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Based on observation and staff interviews, it was determined the facility failed to ensure that the patient's right to be cared for in a safe setting and to receive the highest quality of care that includes the management and assessment of pain, is maintained.

Findings include:

1. The facility failed to ensure that safety risks are removed from all patient care areas.
(Cross refer to Tag A-0144)

2. The facility failed to ensure that the patient's right to receive the highest quality of care that includes the management and assessment of pain, is maintained.
(Cross refer to Tag A-0129)

Based on staff interview, review of the medical record (MR) of one of two patients transferred to the hospital (MR18), and review of facility policies and procedures, it was determined the facility failed to ensure that the patient's right to receive the highest quality of care that includes the management and assessment of pain, is maintained.

Findings include:

Reference: Facility policy titled, "Medical Staff Rules and Regulations" (last revised 12/22/21) states, "... Patient Rights: 1) Each patient has a right to receive the highest quality care provided by qualified and competent staff and delivered in a manner that respects and protects the patient's privacy, dignity, and right to confidentiality. This includes the right to adequate assessment and management of pain."

Review of the medical record of Patient #18 (P18) on 9/12/23, in the presence of Staff #17 (Nurse Educator), revealed that P18 was an involuntary commitment to the facility on 7/24/23 at 12:20 PM with a diagnosis of schizophrenia.

Nurse's notes entered on 7/25/23 at 7:40 AM state, "[P18] reported abdominal pain this morning, verbalized that it was very uncomfortable when asked to rate 1-10. [Staff #34] was notified and [he/she] ordered Maalox 30ml [milliliters] Q6H [every 6 hours] PRN [as needed] (for abdominal pain) and Tylenol 650mg [milligrams] Q6H PRN for pain - administered at 0635 [6:35 AM]. [Staff #34, Physician] asked to sent [sic] pt [patient] to hospital when no relieve [sic] after 1 hr [hour]. At 0715 [7:15 AM] [P18] reported little relieve [sic] and still uncomfortable 4/10 (pain score 4 out of 10). [P18] vital signs at 0700 [7:00 AM] BP [blood pressure] 183/100, PR [pulse rate] 42, pt stated PR is always low. [Staff #34] has been notified by voicemail." There was no evidence that the nurse spoke with Staff #34 regarding P18's abdominal pain after he/she left a voicemail. There was no evidence in the medical record that P18 was sent to the hospital on 7/25/23, after the patient indicated he/she still had pain and was uncomfortable.

Nurse's notes entered on 7/25/23 at 11:53 AM indicated the patient reported abdominal pain rated 3 out of 10 on the pain scale.

Nurse's notes entered on 7/29/23 at 9:56 PM indicated P18 complained of abdominal pain and received Tylenol "with minimal effect." P18 also had an episode of vomiting with multiple belching episodes at this time. There was no evidence in the medical record that the physician was notified of P18's abdominal pain or vomiting.

Nurse's notes entered on 7/30/23 at 3:31 AM indicated P18 reported vomiting and "upper center abdominal pain" rated 5 out of 10 on the pain scale. The APN (Advanced Practice Nurse) was notified and P18 was transferred to the hospital on 7/30/23 at 7:35 AM. P18 returned to the unit on 7/30/23 at 4:00 PM. A CT (Computerized Tomography) scan of the abdomen and pelvis in the hospital revealed two areas of the patient's left kidney were consistent with infection or infarct (area of dead tissue resulting from failure of blood supply to that area).

Physician notes entered by the APN on 7/25/23 at 12:36 PM stated, "Assessment & Plan: ... Rx [prescription] Omeprazole 20 mg qd [every day] and referred to GI [Gastrointestinal physicians - specialize in treating diseases in the digestive tract] for f/u [follow-up] ... ." There was no evidence in the medical record that the patient was seen by a GI physician from 7/25/23 to 7/30/23, when he/she was admitted to the hospital.

Staff #17 (Nurse Educator) confirmed the above findings on 9/12/23 at 1:00 PM.

N.J.A.C. 8:43G-4.1(a)(31)

Based on observation and staff interviews, it was determined that the facility failed to ensure that safety risks are removed from all patient care areas.

Findings include:

During a facility tour conducted on 9/11/23 at 10:26 AM, in the presence of Staff #1 (Director of Nursing), the following was observed:

The bathroom located in the Quiet Room contained a hinged toilet seat that could be easily removed and used as a weapon and a soap dispenser mounted to the wall. The soap dispenser could be easily pulled from the wall and used as a weapon. The door to the Quiet Room bathroom had a "slanted" frame that prevents an individual from hanging anything on the doorframe. Staff #1 confirmed the presence of these findings.

