progress Notes in Medical Record #2 revealed that on 8/28/15 at 0200 the patient was found on the floor on his/her back. The patient reported that while walking, he/she felt dizzy and fell to the floor hitting his/her head on the floor. The assessment by the nurse revealed a "hematoma and bump at ... occipital part of ... head ... Dr. --[name of medical physician]-- was informed ..."

2. The medical physician progress notes lacked evidence of any assessment on 8/28/15 or thereafter related to the patient's fall.

3. The psychiatric progress notes dated 8/29/15 indicated that the patient had a fall, however, there was no physical assessment performed.

A. Based on review of two (2) medical records for patient involvement in their plans of care, it was determined that the facility failed to ensure that Patient #2 was involved in his/her care planning.

Findings include:

Reference: Facility policy 'Comprehensive Treatment Plan (CTP) Developmental Process' states, "... Procedures & Specifications: ... 18) Patient's attendance of the CTP Development Meeting and each subsequent CTP Review Meeting is documented on the "Comprehensive Treatment Team Signature Sheet (CTTSS)."

1. Review of Medical Record #2 indicated the patient attended the initial CTP meeting on 8/20/15. The CTP review meeting dated 8/25/15 and 9/3/15 lacked evidence of the patient's attendance. There was no evidence that the patient refused to attend.

B. Based on review of one (1) of one (1) medical record of a patient with a language barrier, it was determined that the facility failed to ensure that the patient was provided interpreter services.

Findings include:

1. Review of Medical Record #2 indicated the patient was admitted to the facility on 8/27/15. The nursing assessment dated 8/27/15 at 10 PM stated that the patient "can't speak English" and most of the answers to the assessment stated, "unknown." There was no evidence that interpreter services were provided to the patient, or that interpreter services were refused.

2. The above was confirmed with Staff #4.

Based on review of two (2) medical records, review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that Patient #2 received care in a safe setting

Findings include:

Reference #1: Facility policy 'Fall Risk' states, "Procedure: ... 7. If a patient falls, a Patient incident form must be completed by ... The RN will reassess the patient and complete a Risk for Falls Assessment Form."

Reference #2: Facility policy 'Incidents and Occurrences' states, "Procedure: 1. The person finding the incident shall report the problem to the Charge Nurse ... 5. Each incidence of a fall will generate a Physical Therapy Screen ..."

1. The Multidisciplinary Progress Notes in Medical Record #2 indicated that the patient sustained a fall on 8/28/15 at 0200, hitting the occipital part of his/her head on the floor.

2. There was no evidence that the Risk for Fall Assessment Form was completed subsequent to the fall.

3. There was no evidence of a Physical Therapy Screen being generated.

4. Staff #4 confirmed the above.

Reference #3: Facility policy, 'Neurological Check Guidelines' states, "The Neuro Check guidelines are to be implemented when ordered by the physician or as a nursing assessment measure when indicated. Neuro checks are to be done ... and Q [every] shift for 3 days and documented using the Neurological Observation Checklist ..."

1. The Neurological Observation Chart in Medical Record #2 indicated that neurological checks began on 8/28/15 at 12:45 AM and completed on 8/28/15 on the 3:00 to 11:00 PM shift. There was no evidence that neuro checks were performed every shift on 8/29/15 and 8/30/15.

A. Based on staff interviews and review of the facility's QAPI activities, it was determined that the facility failed to allocate resources to allow for the development, implementation, and maintenance of an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

Findings include:

1. The facility failed to ensure its quality assurance program is an ongoing program, that shows measurable indicators for which there is evidence of improved health outcomes, failed to analyze the data to improve the effectiveness and safety of services, and failed to specify the frequency of data collection. (Cross refer Tag 0273).

2. The facility failed to implement all preventative actions identified for preventable events, failed to have written policies supporting a non-punitive approach to staff reporting of adverse events, medical errors, near misses and close calls, and failed to analyze all events and their causes. (Cross refer Tag 0286).

3. The facility failed to ensure that the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety, that all improvement actions are evaluated, and that the determination of the number of distinct improvement projects is conducted annually. (Cross refer Tag 0309 and Tag 0620).

4. The facility failed to allocate adequate resources for measuring, assessing, improving, and sustaining the hospital's performance and reducing the risk to patients. (Cross refer Tag 0315).

