HospitalInspections.org

Based on facility tour observations, review of the unit Environmental Safety Check Logs, CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary dated 12/8/17, personnel files for New Day Behavioral Health Unit (BHU) staff, and staff interviews, it was determined the facility failed to:

1) Ensure patients were cared for in a safe environment.

2) Ensure environmental safety risk assessments identified patient safety risks which included ligature risks and the facility environment safety assessment included a mitigation plan.

3) All BHU staff who cared for psychiatric patients maintained current CPI (crisis prevention intervention) training.

These deficient practices did affect Patient Identifier (PI) # 22 and had the potential to negatively affect all patients admitted to the psychiatric unit.

Findings include:

CMS S&C Memo 18-06-Hospitals
Date: December 08, 2017
Subject: Clarification of ligature Risk Policy

...Background

A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. ligature points include shower rails, coat hooks, pipes, bedsteads, window and door frames, ceiling frames, handles, hinges and closures. The most common ligature points and ligatures are doors, hooks, handles, windows, and belt or sheet/towels...The presence of ligature risks in the physical environment of a psychiatric patient compromised the patient's safety...particularly for a patient with suicidal ideation. The hospital Patient's Right Condition of Participation...provided all patients with the right to care in a safe setting....

safety risks in a psychiatric setting include but are not limited to furniture that can be easily moved or thrown, accessible light fixtures; non-tamper proof screws; etc...

Policy: General Facility Safety and Patient Management
Reference #: 5001
Revised: 9/16/2010

Purpose:

1. To have established rules and guidelines regarding safety concerns and incidents.
2. To ensure a safe and secure environment of care.
3. To report unsafe conditions to appropriate level of management and/or primary physician...

Policy:

1. The facility environment is maintained in a safe, clean and orderly manner at all times. This facility is routinely checked to protect patients, visitors and personnel from potential safety hazards.
2. All patients admitted to the facility are considered at risk for potential injury...

Procedure: Minimal Standard of Care may include the following:

1. There are effective safety committees maintained to evaluate the safety of the facility's procedures and environment. These committees will make recommendations as to modifications and initiations of safety policies and procedures.

2. Personnel are to report all potential safety hazards to their supervisor immediately...

4. All safety concerns regarding patients and their treatment will be documented and communicated during nursing shift reports.

5. Safety rounds of the physical environment of the Behavioral Health Units should be conducted by a member of the multidisciplinary treatment team.

6. All safety concerns may be reported to the charge nurse, Program Director, Safety Officer, Patient Safety Officer, Nursing Supervisor, Chief Nursing Officer, and/or Chief Executive Officer for intervention and plan of action.

1. During a tour of the New Day Behavioral Unit Geriatric Wing on 1/7/2020 at 9:12 AM the following ligature risks were identified:

a) The door hinges on patient rooms 109, 111, 112, 113, 114, 115, and 119 were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

b) The door handles on patient rooms 109, 111, 112, 113, 114, 115, and 119 were installed in an upright position that would allow a rope or other ligature to be attached.

c) The sink faucet handles in patient rooms 109, 111, 112, 113, 114, 115, and 119 were of the type that a rope or other ligature could be easily attached.

d) The plumbing and pipes under the sinks in patient rooms 109, 111, 112, 113, 114, 115, and 119 were exposed and could be used to attach ligature.

e) The bathrooms in patient rooms 109, 111, 112, 113, 114, 115, and 119 had grab bars that were not constructed in a manner that would prevent a rope or other ligature from being passed through and attached.

f) The shower water handles in patient rooms 112, 114, 115, and 119 were exposed and could be used to attach a rope or other ligature.

A review of the Environmental Safety Check Log (Geriatric Wing) for the month of January 2020 revealed no identified environmental safety concerns in the four private patient rooms or in the four semi-private patient rooms.

An interview and walk through tour was conducted on 1/8/2020 at 2:00 PM with Employee Identifier (EI) # 6, New Day Manager, who confirmed the ligature risk in each of the above listed patient rooms.



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2. On 01/07/2020 at 9:20 AM, a tour of the New Day Adult Behavioral Health Unit was conducted with EI # 3, RN, Infection Control Manager, and the below observations were made confirmed:

a) All doors in the adult unit including patient room doors hinges, rooms 121, 122, 123, 124, 125, 126, 129, 127 (seclusion room bathroom door), 130, 131 were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

b) Patient room 124 had a cracked bathroom light cover, which was made of hard plastic and could be used as a weapon.

c) Patient room 124 was missing the baseboard under the window, the sheet rock was exposed.

3. On 01/08/2020 at 8:00 AM, during a medication pass observation, the surveyor observed PI (Patient Identifier) # 22 with 2 hospital gowns on, one tied around the neck, a second gown tied at the waist.

a) Patient gowns in use on the Adult BHU had ties, which were a ligature risk.

4. Review of EI # 12, Registered Nurse (RN) New Day personnel file included 2018 and 2019 annual skills check offs for CPI training. EI # 12's last recertification training documentation for CPI Nonviolent Crisis Intervention was completed 5/15/2018.

There was no documentation EI # 12 had current CPI training.

In an interview on 01/09/2020 at 2:20 PM, EI # 6, New Day Manager confirmed all BHU staff were required to have annual CPI training.

Based on review of Medical Records (MR), policy and procedure, and interview with staff it was determined that the facility failed to follow it's own restraint policy for frequency patient evaluations.

This deficient practice affected 1 of 1 MR reviewed with a patient in restraints including Patient Identifier (PI) # 23 and had the potential to affect all patients admitted to this facility.

