HospitalInspections.org

Based on a review of documentation, the governing body was not responsible for services furnished in the hospital.

Findings were:

During a review of personnel files for 5 pharmacy staff, 1 of the 5 (#1) staff members did not possess the educational requirements stated on the job description.

A review of the job description for "Pharmacy Operations Coordinator" (last reviewed 12-31-11) states, in part,
"MINIMUM REQUIREMENTS
Education:
Bachelor"

A review of the applicant resume for pharmacy staff #1 revealed no documentation that this staff member held the required Bachelor's degree.

Based on review of medical records, policy and procedure review, and interviews, it was determined that the facility failed to ensure that personal privacy was ensured as evidence by directly monitoring patients with no order to perform this observation, which compromised patient privacy; additionally, the facility failed to ensure that proper consent was obtained from patients prior to administering psychotropic medications.

Findings were:

The facility directly monitored patients with no order to perform this observation, which compromised patient privacy.
Cross reference: A0143-Patient Rights: Personal Privacy

The facility failed to ensure that proper consent was obtained from patients prior to administering psychotropic medications.
Cross reference: A0405-Administration of Drugs

Based on a review of facility policies, patient records, and staff interviews, the facility failed to ensure that patient ' s right to participate in the multidisciplinary treatment team planning was maintained.

Findings were:

Review of facility policy entitled "Multidisciplinary Treatment Plans (MTP) - Psychiatric Unit STC 1" stated, in part, "all patients admitted to STC-1 will have an individualized multidisciplinary treatment plan (MTP) initiated based on psychiatric and medical History & Physical and nursing admission assessment within 24 hours. This plan will be updated as indicated and an assessment and plan by social work will be initiated within 72 hours. The plan will be reviewed and updated at least every seven (7) days or more frequently as indicated by changes in the patient's condition. The physician progress notes and orders and the nursing documentation in PCD will also reflect daily updates in the plan ... Multidisciplinary Treatment Plan is a form used in patient care documentation and will consist of patient, medicine, nursing, social work, recreational therapy, occupational therapy and any other disciplines as indicated. ... The multi-disciplinary treatment team will be involved in further development of MTP to include input from the patient. ... The patient's involvement is encouraged and his or her signature is required to reflect the patient's awareness and involvement in his/her plan of care. "

Review of facility policy entitled "Admission Criteria for Inpatient Hospitalization - Psychiatric Unit STC 1" stated, in part, " the admitting psychiatrist assesses the need for inpatient hospitalization as evidenced by one more of the following conditions: ...E. Requires services only available in hospital as evidenced by: ... 3. Comprehensive multi-disciplinary treatment plan requiring dose (sic) skilled medical supervision or coordinator due to the complexity and/or severity of the patient's signs/symptoms."

Review of facility policy entitled "Patients' Rights and Responsibilities" stated, in part, "Patients have a right to: ... 7. Participate in the development and implementation of his/her plan of care, if able. "

Review of facility policy entitled "Patients' Rights and Responsibilities" stated, in part, "patients have a right to: ... 9. Make informed decisions regarding care and to refuse medication or treatment after possible consequences of this decision have been explained clearly, unless the situation is life-threatening or the procedure is required by law."

Findings were:

Review of 6 of 6 STC-1 (psychiatric/substance abuse/detox) patient records revealed that

Review of the available documentation of the dates and times of attendance of the members of the treatment team revealed that patients were not provided the opportunity to participate in meetings with their multidisciplinary team to provide input into the development of a " Comprehensive multi-disciplinary treatment plan ... due to the complexity and/or severity of the patient's signs/symptoms." The documentation reflected that the patient and other members of the treatment team signed the form indicating attendance, hours to days apart, thereby indicating the patient did not actually have the benefit of providing input to the multidisciplinary treatment team, consisting of medicine, nursing, social work, recreational therapy, occupational therapy and any other disciplines as indicated. Further, there was no documented evidence provided of participation in the multidisciplinary treatment team planning for recreational therapists or occupational therapists for 4 of 4 patients that had orders for therapy (patients #3, 4, 7, and 8).

7 day multidisciplinary treatment plan for patient #1:
Medical: 8/18/12 at 11:39 AM
Nursing: 8/18/12 at 12:40 PM
Social work/case manager: 8/20/12 at 8 AM
Patient: 8/18/12 at 3:04 PM

Subsequent multidisciplinary treatment plan for patient #1:
Medical: 8/25/12 at 12:30 PM
Nursing: 8/27/12 at 10:10 AM
Social work/case manager: 8/27/12 at 8 AM
Patient: two RNs documented 8/27/12 at 1 PM

24-hour multidisciplinary treatment plan for patient #3:
Medical: 8/18/12 at 10:02 am
Nursing: 8/18/12 at 12:40 PM
Social work/case manager: 8/20/12 at 8 AM
Patient: 8/18/12 at 12:45 PM
No therapy participation documented

72 hour multidisciplinary treatment plan for patient #3:
Medical: 8/24/12 at 1:55 PM
Nursing: 8/20/12 at 11:30 AM
Social work/case manager: 8/20/12 at 8 AM
Patient: 8/20/12 at 11:34 AM
No therapy participation documented