B. Based on staff interview and review of the facility's QAPI activities, it was determined that the facility failed to conduct QAPI monitoring for each service related to clinical care provided under contract or arrangement.

Findings include:

1. On 9/9/15 review of the facility's QAPI activities lacked evidence of completion of QA activities by the facility for the following contracted services:

a. Dental

b. Laboratory

c. Rehab

d. Organ Procurement Organization

e. X-Ray

d. Pharmacy

2. Staff #13 confirmed in interview that the facility does not do any independent QA of its contracted services, and the information reported into the Quality Committee for these contracted services is information each individual contracted service reports.

Based on document review and staff interview it was determined that the facility failed to ensure its quality assurance program is an ongoing program that shows measurable improvement indicators for which there is evidence of improved health outcomes, failed to analyze the data to improve the effectiveness and safety of services, and failed to specify the frequency of data collection.

Findings include:

1. On 9/8/15 and 9/9/15, the facility's QAPI activities were reviewed in the presence of Staff #13. The facility is monitoring orthostatic blood pressures, review of Universal Transfer forms, pain management, patient medication refusals, and Braden Scale completion on admission and weekly thereafter.

a. Per Staff #13, the former Chief Nursing Officer was monitoring these items, and he/she continued to monitor.

b. There is no evidence of any distinct quality improvement activities that identifies a specific indicator, with specified data collection and frequency of data collection, measurable interventions, and evaluation of interventions for success.

c. There was no evidence to support that the QAPI monitoring the facility is conducting focuses on areas that are high risk, high volume, or problem prone.

i. The monitoring the facility is conducting, does not reflect poor performance.

ii. Per Staff #13, he/she is planning to end some of the above monitoring reviews due to continued compliance/ positive performance.

2. On 9/9/15 at 2:10 PM, Staff #13 stated in interview that there are no quality improvement projects, in which the facility is monitoring and evaluating new interventions, using the facility's QAPI design of IMPROVE [Identify, Measure, Prioritize, Research, Outline, Validate, Execute] that he/she is aware of.

A. Based on review of facility documentation and staff interview, it was determined that the facility failed to implement all preventative actions identified for preventable events.

Findings include:

1. On 9/9/15, review of three (3) RCA's in the presence of Staff #13 identified preventative actions the facility would implement to prevent a recurrence of these events.

2. The facility was not able to provide any evidence that the identified preventative actions were implemented, that the preventative actions were evaluated for success, or any aggregated data.

3. Staff #13 confirmed the above in interview on 9/9/15 at 11:30 AM.

B. Based on staff interview and review of facility policies and procedures it was determined that the facility failed to have written policies supporting a non-punitive approach to staff reporting of adverse events, medical errors, near misses and close calls.

Findings include:

1. On 9/10/15 Staff #8 stated in interview that he/she feels comfortable reporting to his/her management staff, errors in patient care or situations he/she thinks may be unsafe.

2. Review of the facilities polices and procedures and Safety Plan lacks evidence of a non-punitive approach to event reporting.

C. Based on staff interview and document review it was determined that the facility failed to analyze all events and their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Findings include:

1. Review of Infection Control data in the presence of Staff #7 indicated the facility had a rise in Urinary Tract Infections (UTIs) for patients with non-indwelling Foley catheters in the month of January 2015. [On average the facility had zero-two (0-2) UTIs, and in January 2015 had five (5)].

a. Per Staff #7, a urinalysis (UA) is supposed to be done prior to patients coming to this facility, or the facility's practitioners would order a UA.

2. Staff #7 confirmed there was no QA review of the observed increase in patient UTIs for the month of January.

3. Staff #7 confirmed the IC activities and monitoring he/she does, including the tracking of UTIs, has not been reported to the QA committee.

Based on staff interviews and review of the facility's QAPI program and documentation, it was determined that the facility failed to ensure that the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety, that all improvement actions are evaluated, and that the determination of the number of distinct improvement projects is conducted annually.