Findings include:

Policy: Restraints
Effective Date 1/2020

Policy: All patients have the right to be free from restraints or seclusion of any form that are not medically necessary... The term "restraint" includes any physical restraint, mechanical device, material, medication, equipment, or drug that is being used as a restraint...

Patients in medical restraints shall be observed/assessed at intervals not greater than 2 hours...

Assessment to include circulation, hydration needs, elimination needs, level of distress and agitation, mental status, cognitive functioning, skin integrity, nutritional needs, range of motion as indicated.

Changing position and releasing soft restraints will be done at a minimum of every 2 hours...

Restraint documentation: ...

The medical record should include: ...

Assessment of the patient regarding clinical condition may include, level of distress and agitation, mental status, circulation, condition and release of limbs, skin, and attention to hydration, elimination and nutrition at least every 2 hours, or more often if deemed appropriate...

1. PI # 23 was admitted to the Intensive Care Unit (ICU) on 12/22/19 at 6:23 PM with diagnoses including Stab Wound to the Neck, Respiratory Distress, and Surgical Airway.

Review of the Patient Progress Notes dated 12/25/19 at 2:00 AM revealed documentation of restraint reassessment. The next restraint reassessment was not performed or documented until 8:00 AM on 12/25/19, six hours later.

An interview was conducted on 1/9/2020 at 11:30 AM with Employee Identifier (EI) # 2, Director of Quality Assurance/Risk Management, who confirmed the restraint assessments were not performed at least every 2 hours per facility policy.

Based on review of facility policy and interviews, it was determined the facility failed to ensure all areas of the hospital, including the Anesthesia Department participated in the Quality Assessment Performance Improvement (QAPI) activities. This had the potential to negatively affect all patients served by the department.

This deficient practice was observed in the Anesthesia Department.

Findings include:

Subject: Quality Improvement Standards for Perioperative Nursing
Effective Date: August 2005

The goal for quality assurance programs is to improve patient care. Experience has proven that quality cannot be assured, but it can be monitored continuously and improved effectively through a concerted effort by all individuals caring for the patient. Quality improvement is dynamic process that focuses on the evaluation of patient outcomes to determine methods of improving care.

Quality and Performance Improvement Standards for Perioperative Nursing
2005 Standards Recommended Practice, and Guidelines.

... An organization's performance of important functions significantly affects the quality and value of its services.
... bases its evaluation of an institution's Quality/ Performance Improvement activities on:
Designing processes
Monitoring performance through data collection
Analyzing current performance, and
Improving and sustaining improved performance.
... Department initiatives should be systematic, written and communicated to leaders, practitioners and staff.
... Documentation should show that all aspects of care in the department conform to contemporary standards of clinical practice and that data are used to study and improve the quality of care.

An interview was conducted with Employee Identifier (EI) # 17, Certified Nurse Anesthetist, who was responsible for the quality program in the Anesthesia Department, was conducted on 1/8/2020 at 11:30 AM who stated the she/ he does not collect any data or information on anesthetized patient for quality reports nor submit any data to the Quality Coordinator.

An interview was conducted on 1/8/2020 at 3:15 PM with EI # 2, Director of Quality/ Risk Management, who verified there were no reviews or reports received from the Anesthesia Department.

Based on hospital policies and procedure, medical record (MR) review, observations, and staff interviews, it was determined the nursing staff failed to follow orders and department policy:

1) Document daily weights were performed as ordered and affected 1 of 2 Swing Beds records reviewed and included PI (Patient Identifier) # 12.

2) Document care of a midline catheter was completed according to hospital policy and procedure in 1 of 1 midline catheter records reviewed and included PI # 11.

3) Document anatomical location of Haldol IM (intramuscular) injection in 1 of 2 Adult BHU records reviewed which included PI # 13.

4) Start oxygen therapy on an unsampled patient presenting to the Emergency Room (ER) with complaint of chest pain.

This deficient practice did affect PI # 12, PI # 13, PI # 11, an unsampled ER patient, and had the potential to affect all patients under care of this facility.

Findings include:

Policy: PICC (peripherally inserted central catheter) Site Care and Dressing Change
Effective Date: 04/16/2007

Purpose: To outline the steps for providing site care and dressing change...

POLICY...At least every 7 days....

STERILE DRESSING CHANGE

Equipment:
...StatLock PICC Dressing change kit...or the following:
Alcohol swab
Antiseptics swabs(chlorhexidine is preferred, Povidine Iodine may be used)
Sterile gloves
Nonsterile gloves
Transparent dressing
...Catheter stabilization device...

PROCEDURE

...2....aseptic technique throughput procedure
4. Remove dressing and stabilization device
5. Observe site for redness, swelling or drainage.
8....cleanse the insertion site with antiseptic...Chlorhexidine...alcohol or povidine...repeat x (times) 2
12. Apply transparent dressing...

DOCUMENTATION:
...Procedure
Site observations
...Patient tolerance of procedure....

Policy: PICC injection cap change
Effective Date: 04/16/2007

Purpose: To outline the procedure for injection cap change of PICC lines

POLICY: Injection caps for PICC lines should be changed...or at least weekly....

4. Remove of cap and swipe hub with alcohol
5. Connect new cap...aspirate to ensure catheter patency...irrigate cap

DOCUMENTATION:
1. Date, time of procedure...

Policy: Chest Pain or Myocardial Infarction - Standard of Care
Reference # 2113
Revised: 7/2011

Policy: A patient who arrives at the Emergency Department with chest pain or myocardial infarction may receive the following care: ...

