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.

PSYCHIATRIC INSTITUTE OF WASHINGTON DC 4228 WISCONSIN AVENUE, NW WASHINGTON, DC 20016 Sept. 23, 2019
VIOLATION: NURSING SERVICES Tag No: A0385
Based on medical record review, policy review, video footage review, and staff interview, the hospital staff failed to ensure organized nursing services to: monitor 14 patients admitted to the inpatient adolescent psychiatric unit, after a narcotic breach and questionable ingestion of Adderall and/or Focalin (Schedule II controlled substances) (A-0395); ensure the education and competence related to narcotic count; medication security, medication administration and storage (A-0397); prepare and administer medications, in accordance with acceptable standards and practice and hospital policies and procedures (A-405).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Nursing Services.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on observation, record review, policy review and staff interview, the Governing Body failed to ensure that contracted staff provided care in a safe manner, as evidenced by failure to implement safety and security guidelines; secure hazardous equipment; implement necessary infection control measures and reporting; and ensure patient safety management, during repair in construction.

Findings included ...

Cross reference A-0144 -2.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, medical record review, policy review, video footage review, and staff interview, the hospital staff failed to promote and protect patients' rights to receive care in a safe setting, for 15 of 15 patients admitted to an adolescent inpatient psychiatric unit; and one patient admitted as an inpatient, on the Substance Use Disorder unit (A-0144).

Based on observation, medical record review, policy review, and staff interview, the hospital staff failed to promote and protect patients' rights to receive care in a safe setting, for 16 of 16 patients, admitted for inpatient adult psychiatric services (A-0144).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with the condition of participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
1. Based on observation, video review, policy review, record review of 28 sampled patients, and staff interviews, the hospital staff failed to protect 16 psychiatric patients, from undue adverse medication consequences, as evidenced by failure to secure medications to include narcotics, as to prohibit unauthorized access (Patients # 1, 2, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 29, 32 and 33).

Findings included ...

Review of the hospital policy titled, "Patient Rights and Responsibilities," last reviewed 08/17, showed that patients have the right to be safe from harm and to receive services in a safe place.

Review of the hospital policy titled, "Patient Observation Rounds," last reviewed 07/19, showed that staff are to be aware of times that their focus may be diverted to include changes of shift, visiting hours, and crisis de-escalation.

Review of the hospital policy titled, "Controlled Medication Procedure", last reviewed 08/17, showed that the nurse keeps the controlled medication, in the locked drawer of the medication cart.

On 09/12/19 at approximately 2:40 PM, the surveyor reviewed video surveillance dated, 03/11/19 at 8:02 PM, that showed Employee #14, Registered Nurse, pre-pouring patients' medications and placing them in medication cups. Employee #22, Registered Nurse, opened the garage door window, slid aside the Plexiglas window, and proceeded to administer the medications to patients that were prepared by Employee #14. Each nurse took turns exiting the medication room, leaving the windows open, the medication cart and the medication room unsecured, to get patients, who came to the windows to receive their medications. At 8:29 PM, Employee #36, Registered Nurse, entered the medication room, and she and Employee #22 initiated the narcotic count, while Employee #14 continued preparing medications.

At 8:31 PM, a staff member came to the medication window to alert the nurses of a patient emergency. All nurses left the medication room, with the windows open, narcotics on the counter and within reach of passersby, and left the medication cart unsecured. Patient #2 reached in the medication window at 8:32 PM, and took narcotics from the counter and placed them in his pocket and left the window. At 8:36 PM, he returned to the window, sorting through and taking narcotics, until Employee #31, Pharmacist, entered the medication room and dropped off medication on top of the medication cart. Patient #2 backed away and returned at 8:37 PM and removed narcotics from the counter. Employee #22 then went to the medication room and slid close the Plexiglas window, from the outside and entered the medication room, followed by Employee #36, who entered the medication room, but both nurses exited the room again, leaving it unsecured, to assist with Patient #12, who was agitated. At 8:38 PM, Patient #1slid open the Plexiglas window and took narcotics, put them in his pocket, and proceeded in and out of the community room. Staff realized the narcotic breach at 8:51 PM.

