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Based on observation, staff interview, medical record review, and policy review; it was determined that the facility failed take appropriate and immediate action to protect all patients from abuse/harm (A144) and use of restraint or seclusion (A154). The systemic effect of these practices resulted in the facility's inability to ensure the safety of the patients. The facility had a census of 128 patients.

Based on observation of three behavioral health inpatient units (one chemical dependency/detoxification unit and two psychiatric units) and staff interview, it was determined the facility failed to provide a safe environment for care. The following safety risks were observed in patient rooms and had the potential to affect all patients on the psychiatric units. No environmental measures were in place to prevent suicide in patient rooms. The facility census was 128 patients.

Findings include:

Observation of the three inpatient behavioral health units determined the ceiling Heating, Venting, and Air Conditioning (HVAC) vents had wide grids that could be used as a potential ligature suicide point in the restrooms of each patient room.

During the tour of the acute inpatient psychiatric unit on 03/26/15 at 3:00 PM, Staff Q stood on the toilet on the acute care psychiatric unit to determine if the the vents were movable if weight were applied. The observation confirmed that if weight were to be applied the vent would not release from the ceiling. Staff Q stated that if weight were applied the grids would possibly bend.

The acute and geropsychiatric unit had a total of 48 inpatient beds. The chemical dependency/detoxification unit had 27 inpatient beds. Staff C stated this safety risk had not been identified.

Based on medical record review, policy review, and observation, it was determined there was no evidence that a patient was a threat to self or others during the fire drill and was restrained. This affected Patient #35 out of thirty eight medical records reviewed. The active census was 128.

Findings include:

Review of the Restraint Policy and Procedure Policy No.; 100.85 revised 03/15 states all patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time. Restraint or seclusion may only be used while the unsafe situation continues. The use of restraint or seclusion is limited to those situations which there is adequate and appropriate clinical justification.

Review of the medical record revealed Patient #35 was brought to the emergency department by the local police department on 03/24/15. Upon arrival the patient was agitated, confused, and unable to be redirected. The medical record revealed the patient was restrained on 03/25/15 at 1:30 AM after the patient attempted to leave the unit, refused redirection, and wandered into another patient's room. Emergency psychotropic medications were administered. Patient #35 was removed from restraints at 3:00 AM.

On 03/25/15 at 10:00 AM, observation in the psychiatric emergency room area was completed. Observation was made of Patient #35 attempting to exit the locked psychiatric unit during the fire drill. Staff was at the door during the drill and redirected the patient down the hallway toward room four. No physical direction was noted down the hallway. Patient #35 then was directed to get into the bed in room four, at which time the patient did without any resistance. Patient #35 was then placed in a two point restraint one on the right ankle and one on the left ankle. At no time did the patient yell at or attempt to harm staff or other patients. Patient #35 did not appear to be in the act of immediate harm to self at the time. The medical record documented less restrictive measures prior to restraints were attempted. However, no other alternative means to restraint were noted to be attempted at the time of the observation. The medical record documented the patient was placed in four point restraints. Observation was made of two point restraints applied to the patient. The patient was removed from restraints on 03/25/15 at 10:45 AM after contracting for safety.

Further medical documentation confirmed the patient was placed back in restraints on 03/25/15 at 11:07 AM for not following directions, walking into other patient's rooms, trying to walk out of the locked unit and banging on doors. The patient was removed from restraints on 03/25/15 at 11:47 AM.

Staff J was adamant in an interview on 03/25/15 at 2:37 PM, the patient needed to be restrained due to being a risk to self. Staff I stated in an interview on 03/25/15 at 2:50 PM prior to the fire drill the patient was wandering the unit and entering into room three. The patient in room three had a history of assaultive behavior. The patient was placed in restraints due to being a risk to self.

Based on observations, staff interviews, and delinquent record documentation review, the facility failed to ensure paper medical records were protected from potential water damage, and failed to ensure staff promptly completed medical records in accordance with facility policy. This could potentially affect all medical records of patients at the facility The census was 128 patients at the time of the survey.

