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.

PALESTINE REGIONAL MEDICAL CENTER 2900 S LOOP 256 PALESTINE, TX 75801 June 6, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of records, interview, and observation, the facility failed to:

A. ensure the facility followed policy and procedures, and maintained safety for all patients in 3(6, 14, and 19) of 4(6, 12, 14, and 19) charts reviewed.

B. document the patients suicide screening appropriately and accurately to ensure the patient received a full comprehensive suicide risk assessment, be assigned a risk level, and given the appropriate monitoring according to the assessment, to provide patient safety in 3(6, 14, and 19) of 4(6, 12, 14, and 19) charts reviewed.

C. monitor patients with suicidal complaints after the Triage process. Patients were left unattended to leave the facility without medical attention in an unsafe environment in 3 (6, 14, and 19) of 4 (6, 12, 14, and 19) charts reviewed.

D. assess and protect a suicidal child, that was not in attendance with a legal guardian, in potential danger in 1(14) of 4 (6, 12, 14, and 19) charts reviewed.

Refer to Tag A0144


E. ensure staff followed established hospital restraint and seclusion policy in 1 (patient #21) out of 3 charts reviewed.

Refer to Tag A0167
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review, observation, and interviews the facility failed to:

A. document the patient's suicide screening appropriately and accurately to ensure the patient received a full comprehensive suicide risk assessment, be assigned a risk level, and given the appropriate monitoring according to the assessment, to provide patient safety in 3 (6, 14, and 19) of 4 (6, 12, 14, and 19) charts reviewed.

B. monitor patients with suicidal complaints after the Triage process. Patients were left unattended to leave the facility without medical attention in an unsafe environment in 3 (6, 14, and 19) of 4 (6, 12, 14, and 19) charts reviewed.

C. assess and protect a suicidal child, that was not in attendance with a legal guardian, in potential danger in 1(14) of 4 (6, 12, 14, and 19) charts reviewed.


Patient # 19.

1. Review of patient #19's Emergency Department (ED) chart revealed the patient presented at the ED on 4/13/18 at 14:18 (2:18PM). Review of the Nurses Notes revealed staff # 6 documented, "the patient stated, "I have been depressed for the past two weeks and I feel like I want to hurt myself."

4/13/17 at 14:22 (2:22PM), the chart revealed patient #19 was assigned an acuity level of "URGENT (3)." There was no documentation that the patient was taken back to a room or left unattended in the waiting room.


Review of the policy and procedure, "Assessment Organization Wide" revealed, "the triage RN will categorize patients as they present for triage as follows:

a. Level I (priority One- Critical Care) The patient's condition may or does require immediate lifesaving medical intervention. The patient is very briefly evaluated by the triage nurse and immediately sent to the treatment room.

b. Level II (Priority Two- Emergent Care) The patient's condition is potentially unstable. The patient should receive physician assessment as soon as possible.

c. Level III (Priority Three- Urgent care) The patient's condition is stable and no obvious distress noted.

d. Level IV (Priority Four- Non- Urgent Care) The patient's condition is stable with no distress.

e. Level V (Priority Five- Routine Care) The patient's condition is stable with no distress."


Further review of the Triage screening revealed under the question, "SUICIDE SCREENING: Have you recently had thoughts about hurting yourself or others?" Staff #6 documented, "NO." There was no further psychiatric questions or evaluations documented on the patient. There was no documentation if the patient had a plan. There was no documentation if the patient was alone or with someone. There was no documentation found to substantiate that the patient's condition was stable and no obvious distress noted as defined in the definition of a level III urgent care patient.


Review of the nurses note revealed staff #6 documented, "4/13/17 at 15:30 (3:30PM) Eloped prior to medical screening exam, time discovered patient was gone 15:31 (3:31PM). 15:31 (3:31PM) Pt left after Triage. Palestine PD was notified and stated that will notify Cherokee county." (sic) There was no documentation found on patient #19 from 14:22 (2:22PM) to 15:31 (3:31PM) when the patient was noticed missing. There was no documentation found that this suicidal patient who came in to the ED for help was medically supervised for at least 1 hour and 9 minutes; when the patient was found missing.


Review of the policy and procedure for "CO.PA.004 Suicide Risk Assessment/Suicide Precaution" stated,

"A. Inpatient and Emergency Department Procedure:

1. All patients admitted to the Hospital will be screened for suicide risk using the suicide risk screening questions. This screen is integrated into the process of Rapid Initial Assessment.

