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.

OCEANS BEHAVIORAL HOSPITAL OF GREATER NEW ORLEANS 716 VILLAGE ROAD KENNER, LA Feb. 24, 2015
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
Based on record review and interview, the hospital failed to appoint a pharmacist to be responsible for developing, supervising, and coordinating all the activities of the pharmacy services.
Findings:

Review of a contract between the hospital and S7Pharmacist revealed the responsibilities of the Consultant Pharmacist would be to review all areas where medications were stored, review patient charts for pertinent information regarding medication administration each month, and submit a written report to the Administrator and/or Director of Nursing. No documentation of what specifically was to be reviewed in medication storage areas or patient charts.

Review of a contract between the hospital and Company A revealed the responsibilities of the pharmacy company outlined did not include a pharmacist responsible for developing, supervising, and coordinating all the activities of the pharmacy services.

Review of meeting minutes of the Governing Body and of the Medical Staff (noted as "Interim Committee of the Whole") revealed no documentation of the appointment of a Director of Pharmaceutical Services.

In an interview on 2/23/15 at 10:45 a.m. S6RN reported that she did not know who the Director of Pharmacy was.

In an interview on 2/23/15 at 11:25 a.m. S1ADM (Administrator) reported that she thought the Directory of Pharmacy was S3MD (Medical Doctor), the Medical Director. S1ADM reported that the hospital had a contracted pharmacy company that provided medications and stocked the AMD (automated medication dispensing machine). S1ADM further reported that the hospital contracted a separate pharmacist that checked the medication room and reviewed patient charts. After reviewing the pharmacy contracts and Governing Body meeting minutes, S1ADM verified that no pharmacist was appointed to be responsible for developing, supervising and coordinating all the activities of the pharmacy services. S1ADM reported that the hospital did not have a job description for a director of pharmacy.

In a phone interview on 2/24/15 at 1:05 p.m. S7Pharmacist reported that he was not the Director of Pharmacy. S7Pharmacist reported that he inspected the medication areas for expired medications and reviewed patient charts. If he found anything not as it should be he reported it to the hospital administration.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for geriatric psychiatric patients for ligature risks and safety risks.

Findings:

A tour of the main campus of the hospital was conducted on 2/20/15 from 1:45 p.m. to 3:00 p.m. with S2DON (Director of Nursing). There were 9 double occupancy patient rooms with at least 1 (one) patient assigned to each room. All rooms were located down a single hallway. All rooms had a bathroom within the room with a toilet and a sink. All rooms had an outside window view and all rooms opened to the main hallway. The census on 2/20/15 was 15 patients.

The following ligature risk and safety risk observations were made in all the patient rooms.

In all patient rooms 2 hospital beds which had detachable coiled springs as a support for a removable mattress were observed. The springs were visible and accessible beyond the ends of the mattresses. The beds could be raised by use of a hand crank located at the end of the bed. The end of the beds also contained hand cranks to adjust the head and the foot of the bed.

In the patient bathrooms, (located in or between the patient rooms), the toilets were observed the have water pipes and turn off handles exposed on one side of the toilet.

Screws on door handles, door hinges, window hinges, and locks were not of the non-tamper type.

The interior bathroom door hinges were observed to have open-ended door hinges (x3 on each door) separated widely enough to facilitate a potential ligature risk.


S2DON confirmed the observations and reported that all patient rooms, beds, and bathrooms contained the same type of bed, exposed water pipes on one side of the toilets, and screws that were not non-tamper proof. S2DON confirmed the bathroom door hinges were the same in all patient rooms. S2DON confirmed the door hinges and exposed plumbing were potential ligature points.


A tour of the off-site campus of the hospital was conducted on 2/23/15 from 10:10 a.m. to 10:50 a.m. with S1ADM (Administrator). There were 6 double occupancy patient rooms with at least 1 (one) patient assigned to each room. All rooms were located down a single hallway. All rooms had a bathroom within the room with a toilet and a sink. All rooms had an outside window view and all rooms opened to the main hallway. The census on 2/23/15 was 12 patients.

The following ligature risk and safety risk observations were made in all the patient rooms.

2 hospital beds which had detachable coiled springs as a support for a removable mattress. The springs were visible and accessible beyond the ends of the mattresses. The beds could be raised by use of a hand crank located at the end of the bed. The end of the beds also contained hand cranks to adjust the head and the foot of the bed.