Findings include:

1. On 03/24/15 between 1:20 PM and 2:00 PM, a tour was conducted in the medical records department with Staff R (Operations Manger of Health Information Management) and Staff T. Observation revealed a large medical records storage room which contained open shelves of paper medical records, which were located under sprinkler heads. The shelves of paper records were observed at least six to eight shelves tall and were open on both sides.

Interview with Staff R during the tour revealed Staff R and Staff S (Director of Health Information Management) were both aware of the potential for water damage to the records from the sprinkler heads. Staff R stated Staff S had discussed this concern with them approximately one month prior; however, as of current time, there was nothing in place to protect these paper medical records. Staff R confirmed these paper medical records were from 2011, and in 2013 the hospital began using electronic medical records. Staff R confirmed the paper medical records were original, and had not been scanned into the electronic records system.

2. On 03/24/15 between 1:20 PM and 2:00 PM, an interview with Staff R revealed the facility had 504 delinquent electronic medical records of patients which had not been signed timely by physicians within 30 days per facility policy. Staff R stated one physician was currently on suspension until the patients' medical records were completed. Staff R also stated the facility had a system in place to notify physicians of delinquent medical records by sending the physician a letter stating they currently have incomplete medical records over 30 days, asking the physician to complete the records. Staff R stated the facility currently has one physician on suspension for delinquent medical records.

An interview conducted with Staff S on 03/26/15 at 4:00 PM revealed the facility had a total of 485 delinquent records at the end of January 2015, and 407 at the end of February 2015. Staff S stated the facility sends a letter to the physician (with delinquent records) the first and third weeks of each month, and a suspension letter to the physician (not in compliance) the second and fourth weeks of each month. Staff S confirmed the facility requires the medical record to be completed within 30 days.

On 03/26/15 at 3:10 PM, a review of the Medical Staff Bylaws dated November 2014, and approved 05/10/11 contained a procedure for medical staff suspension, stating all records are to be completed within 30 days following discharge.

Based on observations, staff interviews, and policy review, the facility failed to maintain accurate records of a narcotic medication. This involved two staff nurses and one narcotic medication. The census on the first survey day was 128 patients.

Findings include:

On 03/23/15 at 3:10 PM, a review of the narcotic log for unit (five B) was conducted with Staff N. The start of the day narcotic count for this medication was ten. The narcotic log revealed a patient received one dose for the medication at 10:00 AM. A different patient received two doses of the medication, one at 9:58 AM and one at 10:05 AM. However, the narcotic log dated 03/23/15 revealed a narcotic pain medication in the amount of nine doses.

An actual narcotic count of this pain medication was conducted with Staff L at 3:02 PM. The total count of the medication was seven individual doses. However, the narcotic count log revealed a count of nine doses. Staff L proceeded to question two registered nurses, Staff N and Staff O. Both staff stated they each administered one dose of the medication to a patient (not the same patient) since the count was conducted earlier that morning. Both staff admitted the narcotic count log had not been updated to reflect the current count after the medication was administered. Staff L directed both nurses to update the narcotic log sheet with the correct count and an explanation of why the count was incorrect.

An interview with Staff L at 3:17 PM on 03/23/15 revealed Staff N and Staff O failed to follow the facility policy to change the narcotic count for this medication at the time of administering the medication to patients.

On 03/26/15 at 3:00 PM, a review of facility policy titled Medication /Administration: Controlled Substances, revised 12/14, stated "Each time a dose of a controlled substance is removed from Pyxis or the nursing unit's medication box, the nurse enters the appropriate information into Pyxis or narcotic inventory record.

Based on policy review, observation and staff interview, it was determined the facility failed to ensure the security of patient medications. This could potentially affect any of the 10 patients on the unit who have medications stored in the medication room. The facility census was 128.

Findings include:

Review of the facility policy, "Medication Administration: Oral, Intramuscular and Subcutaneous," revised 04/14, revealed at item III, with one asterisk (*), stated: "Unit dose medication carts/drawers are to be locked at all times and/or stored in a secure area on the nursing unit."

