The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SSM HEALTH ST MARY'S HOSPITAL JEFFERSON CITY 2505 MISSION DRIVE JEFFERSON CITY, MO 65109 Nov. 29, 2012
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interview and record review the facility failed to ensure staff on the Behavior Health Unit (BHU) provided direct patient care services in a safe, effective manner for high risk patients that was systematically evaluated and integrated into the facility's quality assessment and performance improvement program (QAPI). This had the potential to affect all patients admitted to the facility's BHU. The BHU census was 18 and the facility census was 103.

Findings included:

1. Review of the facility's Performance Improvement and Safety Plan 2012, gave direction for the following:
-Promote a systematic, organized, functional approach to performance improvement and complexity of services and operations.
-Identify distinct improvement opportunities proportional to the scope and complexity of services and operations.
-To ensure performance improvement activities are consistent with CQIplus (Continuous Quality Improvement) principles.
-To measure, assess and improve the quality and safety of care as evidenced by outcomes and improvement in processes.
-The facility uses its CQIplus model for improvement efforts based on the D_M_A_I_C methodology (D-define, M-measure, A-analyze, I-improve, and C-control) to improve existing processes.
-Appropriate documentation and reporting is maintained.
-Follow-up measurement to assure the desired results have been achieved and sustained is undertaken and communicated.

2. Observation on 11/26/12 from 6:30 PM through 6:40 PM showed the following:
-At 6:30 PM Staff H, Registered Nurse (RN), opened the men's bathroom (bathroom in alcove close to the dining room) on 4 North (N) for Patient #25 to use.
-At 6:23 PM Patient #25 left the bathroom and staff did not lock the bathroom door.
-At 6:32 PM Staff F was the hall monitor and sat at a small desk in the hall across from the dining area. The hall monitor was talking on an internal phone (a phone used to communicate with other staff).
-At 6:35 PM Staff F remained on the internal phone and was looking across the hall into the dining room. The men's bathroom remained unlocked.
-At 6:38 PM Patient #16 walked from his room into the unlocked bathroom.
-At 6:40 PM Patient #26 walked to the unlocked bathroom door, opened it and knocked. Patient #16 yelled out something and Patient #26 walked away. Staff G, Mental Health Technician (MHT), locked the door after Patient #16 left the bathroom.

3. During an interview on 11/27/12 at 7:15 PM Patient #18 stated that he had found the men's bathroom door on 4N opened more than once and on different shifts.

4. During an interview on 11/27/12 at 7:25 PM Patient #2 stated that he had found the men's bathroom door opened once on 4N.

5. During an interview on 11/28/12 at 9:50 AM, Staff X, RN, stated that 4N has had a Hall Monitor since the summer of 2012. Staff X stated that the Hall Monitor was implemented due to problems with the shower/bathroom not being locked after patient use. Staff X stated that when 4C was full women patients sometimes are over-flowed onto 4N. Staff X stated that if patients from 4C are admitted to 4N they stay together and are located next to the nurse's station on 4N and those patients return to 4C to take their showers.

6. Record review of the BHU monitoring tool (implemented after an alleged sexual encounter between patients in the shower/bathroom on 4N in July) of the hall showed the following information:
-Staff documented observations made on the unit from 08/05/12 to 11/03/12 included only one Saturday. Staff documented they made observations during the week and only once on the weekend.
-Staff documented observations were made between 8:30 AM and 5:45 PM from 08/05/12 and 11/03/12.

Staff did not make observations during the time frame or weekend when the second alleged incident occurred in October.

7. During an interview on 11/28/12 at 3:15 PM, Staff BB, RN, BHU Director stated that she received reports of events and incidents from the unit's nurse manager. Staff BB stated that she followed up on all reports and discussed major issues with staff. Staff BB stated she investigated an incident between two BHU patients on the unit who allegedly engaged in sex in the shower/bathroom on the westside of 4N (the alleged incident occurred in October between 7:00 PM and 8:00 PM on the weekend). Staff BB stated the unit implemented patients at risk on the SAM (Sexual Acting Out Management) I and SAM II form, began to lock the shower/bathroom doors and initiated a hall monitor. Staff BB stated that the hall monitor is responsible for keeping the shower/bathroom door locked and to ensure only one patient enters the shower/bathroom at a time. Staff BB stated that she was not on the unit during the time frame of the second alleged incident. Staff BB stated she has been on the unit until 7:00 PM but not the time when the second alleged incident occurred.