72 hour multidisciplinary treatment plan for patient #4:
Medical: 8/18/12 11:35 AM
Nursing: 8/18/12 at 12:40 PM
Social work/case manager 8/20/12 at 8 AM
Patient: 8/18/12 at 12:45 PM
No therapy participation documented

Subsequent multidisciplinary treatment plan for patient #6:
Medical: 8/20/12 at 8:20 AM
Nursing: 8/20/12 at 10 AM
Social work/case manager: 8/20/12 at 8 AM
Patient: 8/20/12 at 3:43 PM

24-hour multidisciplinary treatment plan for patient #7:
Medical: 8/21/12 at 8:25 AM
Nursing 8/21/12 at 11:30 AM
Social work/case manager: 8/21/12 at 8 AM
Patient: 8/21/12 at 1:30 PM
No therapy participation documented

72 hour multidisciplinary treatment plan for patient #7:
Medical: 8/23/12 at 8:06 AM
Nursing: 8/23/12 at 12 PM
Social work/case manager: 8/23/12 at 8 AM
Patient: 8/23/12 at 1:50 PM
No therapy participation documented

24-hour multidisciplinary treatment plan for patient #8:
Medical: 8/21/12 at 9:20 AM
Nursing: 8/21/12 at 11:30 AM
Social work/case manager 8/21/12 at 8 AM
Patient: 8/21/12 at 3:30 PM
No therapy participation documented

In addition, there was no documented evidence in the medical record of a 72 hour multidisciplinary treatment team plan for patient #8, which was due on 8/24/12. The patient was discharged on 8/25/12 at 1:40 PM.

The above findings indicate that the patient was not able to have a "multidisciplinary treatment team" meeting with all members in the development of an individualized treatment plan including input from the patient.

Review of the medical records for 2 out of 6 patients revealed that the patients did not have an "individualized" treatment plan as a generic, preprinted document was used with no evidence of individualized documentation or comments related to the patient ' s plan for the 72 hour treatment plan form for patients #6 and #7; and the "subsequent" treatment plan form for patients #6 was a generic, preprinted document with no evidence of any individualized documentation or comments.

The above was confirmed in an interview on STC-1with the Director of Psychiatric Services on 8/27/12.

Based on a review of medical records and staff interview, the facility failed to provide accurate information related to informed consent, and allowed and witnessed signatures for informed consent for patients that did not have the capacity to consent.

Findings were:

Review of 2 out of 2 medical records for patients with a court order to administer psychoactive medication revealed the patients were provided with information stating they could consent to medications and that they could withdraw medication consent at any time, thereby not providing the patient with true or accurate information. Per the order to administer psychoactive medication, the patients lacked the capacity to make a decision regarding psychoactive medications.

Review of the record for patient #4 revealed a court order to administer psychoactive medication dated August 6, 2012. The order stated, in part, " The patient is in need of psychoactive medication but lacks the capacity to make a decision regarding administration of said medication ... " Patient #4 signed psychoactive medication consent forms, despite a court order which stated he lacked the capacity to consent. Consent forms signed by patient #4 stated, " ...the individual may withdraw consent at any time ...I hereby consent to treatment with a specific psychoactive medication or medication group (class) as indicated on the front of this form. I understand that I may withdraw this consent at any time. " The consent form contained signatures of a nurse and a physician.

The following psychoactive medication consents were signed by patient #4:
Zyprexa: 8/17/12
Depakote: 8/21/12
Haldol: 8/15/12
Ativan: 8/15/12
Benadryl: 8/17/12
Risperdal: 8/15/12

Review of the record for patient #6 revealed a court order to administer psychoactive medication dated July 9, 2012. The order stated, in part, " The patient is in need of psychoactive medication but lacks the capacity to make a decision regarding administration of said medication ... " Patient #6 signed psychoactive medication consent forms, despite a court order which stated he lacked the capacity to consent. Consent forms signed by patient #6 stated, " ...the individual may withdraw consent at any time ...I hereby consent to treatment with a specific psychoactive medication or medication group (class) as indicated on the front of this form. I understand that I may withdraw this consent at any time. " The consent form contained signatures of a nurse and a physician.

The following psychoactive medication consents were signed by patient #6:
Ativan: 8/11/12
Risperdal: 8/11/12
Benadryl: 8/13/12
Haldol: 8/11/12
Depakote: 8/11/12
Abilify: 8/13/12

In an interview with the Director of Psychiatric Services on 8/22/12, she confirmed the above findings. The Director also stated that patients should not have been asked to sign consent forms for psychoactive medications when there is an order to administer psychoactive medication, particularly when the consent form inaccurately states the patient can consent, and can withdraw consent at any time.

Based on review of medical records, policy and procedure review, and interviews, it was determined that the facility failed to ensure that personal privacy was ensured as evidence by directly monitoring patients with no order to perform this observation, which compromised patient privacy, and the hospital failed to ensure that patients on the psychiatric/substance abuse detox unit were able to exercise their right to privacy.


