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.

BEACON CHILDREN'S HOSPITAL 150 HOSPITAL DRIVE LUVERNE, AL Aug. 30, 2013
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and interviews it was determined the facility failed to:

1. Ensure the patients rooms and showers were in good repair and maintained.

2. Ensure rooms were free of potentially infectious and hazardous materials.

This had the potential to affect all patients.

The findings include:

During observations of patient areas with the Registered Nurse, Employee Identifier(EI) # 2, on 8/26/13 at 8:50 AM, the surveyor identified the following areas of concern:

1. Shower room just past room 114 with plaster off the bottom of the wall outside the shower and a hole to the left of the shower in which you could see a screw at the bottom of the hole.

2. Room 116 had red marker on the wall beside the desk area.

3. Shower room just past room 104 with plaster off the bottom of the wall outside the shower and behind the toilet box.

4. Seclusion room had restraints attached to the bed and lying on the floor presenting a hazard to patients.

The surveyor asked EI # 2 why they were attached someone could hurt themselves and she stated she did not know if they would come off.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observations, facility policy review and staff interview, it was determined the facility failed to ensure:

1. There was a designated Infection Control Nurse at the hospital.

2. Proper care was provided to 3 of 3 patients with documented infectious pathogens.

3. Follow their policy and procedure for providing care and protecting other patients/ employees from potential infectious diseases.

4. Ensure contaminated laundry was properly cleaned.

5. Ensure the Infection Control Plan was followed.

6. Follow isolation precautions.

7. The staff followed their own policy for Infection Control.

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

Findings include:

Refer to A 748 and A 749 for findings.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interview and review of policy and procedures it was determined the hospital failed to have a designated infection control nurse. This had the potential to affect all patients served by this hospital.


Infection Control Plan
Policy number A100.1002.01

I. Purpose

The program will identify and reduce the risks of endemic, epidemic and healthcare acquired infections. The program will provide surveillance, prevention, control and investigations of infections and communicable diseases specific to the hospital.

III. Staffing Plan

The Infection Prevention and Control Program functions under the direction of the Director of Nursing (DON). The DON/ Infection Control Nurse:

Conducts surveillance and identifies infection risks based on these surveillance activities.
Prepares reports.
Prepares and presents educational programs/in-services.
Develops and reviews policies and procedures.
Consults with Infection Control Consultant as needed.

V. Surveillance Plan

Data will be collected on a monthly basis and reported to the Committee of the Whole.

A. Surveillance for epidemiologically significant microorganisms.

Review medical records of patient identified with an epidemiologically significant organism (i.e., Methicillin Resistant Staphylococcus Aureus [MRSA], Vancomycin Resistant Enterococcus [VRE].

Determine if organisms are healthcare acquired or community acquired.

Determine if there is any association between cases.

Findings include:

On 8/26/13 at 10:00 AM the surveyor asked Employee Identifier (EI) # 1, the Administrator for the infection control plan and surveillance tools. She was not able to provide them at this time stating since the DON left 8/19/13 she would have to look for them. The prior DON filled the role of Infection Control Nurse from June 2011 until June 2013.


On 8/27/13 the surveyor again asked for the infection control plan and surveillance tools. EI # 1 stated that she was still looking for the information. The DON prior to the one who left 8/19/13 had filled the role of Infection Control Nurse from June 2011 until June 2013.

In an interview with EI # 1 on 8/28/13 at 1:00 PM, she confirmed she did not have any information regarding infection control, that she not found any information from either DON.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedures, review of medical records, observations and interview it was determined the hospital failed to:

1. Provide proper care to 3 of 3 patients with documented infectious pathogens.

2. Follow their policy and procedure for providing care and protecting other patients/ employees from potential infectious diseases.

3. Ensure contaminated laundry was properly cleaned.

4. Ensure the Infection Control Plan was followed.

5. Follow isolation precautions.

This affected medical record # 1, # 2 and # 8. This had the potential to affect all patients served by this hospital.

Hospital policies:

Infection Control Plan
Policy number A100.1002.01

I. Purpose

The program will identify and reduce the risks of endemic, epidemic and healthcare acquired infections. The program will provide surveillance, prevention, control and investigations of infections and communicable diseases specific to the hospital.

V. Surveillance Plan

Data will be collected on a monthly basis and reported to the Committee of the Whole.

A. Surveillance for epidemiologically significant microorganisms.

Review medical records of patient identified with an epidemiologically significant organism (i.e.,Methicillin Resistant Staphylococcus Aureus [MRSA], Vancomycin Resistant Enterococcus [VRE].

Determine if organisms are healthcare acquired or community acquired.

Determine if there is any association between cases.

