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.

TWO RIVERS BEHAVIORAL HEALTH SYSTEM 5121 RAYTOWN ROAD KANSAS CITY, MO March 4, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review and review of facility policies the facility failed to ensure patient safety and security when one patient (Patient #36) was admitted with a history of extreme violence, violent felony criminal history and/or history of sexual aggression. Staff assessed the patient to be delusional, suspicious, had impaired judgment, exhibited bizarre behavior, impulsiveness, acute onset of psychosis or severe thought disorder and severe functional debilitation. Despite this patient's history and current assessment staff failed to implement additional measures to protect other patients. Patient #36 sexually assaulted Patient #40 less than 24 hours after admission. This failure had the potential to affect all patients.

The facility also failed to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in an environmentally safe setting (staffed, designed and equipped to minimize the patient's ability to harm themselves or others). This had the potential to affect three of 12 Geriatric inpatients, eight of 27 Adult Psychiatric inpatients, one of four Child/Adolescent Psychiatric inpatients, and three of 12 Psychiatric/Trauma inpatients (a total of 15 psychiatric patients on Suicide/Self Harm 15 minute watches).

Examples of an unsafe environment that patients had access to included:

-Non Suicide-resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls;
-Sink faucet handles that were 2 1/2 inch long to 4 inches long which provided a potential mechanism to strangle or hang oneself;
-A rectangular metal plate supporting towel hooks; this plate protruded 5/8 inch from the wall and provided a potential looping hazard;
-Metal cage over the thermostat that protruded from the wall which provided a potential looping hazard;

-Shower fixtures with gaps between the fixtures and the shower walls measuring between one eighth and one quarter inch wide, which provided a potential looping hazard;
-Patient bathroom door hinges which provided potential looping hazards;
-Light fixtures above the patient sinks that protruded out from the wall eight inches which provided a potential looping hazard;

-A patient in possession of an elastic stretch wrap bandage that provided potential looping and/or hanging hazard or a strangulation device;

-Electrical cords of varying length from four to six feet which provided a potential looping hazard for all patients; and
-Shower curtains of a non-porous heavyweight vinyl-polymer material which provided a potential suffocation hazard for all patients.

The facility admitted patients with suicidal ideation, history of suicidal ideations, history of sexual assault, attempts at self harm and assaultive tendencies.

Due to the severity of the situation and the potential for harm to all patients in the facility, this resulted in overall noncompliance with the Condition of Participation: Patient Rights CFR482.13 and demonstrated an unsafe patient care environment. This situation constituted a condition of Immediate Jeopardy.
The facility was notified of the Immediate Jeopardy and the facility had implemented a plan to abate the Immediate Jeopardy at the time of exit.
The facility census was 54.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


2. Observation in Module C, Geriatric Psychiatric Unit with census of 12 inpatients on 03/01/11 at 1:00 PM, showed eight patient rooms (rooms 534 through 541), each equipped with private bathrooms, with the following:

- Sink faucet handles that were 2 1/2 inch long to 4 inches long which provided potential mechanism to strange or hang oneself. The configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation).
-A rectangular metal plate supporting towel hooks; this plate protruded 5/8 inch from the wall and provided a potential mechanism to strange or hang oneself looping hazard. The protruding steel plate creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation).
-Light fixture unit above the hand sink that protruded eight inches from wall and 22 inches from the ceiling. The light fixture mounted on the wall above all hand wash sinks creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation).
-Shower curtains of non-porous heavyweight vinyl-polymer material. The vinyl shower curtains were easily detached; however they are composed of heavyweight vinyl and presented a potential suffocation hazard.
-Exposed plumbing behind toilets in two bathrooms (Rooms 535 and 541); Exposed plumbing created an opportunity for a looping or strangulation hazard.
-Eight rooms (534 through 541) had sloped hospital hinges on conventional bathroom doors that left a gap a the top and created a ligature, or looping hazard. Gaps or openings produced a choke point for a looping or strangulation hazard and created an opportunity for injury and presented an additional hazard to patients with suicidal ideations.

3. Observation in Module A, Child/Adolescent Psychiatric Unit, a 20 bed unit with a census of four inpatients on 03/01/11 at 2:15 PM, rooms 109-119, showed each patient room equipped with a private bathroom, with the following:
- Sink faucet handles that were 2 1/2 inch long to 4 inches long which provided potential mechanism to strange or hang oneself; The configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-A rectangular metal plate supporting towel hooks; this plate protruded 5/8 inch from the wall and provided a potential mechanism to strangle or hang oneself .
-Light fixture unit above the hand sink that protruded eight inches from wall and 22 inches from the ceiling of each bathroom; The light fixture mounted on the wall above all hand wash sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Shower curtains of non-porous heavyweight vinyl-polymer material. The vinyl shower curtains were easily detached; however they are composed of heavyweight vinyl and present a potential suffocation hazard, created an opportunity for injury and presented an additional hazard to patients with suicidal ideations.
-Room 109 had a metal cage over the thermostat. The metal cage that protected the thermostat in room 109 could be a potential weapon once small screws were removed.
-Desk in room 111 not secured to wall or floor. Unsecured furniture created an opportunity for injury and presented an additional hazard to patients with suicidal ideations by allowing easier access to looping hazards.
-Gap of 1/8 inch between shower head and shower walls in shower rooms of 116, 118, and room 119. Gaps or openings between the shower head and the shower wall produced a choke point for a looping or strangulation hazard.
-Eleven rooms (109-119) had sloped hospital hinges on conventional bathroom doors that left a gap a the top and created a ligature, or looping hazard. Gaps or openings produced a choke point for a looping or strangulation hazard.