Finds were:

During a tour of the Emergency Department on 08/21/12 and 08/23/12, it was observed that there was a four room area maintained for patients with mental health needs, referred to as "Pod B". There was one patient assigned to each of the four rooms. It was observed that 2-4 Medical Technicians were on constant visual contact, monitoring the patients from a chair positioned in the room doorway. The Medical Technicians assigned to monitor the patients were observed competing observations forms. The observation forms were entitled "Direct Monitor Tool Scott and White Q 15 Minute Safety Checks". It was also observed that a Security Guard is assigned specifically to monitor this hallway, pacing the length of the hall. In an interview the Unit Director and Nurse Manger on, 08/21/12, it was confirmed that these observation forms are not part of the patient medical record. The only documentation of these observations is indicated on the hourly nurse notes in the medical record indicating that "checks are completed".

During an interview on 08/23/12, three Medical Technicians (ER Staff members #4, 5, 6) confirmed that they maintain constant visual contact with the patient they are assigned to monitor, including when hygiene is performed and if the patient goes to the restroom.

A review of Medical Records revealed 6 patients that received care in the ED that were monitored every 15 minutes according to nursing note documentation. There were no physician orders present in the medical record to implement this direct observation/monitoring of the patients. There was no record of the observation of the patients in the medical record, other than an hourly nurse note stating, "Safety Interventions: Patient under close observation with every 15 minute safety checks." No " Direct Monitor Tool Scott and White Q 15 Minute Safety Checks" forms were present in the medical records of these patients.

ED Patient # 1 had no physician order for direct observations. Nursing notes entered hourly stated, "Safety Interventions: Patient under close observation with every 15 minute safety checks." These checks continued from 08/18/12 at 2000 to 08/22/12 at 0600.

ED Patient # 2 had no physician order for direct observations. Nursing notes entered hourly stated, "Safety Interventions: Patient under close observation with every 15 minute safety checks." These checks continued from 08/19/12 at 2125 to 08/20/12 at 1600.

ED Patient # 4 had no physician order for direct observations. Nursing notes entered hourly stated, "Safety Interventions: Patient under close observation with every 15 minute safety checks." These checks continued from 08/10/12 at 1700 to 08/11/12 at 0500.

ED Patient # 5 had no physician order for direct observations. Nursing notes entered hourly stated, "Patient under close observation with every 15 minute safety checks." These checks continued from 08/14/12 at 1808 to 08/15/12 at 1400.

ED Patient # 6 had no physician order for direct observations. Nursing notes entered hourly stated, "Patient under close observation with every 15 minute safety checks." These checks continued from 08/17/12 at 0200 to 08/17/12 at 1400.

ED Patient # 7 had no physician order for direct observations. Nursing notes entered hourly stated, "Safety Interventions: Patient under close observation with every 15 minute safety checks." These checks continued from 08/09/12 at 1300 to 08/10/12 at 1100.

Facility based orientation entitled "Patient Observer Orientation" stated in part, "5. The patient must be observed at all times and never left alone ...11. The Direct Observation Monitoring tool should be filled in every 15 minutes, not all at once. Turn the form in to the charge nurse at the end of the shift."

Facility policy and procedure titled Environmental Suicide Precautions stated in part, "E. Direct Observation and Frequent Assessments.
1. The patient will be placed in 'Direct Observation' which provides for continual, direct monitoring of the patient.
2. If necessary, charge nurses will make arrangements with the staffing office to provide continual, direct monitoring of the patient identified to require 'Direct Observation.'
3. Patient safety checks should be recorded at least every 15 minutes."
Facility policy and procedure titled Patients' Rights and Responsibilities stated in part, " A. Patients have a right to: ...
2. Expect personal privacy and confidentiality of medical information as required by law."

During a tour of the Emergency Department on 08/23/12 the Unit Director and Nurse Manger confirmed that the implementation of direct observations is at the discretion of the nursing staff. During interview the Unit Director was unable to confirm that nursing staff routinely obtain physician orders for implementing these directed observations.

The failure of the facility to ensure privacy for patents in the Emergency Department was confirmed in an interview with the Medical Director and Chief Nursing Officer on 08/28/12.

Review of facility policy entitled "Confidentiality - Psychiatric Unit STC 1" stated, in part, "Confidentiality shall be maintained as an integral part of patient care on STC-1. "

Review of facility policy entitled "Management of Visitation - Psychiatric Unit STC 1" stated, in part, "in order to insure (sic) the privacy and confidentiality of the patients ... visiting hours are restricted to 5 PM to 7 PM Monday through Friday and 12 noon to 7 PM on Saturday and Sunday ... Most patient rooms on STC 1 are semi private, and visitation is provided in the common living area of the unit in order to allow patients that have opted out to maintain their privacy. "

Review of the "UNIT ACTIVITIES SCHEDULE" for STC-1 revealed that visiting hours are between 5 PM and 7 PM Monday through Friday, and between 12 PM and 7 PM Saturday and Sunday. Dinner is between 5 PM and 7 PM Monday through Friday, and at 5:15 PM Saturday and Sunday.

