HospitalInspections.org

Based on observations, review of facility environmental round documentation, policy and procedure and interviews, it was determined the facility staff failed to ensure:

1) oxygen tanks were stored securely.

2) patient room bathroom mirrors were not broken and were free of sharp edges.

3) electrical outlets were covered.

4) there was no peeling paint in the seclusion rooms.

5) the dryer vent was cleaned after every use.

6) outside fences were in good condition.

7) plumbing around toilets in the patient bathroom rooms were covered and not exposed.

8) patient monitoring was completed and documented according to facility policy.

This affected Patient Identifier (PI) # 3, # 1 and # 2 , 3 of 3 active patient records reviewed and had the potential to affect all patients treated at the facility.

Findings include:

Policy #: CTS 5.03
Subject: One to One, Q (every)-15, and Q 30 (Routine) Observations
Revised: 12/17

POLICY:

"When a consumer is unable to function within the structure of the program due to acting out behaviors....and/or verbalizing intention of harming self/others...One to One (1:1), Q (every) 15 minute and Q-30 (Routine) Observations may be ordered as a safety measure.

One to One Observation (1:1)

When a consumer is placed on one to one...status, it is typically because he/she had verbalized intentions of harming himself...

Procedure:

A. 1:1 Observations

1. There are two types of 1:1 Observation; 1:1 Routine and 1:1 Two Arms-Length:

a. 1:1 Routine-Employee must keep consumer within constant visual observations and within auditory contact at all times. The employee must remain within a safe distance/close enough to the delegated consumer and be immediately available to protect the safety of the consumer, peers and staff.
d. When a consumer is on 1:1 observation for suicide precautions, the consumer's hands, head and shoulders must be visible at all times.
e. Document on the Precautions Record form every 15 minutes via the IPAD.

B. Q-15 Minute Observations

Q-15 minute observations means a consumer is to be monitored by staff at least every 15 minutes...the location, activity and behaviors should be documented every 15 minutes...

Procedure:

1. Employee must locate consumer at least once every 15 minutes and document required information on the Precautions Record form. It is extremely important to document what the consumer is doing and to note behavioral observations on this form...

D. Grace Periods for close Observations Monitoring Documentation

The documentation of close observations should be written contemporaneously or at the time of, or as close to, the monitoring described in the medical record. In the event that consumer variable exist... the staff member becomes involved...or is the sole documentor for more than one consumer on the unit..."grace periods" may be utilized:

1. One to One observations- the monitoring outcome may be documented at the time of or within 5 minutes of the required observation time.
2. Q 15 Minute observations-the monitoring outcome may be documented at the time of or within 8 minutes of the required observation time..."

****

During a tour of the facility children and adolescent units on 6/19/18 from 11:00 AM to 1:30 PM, Employee Identifier (EI) # 4, Registered Nurse (RN), Nurse Coordinator accompanied the surveyor and the following observations were made:

A portable oxygen tank in the medication room on the 600 hallway placed on top of the Emergency cart and was not stored securely.

Patient room 508 bathroom mirror was cracked and had uneven/sharp edges.

There was an uncovered electrical outlet in the common bathroom on the 600 hallway.

There was peeling paint on 3 of the 5 walls in seclusion room # 1 and peeled paint on the floor.

There was peeling paint on 3 of the 5 walls in seclusion room # 2.

The dryer vent in the laundry room contained lint and paper. There was a sign posted on the laundry room door which read, " Please make sure that the dryer lint trap is cleaned after every use". Staff failed to complete the task as required.

The courtyard chain-link fence outside the boys unit was 8 foot high according to EI # 4 and was missing the right overhang portion which connected the facility building and fence overhang.

During the facility tour on 6/19/18 at 1:30 PM, EI # 4 verified the findings above.

During a tour of the facility children and adolescent units on 6/19/18 from 2:50 PM to 3:15 PM with EI # 9, Assistant Director, revealed exposed plumbing around toilets in the patient's rooms 610, 611, 612, 613 and 615.