2. Patients responding yes to any of the three screening questions will have a full Comprehensive Suicide Risk Assessment completed, the nurse will perform assessment by completing the Comprehensive Suicide Risk Assessment form. The result of the assessment will determine the level of risk along with corresponding monitoring and interventions required to maintain patient safety."


An interview was conducted with staff #6 on 6/6/18. Staff #6 confirmed he was the nurse that triaged patient #6 on 4/13/18. Staff #6 stated, "I saw the patient and checked her in. She was sent back to the waiting room until a room was available. I think her husband was with her." Staff #6 confirmed he did not do a full psych assessment on the patient in triage. Staff #6 reported that he hit no under the tab in the computer that asked if the patient was having thoughts about hurting yourself or others? Staff #6 stated, "It was my bad. If I had hit yes it prompts you to continue on with the questioning. I should have said yes. I just messed up." Staff #6 reported that he put the patient at a level III urgent after Triage. Staff #6 was unable to give any reason why patient #19 was considered as urgent. Staff #6 stated, "we put all our psych complaints as a level III." Staff #6 was unaware of any policy or process that was in place for a suicidal patient.


An interview was conducted with staff #3 and #4 on 6/6/18. Staff #3 stated there was random audits done for suicidal patients in the ED and staff #4 was performing those audit. Staff #4 brought her Performance Improvement and chart audits for review. Staff #4 confirmed there was no specific audits done on psychiatric patients. Staff #4 was auditing a percentage of patients that have left Against Medical Advice (AMA) and Left without Treatment (LWOT).


Patient #14

2. Review of patient #14's ED chart revealed the patient (MDS) dated [DATE] at 20:59 (8:59PM). The patient was a [AGE]-year-old male. Review of the Nurses Notes revealed the patient's complaint was, "I feel useless, want to end my life." The nurse then documented, "Parent, 'He's been depressed, seeing therapist, no rx in one year.' Grandmother has custody, she grounded him and 'he got a knife and threatened to kill himself.' she took it away. Mom is here, her parental rights were taken away and has siblings in foster care."

Review of the Nurses Triage note stated, "Suicide Screening: Have you recently had thoughts about hurting yourself or others? Yes. The environmental checklist was reviewed and the following were implemented: Hazards removed from care area. No sharps available. Psych: 21:10 Suicide Risk Assessment: Do you have a plan? Yes, patient has a plan. Hazards removed from care area. Patient undressed/scrubs. No sharps available. Sitter/Family/Security present. Do you have the means? No. What is the plan? cut myself. SADD Persons Suicide Risk Assessment: Sex: Patient is a male (1 point). Age: Patient is less than [AGE] years old or greater than 45 years of age (1 point). Depression: Patient has a history of depression (1 point). The patient has no previous attempt of suicide (0 points). Total Points: Patient has a low risk. Subjective: Patient's mood is sad. Objective: Patient is cooperative, using poor eye contact, Speech is normal, Affect is flat, Patient has mutilated themselves by NONE at this time. Interventions: The environmental checklist was reviewed and the following elements were performed: Hazards were removed from patient's care area. The patient was undressed and given scrubs. No sharps are available to the patient. Sitter/Family/Security with patient.

Review of the chart revealed the patient was moved back to ED waiting at 21:12. There was no documentation that showed the patient was in a ED room for observation. There was no documentation that a ED physician saw this patient.

The patient was documented as Leaving Against Medical Advice (AMA) on 4/26/18 at 22:06 (10:06PM) but there was no AMA form signed or documentation from a nurse or physician that the patient and care giver were informed of the risks for leaving AMA. There was no documentation from Triage until the patient was signed out AMA. There is no documentation that the patient was safe or had been observed from 21:12 (9:12PM) until 22:06 (10:06PM) a total of 54 minutes.

The nurse documented on 4/26/18 at 20:59 that the patient was a ward of the grandmother and mother had lost custody. The nurse stated the mother was with the patient but not the grandmother. There was no documentation that the mother had any legal rights to direct medical care for this patient. There was no documentation that the nurse followed up on the patient's guardian and if Child Protective Services (CPS) needed to be contacted. There was no further documentation that discussed whether or not this child had been followed up on. There was no documentation found to ask the child if he was in danger.

An interview was conducted with staff #2, 3 and 4 on 6/6/18. Staff #2, 3, or 4 was not able to give me any more information on this patient.