? Doing a tour of STC - 1, the psychiatric unit on 8/21/12 accompanied by facility and unit staff, the following was observed:
? The general patient day room is located in the center of the psychiatric unit.
? The general patient day room serves as the patient's living room, with television, chairs, and couches.
? The patient hallways branch off of the general patient day room and are accessed through the general patient day room.
? The nurses ' station opens into and is connected to the general patient day room.
? The general patient day room is the central room or hub of the unit, providing access to the patient nutrition area, dining area and patient art room.

In an interview with the Director of Psychiatric Services on 8/21/12, she stated that visitors of the psychiatric or substance abuse patients are screened for contraband, and then are allowed into the general patient day room to visit with the patients. She stated that if a patient did not want to be seen by any person visiting other patients, they would need to go to and remain in their bedroom during the visitation hours. She confirmed that any visitor to the unit would be in the same room with and would be able to see any patient on the unit that chose not to spend the visitation hours in their bedroom.

? As all patients are allowed to have visitors in the general patient day room, a patient may not be aware that someone known to them may be entering the general patient day room during visitation hours.
? Visitation hours consist of 5 PM to 7 PM Monday through Friday evenings and from 12 noon to 7 PM (7 hours) on Saturday and Sunday.
? If a patient desired for their psychiatric or substance abuse/detox admission to be confidential and chose not to be seen by visitors of other patients, the patient would need to remain in their room for up to two hours in the evening on Monday through Friday and up to seven hours on Saturday and Sunday.
? Per the "UNIT ACTIVITIES SCHEDULE" dinner is served on the unit between 5 PM and 7 PM Monday through Friday and at 5:15 PM on Saturday and Sunday. The dining area, patient nutrition area, and other common areas are visible from and accessed through the general patient day room.

The above policy and practice does not allow patients the right to privacy and/or it restricts patients to their bedroom for up to seven hours at a time if they choose to exercise their right to privacy. Patients choosing to eat dinner in the dining room or watch television during visitation hours do not have that option if they wish to ensure confidentiality of their admission to the psychiatric/substance abuse/detox unit.

The above was confirmed in an interview with the Director of Psychiatric Services and the Patient Safety RN on the morning of 8/21/12 on STC-1.

Based on a review of medical records, facility policies, and staff interviews, the facility failed to provide documented evidence that patients were monitored as ordered when on suicide or other precautions.

Findings were:

Review of facility policy entitled "Patient Orientation - Psychiatric Unit STC 1" stated, in part, "the admitting nurse educates and has the patient sign the following forms: ... 5. Patient is informed that they will be monitored every 15 minutes when on the locked wing and every hour when on the open unit."

Review of facility policy entitled "Patient Monitoring - Psychiatric Unit STC 1" stated, in part, "Patients on STC-1 will be placed either on the Locked Wing or the Open Unit based on their acuity, including risk to harm themselves or others. In addition, based on the patient's suicide risk, the patient will be placed on a Suicide Precautions Level I, II, or III. The physician ' s orders will indicate the area the patient is to be admitted to, which determines the patient's monitoring level. In addition, the physician ' s orders will identify the Suicide Precautions Level to be assigned to the patient based on their assessment of patient risk. "

Review of facility policy entitled "Suicide Precautions - Psychiatric Unit STC 1" stated, in part, "SUICIDE PRECAUTIONS - LEVEL I a. The patient may remain on the open unit and shall be encouraged to participate in unit activities with checks by staff every 30 minutes. .. SUICIDE PRECAUTIONS - LEVEL II a. The patient shall be confined to the locked unit with frequent checks by staff every 15 minutes ... SUICIDE PRECAUTIONS - LEVEL III c. The patient shall be confined to the locked unit and provided 1:1 observation/supervision with same gender staff member ...h. A suicide flow sheet shall be initiated to document the patient's status each 15 minutes."

Review of medical records for 8 out of 8 patients on STC-1 revealed no documented evidence that patients were monitored for suicide precautions at the level ordered by the physician.

Patient #1 was admitted to STC-1 to the closed unit (locked wing) on 8/7/12 at 12:30 PM. The Multidisciplinary Treatment Plan dated 8/10/12 documented " Suicide precautions " with a subsequent order to " D/C suicide precautions " on 8/25/12 at 11:45 am. There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered while on the closed unit.

Patient #3 was admitted to STC-1 to the closed unit on 8/17/12 at 2:22 pm. The Multidisciplinary Treatment Plan dated 8/18/12 stated " Elopement precautions." There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered while on the closed unit and no documentation of elopement precautions monitoring.

Patient #4 was admitted to STC-1 to the closed unit on 8/15/12 at 1:45 PM on Level I suicide precautions. The Multidisciplinary Treatment Plan dated 8/16/12 stated "closed unit monitoring. " There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered when on the locked wing from 8/15/12 at 1:45 pm until 8/23/12 at 3:30 pm; observation documentation did not begin until at 8/23/12 at 3:30 pm.

Patient #5 was admitted to STC-1 to the closed unit on 8/23/12 at 11:41 am on Level I suicide precautions. There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered from his admission on 8/23/12 at 11:41 am until 8/24/12 at 4:30 pm; the patient was monitored as ordered from 8/24/12 until he was discharged.