The facility staff failed to cover exposed plumbing that pose a ligature risks for patients.

An interview was conducted on 6/19/18 at 3:16 PM with EI # 9, who confirmed the above findings.

****

On 6/21/18 at 10:30 AM, review of the facility Environment of Care Inspection Checklist for Performance Improvement dated 6/14/18 revealed "508-new mirror needed with screws" and the 6/14/18 Environment of Care Inspection minutes included documentation "508 needs a new bathroom mirror, maintenance to correct issues".

There was no documentation regarding the missing fence overhang and exposed bathroom plumbing.

Review of the BayPoint Environmental Care Checklists completed daily by the Behavioral Unit Technicians revealed on 6/18/18 and 6/19/18 there was no chipped paint on the walls as documented by the facility staff.

In an interview on 6/21/18 at 12:15 PM, EI # 1, Director of Nursing confirmed the aforementioned findings.

****

Medical record review revealed the following:

1. PI # 3 was admitted to the facility on 6/12/18 at 10:27 AM with diagnoses including Post Traumatic Stress Disorder and Major Recurrent Depression.

Review of the Client Profile-Orders Detail dated 6/12/18 at 11:29 AM revealed orders for Observations/Precautions Q (every) 15 minute observations, unpredictable behavior.

Review of the documents titled Suicide Severity Risk Scale/Screening dated 6/12/18 and 6/13/18 revealed the suicide risk level and suicide risk score was "high".

Review of the facility document titled, Observations, revealed staff failed to complete and document patient monitoring every fifteen minutes as ordered and per facility policy on 6/12/18 at the following times:

The Observation Times were due at 2:00 PM, 2:15 PM, 2:30 PM, 2:45 PM and staff documentation entries were completed at 3:49 PM, which was greater than 1 hour (hr) after the observation time.

The Observation Times were due at 3:00 PM and 3:15 PM, and staff documentation entries were completed at 3:48 PM, which was greater than 30 minutes after the observations were due.

Review of the 6/12/18 Psychosocial Assessment documentation revealed PI # 3 reports active SI (suicide ideations), Doctor and staff notified, consumer will be placed on 1:1 (one staff to one patient). On 6/12/18 at 4:13 PM the record included Observations/Precautions orders for 1:1 (one staff to one patient) Routine Suicidal.

Review of facility document titled, Observations, revealed the following documentation while PI # 3 was on 1:1 Routine Suicidal monitoring on 6/12/18:

Observation times 4:00 PM (just prior to Routine SI precautions), 4:15 PM, 4:45 PM and 5:00 PM revealed staff completed the documentation of the patient observations at 5:22 PM, which was 22 minutes to greater than 1 hour after the actual observation times were due.

Observation times 5:30 PM, 5:45 PM, 6:00 PM, 6:15 PM and 6:30 PM revealed staff completed the documentation at 6:43 PM, which was 13 minutes to 1 hour 13 minutes after the actual observation times were due.

Observation times 7:15 PM and 7:30 PM were completed by staff at 11:28 PM, which was greater than 4 hours after the observations were due.

In an interview on 6/20/18 at 3:30 PM, Employee Identifier (EI) # 2, Assistant Director of Performance Improvement confirmed staff failed to follow the facility policy and document patient observation/monitoring at or immediately following the actual monitoring.

2. PI # 1 was admitted to the hospital on 6/8/18 with diagnoses including Unspecified Disruptive Impulse Control and Conduct Disorder.

The Client Profile-Orders Detail dated 6/8/18 at 3:04 PM contained orders for Observations/Precautions 1:1 Routine, Highly Aggressive, Autism.

Review of facility document titled, Observations, contained the following documentation while PI # 1 was on 1:1 Routine on 6/9/18:

Observation times 1:30 AM, 1:45 AM and 2:00 AM revealed staff completed the documentation for the 3 patient observations at 2:37 AM, which was 37 minutes to more than 1 hour after the actual observation times were due.

