HospitalInspections.org

Based on observations and interviews, it was determined the facility failed to ensure the staff followed the facility's process for personal care items in the consumers rooms. This had the potential to affect all patients served by this facility.

Findings include:

During the tours of halls 200, 300, 400 and 500 on 6/23/15 between 9:00 AM and 12:00 PM with Employee Identifier (EI) # 1, Director of Nurses. The surveyors found multiple rooms with combs, brushes, tooth brushes, toothpaste, bottles of shampoo, conditioner, and body lotion.

During a tour of the 400 hall on 6/24/15 at 9:15 AM the surveyor observed a sign on the cabinet in the nurse's station reading, "Attention staff all hygiene boxes should be given to consumers when ready to shower or brush teeth & then must be returned to this cabinet immediately after use!!"

An interview was conducted with Employee Identifier (EI) # 3, Certified Nurse Assistant on 6/24/15 at 9:25 AM. The surveyor asked EI # 3 what the facility's process was for the consumers' personal care supplies. EI # 3 stated the consumers went to a staff member and would request the personal care supplies and were required to return to a staff member immediately after use.

An interview was conducted on 6/25/15 at 2:50 PM with EI # 5, Nurse Coordinator for halls 400 and 500. The surveyor asked why the signs were up concerning the personal care items for the consumers and the response was, "The nurse made new signs because the old signs were to little. The staff has gotten slack on halls 200 and 300 (involuntary) but new signs have been put up".

Based on the review of the medical records and facility policy and interview, it was determined the facility failed to ensure the physician's orders for restraints included the type of restraint and were signed by the IP (Licensed Independent Practitioner) in 3 of 3 records review with restraint orders. This included Consumer Identifier (CI) # 2, 1 and 6 and had the potential to affect all patient served by this facility.

Findings include:

Policy #: CTS 4.2
Subject: Use of Seclusion & Restraint
Revised: 8/14

Consumers may be placed in seclusion, be physically or mechanically restrained only when authorized by a qualified individual and implemented when less restrictive alternative treatment interventions have been unsuccessful or are determined not to be feasible and is documented in the consumer's medical record.

Initiation and Ordering of Seclusion/Restraints

3. As soon as possible, but no longer than 1 hour after the initiation of restraints or seclusion in the absence of a LIP (Licensed Independent Practitioner).

The LIC:

Supplies an order...

1. CI # 2 was admitted to the facility on 6/10/15 with diagnoses including Schizoaffective Disorder and Manic Bipolar.

Review of the restraint order dated 6/13/15 revealed no documentation of the restraint type (physical or mechanical) to be used by the staff.

An interview was conducted on 6/25/15 at 4:05 PM with Employee Identifier (EI) # 1, Director of Nurses who verified the above findings.

2. CI # 1 was admitted to the facility on 10/20/14 with diagnoses including Schizophrenia Impulse Control Disorder and Moderate Mental Retardation.

Review of the Seclusion/Restraint Placement Form for restraint (physical hold) dated 1/5/15 revealed no documentation of a LIP signature.

An interview was conducted on 6/25/15 at 4:25 PM with EI # 1 verified the above findings.

3. CI # 6 was admitted to the facility on 5/13/15 with diagnoses including Psychosis With Delusional Thoughts.

Review of the restraint order dated 5/13/15 revealed no documentation of the restraint type (physical or mechanical) to be used by the staff.

An interview was conducted on 6/25/15 at 4:00 PM with EI # 1, who verified the above findings.

Based on review of the Quality Assurance and Performance Improvement (QAPI) plan and an interview it was determined the hospital failed to assure all hospital services provided participated in QAPI. This affected the dietary services and had the potential to affect all patients served.Findings include:On 6/25/15 at 1:35 PM the hospital QAPI data was reviewed with Employee Identifier (EI) # 9, Director of Performance Improvement. During the review of the data there was no information related to the contracted dietary services which provides all dietary needs for the hospital patients. In an interview on 6/25/15 at 1:40 PM EI # 9 confirmed the dietary does not report QAPI data outside of the environment of care rounds.

Based on the review of the facility's policies and medical records and interview with the staff, it was determined the facility failed to ensure all documentation was complete and factual. This affected Consumer Identifier (CI) # 2 and 3 and had the potential to affect all consumers served.

Findings include:

Policy: # CTS 5.0.5
Subject: Charting
Revised: 03/14

Procedure:

"3. Staff will document pertinent, factual information, assessments regarding consumer care, progress...Documentation will reflect the overall treatment plan...actions implemented, consumer's response and any revisions made...
6. A nurse will document all PRN (as needed) medication given and the consumer's response..."