Review of the facility policy, "Security," last reviewed 06/14, revealed under the heading, "Medication Storage and Medication Preparation Areas": "Security of medication storage areas shall be maintained in accordance with federal laws, the laws of this state and local laws." Under the heading "Access to Medication Storage Areas," the document revealed: "Access to medication storage areas is limited to Pharmacy personnel and persons authorized to handle and administer these medications."

Observation during the tour of the cardiac surgical unit at 2:22 PM on 03/23/15 revealed the medication room door to be propped open. Noted on the counter were two bags of antibiotics for intravenous administration and a "bread box" of drawers containing patient medications that did not fit in the automated medication system. These medications included drugs utilized for the treatment of seizures (phenytoin, divalproex and levetiracetam), a cardiac medication used in the treatment of high blood pressure and chest pain (metoprolol), a phosphate binder (Renvela), an oral antibiotic (Cipro), a medication for the treatment of diarrhea (loperamide), a medication for the use of acid indigestion (sodium bicarbonate) and a medication utilized for the treatment of low blood pressure (midodrine).

Staff G verified at the time of observation at 2:22 PM on 03/23/15 that the medication room door is to be closed and locked when authorized staff are not in attendance.

Based on policy review, observation and staff interview, it was determined the facility failed to dispose of supplies and products upon manufacturer expiration dates. This could potentially affect any patient receiving or utilizing any of these products. The facility census was 128.

Findings include:

Review of the facility policy, "Expiration Dates," revised 05/14, revealed under the heading "Expiration Date Monitoring" in the second paragraph: "Expiration dates of medications and devices shall be checked during the routine medication area inspections and all medications and devices scheduled to expire during the next month shall be removed from stock."

Observation on tour of the intensive care unit beginning at 1:20 PM on 03/23/15 revealed the presence of a green topped vacutainer blood collection tube with an expiration date of 01/15; ten packets of a thickening agent with an expiration date of 08/14/13; one packet of a protein supplement with a "Best By" date of 02/13/14; and two 1,000 milliliter bags of 5% Dextrose and Lactated Ringers intravenous solution with an expiration date of 09/13.

These findings were confirmed at the time of observation with Staff G who accompanied on tour.

Based on observation, interview, and record review, the facility failed to ensure doors protecting corridor openings had suitable means for keeping doors closed, to provide vertical openings with fire resistive rating of at least one hour, to maintain protective rated construction of smoke barriers, to ensure doors in smoke barrier door openings had self closers, to maintain rated construction of hazardous areas, to maintain the fire resistive rating of exit components, to have paved of egress to a public way from exit discharge, to maintain sprinkler system in accordance with NFPA 25, to provide fire extinguishers in accordance with NFPA 10, to provide access for inspection, maintenance, and repair of smoke/fire dampers, to ensure portable heating devices were not in sleeping patient areas, to protect medical gas storage per NFPA 99, to perform quarterly fire drills, and to ensure signs were in place where oxygen is used or stored. This has the potential to affect all patients, staff, and visitors to the facility. The hospital had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

See A709

Based on observation and staff interview it was determined the floor in the dietary department was in need of repair. This has the potential to affect all patients receiving meals prepared in the dietary department. The facility census was 128.

Findings include:

Observation of the dietary department on tour beginning approximately 8:45 AM on 03/25/15 revealed the dietary department floor surface to be composed of tile. The grout between tiles was noted to have pitting, holes and missing chunks throughout the department, with broken and cracked tiles also observed. The floor surface allows for the accumulation of food, dirt, other debris and liquids.