Findings include:

Reference: Facility's 'Quality Improvement Plan 2015' states, "... II. Assigned Responsibility ... B. The Psychiatric Quality Improvement Committee ... 4. The Quality Improvement Committee shall: ... c. Hold Quarterly Quality Improvement meetings during which time all departments, Administration, and the psychiatric (sic) Medical Director participate in discussing the finding of the quality monitoring performed over the past quarter. ... III. Objectives ... C. Identify and correct problems that have the greatest impact on patient care. D. Review of adverse outcomes in order to assure deficiency correction. E. Assurance of effective communication systems for reporting Quality Improvement activities to the Governing Body (Chief Executive Officer of --[another facility]--, Medical staff, and Administration. ..."

1. On 9/8/15. Staff #13 stated in interview that he/she was the QA Nurse from his/her hire date of November 2014, to May 2015, a six (6) month period. Per Staff #13, the Quality Improvement Committee met in January 2015 and May of 2015.

i. The facility could only provide meeting minutes of the Quality Improvement Committee for May 30, 2015.

ii. Per Staff #13 on 9/9/15 at 3:15 PM, there are no meeting minutes of the Quality Improvement Committee with sign in sheets for the year of 2014.

iii. Per Staff #2 on 9/10/15, he/she coul not locate the meeting minutes of the Quality Improvement Committee for 2014.

2. The facility could only provide evidence of one Quality Improvement Committee meeting from January 2014 to date. The facility could not provide evidence that it has the resources for its Quality Improvement Committee to meet quarterly.

3. The QA Plan states the facility will identify and correct problems that have greatest impact on patient care, and will do a review of adverse outcomes in order to assure deficiency correction; but the QA activities the facility is conducting does not show evidence that these areas have great impact on patient care or are problem prone (Refer to Tag 0273). Review of three (3) adverse outcomes lack evidence of the corrective interventions specified, being implemented and evaluated (Refer to Tag 0286, A.).

4. The QA Plan states the facility will ensure effective communication systems for reporting Quality Improvement activities to the Governing Body/ CEO. The CEO delineated in the plan is the CEO of another facility.

a. Staff #2 initially stated in interview on 9/9/15 that the CEO of the other facility is also the CEO of this facility. Staff #2 stated that the other facility is a "sister" facility.

b. On 9/10/15, Staff #2 stated that he/she has been in contact with the Governing Body, and he/she was told that he/she is now the CEO of this facility. Staff #2 confirmed that the other/ "sister" facility is not a partner in a healthcare system with this facility, that shares the same governing body.

Based on staff interviews and review of the facility's QAPI program and documentation, it was determined that the facility failed to allocate adequate resources for measuring, assessing, improving, and sustaining the hospital's performance, and reducing the risk to patients.

Findings include:

Reference: Facility's 'Quality Improvement Plan 2015' states, "... II. Assigned Responsibility ... B. The Psychiatric Quality Improvement Committee ... 4. The Quality Improvement Committee shall: ... c. Hold Quarterly Quality Improvement meetings during which time all departments, Administration, and the psychiatric (sic) Medical Director participate is discussing the finding of the quality monitoring performed over the past quarter. ... III. Objectives ... c. Identify and correct problems that have the greatest impact on patient care. D. Review of adverse outcomes in order to assure deficiency correction. ..."

1. On 9/8/15. Staff #13 stated in interview that he/she was the QA Nurse from his/her hire date of November 2014, to May 2015, a six (6) month period. Per Staff #13, the Quality Improvement Committee met in January 2015 and in May of 2015.

i. The facility could only provide meeting minutes of the Quality Improvement Committee for May 30, 2015.

ii. Per Staff #13 on 9/9/15 at 3:15 PM, there are no meeting minutes of the Quality Improvement Committee with sign in sheets for the year of 2014.

iii. Per Staff #2 on 9/10/15, he/she cannot locate the meeting minutes of the Quality Improvement Committee for 2014.

2. The facility could only provide evidence of one Quality Improvement Committee meeting from January 2014 to date. The facility could not provide evidence that it has the resources for its Quality Improvement Committee to meet quarterly.

3. The QA Plan states the facility will identify and correct problems that have greatest impact on patient care, and will do a review of adverse outcomes in order to assure deficiency correction; but the QA activities the facility is conducting do not show evidence that these areas have great impact on patient care or are problem prone. Review of three (3) adverse outcomes lack evidence of the corrective interventions specified, being implemented and evaluated.