Policy #: CTS 5.03
Subject: One to One (1:1), Q(every)-15 (minute) and Q 30 (Routine) Observations
Revised: 6/13

Policy: When a consumer is unable to function within the structure of the program due to acting out behaviors, being a possible elopement risk and/or verbalizing intention of harming self/others, etc., One to One (1:1), Q-15 minute and Q-30 (routine) Observations may be ordered as a safety measure.

A. 1:1 Observations

2. 1:1 Two Arms-Length - Employee must keep consumer within constant visual observation and within auditory contact at all times. The employee must remain within two arms-length distance from delegated consumer at all times.

1. CI # 2 was admitted to the facility on 6/10/15 with diagnoses including Schizoaffect Disorder and Manic Bipolar.

Review of the Seclusion/Restraint Placement Form dated 6/12/15 revealed the consumer was in the Seclusion Observation room from 9:27 to 11:27 AM.

Review of the Recreational Therapy Note dated 6/12/15 from 10:30 AM to 11:30 AM revealed the consumer participated for 60 minutes.

An interview was conducted on 6/25/15 at 4:20 PM with Employee Indentifer (EI) # 2, Assistant Director who verified the above was a mistake.

2. CI # 3 was admitted to the facility on 5/14/15 with diagnoses including Schizoaffective Disorder and Personality Disorder.

Review of the physician's orders dated 5/14/15 revealed the consumer was placed on 1:1 two arms length.

Review of the 1:1 two arms length observation log revealed no documentation of observations or 1:1 two arms length between 5/14/15 at 6:45 PM to 5/15/15 at 7:00 AM.

An interview was conducted on 6/25/15 at 3:40 PM with EI # 1, Director of Nurses who verified the above findings.

Based on the review of the facility's policy and logs from the dietary department and interview, it was determined the facility failed to ensure the following logs were completed three times a day:

a) Refrigerator/Freezer Temperature Log
b) Sanitizing Solution PPM (parts per million) Log
c) Dry Storage Temperature Log
d) Dishwasher Temperature Log

This had the potential to affect all patient served by this facility.

Findings include:

Policy: Sanitation
Revised: 2/14
no policy #

Temperature sensitive equipment and areas will be checked for proper running temperatures on a daily basis, three times a day.


Review of the Dietary Logs for February 2015 revealed the following temperatures were not documented:

Walk In, Reach In Refrigerator and Freezer, Dry Storage, and Dishmachine Temperature Log :
2/18/15 - midday
2/20/15 - midday and the end of the day
2/21/15 - midday
2/22/15 - end of the day
2/23/15 and 2/24/15 - beginning of the day
2/26/15 - midday and the end of the day
2/27/15 and 2/28/15 - end of the day

Review of the Dietary Logs for May 2015 revealed no documentation of temperatures for the Walk In, Reach In Refrigerator and Freezer, Dry Storage, and Dishmachine Temperature on 5/28/15 at the end of the day.

An interview was conducted with Employee Identifier # 8, Director of Dietary on 6/23/15 at 2:00 PM. EI # 8 verified the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observations, review of the facility's polices and interviews, it was determined the facility failed to ensure the staff followed the facility's standard of practice for hand hygiene and cleansing of the medication splitter between patients' medication. This had the potential to affect all patients served by this facility.

Findings include:

Policy: # IC 3.2
Subject: Hand Hygiene
Revised 07/09

Policy: All AltaPointe Health System employees are responsible for appropriate hand hygiene.

Procedure:

Indications for Hand Hygiene:

After removal of gloves...

Recommended hand-washing procedure:

Use paper towel to turn off water

Observation of medication preparation and administration was conducted on on 6/24/15 between 8:15 AM and 9:00 AM with Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN). EI # 6 washed hands with soap and water 3 times during observation and turned the faucet off with her hands each time. Further observation revealed EI # 6 used the pill splitter on CI # 3's Lopressor (Blood pressure medication) and then on an unsampled patient's Haldol without cleansing between medications. The splitter had medication residue both times EI # 6 used the splitter.

An interview was conducted with EI # 7, Pharmacist on 6/26/15 at 4:00 PM. The surveyor asked what was the standard of practice for the use of the pill splitter and the response was, "the expected practice would be to clean between each medication".