Observation times 3:15 AM, 3:30 AM, 3:45 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:45 AM and 5:00 AM revealed staff documented all 8 at 5:18 AM, which was 18 minutes to more than 1 hour after the actual observation times were due.

Observation times 12:30 PM, 12:45 PM, 1:00 PM, 1:15 PM, 1:30 PM, 1:45 PM and 2:00 PM revealed staff documented all 7 observations at 11:12 PM, greater than 10 hours after the observation times were due.

In an interview on 6/20/18 at 3:30 PM, EI # 3, Hospital Administrator reported there could have been system problems that date and confirmed the findings above. There was no documentation provided the facility had computer system failures on 6/9/18.



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3. PI # 2 was admitted to the facility on 5/4/18 at 2:06 PM with diagnoses including Aggressive Behavior.

Review of PI # 2's medical record on 6/20/18 revealed the following documentation: Oberservation order # / Desc (Description): 786519 dated 5/22/18 at 7:11 AM for Q-15 minute observations.

Review of the facility documentation titled, Observations, revealed staff failed to complete and document patient monitoring every fifteen minutes as ordered and per facility policy on the following observation times:

On 6/2/18 the Observation Times were 8:00 PM, 8:15 PM, 8:30 PM, and 8:45 PM and all documentation entries were completed at 10:02 PM, which ranged from 2 hr 02 minutes to 1 hr 17 minutes after the observations were due.

On 6/18/18 the Observation Times were 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM, 3:15 AM, and 3:30 AM and all documentation entries were completed at 4:04 AM, which ranged from 1 hr 49 minutes to 34 minutes after the observations were due.

On 6/19/18:

The Observation Times were 1:00 AM and 1:15 AM, and all documentation entries were completed at 3:36 AM, which ranged from 2 hr 36 minutes to 2 hr 21 minutes after the observations were due.

The Observation Times were 1:30 AM, 1:45 AM, and 2:00 AM, and all documentation entries were completed at 3:37 AM, which ranged from 2 hr 7 minutes to 1 hr 37 minutes after the observations were due.

An interview was conducted on 6/21/18 at 11:02 AM with EI # 2, Assistant Director of Performance Improvement who confirmed staff failed to follow the facility policy and document patient observation/monitoring at or immediately following the actual monitoring.

Based on observations, review of medical records, policy and procedure and interview, it was determined the facility failed to ensure nursing staff:

1) Were able to access refrigerated controlled medications when needed.

2) Evaluated and documented the therapeutic effectiveness/response to as needed (prn) medications administered.

3) Documented the route and dosage of all medications administered.

This affected Patient Identifier (PI) # 1 and # 2 , 2 of 3 active records reviewed and had the potential to affect all patients treated at the facility.

Findings include:

Policy #: CTS 3.0
Subject: Medication Storage, Control, and Assistance and Administration
Update: 3/22/18

...Procedure:

A. Medication Documentation

8....qualified staff must document information related to a consumer receiving prn...medications including name of medication...amount of medication given, time of administration, and results...


A tour of the facility on 6/19/18 at 12:00 PM and medication pass observations was completed. At 12:30 PM, Employee Identifier (EI) # 4, Registered Nurse (RN), Nurse Coordinator was asked to verify controlled substance count for injectable Lorazepam. The facility used a Pyxis medication management system. EI # 4 was unsuccessful accessing the refrigerated lock box from the Pyxis to verify the Lorazepam count.

EI # 4 requested assistance from EI # 6, Licensed Practical Nurse and EI # 7, staff RN who were also unable to successfully access the injectable Lorazepam.

At 1:10 PM, which was 40 minutes later, EI # 5, the Pharmacist was summoned and EI # 5 successfully accessed the Lorazepam and the medication count was verified. EI # 5 reported all staff had received education on use of the Pyxis medication system which included medication access.