Based on staff interview and review of facility documentation it was determined that the facility failed to have an organized medical staff that operates under bylaws approved by the governing body.

Findings include:

1. On 9/10/15, Staff #2 provided documentation of the members of the facility's Governing Body. The document identified two (2) member names.

a. There was no evidence of Governing Body Meeting Minutes.

b. Staff #2 confirmed in interview on 9/10/15 at 1:00 PM that there are no Governing Body Meeting minutes.

2. There was no evidence of Governing Body Meeting minutes to reflect the governing body's approval of the Medical By-Laws and the appointment of medical staff members (Cross refer tag 0341 and 0354).

Based on review of physician credential files, staff interview, and review of the facility's medical by-laws it was determined that the governing body failed to appoint candidates, who have been recommended for appointment by the medical staff for appointment, prior to those physicians practicing at the facility.

Findings include:

Reference: Facility's Medical By-Laws states on page 2, "... Appointments and Re-Appointments: [1st bullet] --[facility's name]-- has delegated the credentialing process [primary and secondary verification] for all practitioners applying for clinical practice and membership to the --[facility's name]-- Medical Staff to --[*another acute psychiatric facility]-- via --[name of a credentialing company]--, acting as the CVO [Credentials Verification Organization]. This delegation results in practitioners who are members of the --[*other acute psychiatric facility's name]-- are members of [this facility's name]-- Medical Staff. [2nd bullet] Based on the recommendations of the medical staff, the hospital administrator shall carry out all practitioner appointments on behalf of the governing body. ..."

1. On 9/9/15 review of Staff #19's and Staff #20's credential files indicated the Psychiatric Medical Director appointed these two (2) clinicians to the medical staff effective 1/1/15.

a. There was no evidence provided that the governing body approved Staff #19 and Staff #20's appointment to the medical staff.

b. The facility bylaws referenced above does not identify the Psychiatric Medical Director as a single appointing authority for the medical staff members.

2. On 9/9/15 review of Staff #21's credential file indicated Staff #21 was approved to be a member of another psychiatric facility, with an approval signature dates of 9/30/14 by that facility's Chairman of the Medical Executive Committee, and of 10/1/14 by the President of the Governing Body.

a. Staff #2 initially stated in interview on 9/9/15 that the other facility is a "sister" facility.

b. On 9/10/15, Staff #2 stated that he/she has been in contact with the Governing Body. Staff #2 confirmed that the other/ "sister" facility is not a partner in a healthcare system with this facility, that shares the same governing body.

3. The above physicians were practicing at the facility prior to the governing body's approval of their appointment to the medical staff.

Based on facility document review, it was determined that the governing body failed to approve the medical staff bylaws and other medical staff rules and regulations.

Findings include:

1. On 9/9/15, review of the facility's 'Medical By-Laws', dated 7/31/15 and signed by the hospital's administrator, lacked evidence that the bylaws were approved by the facility's governing body.

a. The following policies and procedures, that indicate the 'Manual of Origin: Medical By-Laws', that was signed by the Medical Director and Hospital Administrator, also lack evidence of approval by the governing body:

i. Physician Documentation: Assessments, Orders, Progress Notes, and Discharge Summaries

ii. Multidisciplinary Comprehensive treatment Plan Development and Review/Update Process

iii. Patient competency to Consent to Treatment

iv. Impaired Practitioners

v. Referral Process for Psychiatric Admissions

vi. Behavioral Management Protocol

Based on document review and interview, it was determined that the facility failed to ensure that the nursing staff develop and keep current, a nursing care plan for each patient.

Findings include:

Reference #1: Facility policy 'Fall Risk' states, "Procedure: ... 7. If a patient falls ... The RN will reassess the patient and complete a Risk for Falls Assessment Form."

1. On 9/10/15 at 10 AM Patient #9 was observed sitting in the dining group room with a bruised/bandaged forehead. A nursing note in Medical Record #9 dated 9/9/15 at 12:05 AM indicated that the patient fell out of bed, hit his/her forehead and a small amount of bleeding was noted.

2. Further review of Medical Record #9 indicated the Risk for Fall Plan of Care was established on 9/4/15, and was reviewed on 9/8/15. The care plan was not revised to indicate the patients current status and needs, in accordance with Reference #1.

a. The falls plan of care is generic and does not specify the specific interventions implemented for this patient.