Place patient on oxygen two to six ( 2 - 6 ) liters per minute via nasal cannula, or 10 - 15 liters per minute with mask...

1. PI # 12 was admitted to the Swing Bed Unit from 5/23/19 to 6/12/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition.

MR review revealed nurse orders for daily weights dated 6/5/19.

Record review failed to include documentation that nursing staff completed daily weights following the admitting weight of 297 lbs. (pounds) on 6/5/19.

In an interview conducted on 01/09/2020 at 11:20 AM, EI (Employee Identifier) # 16, Swing Bed Coordinator, confirmed the aforementioned findings.

2. PI # 11 was admitted to the Swing Bed Unit from 6/5/19 to 6/18/19 with diagnoses including Bacteremia, Diabetes Type II, and Diabetic Foot Ulcer.

Review of physician orders dated 6/5/19 at 10:45 AM revealed orders for a midline catheter placement (a central venous catheter inserted peripherally) for intravenous antibiotic administration.

Further record revealed on 6/5/19 at 1:50 PM a midline catheter was inserted with physician orders to change the midline dressing in 7 days and change injection cap every 7 days.

Review of the nurse record documentation dated 6/12/19 at 8:00 AM revealed a midline dressing change was preformed using aseptic technique, a Biopatch was applied over insertion site, then a transparent dressing was applied.

There was no documentation midline catheter insertion site antisepsis was completed with Chlorhexidiene, alcohol or povidine and there was no documentation the injection cap was changed. There was no insertion site assessment documented and no documentation of PI # 11 toleratance of the procedure.

In an interview conducted on 01/09/2020 at 9:20 AM, EI # 16, confirmed the aforementioned findings.

3. PI # 13 was admitted to the Adult BHU on 01/05/2020 at 3:00 PM with diagnoses including Methamphetamine Abuse and Suicidal Ideation.

Review of the MR revealed Haldol Deconate 100 milligram IM was administered without incident on 1/7/2020 at 7:56 AM. There was no anatomical location of the IM injection documented in PI # 13's record.

In an interview conducted 01/09/2020 at 2:10 PM, EI # 6, New Day Manager confirmed the above finding.




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4. On 1/7/2020 at 2:28 PM an observation of care provided was observed on an unsampled patient who presented to the Emergency Room (ER) complaining of chest pain.

The patient was promptly taken to a treatment room by nurse. The vital signs and pulse oximetry were obtained, the patient was placed on cardiac monitor, EKG (Electrocardiogram) was performed, an intravenous access was performed and a blood sample was obtained.

The nurse failed to place the patient oxygen per ER policy.

An interview was conducted on 1/7/2020 at 3:05 PM with EI # 5, ER Manager who confirmed that the patient should have been placed on oxygen on arrival per ER policy for a patient presenting with chest pain.

Based on observations, hospital policy and staff interview, it was determined the staff failed to ensure the patient medication bins on the New Day Adult Behavioral Health Unit were locked when not in a secured area. This had the potential to negatively affect all patients admitted to the Adult Behavioral Health Unit (BHU).

Findings include:

Policy: Access to Medications/Controlled Substances Storage Areas
Effective Date: 05/01/2008

Policy: Only authorized personnel may have access to secure areas where medications and/or controlled substances are stored.

Secure areas are defined as those areas of medication storage which are restricted to authorized personnel. These areas include include...medication storage areas on nursing units...

Narcotic cabinets and medication carts are locked except during medication administration when the cabinet or cart is under supervision of the nurse...

On 01/07/2020 at 11:15 AM, the surveyor observed the Adult BHU patient medication bins on the counter in the nursing station. The medication bins were unattended. The surveyor observed the medication bins were not locked.

In addition, hospital staff entered and exited the Adult BHU from the nursing station. There were non-nursing staff observed in the nursing station where the medication bins were stored and included Security staff, Mental Health Technicians, Counselor and Activity Therapist.

The hospital failed to ensure medications were stored in secure environment to prevent tampering and/or medication removal from the BHU.

During an interview on 01/07/2020 at 11:30 AM, Employee Identifier # 3, Registered Nurse , Infection Control Manager confirmed the medication bins were not locked and not in a secure area.

Based on review of radiology staff personnel files, job descriptions and interview, it was determined the hospital failed to ensure all required staff were equipped to respond to patient/staff emergencies within the department by allowing radiology staff not to have current Cardiopulmonary Resuscitation (CPR) certification. This could negatively affect all patients receiving radiology services at the hospital, staff and visitors.

Findings include:

During a tour of the hospital radiology facilities on 1/8/2020 at 11:30 AM, EI (Employee Identifier) # 13, Director of Imaging, reported all radiology staff should be CPR certified.

Review of job descriptions for Mammography Imaging Service Technologist and MRI Manager/Technician revealed the employees will initiate basic life support action when necessary.

Review of 2 of 3 radiology personnel files for Mammography Imaging Service Technologist, date of hire 08/21/2000, and MRI (magnetic resonance imaging) Manager/Technician, date of hire 10/15/1998, revealed no documentation of current CPR certifications.

An interview was conducted on 01/09/2020 at 2:55 PM with EI #15, Executive Assistant, who confirmed the above findings.

Based on observations of the dietary department on 1/7/2020 it was determined the facility ensure the food items were stored properly, unexpired and in a clean enviroment.

This had the potential to negatively affect all patients served by this facility.

Refer to A 619 and A 621.

