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.

FREEDOM BEHAVIORAL HOSPITAL OF TOPEKA, LLC 1334 SW BUCHANAN STREET TOPEKA, KS 66604 Aug. 21, 2019
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, and document review the hospital failed to verify the identity of five of five patients (Patient 1, 4, 10, 14, and 15) during medication administration. This deficient practice has the potential to place patients at risk for medication errors.

Findings Include:

Document review of hospital policy titled, "Medication Administration," revised 11/2016, showed the medication nurse will identify each patient prior to medication administration using two patient identifiers, one of which is the patient wrist band.

Observation on 08/20/19 at 8:30 AM of Staff L, Licensed Practical Nurse (LPN) passing medications from the medication cart in the dining room. Two staff and 14 patients were present in the room. A binder located on the medication cart was divided into individual patient specific sections. Each section contained a full page black and white picture of the patient and the medication administration record (MAR) listing medications and time of administration for the patient with a check column for nurse initials when the medication is administered.
Staff L, LPN approached Patient 1, called him by his first name, and handed him a medication cup with aspirin (anti-inflammatory), Lipitor (lowers cholesterol), Vitamin D, Neurontin (anti-epileptic), Keppra (anti-epileptic), Linzess (irritable bowel), Zestril (high blood pressure), Toprol xl (high blood pressure), Zyprexa (antipsychotic), Paxil (antidepressant), Fiber Con, and Lorazepam (anti-seizure). Patient 1 refused Neurontin stating it made him too sleepy. Staff L failed to verify the identity of the patient by looking at their wrist band.

Observation on 08/20/19 at 8:40 AM, Staff L, LPN approached Patient 4, called her by first name and administered Celexa (antidepressant). Staff L failed to verify the identity of the patient by looking at their wrist band.

Observation on 08/20/19 at 8:45 AM, Staff L, LPN approached Patient 10, called her by first name and administered vitamin D, B-12, and multivitamin, Midodrine (vasopressor), and Zoloft (depression). Patient 10 refused the Zoloft and Midodrine stating she did not need them. Staff L failed to verify the identity of the patient by looking at their wrist band.

Observation on 08/20/19 at 8:55 AM, Staff L, LPN approached Patient 14, called her by first name and administered Glucotrol (diabetes), Sertraline (antidepressant), and Remeron (antidepressant). Patient 14 refused the sertraline because it makes her sleepy. Staff L failed to verify the identity of the patient by looking at their wrist band.

Observation on 08/20/19 at 9:10 AM, Staff L, LPN approached Patient 15 at the nursing station, called him by first name and administered acetaminophen, Albuterol (bronchodilator), aspirin, Citalopram (antidepressant), Cartia XL (anti-hypertensive), Mucinex (expectorant), Flomax (alpha blocker), Namenda (Alzheimer's), Cozaar (hypertension), isosorbide (hypertension), and Atrovent (muscle relaxer). Staff L failed to verify the identity of the patient by looking at their wrist band.

During an interview on 08/20/19 at 9:15 AM, Staff L, LPN stated she uses the photograph of each patient and calls the patient by their first name for patient identifiers. She further stated she does not use the patient wrist bracelet because she is familiar with the patients.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, and document review, the hospital failed to ensure an active infection control program was in place to prevent, control and investigate potential infections.

The cumulative effects of this deficient practice have the potential to place patients and staff at risk to acquire infections and place them at risk for harm.

Findings Include:

Document review of the hospital's undated document titled, "Infection Prevention and Control Program," showed the infection prevention and control plan ensures the development, implementation and maintenance of a plan intended to control infections and communicable diseases both in patients and staff with oversight of the program performed by an appointed Infection Preventionist. The plan shows the Preventionist is responsible to ensure staff follow the infection control policies, provide education regarding the policies and ensure competencies for following the policies.

Observation showed that personal protective equipment (PPE) was not readily available to staff in three of three areas of potential exposure (dirty utility room, laundry room, and environmental closet), showed that staff failed to maintained a clean and sanitary medication cart when administering medications in five of five observations (Patient 1, 4, 10, 14, and 15), showed that staff failed to monitor water temperatures and detergent dispensing in one of one washing machines, failed to show the laundry room was clean, dust and debris free, and the Infection Control Coordinator failed to provide continuous oversight of the infection prevention and control plan.

During an interview on 08/19/19 at 3:40 PM, Staff C, director of nursing (DON) and infection control coordinator (ICC) stated she was appointed as the Preventionist 07/2019 and just completed a five-hour infection control training course. She stated since she is new to the job, she has not performed any surveillance or staff education regarding infection control and she was unaware of training performed by the prior ICC. She provided a calendar for the remainder of 2019 with dates scheduled for monthly infection prevention staff training and stated the environmental staff receive the same infection control training as patient care staff. Staff C stated, "we are putting the infection control program in place as we speak; nothing has been done since the previous survey." She further stated she has not performed or reported any surveillance monitoring for the quality program in July or August 2019 and she is the only staff member performing surveillance. She provided the surveyors copies of the infection control data sheets (which were blank). Finally, Staff C stated that the hospital did not have an infection control committee. The hospital's failure to have an infection control committee places patients at risk for exposure to healthcare associated infections, communicable diseases, an unsanitary environment

During an interview on 08/20/19 at 11:09 AM, Staff A, CEO and Staff B, Quality Director stated that they spoke with Staff C, ICC yesterday and she indicated the infection control program is not up and running, there are no current surveillance results and no old statistics. During the interview however, Staff B provided the surveyors completed July 2019 infection control data sheets that Staff C sent to her last night at about 7:35 PM. on the contrary, Staff C had provided infection control data sheets that had not been completed to the surveyors the previous day and said that she had not performed or reported any surveillance monitoring for the quality program in July or August. Staff A and Staff B could not explain the discrepancy. They shared that they had no explanation as to how Staff C had completed the data sheets.

(Refer to A0749 for further details).