On 6/19/18 at 12:45 PM in an interview following the observations, EI # 4, the Nursing Coordinator confirmed no staff present would have been able to retrieve the medication timely in the event an order for STAT (immediate) injectable Lorazepam.

****

1. PI # 1 was admitted to the hospital on 6/8/18 with diagnoses including Unspecified Disruptive Impulse Control and Conduct Disorder.

Review of the Client Profile- Orders Detail included Benadryl injection 12.5 mg (milligram) to 25 mg every 4 to 6 hours as needed (prn) for acute agitation, Cogentin 0.5 mg every 4 hours as needed for Extrapyramidal Symptoms (EPS), and Vistaril 25 mg oral two times as needed.

Review of the Nursing Progress Note dated 6/10/18 7:00 AM-7:30 PM included documentation at 4:13 PM, PI # 1 was swinging hands toward staff, unable to be directed and prn Vistaril 25 mg oral was administered. There was no documentation the RN assessed therapeutic response/effectiveness of the Vistaril.

Further review of the 6/10/18 Nursing Progress Note and eMAR (electronic medication administration record) documentation revealed Cogentin 0.5 mg injection was administered on 6/10/18 at 7:05 PM for EPS. There was no documentation the RN assessed the therapeutic effectiveness/response of the Cogentin.

Review of the Nursing Progress Note dated 6/16/18 7:00 AM-7:30 PM revealed nursing documentation at 10:58 AM that PI # 1 attacked staff two times unprovoked and received Benadryl 12.5 mg IM (intramuscular) to decrease agitation and promote stabilization. There was no documentation the RN assessed the therapeutic effectiveness/response of the Benadryl.

Review of the Nursing Progress Note dated 6/17/18 7:00 AM-7:30 PM revealed nursing documentation at 10:54 AM, PI # 1 attacked staff hitting/ pulling hair and staff administered Benadryl 12.5 mg IM (intramuscular) and at 5:37 PM Benadryl 12.5 mg IM was administered for increased aggression. There was no documentation the RN assessed the therapeutic effectiveness/response of the Benadryl.

In an interview conducted on 6/21/18 at 10:47 AM, EI # 2, Assistant Director of Performance Improvement, confirmed the above findings.



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2. PI # 2 was admitted to the facility on 5/4/18 at 2:06 PM with diagnoses including Aggressive Behavior.

Review of PI # 2's medical record on 6/20/18 revealed the following Current Medication Orders:

Benadryl (Diphenhydramine Hydrochloride) 25 - 50 mg every 4 to 6 hours as needed for Acute Agitation (start date 5/4/18). There was no documented route for Benadryl 25 - 50 mg to be administered in the medication order.

Review of the 5/5/18 eMAR documentation revealed Benadryl 25 mg injection was administered at 6:18 PM. The surveyor requested EI # 2 to provide documentation of the effectiveness/response of the Benadryl. There was no documentation provided to the surveyor that the RN assessed the therapeutic effectiveness/response to the Benadryl.

Review of the 5/29/18 eMAR documentation revealed Benadryl undocumented mg (amount of medication) injection was administered at 8:26 PM. The surveyor requested EI # 2 to provide documentation of the effectiveness/response of the Benadryl. There was no documentation provided to the surveyor of the amount/mg of Benadryl PI # 2 received and that the RN assessed the therapeutic effectiveness/response to the Benadryl.

An interview was conducted on 6/21/18 at 11:02 AM with EI # 2, who confirmed the above findings.

Based on observation, policy and procedure and interviews, it was determined Employee Identifier (EI) # 6, Licensed Practical Nurse failed to ensure all medications were secure from medication preparation until medication administration. This had the potential to affect all patients admitted to the facility.

Findings include:

Policy #: CTS 3.0
Subject: Medication Storage, Control, and Assistance and Administration
Update: 3/22/18

"...Procedure:

E. Medication Storage

1. All medication is to be kept in a locked area...All medication areas are locked when not in use. The keys to the medication areas are kept on the person of an authorized staff member.