In the patient bathrooms, (located in or between the patient rooms), the toilets had water pipes and turn off handles exposed on one side of the toilet.

Screws on door handles, door hinges, window hinges, and locks were not of the non-tamper type.

The interior bathroom door hinges were observed to have open-ended door hinges (x3 on each door) separated widely enough to facilitate a potential ligature risk.

An observation was made in Room B with S10RN. The windows were observed to have a metal block in the window track to prevent the window from opening completely. The metal block was observed to be secured with one screw on each side. The screws were observed to be regular Phillips head screws and they were not tamper resistant. S10RN confirmed the metal blocks were secured with regular screws and confirmed all the patient room windows were secured in the same manner.

A regular Philips-head screw was observed in the wall over the B bed in Room, A. S13LPN (Licensed Practical Nurse) unscrewed and removed the screw with her fingers, and reported it was from a bed alarm that had been there before. In the same room, a nail was observed to protrude approximately 1/2 inch from the wall, just above the window. The nail could be touched without difficulty by the surveyor. The drapes were observed to be attached, by Velcro, to a strip of Velcro glued to the wall. In Room A, the Velcro strip glued to the wall was partially unattached, with the Velcro strip containing multiple large staples in a position with the ends opened out.

The above noted observations were verified by S13LPN and S1ADM.

In an interview on 02/24/15 at 3:00 pm S1ADM provided a list titled, "Risk Assessment of Ligature Contacts" that identified ligature risks throughout the hospital. Review of the list revealed the bed frame, bed springs, and bed cranks were identified and ligature points. The section titled, "Control" revealed the MHT is assigned to continuously monitor the hallway and all patients that are in their room. Rounds are to be completed more frequent than 15 minutes when patients are in their room. S1ADM stated the EOC (Environment of Care) director from corporate teaches the staff in orientation on ligature risk. S1ADM stated suicide risk was assessed on the nursing assessment twice a day. S1ADM stated the staff were not given the ligature contact list but were instructed on risks.

In a telephone interview on 02/24/15 at 3:25 p.m. S21EOC was asked to explain how the hospital mitigated the ligature risks identified by the hospital. S21EOC stated they document every 15 minute rounds but they observed the patients more often. S21EOC stated they train the staff, but was unable to explain when the training was done. S21EOC confirmed the hospital did not have a policy that instructed staff on procedures to mitigate the risk of current patient beds as ligature contacts. S21EOC confirmed the patient beds and springs posed a ligature risk.

In an interview on 02/24/15 at 3:47 p.m. S12MHT stated she was employed at the hospital in January of this year and she did not have prior experience in psychiatric hospitals. S12MHT was asked if she had received training regarding the patient bed as a safety hazard. S12MHT stated she had not received any training regarding the patient beds. S12MHT further stated she did not know what ligature risk meant. She stated the only instruction she had received regarding patient beds was to be sure the bed cranks were folded under the bed so the patient would not trip over them. S12MHT stated she received a 3 day orientation, but she had not received "TIDE" (Therapeutic De-Escalation Education) training yet.

Review of the personnel record for S11MHT revealed no documented evidence of orientation or training that included the ligature risks identified by the hospital or the procedures to mitigate those risks.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
Based on observation, record review, and interview, the hospital failed to ensure the patient's visitation rights were protected and promoted as evidenced by failing to permit private communication during family visitation and failing to document restrictions in the patient's medical record. Findings:

Review of the hospital's policy titled Patient Rights/Responsibilities, Policy number RTS-01 revealed in part the following: You are guaranteed certain rights by the Constitution. Through state and federal law, you are guaranteed additional rights as follows: Communication Rights You have the right to private and uncensored communication with persons of your choice by mail, telephone, and visitation. Part VI. Rights of Persons suffering from Mental Illness and Substance Abuse. 171. Enumerations of rights guaranteed: C. (1) The patient in a treatment facility shall be permitted unimpeded, private, and uncensored communication with persons of his choice by mail, telephone, and visitation. These rights may be restricted by the director of the treatment facility if sufficient cause exists and is so documented in the patient's medical records. The patient's legal counsel, as well as his next of kin or responsible party must be notified in writing of any such restrictions and reasons therefore.