Patient #6 was admitted to STC-1 on 8/11/12 at 5:30 am to the closed unit on Level I suicide precautions. On 8/11/12, the physician documented " Elopement precautions on the Multidisciplinary Treatment Plan. There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered from her admission on 8/11/12 at 5:30 am until 8/23/12 at 4:00 pm when observation documentation until she was discharged on 8/27/12.

Patient #7 was admitted to STC-1 on 8/20/12 at 4:01 pm to the open unit on Level I suicide precautions and Elopement precautions. There was no documented evidence in the medical record that the patient was monitored every 30 minutes as ordered from his admission on 8/20/12 at 4:01 pm until 8/23/12 at 3:30 pm when observation documentation began. There was no documentation of elopement precautions monitoring.

Patient #8 was admitted to STC-1 on 8/21/12 at 5:23 am to the open unit on Level 1 suicide precautions. There was no documented evidence in the medical record that the patient was monitored every 30 minutes as ordered from his admission at 8/21/12 at 5:23 am until 8/23/12 at 3:30 pm.

Patient #10 was admitted to STC-1 on 8/10/12 at 11:10 am to the closed unit on Level I suicide precautions. Patient #1 also had the following orders:
8/13/12 at 8:30 am: " Place patient on 1:1 monitoring to protect safety of self, [illegible] and staff. Monitoring staff to sit outside room. "
8/14/12 at 10:15 pm: " Revise previous 1:1 order to apply when patient is awake only. "
8/16/12 at 9:41 pm: " D/C 1:1 sitter. "
There was no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered from his admission at 8/10/12 at 11:10 am until 8/11/12 at 9:00 am. There is no documented evidence in the medical record that the patient was monitored every 15 minutes as ordered from 8/11/12 at 10:00 am until 8/13/12 at 8:35 am. Though the 1:1 monitoring was only required while the patient was awake, the patient remained on level 1 suicide precautions on the closed wing, and there was no documented evidence that the patient was monitored every 15 minutes as ordered from 8/14/12 at 10:30 pm to 8/15/12 at 7:15 am, and from 8/15/12 at 12:00 am until 8/15/12 at 5:00 am. There was no documented evidence in the medical record that the patient was monitored as ordered from 8/15/12 at 10:00 pm until his discharge on 8/17/12 at 9:15 am.

In an interview with the Director of Psychiatric Services on 8/22/12, she stated that there was no protocol or procedure for nurses to follow when a patient had an order for " Elopement Precautions. " She stated that there was a policy on patient elopement, but the policy provided procedures about what to do after a patient eloped. She stated that physicians should not be ordering elopement precautions. The Director of Psychiatric Services confirmed that the physicians are ordering elopement precautions and that patients #3 and #6 had orders for elopement precautions, but there was no procedure or guidance available to staff to implement the orders.

In an interview with the Director of Psychiatric Services on 8/22/12, she confirmed the above findings.

Based on a review of patient records, facility policy, and staff interview, the facility failed to ensure that facility policies were followed when a patient expressed that her rights were being violated.

Findings were:

Review of facility policy entitled " Patient Grievance - Psychiatric Unit STC 1 " stated, in part, " Patients have a right to freedom from abuse, neglect and exploitation. If a patient feels that this right has been violated, or if a patient is dissatisfied with any aspect of care on STC-1, the patient has a right to file a grievance, and to receive a timely response to that grievance ...If a patient reports his belief that his rights have been violated or expresses concern about his care, the staff member must report this to the Mental Health Services administrator, Charge Nurse or relief charge nurse for further investigation. This complaint must be communicated immediately to the Mental Health Services Administrator or Medical Director. "

Review of the Patient notes in the medical record for patient #6 revealed documentation by the RN on 8/22/12 at 9:32 pm which stated, " Told visitors: ' They ' re trying to kill me in here. ' Delusions about rights being violated ... " There was no documented evidence in the medical record that the patient was informed of the right to file a grievance.

In an interview with the Director of Psychiatric Services, when asked, she stated that the nurse did not report the above incident with patient #6 to the Mental Health Services Administrator or Medical Director, nor had a report been made on the patient ' s behalf.

In an interview with the Director of Psychiatric Services on 8/24/12, she confirmed the above findings.

The above findings were confirmed in an interview with the Chief Nursing Officer and the Chief Executive Officer in the board room the afternoon of 8/28/12.

Based on review of medical records, policy and procedure review, and interviews, it was determined that the facility failed to ensure that proper consent was obtained from patients prior to administering psychotropic medications.

Findings were:

A review of the medical records revealed that 1 out of 9 patients on STC-1 received psychotropic medication without documented consent. On STC-1 Patient #1 revealed 2 psychoactive medications administered prior to receiving patient consent per policy.

Per nursing note on 08/08/12 at 1745 stated, "Received 3mh haldol IM at 1745." Nursing note on 08/09/12 at 0816 stated, "Pt. escorted to room to bed, willingly lay down on bed and accepted IM Haldol 3 mg administered to L hip." Nursing note on 08/09/12 at 1354 stated, "Educated that the Haldol would calm her and most likely make her sleep. 'Please give me something' . 5 mg Haldol Admin IM to R hip."