2. All medication is to be kept in a locked area, and kept under conditions complying with standards for storage of each medication..."

1. On 6/19/18 at 12:00 PM, the surveyor observed medication passes with EI # 6 on all inpatient behavioral units. EI # 6 removed medications from the Pyxis for nine patients, placed individual medications in patient specific medication cups and placed the prepared medications in a common medication tray then exited the 600 hallway medication room. EI # 6 then placed the medication tray on the nurse station desk next to the Ward Clerk, EI # 12.

EI # 6 exited the nurse station, retrieved unsampled patient # 1 from the pre-adolescent girls unit, entered the exam room, completed blood pressure monitoring. EI # 6 accompanied the unsampled patient # 1 back to the unit, entered the pre-adolescent boys unit and retrieved unsampled patient # 2. EI # 6 accompanied unsampled patient # 2 to the exam room, completed blood pressure monitoring and returned the patient to the boys unit.

EI # 6 then returned to the 600 hallway nurse station, retrieved the medication tray left beside the Ward Clerk, then proceeded to administer the medications.

The prepared medications were left unsecured at the nurse station with non-licensed personnel and not kept in a locked area per policy.

In an interview on 6/19/18 at 1:10 PM, EI # 4, RN, Nurse Coordinator and EI # 5, Pharmacist verified patient medications were not to be left unattended with non-licensed personnel.

Based on a tour of the Dietary Department, interviews, Safety Data Sheet, manufacturer's directions for use, it was determined the Dietary Department failed to:

1. Use chlorine test strips to check sanitizer solution for the dishwasher that were not expired.

2. Store sanitizing solution properly.

This had the potential to affect all people served by the facility.

Findings include:

Safety Data Sheet
Product Name: Solution QA
Recommended Use: Sanitizer
Revision Date 8/20/15

... 7. Handling and Storage
... Protect from freezing. Store locked up. Keep tightly closed in a dry, cool and well ventilated place.

******

Indigo Instruments

"100 Strips

Precision Chlorine Test Paper:

Use dry fingers to remove strip of paper from vial, dip strip into solution to be tested, without agitation and compare immediately with color chart on label. This color indicates approximate strength of the solution in parts per million (p.p.m.) available chlorine.

Time of test - 1 second ..."

******

During a tour of the Dietary Departments conducted on 6/19/18 at 12:40 PM with Employee Identifier (EI) # 10, Food Service Director, and EI # 9, Assistant Director, the following observations were made:

The dietary staff opened a bottle of chlorine test paper strips to check the chlorine solution in the dishwasher per manufacture's directions for use. The dietary staff started the dishwashing process. The surveyor asked EI # 10 for the bottle of test strips used to verify the chlorine solution. The Precision chlorine test papers (lot # 100115) were expired on 1/2018. The staff failed to verify the expiration date on the chlorine test paper strips.

There were open containers of sanitizing solution buckets throughout the kitchen. The staff failed to follow the manufacturer's instructions for storing sanitizing solutions by keeping the solution tightly closed.

An interview was conducted on 6/19/18 at 12:50 PM with EI # 10, who stated the staff should have verified the chlorine test paper strips were not expired. EI # 10 confirmed the above findings.

Based on review of facility policy, observations, and interview with staff it was determined the facility failed to ensure:

1. supplies available for patient use were not expired.

2. document preventive maintenance (PM) inspection on all equipment was performed.

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

Findings Include:

Title: Medical Equipment Management Plan

"The Medical Equipment Management Plan for AltaPointe is designed to assess and control the clinical and physical risks of equipment used for the care of consumers...

Program Goals:

The overall purpose of the Medical Equipment Management Plan will address the safe function of any consumer diagnostic or treatment equipment that has potential of harm to the consumer if it should malfunction ...

Methodology:

The Medical Equipment Management program will have ongoing monitoring to assure identification of real or potential risks of equipment malfunctioning. This will be accomplished through monitoring and evaluation of medical equipment.

