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The Governing Body failed to;

1.) protect the patient's right to consent to treatment with psychotropic medications in 1 patient (Patient #19) out of 8 (Patient #'s 5, 19, 20, 21, 22, 23, 24, and 25) patient charts reviewed.
Refer to Tag A0131

2.) provide a safe environment in the patient recreation areas.
3.) provide safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.
Refer to Tag A0144


4.) Ensure surgical instruments were properly sterilized for patient use in 42 of 54 instruments found.
5.) ensure the sterilized instruments were documented and tested properly per protocol and CDC guidelines. The Failure to properly sterilize the instruments for medical and surgical instruments increases the risk for patient infections.
6.) the infection control director failed to develop a system for identifying, reporting, investigating and controlling the sanitary conditions of the patient environment.

Refer to Tag A0749



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7. ensure grounds, equipment, and supplies were maintained and stored to protect patient safety.
Refer to tag A0724

Based upon observation, record review, and interview, the facility failed to:
1.) protect the patient's right to consent to treatment with psychotropic medications in 1 patient (Patient #19) out of 8 (Patient #'s 5, 19, 20, 21, 22, 23, 24, and 25) patient charts reviewed.
Refer to Tag A0131

2.) provide a safe environment in the patient recreation areas.
3.) provide safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.
Refer to Tag A0144

Based on review of records and interview, the facility failed to protect the patient's right to consent to treatment with psychotropic medications in 1 patient (Patient #19) out of 8 (Patient #'s 5, 19, 20, 21, 22, 23, 24, and 25) patient charts reviewed.

Review of Patient #19's chart showed that this patient was not under court order to take medications and:

· On 5-16-2016 at 11:28 A.M. the patient was ordered to receive Atarax, 50 milligrams (MG), by mouth every six hours as needed for anemia or insomnia. A consent to receive Atarax was initiated on 5-16-2016 (not timed) by the physician. The consent did not contain the patient's signature. The order was discontinued and a new order placed on 5-17-2016 at 6:31 A.M. The new order was for Atarax, 50 MG, by mouth every six hours as need for anxiety or insomnia. A new consent was not initiated at that time and the previous consent remained unsigned by the patient.

Review of the Medication Administration Records (MAR) showed that the medication was not given until 6-1-2016. The medication had been administered by nursing staff 11 times between 6-1-2016 and 6-15-2016. The medication was discontinued on 6-16-2016.


· On 5-16-2016, the patient was ordered to receive Zyprexa, 5 MG, by mouth once a day at bedtime. A consent for Zyprexa was initiated by the physician on 5-16-2016 (not timed). The consent did not contain the patient's signature. The dosage was increased to 10 MG on 5-20-2016. A new consent for the increased dosage was not initiated at that time. The medication was discontinued on 6-1-2016.

Review of the MAR showed that the medication had been administered by nursing staff 17 times between 5-16-2016 and 5-31-2016.

Review of policy, "RSH OM Policy No: 03-03-06 / Section: Ethics, Rights, and Responsibilities / Title: Individual Rights / Subtitle: Consent to Treatment with Psychoactive Medications" was reviewed. Per the above policy, "Medical staff will gain the patients (sic) informed consent to treatment with psychoactive medications prior to the administration of the medication." Under section 3. "Documentation of informed consent: .... b. Informed consent for the administration of each psychoactive medication will be evidenced by the electronic signature in Avatar CWS on the Psychoactive Medication Consent executed by the patient or his LAR" (legally appointed representative).

Interview with Staff #3 and Staff #25 confirmed the findings.

Based on observation and interview, the facility failed to provide:
1.) a safe environment in the patient recreation areas

On 8-2-2016, a tour of buildings 617, 630, and 626 patient recreation areas, was completed with Staff #2, Staff #3, Staff #5, and Staff #26 present. The following were findings that posed hazard to all psychiatric patients:

· The electrical panel in the recreation area of building 617 had concrete steps so that the panel could be accessible to maintenance personnel without a ladder. The electrical circuit breaker panel was not secured closed and was accessible to patients, posing an electrical shock hazard.

· The patient recreation room had a large-screen television set that was not secured behind Plexiglas or other safety barrier. This presented a hazard of electrical shock or access to glass if broken by a psychiatric patient. The cords to the television set, digital video recorder, and telephone were longer than 12 inches, posing a ligature hazard to psychiatric patients.