The administration of these injections of Haldol 3 mg IM was not reflected on the Medication Administration Record. The Consent to Treatment with Psychoactive Medication form was signed by the patient on 08/09/12.

According to the Nursing Note on 08/11/12 at 2137 stated, "pt refused to sign, med consent for Zyprexa O.D. offered print out and oral information given to pt. pt stated, 'I am not going to sign anything until my son gets here.'" Nursing note on 08/12/12 at 1506 stated, "visited with son, who persuaded pt to sign consent for and take yesterday's Zyprexa dose."

The Medical Administration Record reflected the administration of Zyprexa 5 mg PO on 08/10/12 at 2211. The Consent to Treatment with Psychoactive Medication form was signed by the patient on 08/12/12.

Facility policy and procedure titled Medication Consent Form-Psychiatric Unit STC-1 stated in part, "3. Informed consent for the administration of each psychoactive medication will be obtained by the nurse of physician and evidenced by the Consent to Treatment with Psychoactive Medication (MR Form 8510) executed by the patient or the patient's legally authorized representative."

The lack of properly executed consent to administer psychotropic medication to this patient was confirmed in an interview with the Medical Director and Chief Nursing Officer on 08/28/12.

Based on a review of medical records and staff interview, the facility failed to ensure that the medical record included properly executed informed consents, as the physicians and nurses on STC-1 allowed and witnessed signatures for informed consent for patients that did not have the capacity to consent.

Findings were:

Review of 2 out of 2 medical records for patients with a court order to administer psychoactive medication revealed the patients were provided with information stating they could consent to medications and that they could withdraw medication consent at any time, thereby not providing the patient with true or accurate information. Per the order to administer psychoactive medication, the patients lacked the capacity to make a decision regarding psychoactive medications.

Review of the record for patient #4 revealed a court order to administer psychoactive medication dated August 6, 2012. The order stated, in part, " The patient is in need of psychoactive medication but lacks the capacity to make a decision regarding administration of said medication ... " Patient #4 signed psychoactive medication consent forms, despite a court order which stated he lacked the capacity to consent. Consent forms signed by patient #4 stated, " ...the individual may withdraw consent at any time ...I hereby consent to treatment with a specific psychoactive medication or medication group (class) as indicated on the front of this form. I understand that I may withdraw this consent at any time. " The consent form contained signatures of a nurse and a physician.

The following psychoactive medication consents were signed by patient #4:
Zyprexa: 8/17/12
Depakote: 8/21/12
Haldol: 8/15/12
Ativan: 8/15/12
Benadryl: 8/17/12
Risperdal: 8/15/12

Review of the record for patient #6 revealed a court order to administer psychoactive medication dated July 9, 2012. The order stated, in part, " The patient is in need of psychoactive medication but lacks the capacity to make a decision regarding administration of said medication ... " Patient #6 signed psychoactive medication consent forms, despite a court order which stated he lacked the capacity to consent. Consent forms signed by patient #6 stated, " ...the individual may withdraw consent at any time ...I hereby consent to treatment with a specific psychoactive medication or medication group (class) as indicated on the front of this form. I understand that I may withdraw this consent at any time. " The consent form contained signatures of a nurse and a physician.

The following psychoactive medication consents were signed by patient #6:
Ativan: 8/11/12
Risperdal: 8/11/12
Benadryl: 8/13/12
Haldol: 8/11/12
Depakote: 8/11/12
Abilify: 8/13/12

In an interview with the Director of Psychiatric Services on 8/22/12, she confirmed the above findings. The Director also stated that patients should not have been asked to sign consent forms for psychoactive medications when there is an order to administer psychoactive medication, particularly when the consent form inaccurately states the patient can consent, and can withdraw consent at any time.

Based on direct observation of the kitchen and dietary areas, interviews, and record review, it was determined that the facility failed to ensure that staff maintain sanitation in accordance with accepted practice and facility policy.

Findings were:

During a tour of the kitchen and dietary area conducted on the afternoon of 8/20/12, the following was observed:

