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.

Based on review of records and interview, the hospital failed to offer adult and senior patients the opportunity to have family members (or other designated representative) involved in the development of their inpatient plan of care with treatment goals and modalities.

Review of 15 adult and senior patient charts (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) did not include any documentation that patients were asked if they wished to have family members (or other designated representative) present during scheduled treatment team meetings to participate in the development of the plan of care with treatment goals and modalities.

An interview with Staff #14 was conducted on the morning of 7- 22-16 in the conference room with Staff #6 present. Staff #14 confirmed that the plan of care and updates to the plan of care are accomplished during treatment team meetings. Staff #14 confirmed that staff does not invite families of adult and senior patients to treatment teams. Staff #14 advised that families of the adolescents are involved in the process, but not the families of adults and seniors. Staff #14, when asked about adult patients, stated, "No. We don't invite the families to treatment team. It wasn't until recently that we had the patients come to treatment team."

Review of Adolescent Program Patient Handbook on page 13 stated, "Patient, parent or guardians are invited to attend treatment meeting on Mondays/Wednesday/Fridays at 9:00 am. This is the time when the patient's progress in treatment is discussed. The meeting is held on the unit."

Review of the Adult Program Patient Handbook showed that the information on treatment teams or the right to have family members (or other designated representative) present at treatment team was not included. Staff #14 verified that the information was not contained in the handbook.

Review of the Senior Care Patient Handbook, under the heading "Recreational Activities" stated, "You will see your psychiatrist most days and on a daily basis we have a "Treatment Team Meeting." This is a time when you, all of the staff, including the doctor, meets to discuss your progress and plans for the future. You may request that your representative or family meet with the team if prior arrangements are made with the Case Manager or Therapist."

Staff #14 and Staff #6 agreed that the language in the Senior Care Patient Handbook was such that the treatment team purpose was unclear. It did not clearly explain that the plan of care with treatment goals and modalities for the patient would be decided upon. The language also placed a barrier on the patient in the acute phase of a psychiatric condition by placing the responsibility for making prior arrangements on the patient.
Based on observation, record review, and interview, the facility failed to ensure the defibrillator pads had not exceeded the expiration date on 1 Automatic External Defibrillator (AED) device out of 3 AED devices checked.

On the morning of 7-20-2016 a tour of the Adult Unit was conducted with Staff #11. During a tour of the medication room, the emergency cart was noted to have an AED available for use. The form titled "Crash Cart Check Documentation Form" for the month of July was noted to have been checked every day. As part of the check, nursing staff had documented under the column "First supply expiration date listed and all supplies current". Each line under that column contained a hand written entry that said "AEDv". Upon opening the AED, it was noted that the defibrillator pads that attach to the patient's body had expired at the end of March, 2016.

Staff #11 confirmed that the entry "AEDv" meant that the AED had been checked, was serviceable and ready for use.
Based on review of documents, observation, and interview, the infection control officer failed to develop a program that ensured the maintenance of a sanitary hospital environment in two units (Adolescent Unit and Senior Unit) out of four units observed (Acute Unit, Adult Unit, Adolescent Unit and Senior Unit).

On 07/20/2016 at approximately 0930 AM, a tour of the Acute Unit, Adult Unit, Adolescent Unit and Senior Unit began with Staff #5 and Staff #6.

Room 219 on the Adolescent Unit was toured at approximately 10:00 AM. The room was identified as terminally cleaned and ready for patients. This was confirmed by Staff # 13. The following unsanitary conditions were found:
1. Below the window on a lower ledge, dust, dirt, and what appeared to be a dried liquid was found along the ledge and in the corners. A streak that appeared to be dried liquid ran from the window to the ledge. The window frame had chipped, cracked, and peeling paint.
2. The bathtub/shower enclosure had a film around the tub and around the drain. The drain and grout on the tub/shower enclosure had mildew stains. The shower wall had hair and dirt marks on it.
3. The bathroom sink had a used paper towel on the top and dirt marks on the front edge and bottom lip of the sink.

The medication room on the Senior Unit was toured at approximately 10:30 AM. The following unsanitary conditions were found:
1. Plastic bins to store patient medications were labeled with room numbers. The labels were paper. Some labels had been peeled off and left paper and glue residue on the bins. The paper and glue cannot be cleaned and sanitized properly.
2. A cabinet was designated as the Wound Care cabinet. Inside the cabinet was a plastic bin containing sterile supplies for wound care. Inside the bin was found to contain open containers of sterile gauze sponges and an unpackaged sponge tipped Chloraprep applicator (brand name of antiseptic applicator). These items were no longer sterile but available for use. This was confirmed by Staff #10.
3. Sterile water was opened and sitting on the counter. It was labeled with the name of a patient that had been admitted 15 days earlier on 7-5-2016. The date and time of opening was not marked on the bottle. Staff #10 confirmed that the bottle should have been marked and was only good for use 24 hours after opening.
4. The pill crusher was found to have dirt, dust, and white powder residue built up on it.
5. The medication refrigerator was not in use. It had a dried spill of brown sticky substance on the shelves, door, seal and floor under door. The seal had an accumulation of dust and dirt.
6. There was visible trash and dust between the medication refrigerator and the counter.
7. There was a roll-around computer located in the medication room. Staff #10 confirmed this was taken into patients' rooms at times. The wheel base and wheels had an accumulation of dirt and dust. The castors had a dried, sticky substance on them.

The day room on the Senior Unit was toured at approximately 10:45 AM. The following unsanitary conditions were found.
1. Cabinet doors were found to have a dried, sticky substance on them. It had spilled down the inside of the cabinet door and splattered on the shelf.
2. There was an accumulation of dust, dirt, and dried spill behind the ice machine.

Review of documents provided by Staff #2 showed that Staff #9 rounds quarterly. Environmental Services rounds quarterly, as well as privately retained consulting firm. Documents from the month of June identified Room #228 as having a leaking window, but not Room #219. None of the other unsanitary conditions had been identified during the June rounds.