Policy: Contact Precautions
Policy number A100.1002.10

Policy: It is the intention of Beacon Children's Hospital not to accept patients with known communicable diseases or infectious skin lesions. If one of these conditions is not known until after the patient presents for admission or if they are diagnosed after admission, then contact precautions will be maintained. Contact precautions (in addition to Standard Precautions) will be used for patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient care activities that require touching the the patient's dry skin) or indirect contact ( touching) with environmental surfaces or patient-care items in the patient's environment.

Examples of illness include but are not limited to:
Multi drug resistant organisms

Procedure

1. Place patient in private room.
3. Use personal protective equipment as indicated
4. Dedicate equipment- do not share with other patients
5. Disinfect environmental surfaces or patient care items as needed.

Policy: Isolation Precautions
Policy number A100.1002.23

Purpose: Prevent transmission of infection within the hospital.

Policy: Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals and apply to: Blood, body fluids and excretions regardless of whether or not they contain visible blood, non-intact skin and mucous membranes.

Procedure:

1. When patient is identified as having a known or suspected infection, notify physician and place on appropriate isolation precaution.

4. Place isolation sign on door of patient's room.

5. Place personal protective equipment ( gloves, mask, gown etc.) outside the room.

9. Handle used patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environment.

Policy: Contaminated Laundry
Policy number A100.1002.11

Purpose: Protect employees from infectious pathogens.

Policy: Standard precautions will be used when handling all contaminated laundry. Contaminated laundry will be placed in laundry bag or leak proof container prior to transport from one area to another.

Procedure:

1. Wear gloves when handling laundry.
2. Handle laundry as little as possible with minimum agitation.
3. Bag or contain laundry where it was used (do not sort or rinse).
4. Laundry will be transported in bags or containers which prevent leakage of fluids.


Policy: Washing Machine Disinfection
Policy number 900.703

I. Purpose: To ensure proper disinfection of the washing machine, prevent the spread of communicable disease and provide a safe environment.

II. Policy:

A. The laundry room door will remain locked at all times.
B. The patient washing machine and dryer outer surface will be wiped with a facility approved disinfectant between each patient's uses. Patients will not be allowed to combine clothing in washer or dryer with another patient's load of laundry.
C. Staff will add one cup of Clorox to the water and the washing machine will be run through one cycle between each patient's uses of the machine.
D. This procedure will be documented on a flow sheet posted in the laundry room.

During a tour of the facility 8/26/13, at 9:30 AM, with Employee Identifier (EI) # 2, a Registered Nurse (RN) the surveyor observed the door to the laundry room was unlocked.

While in the laundry room 8/26/13 the surveyor observed the laundry room log posted with the following dates for the bleach cycle to run between patients: 8/16/13, 8/17/13, 8/18/13 then 8 days later 8/26/13 and 8/27/13.
The surveyor asked for the prior form checklist and was provided with a July list that had 8/4/13, 8/7/13, 8/8/13 and 8/12/13.

In an interview with EI # 2, 8/26/13 at 9:30 AM she stated the laundry is done at night by the Mental Health Technicians (MHT).

Medical Record (MR) findings:

1. MR # 8 was admitted to the facility 8/11/13 with diagnoses of Anger, Aggression, Suicidal ideation's and Mood/Conduct Disorder.

The admission assessment by the RN on 8/11/13 documented, " Patient (pt) is unkept has an odor. Pt has discharge in vaginal area white, no color or odor noted. Pt denies itching or burning, pt had a tissue in her underwear.".

The pt was examined by the Physician's Assistant 8/13/13 for, "Complaint of left posterior leg pain times a few days with drainage. Pt c/o (complaint of) white vaginal discharge no itch/burn, no hx (history) of STD ( sexually transmitted disease), positive for sexual activity, poor historian."

On 8/13/13 an order was documented at 6:20 PM," 1. Obtain wound C&S ( culture and sensitivity)- left posterior thigh. 2. Doxycycline 100 mg (milligrams) 1 po ( by mouth) BID ( twice a day) x 10 days, after wound culture C&S is obtained. 3. Flagyl 500 mg 1 po BID x 7 days."

An order was written 8/16/13 for a ," Ped (pediatric) consult for c/o smelly vaginal discharge."

The culture results in the medical record dated 8/16/13 were positive for MRSA from the thigh culture.

There was no documentation in the nurses progress notes from 8/13/13 through discharge 8/23/13 regarding any further vaginal discharge and never any mention of a skin integrity issue on the left posterior thigh. The nurses failed to provide any type of isolation to protect other patients from contact with the infectious organism of MRSA.

There was no update to the treatment plan to include the skin integrity issue, vaginal discharge or the positive MRSA culture.

The patient was in the hospital from 8/11/13 through 8/23/11 a total of 12 days during which time her clothes were laundered, only 4 days during her stay was the washing machine documented as having been disinfected between patient loads.