· There were metal shelves in the patient recreation area that had been recently assembled. The shelves were metal and could be assembled and disassembled without the need for tools. Metal shelving and rails could be easily removed by psychiatric patients and used as a weapon.

· The patient recreation area had fluorescent lights that did not have covers. The lights could be broken and glass from the tubes used by a psychiatric patient to harm self or others.

· Decorations had been hung from strings greater than 12 inches in the patient recreation area. The strings were left hanging after the decorations had been removed and were accessible to psychiatric patients. This presented a ligature hazard for psychiatric patients.



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The gym area had 4 window air conditioning units. The front panels of the units were not secured and were easily removed to use as a weapon.

Staff #2, Staff #3, Staff #5 and Staff #26 confirmed the findings.



2.) safety to the patient and staff on the AU/SJU patient care units. The facility failed to have current Prevention and Management of Aggressive Behavior (PMAB) training in 8 (#15, 27, 28, 29, 30, 31, 32, and 33) out of 8 (#15, 27, 28, 29, 30, 31, 32, and 33) employee education records, assigned to work as room monitors. Failure to have the appropriate training could cause harm to the patient and staff.

On 8/2/2016 a tour was conducted in building 516 unit SJU and AU. The facility had submitted a corrective action plan from a previously cited deficiency, to have sitters in the patient dorm bedroom at all times, to supervise the patients until the ceilings were hardened. Review of the patient bedrooms revealed they did not have hardened ceilings and continued to need sitters to monitor the rooms while patients were present. (In the psychiatric setting, this provides a place for psychiatric patients to hide medications, weapons, or other contraband. The metal supports for the drop down ceilings can be easily pulled down and used by psychiatric patients to harm themselves or others.) Staff #2 confirmed that Psychiatric Nurse Assistant (PNA) staff performing direct patient care take Prevention and Management of Aggressive Behavior (PMAB) training to ensure safety for the patients and staff. An interview with staff #5 confirmed the housekeeping and dietary staff did not have current PMAB training but have been assigned to monitor patients in their dorm rooms giving direct care.

Review of the Policy and procedures "Staff Training" revealed, "A. Staff Training
The facility will ensure that all staff are informed of their roles and responsibilities under this policy. Before assuming job duties involving direct care responsibilities, and at least annually, all staff members must receive training and demonstrate competence in:
1.) Identifying the underlying causes of threatening behaviors exhibited by the individual receiving mental health services.
4.) Using de-escalation, medication, self- protection, and other techniques, such as quiet time."

Staff #2 and #5 confirmed identifying the underlying causes of threatening behaviors exhibited by the individual receiving mental health services, using de-escalation, medication, self- protection, and other techniques, such as quiet time are taught in the PMAB training.

An interview was conducted with staff #15, during the tour. Staff #15 was a sitter in the women's dorm room on SJU unit. Staff #15 stated, "I am the sitter for this room while the patients are in here. I'm here to make sure no one hurts themselves. When the patients leave the room I lock the door." Staff #15 reported that she may be the only person in the room with the patients. Staff #15 reported that she works in housekeeping full time and does this for overtime. Staff #15 reported that she did not have current PMAB training. Without appropriate training the staff member and patients are at risk of harm if a behavioral emergency occurs. The staff member would not have the knowledge or tools to help deescalate the situation or to properly hold the patient to prevent injuries.

Based on review of records and interview, nursing staff failed to administer psychotropic medications appropriately in 1 patient (Patient #19) out of 8 (Patient #'s 5, 19, 20, 21, 22, 23, 24, and 25) patient charts reviewed.

Review of Patient #19's chart showed that this patient was not under court order to take medications and:

· On 5-16-2016 at 11:28 A.M. the patient was ordered to receive Atarax, 50 milligrams (MG), by mouth every six hours as needed for anemia or insomnia. A consent to receive Atarax was initiated on 5-16-2016 (not timed) by the physician. The consent did not contain the patient's signature. The order was discontinued and a new order placed on 5-17-2016 at 6:31 A.M. The new order was for Atarax, 50 MG, by mouth every six hours as need for anxiety or insomnia. A new consent was not initiated at that time and the previous consent remained unsigned by the patient.

Review of the Medication Administration Records (MAR) showed that the medication was not given until 6-1-2016. The medication had been administered by nursing staff 11 times between 6-1-2016 and 6-15-2016. The medication was discontinued on 6-16-2016.


