HospitalInspections.org

Based on review of credential files, facility policies, Medical Staff Bylaws and staff interview, it was determined that the Governing Body failed to ensure the quality of care provided by the physicians.

Findings:

Review of two (2) credential files (#s 1 and 4) revealed that both physicians had current medical and DEA licenses, privileges, appointments, and malpractice insurance. The files did not contain evidence that quality reviews had been conducted.

Review of facility policies and Medical Staff Bylaws failed to reveal directives for physician quality reviews.

Interview on 8/5/15 at 3:30 p.m.with the Quality and Compliance Manager in the conference room, revealed that the facility did not perform quality reviews on credentialed staff.

Based on review of the facility's policies and procedures, observation, and staff interviews, it was determined that the facility failed to ensure that care was provided in a safe environment.

Findings:

1. Seventeen (17) of thirty (30) patient beds: 404, 405, 406, 407, 408, 413, 501, 500, 502, 503, 504, 505, 506, 507, 508, 512, 513, lacked a functioning emergency call system.

2. Toilet tissue holders in three (3) of thirty (30) bathrooms (406, 407, 408) were of the type that patients could remove the springs that held the paper rolls in place. These springs could be used as weapon or other harmful object.

3. The electrical cords in four (4) of thirty (30) bedrooms (beds 404, 405, 411, and 413) were observed to be long enough so that they could be used as strangulation devices.

During facility tour on 8/4/15 at 5:10 p.m. with the Behavioral Health Manager the following was observed:

· Room 400/401 Call bell (all were like a front desk hotel call bell) on bedside table was secured to the table, but the bell could be easily unscrewed from the base.
· Room 404/405 semi private. No call bells. Restroom shared with next two rooms 406/407 had spring loaded toilet paper holder in place. Two large electric beds in this room which had electrical cords over 5'10" in length and could be used as a ligature.
· Room 406/407 semi private. Call bells on bedside table were secured to the table but the bell could be easily unscrewed from the base. Base then becomes a point for injury because of protruding part. Spring loaded toilet paper holder which could easily be disassembled and the wire removed.
· Room 408 There was a previously used metal bracket protruding (about 1/2 inch) from the wall close to the toilet which had sharp edges. No call bells, base screwed to night stand, possible point for injury because of protruding part. Restroom had spring loaded toilet paper holder which could easily be disassembled and the wire removed.
· Room 409 Call bell on bedside table is secured to the table, but the bell could be easily unscrewed from the base.
· Room 410 Call bell on bedside table is secured to the table, but the bell could be easily unscrewed from the base. Also, there was a setup with oxygen tubing hanging from the wall which could be used as a ligature.
· Room 411/413 semi private. Call bells at bedside table were secured to the table, but the bells could be easily unscrewed from the base. 413 call bell is broken. Base then becomes a point for injury because of protruding part. Two large electric beds in this room with cords which were over 5'10" in length and could be used as a ligature.
· Room 501/500 semiprivate had no nurse call system at all.
· Room 502/503 semiprivate had no nurse call system at all.
· Room 504/505 semiprivate had no nurse call system at all.
· Room 506/507 semiprivate had no nurse call system at all.
· Room 508/509 semiprivate had no nurse call system at all.
· Room 512/513 semiprivate had no nurse call system at all.

The Behavior Health Manager acknowledged the above findings at 8/4/15 at 5:10 p.m. while touring.

Review of facility policies failed to reveal a policy which addressed a patient call system.

During a second tour on 8/5/15 at 4:45 PM it was observed that all four beds with long electrical cords had been physically removed from the patient care rooms.

Based on observation, policy search and staff interviews, the facility failed to ensure that care was provided in a safe environment.

Findings included:

1. Seventeen (17) of thirty (30) patient beds: 404, 405, 406, 407, 408, 413, 501, 500, 502, 503, 504, 505, 506, 507, 508, 512, 513, lacked a functioning emergency call system.

2. Toilet tissue holders in three (3) of thirty (30) bathrooms (406, 407, 408) were of the type that patients could remove the springs that held the paper rolls in place. These springs could be used as weapon or other harmful object.

3. The electrical cords in four (4) of thirty (30) beds (beds 404, 405, 411, and 413) were observed to be long enough so that they could be used as strangulation devices.

During facility tour on 8/4/15 at 5:10 PM with the Behavioral Health Manager the following was observed:

· Room 400/401 Call bell (all were like a front desk hotel call bell) on bedside table was secured to the table but the bell could be easily unscrewed from the base.
· Room 404/405 semi private. No call bells. Restroom shared with next two rooms 406/407 had spring loaded toilet paper holder in place. Two large electric beds in this room which had electrical cords over 5'10" in length and could be used as a ligature.
· Room 406/407 semi private. Call bells on bedside table was secured to the table but the bell could be easily unscrewed from the base. Base then becomes a point for injury because of protruding part. Spring loaded toilet paper holder which could easily be disassembled and the wire removed.
· Room 408 There was a previously used metal bracket protruding (about 1/2 inch) from the wall close to the toilet which had sharp edges. No call bells, base screwed to night stand, possible point for injury because of protruding part. Restroom had spring loaded toilet paper holder which could easily be disassembled and the wire removed.
· Room 409 Call bell on bedside table is secured to the table but the bell could be easily unscrewed from the base.
· Room 410 Call bell on bedside table is secured to the table but the bell could be easily unscrewed from the base. Also, there was a setup with Oxygen tubing hanging from the wall which could be used as a ligature.
· Room 411/413 semi private. Call bells at bedside table were secured to the table but the bells could be easily unscrewed from the base. 413 call bell is broken. Base then becomes a point for injury because of protruding part. Two large electric beds in this room with cords which were over 5'10" in length and could be used as a ligature.
· Room 501/500 semiprivate had no nurse call system at all.
· Room 502/503 semiprivate had no nurse call system at all.
· Room 504/505 semiprivate had no nurse call system at all.
· Room 506/507 semiprivate had no nurse call system at all.
· Room 508/509 semiprivate had no nurse call system at all.
· Room 512/513 semiprivate had no nurse call system at all.

The Behavior Health Manager acknowledged the above findings at 8/4/15 at 5:10 p.m. while touring.

Review of facility policies failed to reveal a policy which addressed a patient call system.

During a second tour on 8/5/15 at 4:45 p.m. it was observed that all four beds with long electrical cords had been physically removed from the patient care rooms.