3. The above was confirmed by Staff #4 on 9/10/15 at 1:15 PM.


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4. The Multidisciplinary Progress Notes in Medical Record #2 indicated the patient sustained a fall on 8/28/15 at 0200, hitting the occipital part of his/her head on the floor.

5. Patient #2's Risk for Fall Plan of Care was established on 8/13/15. The care plan was not revised to indicate the patient's current status and needs, in accordance with Reference #1.

a. The falls plan of care is generic and does not specify the specific interventions implemented for this patient.

6. The above was confirmed by Staff #4.

Based on review of two (2) medical records for medication administration, it was determined that the facility failed to ensure that medication was administered in accordance with physician orders for Patient #2.

Findings include:

1. In Medical Record #2, the physician order dated 8/18/15 at 0145 stated, "TVO [telephone verbal order] ... Ativan 0.5 mg [milligrams] IM [intramuscular] now for restlessness-agitation ...", and on 8/29/15 at 11:40 PM "Ativan 0.5 mg IM now acute agitation."

a. The Multidisciplinary Progress Notes for 8/17/15 and 8/18/15 lacked evidence of the patient assessment necessitating the need for the Ativan medication. The control house stock medication sheet indicated that on 8/18/15 at 1:50 AM Ativan, 2 mg/ml [milligram/milliliter] was taken out of stock, but failed to document how much was administered to the patient. The MAR [medication administration record] lacked evidence of documentation of administration of the medication. The physician order was not implemented.

b. The Multidisciplinary Progress Notes for 8/29/15 and 8/30/15 lacked evidence of the patient receiving Ativan. The control house stock medication sheet indicated that on 8/29/15 at 11:40 PM, Ativan 2 mg/ml was taken out of stock and was wasted. The MAR had two entries for the same date and time, indicating administration and non- administration of Ativan. It could not be determined if the patient received Ativan as ordered.

c. The above was confirmed with Staff #4.

Based on review of one (1) of one (1) medical record for referral to physical therapy, and staff interview, it was determined that the facility failed to ensure that the medical record reflected the findings of the evaluation.

Findings include:

1. Medical Record #2 evidenced a physician order dated 8/14/15 at 9 (sic) that stated, "PT [physical therapy] eval -weakness/ ... [illegible] chair ... [illegible]."

2. As of 9/8/15, the day of survey, there was no evidence that a physical therapy consult had been completed.

3. The above was confirmed by Staff #4.

Based on document review, staff interview and observation, it was determined that the facility failed to ensure that the director of food services provided effective daily management of the food services department in accordance with the "Food Services Director/Manager" job description.

Findings include:

Reference #1: 'Food Services Director/Manager' job description states, "Manages the food service program in a single site according to policies and procedures, and federal/state requirements."

Reference #2: 'Dining Services Quality Assurance & Performance Improvement Manual' states, "The Healthcare Services Group Quality Assurance and Performance Improvement Program includes work tools for guiding staff practice and targeted performance audit tools for evaluating performance in four domains of care: 1. Safety; 2. Dining Services Operations; 3. Customer Satisfaction; 4. Clinical Care. The data from the performance assessments will be used to identify focused and individualized Performance Improvement Plans ... Evaluate the performance assessments relative to the identified goals and submit the findings to the Quality Assurance/Performance Improvement Committee. Include in the report the following: a. Outcome data vs. goal, b. Ongoing performance assessment/monitoring process for sustaining the improved performance, c. Proposed alternate strategies for outcomes that did not support measurable performance improvement."

1. On 9/10/15, Staff #10 could not provide for review, focused and individualized Performance Improvement Plans, based on performance assessment data collected during the 2014-2015 years for Dietary Audit; Food Service Division Unit Inspection; local Health Inspections 4/14, 3/15, 5/15 and 6/15; test trays and patient satisfaction, in accordance with References #1 and #2.

2. On 9/10/15, Staff #10 could not provide for review, individualized Performance Improvement Plans, that evaluated the performance data collected and that were reported to the Quality Assurance/Performance Improvement Committee, in accordance with References #1 and #2.