This finding was confirmed at the time of the observation with Staff P.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, staff, and visitors to the facility. This had the potential to affect all patients, staff, and visitors to the facility. The hospital had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

K18 Failed to ensure doors protecting corridor openings had suitable means for keeping doors closed.
K20 Failed to provide vertical openings with fire resistive rating of at least one hour.
K25 Failed to maintain protective rated construction of smoke barriers.
K27 Failed to ensure doors in smoke barrier door openings had self closers.
K29 Failed to maintain rated construction of hazardous areas.
K33 Failed to maintain the fire resistive rating of exit components.
K38 Failed to have paved of egress to a public way from exit discharge.
K62 Failed to maintain sprinkler system in accordance with NFPA 25.
K64 Failed to provide fire extinguishers in accordance with NFPA 10.
K67 Failed to provide access for inspection, maintenance, and repair of smoke/fire dampers.
K70 Failed to ensure portable heating devices were not in sleeping patient areas.
K76 Failed to protect medical gas storage per NFPA 99.
K130 In offsites, failed to maintain sprinkler system in accordance with NFPA 25 and failed perform quarterly fire drills.
K141 Failed to ensure signs in place where oxygen is used or stored.

Based on observation, staff interview and policy review, the facility failed to ensure infection prevention practices with regard to hand hygiene for one of two (Patient #26) surgical patients observed. This potentially affects all patients receiving services at the hospital. The facility failed to ensure gloves were appropriately utilized and hand hygiene performed when required during preparation of the steam table and set-up of patient trays. This could potentially affect all 155 patients receiving trays from the kitchen. The facility failed to ensure all staff followed the infection control policy for changing gloves when moving from clean to dirty tasks so as not to contaminate clean supplies. This affected one of two blood sugar testing observations (Patient #39). The facility failed to ensure all vinyl covered items were identified and removed from service when cracked or ripped. This had the potential to affect all patients receiving services at the hospital. The facility census was 128 on entrance.

Findings include:

1. Patient #26 underwent a surgical procedure in Room 10 on 03/23/15. At 7:45 AM, the anesthesia assistant (Staff E) removed gloves from his/her hands, did not perform hand hygiene, and donned new gloves. At 7:47 AM, Staff E removed gloves from his/her hands and donned new gloves without performing hand hygiene in between. This observation was confirmed by interview with Staff D and Staff F during the operating room tour on 03/23/15 at 7:47 AM.



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2. Review of the Guidelines for Handwashing and Hand Hygiene policy, with date of revision 07/14, revealed hand washing was to be performed before donning sterile gloves, and before and after using gloves.







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3. Observation during tour of the dietary department on 03/25/14 beginning approximately 8:45 AM on 03/25/15 revealed bags of broccoli, carrots, corn, vegetable medley and chicken which were completely open to the fan forced air in the freezer, exposing the meat and vegetables to any particulate matter being carried by the fan. Additionally, packages of chicken, hot dogs, chicken chunks, smoked sausage, tempura chicken and breaded veal patties were noted to be opened but not dated when opened.

Additional observation noted the collection of food and debris at the bottom of the cart containing the "monkey" dishes, the milk cooler, cart wheels and the area of the dumbwaiter. A thick accumulation of burned on debris was noted on the range.

During interview at 9:15 AM on 03/25/15, Staff P confirmed packages were to be dated when opened, and food was to be covered and protected from the circulating air. Staff P also confirmed the cleaning needs identified during tour.


4. Facility policy for the food and nutrition services department, "Plastic Gloves," revised 02/14, revealed at item 1 - "Plastic gloves are worn whenever handling ready-to-eat foods"; at item 2 - "Gloves are not a substitute for hand washing. Gloves are changed in any situation in which hands should be washed"; at item 3 - "Gloves are worn on clean hands; hands are washed before putting on gloves," and at item 4 - "Gloves should be changed immediately when they become contaminated or torn."

5. Observation of the set-up of the steam table and patient tray preparation in the dietary department beginning at 11:00 AM on 03/26/15 revealed Staff K left the steam table area and threw cellophane away in the waste can, touching the lid with gloved hands. Staff K was then observed to return to the work area and was "coached" by the dietitian to change gloves. Staff K was observed to change gloves but performed no hand hygiene. At 11:11 AM Staff K was observed to return to the trash can touching the lid with bare hands and without hand hygiene obtain a scoop from the supply case on the rack.