Based on United States Health Public Food Code 2009 regulations, facility policy and procedures, observations and interview, it was determined the hospital failed to ensure:

a. Food was stored in a safe and sanitary manner

b. Food items were labeled once opened with date opened and food product name

c. All expired food products were removed once expired.

d. Freezers were defrosted per dietary policy.

e. Stove hood and stove were without grease.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

Policy: Defrosting Freezers
No Policy Number
Effective Date: February 2018

Procedure:

Upright Freezer:
They (The) upright freezer will be defrosted once a month by a department supervisor or cook. All food will be removed to the walk-in freezer until defrosting is complete...

Policy: Food Storage:
No policy number
Effective Date: 3/2018

Policy: To provide and effective storage program for food and supplies in Dietary.

Procedure:
Dry Storage:

8. Any dry items (after opening) are properly stored in sealable containers with date and time. These products will be disposed of after thirty (30) days of opening date.

Perishable Storage:

...18. Any open containers will have contents listed and date and time written on it and be disposed of after 3 days.

A tour of the Dietary department was conducted on 1/07/2020 at 9:15 AM with Employee Identifier (EI) # 9, RN (Registered Nurse), Electronic Health Record Nurse, revealed the hood over the stove contained grease drops over a large area of the hood and thick grease was also observed down the side of the the stove area. In the dry storage area the following open food items with no label to indicate what type of food, the date opened or expiration dates on items:

9 - 26 ounce (oz) containers Morton Salt with no expiration date on container
11 - 36 oz boxes iodized table salt no expiration dates
3 - 15 oz packs of Sloppy Joe mix with no expiration dates
1 - 15 oz half a pack Sloppy Joe mix opened and wrapped in clear wrap with no date opened.
19 - 16 oz Instant cheese sauce mix with no expiration date.
6 - 13 oz Brown gravy mix with no expiration date.
1 - 13 oz half of pack brown gravy mix opened and wrapped in clear plastic with no open date.
2 - 7 oz Aujus gravy mix no expiration date.
6 - 24 oz packs white gravy mix no expiration date
1 - 4 oz pack Butter Buds no expiration date
1 - 40 oz Hash Brown Potatoes opened and open date written as use by 1/23/2019. This item was expired as of 1/23/19 and should have been removed from the shelf.
1 25 pound (lb) white rice half a bag opened and not sealed closed and no use by date.
2 - 6 lb sliced pineapple cans with no expiration date
1 - 6 lb crushed pineapple cans no expiration date
1 - 16 oz container Alfredo sauce no expiration date
1 - 5 lb bag white noodles no expiration date
3 - large bags no salt cracker crumbs no expiration date
1 - large bag of spaghetti noodles no expiration date
1 - opened pack of spaghetti noodles marked with use by date of 12/6/2019.
94 - double packs saltine cracker no expiration date
100 - individual packs of saltine crackers no expiration date.
1 - 7 lb 5 oz box honey graham crackers no expiration date.
4 - 1 lb bags vanilla wafers no expiration date.
100 - individual wrapped honey graham crackers no expiration date.
1 - 35 lb bottle cooking oil opened approximately 1/4 bottle left with no open date.
1 - 35 lb bottle vegetable frying oil no expiration date.
11 - 20 oz gelatin mix bags no expiration date.
1- 16 oz bottle Cayenne pepper open and no open date.
1 - 35 oz meat tenderizer opened and no open date.
1- 21 oz garlic powder opened and no open date.
1 - 18 oz ground black pepper opened and no open date.
1 - 18 oz ground cinnamon opened and no open date.
1 - 19 oz garden seasoning opened and no open date.
1 - 18 oz Spanish Paprika opened and no open date.
1 - 28 oz Lemon Pepper opened and no open date.
1 - 18 oz whole sesame seeds open and no open date.
1- 9 oz yellow mustard opened and no open date.
1- 26 oz Morton Salt opened and no open date.
1 - 11 oz parsley flakes opened and no open date.
1 - gallon Kikoman soy sauce open and no open date.
1 - 61 oz sesame oil opened and no expiration or no open date.
8 - 16 oz jars beef flavored base no expiration date.
1 - cream of chicken soup base opened and no expiration date or open date.
1 - 16 oz jar creamy peanut butter expired.
4 - 25 lb deli breading no expiration date.
13 - 0.63 oz packs of rice crispy cereal no expiration date.

Walk In Cooler:
9 - 12-16 oz packs sliced turkey no expiration date.
1 - 5 lb pack pasteurized cheese slices opened and no open date.
5 - 5 lb cheese loaf no expiration date.

Walk in Freezer:

1 - box sausage patties opened and no open date.
1 - box skinless fish fillets opened and no open date.

Upright Freezer:

1 - 1.5 quart vanilla ice cream with clear wrap and no open date.
1 - pack of blue berries opened and wrapped in clear plastic no no open date.
4 - rolls in zip lock bag with no open date or lable of what food was in the bag.
1 - zip lock bag of cinnamon rolls with no open date.
1 - Gallon zip lock bag with meat no label for type of meat or no open date.
1 - bag boneless chicken breasts with no label of what the food was and no open date.
1 - zip lock bag of dough no label for what the food was and no open date.
1 - gallon zip lock bag of with no label of what the food was or an open date. Food appeared to be possibly ingredients for chicken pot pie.
1 - pack skinless chicken breasts with clear wrap with no label for the food or open date.
1 - half a bag of some type of breaded meat with no label for the food or open date.
1 - half a gallon bag with frozen ham pieces with no label for the meat or open date.
1- gallon bag with sweet potatoes patties with no label for food or open date.
2 - half a bag of hash rounds no open date.
1 - half a bag of french fries with no open date.
1 - bag chicken fried steaks with no label for meat or open date.