4. Observation in Module A, an 18 bed Psychiatric Trauma Unit with a census of 12 inpatients, on 03/01/11 at 2:50 PM, with rooms 101 through 108, showed each equipped with private bathrooms and the following:
- Sink faucet handles that were 2 1/2 inch long to 4 inches long which provided potential mechanism to strange or hang oneself. The configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-A rectangular metal plate supporting towel hooks; this plate protruded 5/8 inch from the wall and creates a looping hazard (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Light fixture unit above the hand sink that protruded eight inches from wall and 22 inches from the ceiling of each bathroom. The light fixture mounted on the wall above all hand wash sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Shower curtains of non-porous heavyweight vinyl-polymer material. The vinyl shower curtains were easily detached; however they are composed of heavyweight vinyl and present a potential suffocation hazard.
-Desk in room 111 not secured to wall or floor; Unsecured furniture created an opportunity for injury and presented an additional hazard to patients with suicidal ideations by allowing easier access to looping hazards.
-Gaps of up to one quarter inch wide between shower head cover plate and shower walls in shower rooms of 103, 104, 105, 106, 107 and 108; Gaps or openings between the shower head and the shower wall created by missing screws and little or no caulk filling produced a choke point for a looping or strangulation hazard, and unsecured furniture created an opportunity for injury and presented an additional hazard to patients with suicidal ideations.
-Eight rooms (101 through 108) had sloped hospital hinges on conventional bathroom doors that left a gap a the top and created a ligature, or looping hazard. Gaps or openings produced a choke point for a looping or strangulation hazard to patients with suicidal ideations.

5. Observation in Module B, a 40 bed Adult and Dual Diagnosis Unit with a census of 27 inpatients on 03/01/11 at 2:50 PM, and 03/02/11 at 9:35 AM, with rooms 200 through 219, each equipped with private bathrooms, showed the following:
- Sink faucet handles that were 2 1/2 inch long to 4 inches long which provided potential mechanism to strangle or hang oneself; the configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-A rectangular metal plate supporting towel hooks; this plate protruded 5/8 inch from the wall and provided a potential mechanism to strangle or hang oneself;
The protruding steel plate creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Handles (4 ? inches long) on sink fixture in room 205; the configuration of any moderate to long handles on hand washing sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Light fixture unit above the hand sink that protruded eight inches from wall and 22 inches from the ceiling of each bathroom;
The light fixture mounted on the wall above all hand wash sinks creates looping hazards (material or a device could be looped around/over the objects to be use for choking and strangulation) for all patients in the secured module.
-Shower fixture with 1/8th inch open gap between the fixture and wall of the shower; Gaps or openings between the shower head cover plate and the shower wall created by missing screws and little or no caulk filling produced a choke point for a looping or strangulation hazard to patients with suicidal ideations.
-Shower curtains of non-porous heavyweight vinyl-polymer material; The vinyl shower curtains were easily detached; however they are composed of heavyweight vinyl and present a potential suffocation hazard.
-Twenty rooms (200 through 219) in the combined unit had sloped hospital hinges on conventional bathroom doors that left a gap a the top and created a ligature, or looping hazard.


6. During interviews on 03/02/11 at 9:35 AM through 03/04/11 at 1:00 PM, the Director of Plant Operations (DP) stated he was aware of the potential environmental hazards including toilet plumbing, faucet handles, shower handles, metal support panel, thermostat covers, gaps between the shower head and shower wall, shower curtains . The DP stated he was developing a plan to address these hazards but it had not been implemented yet.





Based on observation, interview, record review and review of facility policies the facility failed to ensure patient safety and security when one patient (Patient #36) was admitted with a history of extreme violence, violent felony criminal history and/or history of sexual aggression. Staff assessed the patient to be delusional, suspicious, had impaired judgment, exhibited bizarre behavior, impulsiveness, acute onset of psychosis or severe thought disorder and severe functional debilitation. Despite this patient's history and current assessment staff failed to implement additional measures to protect other patients. This failure had the potential to affect all patients. Patient #36 sexually assaulted Patient #40 less than 24 hours after admission.

The facility also failed to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in an environmentally safe setting (staffed, designed and/or equipped to minimize the patient's ability to harm themselves or others). This had the potential to affect three of 12 Geriatric inpatients, eight of 27 Adult Psychiatric inpatients, one of four Child/Adolescent Psychiatric inpatients, and three of 12 Psychiatric/Trauma inpatients (a total of 15 psychiatric patients on Suicide/Self Harm 15 minute watches).