Review of the 'Report of Theft or Loss of Controlled Substances' form revealed 25 Adderall tablets and nine Focalin tablets were missing. Through patient interviews, room and body search, and recommendation from Poison Control, the hospital staff concluded that Patient #1 ingested an undetermined amount of Adderall; and he was transferred to an acute care children's hospital at 12:00 AM on 08/12/19. He returned to PIW on 08/13/19 at 1:44 PM. Staff could not determine if Patient #2, or other patients who had unmonitored interactions with Patient's #1 and #2, received or ingested medications.

During a face to face interview with Employee #33, Risk Manager, he explained that since then, the following measures were implemented to include: stationary Plexiglas windows, with a small opening to pass medications were inserted; and the nursing staff received education and training to administer medications through the new Plexiglas medication window, about end of shift narcotic count, narcotic documentation and double lock storage, securing medications, and emergency drills.

However, during a medication pass observation on 09/11/19, at 1:00 PM, on the Adult Substance Use unit, the surveyor observed Employee #17, Registered Nurse, administer medication to Patient #29 through a door window, not the new stationary Plexiglas medication window. She left the medication cart unlocked, within reach and accessible to passersby, turned her back to the unsecured cart, door window, and patient, to prepare the medication on the counter. The observation was in the presence of Employee #2, Chief Nursing Officer.

Additional medication pass observations, conducted that same day, in the presence of Employee #2, at 1:20 PM on Unit 1 (Adult), 2:05 PM on Unit 3 (Adult Intensive Care Subacute), and 2:20 PM on Unit 7 (Adolescent Intensive Care Unit), revealed the nursing staff failed to secure medication carts, where controlled substances are stored, after use. During a tour of Unit 4 (Adult Substance Use), Employee #28, Registered Nurse, failed to demonstrate how to lock the medication cart, stating he had not received orientation to the medication cart.

The practice lacked evidence that staff maintained a safe patient environment.

During a face to face interview on 09/12/19 at 11:50 AM, with Employee #7, Director of Education and Staff Development, he was requested to provide policies and procedures related to safe medication administration; securing medications to include controlled substances and the medication cart; as well as staff education, training, and competencies. He could not provide the requested documents.

Employees #2 and 7 acknowledged the findings.


2. Based on observation, record review, policy review and staff interview, the hospital staff failed to protect 16 psychiatric patients, as evidenced by failure to: implement safety and security guidelines; secure hazardous equipment; implement necessary infection control measures and reporting, and ensure patient safety management, during repair in construction (Patients #37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 and 52).

Findings included ...

Review of the hospital policy titled, "Patient Rights and Responsibilities," last reviewed 08/17, showed that patients have the right to be safe from harm and to receive services in a safe place.

Record review of hospital policy titled, "Regulations for Equipment Vendors, Installers, and Construction Workers," revised 04/17 showed that patients, visitors, and hospital staff shall be restricted from projects areas, whenever possible. Workers are to ensure that equipment, tools and solutions are not left unattended and maintenance staff is to monitor the workers' performance to ensure compliance. Workers are to report any plans that may interrupt the functions of the hospital to the hospital administration.

Review of the hospital's "Contractor/Subcontractor Safety and Security Guidelines," dated 2017, showed the safety and security understanding and expectations that contracting staff are to comply with, related to patient confidentiality; identification and access; clothing and equipment safety; permits and procedures; housekeeping; electrical safety and environmental issues and hazards; tools; and patient safety. Contracting staff are to sign an orientation and confidentiality agreement to ensure compliance to the safety and security guidelines.

Review of the hospital policy titled, "Patient Observation Rounds," last reviewed 08/17, showed that staff are to conduct every 15-minute patient observation rounds to include identifying and reporting safety hazards in all areas.