An observation of the upright freezer was conducted on 1/7/2020 at 10:30 AM with EI # 9. The freezer was found to be full of frost and ice and covering some of the frozen items in the freezer. EI # 10, Dietary Manager, approached the freezer and the surveyor pointed out the large amount of frost on the inside of the freezer and EI # 10 stated "yes it does need defrosting." When asked how long it has been since the last time it was defrosted EI # 10 replied "its been awhile and should have been done."

An interview was conducted on 1/7/2020 at 10:45 am with Employee Identifiers (EI) # 9 and EI # 10 who confirmed the above mentioned findings.

Based on review of medical records (MR) and interview, it was determined the hospital failed to ensure the dietitian performed a dietary consult according to physician's order in 1 of 2 Swing Bed records reviewed. This affected PI (Patient Identifier ) # 12 and had the potential to negatively affect all patients admitted to this hospital.

Findings include:

1. PI # 12 was admitted to the Swing Bed Unit from 5/23/19 to 6/12/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition

Review of the physician orders dated 5/31/19 revealed orders for a dietary consult, reason for consult was weight loss.

MR review failed to include documentation the RD performed a dietary consult.

In an interview conducted on 01/09/2020 at 11:20 AM, Employee Identifier # 16, Swing Bed Coordinator, confirmed the aforementioned finding.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on the hospital document titled, Accu-Chek Inform II System Cleaning guidelines, observation and interview, it was determined the hospital failed to ensure staff followed the cleaning guidelines for the Acc-Chek glucometer in 1 of 2 observations of care and the staff followed hospital guidelines for hand hygiene and glove change during observations. This had the potential to negatively affect all patients admitted to the hospital and staff.

Findings include:

Accu-Chek Inform II System Cleaning guidelines

...Meters are to be cleaned daily before use and cleaned and disinfected between patients.

...Meters are cleaned using the Super Sani cloth...when you have performed a patient test.

Policy: Hand Hygiene- CDC (Center for Disease Control and Prevention) Guidelines

Purpose: to provide guidelines for effective hand hygiene, in order to prevent transmission of bacteria, germs and infections.

Policy: All staff should use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use non-antimicrobial soap and water, and antimicrobial soap and water or alcohol-based hand rub:

When hands are soiled
Before each patient encounter...
After coming in contact with patient's intact skin...
After working on a contaminated body site and then moving to a clean body site...
Always after removing gloves or facemask...

1. On 01/07/2020 at 11:35 AM in the New Day Adult BHU (Behavioral Health Unit), EI (Employee Identifier ) # 11, New Day, Registered Nurse, performed blood glucose testing on an unsampled patient. EI # 11 retrieved the Accu-Chek II meter from the docking station, tested the unsampled patient's blood glucose, disposed of the sharps and blood strip, then replaced the Accu-Chek Inform II back onto the docking station.

EI # 11 failed to disinfect the Accu-Chek Inform II meter using the Super Sani cloths after use.

In an interview on 01/09/2020 at 2:10 PM, EI # 6, New Day Manager, confirmed staff failed to follow hospital policy and clean the glucose meter after use.



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2. On 1/8/2020 at 9:20 AM observations were conducted on the medical surgical floor to observe medication administration.

During the observation EI # 18 entered the patient room and explained to patient about each medication as he/she scanned the medication. After completion of scanning the medications and the patient's identification bracelet EI # 18 donned gloves and did not sanitize hands prior to donning the gloves.

On 1/8/2020 at 10:00 AM EI # 19 was observed administering medications. EI # 19 removed gloves, opened a Lidocaine patch packet, donned clean gloves and applied patch to the patient. EI # 19 failed to sanitize hands after removing gloves and before cutting open the Lidocaine patch and failed to sanitize hands prior to donning clean gloves.

An interview was conducted on 1/8/2020 at 11:15 AM with EI # 9, RN, Electronic Health Record Nurse, who confirmed the above mentioned findings.

Based on the hospital Rehabilitation policy and procedure, medical records (MR), and staff interview, it was determined the staff failed to update the patient's discharge plan to ensure post discharge needs were met which included use of social services prior to patient discharge.

This affected 1 of 2 Swing Bed records reviewed and included PI (Patient Identifier) # 12 and had the potential to negatively affect all patients admitted to swing bed unit.

Findings include:

Policy Title: Social Services
Effective Date: 11/1/2016
Department: Rehabilitation Program

POLICY:

1...Rehabilitation Program shall provided medically-related Social Services to attain the highest practical physical, mental, and psychosocial well-being of each patient/family/significant other and staff members. These services shall serve as the linkage between the treatment process and the pre-admission process through follow-up after discharge.

2. "Medically-related social service" means services provided by the facility's staff to assist patients in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs.

3. The Care Manager or designee at Dale Medical will be responsible for the following and may consult with LSW (licensed social worker) from New Day as needed:

...Maintaining contact with family...to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning;

...Making referrals and obtaining services from outside entities...

Discharge planning services(e.g. (for instance), helping to place a patient on a waiting list for community congregate living...assisting with transfer arrangements to other facilities);

Finding options that meet the physical and emotional needs of each patient...

1. PI # 12 was admitted to the Swing Bed Unit from 5/23/19 to 6/12/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition.

Record review revealed the following Case Management Referrals documentation:

On 5/23/19 at 9:19 AM, "Home Health Agency, has already been referred to DMC (Dale Medical Center) HHN (home health nurse) for Home Care upon D/C (discharge). At 10:39 AM, ..."Consent for treatment, Rights and responsibilities. Pt (patient) had no questions or concerns. Plans were for pt to go to the nursing home for rehabilitation, but pt's. son did not complete the paperwork."