The facility had a total census of 54 on the first day of survey.

Findings included:

1. Review of facility policy titled, "PC-PROVISION OF CARE TREATMENT SERVICES, Number: PC-592, TOPIC: PRECAUTIONS", dated 11/18/2010, showed the following definitions (in part):
Assaultive Precautions (AP)
All patients who actively assault or have a recent history of violent aggressive behavior, or verbal threats placing themselves, others, or property in immediate or imminent danger will be placed on Assault Precautions. Patients on Assault Precautions will be monitored at 15 minute intervals to provide for their own and others safety.
Suicide Precautions (SP)
All patients who verbalize suicidal ideation with/or without plan and/or intent or have attempted suicide or self-injury will be considered in imminent danger and will be placed on Suicide Precautions. Patients on Suicide Precautions will be carefully monitored and assessed every 15 minutes to minimize the potential for self harm. Shoelaces, belts and other potentially dangerous items will be removed from the patient's possession.
Sexual Aggression (SA)
All patients who are admitted with a history of aggressive sexual behavior will be placed on SAO (Sexual Aggression Observation) Precautions. Patients who are "presently" demonstrating sexually aggressive behavior will be placed on SAO I, SAO II or SAO III precautions depending on the severity of behavior . (Notation: SAO I, SAO II and SAO III is not further defined in the facility policy).
Review of this policy indicated there was no difference between the precautions other than staff will remove shoelaces, belts and other potentially dangerous items from the patient's possession for patients on suicide precautions. The facility routinely performs fifteen minute checks on all patients not on one to one (1:1) monitoring, staffing or rounding frequency is not increased for patients on precautions.
Review of facility policy titled, "PC-PROVISION OF CARE TREATMENT SERVICES, Number: PC-1000, TOPIC: Patient Observation", dated 5/4/2010, showed the following definition (in part):
1:1 Observation
Purpose: To provide safe care for any patient who is exhibiting highly dangerous behaviors or is deemed highly dangerous to self and/or others.
Review of the 1:1 Policy indicates there was no guidance to assist staff in deciding what defined "highly dangerous."
Review of discharged Patient #36's Assessment and Referral Center Assessment Form dated 01/16/11 at 1:10 PM, showed the patient had been treated at an emergency room for a head laceration sustained while running down the street naked. On page 4 of the assessment in "Section III - History of Violence/Sexual Aggression" staff documented the patient is a registered sex offender per wife and daughter. Staff also documented the patient had a history of extreme violence, violent felony criminal history or history of sexual aggression. Review of "Section VI - Suicide Risk Factors" showed staff identified the patient's stressors included severe problems with significant others, command hallucinations, separation from wife, announcing he is gay and conflict with male partner. The assessment also included the patient was delusional, suspicious, had impaired judgment, bizarre behavior, impulsiveness, acute onset of psychosis or severe thought disorder and severe functional debilitation. Documentation showed staff admitted the patient to inpatient with suicide/self injury precautions (SP) only. Staff did not institute Assault Precautions (AP), Sexual Aggression (SA) and/or 1:1 precautions.

Review of the "Admission Report Form" dated 01/16/11 showed staff assessed Patient #36 as psychotic, a registered sex offender and reported the patient being bisexual and was given a private room and placed on SP and risk for self injury.

Review of the "Comprehensive Assessment High Risk Notification Alert Form" (used to alert the receiving unit of precautions) for Patient #36, dated 01/16/11 included SP precautions only. Staff did not institute AP and SA precautions, or 1:1 monitoring.

Review of Individual Observation Record dated 01/16/11 showed Patient #36 was on SP only.

Review of the patient's Master Treatment Plan dated 01/16/11 showed staff failed to include the information that Patient #36 was a registered sex offender and interventions only included suicide precautions.

Review of the Nursing note dated 01/17/11 at 5:30 AM, showed staff documented: Patient #36 was up and about trying to enter into other patients' rooms all night. He/she had to be re-directed several times and he/she was informed that was inappropriate. Patient is touchy and needs to be closely monitored around other patients.

Review of the Nursing note dated 01/17/11 at 1:00 PM, showed staff documented: Patient #36 was found in Patient's #40's room with his/her pants around his/her ankles and trying to take Patient's #40's pants off. Staff instructed Patient #36 to stop and return to his/her own room. Staff placed Patient #36 on a 1:1 to provide for the safety of other patients.

Review of Individual Observation Record dated 01/17/11 and 01/18/11 showed staff placed Patient #36 on 1:1 observation after the sexual assault incident.

During an interview on 03/03/11 at 4:08 PM Staff #EE, staff Registered Nurse (RN), stated he/she was assigned to Module B on 01/17/10 and the sexual assault incident involving Patient #36 occurred between 7:45 AM and 8:30 AM on 01/17/11 and believed the incident occurred around 8:15 AM. He/she stated he/she found Patient #36 and Patient #40 in Patient's #40 room. (Patient #36 had his/her pants around his/her ankles and was trying to take Patient #40's pants off). He/she stated Patient #40 did not understand what was happening to him/her due to his/her diagnosis of Schizophrenia and was not able to recall the incident.