Monitoring:

Monitoring will be conducted through the following means:

... Review of annual medical equipment inspections ..."

****

A tour of the Laboratory Department (Exam Room # 1) was conducted on 6/20/18 at 8:29 AM with Employee Identifier (EI) # 4, Nurse Coordinator, and EI # 9, Assistant Director.

The surveyor observed:

There was no documented PM sticker on the EKG (electrocardiogram) machine MAC 1200. The surveyor asked EI # 4, Who perform PM on the hospital equipment? EI # 4 stated, an outside vendor. The surveyor requested the outside vendor's service documentation for the EKG machine. EI # 9 provided the surveyor with the facility's Medical Equipment Management Plan excel spread sheets that was completed by the facility's staff. There was no documentation provided to surveyor for outside PM service performed on the EKG machine.

A Baptist Health rental centrifuge: serial # 404146679 control # 10565. There was no documented PM sticker on the centrifuge machine. The surveyor requested the outside vendor service documentation from EI # 9. EI # 9 provided the surveyor with the facility's excel spread sheets. Further review of the facility's excel spread sheet revealed a different documented serial # 4270061 listed for the above centrifuge. There was no documentation provided to the surveyor for outside PM service performed on serial # 404146679.

A Labcorp Centrifuge machine: serial # 403431202 had a documented PM inspection due date of 1/2016. The surveyor requested the outside vendor's service documentation from EI # 9. EI # 9 provided the surveyor with the facility's excel spread sheets. Further review of the facility's excel spread sheet revealed a different documented serial # 471003-960 listed for the above centrifuge. There was no documentation provided to the surveyor for outside PM service performed on serial # 403431202.

93 - Red top lab tubes expired on 5/31/18. The staff failed to remove expired supplies per facility policy. The surveyor asked EI # 4, should the expired lab tubes be store in cabinets for patient use? EI # 4 stated, "No." EI # 4 removed the expired lab tubes from the cabinet and discarded them.

An interview was conducted on 6/20/18 at 8:45 AM with EI # 4 and EI # 9, who confirmed the above findings.

Based on observations, facility policies and procedures, the facility Infection Prevention and Control Plan and interviews, it was determined the facility failed to ensure all staff:

1) Performed hand hygiene according to policy/procedure.

2) Maintained a clean and sanitary medication room.

3) Cleaned the pill splitter after each use.

4) Disinfected all re-usable equipment, stethoscope and sphygmomanometer between patients.

5) Monitored the pharmacy medication refrigerator temperature daily.

6) Performed and documented ongoing direct surveillance of clinical staff compliance with infection control policies/procedures.

Findings include:

Infection Prevention and Control Plan
AltaPointe Health, INC. (incorporated)

...The goal of the Infection Prevention and Control Program....is to reduce there risk of acquisitions of healthcare associated infections in consumers and occupationally acquired infections in healthcare workers...

C. Ongoing Surveillance

...Hand Hygiene

AHS (AltaPointe Health System) complies with the CDC (Centers for Disease Control and Prevention) for hand hygiene. Indirect and direct monitoring of hand-hygiene compliance are conducted during inspections and monitoring programs. The Consumer Needs department observes for missed opportunities during walk-through visits...

Environmental Care Inspections

The environment of care (EOC) is monitored via safety officers and monthly inspections...
Signage is utilized to cue staff...regarding measures to prevent the spread of infections to include...hand-hygiene...

The data gathered from the above reporting process is complied and analyzed and reviewed in the infection Prevention and Control Sub-committee and EOC Sub-committee for trends...

Policy #: IC 3.2
Subject: Hand-Hygiene
Update: 3/18

Policy:

All ...employees are responsible for appropriate hand hygiene.

...Procedure:

Indications for hand hygiene:

Before and after any consumer (patient) procedure
...Before handling food and medications...
After contact with inanimate objects or medical equipment close to consumer

After removal of gloves...

Hand-Hygiene Monitoring:

Hand Hygiene monitoring will be done by direct observation or verbal demonstration on a quarterly basis by the risk manager. The findings...reported in the quarterly infection control and prevention...meeting...