When obtaining the food temperatures, Staff K was observed to drop the thermometer into the soup. Staff K obtained another thermometer and proceeded to check the soup when Staff P "coached" Staff K the soup had to be disposed of. While setting up the remainder of the steam cart, Staff K was observed not wearing gloves and was "coached" again to put gloves on.

At 11:20 AM, Staff K was observed to pick up a thermometer that had been dropped on the floor, took it to the sink and washed it, put it in the sanitizing solution and then proceeded to begin dishing up trays with no glove change.

At 11:40 AM, Staff K threw away used gloves in the trash but failed to perform hand hygiene after touching the trash can lid before putting on new gloves.

These findings were confirmed with Staff P at 12:05 PM on 03/26/15.


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6. On 03/23/15 at 11:58 AM, Staff M (Registered Nurse) was observed performing a blood sugar fingerstick on Patient #39. Staff L (Director of Medical-Surgical unit) was present during the observation. The employee was observed wearing non-sterile gloves to perform the fingerstick. Staff M obtained a test strip from one of two containers with a twist-on lid, which was located inside the glucose monitoring device kit. Staff M performed the fingerstick and was unable to obtain enough blood to perform the test. Staff M was observed touching the patient, the lancet, and the test strip with blood, then proceeded to obtain another test strip from the container. While wearing the same gloves, Staff M was observed twisting the lid off the container, to take a test strip from the container, replace the lid, and place the container in the testing kit. Staff M proceeded to complete the blood sugar fingerstick. Although the testing device was cleaned with a disinfectant cloth, the container was not wiped off or cleansed. Staff M was present at the time of the observation. When questioned as to whether Staff M cleaned off the test strip container after handling with potentially contaminated gloves, Staff M confirmed they had not cleaned the container before placing it into the test kit. Staff M stated they did not recall which one of the two containers was handled. Staff L then directed Staff M to throw both containers in the trash due to possible contamination.

On 03/26/15, a review was conducted of facility policy titled Infection Prevention and Control, Policy Number 200.28, revised 07/14. The policy revealed the following: "Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms or any time there would be an indication for hand hygiene." On 03/26/15 at 2:00 PM, Staff C was informed the facility policy was not followed during the blood sugar check of Patient #39.

7. On 03/24/15 at 2:54 PM, a tour was conducted in Nuclear Medicine with Staff V. During the tour, one of the nuclear medicine rooms was observed with a wedge which contained separated edges in the vinyl cover which caused the foam insides to be exposed. Staff V confirmed the wedge was used for positioning of patients and agreed the wedge could not be disinfected due to the exposed foam and split covering.

Based on review of medical records, review of policy, and staff interview, the facility failed to ensure physician orders were obtained for therapy services. This affected one (Patient #32) of three patients receiving outpatient therapy services. This had the potential to affect all patients receiving therapy outpatient services.

Findings include:

Review of the medical record for Patient #32 revealed a physician's order, dated 12/30/14, for physical therapy services for evaluation and treatment after a right shoulder arthroscopy. The physician's comments on the order indicated to work on range of motion and strengthening. Further record review indicated an occupational therapy evaluation was completed on 01/20/15. The evaluation indicated the patient was to be seen by occupational therapy two times per week for four to six weeks for neuromuscular reeducation, therapeutic exercises, manual therapy, electric stimulation and self care/activities of daily living, and home exercise program of the upper extremities.

On 03/25/15 at 2:20 PM, interview with Staff H confirmed physician orders for Patient #32 on 12/30/14 was for physical therapy services. Staff H also confirmed he/she was unable to find the orders for occupational therapy services. Staff H had confirmed Patient #32 was still receiving occupational therapy services for the right shoulder.

Review of the policy for Patient Referrals for Rehabilitation Services, with date of revision 2/11, revealed the policy was to provide evaluation and treatment as directed by the physician.