· On 5-16-2016, the patient was ordered to receive Zyprexa, 5 MG, by mouth once a day at bedtime. A consent for Zyprexa was initiated by the physician on 5-16-2016 (not timed). The consent did not contain the patient's signature. The dosage was increased to 10 MG on 5-20-2016. A new consent for the increased dosage was not initiated at that time. The medication was discontinued on 6-1-2016.

Review of the MAR showed that the medication had been administered by nursing staff 17 times between 5-16-2016 and 5-31-2016.

Review of Nursing Policy and Procedures Manual, XI. Policy Statement - Technical Skills, page 140, item 5, Psychoactive Medication Administration Procedures showed the policy as, "a. It is the responsibility of the nurse administering the medication to make sure there is a signed consent or court order prior to giving medication. b. If there is no consent, withhold the medication and notify the physician. c. The night shift nurse checking charts will check that the consents/court orders are in place. If they are not, he/she will report to the oncoming shift that they are not in place. The night shift nurse will place a red "C" next to all medications that have a signed consent."

Interview with Staff #3, Staff #5, and Staff #25 confirmed the findings.

Based on document review and interview the facility failed to maintain a safe enviornment for patient to receive care and treatment. The facility failed to ensure grounds, equipment, and supplies were maintained and stored to protect patient safety.

Refer to tag A0724

Based on observation and interview, the facility failed to ensure grounds, equipment, and supplies were maintained and stored to protect patient safety.

A tour of the facility began at the facility ' s Administrative building and crossed the property on foot. When passing the cafeteria a moat (a deep, wide ditch) around the building was filled with grass and held standing water. The drain area of the moat was clogged with plastic bottles and trash.
A tour of the Patient Education, Activity, and Recreation (PEAR) Building 611 was conducted on 8-2-2016. An observation of the activity room revealed three blowup beach balls on the floor scattered through the room. A storage closet was located in the corner of the room was filled with balls several drums, board games and other activity supplies too numerous to list. The staff was asked if the room was ready to receive the next class and staff responded " yes " . The staff was asked how the equipment was cleaned and made ready for the next patients. Staff responded they used antiseptic whips to clean equipment. When asked if the three balls on the floor in the activity room had been cleaned, the staff could confirm the equipment had been cleaned.
A metal door exiting the activity room had large pieces of paint flaking off of it. The floor were dirty and un-kept. Dirt and dust had collected on and near the baseboards in the hallways.
A communal drinking fountain was observed in the hallway. Directly under the drinking fountain a plug was observed protruding from the wall as if it had been pried out exposing wires.
A patient bathroom was toured and found to have paint flaking off the walls. The floors were un-kep,t dirt and dust collecting on the base boards and in all the corners of the bathroom. The divider wall between the stalls were rusted and pitted. The walls were stained and covered with peeling paint. A living spider was observed on a web connected to the ceiling and a wall. A second living spider was observed in the corner of a bathroom stall where it had built an intricate web. Hanging on the wall in the bathroom near the sink was a broken plastic soap dispenser with jagged edges.
A second patient bathroom was toured and found to have dirty un-kept floors. The bracing that attaches to the floor and supports the stall divider walls had rusted and separated from the floor leaving rusted bolts protruding from the floor. The divider wall between the stalls were rusted and pitted.
A second patient bathroom was toured and found to have dirty un-kept floors. The divider wall between the stalls were rusted and pitted. The divider walls were covered with random holes. Each hole protruded outward towards the stall leaving sharp edges and potential for injury to anyone that came in contact with the holes. The hinges on the stall doors were bent and broken and in need of repair. The electric hand dryer was rusted and in need of repair.
The tour continued to a large open recreational room. A standup video game was observed covered with dust. A thin black plastic laminate covered the standup game. The black plastic laminate had been peeled off and torn leaving sharp edges that had the potential to cut and injure anyone that came in contact with the plastic. A housekeeping closet was observed to be dirty and in disarray. The housekeeping cart used for cleaning was dirty and un-kept. The cart was covered in a buildup of grime so thick it could not be cleaned with a rag. The metal pieces of the cart were rusted. The mop bucket was so covered in grime the lettering on the sides could not be read. On small wall next to the door that exited the room, there had been a hole knocked in the cinderblock and a wire was threaded through the hole and continued up through the ceiling.
During the tour, an electrical breaker box was observed to have a hasp and lock placed on it in an attempt to secure the box. The breaker box door could be opened enough the breaker could be seen and tampered with. A metal electrical plug was attached to a cinderblock wall. The metal box had a half inch hole on the side of it. The plug wires could be seen and tampered with through the hole. A wooden piano was observed with splinters and chipped wood covering it. The piano was covered in thick dust. The dust was so thick, when a hand was whipped across the top of the piano, the dust collected and had the appearance of grey cotton. An eight foot table was observed covered in grime and tape. The grime on the table was scratched with a finger nail leaving the original paint contrasting with the grime.
The finding were observed and confirmed by staff #24 at the time of the tour.