In an interview on 8/28/13 at 1:30 PM with Employee Indentifer (EI) # 1, the Administrator, it was confirmed the nurse notes and the treatment plan failed to document issues of skin integrity and that the patient had MRSA but had no precautions put into place.

2. MR # 2 was admitted to the facility on [DATE] with diagnoses of Depression with Psychosis, Suicidal Ideation's and Bipolar.

On 8/6/13 the physician ordered a " Urinalysis (UA) with a C&S and started the patient on Bactrim DS 1 tablet by mouth BID pending C&S results."

On 8/7/13 the physician ordered, " Urine C&S was clear. Start patient on Acyclovir 400 mg every 8 hours for treatment of recurrent genital herpes."

On 8/9/13 the physician's assistant ordered, " UA with reflex to C&S ( clean catch)."

On 8/20/13 the physician ordered, " Clean catch urinalysis and C&S today. Pyridium 100 mg TID (three times a day) PRN (as needed) for dysuria until C&S results are back. Bactrim DS 1 po BID pending urine C&S."

On 8/21/13 the physician ordered, " Apply Nystatin cream tid to affected area. Diflucan 150 mg po x 1 dose."

The C&S from 8/20/13 had no documented results on the medical record 8/27/13, 7 days later.

In an interview on 8/28/13 at 1:35 PM with EI # 1, the Administrator, it was confirmed the culture results were not present, they were obtained and discussed on 8/27/13.

The facility failed to document any type of special precautions on this patient with an active recurrent case of genital herpes.

3. MR # 1 was admitted to the facility 8/13/13 with diagnoses of Psychotic Disorder, Panic Attacks and Substance Abuse.

The patient was examined by the Physician's Assistant (PA) 8/14/13. The review of the systems documented, " Scrotal pain per nurse, abdominal pain- umbilical and dysuria x 1 today- none now."

Abdomen GI/GU (gastro/ genitourinary) the PA documented, " No abnormality of penis on visual exam, Tanner 5, no swelling/ lesions or erythema."

On 8/15/13 the PA ordered, " UA with reflex to C&S."

On 8/16/13 the physician ordered, " Ped consult for c/o yellowish greenish penile discharge."

On 8/17/13 the physician ordered, " UA with Gonorrhea and Chlamydia (culture drainage from penis), Rocephin 250 mg IM (intramuscularly) x 1 dose. Doxycycline 100 mg BID x 7 days. Start 8/18/13."

On 8/20/13 the physician ordered, " Contact isolation."

The physician received the results 8/22/13 that both cultures were negative for Gonorrhea and Chlamydia.

The nurses failed to document any problems under genitourinary every note except 8/18/13 on the 7AM till 7 PM note it was added. The nurses failed to document any teaching to the patient regarding being place in isolation.

During the tour of the boys ward 8/26/13 and a revisit 8/27/13 the surveyor did not see an isolation sign on the door. A sign was placed on the door 8/28/13 while the surveyor was in the building.

The treatment plan was not updated to reflect the patient was in isolation.

The patient was in the hospital from 8/13/13 through the present 8/28/13 a total of 15 days during which time his clothes were laundered, only 5 days during his stay was the washing machine documented as having been disinfected between patient loads.

In response to written questions left with the Administrator, EI # 1 on 8/28/13 the above information was confirmed 8/30/13.
VIOLATION: MEDICAL STAFF - BYLAWS Tag No: A0047
Based on review of personnel files, policies and procedures, incident reports, CDC (Centers for Disease Control and Prevention) recommendations for Hepatitis B immunizations and interview with staff, it was determined the facility failed to:

1. Complete incident reports and follow through with documented investigation of incidents. This had the potential to affect all staff and patients.

2. Follow their Employee Health policy for TB (Tuberculosis) testing and Hepatitis B vaccine in 4 of 6 employees. This had the potential to affect all staff and patients.

Findings include:

Policy A 100.413 Incident Management

Policy: It shall be the policy of Beacon Children's Hospital to establish and maintain an Incident Management System, as a component of the Hospital's Performance Improvement Plan, in order to promote an environment that is caring, free from harm and respectful of patient's rights.

Procedure:

A. Reporting of Incidents: To ensure proper and timely reporting of incidents the following procedures shall be adhered to:

1. Immediately upon discovering or having knowledge of an incident, the staff person shall ensure the patient's health and safety, provision of necessary first aid and/or other medical attention as indicated and make a verbal report to the Charge Nurse on duty.

2. If any report of a violation of patient's right is made, an incident report is to be initiated.

5. The Charge Nurse upon notification of the incident, shall go to the scene and immediately ensure any necessary first aid/or medical treatment has been provided and patient's designated family member or other designated person has been notified of the incident. The Medical Director or his/her designee should also be notified. The Charge Nurse shall review the Incident report for completeness and before the end of the shift, route to the hospital's Quality Assurance Coordinator or Director of Nursing.