? 12 old large muffin tins and 8 smaller muffin tins were observed to be sticky and dirty and caked with raised, brownish food debris on the underside, the top and the cup of the muffin tins. The sticky, brownish food debris on these "clean" muffin tins was easily scraped off.
? There was white or brown food debris adhered to the inside of 3 large cooking bowls, 2 large trays, and 4 large pans which were "clean" and available for use in food preparation.
? 16 clear plastic deep pans used in food preparation had partially removed sticky, dirty labels adhered to the sides. The pans were stacked, so the sticky, dirty residue from the label of one pan was in contact with the inside of another pan.
? There were 6 large spoons with yellow and brown food debris, a large knife with a broken handle, and a large knife with a black, dirty substance in the grooves of the handle in the large cooking utensil bin containing, "clean" utensils ready for use in food preparation.
? The above examples are indicative of the dishes being placed in the dishwasher without being thoroughly cleaned prior to sanitation or inspected after washing and the potential for contamination of patient food during food preparation. Several items were in need of replacement as they could not be cleaned properly and pieces of the broking utensils could contaminate patient food. The staff of the dietary department immediately responded by sending the utensils back through for reprocessing or throwing the broken utensils away.
? 15 loaf pans, 10 large trays, and 18 large pans used in food preparation were observed on the shelf available for use which had been stacked while they were still very wet, without being dried. A clear liquid dripped from the pans and trays when they were lifted from the shelf for inspection. There were 28 flat trays used in food preparation that were visibly wet with a clear liquid and dripping which were stacked together. The clear liquid, probably water, would allow for the incubation of various organisms.
? There was brown, greasy dust and dirt/debris on high horizontal surfaces in the kitchen area, including on top of the ovens and warmers, which indicated a lack of cleaning and the potential for dust or dirt/debris to fall into the food when doors are opened and food is removed or inserted.
? A plastic cup, which was being used as a scoop, was lying in contact with the food product in the granola bin. This presents a risk for contamination of the food.
? The floor under the cooking, baking, and frying areas was dirty, with a large accumulation of raised, dark, greasy dust and debris, especially around the legs or the bases of the equipment. These areas were noticeably dirtier than the rest of the floors in the kitchen and did not appear to have been cleaned for some time and also created a fire hazard by the potential for grease and dust ignition.
? There were two containers of Similac Sensitive infant formula, 12.6 ounces, expired 1 August, 2012, and one container of Infant NeCate formula expired 12/13/11 in the kitchen, which were available for patient use.

The Director of System Food Services, the Kitchen Production Manager, the Director of PI the Life Safety Director, and the Quality Improvement RN confirmed the above findings at 2:00 pm on 8/20/12 in the hospital kitchen.

During a follow-up tour of the kitchen and dietary area the morning of 8/24/12, the following was observed:

? There were 8 brand-new, shiny large muffin tins on the shelf where the old, dirty muffin tins had been observed on 8/20/12. However, the 8 muffin tins were visibly wet with a clear liquid which had pooled in the muffin cups. When each of the muffin tins was lifted for inspection, the clear liquid dripped onto the floor. Again, the clear liquid, presumably water, would allow for the incubation of various organisms.
? There were 12 clear plastic deep pans used in food preparation that still had partially removed sticky, dirty labels adhered to the sides. The pans were stacked, so the sticky, dirty residue from the label of one pan was in contact with the inside of another pan. This indicated a potential for food contamination.
? In the large cooking utensil bin containing " clean " utensils ready for food preparation, there were 3 chunks of a pinkish substance which appeared to be diced ham lying in and among the large cooking spoons and utensils. One of the large cooking spoons was filthy and had a yellow substance which appeared to be dried eggs, and a green substance which appeared to be dried food, both of which were approximately 0.5 x 0.125 inches in size adhered to the bowl of the spoon; and a green substance and a brown substance, which appeared to be dried food approximately 0.5 x 0.125 inches in size adhered to the back of the spoon. There was dried food debris adhered to 6 other large spoons, 2 large cooking forks, 3 large knives, and there was brown and black dried food debris adhered to a pair of broken tongs.
? The above examples are indicative of the dishes and utensils being placed in the dishwasher without being thoroughly cleaned prior to sanitation or inspected after washing and the potential for contamination of patient food during food preparation. Several items were in need of replacement as they could not be cleaned properly and pieces of the broking utensils could contaminate patient food. The staff of the dietary department immediately responded on this re-tour of the kitchen area by sending the identified dishware and utensils back through for reprocessing or throwing the broken utensils away.


The Director of System Food Services, the Life Safety Director, and the Quality Management RN confirmed the above findings at 11:50 AM on 8/24/12 in the hospital kitchen.

Review of policy entitled, "Food and Nutrition Policies & Procedures", last review date 11/30/2011 stated, in part, "Procedure for Washing Pots and Pans ...Remove heavy soils with scraper and deposit in waste can or disposal. Place ware in sink to soak. Remove as much loose soil as possible ...wearing heavy gloves, thoroughly scrub all ware with nylon brush. (Use non metallic scouring pads to remove stubborn soils). Wash small utensils and place them in the mesh basket ...Remove ware from sink and place on drain-board, tipped in such a way that solution will drain completely. Allow to air dry ...Remove ware to proper storage until next use."

Review of policy entitled, "Food and Nutrition Policies & Procedures", last review date 11/30/2011 stated, in part, " Procedure for Cleaning Stainless Steel Daily" stated, in part, "Wash a small area of the surface at a time with cloth dipped in detergent solution. Use brush for stubborn soils and heard to reach places ...Wipe dry with clean cloth."

Review of policy entitled, "Food and Nutrition Policies & Procedures", last review date 11/30/2011 stated, in part, "Procedure for Wet Mopping Daily" stated, in part, "Mop all corners using the heel of the mop. On floor surfaces which are heavily soiled, a deck brush must be used. Mop should not be forced into corners or against baseboard. This prevents soil and solution from accumulating in corners."