3. The above was confirmed by Staff #10 on 9/10/15 at 1:15 PM.

Based on interview and review of documentation, it was determined that the facility did not have in effect, a Utilization Review (UR) Plan and committee, including at least two or more doctors of medicine or osteopathy who do not have a relationship with facility patients.

Findings include:

1. The facility failed to establish a UR committee with at least two or more doctors of medicine or osteopathy who do not have a relationship with facility patients.

Based on document review and interview, it was determined that the facility failed to establish a Utilization Review (UR) Committee with at least two or more doctors of medicine or osteopathy who do not have a relationship with facility patients.

Findings include:

1. On 9/8/15, Staff #13 stated that the UR committee does not meet separately; they meet during the Quality Improvement Committee meetings.

a. On 9/8/15, review of the staff sign in sheet for the Quality Improvement Committee meeting dated 5/13/15, lacked evidence of physician signatures to indicate participation in the UR. Staff #13 stated that he/she reviewed the 1/1/15 -3/31/15 data presented on the UR reporting form. Staff #13 confirmed that physicians did not participate in the UR.

2. On 9/8/15, review of UR meeting minutes, dated September 22, 2014, documented two physician chairpersons in attendance. Staff #13 confirmed that the two physicians are active staff members and have/had a relationship with all facility patients. Staff #1 stated that since they are a small hospital, all physicians on staff have a relationship with facility patients.

3. The above was confirmed by Staff #13 on 9/10/15 at 2:15 PM.

Based on observation and staff interview, it was determined the facility failed to ensure that a safe and clean environment was maintained for patients, staff and the general public.

Findings include:

1. On September 8, 2015 at approximately 11:15 AM, in the presence of Staff #14, three stained and discolored ceiling tiles were found within the Patient Treatment Room.

2. This finding was confirmed by Staff #14.

Based on observation and staff interview, it was determined that the facility failed to ensure that a fire safe environment was maintained for patients, staff and the general public.

Findings include:

1. On September 8, 2015 at approximately 10:00 AM, in the presence of Staff #14, it was discovered that no emergency evacuation diagrams were posted throughout the building. Therefore, any information providing the quickest means of exit in an emergency would be unavailable to the occupant(s).

2. This finding was confirmed by Staff #14.

A. Based on tour, observation, staff interview and review of facility policies and procedures, it was determined that the facility failed to implement its infection control policies and procedures, and guidelines.

Findings include:

Reference #1: Facility policy titled, 'Handwashing Guidelines' states, "... II. Requirements for Handwashing: ... 2. Hands should be washed before and after wearing gloves. ... a. Frequency: ... 2. Before, between and after giving patient care. ... (bottom notation: after 8-10 uses of sanitizer) ... 10. Before and after wearing gloves. ... 12. Before and after treatments. ..."

Reference #2: Facility policy titled, 'The exam room' states, "... Objective: To ensure proper cleaning and disinfecting in accordance with environmental cleaning and disinfectant guidelines of the physicians' exam room, as to help reduce and prevent the spread of infection. Procedure: ... 2. A container of an EPA approved germicidal wipes will be kept in the exam room. The exam room table will be wiped down after every patient use by the staff person accompanying the patient. ..."

Reference #3: Facility guidelines titled, 'Introduction to Cleaning Procedures' states, "... Stocking a Cart: ... Additional Information: ... Bottles must be labeled properly ... Care of Storage Area: ... Supplies upon pallets- protect paper products from insect infestation. ... Admission/Discharge Cleaning: ...Discharge: 1) ... Nursing must empty dressers and closets. ... Do high dusting and sanitize walls. ..."

Reference #4: Facility policy titled 'Respiratory Care' states, "... Definition: C-PAP - continuous positive airway pressure and BiPAP (bi-level) positive airway pressure. Procedure: 9. Environmental Services will disinfect O2 concentrator and suction machine following use of each apparatus. ..."