Patient #6

3. Review of patient #6's ED chart revealed, she (MDS) dated [DATE] at 12:24PM. Review of the nurses notes dated 5/18/18 at 12:24PM revealed the patient stated, "pt. states not taking meds has been smoking meth crack and marijuana hearing voices wants to go to rehab. Patient is alert and oriented to person, place and time." Review of the Nurses Triage note stated, "Suicide Screening: Have you recently had thoughts about hurting yourself or others? NO" No other screening questions were asked even though the patient signed in with suicidal thoughts and hearing voices.

Review of the ED physician notes dated 5/18/18 at 13:13 (1:13PM) stated, "This is a 47- year-old African American female with a history of hypertension, diabetes, COPD, schizophrenia who presents with suicidal ideation and hearing voices. Patient has active substance abuse as well as crack cocaine. Patient presents asking for inpatient therapy for her suicidal thoughts and to help her get off drugs. Patient has had inpatient stays in the past. Multiple previous suicide attempts using pills. Patient denies any ingestion today or any self-harm at this time."


Review of policy titled "CO.PA.004 Suicide Risk Assessment/Suicide Precautions" revealed:

"b. Low Risk:

Notify physician of assessment results

ii. Conduct 15-minute safety checks using Patient Observation Form/Documentation

iii. Search all patient belongings and remove those items which are deemed hazardous to the patient

iv Place patient close to nurse's station

v. Place sign on door requiring visitors to check-in with the Registered Nurse,

vi. Search any bags brought by visitors and remove any hazardous items. Contact Hospital Security to secure items, as necessary.

vii. Update Plan of Care

viii. Patient is accompanied by staff 1:1 for any off unit activities.


c. Moderate Risk: Implement all of the interventions for low risk patients, as well as:

i. Remove personal belongings that pose a safety issue (shoe laces, belts, etc)

ii. Observe/document every 15 minutes using the Patient Observation Form/Documentation.

iii. Complete family/visitor education

iv. Place patient in a room where continuous, direct line of sight visual observation and monitoring is maintained at all times by trained staff

v. No curtains are to be drawn unless staff is in the room with the patient

vi. The Registered Nurse will stay with patient during medication administration to ensure patient has taken all medications and is not stockpiling medications for future use

vii Staff assigned will be responsible for reporting to the Registered Nurse any changes in patient's behavior and/or mood

viii. Update Plan of Care

ix. Patient is accompanied by staff 1:1 for any off unit activities.


d. High Risk (1:1): Implement all of the interventions for low and moderate risk patients as well as:

i. Place patient in a room where 1:1 monitoring at the patient's bedside is maintained at all times by trained staff

ii. The patient is restricted to the unit

iii. For any medically necessary transport to other departments (e.g., radiology, surgery), the patient will have 1 staff member accompany at all times

iv. Visitors may be supervised until the Registered Nurse has determined the benefit to the patient or therapeutic nature of the visit."


Patient #6 came in by EMS and was taken to the "holding psych room" This is a room in the ED close to the nurse's station with a chair in it. There are also monitoring cameras in the room. Patient #6 was set with a level II (Emergent) acuity.

Review of patient #6's physician notes stated, "14:54 (2:54PM) Patient medically cleared. I feel this patient is an active danger to herself. We will find an inpatient place for her to stay. There was no documentation found that the patient was assessed and given a Comprehensive Suicide Risk Assessment, according to the policy and procedure "CO.PA.004 Suicide Risk Assessment/Suicide Precautions. There was no documentation found of any interventions or precautions taken to keep this patient safe at this time.

Review of patient #6's nurse's notes dated 5/18/18 at 14:08 (2:08PM) stated," Amy PRMC Psych notified of need to eval patient for admission. 15:04 (3:04PM) patient at desk asking what is going on explained waiting for Amy or Dr. Chavez to come evaluate patient, patient stated doesn't want to go down there they don't do anything for me. 15:14 (unable to locate patient, belongings in room but unable to find patient. ERP (emergency room Physician) aware. 15:29 (3:29PM) Amy psych intake coordinator here to see patient, but unable to find patient. Outcome: 15:55 (3:55PM) AMA left before signing form."