During an interview with Staff #1 on 9/11/23 at 11:36 AM, Staff #1 stated that the Quiet Room was used as a de-escalation room as well as a seclusion room. Staff #1 stated that patients who enter the Quiet Room are on one-to-one (1:1) close observation while in restraints. Staff #1 stated that while a patient is in the Quiet Room in restraints, a staff member is always present and the door to the Quiet Room is not closed or locked. Staff #1 stated that there is always a staff member present in the room with the patient.

During an interview with Staff #10 (Registered Nurse) on 9/11/23 11:40 AM, Staff #10 was asked if there is always a staff member performing 1:1 observation on patients when they are in the Quiet Room. Staff #10 stated, "Yes if the patient is restrained. But sometimes, some patients want to come into the Quiet Room if they feel like they need some space or if they want to sleep and cannot because their roommate is disruptive." Staff #10 was asked how those patients are monitored in the Quiet Room. Staff #10 stated, "The patient is monitored by a nursing staff member. We always have the room door open and we stand right in the doorway so we can always see the patient." Staff #10 stated that when the Quiet Room is not in use the door is always locked and the patient must ask a staff member to open the door in order to enter the room.

During an interview with Staff #14 (Psychiatric Aid), on 9/11/23 at 11:45 AM, Staff #14 stated not all patients that go in the Quiet Room are restrained and are on 1:1 observation. Staff #14 stated, "Sometimes patients ask to be in the Quiet Room to calm down if they need a quiet place. If the patient is placed in restraints, there is always a 1:1 with that patient." Staff #14 was asked if patients in the Quiet Room use the bathroom located in the Quiet Room. Staff #14 stated, "Yes. Sometimes they will just go back to their room, but they also use the bathroom in the Quiet Room. We give them privacy and let them use the bathroom. They close the door and ask if they're ok. The door doesn't lock though."

Upon interview on 9/11/23 at 2:32 PM, Staff #1 (Director of Nursing) stated, "That room should be used as a seclusion room only. They should not be using it as a quiet room. There are other rooms they can use."

N.J.A.C. 8:43G-26.2(a)(2)

Based on review of medication refrigerator temperature logs dated 10/1/22 through 8/31/23, facility document review, and staff interviews, it was determined the facility failed to ensure that policies and procedures addressing the storage of medications at refrigerated temperatures, are implemented.

Findings include:

Reference: Facility policy titled "Medication Administration and Use: Medication Storage" (dated 11/21) states, "... Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius [36 to 46 degrees F(Fahrenheit)]... If the temperature is out of range, the refrigerator thermostat will be adjusted ... ."

During a tour of the Medication Room on 9/11/23 at 11:30 AM, in the presence of Staff #6 (Licensed Practicing Nurse (LPN), the medication refrigerator temperature logs dated 10/1/22 through 8/31/23 were reviewed. Staff #6 stated that the thermostat in the refrigerator should be adjusted if the temperature was out of range and that the adjustment should be documented on the log in the space labeled as "comments."

Review of the medication refrigerator temperature logs revealed the following:

During the month of December 2022, the medication refrigerator temperatures were out of range on the following dates: 12/6/22 at 7:50 AM - 35 degrees F (Fahrenheit), 12/7/22 - 34 degrees F, 12/8/22 - 32 degrees F, 12/9/23 - 34 degrees F, 12/12/22 - 28 degrees F, 12/21/22 - 48 degrees F, 12/23/22 - 48 degrees F, 12/25/23 - 56 degrees F and 48 degrees F, 12/26/22 - 32 degrees F, and 12/29/22 - 34 degrees F. On 12/6/22 and 12/12/22, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of January 2023, the medication refrigerator temperatures were out of range on the following dates: 1/9/23 - 30 degrees F, 1/18/23 - 30 degrees F, 1/20/23 - 30 degrees F, 1/26/23 - 48 degrees F, and 1/31/23 - 32 degrees F. On 1/26/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of February 2023, the medication refrigerator temperatures were out of range on the following dates: 2/1/23 - 32 degrees F, 2/3/23 - 32 degrees F, 2/4/23 - 32 degrees F, 2/8/23 - 50 degrees F, 2/16/23 - 48 degrees F, 2/21/23 - 32 degrees F, 2/22/23 - 50 degrees F, and 2/23/23 - 32 degrees F. On 2/16/23, 2/22/23, and 2/24/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of March 2023, the medication refrigerator temperatures were out of range on the following dates: 3/6/23 - 48 degrees F, 3/7/23 - 48 degrees F, 3/8/23 - 48 degrees F, and 3/10/23 - 52 degrees F. On 3/6/23, 3/8/23, and 3/10/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of June 2023, the medication refrigerator temperatures were out of range on the following dates: 6/3/23 - 48 degrees F, 6/5/23 - 48 degrees F, 6/11/23 - 48 degrees F, 6/16/23 - 48 degrees F, and 6/24/23 - 48 degrees F. On 6/5/23, 6/11/23, and 6/16/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of July 2023, the medication refrigerator temperatures were out of range on the following dates: 7/3/23 - 52 degrees F and 48 degrees F, 7/6/23 - 32 degrees F, 7/9/23 - 32 degrees F, 7/10/23 - 32 degrees F, 7/21/23 - 34 degrees F, 7/26/23 - 56 degrees F and 32 degrees F, 7/28/23 - 32 degrees F and 32 degrees F, and 7/29/23 - 30 degrees F. On 7/3/23, 7/6/23, 7/9/23, 7/21/23, 7/26/23, 7/28/23, and 7/29/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