Review of policy entitled, "Food and Nutrition Policies & Procedures", last review date 11/30/2011 stated, in part, "Dishwashing ...Purpose: to ensure that once cleaned, dishes utensils will be handled and stored to avoid contamination ...Preparation of Dishes for Washing ...Remove food debris and gross soil from dishes by scraping, or preferably, by passing under water ...Handling and Storing of Clean Dishes and Utensils ...Examine all dishes and utensils for cleanliness after final rinse and re-wash if necessary."

Review of document entitled, "Sanitation Checklist" in the Food Service Operations Manual, stated, in part, "Dishroom/Pot and Pan Areas ...Are dishes, utensils, pots and pans pre-flushed on (sic) before washing?...Are dishes, pots and pans air dried and stored in the proper manner?"

Review of policy entitled, "Food and Nutrition Policies & Procedures", last review date 11/30/2011 stated, in part, "Safe Food Handling ...1. Appropriate utensils (i.e., forks, knives, tongs, spoons, scoops) are provided and used in all food preparation to minimize handling. 2. The handles of these utensils will not come in contact with the food."

Review of policy entitled, "Infant Formula Preparation" stated, in part, "Formula Preparation and Handling ...1. When stocking the Infant Formula Preparation Area with infant formula products, care must be taken to pull all expired products or damaged containers ....11. Inspect the infant formula container or ingredient container before use. The product must not be used if it is beyond its expiration date or if the container is damaged, leaking, or swollen."

Based on direct observation of the in-patient dialysis area, and the kitchen and dietary areas, interviews, and record review, it was determined that the facility failed to ensure that staff maintain sanitation in accordance with accepted practice and facility policy.

Findings were:

Sanitation of the in-patient dialysis area was not maintained in accordance with accepted practice and facility policy.
Cross reference: A0749-Infection Control Officer Responsibilities

Sanitation of the kitchen and dietary areas were not maintained in accordance with accepted practice and facility policy.
Cross reference: A0620-Director of Dietary Services

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

Facility policy entitled "Water Intrusion" stated in part
1. " Water intrusion issues will be reported immediately to the Customer Service Center (ext 4-2216). These would include plumbing leaks, stained ceiling tiles, water entry into building through windows, peeling vinyl wall coverings, black stains, puddles, etc."
2. The Customer Service Center will take information and utilizing a decision tree, contact proper staff to evaluate and respond to the situation on a 24/7 availability.
3. Plant Services will utilize work orders for routine maintenance and will respond to site if water intrusion is occurring at that time. It is important to dry water damaged areas and items within 24-48 hours to prevent mold growth.
4. Nursing Administration will have the authority to block patient rooms if necessary.
5. The Safety Compliance Office will evaluate reported area and make recommendations for resolution.
6. Infection Control will be will be consulted in contaminated events for recommendations.
7. Visible molds will be remediated using the indoor environmental standards and guidelines from the New York City Department of Health's "Guidelines on Assessment & Recommendation of Fungi in Indoor Environments" as a general guideline.
8. If water was contaminated, Environmental Services will utilize appropriate PPE and decontamination cleanser in the area."

Facility policy entitled "2012 Utilities Management Plan" stated in part " Utility system deficiencies are addressed through the generation of work orders via the computerized maintenance management system. Qualified technicians using appropriate tools accomplish tasks contained in each work order. Input used to generate corrective maintenance work orders originate from building Occupants/Customers or from support services staff by contacting the Customer Service Center by means of telephone, email or direct contact.
Maintenance Work Order completion and history is documented through the computerized maintenance system. History is monitored and assessed to evaluate and identify the components and systems that need improvement, need frequency of maintenance alteration, need planned component replacement or need repairs. "

Tour of the acute dialysis unit (STC 3) on 8/20/12 revealed the following:

? The floors throughout the unit were visibly dirty with medical trash (4 bottle caps, 1 tissue, 1 used glove, 2 visibly soiled alcohol pads and 1 2X2 gauze pad). The corners in behind the dialysis machines had an accumulation of grime and litter which indicated inadequate cleaning of the area.
? The nurses station desk had cracks in the plastic corner guards and the laminate on the desk top had cracks. The 1 hand washing sink on the unit also had cracks on the edges of the sink. These cracks make thorough cleaning of the area impossible.
? The water room had a leaking chlorine test port. This drip created an area that measured approximately 2X3 feet of 1/3 inch of standing water. This water was malodorous and had black mold/mildew that climbed the baseboards. 2 wooden palates were stored on the floor in the standing water. When the boards were shifted to view in behind, a coat hanger, a syringe top and thick mold was noted. Chipped tiles were also observed in the water room; an unsealed pipe that went into the ceiling was seen. In the treated water closet, the floor was littered with trash (2 soiled alcohol prep pads, a syringe wrapper) and dirt. A dirty towel was spotted on the floor in this closet.

In an interview with the Vice President of Quality and Patient Safety and the Director of Nephrology on 8/20/12, it was admitted that there was no set cleaning schedule for the acute dialysis area and that there was no facility policy for cleaning of the area. She stated "The dialysis nursing staff is responsible for cleaning the acute dialysis room" (including sweeping and mopping the floor.) It was also disclosed that the standing water and mold/mildew in the dialysis area had not been reported and addressed according to company policy.