6. If the incident resulted in serious injury or major damage to property the hospital administrator should be notified at the time of the incident.

7. The Quality Assurance Coordinator/ Director of Nursing (DON) shall review the incident form and begin the incident report quality worksheet.

A. If incident involves allegations of abuse, neglect or mistreatment, the accused staff person should be suspended pending completion of the investigation. If suspension is determined to be appropriate, contact the Director of Human Resources at the corporate level for guidance.

10. If the incident involves a violation of patient rights or a grievance concerning allegations of abuse, a formal investigation is warranted. Commence the investigation immediately upon assignment and instruct/supervise staff in preserving the incident scene and other physical evidence as indicated.

D. Complete thorough investigation report within 4 days of assignment to include:
Summary of the initial incident report
Description of the investigative process
Summary of evidence
Conclusions.

The Incident Report and any other relevant documents will be reviewed by the Medical Director and Administrator for action.

A review of incident reports revealed the following incomplete data:

Incident dated 6/18/13 at 11:00 AM, description of incident- patient (pt) hit MHT (mental health technician) on the left arm several times while trying to walk out of the room without permission, pt also bit MHT on her left hand while trying to kick her.

The report form failed to document any injury to staff or treatment. The bottom section of the report was not completed as to forwarding the report to the DON, QA (quality assurance) worksheet started, incident reviewed in morning meeting or follow up comments. The only signature on the form was from the Medical Director 6/19/13. No signatures from the Administrator, Treatment representative or DON were on the form.

Incident dated 6/20/13 at 3:40 PM, description of incident- location- seclusion room, pt was put in therapeutic hold and taken to seclusion room for running into other group, then patient was trying to choke himself with restraints and put a pillow case over his head. He was moved to other seclusion room and got angry and punched wall and glass...The form was not completed. The Medical Director was not notified,the family was not notified, the DON nor QA were notified, the Administrator was not notified,there was no discussion at the morning meeting and no one signed the form.

Incident dated 6/22/13 at 5:00 AM, description of incident- location- recreation room, while reviewing film (video) for a separate allegation of abuse, note on film excessive force being used by MHT while removing pt from (blank after that), the medical Director was notified 7/17/13. There was no documentation of any injury to pt or staff and the entire bottom section of the report was blank and no signatures were present. (No description of the excessive force was on the incident report.)

Incident dated 8/5/13 at 12:20 PM involved 4 different patients," pt # 1 was in his room and pt # 2 ran into the room and punched pt #1 in stomach and ribs repeatedly and pt # 3 grabbed pt # 2 and got him off pt # 1. MHT didn't see fight with own eyes. MHT was dealing with another pt while all other patients were running into each other's rooms. MHT constantly redirected pt's to stay in their rooms and was unaware of what had happened until pt # 1 came from his room and told MHT what had happened. MHT called for nurse at desk but they were gone to lunch and were busy with treatment team. MHT had pt # 1 stay at chair until nurse come back from treatment team."

The form was not completed, the Medical Director was not notified,the family was not notified, the Administrator was not notified and there was no documentation this incident was discussed at the morning meeting. The only signature on the incident report was the Medical Director dated 8/6/13.

On 8/26/13 at 2:30 PM, the surveyor asked Employee Identifier (EI) # 1, Administrator about these particular incidents and any further information available. EI # 1 did not provide any further information to the surveyor.

***
Findings include:

Policy A 100.1002.01 Infection Control Plan

III. Staffing Plan
The Infection prevention and Control Program functions under the direction of the Director of Nursing (DON).

V. Surveillance Plan

C. Employee Levels of Wellness
Monitoring activity includes but is not limited to:

Risk-reduction activity and reporting with special emphasis on Hepatitis B Vaccine
Employees may bring proof of immunity or immunizations, sign a refusal, or have a titer drawn. Vaccines can be provided as needed to those employees having negative titers.
TB (tuberculosis) screening upon hire and annually.

VI. Process

B. All new employees will be offered Hepatitis B Vaccine.
Employees who refuse vaccine will be required to sign a waiver stating that they have been offered the vaccine and that they are refusing.

C. The DON/Infection Control Nurse and the Committee of the Whole will assist in the development, implementation and ongoing support of the system-wide TB Exposure Control program.

All new staff will receive TB a skin test or chest x-ray, if indicated upon hire and annually unless proof of a skin test or chest x-ray within the past year has been provided.


CDC- Recommended Adult Immunization Schedule- United States 2012 weekly February 3, 2012.

Hepatitis B vaccination: Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated. The second dose should be administered 1 month after the first dose; the third dose should be given at least 2 months after the second dose (at least 4 months after the first dose).