During the month of August 2023, the medication refrigerator temperatures were out of range on the following dates: 8/5/23 - 34 degrees F, 8/7/23 - 32 degrees F, 8/10/23 - 48 degrees F, 8/11/23 - 34 degrees F, 8/14/23 - 34 degrees F, 8/15/23 - 34 degrees F, 8/20/23 - 32 degrees F, 8/21/23 - 34 degrees F, 8/22/23 - 32 degrees F, and 8/23/23 - 34 degrees F. On 8/10/23 and 8/22/23, a note included in the "comments" column of the log indicated that the temperature was adjusted. The remaining dates failed to include documentation that action was taken and the thermostat was adjusted.

These findings were confirmed by Staff #6 on 9/11/23 at 11:34 AM.

N.J.A.C. 8:43G-23.8(a)

Based on facility document review and staff interviews, it was determined the facility failed to ensure that policies and procedures that address the accountability of Controlled Dangerous Substances (CDS), are implemented.

Findings include:

Reference: Facility policy titled "Controlled Dangerous Substance (CDS) Accountability" dated 2/2021, states, "... An inventory count of all CDS medications stored in bingo cards and in the Omnicell shall be performed at each change of shift ... ."

During an interview conducted on 9/11/23 at 11:14 AM, Staff #6 (Licensed Practical Nurse (LPN), stated that the CDS stored in the Omnicell, an automated dispensing cabinet, and the patient specific CDS stored in the medication cart, are counted each shift (a cycle count) to ensure accountability. S6 confirmed that the facility nurses usually work 8 hour shifts, and that there are three shifts each day.

On 9/12/23 at approximately 11:25 AM, the Omnicell cycle count reports for the CDS dated 6/1/23 through 9/10/23 were requested.

On 9/12/23, the Omnicell cycle count reports were reviewed with Staff #1 (Director of Nursing). During an interview on 9/12/23 at 1:40 PM, Staff #1 explained that the CDS stored in the Omnicell should be counted during each nursing shift, which is usually three shifts per day.

The Omnicell reports documenting the completion of cycle counts of CDS stored in the Omnicell dated 6/1/23 through 9/10/23 indicated that the cycle counts were not completed three times each day, in accordance with facility policy. The following was identified:

The Omnicell CDS cycle count was not completed at all on the following days: 7/8/23, 8/3/23, 8/15/23, and 8/21/23.

The Omnicell CDS cycle count was only completed one time daily, instead of three times daily, on the following days: 6/3/23, 6/13/23, 6/14/23, 6/15/23, 6/16/23, 6/25/23, 7/4/23, 7/13/23, 7/16/23, 7/21/23, 7/23/23, 7/30/23, 8/2/23, 8/6/23, 8/8/23, 8/10/23, 8/13/23, 8/17/23, 8/18/23, 8/20/23, 8/27/23, 8/28/23, 8/29/23, 8/30/23, 9/2/23, 9/4/23, 9/6/23, and 9/10/23.

During the interview on 9/12/23 at 1:42 PM, while reviewing the Omnicell cycle count reports, Staff #1 stated there may be some dates when a nurse worked a double shift and the cycle count would be completed twice instead of three times in one day. The Omnicell cycle count report for June of 2023 was compared with the staff schedule for June 2023 to identify any correlation between the dates that a staff member worked a double shift and the CDS cycle count being completed twice daily.
The comparison of the CDS cycle count reports and the staff schedule indicated that the CDS cycle count was completed twice instead of three times in a day on the following dates that did not include a double shift for a staff member: 6/1/23, 6/2/23, 6/7/23, 6/9/23, 6/21/23, 6/23/23, and 6/29/23.