Staff EE confirmed there is not a list available of registered sex offenders in the facility and stated being on a sex offender list would not be a reason to put someone on SA precautions. He/she also stated the Individual Observation Record is a "working document" and confirmed it is not timed on the document when staff placed Patient #36 on a 1:1 and the staff failed to include a signature of who made the change.


During an interview on 03/03/11 at 4:08 PM, Staff G, Assistant Director of Nursing, confirmed the facility did not have a tool to show which patients, if any are on a sex offender registry. Staff G stated the floor nurse would have to read the intake assessment to be informed if the patient had sexual abuse history.

Review of the physician note dated 01/17/11 (the note is not timed) showed Patient's #36 admitting diagnosis included Bipolar (mood swings from manic to depressed); sexual abuse; perpetrator/victim; questionable paranoid ideations; and dangerous to self, others or property with need for controlled environment and on sex registry.

Review of the physician note dated 01/17/11 at 12:45 AM, showed Patient #36 informed the physician he had sexually assaulted another patient (Patient #40) and was in the process of continuing the sexual assault when staff intervened.

Review of the Physician's order dated 01/17/11 at 8:55 AM, showed the physician directed staff to discharge Patient #36 to the police.

During an interview on 03/04/11 at 8:49 AM, with Staff B, Director of Risk Management, stated the facility did not have a policy addressing admitting patients with sex offender history or monitoring requirements of these patients. Further, on the evening of 03/03/11 the facility implemented a new practice to check a national data base for registered sex offenders when admitting all adult patients. The facility also ran all existing adult patients through the national sex offender registry and found they did have one current patient on the registry, Patient #22. On the evening of 03/03/11, staff placed Patient #22 on SA precautions and moved him/her closer to the nurse's station. Staff B stated a performance improvement team will develop processes for identification of persons on the sex offender registry and work on improving effective communication from admission intake to the nursing units regarding patients found on the sex offender registry.




9. Review of current Patient #13's History and Physical (H & P), dated 02/15/11, revised on 03/06/11 showed the patient was admitted on [DATE] for agitation and confusion.

Review of the Master Treatment Plan dated 02/15/11 showed the patient's problem list included:,
-Dementia; (Loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.)
-Suicide/Self Injury Precautions (patient threatened to shoot self and family found a gun in patient's closet);
-Assaultive Precautions due to physical altercation with family member;
-High Fall Risk due to confusion and high fall risk;
-Wound to bottom of right foot.

Review of the Physician Orders showed:
-On 02/27/11 at 3:15 PM, the physician ordered an elastic stretch wrap bandage be applied to the patient's left ankle (used to decrease swelling).

Review of the Nursing Report Sheet (used by staff to communicate information about the patients) dated 03/02/11, showed the patient to be on suicide precautions, aggression precautions, elopement and fall precautions.

During an interview on 03/02/11 at 3:10 PM, Staff P, Social Worker stated Patient #13 was aggressive and agitated in the evenings.

Observation on 03/03/11 at 9:10 AM, showed Staff W, Registered Nurse (RN), applied an elastic stretch wrap (the wrap was over 5 feet long) to Patient #13's left ankle. During an interview upon the observation, Staff G, RN, Assistant Director of Nursing stated the patient was not on suicide precautions. Staff W and G failed to identify the elastic stretch wrap presented a hanging/looping hazard or could be used as a strangulation device.

During an interview on 03/03/11 at 10:45 AM, Staff G stated staff should have been doing rounding sheets on the elastic stretch wrap. Staff G provided a copy of the rounding sheet for the elastic stretch wrap showing staff implemented the rounding sheet on 03/03/11 at 9:15 AM.

Further review of the Physician Orders showed:
-On 03/03/11 at 2:00 PM, the physician discontinued the order for the elastic stretch wrap and ordered a below the knee compression stocking (used to decrease swelling) be applied to the left leg.

During an interview on 03/04/11 at 8:40 AM, Staff W stated the physician had discontinued the elastic stretch wrap and staff threw it away. Staff W obtained another elastic stretch wrap from the supply area and stated that it was the same. The elastic stretch wrap measured five feet 10 inches long and three inches wide. The elastic stretch wrap presented a hanging/looping hazard or could be used as a strangulation device.














