8. Record review of the BHU's Wellness Safety Plan: A Tool for Keeping Patients Safe showed the plan only addressed suicide.
Staff did not initiate a sexual incident prevention plan into the departments' goal after two alleged incidents had occurred in the shower/bathroom on 4N.

9. Record review of the BHU's 2012 Operational Plan Dashboard showed the staff did not initiate a sexual incident prevention plan into the 2012 Operational Plan Dashboard after two alleged incidents had occurred in the shower/bathroom on 4N.

10. During an interview on 11/28/12 at 3:35 PM, Staff BB was asked if the services on the BHU's quality data revealed a pattern of serious incidents occurring on particular shifts or days of the week. Staff BB stated that sexual incident prevention was not a part of this year (2012) goals for the BHU and she did not think to incorporate a goal after two alleged incidents of sexual encounters had occurred on the unit in the shower/bathroom on 4N.

11. During an interview on 11/28/12 at 4:00 PM, Staff J, Director of Performance stated that she had worked with the BHU to implement the hall monitor. Staff J stated that she gives over sight for data collection and analysis of the data. Staff J stated that she looks at data to see if the department is meeting their goal. Staff J stated that it is leadership's responsibility to ensure monitoring is being done. Staff J stated that she would expect validating of data per observations and she would expect staff to monitor and talk to staff at different times.

12. During an interview on 11/29/12 at 12:10 PM Staff R, RN, Chief Nursing Officer (CNO) stated that she expected staff to come up with a plan and follow-up to check if the plan is meeting the goal set. Staff R stated she had seen very few event reports. Staff R stated that she sits on the Quality Council and she had concerns with the facility's quality assessment and feels the process is incomplete. Staff R stated that she did not know what the plan for the BHU was related to the shower/bathroom incident or the hall monitor. Staff R stated she had been told an event occurred but was not included in the plan.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
Based on interview, personnel record review and policy review the facility failed to ensure current Missouri license as a Registered Nurse (RN) for nursing staff and failed to maintain documentation in the personnel file of current Missouri license to practice for one of six RN personnel records reviewed. The facility census was 103

Findings included:

1. Review of Human Resource Policy "Verification of Licensure/Registration/Certification" revised 04/01/11, showed the following:
-Revalidation of licensure/certification/registration is completed by the Human Resources Department for positions requiring on-going renewal.
-Personnel required to have licensure/registration/certification may not work without a current license/registration/certification. Personnel who allow their license /registration/certification to expire are suspended without pay until the license/registration/certification is renewed.

2. Record review of Job Description and Position Requirements "Vice President, Acute Care Services - CNO (Chief Nursing Officer)" showed the requirement for current Missouri license as a Registered Nurse.

3. Record review of personnel files on 11/28/12 showed personnel record for Staff R, Chief Nursing Officer (CNO) showed license verification by primary source verification (electronic license validation through the Missouri Division of Professional Registration) with an expiration date of 11/01/12.

4. During an interview on 11/28/12, Staff GG, Human Resources Director, stated that the personnel record for Staff R, CNO is not kept in Human Resources, it is kept in Administration.

5. Observation on 11/28/12 showed Staff GG, Human Resources Director placed verification of current license for Staff R, CNO, in the personnel file.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observation, interview, record review and policy review the facility failed to ensure supervision of patients using the bathroom and to follow the facility policy to ensure the men's bathroom door (in the alcove and closest to the dining room) was locked on the 4 North (N) Behavioral Health Unit (BHU) after a patient used it for one (#25) of three patients observed. The facility failed to ensure staff performed hand hygiene (to wash hands with soap and water or with hand sanitizer) after they removed their gloves for three (#10, #15 and #22) of four patients observed. The facility census was 103.

Findings included:

1. Record review of the facility's policy titled, "Charge Nurse Duties, Behavioral Health Unit," dated 10-12 showed direction for Charge Nurses to assign a hall monitor (a staff member that is assigned to be present in the hallway on 4N to observe bathrooms) at all times and to provide hall monitor relief as needed. The Charge Nurse is responsible to check that bathroom doors are locked at all times.

Record review of the facility's policy titled, "Behavioral Health Guidelines for Hall Monitor," dated 11-12 showed direction for the hall monitor to be in the hallway on 4N to view the bathrooms at all times. The bathroom doors will remain locked at all times when not in use by patients.