Review of the hospital policy titled, Visitation Guidelines, Policy number PC-14 revealed in part the following: This facility does not allow visitors to bring personal belongings into secured areas of the facility. Visitors are required to store personal belongings in their private vehicles during visitation hours....Visitation will be supervised by staff to promote safety for patients and visitors and for control of contraband....A staff member will be present during visitation to promote safety and for control of contraband. Staff members must visualize patients and visitors at all times during visitation to ensure safety and control of contraband.

In an interview on 02/20/15 at 8:49 a.m., the daughter of Patient #3 confirmed that she had visited her father on 10/28/14 in the evening and she was allowed to visit in the Dining Room. She indicated the staff told her another family was in the "visiting room". She stated that during her visit other patients were walking around and the aides (MHTs) kept walking in and out. The patient's daughter indicated the noise from the ice machine and the refrigerator were very loud and she could not understand what her father was trying to say because of the noise level from the appliances.

On 02/20/15 at 2:10 p.m., an observation was made of the Dining Room at the main campus with S2DON (Director of Nursing). S2DON confirmed visitors met with the patients in this room. She stated visitors were not allowed to meet with the patients in their rooms because the family may bring contraband in. S2DON stated if they want to meet privately they can go to the group room. During the observation the Ice Machine in the room was observed to make a loud noise. S2DON confirmed the noise made by the ice machine was loud and may make it difficult for patients and visitors to converse.

On 02/23/15 at 10:15 a.m., an observation was made of the Dining Room at the off-site campus (Where Patient #3 was a patient) with S10RN. S10RN stated this was the room where family members meet with the patients. She confirmed the patients were not allowed to meet with visitors in their rooms. S10RN stated the patients and their visitors are supervised at all times. During the observation the ice machine began to make a loud noise. S10RN confirmed the ice machine was loud and stated patients who are hard of hearing can request a different room. S10RN stated the other room that could be used was the "OT" (Occupational Therapy) room that they use for their team meetings.

In an interview on 02/24/15 at 10:44 a.m. S6RN was asked to explain the hospital's visitation procedure. After review of the hospital's patient rights policy, she verified patients are not allowed privacy during family visits. She stated the staff supervise all visits to ensure contraband was not given to patients. S6RN stated they could monitor by video since visitors all meet in the dining room and there was a camera in the dining room. She stated visitors were not allowed in patient rooms. S6RN confirmed all patients/family do not have issues with contraband and none of the hospital's current patients had concerns with the family passing contraband to the patient. She stated even if family requested a private place to meet, the staff would still stand at the door to supervise. S6RN verified this was the process even if patient was not on 1:1 observation level. S6RN stated she just went by the policy on visitation which indicated, "Visitation will be supervised by staff to promote safety for patients and visitors and for control of contraband."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the Registered Nurse (RN) failed to supervise and evaluate the nursing care for each patient as evidenced by:
1) failure to assess the patient's wound for 1 of 1 (#3) sampled patients reviewed for wound assessments out of a total sample of 5 (#1-#5);
2) failure to notify the patient's family of a fall and sexually inappropriate behavior for 1 (#3) of 5 sampled patients
3) failing to ensure the hospital's "Walk Program" was implemented according the the hospital policy for 2 (#1, #5) of 5 sampled patients, and;
4) failure to provide ADL (Activities of Daily Living) care for 1 (#3) of 5 sampled patients.

Findings:

1) Failure to assess the patient's wound:

Patient #3

Review of the medical record for Patient #3 revealed the patient was a [AGE] year old male admitted to hospital on [DATE] with a diagnosis of Dementia with Behavioral Problems. The patient was admitted under a PEC (Physicians Emergency Certificate) dated/timed 10/19/14 at 4:30 p.m. The PEC revealed the patient was dangerous to self, gravely disabled, and unable to seek voluntary admission.

Review of the Multi-Disciplinary Notes revealed the following:
10/27/14 at 8:10 p.m. Spoke to spouse and notified her that patient is restless and anxious provided updated. The entry was signed by S22RN.
10/27/14 at 10:20 p.m. - patient on floor in his room, prone position. Laceration noted to bridge of nose and lip. Left pinky finger deformed. Patient refused wound care and assistance and became combative and uncooperative. Called S3MD & S18MD to notify and get transfer orders. Called DON and administrator to notify. Awaiting transport. The entry was signed by S22RN.
10/27/14 at 11:30 p.m. Patient's transport arrives. He remains uncooperative. MHT sent along to assist with patient.
10/28/14 ad 6:00 a.m. Patient returned to unit via ambulance. New orders for patient in physician's orders. The entry was signed by S22RN.
There was no documented evidence of an assessment of the patient's wounds upon return from the emergency department (ED).