Based on the review of the medical records and interview with staff, it was determined the facility failed to ensure the Treatment Plans were revised when the consumer was not meeting goals or expectations. This affected Consumer Identifier (CI) # 3, 2, 4, 6 (4 of 8 records reviewed) and had the potential to affect all patients served by this facility.

Findings include:

1. CI # 3 was admitted to the facility on 5/14/15 with diagnoses including Schizoaffective Disorder and Personality Disorder.

Review of the Hospital Treatment Plan dated 5/15/15 revealed the following treatment modalities:

Number of individual therapy: 3-5/week
Number of group therapy: 1-2/day
Number of therapeutic/rehab (rehabilitation) activities: 1-2/day

Review of the Group and Individual Progress Notes reveal no documentation of treatment modalities for 5/14/15, 5/15/15, and 5/16/15.

Review of the Group and Individual Progress Notes dated 5/17/15 revealed the consumer did not attend any group or therapeutic/rehab activity.

Review of the Hospital Treatment Plan Meeting dated 5/18/15 revealed no documentation of discussion of lack of Group and Individual Progress Notes for 5/14/15, 5/15/15, and 5/16/15 and not attending 5/17/15. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 5/18/15 and 5/19/15 revealed no documentation of a therapeutic/rehab activities.

Review of the Group and Individual Progress Notes dated 5/20/15 and 5/21/15 revealed the consumer did not attend a group or therapeutic/rehab activities.

Review of the Hospital Treatment Plan Meeting dated 5/22/15 revealed documentation that the consumer shows improvement and if remains stable for 3-4 days the consumer will be evaluated for a group home. There was no documentation the consumer was not meeting the Treatment Plan for group and therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 5/23/15 revealed the consumer did not attend any group sessions.

Review of the Group and Individual Progress Notes dated 5/24/15, 5/25/15 and 5/27/15 revealed the consumer did not attend a group, individual or therapeutic/rehab activities.

Review of the Group and Individual Progress Notes dated 5/26/15 revealed the consumer did not attend a group or therapeutic/rehab activities. Further review of the Group and Individual Progress Notes dated 5/26/15 revealed an individual therapy note at 8:34 AM stating, "8:34 a.m. and 3:58 p.m. Therapist attempted to meet with consumer twice but she was asleep both times and wouldn't get up".

Review of the Hospital Treatment Plan Meeting dated 5/29/15 revealed documentation that the consumer was started on a new medication due to being delusional and if remains stable will be taken off 1:1. There was no documentation the consumer was not meeting the Treatment Plan for group, individual and therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 5/30/15 and 5/31/15 revealed the consumer did not attend a group, individual or therapeutic/rehab activities.

Review of the Hospital Treatment Plan Meeting dated 6/1/15 revealed no documentation the consumer was not meeting the Treatment Plan for group, individual and therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/3/15 revealed the consumer did not attend a group or therapeutic/rehab activities. Further review of the Group and Individual Progress Notes dated 6/3/15 revealed an individual therapy note at 1:46 PM stating, "Therapist attempted to meet with consumer as...(the consumer)...walking out of dayroom. (the consumer) looked at therapist and said "I told you not to speak to me anymore...".

Review of the Group and Individual Progress Notes dated 6/4/15 revealed the consumer did not attend a group or therapeutic/rehab activity.

Review of the Hospital Treatment Plan Meeting dated 6/5/15 revealed the following documentation, "consumer believes that the therapist is related (someone's name) and therefore will not talk to therapist". There was no documentation the consumer was not attending group or therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/6/15 and 6/7/15 revealed the consumer did not attend a group, individual or therapeutic/rehab activities.

Review of the Hospital Treatment Plan Meeting dated 6/8/15 at 11:41 revealed no documentation the consumer was not attending group or therapeutic/rehab activity. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/8/15 revealed the consumer did not attend a group session. Further review of the Group and Individual Progress Notes dated 6/8/15 revealed an Individual Therapy note at 4:19 PM stating, the consumer did not want that therapist to come back.

Review of the Group and Individual Progress Notes dated 6/9/15 revealed the therapist attempted to meet with consumer for an individual session. The consumer told the therapist, "You're not my therapist" and walked away.

Review of the Group and Individual Progress Notes dated 6/10/15 revealed the consumer did not attend a group or therapeutic/rehab activity.

Review of the Group and Individual Progress Notes dated 6/11/15 revealed the consumer did not attend a group session.

Review of the Hospital Treatment Plan Meeting dated 6/12/15 revealed the no documentation the consumer was not attending group or therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/13/15 revealed no documentation the consumer was not attending group, individual or therapeutic/rehab activity.