7. Observation on 03/01/11 at 4:05 PM, on Module C in room 539, bed A had an electrical cord approximately 6 feet long laying on the floor attached to an air mattress. Review of Patient's #13 and #31 precautions showed that both patients were on suicide precautions. Patient #13 assigned to bed A with the attached electrical cord was also on Assaultive Precautions.
8. Observation on 03/01/11 at 4:10 PM, on Module A, Adolescent and Trauma Units showed two seclusion rooms currently unoccupied. One seclusion room contained a bed with a 4 foot electrical cord that was lying on the floor attached to the bed. The electrical cord was not secured and provided enough length to provide a choking/strangling device. The seclusion room was available for immediate use by any of all 16 Patients in Module A. The second seclusion room was empty. The ceiling light frame was loose on two sides with screws protruding. During an interview upon the observation, Staff E, RN (Registered Nurse) Director of Nursing confirmed the light fixture was loose and could be pulled down.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interviews, the facility failed to send an employee (Staff S, Mental Health Technician [MHT]) home after one Patient (#14) of 54 Patients reported the employee sexually abused him/her. The facility failed to follow facility policy and procedure for abuse/neglect and standard of practice for safety, security and emotional health by allowing the employee to remain in the facility for the remainder of the night shift failing to provide security for 54 of 54 patients. The facility census at the time of survey was 54.

Findings included:

1. Record review of the facility's policy titled, "RIGHTS AND RESPONSIBILITIES, NUMBER:Rl-001, TOPIC: Abuse/Neglect: Prevention, Identification, Investigation and Reporting", dated 05/10/2010, directed the following:
PROCEDURE:
3. All employees will be required to be educated about and pass a competency test regarding abuse and neglect. This includes reporting requirements. This is an initial requirement as well as an annual requirement.
a. Immediately upon an allegation of abuse, neglect or harassment, steps will be taken to protect patients from abuse during the investigation. The accused employee must be immediately removed from all potential patient contact within the hospital.

Record review of the facility reported complaint made by Patient #14 accusing Staff S, MHT (Mental Health Technician) of sexual abuse showed that after the Patient (#14) reported the abuse to Staff T, RN, House Supervisor, that Staff S, MHT (employee accused of sexually abusing Patient #14) was sent to another Module in the facility for the remainder of the current shift and was scheduled to remain in the facility for the following shift (a total of 16 hours).

During an interview on 03/02/11 at 2:00 PM with alleged sexual perpetrator, Staff S, MHT, stated that that he/she was told to go to Module C and not return to Module A for the remainder of the shift. Staff S said he/she was not made aware of the accusations by Patient #14 until after his shift was over and he was sent home by Staff G, RN (Registered Nurse), ADON (Assistant Director of Nursing).

During an interview on 03/02/11 at 3:30 PM, with Staff G, RN, ADON, stated that on the day of the alleged sexual abuse (01/21/11) he/she arrived at the facility at approximately 6:15 AM. Upon learning of the abuse allegations made by Patient #14 he/she explained to Staff T, RN, House Supervisor that the accused employee should have been sent home immediately and that he/she cannot work until the investigation has been completed and findings are analyzed and confirmed.

During an interview on 03/03/11 at 8:45 AM, Staff T stated that Patient #14 reported the allegation of sexual abuse to him/her, but that he/she moved the employee accused of the abuse to another module to work. Staff T stated that he/she didn't follow the facility Abuse/Neglect Policy and Procedure because he/she followed the Policy and Procedure on Disruptive Conduct. Staff T has been employed with the facility for 11 years and employee personnel records show completed education on abuse/neglect and hospital policies and procedures. Staff T stated that Staff S, MHT was not sent home because he/she didn't have enough staff on the night shift to cover if he/she sent the employee home.

During an interview on 03/03/11 at 9:15 AM, Staff B, Director of Risk Management, responsible for the facility wide Quality Assurance and Improvement Program, stated that it is the first time he/she heard that the wrong Policy was used by the House Supervisor, but that explains why Staff T did not follow the correct procedures. Staff B stated that the Policy entitled, "Disruptive Conduct" was used for employee to employee problems and not abuse/neglect issues concerning an employee to patient.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observation, interview, and policy review facility staff failed to have sufficient safeguards to ensure the access to all information regarding patients was limited to those individuals designated by law, regulation and policy caring for the patients. The facility also failed to protect the records so that only those persons having a part in the patients' care could view the records when they were caring for patients. The facility failed to secure medical records in the outpatient unit for 14 of 14 patients. The facility's census was 54 patients.

Findings Included:

1. Record review of facility's Policy and Procedures #IM-180, titled, "Accessibility of Medical Records," dated 07/30/2009, showed the following direction:

-The Medical Records Department shall maintain, control and supervise patient records.
-Authorized access to the Medical Records Department is RESTRICTED to the following: Medical Staff Members, Director of Clinical Services/Social Work, Director of Nursing, Director of Risk Management, CEO, Director of Assessment & Referral, House Supervisors
-Only authorized personnel shall have access to patient charts. Limited access to the central file area and incomplete file area shall be assured by keeping the Medical Record Department locked whenever the department is unattended. A combination to the department lock shall be given to a member of the clinical staff for after hour access.

2. Review of the Health Information Management Department and interview with Staff JJ (Director of Health Information Management) on 03/03/11 at 3:15 PM, showed a list of seven persons, in addition to the Health Information Staff, who had access to the department in which Staff stored patients' closed medical records. Staff JJ stated the department opened at 8:00 AM and closed at 5:00 PM daily, Monday through Friday. Staff JJ stated all Medical Staff Members along with other members on the list had access to the department after hours and could get what record they needed.