Policy #: IC 3.7
Subject: Cleaning of Patient Care Equipment and the Environment
Update: 3/18

Policy:

Each AltaPointe Health...program will ensure that the environment is maintained in a clean and sanitary condition. The accumulation of dust, soil, and microbial contaminants on environmental surfaces is both aesthetically displeasing and a potential source of health-care associated infections. The overall responsibility for infection prevention and control, resides with the Infection Prevention Practitioner...

Procedure:

3. Employees are responsible for cleaning/sanitizing consumer equipment between uses.
7. Equipment cleaning guidelines include:

B. Automated vital sign machines

i. Disinfect with a Sani-cloth after each consumer use.
ii. Clean blood pressure cuff with a Sani-cloth between consumer use.

C. Stethoscope:

i. Wipe with alcohol or Sani-cloth after each consumer use...

K. Medication Room Pill Splitter
i. The pill splitter must be wiped with an alcohol pad between use to prevent cross-contamination...

Policy #: IC 3.6
Subject: Refrigeration of foods, Medication and Specimens
Update: 3/18

...Food and Medication Storage:

...All refrigerators must have a thermometer and must be checked daily to ensure...medications are kept at appropriate temperatures. **Note: IN pharmacies where staff are not present over the weekends, the temperature will be checked on the first day of the staff's return to the pharmacy and before...medications is dispensed...

****

An observation of Food Services preparation was conducted on 6/19/18 at 11:30 AM with EI # 10, Food Service Director, and EI # 9, Assistant Director.

EI # 10 performed hand hygiene and donned gloves to check the temperature of the food on the serving line. EI # 10 used a temperature gauge to verify the temperature of the Lasagna. EI # 10 left the kitchen serving line area touching the door knob with gloved hands. EI # 10 returned to the kitchen serving line area touching the door knob again with the same gloves. EI # 10 proceeded to check the temperature on the other food without changing gloves and performing hand hygiene.

EI # 10 failed to perform hand hygiene before handling food and after contact with inanimate objects per facility policy.

An interview was conducted on 6/19/18 at 12:50 PM with EI # 10 and EI # 9, who confirmed the above findings.

Observations of care on 6/19/18 from 11:50 AM to 12:45 PM were conducted with Employee Identifier (EI) # 6, Licensed Practical Nurse on the behavioral units. EI # 6 prepared and administered medications on all three units. In addition, EI # 6 completed patient assessments for blood pressure monitoring for 2 unsampled patients.

In the medication room, the surveyor observed brown liquid (coffee/soda) in the hand hygiene sink, a purse and soda in the cabinet underneath the sink, numerous brown dried stains on the cabinet above clean wound supplies, dirt/dust build up on shelves and on the floor behind an oxygen concentrator.

During medication preparation, EI # 6 retrieved a pill splitter which contained a large amount of white dust particles. EI # 6 divided (split) 2 medications for different patients using the pill splitter without cleaning the pill splitter before use, between use or after use.

After medications were prepared for all three units, EI # 6 exited the locked medication room and the 600 hallway nurse station, entered the boys (locked) unit and entered the nurse station to dispense medications.

EI # 6 failed to perform hand hygiene prior to medication administration to the first patient.

EI # 6 returned to the pre adolescent boys and girls unit, retrieved an unsampled patient # 1, accompanied the patient to the exam room where EI # 6 used an automated vital sign machine machine and blood cuff to take the patients blood pressure prior to medication administration.

EI # 6 failed to disinfect the automated vital sign machine and blood pressure cuff after use.

EI # 6 returned to the pre-adolescent unit, retrieved unsampled patient 2, then entered the exam room and monitored the patients' blood pressure with the automated vital sign machine. EI # 6 failed to disinfect the automated vital sign machine, blood pressure cuff and stethoscope after use.