Review of the Group and Individual Progress Notes dated 6/14/15 revealed no documentation the consumer was not attending individual or therapeutic/rehab activity.

Review of the Hospital Treatment Plan Meeting dated 6/15/15 revealed no documentation the consumer was not attending group or therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/16/15 revealed no documentation the consumer attended a group session.

Review of the Group and Individual Progress Notes dated 6/17/15 and 6/18/15 revealed no documentation the consumer attended a group or a therapeutic/rehab activity.

Review of the Hospital Treatment Plan Meeting dated 6/19/15 revealed no documentation the consumer was not attending group or therapeutic/rehab activities. There was no documentation the Hospital Treatment Plan had been revised.


Review of the Group and Individual Progress Notes dated 6/20/15 and 6/21/15 revealed no documentation the consumer attended a group, individual or therapeutic/rehab activity.

An interview was conducted on 6/25/15 at 4:10 PM with Employee Indentifer (EI) # 2, Assistant Director who verified the above findings.

2. CI # 2 was admitted to the facility on 6/10/15 with diagnoses including Schizoaffective Disorder and Manic Bipolar.

Review of the Seclusion/Restraint Placement Form dated 6/12/15 revealed the consumer was in seclusion in the observation room from 9:27 to 11:27 AM.

Review of the Seclusion/Restraint Placement Form dated 6/13/15 revealed the consumer was in restraint from 2:17 to 2:18 PM.

Review of the Seclusion/Restraint Placement Form dated 6/13/15 revealed the consumer was in seclusion in the observation room from 2:17 to 5:18 PM.

Review of the PRN (as needed) medication administration records revealed the CI # 2 received the following PRNs:

6/12/15 at 9:24 AM for severe agitation
6/13/15 at 2:32 PM for severe agitation
6/14/15 at 12:57 AM for severe agitation/aggression

Review of the Hospital Treatment Plan Meeting dated 6/15/15 revealed the following documentation, "Consumer required a PRN over the weekend". The Hospital Treatment Plan Meeting dated 6/15/15 did not include the 3 PRNs the consumer required for severe agitation. There was no documentation of the Seclusion on 6/12/15 and 6/13/15 or the restrain on 6/13/15. There was no documentation the Hospital Treatment Plan had been revised.


Review of the PRN medication administration records revealed the CI # 2 received the following PRNs:

6/21/15 at 2:32 AM for severe agitation/aggression

Review of the Hospital Treatment Plan Meeting dated 6/22/15 revealed no documentation the patient required a PRN.

An interview was conducted on 6/25/15 at 4:20 PM with EI # 2, who verified the above findings.

3. CI # 4 was admitted to the facility on 6/11/15 with diagnoses including Paranoid Schizophrenia.

Review of the MAR (Medication Administration Record) dated 6/15/15 revealed the consumer received a PRN of Ativan, Benadryl and Haldol at 8:08 AM for severe agitation/aggression and was placed in the observation room for seclusion until 9:45 AM.

Review of the Hospital Treatment Plan Meeting dated 6/15/15 at 11:59 revealed the following documentation, "Consumer has had several days of no aggressive outburst. There was no documentation of the seclusion episode earlier that same day.

An interview was conducted on 6/25/15 at 4:20 PM with EI # 2, who verified the above findings.

4. CI # 6 was admitted to the facility on 5/13/15 with diagnoses including Psychosis With Delusional Thoughts.

Review of the Hospital Treatment Plan dated 5/13/15 revealed the following treatment modalities:

Number of individual therapy: 3-5/week
Number of group therapy: 1/day
Number of therapeutic/rehab activities: 3/week

Review of the Group and Individual Progress Notes from 5/13/15 to 6/5/15 revealed no documentation the consumer attended any group activity and only attended one therapeutic/rehab activity.

Review of the Group and Individual Progress Notes for the week of 6/7/15 revealed no documentation the consumer attended any group activities.

Review of the Group and Individual Progress Notes for the week of 6/14/15 revealed no documentation the consumer attended any group and only 2 of the 3 therapeutic/rehab activities.

Review of the Hospital Treatment Plan Meetings dated 5/18/15, 5/22/15, 5/29/15, 6/1/15, 6/5/15, and 6/15/15 revealed no documentation the consumer was not attending any group and therapeutic/rehab activities as per the Hospital Treatment Plan dated 5/13/15. There was no documentation the Hospital Treatment Plan had been revised.

An interview was conducted on 6/25/15 at 4:36 PM with EI # 2, who verified the above findings.