Review of the hospital policy titled, "Safety Management Protocol," last reviewed 08/17, showed that staff are to conduct risk assessments to evaluate property damage to ensure statement of conditions; facility operations, utility management, equipment management, and hazard surveillance inspections; hospital occurrence and supervisor reports; employee competence; examine safety issues; report risk data to Administration, Nursing, Clinical Services, Quality/Risk Management and Internal Medicine; and implement and enforce safety policies and procedures.

Review of the hospital policy titled, "Construction Within the Facility," last reviewed 08/16, showed that The Director of Plant Operations and the Infection Preventionist perform construction assessment; plan alternative traffic routes for patients, staff and visitors; ensure proper air handling; supervise waste material disposal by contractors; and report to the Medical Staff Committee for infection solutions and recommendations, related to construction in the facility.

During a tour of Unit 1 on 09/19/19 at approximately 8:25 AM, in the presence of Employee #2, Chief Nursing Officer, the surveyor observed contracting staff, knelt facing the wall, in patient care Room 302. He was repairing a hole in the wall (replacing drywall), while Patient #37, who was on suicidal precautions, was entering and exiting the room, multiple times. There was no containment barrier; and drywall and dust was on the floor. A hand saw was on the floor at the entrance to the room, unattended and unsecured; and a drill and other tools were on a cart inside the room, unattended and unsecured. Employee #40, Patient Counselor, entered and exited the room, pass the construction. The surveyor queried if there was another patient in the room, she stated, "Yes, would you like me to wake him up?" Patient #38 was asleep in the bed. Employee #2 notified nursing, infection control, and plant operations staff, regarding the unsafe patient environment.

Review of the Unit 1 patient census and medical records for Patients #37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 and 52, revealed Patients' #37, 39, 43, 46, 47, and 48 were on suicidal observation; Patients' #40, 42, and 50 were on homicidal observation; and Patient #41 was on suicidal and homicidal observation.

During a face to face interview on 09/19/19 at approximately 10:00 AM, with Employee #7, Designated Infection Control Staff, he shared that Employee #2 called him to inform him of the construction, when she was with the surveyor, in Room 302. He did not have prior notification, from the Plant Operations staff, but he was in the process of preparing a risk assessment report; construction had ceased; patients were moved out of the room; and the room was closed.

Review of the patient rounds documentation, dated 09/18/19 and 09/19/19, failed to reveal alterations in the wall, in Room 302, or any potential safety hazards.

During a face to face interview on 09/19/19 at approximately 10:50 AM, with Employee #39, Interim Director of Plant Operations, he shared that staff provided a work order to repair a hole in the wall in Room 302; and he authorized contracting staff to perform the repair. Although he knows the process to inform nursing, infection control, and administration, for any construction project, he didn't because he "didn't think it was a big issue." Employee #39 explained that usually he monitors the activities of contracting staff to ensure they are working in a safe manner; however, he did not that day and was not aware of the unsafe environment.

During a face to face interview on 09/19/19 at approximately 12:40 PM, with Employee #38, Chief Financial Officer, he shared that he has oversight over plant operations. During the morning leadership meeting, Employee #39 did not mention any construction in the hospital; however, after the incident he mentioned that contracting staff was patching a hole in the wall, in Room 302. Employee #38 explained that though he had no orientation to his position for having oversight of plant operations and doesn't have a job description, he knows that the room needs to be prepped, secured, and collaboration with the Unit Program Manager and Infection Control staff is expected to "establish potential hazards." He shared that Employee #39 had been at the facility for seven years, in maintenance, and is fully aware of the process for safety management.

During a face to face interview on 09/19/19 at approximately 2:40 PM, with Employee #40, the surveyor queried how she conducted and documented observations, during patient rounding. She explained the process, but denied noticing a hole in the wall or construction, in Room 302, though she was in the room.

On 09/19/19 at approximately 3:00 PM, review of Employees #38 and #39's human resource files and education and training, lacked evidence of their job descriptions, orientation, or education and training, related to safety management, facility construction, and the hospital's safety and security guidelines for contractors. Additionally, there was no evidence of orientation and confidentiality agreements signed by contracting staff for understanding and compliance to safety and security guidelines.