****

During a tour of the pharmacy on 6/20/18 at 10:00 AM, the surveyor inspected the medication refrigerator which included multiple bottles of insulin, injectable Lorazepam and injectable Tuberculin.

Review of the pharmacy medication temperature logs documentation for 2018 revealed the on the following dates no documented refrigerator/freezer values on:

January 1 (Monday) 6, 12, 13, 14, 15 (Monday), 17 (Wednesday),18 (Thursday), 19 (Friday), 20, 27, 28
February 3, 4, 10, 11,17, 18, 24, 25
March 3, 4, 10, 11, 17, 18, 24, 25, 30
April 1, 6, 7, 14, 15, 28, 29
May 5 ,6,12,13,19, 20
June 9, 10, 16, 17

In an interview on 6/20/18 at 11:00 AM, EI # 5, Pharmacist verified on weekends no temperature monitoring was performed.

****

During interview with Registered Nurse, Employee Health Nurse, EI # 8 on 6/21/18 at 8:55 AM, the surveyor reported the above infection control findings, asked EI # 8 how/when infection control surveillance was completed and requested infection control surveillance documentation.

EI # 8 reported monthly infection control surveillance was completed on environmental rounds. EI # 8 reported the surveillance was to identify that soap/towels available for hand hygiene was available in the employee areas. EI # 8 reported she interviewed staff about how they perform hand hygiene.

EI # 8 reported no observation/direct hand hygiene surveillance was completed, she had not found a suitable tool for the task.

At 9:30 AM on 6/21/18, EI # 8 provided Environment of Care Inspection Checklists for Performance Improvement and Medication Storage Room Checklists documentation dated 3/29/18 and 6/14/18 that was completed on monthly environmental rounds.

There was no surveillance documentation of observations for hand hygiene and equipment cleaning with employees.

In an interview on 6/21/18 at 10:10 AM with EI # 10, Director of Performance Improvement, the surveyor requested facility infection control surveillance documentation and none was provided.




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Based on review of medical record, facility policy and procedure, it was determined the staff failed to complete/update Treatment Plan documentation to include all identified medical conditions/diagnoses. This affected Patient Identifier (PI) # 3, 1 of 1 active records reviewed with cardiology consultation (consult) ordered and had the potential to affect all patients treated at the facility.

Findings include:

Policy #: CTS 1.2
Subject: Treatment, Treatment Plan, and Review

POLICY:

" In order to ensure the appropriateness of care, treatment plans and reviews will be conducted for all consumers....meet expected standards...

...services must be individualized, well-planned, and should include treatment designed to enhance the consumer's ability to recover...

Procedure:

1. The development and initiation of the treatment plan will begin at intake...completed, staffed, and signed...within 72 hours for inpatient programs

2. The treatment plan will include clinical issues to be addressed in treatment and the services to be provided to address those issues...The treatment plan will state the expected outcomes for each goal.

3. Treatment plans should include referrals for services not provided directly by AltaPointe Health, Inc...

12. The treatment plan is reviewed when major changes occur...presenting problems or disabilities and is revised as necessary...

1. PI # 3 was admitted to the facility on 6/12/18 at 10:27 AM with diagnoses including Post Traumatic Stress Disorder and Major Recurrent Depression.

Review of the Psychiatric Evaluation dated 6/12/18 contained request for a medical consult (consultation).

The medical consult was completed on 6/14/18 and contained documentation for results of the electrocardiogram (EKG) which were sinus rhythm, LAE (left atrial enlargement), consider bilateral enlargement. The medical consult recommendations as a result of the abnormal EKG were a cardiology consult. The cardiology appointment was scheduled on 6/20/18.

Review of the initial and updated treatment plan documentation failed to document a problem, plan (intervention) or goal for the abnormal cardiac finding.

The treatment team staff failed to document a treatment plan update for services not provided directly by AltaPointe as per the policy.

An interview was conducted on 6/21/18 at 11:10 AM with Employee Identifier # 1, Director of Nurses who confirmed the aforementioned finding.