Staff JJ stated he/she remembered receiving a citation in the past for the non-compliant practice, but apparently various staff petitioned to the previous CEO reasons for leaving their names on the list and they remained on the access list. Staff JJ stated the list was shortened from the previous list.

Staff JJ stated he/she maintained a log of who entered the department in the absence of Health Information Management staff. Staff JJ stated facility staff who entered the department did a good job of recording which record they took.






3. Observation on 03/04/11 at 9:15 AM, showed 14 patient charts in a rack which contained patient information regarding diagnosis, treatment, and personel information of each patient. The chart racks were in the outpatient office located on the lower level of the facility, included on the same level with the patient care Modules.

4. During an interview on 03/04/11 at 9:25 AM, Staff CC, LCSW (Licensed Clinical Social Worker), CSAC II (Certified Substance Abuse Counselor), stated the charts were of those patients participating in the outpatient programs. When the outpatient staff leaves the office area, or for the day the door automatically locks.

5. During an interview on 03/04/11 at 9:30 AM, Staff DD, Housekeeping Supervisor, stated that the outpatient area is cleaned in the afternoon and there is a master key that allows housekeeping to enter the office where the outpatient charts are kept. Housekeeping is not always supervised when in these offices.

6. During an interview on 03/04/11 at 9:55 AM, Staff CC stated that all facility staff could have access to the outpatient office where the charts are kept because the lock to the office opens with a master key. This would allow staff that are not directly involved in outpatient care to be able to look at the charts when the outpatient staff were not in the office.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, interview, and policy review the facility failed to properly secure medications in the outpatient area for two of 14 patients. The facility census was 54.

1. Record review of the facility's policy titled, "Medication; Self Administration of & Storage of," dated 05/07/09 showed the direction for facility staff to put all medication brought into the facility be placed in a designated cabinet in the medication room, Adult PHP (Partial hospitalization Program) office. The policy does not state if the cabinet or office door has to be locked.

2. Observation on 03/04/11 at 9:50 AM, showed a bottle of Clonazepam (This medication is used in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks [sudden, unexpected attacks of extreme fear and worry about these attacks]. It works by decreasing abnormal electrical activity in the brain.), 0.5 mg (milligrams) with approximately four tablets and a bottle of Alprazolam (This is a medication used to treat anxiety disorders and panic attacks.), 0.25mg with approximately 50 tabs in the bottle. The bottles were both in the top drawer of an unlocked file cabinet in the Adult PHP office.

3. During an interview on 03/04/11 at 9:55 AM, Staff CC, LCSW (Licensed Clinical Social Worker) and CSAC II (Clinical Substance Abuse Councelor) stated that the file cabinet is not locked because the office door locks when staff leave. All staff, staff from every department, could have access to the outpatient office where the medications are kept because the lock to the office opens with a master key.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview, hospital staff failed to ensure outdated supplies and equipment were not available for patient use. The facility census was 54.

Findings included:

1. Record review of the MONTHLY WALK THROUGH INSPECTION REPORT for MODULE A DATED 02/28/11 (day before the survey), showed Staff U , RN, Infection Control Officer documented he/she inspected and found all checked areas to be compliant including:
-Number 28: Check dates on supplies clean utility;
-Number 18: Check expiration dates on eyewash station.

2. Observation on 03/02/11 at 1:20 PM, of the medication room on the Geriatric Unit showed one expired strep test probe (used to test for strep throat), expiration 04/2010 and four, four ounce expired containers of antiseptic hand cleansers;
-One lot , expiration 03/10;
-One lot , expiration 08/10;
-Two lot , expiration 01/10.

Observation on 03/01/11 at 3:05 PM, in the clean utility room of Module A with Staff E, RN (Registered Nurse), Director of Nursing, the eye wash station used to flush foreign objects or contaminates from the eyes contained two bottles of eye wash solution (North Buffered Eye-Lert). One of the bottles of eye wash solution was stamped with an expiration date of 2009.

During an interview on 03/02/11 at 2:00 PM, Staff U, RN, Infection Control Officer stated, "I personally replaced all of those [eye wash solutions] myself and none of them should expire until 2012."

3. Observation of the medication cart in the Geriatric Unit medication room on 03/02/11 at 1:40 PM, showed a layer of an off white colored powder, in the corner, at the back of the top drawer. An individual prepackaged dose of medication lay in the off white colored powder. There were areas of a dried orange substance and rust spots in the top drawer.

During an interview on 03/02/11 at 1:50 PM, Staff Q Pharmacist stated pharmacy staff were not responsible to clean the medication carts, but would if the carts were dirty.

During an interview on 03/02/11 at 2:00 PM, Staff G, RN, Assistant Director of Nursing stated that there was no set schedule, or anyone specifically assigned to clean the medication carts.

