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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 April 9, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record reviews, complaint-grievance reports review and staff interviews the hospital failed to provide a patient of a written notice to a grievance decision in 1 of 1 patients with a grievance (Patient #1).


The findings include:
Review of the policy and procedure " CS 6.1.6 Client Advocate-Grievance Process" last reviewed 03/06/2014. PURPOSE.. To educate residents on the grievance process.. To establish a process for prompt resolution of resident complaints and/or grievances.. To increase resident satisfaction and promote the resolution of conflicts in a non-adversarial manner. PROCEDURE.. A "resident grievance" is defined as a formal, written, or verbal grievance that is filed by a resident or family member or support system member, when a resident issue cannot be resolved promptly by staff present. A "resident complaint" is an allegation or source of dissatisfaction expressed verbally or in writing. Complaints relevant to change in bedding, housekeeping of a room, and serving preferred food and beverages are expectations that are require the implementation of a relative minor change in a timely manner than a written response. .... D. The Milieu Manager is responsible for notifying the Director of Risk Management, who will make personal contact with the resident making the request within one working day of receipt of the grievance/complaint. 1. Jointly, the resident and the Director of Risk Management will discuss the resident's verbal or written information in order to clarify the resident's concerns and formulate a statement of grievance/complaint. 2. When the Director of Risk Management and the resident come to a resolution of the issue expressed, no further action will be necessary. The Clinical Director will assist as requested resolution facilitation, as needed. 3. A written response will be provided to the resident within three working days of the initial meeting of the Director Risk Management and the resident. The response will include.. Name of facility contact person. The steps taken on behalf of the resident to investigate the grievance. The results of the grievance process. The date of completion".

Closed medical record review on 04/07/2015 revealed Patient #1 was admitted to the facility on [DATE] for Suicidal and Homicidal Ideations. Review of the Complaint/Grievance form revealed a grievance filed by the patient's mother on 01/22/2015 regarding "Her daughter not revieving her clothing since she was admitted (1/21/15)..Not getting female products when requested.. She wanted her daughter discharged ."

Interview on 04/9/2015 with the Director of Risk Management revealed facility makes telephone contact with persons filing grievance and a letter is also sent out to complainants. Interview revealed "unsure if letter sent to this family". No further grievance documentation available for review. Interview revealed the facility failed to follow the grievance policy.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on hospital policy reviews, observations during tours, emergency bag log reviews, blood glucose monitor log reviews, medication refrigerator temperature log reviews, and staff interviews; the hospital's nursing staff failed to maintain the facilities, supplies, and equipment in a manner to ensure an acceptable level of safety and quality on 3 of 3 acute inpatient units toured (Halls 100, 700, and 800).

The findings include:

1. Review of current hospital policy "ME 3.1 Clinical Equipment" effective 07/02/2012, revealed "PURPOSE: To assure the proper function and utilization of clinical equipment at (Hospital Name). To minimize clinical and physical risks, maximize patient safety and quality of care. DISCUSSION: It is the policy of (Hospital Name) that all clinical equipment be....periodically checked to ensure proper function and operation... PROCEDURE: ...3. Periodic testing, at least annually and usually semi-annually, shall be conducted to ensure the safe and proper operation of biomedical equipment. ..."

Review of current hospital policy "ME 5.1 Defective Equipment" effective 07/02/2012, revealed "PURPOSE: To define the procedures for the proper tagging and removal from service any equipment that is broken, damaged, or not operating according to the manufacture specifications. PROCEDURE: 1. When any piece of equipment that is used or may come into contact with a patient, visitor, or employee is deemed not to be operating properly or has been broken or damaged, it should be removed immediately from service... ."