EI # 5, a Mental Health Technician (MHT),was hired 7/1/2013. The employee failed to have a TB test done on hire. The employee had not received any of the Hepatitis B vaccination and no refusal form was in the personnel file. The facility administered the TB test 8/28/13 while the surveyor was in the building and stated she would receive the Hepatitis B vaccine.

EI # 6, a MHT,was hired 6/24/13. EI # 6 received a TB test 7/1/13 but there was no documentation the test was read in the personnel file. EI # 6 received her first Hepatitis B vaccine injection on 7/1/13 and failed to receive the second injection 1 month later.

EI # 8, a Registered Nurse,was hired 6/24/13 and resigned without notice 8/27/13. There was no proof of verification of Registered Nurse license in the personnel record. EI # 8 received a TB test 7/1/13 but there was no documentation the test was read in the personnel file.

EI # 9, a MHT,was hired 3/5/13. EI # 9 received her second Hepatitis B vaccine 4/5/13 and had not received the 3rd dose which was due 2 months after the second dose (at least 4 months after the first dose).

In an interview on 8/28/13 at 2:45 PM with EI # 10, Administrative Assistant, confirmed the above personnel information.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, tour of the facility, review of policies and procedures and an interview, the hospital failed to:

1. Provide an environment for the patient that was maintained to prevent opportunities for self injurious behavior and assure patient dignity.

2. Follow their policy for restraint and seclusion and time-outs.

3. Document appropriate use of restraint and seclusion.

4. Limit the time of restraint to 2 hours as recommended per policy and regulation for adolescents and complete a debriefing after use of restraints.

This had the potential to affect all patients in the facility.

Findings include:

Refer to A 144, A 154 and A 171 for findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of policy and procedure, incident reports, tour of the facility and interview it was determined the facility failed to:

1. Provide an environment for the patient that was maintained to prevent opportunities for self injurious behavior and assure patient dignity.

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

Findings include:

Policy A 100.413 Incident Management

Policy: It shall be the policy of Beacon Children's Hospital to establish and maintain an Incident management System, as a component of the Hospital's Performance Improvement Plan, in order to promote an environment that is caring, free from harm and respectful of patient's rights.

Procedure:

A. Reporting of Incidents: To ensure proper and timely reporting of incidents the following procedures shall be adhered to:

1. Immediately upon discovering or having knowledge of an incident, the staff person shall ensure the patient's health and safety, provision of necessary first aid and/or other medical attention as indicated and make a verbal report to the Charge Nurse on duty.

2. If any report of a violation of patient's right is made, an incident report is to be initiated.

Policy: Washing Machine Disinfection
Policy number 900.703

I. Purpose: To ensure proper disinfection of the washing machine, prevent the spread of communicable disease and provide a safe environment.

II. Policy:

A. The laundry room door will remain locked at all times.

Policy # A 100.303 Use of Restraint and Seclusion

I. Purpose: To ensure the rights and safety of patients when the use of Restraint or Seclusion are clinically justified.

II. Policy: Beacon's Children's Hospital is committed to promoting an environment that avoids use of restraint, seclusion, coercion by effectively using less invasive and restrictive measures.

Inspecting and Cleaning:

Clean restraints as per manufacturer's recommendations.

Findings include:

During a tour of the facility 8/26/13, at 9:30 AM, with Employee Identifier (EI) # 2, a Registered Nurse (RN) the surveyor observed the door to the laundry room was unlocked.

During a tour of the facility 8/26/13 at 9:50 AM, with EI # 2, the surveyor observed the seclusion room with restraints to 4 corners of the bed lying on the floor. The surveyor interviewed EI # 2 and asked why the restraints were laying out and the door to the room was opened.

The surveyor asked EI # 2 why they were attached someone could hurt themselves and she stated she did not know if they would come off. There was no indication of when the restraints were last cleaned.


A review of incident reports 8/26/13 included the follow incidents related to an unsafe environment.

1. Incident dated 6/20/13 at 3:40 PM, description of incident- location- seclusion room, pt (patient) was put in therapeutic hold and taken to seclusion room for running into other group, then patient was trying to choke himself with restraints and put a pillow case over his head. He was moved to other seclusion room and got angry and punched wall and glass.The form was not completed, the Medical Director was not notified,the family was not notified, the DON (Director of Nursing) nor QA(Quality Assurance) were notified, Administrator was not notified,
no discussion at morning meeting and no one signed the form.

2. Incident dated 7/24/13 at 3:45 PM, description of incident- location- seclusion room, patient went into seclusion room and was trying to strangle himself with restraints. MHT (Mental health technician) pulled him away and used therapeutic escort to other seclusion room and the patient put his extra shirt around his face and tried to smother himself. MHT took shirt away and then patient tried to elope out of the double doors but was caught quickly. Pt states he wants to kill himself because of another pt wants to fight him.