An incident report was filed on patient #6 on 5/18/18 by Staff #13 RN titled Left Against Medical Advice. The incident report stated, "Brief Factual Description. Patient 60 arrived to the ER via EMS from home for family (sic) stating patient is having SI thoughts and seeing things, patient states no one loves me not even my son and I would just be better off it (sic) I ran out in front of a car on the road, patient was tearful, then immediately requested something to eat and a DR. Pepper. ____ Intake Coordinator was notified of need for placement of patient per Dr. ____ (ED physician) request, it was stated that DR.____(psychiatrist) states that patient didn't meet inpatient criteria. Dr.____ (ER physician) requested that someone from psych come see patient, ____intake coordinator notified and stated she would be here to see patient after eating lunch. Patient came to desk stating she didn't want to go down there that they don't do anything for me, patient went back into room and after checking in ambulance patient I was unable to locate patient, her belongings remained in the room but unable to locate her. ____ (intake coordinator) notified and _____ (the mental health authority) and came to the ER. ____ (the mental health authority) notified PD."

Review of patient #6's incident report revealed the patient was suicidal, had a plan and what the plan was. Patient #6's medical record did not have any nursing documentation stating the patient had a plan for suicide and what the plan was.

A tour was taken of the ED department on 6/5/18 with staff #1,2,3,4. A patient room in the ED was located near the nurse's station called the "Holding" room. Staff #4 stated the room is used to hold psychiatric patients while they are waiting to be medically cleared for a psychiatric inpatient admission. Inside the room it was observed to be in a L shape. There was a blue chair that turns into a recliner in the room. The room had a locked bathroom and door handles approved for a psychiatric room. The ceiling had "drop down ceilings. The ceilings nor the florescent light fixtures were secured. There were two cameras in the corner of the room that allowed the patient to be visually watched from the nurse's station. Although the ceilings and the fixtures were not secured staff #1, 3, and 4 stated the patients in this room were always under visual observation by staff. Review of patients #6's chart revealed the patient was in this room and was not found to be missing for 10 minutes. There was no one monitoring the patient during this time. Patient #6 had verbalized suicidal ideation's, a plan and how the plan was to be carried out. Patient #6 was not being monitored for up to 10 minutes. During this time the patient could have hanged herself from the drop down ceilings, opened the florescent light fixtures and used the bulbs to cut herself or swallowed.








On the afternoon of 6-5-2018, Staff #10 was interviewed in the Emergency Department. Staff #10 was working as the Charge Nurse for the Emergency Department at that time. Staff #10 was asked to explain the role of the Charge Nurse in monitoring psychiatric patients in the holding room. Staff #10 stated the patients in the holding room were assigned to the Charge Nurse; and the Charge Nurse was responsible for monitoring and documenting on the psychiatric patient. When asked how the Charge Nurse could be responsible for the nursing staff in the Emergency Department, coordinate the flow of work, and monitor a psychiatric patient, Staff #10 stated that the other tasks could be done while monitoring the patient via cameras in the room. Staff #10 denied that carrying out the duties as a Charge Nurse would prevent safe observation of the psychiatric patient in the holding room.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**





Based on review of records and interview, the facility failed to ensure staff followed established hospital restraint and seclusion policy in 1 (patient #21) out of 3 three charts reviewed.

Findings were as follows:

Patient #21's chart was reviewed on 6-6-2018. The patient was a [AGE]-year-old male, who was brought to the Emergency Department by ambulance on 5-14-2018 at 10:17 PM. The patient was suspected of swallowing a transdermal fentanyl patch (a patch to be placed on the skin for absorption of the synthetic opioid, fentanyl) just prior to EMS arrival. Patient was positive for cannabis and amphetamines on initial drug screen.

Review of nursing notes for 5-14-2018 at 10:38 PM states the patients "behavior is inappropriate for age, combative, uncooperative". The patient was given Ativan at 10:22 PM and Geodon at 10:27. Follow-up to the medication was not charted until 5-15-2018 at 1:44 AM, over 3 hours later. Nursing notes do not indicate what behaviors were occurring prior to the medication administration or mention any physical restraints.

The physician's notes dated 5-15-2018 at 12:59 AM stated, "patient came in agitated and screaming and had to be restrained by multiple people - required anxiolytics for his won (sic) safety." No record was found of staff members involved, their role in the restraint, how long the restraint lasted, written order for the restraint, patient's response to the restraint, or other information required by policy.

The emergency department restraint log was reviewed. No record was found of Patient #21 being physically restrained or given emergency behavioral medications.


The policy for Emergency Medication, PolicyStat ID: 86, Approved 12/2016, was reviewed as follows:

"PURPOSE:

To policies and procedures in place for the emergency use of psychoactive medications, including their ordering, administration, documentation and monitoring.

Emergency medications are intended ameliorate the signs and symptoms of a patient's mental illness to prevent:

imminent probable death or substantial bodily harm to the patient because of the patient:

is threatening or attempting to commit suicide or serious bodily harm; or

is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection: or

imminent physical or emotional harm to others because of threats, attempts, or others acts the patient makes or commits.