1. A tour was conducted on 9/8/15 of the thirty (30) bed in-patient behavioral unit, accompanied by Staff #4. Staff #4 explained that, for safety, all doors and areas are locked except for individual patient rooms. Patients going to the Exam/Treatment Wound Care Room and the Shower Room, located in the male hallway, are always accompanied by staff for care and/or treatments. During the tour, the following was observed:

a. The Female hallway - Room #6 had a strong smell of urine after being cleaned.

b. The tile surfaces in Female hallway Shower Room D, have a visible build-up of old residue.

c. The windows in the Social Room have visible old smudges and smears.

d. The Male hallway - Storage closet has wheelchair cushions stored on the floor.

e. In the Male hallway - Shower Room, rust was visible around the metal fixtures. Old residue was observed on the tile surfaces, borders, equipment within the room, the shower chair's cushion, and the Hoyer lift. The tub had visible brown staining in the basin, and the mirror had visible drip markings.

f. In the bathroom of Room #15, brownish smears were observed on two (2) walls.

(i) There was a dirty yellowed-tinged towel in the patient's dresser drawer.

g. The Storage Closet labeled "Personal Belongings/New Admissions" had patient's belongings/clothes in a box, with crackers and a water bottle on the floor.

h. The tiled surfaces in Shower Room C had visible residue build-up.

i. Within the Laundry Room, the tiled floors were visibly dirty, the washing machine had a build-up of dust and debris. The laundry basket had visible dirt and dust.

j. In the Activities Room the table surfaces and window sills have residual stains from prior use.

k. The patient activity equipment in the Activities Storage Closet was unorganized, debris and dead insects were visible on the floor.

2. The Exam/Treatment Wound Care Room and the Male hallway shower room do not have readily accessible PDI (germicidal) wipes for staff to use after medical equipment use, care and/or treatment is provided.

a. The Exam/Treatment Wound Care Room's counter had multiple areas of old residue from not being wiped down after each use.

3. Staff #4 confirmed the above findings.

4. On 9/9/15 at 10:30 AM, during wound care of Patient #10, the following was observed:

a. Patient #10 had a superficial scratch on the right forearm. Staff #7 washed his/her hands, donned gloves, and washed Patient #10's right forearm area with soap and water. Staff #7 proceeded to dry the area and apply an ointment. He/she then changed gloves, went into the wound care cart, took out Patient #10's facial rash cream, and administered the cream to Patient #10's face from the tip of his/her gloved finger. Staff #7 then removed gloves and washed his/her hands.

(i) Staff #7 failed to wash hands after removing his/her first set of gloves and before donning new gloves during two (2) different skin treatments on Patient #10.

b. Staff #7 confirmed the above findings.

5. On 9/9/15 at 12:50 PM, one (1) of two (2) oxygen concentrator units stored in the "Exam/Treatment Wound Care Room," was observed with visible red remnants of drip-markings down the side of the machine, dust and dirt build-up on the front screen component, and dust build up on the filter.

a. The above was confirmed by Staff #7 and Staff #18.

B. Based on tour, observation, staff interview and review of facility policies and procedures, it was determined that the facility failed to develop a policy and procedure for cleaning and disinfecting respiratory equipment after patient use.

Reference #1: Facility policy titled 'Respiratory Care' states, "... Definition: C-PAP - continuous positive airway pressure and BiPAP (bi-level) positive airway pressure. Procedure: 5. The nurse will wash, label with date and time and store each patient's air dried apparatus i.e., nebulizer, O2 tubing, separately in a plastic bag in the Exam Room on Evergreen Court after each use. ... 7. The Charge Nurse will instruct staff on how to use specific respiratory care apparatus when necessary. The nurse will attempt to obtain the manufacturer's recommendations for use (see attached for example). ..."

Reference #2: Facility's "attached for example" guideline titled, 'CPAP, Recommended Cleaning and Replacement Schedule for Supplies' as referenced in policy titled: 'Respiratory Care' item #7, states, "Cleaning-Daily: Wash mask with a mild soap and water, Do not use alcohol or any harsh chemicals on the mask, Wash humidifier chamber with soap and water, then soak chamber in 1/2 cup of white vinegar and 1/2 cup water for 10 minutes, rinse and dry, ..."

1. Staff #7 and Staff #8 confirmed in interview on 9/9/15 at 2:00 PM, that not all nurses clean respiratory equipment tubing on their assigned shifts. Staff #8 confirmed she/he does not know the proper way to clean respiratory tubing for CPAP and BiPAP patients after use.

a. Staff #7 and Staff #18 confirmed the "see attached for example" information in the facility policy and procedure, is not being followed by staff for respiratory equipment cleaning and should not be a part of the policy and procedure.