Review of the ED record for Patient #3 revealed the patient was accompanied by his wife who reported the patient had a deformity to his left 5th finger with a wound to the left 5th finger. The record revealed the patient also had active bleeding from an abrasion to the bridge of his nose and bleeding from his mouth. Review of the ED record revealed a manual reduction was performed to the left 5th finger and a 3 cm (centimeter) laceration to the left 5th finger was sutured closed with 4-0 prolene (non-absorbable sutures).

Further review of the Daily Nurse Notes revealed the following:
10/28/14 (7A-7P) - Left hand wrap d/t (due to) dislocated finger. Geri Chair for safety. Patient sitting in chair eyes closed, playing with tray table.
10/28/14 (7P-7A) - no documentation of wound assessment or presence of dressing to left hand/finger.
10/29/14 (7A-7P) - Bruises/Abrasions (Checked) Other: Left hand wrapped d/t dislocated finger.
10/29/14 (7P-7A) - Bruises (Checked) and no documentation of a wound assessment or the presence of a dressing to the left hand/finger.
10/30/14 (7A-7P) - Bruises (Checked) Other: Left hand wrapped.
10/30/14 (7P-7A) - Bruises (Checked) and no documentation of a wound assessment or the presence of a dressing to left hand/finger.
10/31/14 (7A-7P) - no documentation of wound assessment or presence of dressing to left hand/finger.
10/31/14 (7P-7A) - no documentation of wound assessment or presence of dressing to left hand/finger.
11/01/14 (7A-7P) - Bruises/Abrasions (Checked) and no documentation of a wound assessment or the presence of a dressing to the left hand/finger.
11/01/14 (7P-7A) - no documentation of wound assessment or presence of dressing to left hand/finger.
11/02/14 (7A-7P) - Bruises/Abrasions (Checked) and no documentation of a wound assessment or the presence of a dressing to the left hand/finger.
11/02/14 (7P-7A) - no documentation of wound assessment or presence of dressing to left hand/finger.
11/03/14 (7A-7P) and (7P-7A) - no documentation of wound assessment or presence of dressing to left hand/finger.

Review of the physician's orders revealed no documented evidence of any physician's orders for wound care to the Left 5th finger.

In an interview on 02/24/15 at 2:11 p.m., S10RN stated the patient fell on [DATE] and she was not here that day. She stated when she returned to work (10/29/14) the patient had a bruise on his nose. She stated the patient had a dressing on his finger but she did not remember stitches or an open wound. She stated he had bruises and abrasions on his nose. After reviewing the patient's record, S10RN indicated her note on 10/30/14 revealed she had assessed the patient as having bruises on 10/29/14 and the left hand was wrapped due to the dislocated finger. The ED record was reviewed with S10RN and she verified the ED record dated 10/28/14 revealed the patient received sutures in the ED on the 5th finger that was dislocated. Review of the ED record with S10RN revealed the patient had a 3 cm. laceration on the left 5th finger that was sutured with 3-0 prolene. S10RN verified there was no documentation in the nursing assessments of an assessment of the sutured wound. S10RN verified the only documentation related to the wound on the patient's fifth finger was a dressing was on the hand. S10RN verified there were no wound care orders and no discharge orders from the ED.


2) Failure to notify the patient's family of a fall and sexually inappropriate behavior:
Patient #3
Review of the medical record for Patient #3 revealed the patient was a [AGE] year old male admitted to hospital on [DATE] with a diagnosis of Dementia with Behavioral Problems. The patient was admitted under a PEC (Physicians Emergency Certificate) dated/timed 10/19/14 at 4:30 p.m. The PEC revealed the patient was dangerous to self, gravely disabled, and unable to seek voluntary admission. The PEC revealed the patient punched another resident at an assisted living center that he had just moved in 2 days prior. Dementia rapidly worsening per family.