Observation during tour of Hall 100 (acute unit) on 04/09/2015 at 1000 to 1045 revealed one (1) "Broselow-Hinkle" emergency bag stored in a medication room shared by Hall 100 and Hall 200 (a Psychiatric Residential Treatment Facility [PRTF] unit). Observation revealed the bag was sealed with a plastic purple lock # 45. The lock (seal) was removed by RN #3 in the presence of the Surveyor. Observation of the contents of the emergency bag revealed one (1) battery powered portable Laerdal Compact Suction Unit. Observation revealed the suction unit failed to function when tested by RN #3. Further observation revealed RN #3 was unable to locate the power cord in the emergency bag, needed to power the suction unit and/or recharge the battery. Review on 04/09/2015 of the log sheet for the emergency bag, revealed "Emergency Bags checked every month and after opening (broken seal/red tag)." Review revealed "Location of bag: 100/200 (handwritten)." Review revealed the emergency bag was restocked on 01/22/2015 and re-sealed with purple lock # 45. Review revealed the bag was subsequently checked on 02/06/2015 and 03/06/2015 and seal (lock) # 45 remained intact and the bag had not been opened nor restocked. Review revealed as of 04/09/2015 the emergency bag had not been opened nor its contents checked since 01/22/2015 (77 days ago). Interview during tour with RN #3 revealed the emergency bag is checked monthly. Interview revealed the emergency bag is checked to see if the seal has been broken. If the seal has not been broken the staff do not open the bag and check the contents. Interview revealed the contents of the bag are checked and restocked only if the seal has been broken. Interview revealed the nurse did not know how long the suction unit had not functioned. Interview verified the emergency bag had been checked monthly and was last restocked in January 2015. Interview revealed the hospital has two (2) emergency bags, one (1) located on Halls 100/200 and one (1) located on Halls 300/400 (PRTF units). VPO (Vice President of Operations) #1 was present and witnessed the above observation.

Interview on 04/09/2015 at 1210 with Director #1 revealed the hospital has 2 emergency bags in-house, one (1) on Halls 100/200 and one (1) on Halls 300/400. Interview revealed each bag contains a portable suction unit. Interview revealed the emergency bags are checked monthly. Interview revealed if the seal is not broken, the nursing staff do not open the bags to check contents. Interview revealed they document the seal is intact. Interview revealed if the bags are opened then the contents are checked and restocked. Interview revealed the emergency bag located on Halls 100/200 was last restocked on 01/22/2015 by RN #4. Interview revealed the Director could not determine from the logs how long the emergency bag's portable suction machine had not been functioning. Interview revealed the portable suction machines in the emergency bags were the only two suction machines available in the hospital.

2. Review of current hospital policy "RX30.1 Vials and Ampules of Injectable Medications" last reviewed/revised 06/20/2013, revealed "...Procedures: ...2. The date to expire (28 days) and the initials of the person to use the vial shall be recorded on multi-dose vials. ...4. ...Medication in multi dose vials may be used for 28 days from the date opened... ."

Observation during tour of Hall 700/800 (acute units) on 04/08/2015 at 1517 to 1600 revealed a medication refrigerator located in the medication room shared by both halls. Observation of the contents of the refrigerator revealed one (1) opened multi-dose vial of Novolog Insulin with a manufacturer's expiration date of 07/2015. Observation of the vial's label revealed no documentation of an expiration date, date opened, nor nurse's initials handwritten on the label indicating when the vial had been opened. Interview during tour with RN #1 revealed "I heard" the vial was opened last night. Interview revealed RN #1 did not witness the vial being opened. Interview with RN #2 revealed the nurse who opened the insulin vial should have dated and initialed the label when the vial was opened. Interview revealed the insulin was good for 28 days after being opened. Interview revealed the insulin was available for patient use by staff. Director #1 was present and witnessed the above observation.

Interview on 04/09/2015 at 1210 with Director #1 revealed when the multi-dose insulin vial was first opened the nurse who opened the vial should have written the date opened, expiration date, and their initials on the label. Interview revealed the nursing staff failed to follow the hospital's policy.

3. Review of current hospital policy "NS 4.1.2 Quality Control, Blood Glucose Monitor" last reviewed/revised 03/23/2011, revealed "...POLICY: ...When a client requires glucose monitoring daily, the machine will be tested daily to include levels of control on each day of testing. When the Blood Glucose Monitor is not in use, the quality controls will be performed and logged on a weekly basis. The results are maintained in an ongoing log. ..."

a. Observation during tour of Halls 700/800 on 04/08/2015 at 1517 to 1600 revealed one (1) Blood Glucose Monitoring (BGM) device stored in the medication room shared by both halls. Review of the BGM's "Glucose Monitoring Quality Control (QC)" log for the month of April 2015, revealed daily QC checks performed on 04/01, 04/02, 04/03, 04/05, 04/07, and 04/08. Review failed to reveal any available documentation of a QC check recorded by nursing staff on 04/04 and 04/06. Interview during tour with RN #1 and RN #2 revealed QC checks are performed by the third shift nurse (2300-0700). Interview revealed the QC checks are supposed to be performed nightly and recorded on the QC log. Interview verified no documentation of QC checks recorded on the QC log on 04/04/2015 and 04/06/2015.