The practice lacked evidence that staff followed hospital policies and safety and security guidelines to maintain a safe environment for patients, visitors and staff.

Employees #2, 7, 38 and 39 acknowledged the findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observation, video review, policy review, record review of 28 sampled patients, and staff interviews, the nursing staff failed to monitor or evaluate 14 patients that could have potentially ingested breached medications (Adderall and Focalin- used to manage Attention Deficit Hyperactivity Disorder), for adverse medication side effects (Patients #10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 29, 32 and 33).

Findings included ...

Review of the hospital policy titled, "Change of Condition", last reviewed 09/17, showed that " ...patients are continually assessed and reassessed to identify changes in condition that prompt the initiation of/ change in medical compromised precautions and level of monitoring..."

On 09/12/19 at approximately 2:40 PM, the surveyor reviewed video surveillance dated, 03/11/19 at 8:31 PM, that showed Employees #14, 22, and 36, Registered Nurses, all left the medication room, with the windows open, narcotics on the counter and within reach of passersby, and left the medication cart unsecured. Patient #2 reached in the medication window at 8:32 PM, 8:36 PM, and 8:37 PM, sorting through and taking narcotics, from the counter; while the nurses assisted with Patient #12, who was agitated. At 8:38 PM, Patient #1slid open the Plexiglas window and took narcotics, put them in his pocket, and proceeded in and out the community room. Staff realized the narcotic breach at 8:51 PM.

Review of the 'Report of Theft or Loss of Controlled Substances' form revealed 25 Adderall tablets and nine Focalin tablets were missing. Through patient interviews, room and body search, and recommendation from Poison Control, the hospital staff concluded that Patient #1 ingested an undetermined amount of Adderall; and he was transferred to an acute care children's hospital at 12:00 AM on 08/12/19. He returned to PIW on 08/13/19 at 1:44 PM. Staff could not determine if Patient #2, or other patients who had unmonitored interactions with Patient's #1 and #2, received or ingested medications. However, the record lacked evidence that nursing staff monitored or evaluated the patients for potential adverse side effects of ingestion of the Adderall or Focalin.

During a face to face interview on 09/13/19 at approximately 7:05 AM, with Employee #14, Registered Nurse who was assigned to care for patients on Unit 8 on 03/11/19, she shared that one patient, who admitted to taking Adderall was transferred to the emergency department and the other patient who took narcotics said he trashed the medications, in the sink. No other patients admitted to ingesting the narcotics, so staff conducted the usual every 15-minute patient rounds and monitoring.

During a face to face interview on 09/13/19 at approximately 11:00 AM, with Employee #4, Psychiatrist assigned to Patient #1 and to the patients on Unit 8, he shared that staff informed him of the incident on 03/12/19. He explained the half-life of Adderall is 24 hours and that half of the drug is eliminated in about 12 hours, but and he ordered toxicology screening for all the patients on Unit 8, that same day. However, the hospital staff could not provide the orders or the results for the urine toxicology screens, on the remaining patients.

During a subsequent telephone interview on 09/18/19 at approximately 9:50 AM, with Employee #37, on call Psychiatrist on 03/11/19, she did not recall the incident or her involvement.

During a subsequent telephone interview on 09/18/19 at approximately 11:00 AM, with Employee #22, Registered Nurse who was assigned to care for patients on Unit 8 on 03/11/19, she explained that the nursing supervisor spoke to Poison Control, who recommended staff transfer Patient #1 to the emergency department and to monitor vital signs for two patients (she could not recall patient names), known to her to be involved, in addition. For the other patients, staff performed the usual 15-minute rounding and monitored for normal side effects like stomach upset and mental status changes.

The practice lacked evidence that staff monitored the patients for adverse side- effects, who had unmonitored interactions, with known patients involved in taking narcotics from the medication room.

