HospitalInspections.org

Based on observation of an adult psychiatric unit room and staff interview, it was determined the facility failed to provide a safe environment for care. The following safety risks were observed in a patient room and had the potential to affect all 16 patients on the adult psychiatric unit. No environmental measures were in place to prevent suicide in patient rooms.

Findings include:

Observations of an adult psychiatric unit room (Room 420) determined the ceiling Heating, Venting, and Air Conditioning (HVAC) vent had wide grids that could be used as a potential ligature suicide point in the restroom.

The findings were shared with Staff B on 08/11/15 at 2:55 PM and verified. Staff B reported the new vents had not been installed in all of the rooms yet.

Based on medical record review, policy review and interview, the facility failed to ensure orders for restraints were obtained every 24 hours for one (Patient #23) of three medical records reviewed of patients in restraints. The facility's active census was 128 patients and there were a total of three patients in restraints.

Findings include:

Patient #23 was admitted to the facility on 08/05/15 with a diagnosis of chronic alcohol abuse and alcohol withdrawal. A history and physical from 08/05/15 reported Patient #23 was clearly hallucinating. The medical record for Patient #23 contained orders for restraints on 08/06/15 at 4:24 AM, 08/09/15 at 11:289 AM and 08/10/15 at 4:31 PM. The medical record did not contain orders for restraints on 08/07/15 and 08/08/15. The medical record review contained nursing notes on 08/07/15 at 5:54 AM, 7:45 AM and 5:20 PM and on 08/08/15 at 2:22 AM and 7:54 AM which referenced Patient #23 remained in restraints.

The findings were shared with Staff A on 08/11/15 at 2:30 PM and verified. Staff A reported the orders for restraints are not in the medical record from 08/07/15 and 08/08/15.

The facility's Restraint Policy was reviewed. The policy stated orders obtained to address a patient's medical care related needs that are evidenced by non-violent or not destructive behavior are considered to be in full force and effect for up to one calendar day. This includes the day the order was obtained. If the patient remains in restraint for more than one calendar day, then a new order must be obtained. If a restraint is discontinued prior to the expiration to the original order a new order must be obtained prior to reinitiating the use of a restraint.

31597

Based on staff interview, review of the facility's Medical Staff Policies and delinquent record documentation review, the facility 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 08/10/15 at 2:15 PM, Staff C was interviewed. The director reported the facility has 343 delinquent medical records of patients which had not been signed timely by physicians within 30 days per facility policy. The director stated the facility currently has ten physicians on suspension for delinquent medical records. The facility's Physician Delinquent List summary was reviewed and revealed a total of 348 records were incomplete greater than 30 days after patient discharges.

The facility's Medical Staff Policies were reviewed and stated all records are to be completed within 30 days following discharge.

Based on observation, interview, and record review, the facility failed to ensure doors protecting corridor openings had suitable means for keeping doors closed, failed to maintain rated construction of hazardous areas, and failed to maintain the fire resistive rating of exit components. (A709) This has the potential to affect all patients, staff, and visitors to the facility.The facility had a census of 128 patients.

Based on observation and interview, 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 has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

The facility failed to ensure doors protecting corridor openings had suitable means for keeping doors closed. Please refer to K18.
The facility failed to maintain rated construction of hazardous areas. Please refer to K29.
The facility failed to maintain the fire resistive rating of exit components. Please refer to K33.