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.

BROOKHAVEN HOSPITAL, INC 201 SOUTH GARNETT ROAD TULSA, OK 74128 Dec. 2, 2019
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on record review and interview, the hospital failed to ensure the practitioner completed the history and physical for two (Patient #3 and #10) of 11 patients.

This failed practice has the likelihood to place patients at risk of receiving care that is non-therapeutic and not having their individualized patient history information communicated.

Findings:

Review of Policy #5415 "Time frame for entries into the medical record" read in part, "History and Physical within 24 hours of admission."

Patient #3

Review of a document titled "History and Physical" showed Patient #3 was admitted on [DATE] and the practitioner signed the document 11/21/19 (2 days after admission ).

On 12/02/19 at 12:17 PM, Staff B reviewed the medical record for Patient #3 and stated the history and physical was supposed to be signed by a practitioner within 24 hours of admission.

Patient #10

A review of a document titled "History and Physical Exam" dated 11/09/19 showed signature of the physician with no date and time.

On 12/02/19 at 12:15 PM, Staff G stated a physician was required to sign, date, and time the History and Physical form.




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VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, interview, and record review, the hospital failed to ensure daily supervision of dietary services.

This failed practice has the likelihood to result in patients and staff developing food-borne illness.

Findings:

Review of a record titled "Dietary In-Service" dated 08/19/19, read in part, "Date Marking...all ready to eat TCS foods that are going to be stored for more than 24 hours must be properly labeled/dated...after the 7 day mark, the food item must be discarded. Date marking is crucial in preventing use and service of food that has been refrigerated for long periods."

On 11/26/19 from 11:17 AM to 12:50 PM, during a kitchen tour, the following was observed:

Refrigerator #1

1. An opened ziplock bag of yellow cheese slices with no date marked.
2. An opened ziplock bag of ham slices with no date marked.
3. An opened ziplock bag of turkey slices with no date marked.
4. An opened ziplock bag of swiss cheese slices with no date marked.
5. An opened ziplock bag of tomato slices with no date marked.
6. An opened package of butter x 3 with no date marked.
7. An opened bag of whipped topping with no date marked.
8. An opened container white yogurt with expiration date "11/24/19."

On 11/26/19 at approximately 11:59 AM, Staff C stated they did not have any dates on these products and the person who opened or prepared the item was responsible for labeling it with the date opened. Staff C stated the yogurt was expired and threw the item away.

Refrigerator #2

1. An opened jar of mayonnaise with no date marked.
2. An opened jar of kalamata olives with no date marked.
3. An opened bottle of sweet and sour sauce with no date marked.
4. Tupperware container of liquid labeled with a sticker that read, "Soup 11-25-19" and another sticker that read, "Ranch 11-2-19," (17 days past due).

On 11/26/19 at approximately 11:30 AM, Staff C stated the cook should have marked the opened bottle,jars, and container with the date they were opened; and the tupperware container should not have two labels.

Countertop

1. An opened bottle of Curry spice with sticker that read, "09/20/16."
2. An opened bottle of whole cumin with no expiration date.
3. An opened bottle of pure gelatin with no expiration date
4. An opened bottle lemon pepper seasoning with no expiration date.
5. An opened bottle of soy sauce with no expiration date.
6. An opened bottle of a brown liquid with no label stating its contents and no expiration date.

On 11/26/19 at approximately 11:17 AM, Staff C stated they did not know when the curry expired, but was sure the quality had gone down. Staff C stated they did not see any expiration dates; could not determine when items were opened; and threw the items away.

Freezer #1

1. An opened bag of enchiladas with a sticker that read, "11/10," (3 days past due)

On 11/26/19 at approximately 12:05 PM, Staff J stated the enchiladas were expired; that they can use frozen foods for two weeks once opened; and threw the bag away.

Freezer #2

1. Two packages of hamburger buns, each with freezerburn and no expiration date.

On 11/26/19 at approximately 12:25 PM, Staff C stated they did not see an expiration date and threw the items away.

Freezer #3

1. Upper portion had approximately three inches of ice crystal buildup.

Review of a document titled "Cleaning Assignments" read in part, "Once a week: Clean out freezers: inside walls, racks, gaskets, door, sides, and slats on top. (Mondays)."

Review of record showed no documentation of freezer weekly cleanings.

On 11/26/19 at approximately 12:20 PM, Staff C stated all freezers are cleaned monthly on the first Wednesday of the month and, due to being short-staffed, the last time Freezer #3 was cleaned was three months ago (12 weeks late), and they do not keep a log of when the freezer was cleaned.

Back Kitchen Office

1. Package of unrefrigerated Kings Hawaiian rolls with "11/10" written in marker (3 days past due).

A Kings Hawaiian cardboard box was reviewed and read, "Please code date with a 14-day pull date from time of thaw and placement."