2. Observation of facility's BHU on 11/26/12 at 6:00 PM showed the unit was constructed like a T. Upon entry onto the unit the first hall, 4 Center (C) is where female patients are housed. The rooms on 4C had bathrooms located in each patient room. At the end of 4C was another long hallway 4 North (N) where male patients are housed. The hall was divided into two separate areas west and east. The east area just off the nurse's station is where over flow of female patients are housed. The rooms on 4N did not have bathrooms in the patient rooms. 4N on the west side had one shower/bathroom combination located in the hallway close to the dining area and the east side had one
shower/bathroom combination located in between patient room 405 and an office.

Observations made on the unit from 11/26/12 to 11/28/12 showed 4C contained a video camera located at the nurse's station. A large monitor screen divided into four sections showed the following areas of the entire unit:
-Screen #1 provided a view of the hall just outside the door of the unit.
-Screen #2 provided a view of the day room located on 4N.
-Screen #3 provided a view of the lobby before the entryway into the day room located on 4N.
-Screen #4 provided a view of a different angle of the day room located on 4N.

3. During an interview on 11/28/12 at 9:50 AM, Staff X, Registered Nurse (RN), stated that 4N has had a Hall Monitor since the summer of 2012. Staff X stated that the Hall Monitor was implemented due to problems with the shower/bathroom not being locked after patient use. Staff X stated that when 4C was full women patients sometimes are over-flowed onto 4N. Staff X stated that if patients from 4C are admitted to 4N they stay together and are located next to the nurse's station on 4N. Staff X stated if patients are over-flowed from 4C to 4N those patients return to 4C to take their showers.

4. Observations made on the unit from 11/26/12 to 11/28/12 showed 4N contained a video camera located at the nurse's station. A large monitor screen divided into four sections showed the following areas of the unit:
-Screen #1 provided a view of the hall just outside the door of the unit.
-Screen #2 provided a view of the dining room.
-Screen #3 provided a view of the game room.
-Screen #4 provided a view of the front part of the dining room.

5. During an interview on 11/28/12 at 10:20 AM, Staff Z, RN, stated that the video camera did not show the hallways, shower/bathroom, or patients' rooms and that is why the unit has a Hall Monitor and staff did rounds.

6. During an interview on 11/28/12 at 10:25 AM Staff T, RN, stated that the Hall Monitor was initiated sometime mid-summer since the video camera on 4N does not show patients' rooms, hallways or the shower/bathroom.

7. During an interview on 11/29/12 at 12:45 PM, Staff I, RN, Risk Manager stated the video cameras are not taped/recorded in the BHU because the cameras are in common and patient care areas.

8. During an interview on 11/26/12 at 6:15 PM Staff F, MHT (Mental Health Tech) stated that a staff member stayed at the small desk, which is in the hall across from the dining area, at all times. The staff at the desk could get up and go into the dining room to check on patients.

9. Observation on 11/26/12 from 6:30 PM through 6:40 PM showed the following:
-At 6:30 PM Staff H, RN opened the men's bathroom on 4N (bathroom in alcove and closest to the dining room) for Patient #25 to use.
-At 6:32 PM Patient #25 left the bathroom and staff did not lock the bathroom door.
-At 6:32 PM Staff F was the hall monitor and sat at a small desk in the hall across from the dining area. The hall monitor was talking on an internal phone (a phone used to communicate with other staff).
-At 6:35 PM Staff F remained on the internal phone and was looking across the hall into the dining room. The men's bathroom remained unlocked.
-At 6:38 PM Patient #16 walked from his room into the open bathroom.
-At 6:40 PM Patient #26 walked to the unlocked bathroom door opened it and knocked. Patient #16 yelled out something and Patient #26 walked away. Staff G, MHT locked the door after Patient #16 left the bathroom.

10. During an interview on 11/27/12 at 7:15 PM Patient # 18 stated that he had found the men's bathroom door on 4N opened more than once and on different shifts.

11. During an interview on 11/27/12 at 7::25 PM Patient #2 stated that he had found the men's bathroom door opened once on 4N.

12. During an interview on 11/29/12 at 9:34 AM Staff H, RN stated that it was the responsibility of the hall monitor to lock and unlock the bathroom doors.