4. Observation on 03/02/11 at 1:55 PM, of a refrigerator used to store protein drinks located behind the nurses' station on the Geriatric Unit showed an open, undated four ounce container of applesauce. During an interview upon the observation, Staff G stated staff should not save the open, undated applesauce.

5. Observation 0n/03/01/11 at 2:50 PM of the medication cart in the Trauma Unit medication room showed an open expired bottle of antiseptic hand cleaner, lot 21E9, expiration 11/10.

6. Observation on 03/01/11 at 3:10 PM of the clean utility room on the Trauma Unit showed three urinary catheter insertion trays, lot 08KB3444, expiration 10/10.

7. Observation on 03/02/11 at 3:20 PM, of Patient #13's bed pad (a device placed on the bed that alarms if the patient tried to get up) showed information printed on the top of the pad included:
-Sensor pad is intended to be used for individual patients for the time period indicated under the warranty only;
-Recommend use of the product not exceed six months.
Set-up Instructions included:
-Record initial use date here with non-erasable marker (there was a line for staff to document initial use date on). Staff did not document the date the pad was put into use;
-Record expiration date here with non-erasable marker (there was a line for staff to document the expiration date on). Staff did not document the date the pad was no longer in use.

During an interview on 03/02/11 at 3:35 PM, Staff O, RN identified four additional patients (#16, #33, #34 and #35) who were on fall precautions and had bed alarms. Observation of these patient bed pads showed staff did not document the date the bed pads were put into use. Staff O stated he/she did not know how long the bed pads had been in use.

During an interview upon the observation, Staff G stated the facility did not have a policy to date the pads when staff put the pads into use.

During an interview on 03/02/11 at 3:25 PM, Staff O, RN stated he/she had never been instructed to document the date the pads were put into use.

During an interview on 03/02/11 at 3:30 PM, Staff N, Mental Health Technician (MHT) stated that he/she had never been instructed to document the date the pads were put into use.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

9. Observation during tour on 03/01/11 at 2:10 PM and 03/02/11 at 4:00 PM, showed dingy, yellowed, streaked and soiled vinyl floor tile in the access corridor to an exit egress at the loading dock. Three wood pallets with boxed supplies on them, a table and two chairs, a geri-chair,and a housekeeping floor machine Dust balls and bits of plastic wrap were under some of the pallets and dust had accumulated along the walls. The corridor is the main service entry and exit for the kitchen, medical supply, maintenance, housekeeping and all shipped products delivered to the facility.

10. Observation of the terminal end of the service corridor showed the corridor exited onto the loading dock where two dumpsters were positioned. Both dumpsters had open lids, offering a potential food source to pests and vermin. Dumpster lids were observed to be open on 03/01/11 at 2:10 PM and at 4:05 PM, and on 03/02/11 at 12:50 Noon.

11. Observation on 03/03/11 at 1:10 PM ,of the back service corridor outside of CS (Central Supply) showed dirt on the floor, tables and chairs.

During an interview on 03/02/11 at 2:00 PM, the Director of Plant Operations stated the service corridor is used by staff and service technicians. He stated it gets cleaned irregularly and it is not on a schedule. He stated he has had to remind housekeepers too many times about leaving the dumpster lids open.

During an interview on 03/03/11 at 1:10 PM, in the back service corridor outside of CS with Staff E, RN (Registered Nurse), Director of Nursing and Staff V, Accounts Payable Representative stated they could feel the dirt under their shoes and the area was utilized by the Housekeeping Department.



















2. Observation on 03/01/11 at 2:40 PM, of the medication refrigerator on Module A-Trauma Unit showed multiple dried red splatters inside the door storage area and multiple smaller dried red splatters and dirt on the bottom shelf. There were two glass shelves that were dirty and had patient drinks stored on the dirty shelves.

During an interview on 03/01/11 at 2:45 PM, Staff F, Licensed Practical Nurse (LPN) verified the refrigerator was dirty and stated he/she did not know who was responsible to clean it.

3. Observation on 03/01/11 at 3:00 PM, of a second medication refrigerator on Module A-Trauma Unit showed the refrigerator to be dirty with dried residue in the refrigerator on the shelf.

During an interview on 03/01/11 at 3:00 PM, Staff D, Director of Pharmacy stated no one is designated to clean the medication room refrigerators. Staff D verified the refrigerators were dirty and stated that the lack of cleaning was a process problem.

During an interview on 03/01/11 at 3:05 PM, Staff E, Registered Nurse (RN) Director of Nursing, stated nursing staff were responsible to check the medication rooms including the medication refrigerators for cleanliness.

4. Observation on 03/01/11 at approximately 3:10 PM, of the patient kitchenette in Module A-Trauma Unit showed crumbs and debris in the top drawer and a fourth drawer had dried food residue. Staff E, RN, Director of Nursing verified the drawers were dirty upon the observation and stated nursing staff were responsible to clean the drawers.