3. Incident dated 7/24/13 at 3:40 PM, description of incident- location- Laundry room, pt ran into laundry room closing the door behind him and stood behind the door to keep anyone from coming in. Pt was verbally threatening staff about what he would do."I pushed my body against the door to open it so the patient would come out and he did. The laundry room was then locked."

In an interview 8/26/13 at 2:30 PM with Employee Identifier (EI) # 1, Administrator, was questioned why the laundry roo door was unlocked and the restraints were on the floor. EI # 1 stated the laundry was always to be locked and she added it to the maintenance man's checklist to verify daily.

After reviewing the incident reports 8/26/13 at 2:30 PM, EI # 1 was made aware of the patients trying to injure themselves with the restraints.

EI # 1 informed the surveyor 8/27/13 the seclusion rooms had been locked to limit access to the patients.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, review of policy and procedures and interview it was determined the facility failed:

1. To document appropriate use of restraint/seclusion. Refer to A171

2. To follow facility policy and procedures for use of time-outs.

3. Document in the medical record information regarding the conditions under which the time out occurred.

This had the potential to affect all patients in the facility.

Findings include:

Policy # A100.309 Time Out

I. Definitions:

A. Clinical Time-Out- A procedure in which an individual, in voluntary response to verbal direction from staff, cooperatively enters and remains in a designated area from which egress is not blocked for a period of time, not to exceed thirty (30) minutes without specific joint re-determination by the individual and staff of the need for continuation of the procedure.

II. Policy:

A. Clinical time-out may be used as a preventive and de-escalating intervention to preclude the necessity for the emergency use of restraint or seclusion.

B. Clinical Time-Out:

1. Clinical time-out may be initiated by staff but require the individual's cooperation.

2. Time-out may be used as an ongoing behavioral treatment option provided it is documented on the patient's treatment plan along with specific identified behaviors for which it is used.

4. Each use of clinical time-out must be documented in the individual's record with information regarding the conditions (variant behavior) under which the time out occurred.

Medical Record (MR) findings:

1. MR # 5 was admitted to the hospital 6/12/13 with a diagnoses of Psychosis Not Otherwise Specified and Aggression.

MR # 5 was admitted [DATE] at 9:35 AM with verbal orders for Vistaril 50 mg (milligrams) by mouth or IM (intramuscularly) twice a day for agitation or insomnia.

A second verbal order was written 6/12/13 at 1: 31 PM for Zyprexa 5 mg (milligrams) by mouth or IM twice a day as needed for agitation or aggression. Zyprexa 5 mg BID ( twice a day) first dose now by mouth or IM.

The Multidisciplinary Progress note documented by the Registered Nurse(RN) on 6/15/13 at 4:15 PM, " Pt became upset after phone call to mother became very loud and aggressive acted like he wants to attack another peer. Pt redirected to SR (Seclusion Room), prn (as needed) Zyprexa 5 mg given po (by mouth) as directed, will continue 1:1 observation."

There was no order for seclusion on 6/15/13. There was no documentation the patient was sent to the SR for time-out. There are no other interventions documented to redirect the patient or what type of behavior indicated he acted like he wanted to attack a peer. There are no treatment plan options related to the use of time-outs.


In response to written questions submitted 8/27/13 and responded to 8/30/13 at 11:00 AM by Employee Indentifer (EI) # 1, Administrator it was confirmed the patient was placed in time-out not seclusion on 6/15/13. EI # 1, also confirmed no other interventions were documented prior to the use of time-out. EI # 1 stated no change in the treatment plan reflected the use of time-outs because this was an option not an intervention.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, interview and review of policy and procedures the hospital failed to:

1. Follow their policy for restraint and seclusion.

2. Create a safe environment for patients care.

3. Limit the time of restraint to 2 hours as recommended per policy and regulation for adolescents.

4. Complete a debriefing after use of restraints.

This affect 1 of 3 records reviewed with patients who had been restrained. This had the potential to affect all patients served by this hospital and did affect Medical Record (MR) # 5.

Findings include:

Policy # A100.303 Use of Restraint and Seclusion

I. Purpose: To ensure the rights and safety of patients when the use of Restraint or Seclusion are clinically justified.

II. Policy: Beacon's Children's Hospital is committed to promoting an environment that avoids use of restraint, seclusion, coercion by effectively using less invasive and restrictive measures.

III. Definitions:

A. Restraint is defined as the use of personal restraint or a mechanical device or a Therapeutic Hold to involuntarily restrict the free movement of the whole or a portion of a patient's body in order to control physical activity that prevents injury to patient and/or others.

G. Episode- The time period from the initiation of restraint until the release of the patient.

IV. Standards:

H. Restraint or seclusion should be used for the shortest periods of time necessary to enable the patient to effectively cope with his or her environment.