Review of the Multi-Disciplinary Notes revealed the following:
10/21/14 at 11:30 a.m. Patient sitting in chair in dining area very confused. Patient leaning/pushing on the back of the chair he was sitting on while also scooting the chair back, attempting to stand. Patient fell . AROM (Active Range of Motion) exercises performed to all extremities no grimacing noted. Patient was assisted up and full assessment performed. Small skin tear to right elbow noted. Cleaned with normal saline, TAO (Triple Antibiotic Ointment) applied and dressed.
10/21/14 at 11:45 a.m. - Review of the entry revealed the nurse attempted to contact the patient's wife and daughter two times and there was no answer.
There was no documented evidence of any further attempts to notify the family and there was no evidence the family was notified. There also was no documented evidence that an incident report was documented for the patient's fall.

Further review of the Multi-Disciplinary Notes revealed the following:
10/23/14 at 4:50 p.m. - Patient standing in hallway in front of another patient, playing with the other patient's penis and the other patient play with his, redirected by staff.
10/23/14 at 5:55 p.m. - Patient sitting in TV room, jumped up, pulled pants down had bowel movement on floor, urinated on floor. Staff present, fighting staff while being cleaned.
There was no documented evidence that the patient's wife was notified of the patient's behaviors.

In an interview on 02/24/15 at 8:54 a.m., S1ADM (Administrator) reviewed the medical record for Patient #3 and confirmed there was no documented evidence that the patient's wife was notified of the patient's fall on 10/21/14. S1ADM confirmed there was no incident reported completed for the fall and stated she was not aware that the patient had sustained a fall on 10/21/14. She verified the staff attempted to contact the family but there was no documentation that they were ever notified. S1ADM verified the patient's wife should have been notified of patient's behavior on 10/23/14, but there was no documentation that they were.


3) Failing to ensure the hospital's "Walk Program" was implemented according to hospital policy:

Review of the hospital policy titled, "Walk Program", policy number NSG-33, dated August 2011, revealed in part the following: It is the policy of Oceans Behavioral Hospital that all patients admitted to the geriatric program will participate in the established guidelines for the walk program in not medically prohibited. Each patient participates at least once on a daily basis unless otherwise requested by the physician with modification as needed to accommodate physical abilities/limitations. Participation begins on the first day of admit....Refusal or inability to participate needs to be reported to the charge nurse. Recreational Therapist/AT or Designee: is responsible for documentation and monitoring of the progress of the patient's walk program goal. Objectives: Ambulatory Patients: Patient will participate in stretching and walking exercised 1-2 times daily completing a minimum of 1-3 laps or as tolerated to the best of their ability with assistance as needed to accomplish the goals in conjunction with continuous treatment as outlined in the individualized treatment plan. Wheel Chair Patients: Patient will participate in modified exercise 1-3 times daily completing a minimum of 2 laps with assistance as needed to the best of their ability to accomplish program goals in conjunction with continuous treatment as outline ion the individualized care plan.

Patient #3
Review of the physician admit orders dated 1019/14 revealed an order for the patient to participate in exercise groups as tolerated.

Review of the walk program documentation for Patient #3 revealed 3 possible goals and indicated one goal was to be checked. The form also indicated 3 possible objectives and indicated one objective was to be checked. There was no documented evidence that a goal or objective was checked for Patient #3. Further review of the form revealed sections to document the date, number of laps, minutes, response key and the MHT (Mental Health Technician) initials. Review of Patient #3's walk program form revealed a column dated 10/20 (10/20/14) but the number of laps, minutes duration, response key and MHT initials were blank. Review of the form revealed on 10/27, 10/28, 10/29, 10/30, and 11/2 "0" was marked in the number of laps and the duration of minutes section, and U/A (Unable) was documented in the response key section. The form revealed if UA was documented, it must be explained. Review of the section of the form titled Response revealed on 10/28 the patient was unsteady on his feet. There were no other explanations of why the patient was unable to participate. There was no documented evidence that 11/03/14 was included on the form or if any activity was provided.