On 5/24/19 at 11:00 AM, "...IDT (interdisciplinary team) meeting...evaluated by PT (physical therapy) and OT (occupational therapy) ...receiving Ensure with all three meals...moderate protein malnutrition...will be d/c...DMC HH. No other concerns."

On 5/28/19 at 11:53 AM, "...IDT meeting...continues to receive PT and OT....continues to get Ensure...no skin issues. At d/c pt will go home with HH. (home health)..."

On 6/3/19 at 3:27 PM, " Made 2 attempts by phone to have a care plan meeting with pt's son. No answer. Left message...to cal me at his earliest convenience. Pts d/c date is...June 12, 2019."

On 6/4/19 at 7:59 AM, "...IDT meeting held with (contacted rehabilitation services director) Pt is supervision on all...ADL's (activities of daily living)...ensure with meals...pt...working with OT and PT. No skin breakdown...d/c date is 6/12/19...with DMC HH..(neighbor's name) will be here on 6/12/19 to pick him/her up." At 8:31 AM, "...son called...advised...nurse...(neighbor) will be here on 6/12/19 to pick (pt) up." At 8:34 AM, "...advised son that d/c with DMC HH....thanked me for updating...status. No other questions at this time." 12:34 PM, "... will D/C to home...Pt and HHN aware that...does live alone and needs intervention from LBSW (licensed...social worker) to assure family is involved with care and that if needed DHR will be contacted to further assist as needed."

On 6/11/19 at 9:20 AM, "IDT meeting...will be d/cd 6/12/1 with HH...Pt's neighbor...will be picking pt. up. Pt's children both live outside of the state...."

Record review revealed documentation the neighbor picked up PI # 12 at the hospital and PI # 12 was discharged home on 6/12/19.

Further MR review revealed a typed letter dated 6/14/19, 2 days after PI # 12's hospital discharge, completed by the hospital's discharging physician, addressed to the local Department of Human Resources. The letter stated PI # 12's son, (the Power of Attorney), failed to return calls and complete skill nursing facility paperwork during the last hospital admission 5/8/19 to 5/23/19. This admission, 5/23/19 to 6/12/19, physical and mental capabilities were discussed with pts' son and again he would not do anything to help. We had no choice but to discharge back to home. It is my opinion, PI # 12 needs the care of a skill nursing facility for medical and physical needs and the family is not capable of caring for the patient at home and (I) ask that a guardian be appointed.

There was no documentation of any social service contact (there were 2 social workers assigned to the Behavioral Health Units) performed prior to PI # 12's hospital discharge back into the home setting.

There was no documentation PI # 12's original discharge plans home with HHC was re-evaluated after the Swing Bed staff determined the family was not able and/or willing to provide for PI # 12's care needs at home.

In an interview conducted on 01/09/2020 at 11:20 AM, Employee Identifier # 16, Swing Bed Coordinator, confirmed the above finding and stated no social workers had been assigned to assist with Swing Bed patient care

Based on review medical records (MR) and staff interview, it was determined the hospital failed to ensure PT (physical therapy) treatments were provided according to physician orders in 1 of 2 Swing Bed records reviewed. This affected PI (Patient Identifier) # 12 and had the potential to negatively affect all Swing Bed patients admitted.

Findings include:

1. PI # 12 was admitted to the Swing Bed Unit from 5/23/19 to 6/12/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition.

Review of physician orders dated 5/23/19 at 9:30 AM included PT evaluate and treat.

Review of the PT Plan of Care (POC) dated 5/23/19 and signed by the physician revealed PT treatments ordered 6 times a week for 4 weeks.

Review of a PT Addendum Note dated 6/7/19 revealed the PT treatment frequency was decreased from 6 days per week to 5 days per week. There was no signed physician order to decrease the PT treatment frequency in the MR.

In an interview conducted on 01/09/2020 at 11:20 AM, Employee Identifier # 16, Swing Bed Coordinator, confirmed the above finding.

This condition is not met based on review of hospital policies and procedures, medical records, and interview, the Rehabilitation Program Staff failed to meet the needs of patients admitted to swing beds.

Findings include:

Refer to A 1562 and A 1564 for findings.

Based on review of hospital Rehabilitation program policies and procedures, Dale Medical Center Rehabilitation Program Patient Orientation Packet, medical records and staff interviews, it was determined the staff failed to follow their own rehabilitation program services and ensure:

a) The Interdisciplinary Team (IDT) developed a comprehensive care plan for each Swing Bed patient and revised the care plan weekly.

b) The IDT meetings included all disciplines who provided patient care and documented patient status and progress on the Weekly Interdisciplinary Team meeting form.

c) The Rehabilitation Program included activities which were directed by a trained and qualified Activities Director.

This affected 2 of 2 Swing Bed patient records reviewed, PI (Patient Identifier) # 12, PI # 11 and had the potential to negatively affect all Swing Bed patients.

Findings include:

Policy: PPS (prospective payment system) Comprehensive Care Plan
Effective Date: 11/1/2016
Department: Rehabilitation Program

POLICY:

The Interdisciplinary Treatment Team, in conjunction with the patient, family...shall develop a comprehensive care plan that includes measurable objectives and timetables to meet the patient's medical, nursing, rehabilitation, and psychosocial needs.