N. A debriefing of the patient will be conducted by a Trained registered Nurse prior to the patient's release, after each episode of restraint or seclusion. A debriefing of the staff will be conducted by a trained Registered Nurse within 12 hours of the patient's release after each episode of restraint or seclusion.

P. All episodes of restraint will be documented on an Incident report Form for review by the Committee of the Whole.

V. Procedures:

1. Restraint shall only be implemented pursuant to a written order by a Physician or Certified Nurse Practitioner.

4. Written Orders for restraint shall be time limited and meet the following criteria:

a. Designate the specific intervention/procedures authorized, including any specific measures for ensuring the patient's safety, health and well being.

b. Specify the date, time of day, and maximum length of time for which the intervention/procedure may be used, which will not exceed four (4) consecutive hours for patients [AGE] or older and two (2) consecutive hours for adolescent patients [AGE]-17 years.

5. An assessment of the patient and the alternative treatment techniques attempted shall be documented in the patient's record.


Inspecting and Cleaning:

Clean restraints as per manufacturer's recommendations.

Medical Record Findings:

1. MR # 5 was admitted to the hospital 6/12/13 with a diagnoses of Psychosis Not Otherwise Specified and Aggression.

MR # 5 was admitted [DATE] at 9:35 AM with verbal orders for Vistaril 50 mg (milligrams) by mouth or IM (intramuscularly) twice a day for agitation or insomnia.

A second verbal order was written 6/12/13 at 1: 31 PM for Zyprexa 5 mg by mouth or IM twice a day as needed for agitation or aggression. Zyprexa 5 mg BID ( twice a day) first dose now by mouth or IM. Restraint order.

A third verbal order was written at 1:31 PM, " Restraint order- place pt (patient) in 4 point restraints up to 2 hours (hrs) due to pt being a potential threat/harm to self/others with aggressive behavior; hitting, punching. Less restrictive measures ineffective. Pt may be released from restraint when these behaviors subside and pt is no longer a threat to self or others and is able to verbalize behaviors that led to restraint."

The multidisciplinary progress documented by the Registered Nurse (RN) 6/12/13 at 12:40 PM, " Four point restraints in use at present time. Behavior prior to restraints was physical aggression, unable to be redirected. Hyperverbal inappropriate verbal comments, verbal threats and physical threats noted."

MR # 5 was placed in restraints at 12:40 PM and the order was not recieved and documented until 1:31 PM.

The multidisciplinary progress documented by the RN 6/12/13 at 1:30 PM, " Four point restraints remain in place. Verbally disruptive..."

The multidisciplinary progress documented by the RN 6/12/13 at 2:30 PM, " Four point restraints remain in place R/T (related to) patient presents as danger to others. Less restrictive methods were utilized without success."

The multidisciplinary progress documented by the RN 6/12/13 at 3:15 PM, " Four point restraints released."

The time recorded by the nurse was greater than the 2 hours ordered.

The Restraint Flowsheet documented 6/12/13, " In restraints 12:40." The flow sheet continued to document at 15 minute intervals until 3:15 PM when he was released from restraint.

The restraint/seclusion protocol MD ( medical doctor) orders documented 6/12/13 no time of order was on the form, orders for restraint/seclusion are limited to, " 2 hrs for adolescents 10-18 years of age."

The form documented 6/12/13 at 12:55 PM, " 4 point restraint initiated."

The form documented 6/12/13 at 3:15 PM, " 4 point restraint released."

The time is different on the order form but continued to document greater than 2 hours time period for the adolescent being restrained.

The restraint/seclusion debriefing form date 6/12/13 at 3:15 PM, documented no one in attendance except for the RN (Employee Identifier [EI]# 3) completing the form. EI # 3 added to the bottom of the form handwritten information, " 6/12/13 at 3:15 PM, No staff debriefing at present time. 6/13/13 at 12:00 noon, No debriefing with patient noted."

The debriefing with the patient was to have been completed prior to discontinuing the restraints according to policy and the debriefing of the staff was to be completed within 12 hours of the patient's release after each episode of restraint.

In an interview with EI # 1, Administrator 8/28/13 at 2:00 PM, it was confirmed the time documented by EI # 3 was greater than 2 hours and the patient was not debriefed. The policy for restraint and seclusion was not followed.
VIOLATION: PHARMACY PERSONNEL Tag No: A0493
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Incident Reports, medical records, Pharmacy Contract and interview it was determined the hospital failed to ensure all patients received medications as ordered. This had the potential to affect all patients served by the hospital and did affect Medical Record (MR) # 1, # 4 and # 8.

Findings include:

Pharmacy Services Agreement entered into the 9th day of September 2011 between I.V.Stat, Inc. and the facility.