On 11/26/19 at approximately 12:10 PM, Staff C reviewed the cardboard box and stated the rolls arrive to them frozen and they date the packages when they remove them from the freezer to thaw. Staff C stated the package of rolls dated "11/10" were expired and threw them away.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the hospital failed to ensure the windows and doors were safely maintained for three (Room #100, #105, #110) of 10 rooms.

This failed practice has the likelihood to result in patients receiving care in an environment that is not therapeutic.

Findings:

Review of a document titled "Environment of Care/Patient Safety Rounds Tool" dated 11/19/19, read in part, "Are floors, walls, ceiling tiles, or doors damaged? (i.e. holes, cracks, chips, openings, etc.)" and "OK" was checkmarked.

On 11/26/19 from 9:44 AM to 10:51 AM, during a tour of the Behavioral Health Unit, the following was observed:

1. Room #100
a. Hole in middle vertical window frame with exposure to outdoors
b. Separation of window from frame along entire left half of window base
2. Room #105
a. Eight holes in the window frame with exposure to outdoors
4. Room #110
a. An approximately six inch crack at left lower corner of window

On 11/26/19 at 10:44 AM Staff K stated a patient busted out the window in Room #105 a few months ago.

On 11/26/19 at 10:51 AM Staff B stated the Chief Nursing Officer and Quality Assurance personnel conduct weekly checks of patient rooms and that Staff G walks the rooms daily.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview, the hospital failed to ensure level of consciousness was documented for two (Patients #2 and #5) of 11 patients.

This failed practice has the likelihood to place patients at risk of inability to have the effectiveness of their treatment evaluated.

Findings:

Review of a policy titled "Fall Assessment" read in part, "treatment measures status post fall may include any or all of the following...Incident Report documenting:...Patient's level of consciousness."

Patient #2:

Review of two documents titled "Brookhaven Hospital Risk Incident Report" dated 09/20/19 and 11/20/19 showed patient fell , hit their head, and no level of consciousness was documented.

Patient #5

Review of a document titled "Brookhaven Hospital Risk Incident Report" dated 09/20/19 showed patient fell , hit their head, and no level of consciousness documented.

On 12/02/19 at 12:20 PM, Staff G reviewed the incident reports for Patient #2 and stated they did not see where the level of consciousness was recorded or where the form addressed level of consciousness.
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on observation, record review, and interview, the hospital failed to ensure patient received care in a safe setting for 12 of 12 patients.

This failed practice has the likelihood to result in physical and emotional harm and injury, thereby impeding on a patient's right to care in a safe setting. (See Tag 0144)

Based on observation, record review, and interview, the hospital failed to ensure restraint orders were in place for one (pt #1) of one patients.

This failed practice has the likelihood to result in violation of a patient's right to be free from unauthorized and unnecessary restraints. (See Tag 0167).

Based on observation, record review, and interview, the hospital failed to follow policy for mechanical restraints for two (pt #1 and pt #11) of two patients.

This failed practice has the likelihood to result in patient being restrained by mechanical restraints. (See Tag 0168)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, and interview, the hospital failed to ensure care in a safe setting for 12 of 12 patients.

This failed practice has the likelihood to result in physical and emotional harm and injury, thereby impeding on a patient's right to care in a safe setting.

Findings:

On 11/26/19 from 9:44 AM to 10:51 AM, during a tour of the Behavioral Health Unit, the following was observed:

1. Rooms #101, #103, and #109: Pointed end of screws were exposed in the door frames inside the entry room doors for patient.

2. Room #107: Broken vent pieces with jagged edges on the heating unit.

3. Separation of mitered edges of doorframes showed exposed sharp corners in:
a. Room 100, patient bathroom door: exterior, top, left
b. Room 101, patient entry door: interior, top, left
c. Room 102, patient bathroom door: interior, top, right
d. Room 110, patient entry door: interior, top, left

4. Room 100: Interior bathroom door with an approximately four-inch diameter hole at the bottom with splintered edges.

5. Rooms #101, #103, #108, #110, and the seclusion room bathroom: Exposed blunt-ended screws extending approximately three inches from either side of toilet base.

6. Room #100 and #105: Sharp metal edges of holes drilled into the window sills.

7. Room #109 and Seclusion Room
a. Two approximately 1-cm diameter holes on the interior top portion of door

On 11/26/19 at 10:51 AM, Staff B stated maintenance would make the repairs immediately.

On 11/26/19 at 2:31 PM, Staff G stated,"We have been working diligently on ligature risk protocol," but it is not written.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on observation, record review, and interview, the hospital failed to ensure restraint implementation was ordered and followed hospital policy for one (pt #1) of one patients.

This failed practice has the likelihood of placing patients at risk of emotional and physical injury and restraint use beyond necessity.

Findings:

A policy titled "Mechanical Restraints" stated that the use of mechanical restraints is not permitted.

A review of the medical record for patient #1 showed no order for restraints.

On 11/26/19 at 10:05 AM, patient #1 was observed in the NRI dayroom with a posey pelvic belt around their waist tied to back of geri-chair (mechanical restraint).