In an interview on 02/24/15 at 8:54 a.m., S1ADM reviewed the medical record for Patient #3 and stated the MHT was responsible for documenting the patient's participation in the walk program. S1ADM verified the MHT did not document why the patient was unable to participate on 10/28, 10/29, 10/30 and 11/2. S1ADM verified nothing was documented on 11/03/14 and the column dated 10/20/14 was left blank. S1ADM stated if the patient was unable to participate it may be documented in the Multi-Disciplinary Notes. After reviewing the Multi-Disciplinary Notes, she confirmed there was no documentation of why the patient was unable to participate.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a [AGE] year old female admitted to the hospital 2/18/15 with a diagnosis of Dementia. The patient's admission was a non-contested admission. Further review of Patient #5's medical record revealed she was assessed as a high risk for falls; the patient's score on the At Risk for Falls (ARF) Score Sheet was 36, with High Risk being any score greater than 17. Her risk factors were documented as over 65 years of age, history of fall(s), fait unsteady/poor balance, secondary cardiac/circulatory diagnosis, cognitive impairment, and gait weak/slow.

Review of the physician admit orders dated 2/18/15 revealed an order for the patient to participate in exercise groups as tolerated. Further review of physician orders revealed an order, dated 2/23/15 at 8:00 a.m., that read "May use Geri-chair with tray for patient safety related to unsteady gait."

Review of the walk program documentation for Patient #5 revealed 3 possible goals and indicated one goal was to be checked. The form also indicated 3 possible objectives and indicated one objective was to be checked. There was no documented evidence that a goal or objective was checked for Patient #5. Further review of the form revealed sections to document the date, number of laps, minutes, response key and the MHT (Mental Health Technician) initials. Review of Patient #5's walk program form revealed a column dated 2/18 (2/18/15) , 2/19, 2/20, 2/21, 2/22, 2/23, and 2/24. Review of the form revealed on 2/18, 2/19, 2/20, 2/21, and 2/22 "0" was marked in the number of laps and the duration of minutes section, and U/A (Unable) was documented in the response key section. The form revealed if UA was documented, it must be explained. Review of the section of the form titled Response revealed on 2/20, 2/21, and 2/22 the patient was unsteady on her feet. There was no documented explanations of why the patient was unable to participate on 2/18 and 2/19.

In an interview on 02/24/15 at 8:54 a.m., S1ADM reviewed the medical record for Patient #5 and stated the MHT was responsible for documenting the patient's participation in the walk program. S1ADM verified the MHT did not document why the patient was unable to participate on 2/18 and 2/19.



4) Failure to provide ADL (Activities of Daily Living) care:

Patient #3

Review of the medical record for Patient #3 revealed the patient was a [AGE] year old male admitted to hospital on [DATE] with a diagnosis of Dementia with Behavioral Problems. The patient was admitted under a PEC (Physicians Emergency Certificate) dated/timed 10/19/14 at 4:30 p.m.

Review of the record revealed documentation that ADL care was provided on the following dates only: 10/20/14 at 6:00 p.m., 10/25/14 at 7:00 a.m., 10/29/14 at 5:45 a.m., 10/31/14 at 6:30 a.m., and 11/02/14 at 5:45 a.m.

In an interview on 02/24/15 at 12:30 p.m. S6RN reviewed the patient's record. She stated the MHT should have documented the ADL care on the Close Observation Check Sheets. S6RN stated ADLS consisted of mouth care, cleaning the patient's face and hands. She stated ADL care was 31 on the observation sheets. After reviewing the observation sheets for Patient #3, she verified the ADLs were not documented daily and they were required to be done daily.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and interview, the hospital failed to ensure the facility and all patient care equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1) failing to ensure the suction machine on the emergency cart was usable and in working order for 2 of 2 emergency carts on both campuses of the hospital, and;
2) failing to ensure the walls and ceiling in patient care areas were maintained in good repair.

Findings:

1) Failing to ensure the suction machine on the emergency cart was usable and in working order:

Review of hospital policy TX-SPEC-08: Emergency Care, provided by S1ADM as current, revealed, in part, the emergency cart would be housed on each distinct unit and inspected/stocked by nursing staff on a regular basis. Further review of the policy revealed the Nursing staff (Night shift) would inspect the emergency cart daily and document findings on the "Ready for Use" checklist. The nursing staff would check, stock, and clean the emergency cart. The nursing staff would notify the DON (Director of Nursing) and supply clerk for missing or expired items to be restocked.