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Findings include:

On 8-3-2016 a tour of building 614, the supply warehouse, was conducted with Staff #3 and Staff #7. One bay of the warehouse contained two pallets with 15 each 50 pound bags of popping corn. On the floor and ledges surrounding the pallets were 6 large sticky traps commonly used to catch rats. The bags used for the popping corn were thick paper-type bags. On the top layer of bags were what appeared to be mouse droppings. Staff #3 and Staff #7 confirmed that all of the bags on the top layer had this matter on them and the matter appeared to be mouse droppings. During the inspection of the bags, Staff #7 attempted to knock a large roach off of a bag of popping corn but the roach ran away. Inspection of the other items in the bay showed that none of the other items were surrounded with large sticky traps or had the matter that appeared to be mouse droppings on them.

A tour of the Patient Education, Activity and Recreation (PEAR) Building 611 was conducted on 8-2-2016. The garden area by patient classroom patio was overgrown with weeds and grass. This presented a potential nesting spot for mice, snakes, or other animals.

A tour of the patient recreation buildings was conducted on 8-2-2016. In the recreation area was a patient gymnasium area with weight lifting stations and exercise equipment. A rope to pull weights on the weight lifting station was frayed. Hinges on a Bow Flex exercise station were rusted. Protective coverings on the Bow Flex flex-bands were deteriorated. Staff #25 and Staff #14 confirmed that there was not an inspection schedule or maintenance log on any of the exercise equipment.

A tour of the patient recreation areas was conducted on 8-2-2016. In an open recreation area, decorations had been hung over electrical junction boxes and from fire extinguisher sprinkler system plumbing with long lengths of string. The decorations had been removed, but the strings remained. Staff # 6 confirmed that these strings were for hanging decorations.

A tour of Building 513, San Jacinto Unit medication room was conducted on 8-2-2016. Staff #5 was present. The following items were found stored together: hand cleaner, medication pill crusher with white powdery residue and patient nutrition items. This presented a hazard of cross-contamination of patient nutrition items.

A tour of the grounds was conducted on 8-2-2016. The concrete wall along the sidewalk by Building 505 on Avenue B was crumbling with metal rebar and sharp rusted rebar tie wires exposed. Staff #3 confirmed that some psychiatric patients were allowed to wander on grounds unescorted if approved by the physician.

Based upon observation, record review and interview, the facility failed to:
1.) Ensure surgical instruments were properly sterilized for patient use in 42 of 54 instruments found.
2.) ensure the sterilized instruments were documented and tested properly per protocol and CDC guidelines. The Failure to properly sterilize the instruments for medical and surgical instruments increases the risk for patient infections.
3.) the infection control director failed to develop a system for identifying, reporting, investigating and controlling the sanitary conditions of the patient environment.

Refer to Tag A0749




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4. ensure grounds, equipment, and supplies were maintained and stored to protect patient safety.
Refer to tag A0724

Based on observation and policy and procedures the facility failed to;
1.) Ensure surgical instruments were properly sterilized for patient use in 42 of 54 instruments found.
2.) ensure the sterilized instruments were documented and tested properly per protocol and CDC guidelines. The Failure to properly sterilize the instruments for medical and surgical instruments increases the risk for patient infections.
3.) the infection control director failed to develop a system for identifying, reporting, investigating and controlling the sanitary conditions of the patient environment.