Interview on 04/09/2015 at 1210 with Director #1 revealed the nursing staff are supposed to perform nightly QC checks on the BGM and record them on the QC log. Interview verified no documentation of a QC check recorded on the QC log for Hall 700/800's BGM on 04/04/2015 and 04/06/2015. Interview revealed "her" expectation is for QC checks to be performed nightly regardless if the BGM was used. Interview revealed the nursing staff failed to follow the hospital's policy.

b. Observation during tour of Hall 100 on 04/09/2015 at 1000 to 1045 revealed one (1) Blood Glucose Monitoring (BGM) device stored in the medication room shared by Hall 100 and Hall 200. Review of the BGM's "Glucose Monitoring Quality Control (QC)" log for the month of April 2015, revealed daily QC checks performed on 04/01, 04/02, 04/03, 04/04, 04/08, and 04/09. Review failed to reveal any available documentation of a QC check recorded by nursing staff on 04/05, 04/06, and 04/07. Interview during tour with RN #3 revealed QC checks are performed by the third shift nurse. Interview revealed the QC checks are supposed to be performed nightly and recorded on the QC log. Interview verified no documentation of a QC check recorded on the QC log on 04/05/2015, 04/06/2015, and 04/07/2015.

Interview on 04/09/2015 at 1210 with Director #1 revealed the nursing staff are supposed to perform nightly QC checks on the BGM and record them on the QC log. Interview verified no documentation of a QC check recorded on the QC log for Hall 100's BGM on 04/05/2015, 04/06/2015, and 04/07/2015. Interview revealed "her" expectation is for QC checks to be performed nightly regardless if the BGM was used. Interview revealed the nursing staff failed to follow the hospital's policy.

4. Review of current hospital policy "NS 2.2.3 Medication, Refrigeration" last reviewed/revised 04/27/2011, revealed "...Policy: (hospital name) monitors the temperature and cleanliness of the medication refrigerator to assure safe storage of medications. Procedure: ...2. The temperature of the medication refrigerator will be monitored and recorded in the Temperature Logbook during each night shift by the nurse. ..."

a. Observation during tour of Halls 700/800 on 04/08/2015 at 1517 to 1600 revealed a medication refrigerator located in a medication room shared by both halls. Observation of the contents of the refrigerator revealed medications and vaccines being stored that required refrigeration. Review of the medication refrigerator's "Kitchen Appliance Temperature Log" for the month of April 2015, failed to reveal any available documentation of a daily temperature check recorded by nursing staff for 2 out of 8 days (04/04/2015 and 04/06/2015). Interview during tour with RN #1 and RN #2 revealed the medication refrigerator's temperatures are checked by the third shift nurse. Interview revealed the temperatures are supposed to be checked nightly and recorded on the temperature log. Interview verified no documentation of a temperature check recorded on the temperature log for the medication refrigerator on 04/04/2015 and 04/06/2015.

Interview on 04/09/2015 at 1210 with Director #1 revealed the nursing staff are supposed to perform nightly medication refrigerator temperature checks and record them on the temperature log. Interview verified no documentation of a temperature check recorded on the temperature log for Hall 700/800's medication refrigerator on 04/04/2015 and 04/06/2015. Interview revealed the nursing staff failed to follow the hospital's policy.

b. Observation during tour of Hall 100 on 04/09/2015 at 1000 to 1045 revealed a medication refrigerator located in the medication room shared by Hall 100 and 200. Review of the medication refrigerator's "Kitchen Appliance Temperature Log" for the month of April 2015, failed to reveal any available documentation of a daily temperature check recorded by nursing staff for 3 out of 9 days (04/05/2015, 04/06/2015, and 04/07/2015). Interview during tour with RN #3 revealed the medication refrigerator's temperatures are checked by the third shift nurse. Interview revealed the temperatures are supposed to be checked nightly and recorded on the temperature log. Interview verified no documentation of a temperature check recorded on the temperature log for the medication refrigerator on 04/05/2015, 04/06/2015, and 04/07/2015.

Interview on 04/09/2015 at 1210 with Director #1 revealed the nursing staff are supposed to perform nightly medication refrigerator temperature checks and record them on the temperature log. Interview verified no documentation of a temperature check recorded on the temperature log for Hall 100's medication refrigerator on 04/05/2015, 04/06/2015, and 04/07/2015. Interview revealed the nursing staff failed to follow the hospital's policy.

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