Procedure:

1. An initial care plan will be initiated by the licensed nursing staff on admission and added to as needed when new potential or actual problems are identified.
3. The PT (physical therapy), OT (occupational therapy), SLP (speech language pathologist), Dietician, RT (respiratory technician) will develop discipline plan and add (the) treatment plan to the initial nursing plan as appropriate once they have completed their comprehensive assessments.
5. Patient discharge goals will be determined during the initial IDT and the care plan will be reviewed at this time and weekly thereafter to ensure that all identified issues are documented and care planned.
6. Nursing will document to the care plan problems on a daily basis.
...

Policy: Interdisciplinary Team (IDT) Process
Effective Date: 11/1/2016

Department: Rehabilitation Program

POLICY:

The program will have an identified IDT to ensure a comprehensive approach to the patient medical and/or rehabilitation needs ...

There will be a pre-determined scheduled IDT meeting on set days and time twice per week to allow for a first IDT within 2-3 days of admission and weekly thereafter.

Team members may include:
Care Manager/Social Worker
Therapists (PT [physical therapy/OT [occupational therapy]/SLP[speech language therapy
Nurse Manager
Respiratory Therapists (RT)
Pharmacist
Dietician or representative
Physician caring for the patient
...

Procedure:
1. Each discipline will complete a discipline specific admission assessment to include therapy ...as ordered ...within 4 to 48 hours of admission based on the discipline.
...3. The patient and family will be informed about the IDT process ...availability of the IDT to meet with the patient...
4. At the IDT meeting, the Care Manager will ...start ...the discharge planning assessment...
5. Each discipline included will share the outcomes of the discipline specific assessment and treatment plan with the team.
6. The IDT members will then discuss skilled needs ...agree on key functional and measurable discharge goals, discharge disposition and the estimated length of stay.
7. The Care Manager will meet with the patient/family following the initial IDT meeting to discuss outcome and discharge goals ...
8. There will be a weekly IDT meeting ...to discuss progress, make changes in the treatment or discharge plan ...to ensure a clinically strong ...program.
9. The Care Manager will meet with the patient/family weekly ...post each IDT ...update ...on progress ...and/or discharge date.
11. The Case Manager starts the review of each patient care by giving a ...overview of the patient ...
12. The Care Manager will then lead the team in reporting their findings based on discharge goals to determine readiness. This meeting will ...serve to discuss ...other services the patient may need during the program or post discharge.
13. Any ...issues which may impact the discharge plan will be documented on...the IDT form.
16. The care plan will be revised weekly as part of the IDT process...incorporated into the team meeting. This revision of the care plan must occur weekly...based on the IDT review...

Policy: Patient Orientation
Effective Date: 11/1/2016
Department: Rehabilitation Program

POLICY:

Each patient...will receive an orientation to...to ensure that they will be informed...comfortable...

Procedure:

3. An oral summary along the written documentation...will be given to the patient as an Orientation Packet:

c. List of services
g. List of available activities...

Rehabilitation Program at Dale Medial Center

Patient Orientation Packet

...List of Patient Services

Activities

The Rehabilitation Coordinator will evaluate your leisure needs, abilities, and interests....A cart of activities will be offered to you at least twice a day every day of the week...

1. PI # 12 was admitted to the Swing Bed Unit from 5/23/19 to 6/12/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition.

Record review revealed an initial nurse interview completed 5/23/19, a nursing physical assessment completed 5/23/19, a PT POC developed/dated 5/23/19, and an OT POC developed/dated 5/24/19 at 12:51 PM.

Review of the Case Management Note documentation dated 5/23/19 at 11:03 AM revealed "Pt (patient) enjoys watching TV, drinking her/his coffee and taking strolls in the yard to look at his/her flowers" which was PI # 12's activity assessment.

Review of the Weekly IDT Meeting documentation dated 5/24/19 (no time documented) failed to include PT and OT discipline specific patient treatment plan documentation. There was no documentation the PT and OT participated in the IDT process. There was no patient activity participation and no level of participation for activities documented.

Record review revealed a "Care Plan" verified (dated) 5/25/19, which included Nursing Diagnoses for Potential for Activity Intolerance, Alteration in Comfort (pain) and Potential for Falls. There was no initial comprehensive plan of care in the medical record.

Record review revealed physician orders dated 5/27/19 at 4:10 PM for Atrovent respiratory inhalation nebulizer and Xophex inhalation nebulizer, use as needed.

Review of Respiratory Therapy (RT) documentation dated 5/27/19 at 12:15 PM, 6/7/19 at 7:20 AM and 6/8/19 at 9:10 AM revealed the above nebulizer treatments were provided. There was no RT care plan documented.

Record review revealed additional physician orders dated 5/31/19 for a dietary consult. There was no update to the care plan regarding nutritional needs.

Review of the MR from 5/23/19 to discharge on 6/12/19 revealed on 6/1/19 at 8:00 AM the Licensed Practical Nurse documented "Today I got patient up to nurse station desk for lunch. He/she sat and socialized for approximately 2 hours. She/he read magazines, listened to music and conversed with staff. Patient reports having the best day ever." There was no other record documentation that activities were offered to PI # 12 during the Swing Bed stay.

Review of the Weekly IDT Meeting documents dated 5/31/19, 6/4/19 and 6/11/19 failed to include PT and OT discipline specific patient treatment plan documentation. There was no documentation PT and OT participated in the IDT process. There was no documentation the dietician and the RT were included in the Weekly IDT Meeting. There was no documentation of the response to the respiratory treatments. There was no documentation of patient activity participation and no level of participation for activities documented.

In an interview conducted on 01/09/2020 at 11:20 AM, EI (Employee Identifier) # 16, Swing Bed Coordinator reported there was no scheduled weekly IDT meetings that included the OT and PT. EI # 16 confirmed the weekly IDT documentation failed to include PT/OT/ RT documentation and there was no comprehensive plan of care developed/updated.