Employees #2, Chief Nursing Officer, and 3, Director of Quality, acknowledged the findings.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on observation, video review, policy review, record review of 28 sampled patients, and staff interviews, the hospital staff failed to ensure the appropriate education and competence of nursing staff related to narcotic count; medication security and storage to include narcotics; and medication administration; for 11 nursing staff, who prepared and administered medications to psychiatric patients (Employees #12, 14, 16, 17, 19, 21, 22, 23, 26, 27, and 28).

Findings included ...

Review of the hospital policy titled, "Medication Administration HCS [Health Care Systems -computer/documentation system]", last reviewed 03/19, showed that the nurse is to arrange to be free from interruption, while preparing medications. To identify the patient, the nurse requests the patient to state name, compare the name on the picture that's on the patient arm band, and recheck the stated name with the name and picture in the HCS system. The nurse who prepares the medication, administers it to the patient; and watches the patient take and swallow the medication. The nurse enters given on the medication administration record, as soon as the medication is given. Each unit will have one set of keys to open the medication room, medication cart, and the narcotic drawer; which will be passed to the responsible nurse, from shift to shift.

Review of the 'Nurse Advisory' documentation dated 12/21/16 that was posted in the Unit 8 medication room revealed that staff are not to "Pre-pour or Pre-Pull medications. Staff are to not to put medications in dispensing cups, until the medication is ready for administration. Staff are to document narcotic administration at the time of administration.

Review of the hospital policy titled, "Controlled Medication Procedure", last reviewed 08/17, showed that the nurse is to document and sign the administration of the controlled substances on the controlled medication record form.

On 09/12/19 at approximately 2:40 PM, the surveyor reviewed video surveillance dated, 03/11/19 at 8:02 PM, that showed Employee #14, Registered Nurse, pre-pouring patients' medications and placing them in medication cups. Employee #22, Registered Nurse, opened the garage door window, slid aside the Plexiglas window, and proceeded to administer the medications to patients that were prepared by Employee #14. Employee #22 did not sanitize her hands between patients. Each nurse took turns exiting the medication room, leaving the windows open, the medication cart and the medication room unsecured, to get patients, who came to the windows to receive their medications. At 8:29 PM, Employee #36, Registered Nurse, entered the medication room, and she and Employee #22 initiated the narcotic count, while Employee #14 continued preparing medications. At 8:31 PM, the nurses all left the medication room, with the windows open, narcotics on the counter and within reach of passersby, and left the medication cart unsecured. Patients #1 and 2 reached in the medication window and took narcotics, from the counter; while the nurses assisted with Patient #12, who was agitated.

During a medication pass observation on 09/11/19, at 1:00 PM, on the Adult Substance Use unit, the surveyor observed Employee #17, Registered Nurse, administer medication to Patient #29 through a door window, not the new stationary Plexiglas medication window. She left the medication cart unlocked, within reach and accessible to passersby, turned her back to the unsecured cart, door window, and patient, to prepare the medication on the counter. The observation was in the presence of Employee #2, Chief Nursing Officer.

Additional medication pass observations, conducted that same day, in the presence of Employee #2, at 1:20 PM on Unit 1 (Adult), 2:05 PM on Unit 3 (Adult Intensive Care Subacute), and 2:20 PM on Unit 7 (Adolescent Intensive Care Unit), revealed Employee #27 did not request the patients to state their names and Employees #27, 21, and 16, failed to secure medication carts, where controlled substances are stored, after use. Employee #16 said the medication cart was to lock automatically; however, it had been malfunctioning but she did not report it. During a tour of Unit 4 (Adult Substance Use), Employee #28, Registered Nurse, failed to demonstrate how to lock the medication cart. He stated it should automatically lock but it doesn't, and that he had not received orientation to the medication cart.

During observation of the narcotic count on 09/12/19 at 7:30 AM, with Employees #12, Oncoming Registered Nurse, and 13, Outgoing Registered Nurse, Employee #13 presented the packet of Lorazepam 2 milligrams (mg) to the outgoing nurse, asking, "You see its six in here?" When queried regarding the process for narcotic count, she explained that the count requires the oncoming nurse to specify the name of the medication, dose, strength, and confirm the amount of medication available, but admitted she did not do that. Additionally, during medication pass observation that same day at 8:28 AM, Employee #13 withdrew Adderall XR (extended release)10 mg and Adderall XR 20 mg to administer to Patient #26, and failed to sign out the narcotics and ensure the correct count.