Based on staff interview and document review it was determined that the facility failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program addresses problems identified by the infection control officer, and failed to ensure implementation of a corrective action plan in an affected problem area.

Findings include:

1. Review of Infection Control data in the presence of Staff #7 indicated the facility had a rise in Urinary Tract Infections (UTIs) for patients with non-indwelling Foley catheters in the month of January 2015. [On average the facility had zero-two (0-2) UTIs, and in January 2015 had five (5)].

a. Per Staff #7, a urinalysis (UA) is supposed to be done prior to patients coming to this facility, or the facility's practitioners would order a UA.

2. Staff #7 confirmed there was no QA review of the observed increase in patient UTIs for the month of January.

Based on a review of two (2) medical records for discharge interventions, it was determined that the facility failed to ensure that the Comprehensive Treatment Plan Interventions and Documentation policy was implemented for Patient #2.

Findings include:

Reference: Facility policy 'Comprehensive Treatment Plan Interventions and Documentation' states, "... A. Guidelines For Writing Interventions On The CTPs [comprehensive treatment plan] ... Social Services: Interventions to address post discharge placement/community services oriented goals: Must indicate staff implementation. Must identify under representative staff, the CTT [comprehensive treatment team] member writing the intervention ... Furthermore: CTT members will provide at least weekly documentation in the MDPN [multidisciplinary progress note] Section of the Medical Record to address discipline specific CPT interventions ... CTT will hold a "CTP Discharge Meeting" with the patient and the Program Coordinator will provide corresponding documentation in the Treatment Plan Section of the Medical Record."

1. Review of Medical Record #2 indicated that the patient was admitted on 8/13/15. The initial social worker evaluation was completed on 8/18/15. The Comprehensive Treatment Plan (Individualized Comprehensive Recovery Plan) failed to address discharge planning, post discharge goals and staff interventions related to discharge planning.

2. As of 9/8/15, there was no evidence in the medical record of at least weekly documentation related to discharge planning since 8/18/15.

3. The Treatment Plan Section of the medical record dated 9/3/15 failed to document the status of the discharge plan.

4. The above was confirmed with Staff #4.

Based on medical record review, staff interview, review of facility policy and procedure, review of the facility's contract with an Organ Procurement Organization (OPO), and the facility's QAPI documentation, it was determined that the facility failed to notify the OPO of a patient's death at the facility, and failed to ensure the the organ, tissue and eye donation program is included in its QAPI activities.

Findings include:

Reference #1: Facility policy and procedure Subject 'Organ/tissue/eye donation and procurement' states, "... 4. In the event of the patient's imminent demise or death, the Charge Nurse will notify the OPO to report the organ donor's health status. ..."

Reference #2: The facility's OPO contract dated April 1, 2014 states, "... 3. DONOR INSTITUTION Donor Institution shall: 3.1 Work collaboratively with --[OPO name]-- in the implementation and maintenance of current policies and procedures to provide for organ and tissue referral and donation (including, without limitation, criteria for the timely referral of imminent deaths, criteria for determination of death, and policies to facilitate donation after cardiac death). ... 3.2 cause the timely referral of each patient whose death is imminent or who had died, whichever is earlier, and in collaboration with --[OPO name]-- establish and implement a procedure to support that process. ..."

1. On 9/8/15 Staff #2 stated in interview that the facility has had only one patient death in the past three years.

2. A review of Medical Record #4 was conducted and indicated the patient expired at the facility on 9/26/14. There was no evidence within the medical record to indicate the facility notified it's OPO of the patient's death.

a. Per a nursing note in Medical Record #4, dated 9/26/14 at 10:05 AM, "... Remains released to --funeral home-- on 9/26/14. DON [Director of Nursing] and Administration aware."

3. Staff #13 reviewed Medical Record #4 and confirmed that the facility did not notify the OPO of this patient's death.

4. The facility failed to implement its policy and procedure and OPO contract in reporting all patient deaths to the OPO for possible tissue and organ donation.

5. Review of the facility's QAPI documents lacked evidence of inclusion of the organ, tissue and eye donation program.