On 11/26/19 at 10:06 AM, Staff A stated "This is a positioning device but we know this is a restraint."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on observation, record review, and interview, the hospital failed to follow policy for mechanical restraints for two (pt #1 and pt #11) of two patients.

This failed practice has the likelihood of restraint misuse and violation of patient's rights.

Findings:

A policy titled "Mechanical Restraints" stated that the use of mechanical restraints is not permitted.

On 11/26/19 at 10:05 AM, patient #1 was observed in the NRI dayroom with a posey pelvic belt around their waist tied to back of geri-chair (mechanical restraint). A review of the medical record for patient #1 showed no order for restraints.

On 11/26/19 at 10:06 AM, Staff A identified pt #1 and stated the patient would not be able to remove the device on their own. Staff A stated "this is a positioning device but we know this is a restraint."

A review of a nursing note for pt #1, written on 11/18/19, on a facility form titled "Brookhaven Hospital MHT NRI 3-11 Shift Note" stated; at 7:00 PM patient found with foot twisted in posey, at 7:15 PM the patient twisted foot trying to escape pelvic posey, at 9:00 PM patient kept trying to get out of posey.

A review of a nursing note for pt #11 dated 10/01/19, on a facility form titled "Brookhaven Hospital Nurse Reassessment NRI Shift Report" stated the patient was secured in wheelchair with a safety pelvic posey.

On 11/26/19 at 1:15 PM, Staff B stated mechanical restraints were not used in the facility.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview, the hospital failed to ensure treatment plans addressed individualized patient needs for one (Patient #2) of 11 patients.

This failed practice has the likelihood to result in poor quality of care.

Patient #2

1. Review of the medical record showed a physician order dated 11/09/19 read, "Lantiseptic cream TID to fingers...x 1 week," and the skin issue was not added to the treatment plan.

On 12/02/19 at 1:40 PM, Staff M reviewed the medical record for Patient #2 and stated the skin issue should have been added to the nursing treatment plan and the multidisciplinary treatment plan but was not.

2. Review of two documents titled "Brookhaven Hospital Risk Incident Report" dated 09/20/19 and 11/20/19 showed patient had fallen.

Review of the Nursing Treatment Plan showed no update for September, October, November 2019 related to patient falls.

On 12/02/19 at 1:40 PM, Staff M reviewed the medical record for Patient #2 and stated the last time the nursing treatment plan was updated was 8/19/19.

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VIOLATION: HOSPITAL PROCEDURES Tag No: A0410
Based on record review and interview, the hospital failed to ensure medication error policy was followed for one (Patient #4) of 11 patients.

This failed practice has the likelihood to result in unidentified patient medication errors.

Finding:

Review of a policy titled "Medication Error Reporting" read in part, "The following...constitute a medication error...Medication is given to wrong patient. Complete the Medication Error Record...and file the record in the medication error logbook. Record the error in M.A.R. Nurses are to check the Medication Error books...and sign monthly log sheets. This is to enable nurses to learn from peers."

Review of a document titled "Brookhaven Hospital Risk Incident Report" dated 10-28-19 for Patient #4 read in part, "Med error wrong pt."

Review of a document titled "Medication Error Monthly Log October 2019" showed no signature by the nurse involved in the medication error and was signed by two staff members without documentation of credentials.

Review of the 10/28/19 medication administration record (M.A.R.) for Patient #4 showed no documentation of a medication error.

On 11/27/19 at 1:16 PM, Staff G reviewed the medical record for Patient #4 and stated they did not see documentation of the medication error record in the log book, or the involved nurse's signature in the log book, or documentation of the medication error on the M.A.R.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation, interview, and record review, the hospital failed to ensure kitchen equipment temperature checks for:
1) three (Freezer #1, #2, #3) of three freezers
2) two (Refrigerator #1, #2) of two refrigerators
3) one (Dish Machine) of one dish machines

This failed practice has the likelihood to place patients at risk of food-borne illness due to inadequate storage maintenance.

Review of a policy titled "Temperature Log" read in part, "Record temperatures of freezer, refrigerator and dish machine in appropriate slot on the temperature log, twice daily, once in the morning and once in the afternoon."

On 11/26/19 from 11:17 AM to 12:45 PM, during a kitchen tour, temperature logs were observed to show no documentation of temperature readings for the following:
1) Freezer #1
a) afternoon temperature on 11/02/19
2) Freezer #1, Freezer #2, and Freezer #3
a) afternoon time, temperature, initials on 11/23/19, 11/24/19, 11/25/19
3) Refrigerator #1 and Refrigerator #2
a) afternoon time, temperature, initials on 11/23/19, 11/24/19, 11/25/19
3) Dish Machine
a) afternoon time, temperature, chlorine, initials on 11/01/19, 11/23/19, 11/24/19
b) morning or afternoon time, temperature, chlorine, initials on 11/25/19
c) morning time, temperature, chlorine, initials on 11/26/19

On 11/26/19 at 12:30 PM, Staff C stated the temperature logs should have been completed.