5. Observation on 03/01/11 at 3:20 PM, of the lab specimen refrigerator on Module A-Trauma Unit showed a specimen cup containing a thick, cloudy yellow/orange substance. Staff did not document the date the specimen was obtained, or the contents of the specimen. The specimen cup was labeled with the first name and last initial of a patient. Review of the patient census sheet showed there was no current inpatient with the same first name and last initial. During an interview upon the observation Staff E, RN, Director of Nursing stated the specimen needed to be disposed of.

6. Observation on 03/01/11 at approximately 3:20 PM, of the back hall of Module A-Trauma Unit showed dust and debris throughout the hallway.

7. Observation on 03/01/11 at 3:30 PM, of the seclusion room on the back hall of Module A-Trauma Unit showed a small window in the door. The window sill was very dusty.

During an interview on 03/01/11 at 3:35 PM, Staff E, RN Director of Nursing confirmed the back hall floor and clean utility room of Module A were dirty.

8. Observation of the medication cart in the Geriatric Unit medication room on 03/02/11 at 1:40 PM, showed a layer of an off white colored powder, in the corner, at the back of the top drawer. An individual prepackaged dose of medication lay in the off white colored powder. There were areas of a dried orange substance and rust spots in the top drawer.

During an interview on 03/02/11 at 1:50 PM, Staff Q Pharmacist stated pharmacy staff were not responsible to clean the medication carts, but would if the carts were dirty.

During an interview on 03/02/11 at 2:00 PM, Staff G, RN, Assistant Director of Nursing stated there was no set schedule or anyone specifically assigned to clean the medication carts, the medication refrigerators, the protein drink refrigerator and the food drawers.




Based on observation, interview and record review the facility failed to:
-Follow the facility policy and procedure for an indwelling urinary catheter (small plastic tubing inserted through the urethra to continuously drain urine from the bladder) for one Patient (#16) of one patients with a urinary catheter.
-Provide staff education for indwelling urinary catheter care.
-Ensure all areas of the facility were clean . The facility census was 54.

Findings included:
1. Observation on 03/02/11 at 10:25 AM, on Module C showed Patient #16 sitting in a wheelchair in the main living/dining area. The indwelling urinary catheter tubing was coiled up and secured off of the floor and the uncovered urinary bag was hung on the back of the wheelchair approximately four feet off of the floor above the Patient's bladder height. Coiling of the catheter tubing and the height of the urinary bag above the Patient's bladder can cause a back flow of urine and increase the risk of infection. Record review of Patient #16's medical record showed he/she was admitted on [DATE] with an indwelling urinary catheter.

Record review of the facility's policy titled, "Catheters; Indwelling Urinary, PURPOSE: To establish criteria that will minimize the risk of infection associated with indwelling urinary catheters", dated 02/05/2009, directed nursing staff in the care of patients with a urinary catheter:
8. Urinary Flow:
b. To achieve free flow of urine:
iv. The collecting bag should always be kept below the level of the bladder.

During an interview on 03/03/11 at 1:10 PM, Staff U, RN, Infection Control Officer responsible for the facility-wide Infection Control Program and staff education, stated that when a patient had an indwelling urinary catheter that he/she would personally check the patient for the following:
-if the patient had pain;
-if the urine was flowing appropriately;
-any pinching or clamps of the tubing;
-any potential hazards;
-the insertion site for drainage or signs of infection;
-even smelling the urine for an odor; and
-the urinary drainage bag should not be on the floor.

Observation on 03/01/11 at 4:00 PM, on Module C showed Patient #16 sitting in a wheel chair in the main living/dining area. Patient #16 had an indwelling urinary catheter with the urinary catheter tubing lying on the floor underneath the wheelchair and attached to the bottom of the wheelchair touching the floor providing a pathway for infectious organisms.

During an interview on 03/01/11 at 4:00 PM, with Staff E, RN (Registered Nurse), Director of Nursing stated the indwelling urinary catheter tubing and urinary bag should not be touching the floor and put the Patient (#16) at risk for infection.

During an interview on 03/03/11 at 2:00 PM, with Staff U, RN, Infection Control Officer stated that he/she was not aware that Patient #16's indwelling urinary catheter tubing and urinary bag were on the floor. Staff U stated that Patient #16 was the only patient in the facility with an indwelling urinary catheter.

Record review of the facility's "INFECTION CONTROL WALK-THROUGH" dated 02/11 and completed by Staff U, RN (Registered Nurse), Infection Control Officer responsible for the facility-wide Infection Control Program, showed four weeks of infection control inspections on Module C, but the inspections did not include indwelling catheter observations. All items on the document were marked as satisfactory through the date of 02/28/11. Patient #16 was admitted on [DATE] with an indwelling urinary catheter.

During separate interviews on 03/03/11 on Module C between 1:10 PM and 4:00 PM, with four nursing staff (Staff H, RN, Charge Nurse, Staff R, Staff Y, and Staff AA) on Module C each individually stated that Staff U, RN, Infection Control Officer, had not personally checked patients with catheters to their knowledge and they had not been educated by him/her regarding indwelling urinary catheter care.

During an interview on 03/03/11 at 1:10 PM Staff U, Infection Control Officer stated that there was not any education on indwelling urinary catheter care given to employees.