On 02/20/15 at 2:30 p.m., an observation was made of the emergency cart in the nurse's station on the main campus. S2DON (Director of Nursing) was present for the observation. The suction machine was turned on to verify the machine working. No suction was obtained from the machine. Under further inspection, the lid of the suction canister was observed to have a 3-4 inch crack. S2DON confimed the lid was cracked and the suction was not working. Review of the emergency cart check list revealed the cart had been checked daily, including 2/20/15, and the checklist indicated the suction was working.

On 2/23/15 at 11:40 a.m., an observation was made of the emergency cart in the nurse's station on the offsite campus. S10RN (Registered Nurse) was present for the observation. The suction machine was turned on to verify the machine was working. No suction was obtained from the machine, even though the motor was running. S10RN confirmed there was no suction obtained from the machine, and reported she could find no reason for there to be no suction produced. Review of the emergency cart check list for February revealed documentation the cart had been checked daily and the checklist indicated the suction was working. S10RN reported that they (the nurses) turn on the machine to see if it runs, but didn't actually check to see if suction was produced.

In an interview on 02/24/15 at 7:30 a.m., S9RN stated when she checked the emergency cart, she turned the suction machine on, but she did not check to see if the suction was working.


2) Failing to ensure the walls and ceiling in patient care areas were maintained in good repair:

On 02/23/15 at 10:35 a.m., an observation of the male shower at the off-site campus was made with S10RN. The area of the wall adjacent to the shower and above the base board was observed to have a hole in the wall with the plaster missing around the hole. S10RN confirmed the finding and that the area could not be disinfected.

On 02/23/15 at 10:45 a.m., an observation was made in Room C at the off-site campus with S13LPN. The ceiling adjacent to the window and in the right corner of the room was observed to have multiple cracks in the plaster. S13LPN confirmed the observation.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record reviews and interviews, the hospital failed to ensure the effective implementation of policies/procedures relative to infection control to include a system for identifying, reporting, investigating, prevention,and controlling infections and communicable diseases of patients and personnel. This was evidenced by the hospital's:
1) failure to ensure that nursing staff disinfected/cleaned a multiple patient use glucometer.....
2) failure to maintain a sanitary physical environment as evidenced by:
a. Dining/Activity room and nurse's station with visibly soiled floors
and tables at the main campus;
b. having patients care equipment with noted red substance on
cleaned shower chair in male shower on off-site campus;
c. female shower on off-site campus not cleaned after use;
d. adhesive substance on multiple walls and doors at the off-site
campus.


Findings:

1) Failure to ensure that nursing staff disinfected/cleaned a multiple patient use glucometer:

Review of hospital policy NSG-24: Glucometer Method for Obtaining (2013), provided by S1ADM as current, revealed the care of Meter (Glucometer) and strips included "Clean the meter between patients and per manufacturer's instructions."

Review of a Manufacturer's Manual for the hospital glucometer revealed, in part, the meter should be cleaned and disinfected between each patient (page 46). Further review revealed a list of Disinfectant Products approved for cleaning and disinfecting the glucometer.

In an interview on 2/23/15 at 10:40 a.m., S13LPN (Licensed Practical Nurse) reported the glucometer was cleaned between patients with alcohol.

After an observation on 2/23/15 at 11:20 a.m. of S13LPN performing a capillary blood glucose on an inpatient then cleaning and disinfecting the glucometer with disinfectant wipes, S13LPN was asked if that was the way she usually cleaned the glucometer. S13LPN reported that she usually used alcohol wipes to clean the glucometer between patients, but had been instructed by S10RN (Registered Nurse) that she was supposed to use disinfectant wipes between use on patients.


2) Failure to maintain a sanitary physical environment as evidenced by:
a. Dining/Activity room and nurse's station with visibly soiled floors and tables at the main
campus:

Review of hospital policy HK-01: Housekeeping Services Introduction (2013), provided by S1ADM as current, revealed, in part, facility grounds and interior would be kept in good repair, clean sanitary and safe at all times.

Review of hospital policy IC-30: Environmental Services(2013), provided by S1ADM as current, revealed in part, the purpose of the policy and procedure was to control the spread of infection within the hospital by maintaining a thoroughly clean and safe environment. Further review revealed the procedure was, "Sanitation within the hospital environmental depends upon cleaning thoroughness and frequency. There shall be procedures for cleaning walls, floors, windows, beds, furniture, waste containers, bathrooms, equipments..."