1. Services. IV Stat, Inc. shall provide pharmacy products and services to patients of the facility only on the order of a duly licensed and authorized physician. Pharmacy services will include:

a. Unit dose- Supply all prescriptions in bingo cards that will meet the unit dose requirement for the facility.

c. Emergency Drug box formulary- Provide, maintain and replenish an emergency supply of the most commonly prescribed medications for the facility. IV Stat, Inc. will concur with the facility MD ( medical doctor)... on a "formulary" for this box in order to provide important medications upon patient arrival as needed.

d. Backup pharmacy services- A local pharmacy will be contracted for items that are not readily available in the event the MD... deems it can not wait until the next scheduled delivery. Charges for those items will be billed to the facility accordingly.

e. Medication Administration Record (MAR)- supply a computer generated MAR to include admission medications, diet, allergies and therapy orders.

f. Delivery- Supply free next day delivery via UPS (United Postal Service) or hand delivery of properly packaged medication orders with a printed MAR upon patient admission.

l. Pharmacist Availability- A pharmacist is available at the pharmacy Monday- Friday 8 am-5 pm with nights, weekends and holiday on-call service 24/7.

Medical record findings:

1. MR # 1 was admitted to the facility 8/13/13 with diagnoses of Psychotic Disorder, Panic Attacks and Substance Abuse.

On 8/14/13 at 10:45 AM the physician ordered, " Zydis 2.5 ml ( milliliter) S/L (sublingual) AM (morning) 7/5 ml S/L HS (hour of sleep). Ativan 1 mg ( milligram) po (by mouth) TID (3 times a day), Cogentin 1 mg po BID (2 times a day), Flexeril 10 mg po TID."

On 8/14/13 at 1:49 PM the physician's order was clarified, " Zyprexa 5 mg 1 tablet (tab) po stat, Zyprexa 2.5 mg 1 tab po every AM and Zyprexa 5 mg 1 tab po HS."

The Medication Administration Record (MAR) documented on 8/14/13 no Ativan was given, 8/15/13-2 doses given one at 9 AM and 1 at 9 PM, 8/16/13-1 dose given at 9 PM, 8/17/13-2 doses given one at 9 AM and 1 at 9 PM and 8/18/13-1 dose at 9 AM . The patient did not receive the TID dosage for 3 days as ordered.

On 8/17/13 the physician ordered, " UA (urinalysis) with Gonorrhea and Chlamydia (culture drainage from penis), Rocephin 250 mg IM (intramuscularly) x 1 dose. Doxycycline 100 mg BID x 7 days. Start 8/18/13."

The MAR documented on 8/18/13 only one dose of Doxycycline given at 9:00 AM and only one dose given at 9 AM on 8/24/13 the 7th day. The patient missed 2 doses of the 14 doses ordered.

The nurse failed to document why the doses were missed.

2. MR # 4 was admitted to the facility 6/19/13 with diagnoses of Defiance, Fire Setting and Isolating.

The physician ordered on [DATE] ( a Wednesday) to continue home meds (medications) Risperdal 0.25 mg by mouth twice a day and to discontinue Vyvanz.

A review of the MAR revealed the Risperdal 0.25 mg was not administered 6/19/13 and 6/20/13.

An incident report was completed documenting the dates of the incident "6/19/-6/20". Staff description of incident, " Risperdal 25 mg order on admission 6/19 at 8:05, Risperdal 0.25 mg unavailable in stock med is 1 mg, cannot 1/4 tab and be accurate."
The follow up comments, " Re-faxed to IV Stat at 4:57 AM on 6/21/13."

There was no documentation the physician was notified of the missed medication doses, no documentation of the nurses trying to obtain the medication and no documentation of the patient's behavior from missing 4 doses of medication.

In an interview 8/28/13 at 1:20 PM with Employee Identifier (EI) # 1, Administrator, confirmed the medication was missed and they were researching the problem.

3. MR # 8 was admitted to the facility 8/11/13 with diagnoses of Anger, Aggression, Suicidal ideation's and Mood/Conduct Disorder.

On 8/13/13 an order was documented at 6:20 PM," 1. Obtain wound C&S ( culture and sensitivity)- left posterior thigh. 2. Doxycycline 100 mg (milligrams) 1 po ( by mouth) BID ( twice a day) x 10 days, after wound culture C&S is obtained. 3. Flagyl 500 mg 1 po BID x 7 days."

A review of the MAR revealed the Flagyl was not administered 8/13/13 at 9:00 PM or 8/14/13 at 9:00 AM. The physician was not notified of the missed doses of antibiotics.

In an interview on 8/28/13 at 1:30 PM with EI # 1, the Administrator, it was confirmed the Flagyl was not available but was delivered the next day about 3:30 PM.