During a tour of the clinic on 8/2/2016 a cabinet was found holding 8 packages of Ronguers (large nail clippers) that were inside sterile autoclaved packages. The packages were wet and the paper on the back of the packages were coming apart. The Clinic Licensed Vocational Nurse (LVN) reported that the instruments had just been washed and was up in the cabinet to be autoclaved. (An autoclave is a strong, heated container used for chemical reactions and other processes using high pressures and temperatures, e.g., steam sterilization.)The LVN was shown the packages and revealed to the LVN a date that was placed on each package that read, "7-22-2016." The LVN reported the items are washed and then sterilized. After they are sterilized they are put in the shelf. The LVN reported that if a date was written on them they should have been autoclaved. The LVN inspected the 8 packages and could not give a definite answer if the packages were sterile. The LVN reported that she was on vacation and she was really not sure if they had been sterilized in the autoclave or not.

Review of the policy and procedure "Podiatry Services Infection Control #6. Non- disposable equipment shall be autoclaved or receive high level disinfection."
Review of policy and procedure "Auto Clave Steam Sterilization" stated, "Packaging;
a.) Package instruments according to size in self- sealing sterilization bags with a steam indicator strip if package is not provided with one.
b.) label packages with the following information;
(1) Current date
(2) Identification number, personnel running loads initials, load number- the number of loads autoclaved that day. (This number is transferred to the sterilization log for reference)
c.) Enter the identification number in the sterilization log book with any other information."

The facility provided the surveyor with a list of dates the autoclave (that's used for podiatrist office) was cleaned and a sterilization log. There was no date found on the log for 7/22/16 of any items autoclaved. However, the items were dated and placed in the cabinet where items that were sterilized should be.

During the clinic tour a "clean" supply room had metal cart with drawers. In the drawers were 46 metal instruments in autoclaved pouches. The instruments had hinges and were dated and signed to have been autoclaved. 34 of the 46 hinged instruments were in the packages with closed hinges. Staff #5 confirmed the findings.

According to the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) stated, "Packaging. Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI and other professional organizations 454, 811-814, 819, 836, 962. These guidelines state that hinged instruments should be opened; items with removable parts should be disassembled unless the device manufacturer or researchers provide specific instructions or test data to the contrary."

An interview was conducted with staff #22 on 8/3/16. Staff #22 stated that she had just came back into this role and was attempting to organize the infection control piece. Staff #22 was not aware of the sterilization issues. Staff #22 stated enviromental rounds were done every 2 weeks and issues have been found and data was present. There was limited or no process in place to correct the infection control data issues.


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The following unsanitary conditions were identified:

· A tour of the Patient Education, Activity, and Recreation (PEAR) Building 611 was conducted on 8-2-2016. Room 118 was identified as a staff office. This office was next to room 120, a patient classroom. During the tour, a class was in session with five patients from the San Jacinto Unit. In Room 118, staff office, it was found that the office was full of clutter. Cardboard boxes, paper bags, trash, decorations, a partial bag of potting soil, a shovel, a rake, food items, an empty ceramic coffee mug, and personal bags belonging to staff were stored on the floor. The floor was carpeted. The carpeting was visibly soiled and stained.
· The patio area by the classroom of the PEAR building had trash on tables, large amounts of mud dauber wasp nests on ceilings and walls, large amounts of spider webs on ceilings, walls, and furniture and the garden area was overgrown with weeds.
· The Canteen entrance area of the PEAR building had evidence of a dried spill down the door. The bench for patients to sit on in front of the Canteen had a cushion that was visibly soiled and stained. The wall inside the Canteen by the windows had evidence of water leak with stains and blistering paint.
· Inside the patient recreation area the door was visibly soiled. An arcade type game used by patients had the decals peeling off, exposing particle board that was visibly dirty and stained. An unknown, white, sticky substance that had the appearance of chewing gum was stuck to the side of the arcade game in two spots.
· The weightlifting station in the gym area had a bench with a back on it. The area of the back where patients using the equipment would rest their heads had a discolored area in the shape of a halo. Upon wiping the discolored area with a tissue, a brown, oily residue was left on the tissue. The eliptical machine, treadmill, and Bow Flex machines were all found to be dusty and soiled. Staff #26 confirmed that a cleaning schedule for gym equipment had not been developed and that there was no policy to clean after use.
· Patient bathroom in the recreation area was found to have rusted walls and the toilet was visibly soiled.
· Wall vents in the recreation area were visibly dusty.
· Two arm chairs were found in the Arts and Crafts room. The material on both chairs were visibly soiled and cracked. The seat cushions to both chairs were removed. It was found that dirt, debris, trash, stains, and food particle were under both cushions.

Staff #3 verified the findings.