During an interview on 9/12/23 at 2:36 PM, Staff #1 confirmed these findings and stated that if the cycle count was missing, completed only once daily, or completed only twice daily (without a staff member scheduled for a double shift), the facility policy was not followed. The facility failed to ensure the accountability for the CDS stored in the Omnicell.

N.J.A.C. 8:43G-23.2(a)(5)

Based on random observation, facility document review, medical record review, and staff interviews, it was determined the facility failed to ensure the development and implementation of policies and procedures that address the maintenance of the patient list in the Omnicell, an automated dispensing cabinet, and the accessibility of medications, including Controlled Dangerous Substances (CDS), stored inside.

Findings include:

On 9/11/23 at 11:35 AM, during a facility tour in the medication room, Staff #6, (Licensed Practical Nurse), explained that medications are removed from the Omnicell (automated dispensing cabinet) using each patient's profile. Staff #6 stated that patient profiles are usually added and removed by the provider pharmacy, however nursing staff could add a patient profile if necessary, if they were required to remove a medication. Staff #6, stated that the Omnicell was connected with the electronic medical record and the patients were removed from the patient list in the Omnicell upon discharge.

On 9/11/23 at 11:37 AM, in the Medication Room, Staff #6, stated that the unit census was 27 patients. However, upon review, there were 36 patients included on the electronic patient list in the Omnicell. Staff #6 confirmed this finding at the time of discovery. Staff #6 reviewed the patient list and stated that the additional 9 patients were not currently inpatients.

Upon request on 9/11/23 at 11:40 AM, Staff #6, attempted to remove a medication from the Omnicell using Patient (P)28's profile. P28 was a discharged patient. Staff #6 was able to remove a medication using P28's patient profile, which confirmed that medications could be accessed through the discharged patient's profiles. Staff #6 confirmed that the facility stored CDS, including Schedule II CDS, in the Omnicell.

Medical record review conducted with Staff #1 (Director of Nursing), on 9/12/23 at 10:50 AM, identified the discharge dates of each of the patients found on the Omnicell list. They were as follows: Patient 14 (P14) was discharged on 9/1/21, P22 was discharged on 3/2/22, P23 was discharged on 2/6/22, P24 was discharged on 4/24/22, P25 was discharged on 11/10/21, P26 was discharged on 1/6/21, P27 was discharged on 9/5/21, and P28 was discharged on 9/2/21.

Medications, including CDS, could have been removed from the Omnicell using these discharged patients' profiles between their date of discharge and the survey date of 9/12/23.

During an interview on 9/12/23 at 11:17 AM, in the Medication Room, Staff #33 (Pharmascript Representative), stated that the patient names should be removed from the Omnicell patient list within 24 hours of discharge. Staff #33 confirmed that he/she was aware that the patient list in the Omnicell included discharged patients on 9/11/23. The Omnicell patient list was reviewed with Staff #33 on 9/12/23 at 11:19 AM and the discharged patient names found on 9/11/23 were already removed.

Omnicell reports of medication withdrawals made after the discharge date for the patients listed above were requested on 9/11/23 and reviewed on 9/12/23 with Staff #1, (Director of Nursing). No medications were found to be removed after discharge, except for the test medication removed for P28 on 9/11/23.

On 9/12/23 at 11:10 AM, the facility's policy and procedure that addressed the maintenance of the Omnicell patient list was requested from Staff #1. On 9/12/23, Staff #1 failed to provide this requested policy.

N.J.A.C. 8:43G-23.2(a)(5)

Based on staff interviews and review of the personnel file of Staff #17 (Nurse Educator), it was determined the facility failed to ensure that the designated infection control professional (ICP) is qualified through education, training, and experience, to oversee the infection control program.

Findings include:

During the entrance conference on 9/11/23 at 9:50 AM, Staff #1 (Director of Nursing) identified Staff #17 as the facility's infection control professional. Upon interview on 9/12/23 at 10:05 AM, Staff #17 stated that he/she has been the facility's ICP for less than a year. Staff #17 stated he/she is the only ICP in the facility, however, he/she can use the previous ICP "as a resource." Staff #17 confirmed that he/she does not have a certification in infection control (CIC) and does not have any additional infection control training. Staff #17 stated, "I signed up for the a CIC study group in July."

Review of Staff #17's personnel file on 9/13/23 at 11:25 AM lacked evidence of infection control training or education for an ICP.

On 9/13/23 at 12:35 PM, Staff #1 confirmed that Staff #17's personnel file did not have evidence of infection control training and education for an ICP.

N.J.A.C. 8:43G-14.3