13. During an interview on 11/29/12 at 11:05 AM Staff F, MHT stated that it was her responsibility to lock the bathroom door after a patient used the bathroom. She was aware the door was opened by Staff H for Patient #25.

14. During an interview on 12/11/12 at 7:40 PM Staff G, MHT stated that Staff F asked her to lock and unlock the men's bathroom door when Staff F was the hall monitor.

15. Record review of the facility's policy titled, "Hand Hygiene," revised 09/11 showed direction for facility staff to perform hand hygiene after removing gloves.

16. Observation on 11/27/12 at 9:45 AM showed Staff L, RN with gloves on to clean around the Patient #10's tracheotomy tube (a surgical opening in the trachea or windpipe in which a tube is placed). She then removed her gloves and donned sterile gloves. She failed to perform hand hygiene after removing her gloves.

17. Observation on 11/27/12 at approximately 10:00 AM showed Staff L completed medication administration through a gastric tube (a tube placed into the stomach for medication and fluid) and removed her right hand glove. She then turned on the pump for the gastric tube feeding. She failed to perform hand hygiene after she removed her right hand glove.

18. Record review of Patient #10's medical record showed he was in contact isolation for Clostridium Difficile (C-Diff, bacteria that causes severe diarrhea).

19. During an interview on 11/27/12 at 10:45 AM Staff L stated that she performed hand hygiene before entering and leaving a patient's room, but failed to complete hand hygiene when she removed her gloves while in a patient's room.

20. Observation on 11/27/12 at 2:55 PM showed Staff M, RN removed gloves after she started blood and charter on Patient #15. She failed to perform hand hygiene after she removed her gloves.

21. During an interview on 11/28/12 at 10:40 AM Staff M stated that she failed to perform hand hygiene after she removed gloves, but she performed hand hygiene before entering and leaving a patients room or starting a new procedure.

22. Observation on 11/28/12 at 9:45 AM showed Staff DD, RN removed gloves after she removed Patient #22's dressing. She then donned gloves and covered the incision with a new dressing. Staff DD failed to perform hand hygiene after she removed her gloves.

23. During an interview on 11/28/12 at 9:50 AM Staff DD stated that she was not sure about the policy, but it was not uncommon that she failed to perform hand hygiene after she removed gloves.

24. During an interview on 11/28/12 at 10:00 AM Staff S, Infection Preventionist, stated that she expected staff to perform hand hygiene after removing gloves.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on interview, personnel record review and policy review the facility failed to follow their policy to ensure agency staff received orientation and documented competency in the personnel file for services provided on the Behavioral Health Unit (BHU) for one of one agency staff reviewed. This had the potential to impact the safety of all patients and staff on the BHU. The BHU census was 18 and the facility census was 103.

Findings included:

1. Record review of the facility policy titled "Orientation Plan", revised 05/01/12 showed orientation is to be provided to all employees new to the organization, to a department/unit or new to a specific job and direction for responsibility of the department director to maintain an up to date Orientation Check Sheet.

2. Review of staffing assignments for 09/10/12, 11:00 PM-7:00 AM shift showed Staff FF, Agency Patient Care Tech (PCT), was assigned to the Behavioral Health Unit, 4N.

3. Record review of Staff FF's personnel record on 11/28/12 at 3:00 PM showed she attended General Orientation for Agency staff on 02/16/12.

4. During an interview and personnel record review on 11/28/12 at 3:00 PM, Staff GG, Human Resources Director stated that she could not show evidence of Unit Specific orientation to the BHU. Staff GG stated that the document may have been turned in to the Education department.

5. During an interview on 11/29/12 at 10:45 AM, Staff CC, RN Educator stated that the education department covers restraints during general orientation and they do not require agency staff to attend SECURE training, (to provide patients and staff a "Safe and Secure Environment through, Caring, Understanding, Relationships, and Empathy"). She stated normally the departments where they are assigned have them complete specific orientation before they work. Per policy, agency staffs are required to attend house wide orientation prior to working their first shift.

Staff CC could not show evidence of Unit Specific orientation to the BHU for Agency Staff FF.

6. During an interview on 11/29/12 at 10:55 AM, Staff V, RN Manager of the BHU stated that agency staff and float staff from other units cannot work on the BHU without completing the department orientation checklist and reviewing the guide book the first time they are assigned. Staff V stated that she could not show documentation of unit specific orientation to the BHU for Staff FF, Agency PCT.

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