Review of human resources files on 09/13/19 at 4:00 PM, for Employees #14, 16, 22, 23, and 28, Registered Nurses, lacked documented evidence of education, training, and competencies on safe medication administration; narcotic count and documentation, securing medications to include controlled substances and the medication cart, and use of the Metro Lionville Medication Cart.

During a face to face interview on 09/12/19 at 11:50 AM, with Employee #7, Director of Education and Staff Development, he was requested to provide education and training related to safe medication administration; narcotic count and documentation, securing medications to include controlled substances and the medication cart; as well as competencies for 11 nursing staff who prepared and administered medications to psychiatric patients, during the survey. He could not provide the requested documents.

The practice lacked evidence that demonstrated the nursing staff safely conducted the narcotic count and prepared and administered medications.

Employees #2 and 7 acknowledged the findings.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, video review, record review of 28 sampled patients, and staff interviews, the nursing staff to failed prepare and administer medications, in accordance with acceptable standards and practice and hospital policies and procedures, as evidenced by nursing staff pre- pouring medication; failing to appropriately identify the patient; failing to appropriately document controlled substances; failing to correctly perform the narcotic count, and administer and document narcotics.

Findings included ...

Cross Reference A-0397.
VIOLATION: Condition of Participation: Pharmaceutical Se Tag No: A0489
Based on medical record review, policy review, video footage review, and staff interview, the hospital staff failed to develop and implement policies and procedures to minimize medication errors that included provisions to secure medications (A -0502); to lock controlled substances to prohibit unauthorized access (A-0503); and address how it prevents unauthorized persons from gaining access to medications (A-0504).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Pharmaceutical Services.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, video review, record review of 28 sampled patients, and staff interviews, hospital staff failed to secure medications.

Findings included ...

Cross Reference A-0144
VIOLATION: ACCESS TO LOCKED AREAS Tag No: A0504
Based on observation, record review, policy review, and staff interviews, the hospital staff failed to ensure policies and procedures for medication management, security, and prevention of unauthorized access to controlled substances.

Findings included ...

Review of the hospital policy titled, "Controlled Medication Procedure", last reviewed 08/17, showed that the nurse is to document and sign the administration of the controlled substances on the controlled medication record form. The nurse keeps the controlled medication, in the locked drawer of the medication cart. The off-going and on-coming nurses will count all controlled medications and check the count against the records. The on -coming registered nurse counts the medications in the drawer and the off-going registered nurse checks the record.

Review of the hospital policy titled, "Medication Administration HCS [Health Care Systems - computer/documentation system]", last reviewed 03/19, showed that the nurse is to arrange to be free from interruption, while preparing medications. To identify the patient, the nurse requests the patient to state name, compare the name on the picture that's on the patient arm band, and recheck the stated name with the name and picture in the HCS system. The nurse who prepares the medication, administers it to the patient; and watches the patient take and swallow the medication. The nurse enters given on the medication administration record, as soon as the medication is given. Each unit will have one set of keys to open the medication room, medication cart, and the narcotic drawer; which will be passed to the responsible nurse, from shift to shift.

Review of the hospital's Health Care System's Quick Reference guide showed that staff are to verify medication orders, prior to administration. Medications may be documented by scanning the patient's barcode or entering the patient's name in the system, then medications may be added, changed, discontinued, re-ordered or signed electronically.

During a medication pass observation on 09/11/19, at 1:00 PM, on the Adult Substance Use unit, the surveyor observed Employee #17, Registered Nurse, administer medication to Patient #29 through a door window, not the new stationary Plexiglas medication window. She left the medication cart unlocked, within reach and accessible to passersby, turned her back to the unsecured cart, door window, and patient, to prepare the medication on the counter. The patient did not have an arm band to scan. The nurse used the scanning system to identify the medication only. The observation was in the presence of Employee #2, Chief Nursing Officer.