Review of hospital policy HK-08: Floor Maintenance (2013), provided by S1ADM as current, revealed the purpose of the policy and procedure was to maintain the hospital flooring to ensure floors were presentable, cleaned, sanitized and safe at all times. Further review revealed the policy was that a daily, monthly, and yearly floor schedule would be maintained. Wet mopping was to be performed daily.

Review of hospital policy HK-7: Cleaning of Hospital Units (2013), provided by S1ADM as current, revealed work areas, hallways, and other areas of the hospital's unit would be cleaned daily to promote a clean and sanitary area.

Review of hospital policy HK-03: Patient Room and Bathroom Cleaning-Daily Maintenance and Discharge (2013) provided by S1ADM as current, revealed the purpose was to ensure patient rooms and bathrooms were cleaned/disinfected daily and after discharge. Further review revealed the policy was that housekeeping would clean patient rooms and showers seven days a week. All cleaning standards and infection control policies and procedures were to be followed. Further review revealed Shower rooms were to be cleaned a minimum of one time per day by housekeeping as well as in between each patient by Mental Health Technicians.

On 02/20/15 at 2:10 p.m., an observation was made in the Dining/Activity room at the main campus with S1ADM (Administrator). Six (6) patients were observed to be seated in the room. 2 of the patients were seated in Geri Chairs, 1 patient was seated on a rolling walker and the 3 other patients were seated in chairs at the tables. An MHT (Mental Health Technician) was observed in the room also. The floor in the Dining/Activity room was observed to be visibly soiled with black/gray discoloration noted throughout the room. Trash and food debris was noted on the floor. An over bed table in the room was observed to have a brown substance on the legs and top of the table. S1ADM verified the above findings and confirmed the floors and table were not clean. S1ADM stated the hospital contracted with the nursing home that was located in the same building for housekeeping services. S1ADM stated S14Housekeeping provided cleaning for the hospital and the nursing home.

On 2/20/15 at 2:35 p.m. S14Housekeeping was observed to enter the Dining/Activity Room of the main campus. S14Housekeeping was asked when the room was last cleaned. She stated she last cleaned the room yesterday.

On 02/20/15 at 2:45 p.m., an observation of the nurse's station at the main campus was made with S2DON (Director of Nursing). A large accumulation of gray/black dust was noted on the floor around the copy machine. Black/gray substance along with pieces of tape were noted on the floor. S2DON confirmed the floor in the nurse's station was not clean.

On 02/23/15 at 10:20 a.m., an observation of the Dining/Activity Room at the off-site campus was made with S10RN. An adhesive substance measuring 8 by 11 inches was noted on the walls in several places. S10RN stated this substance was glue that was used to adhere signs to the wall. She stated patients had pulled the signs off and the glue residue was left on the wall. Further observation of the unit revealed multiple areas of adhesive residue left on the doors and walls of patient rooms and the hallway walls. S10RN confirmed the glue residue did not provide a smooth wipeable surface for disinfection.

On 02/23/15 at 10:30 a.m., an observation of the female shower at the off-site campus was made with S10RN. A white substance was noted on the wall of the shower. S10RN applied gloves and removed the white substance, stating it was toothpaste. S10RN removed a sticker and a white substance from the floor of the shower. S10RN stated the shower was used this morning and the MHT should have cleaned the shower after it was used. S10RN confirmed the shower was not clean. Further observation of the shower room revealed a shower chair with a red substance on the base of the chair. The shower curtain contained visible soap scum. S10RN confirmed the shower chair and the shower curtain were not clean.

On 02/23/15 at 10:35 a.m., an observation of the male shower at the off-site campus was made with S10RN. A shower chair was observed in the shower and a red substance was observed on the arm of the chair and down the legs of the chair. S10RN confirmed the shower chair was not clean. Over the sink on the wall there were holes in the wall that were filled with putty and and 8 by 11 inch area of glue residue was observed. S10RN confirmed the wall over the sink did not provide a smooth wipeable surface for disinfection.


On 02/23/15 at 10:45 a.m., an observation was made in Room C at the off-site campus with S13LPN. The ceiling adjacent to the window and in the right corner of the room was observed to have a spider web over multiple cracks in the plaster. S13LPN confirmed the observation.