The specific medication and dosage ordered should be clinically justified as in keeping with standard clinical practice and are appropriate for the reduction of specified target symptoms.


PROCEDURE:

ORDER

A. Will include:

1. Indication for use
2. Medication
3. Route
4. Dose
5. Clarification that this is an Emergency Dose


PHYSICIAN DOCUMENTATION

A. Why the order was necessary

B. Other treatment that was considered, but was rejected and rationale


ADMINISTRATION

The administration of emergency medications will be given in a manner that provides for the privacy of the patient while maintaining a safe milieu for all patients and staff.

The procedure will be explained to the patient and the patient will be provided the opportunity to comply with the medication administration.

If patient is unwilling or unable to assist with the administration, the RN direct the clinical team to physically hold the patient for the medication administration. The physical hold is considered a restraint and must follow
all guidelines as such (please see Restraint & Seclusion policy). Physical holds and Emergency Medication must be logged in the Restraint Log.


NURSING DOCUMENTATION

A. Behaviors and previous interventions that were attempted but unsuccessful, requiring the administration of the emergency medication (sic)

B. Date and time of the administration of medication

C. Basic physical assessment following medication administration to ensure no adverse reaction is present

D. Vital Signs: 15 min, 1 hr post administration. If patient refuses vital signs there must be clear documentation of patient;s (sic) refusal and staff's repeated attempts.

E. Patient's response to medication at 30 minutes and 1 hour post administration

F. A Face-to-Face evaluation shall be conducted by the physician, L IP or a qualified registered nurse within one hour of initiating the Emergency Medication"



Review of the policy Restrains and Seclusion, pages 19-20, PolicyStat ID: 47, Approved 02/2016, was as follows:

"DOCUMENTATION

(All actions taken regarding restraint and/ or seclusion must be documented in the patient's medical record). Documentation in the patient's medical record should indicate a clear progression in how techniques are implemented with less intrusive restrictive interventions attempted (or considered prior to the introduction of more restrictive measures).

Each episode of the use of restraint or seclusion is documented in the patient's medical record and contains the following:

A. The patient and/or families (sic) advisement of the hospital's policy on restraint/seclusion

B. Any pre-existing medical conditions or other physical disabilities that would place the patient at greater risk during restraint or seclusion

C. Any history of physical or sexual abuse that would place the patient at greater psychological risk during restraint or seclusion

D. Each episode of use:

Patient assessment prior to the implementation of restraints

Circumstances that led to restraint or seclusion

The date and time the intervention began and ended

The name, title, and credentials of any staff members present at the initiation of the intervention, with identification of the staff member's role in the intervention, including as an observer, or status as an uninvolved witness, as applicable

Consideration or failure of alternatives

Rationale for type of physical intervention selected, including assurance that method of restraint chosen is the least restrictive device according to individual needs.

Type of restraint or seclusion used

Notification of family as appropriate

Written order for use

Physician notification immediately of any significant change in condition

Individual's response to the use of restraint or seclusion

Behavior criteria for discontinuing restraint or seclusion

Informing the patient of behavior criteria for discontinuing restraint or seclusion

Each telephone/verbal order received from the LIP

Each in-person evaluation and reevaluation of the patient

15 min assessments of the patient's status

Assistance provided to the patient to assist him/her meet the behavior criteria for discontinuance of restraint or seclusion

Continuous monitoring (results of patient monitoring

Debriefing with the staff
Any injuries or deaths


A. Documentation of all events is maintained on a monthly restraint or seclusion log that allows for collection and analysis for PI."

Interview was conducted with Staff #2 on 6-6-2018. Staff #2 confirmed that the patient had been restrained and that the policy for restraints and emergency medications had not been followed.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation and interview, the facility failed to provide a sanitary environment in the Emergency Department (ED).

During a tour of the ED on 6/5/18 with staff #1, 2, 3, and 4, the following issues were found:

Triage Room #1

1.) The Dynamap (blood pressure machine and monitor) in the triage room was heavily soiled with dust, hair and dirt.

2.) The Dynamap has a disposable finger monitor attached. the Dynamap was still in place from the last patient and ready to be used instead of disposed.

3.) The metal cart in the triage room had disposable syringes on top and a file caddy. The cart was soiled with dust, and hair.

4.) The computer monitor in the triage room was dusty and the table it sat on was missing paint with bare wood exposed.