In addition, EI # 16 reported the nursing staff were supposed to offer daily activities. EI # 16 confirmed there was no follow up to ensure the dietary consult was completed.

2. PI # 11 was admitted to the Swing Bed Unit from 6/5/19 to 6/18/19 with diagnoses including Bacteremia, Diabetes Type II, Diabetic Foot Ulcer. There were physician orders dated 6/5/19 for IV Vancomycin, wound care, Contact Isolation precautions, and daily weights.

Record review revealed an initial nurse interview completed 6/5/19, a nursing physical assessment completed 6/5/19, a PT POC developed/dated 6/6/19, and an OT POC developed/dated 6/6/19.

Record review revealed a "Care Plan" not dated, printed 6/5/19 which included Nursing Diagnoses for Infection, Alteration in Comfort, Impaired Physical Mobility, and Impared Skin Integrity. There were no measurable goals documented. There was no initial comprehensive plan of care in the medical record.

Review of the Weekly IDT Meeting documentation dated 6/7/19 failed to include PT and OT discipline specific patient treatment plan documentation. There was no documentation the PT and OT participated in the IDT process. There was no patient activity participation and no level of participation for activities documented.


Review of the Weekly IDT Meeting document dated 6/11/19 failed to include PT and OT discipline specific patient treatment plan documentation. There was no documentation PT and OT participated in the IDT process. There was no documentation of patient activity participation and no level of participation for activities documented. There was no documentation of wound progress and no follow up for daily weights/nutritional status.

Review of the MR from 6/5/19 to discharge on 6/18/19 revealed no documentation activities were offered to PI # 11 during the Swing Bed stay.

In an interview on 1/8/2020 at 9:20 AM, EI # 6 confirmed the above findings.

Based on medical record review, hospital policy and interview, it was determined the hospital failed to ensure staff informed all patients timely using the completed written notice of discharge and documented the effective date of Swing Bed unit discharge.

This affected 1 of 2 Swing Bed records reviewed and included PI (Patient Identifier) # 12 and had the potential to negatively affect all Swing Bed patients admitted to Dale Medical Center Rehabilitation Program.

Findings include:

Policy: Notice of Planned Discharge
Effective Date: 11/1/2016

POLICY:

It is the policy of Dale Medical Center Rehabilitation Program to provide clear, consistent and accurate information to our patients to any planned discharge home or to a lesser care environment. We want to assure adequate time for planning and preparation to facilitate a smooth discharge...

Procedure

2. Notice shall be given to a patient...as soon as practical. This may occur following the initial or subsequent Interdisciplinary Team Conference. Sufficient time (generally no less than 3 days prior to planned discharge) should be provided to prepare and orient patient to a safe and orderly discharge from the facility...

4. Written notice will be provided to patient...
7. A copy of the signed "Notice of Medicare Non-Coverage" will be maintained in the Medical Record.

1. PI # 12 was admitted to the Swing Bed Unit on 5/23/19 with diagnoses including Generalized Debility, Fracture of Coccyx and Moderate Malnutrition and was discharged home on 6/12/19.

Record review revealed a Notice of Medicare Non-Coverage. There was no effective date for the current skilled nursing facility services coverage end documented and no date was documented when the Notice of Medicare Non-Coverage was provided to PI # 12.

In an interview conducted on 01/09/2020 at 11:20 AM, Employee Identifier # 16, Swing Bed Coordinator, confirmed the above findings that was her/his oversight.

Based on review of medical records (MR), facility policy, and interview with staff it was determined the facility failed to ensure the initial psychiatric evaluation was completed by a qualified psychiatrist and in the MR within 24 hours of admission.

This deficient practice affected 1 of 2 records reviewed in the New Day Geriatric Behavioral Unit (BHU) including Patient Identifier (PI) # 15 and 1 of 2 Adult BHU records reviewed and included PI # 13.

This had the potential to negatively affect all patients admitted to the psychiatric unit.

Findings include:

Policy: Psychiatric Evaluation
Reference # 3026
Reviewed: 9/7/2012

Purpose: To ensure the physical and psychiatric needs of the patient are assessed by a psychiatrist.

Policy:

1. The psychiatric evaluation should be completed and in the patient's medical record within twenty four (24) hours of admission...

1. PI # 15 was admitted to the Geriatric Unit on 1/4/2020 at 3:00 PM with diagnoses including Bipolar Disorder and Chronic Obstructive Pulmonary Disease (COPD).

A review of the MR on 1/7/2020 at 9:30 AM revealed no documentation of a Psychiatric Evaluation.

An interview was conducted on 1/9/2020 at 5:00 PM with EI # 6, New Day Manager, who confirmed the psychiatric evaluation on PI # 15 was not completed withing 24 hours.






30952

2. PI # 13 was admitted to the Adult BHU on 01/05/2020 at 3:00 PM with diagnoses including Methamphetamine Abuse and Suicidal Ideation and left Against Medical Advise on 01/07/2020.

Review of the MR on 01/07/2020 at 3:20 PM failed to include documentation of a physiatrist evaluation and a psychiatric evaluation had not been dictated or available for the BHU staff's review.

On 01/09/2020 at 10:30 AM, review of the MR revealed a psychiatric evaluation, dictated 01/07/2020.

During an interview on 01/09/2020 at 2:10 PM, EI # 6, New Day Manager confirmed the psychiatric evaluation was completed greater than 24 hours and not in compliance with the hospital policy.