Additional medication pass observations, conducted that same day, in the presence of Employee #2, at 1:20 PM on Unit 1 (Adult), 2:05 PM on Unit 3 (Adult Intensive Care Subacute), and 2:20 PM on Unit 7 (Adolescent Intensive Care Unit), revealed Employee #27 did not request the patients to state their names and Employees #27, 21, and 16, failed to secure medication carts, where controlled substances are stored, after use. Employees #27 and 21 locked the medication carts, using a lever on the side of the cart; not keys, as indicated in the policy. Employee #16 said the medication cart was to lock automatically; however, it had been malfunctioning but she did not report it. During a tour of Unit 4 (Adult Substance Use), Employee #28, Registered Nurse, failed to demonstrate how to lock the medication cart. He stated it should automatically lock but it doesn't and that he had not received orientation to the medication cart.

During observation of the narcotic count on 09/12/19 at 7:30 AM, with Employees #12, Oncoming Registered Nurse, and 13, Outgoing Registered Nurse, Employee #13 presented the packet of Lorazepam 2 milligrams (mg) to the outgoing nurse, asking, "You see its six in here?" When queried regarding the process for narcotic count, she explained that the count requires the oncoming nurse to specify the name of the medication, dose, strength, and confirm the amount of medication available, but admitted she did not do that. Additionally, during medication pass observation that same day at 8:28 AM, Employee #13 withdrew Adderall XR (extended release)10 mg and Adderall XR 20 mg to administer to Patient #26, and failed to sign out the narcotics and ensure the correct count. The patient did not have an arm band to scan. The nurse used the scanning system to identify the medication only.

During review of policies and procedures related to medication management and medication storage and security on 09/12/19 and 09/13/19, provided by Employee #7, Director of Education and Staff Development, there was no evidence that the hospital staff established and implemented policies and procedures that incorporated the use of the Medication Administration HCS system, in the actual medication administration practice, and addressed how to prevent unauthorized access to controlled substances.

During a face to face interview on 09/12/19 at 11:50 AM, with Employee #7, Director of Education and Staff Development, he was requested to provide policies and procedures related to safe medication administration using their Medication Administration HCS system [computer/documentation system]; narcotic count and documentation, securing medications to include controlled substances and the medication cart, and use of the Metro Lionville Medication Cart. He could not provide the requested documents.

Employees #2 and 7 acknowledged the findings.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, medical record review, policy review, and staff interview, the hospital staff failed to ensure a safe environment, on Unit 1, to minimize hazardous risks, for 16 of 16 patients, admitted for inpatient adult psychiatric services (A-0701).

The effect of the systemic practices resulted in the hospital failure to comply with conditions of participation for physical environment.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, record review, policy review and staff interview, staff failed to ensure a patient environment that minimized hazardous risks to patient safety and failed to implement containment measures, during repair in construction, for 16 of 16 patients (Patients #37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 and 52).

Findings included ...

Cross Reference A-0144- 2.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, review of the Infection Control (IC) program, policy review, and staff interview, the Governing Body failed to ensure the Infection Control Officer was qualified and trained in infection control practices, consistent with the specific hospital services and infection prevention practices.

Findings included...

Cross reference A-0144-2.

On 09/19/19 at approximately 3:00 PM, review of Employee #7's human resource file, education and training, lacked evidence of an Infection Preventionist job description, orientation, or education and training, related to infection control and prevention.

The Governing Body failed to ensure the designated Infection Preventionist had infection prevention and control training that included the hospital-wide policies and procedures for preventing, identifying, reporting, investigating, and controlling infections, to mitigate infection risks and monitor compliance, with infection prevention practices.

During a face to face interview on 09/19/19 at approximately 4:00 PM, with Employee #2, Chief Nursing Officer, who had oversight over the infection control, she explained that Employee #7 did not take the required training and courses in infection control, as directed. The hospital was in the process of hiring another employee who will take training to become the designated Infection Preventionist. She acknowledged the findings.