5.) The hand sanitizer on the wall in the triage room was empty and soiled with dust, dirt and hair.

6.) The glass sliding door to the triage room was heavily soiled with dried liquids on the glass and dust



Triage Room #2

7.) The Dynamap monitor and base, in triage room #2, was soiled with dust and hair.

8.) Two IV poles was found to be soiled with dust and rust on the base.



Nursing Work Area

9.) The nursing work station was dirty and dusty. The Formica on the side of the work station table was broken and missing; exposing bare wood.

10.) The Blanket warmer was sitting under the nurse's work station desk. The warmer was soiled on the inside with dust and dirt particles.

11.) Three black mesh and metal chairs on rollers were found at the nurse's work station. The chairs were found to be heavily soiled with dust, dirt and hair.


Patient ED Room #8

Room 8 was confirmed by staff #4 that the room was terminally cleaned.

12.) a large slit lamp microscope (used to look into a patient's eyes) was found sitting on a table uncovered and soiled with dust.

13.) A metal stepping stool was found. The stool was soiled with spilled dried liquids and dust. The bottom of the stool had rusted and had missing and broken rubber caps on legs.

14.) The floor was found to be soiled with trash, dust, dirt and hair.

15.) The stretcher was found to have dried substance that looked like blood dripping down the frame of the bed. Staff #4 took an alcohol pad and wiped the dried substance off of the bed. The frame of the stretcher was found to be dirty, and rusted.

16.) The stretcher mattress pad was found to be torn in 4 places. The mattress cannot be cleaned properly to prevent infection.

17.) Biohazard trash was found in the biohazard trash.

18.) The wooden door to room 8 was heavily scratched and missing veneer. The door had exposed wood. Exposed wood can harbor bacteria and is unable to be cleaned properly.


Urgent Care Area

19.) In the Urgent care area 5 Dynamaps were found soiled with dust and debris.

20.) A three tier, wire metal shelf was found holding supplies. The bottom shelf had patient medical supplies and there was no barrier between the supplies and the floors. A plastic three drawer container was found soiled with dust and hair.

21.) A 250 ml bottle of saline was found opened with no dates. The bottle was with patient supplies in a terminally cleaned room.

22.) A syringe of Normal Saline was found accessible to patients. In the urgent care area.

23.) The computer was soiled with dust and hair.

24.) The stretcher was found to be soiled on the mattress and the metal base under the mattress was heavily rusted. It was found to be rusted and peeling paint on the frame.

25.) Trash and medical supplies were found behind the stretcher on the floor and on a metal shelf covered in dust.

26.) The door was scratched and bare wood was exposed.



Linen Room

27.) The linen room had a metal cart holding linen. The linen was not covered and was exposed to dust and hair from the floor.


Patient Medical Supply Room

28.) The patient supplies room had supplies spilled out of plastic containers onto the floor.


Holding Room in the ED

29.) A vinyl chair in the "holding room" of the ED was found to be soiled and dirty. A large piece of soiled tape was removed from the chair with hair and a bloody substance on the tape.


During the tour on 6/5/18 staff #4 stated that there has been issues with housekeeping in the ED and she was already aware of that. Staff #4, 2, and 3 confirmed the findings in the ED. Staff #4 stated they have been discussing how they can get staff to turn over the rooms quicker yet allow housekeeping to come in and clean between patients. Staff #4 confirmed there was no PI project at this time for the environmental and infection control issues in the ED.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review, observation and interview the Governing Body failed to:


A. ensure that the facility followed its policy and procedures and maintained safety for all patients in 3 (6, 14, and 19) of 4(6, 12, 14, and 19) charts reviewed.

B. document the patients suicide screening appropriately and accurately to ensure the patient received a full comprehensive suicide risk assessment, be assigned a risk level, and given the appropriate monitoring according to the assessment, to provide patient safety in 3 (6, 14, and 19) of 4(6, 12, 14, and 19) charts reviewed.

C. monitor patients with suicidal complaints after the Triage process. Patients were left unattended to leave the facility without medical attention in an unsafe environment in 3 (6, 14, and 19) of 4 (6, 12, 14, and 19) charts reviewed.

D. assess and protect a suicidal child, that was not in attendance with a legal guardian, in potential danger in 1 (14) of 4 (6, 12, 14, and 19) charts reviewed.

Refer to Tag A0144


E. ensure staff followed established hospital restraint and seclusion policy in 1 (patient #21) out of 3 charts reviewed.

Refer to Tag A0167