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Based on tour of the hospital, observation, review of facility documentation and staff interview for 1 of 2 patient units, (Unit B) the hospital failed to maintain a behavioral health ligature resistant environment. The findings include:

a. Observations during a tour of the B unit on 10/24/23 at 9:50 AM (census of 5 patients out of 16 beds) identified room 149 bed-1, the electrical cord from the patient's bed was lying on the floor with approximately 3 feet of the cord looped. Further observation during the tour noted in the patients dining area a plastic bag was noted lining the garbage.

Interview with Infection Preventionist at that time stated that patients are never left unattended in the dining room. Review of the Environmental Ligature Risk Assessment dated 10/24/23 failed to identify the electrical cord from bed 1 in room 149.

Interview with RN #3 on 10/24/23 at 10:30 AM stated that she did environmental rounds around 7:00 AM and saw the electrical cord on the floor but did not identify it as a risk. Subsequent to surveyor inquiry the electric bed was removed from the patient area.

b .Tour of the Hospital's 'A' unit room # 127, 128 and 134 with Directors # 1, Director #2 and Director #3 on 10/24/23 at 9:25 AM identified bathrooms with toilet bedpan lever sprayers that extended from the wall to approximately 10 - 12 inches over the toilet bowls and approximately 16 inches above the floor.

Interview with Director #1 and Director #2 on 10/24/23 at 9:25 AM identified the pipe fixtures as bedpan washers that were no longer used by the Hospital for the earlier intended purpose. Director #2 identified that bed pan washers were in all 12 bathrooms located in the patients' bedrooms on the hospital's A unit.

Review of the hospital's Environmental safety ligature risk assessment checklist dated 10/25/23 identified the checklist lacked documentation the bed- pan lever sprayers located in all 12 bathrooms of Unit A were identified by the Hospital as ligature risk points.

In an interview and review of the ligature risk concerns with the CEO on 10/24/23 at 4:00 the CEO identified the toilet sprayers/bed pan washers have been in place since 2005 and were not assessed as ligature points due to the elderly population served. The CEO identified that safety rounds were completed on the unit every 15 minutes. Subsequent to the surveyor's observation, review of the hospital environmental risk assessement documentation identified that on 10/25/23 the identified toilet sprayers were added to the environmental ligature risk assessment unit safety checklist.

Review of the Hospital's Environmental Ligature risk Assessment policy identified the purpose of the policy is to ensure that all patients receive care in a safe setting that is ligature resistant.



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Based on clinical record review, review of hospital policy and staff interview for 1 of 1 sampled patient who utilized an enclosed bed, (Patient #10) the hospital failed to implement least restrictive interventions prior to placing the patient in an enclosed bed. The finding includes:

Patient #10's diagnoses included dementia. Review of the clinical record dated 10/8/23 noted the patient received Trazodone 50 mg at 3:54 PM for agitation. Review of the APRN note dated 10/8/23 at 10:05 PM noted the patient remains restless in tilt/space chair, nursing unable to redirect, the patient gets agitated easily, and remains at risk for self-harm. The note further identified attempted open soma bed the previous night was unsuccessful and resulted in high fall risk. The note identified will place in closed soma bed tonight and overnight for safety. Additionally, the note identified reason for discontinuation as, not a danger to self/others and exhibits calm behavior.

Review of the nurse's note dated 10/9/23 at 7:02 AM noted the patient was placed in an enclosure bed on 10/8/23 at 9:02 PM and was taken out of the bed at 7:40 AM on 10/9/23. Interview and review of Patient #10's clinical record with LPN #1 on 10/25/23 at 1:40 PM noted the fifteen minute checks dated from 10/8/23 at 9:00 PM through 10/9/23 at 7:45 AM identified the patient in the room asleep from 10:00 PM until 3:45 AM (a total of 5 hours and 45 minutes) and then remained awake and in room until 7:45AM when the patient was removed from the enclosure bed. LPN #1 stated that patients are to be removed from the enclosure bed when the patient is calm and not having behaviors.

Review of the hospital policy for restraints/seclusion identified patients need to be removed from the enclosure bed as soon as possible, the nurse or medical provider will assess the need for discontinuation on an ongoing basis and will deem when appropriate.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 sampled patients (patient #9 and #10) who were reviewed for restraints/seclusion, the hospital failed to obtain a physician's order for the use of restraints/seclusion. The findings include:

a. Patient #9's diagnoses included agitation and anxiety. The nurse's note dated 10/15/23 at 6:58 PM noted the patient received Trazodone 50 mg at 1:57 PM for escalating behaviors without effect. The note identified the patient was slamming doors and attacking staff. The note identified that at 2:35 PM the APRN was notified and ordered the restraint chair. The patient was released from the restraint chair at 3:15 PM.

Review of the clinical record with LPN #1 on 10/25/23 at 11:30 AM identified the non-violent SOMA bed order was cancelled but the record failed to identify an order was obtained for the use of the restraint chair on 10/15/23 at 2:35 PM. LPN #1 stated that a new order should have been written for the use of the restraint chair.

b. Patient #10's diagnoses included dementia and restlessness. The nurse's note dated 10/7/23 at 11:05 PM noted the patient was placed in the SOMA bed at 9:15 PM. Review of the clinical record and interview with LPN #1 on 10/25/23 at 11:50 AM failed to identify a physician's order was written for the use of the SOMA bed. LPN #1 stated that an order should have been written.

Review of the hospital policy for Restraint/ Seclusion noted when the restraint chair is used an order must be obtained by the physician for the use of the restraint chair. Additionally, the policy identified when an enclosure bed is used for a patient a physician order is required initially and every calendar day with appropriate documentation of necessity.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 sampled patients reviewed for restraints/seclusion (Patient #9 and #11), the hospital failed to monitor the patients' behaviors every 15 minutes and failed to remove the restraint when the patient stopped exhibiting the behaviors. The findings include:

a. Patient #9's diagnoses included agitation and anxiety. Review of the hospital restraint/seclusion observation form dated 10/15/23 noted Patient #9 was placed in seclusion at 9:45 PM and removed from the seclusion room at midnight (a total of 2 hours and 15 minutes). Further review of the observation form identified Patient #9's behaviors were only monitored from 11:00 PM until 12:00 AM.

Interview with LPN #1 on 10/25/23 at 1:10 PM stated that when a patient is in seclusion their behaviors are to be monitored every fifteen minutes. LPN #1 further stated that the patient's behavior monitoring should have begun at 9:45 PM when the patient was placed in seclusion.

b. Patient #11's diagnoses included delusions and confusion. Review of the restraint/seclusion documentation dated 10/14/23 at 2:54 PM noted the patient was placed in a restraint chair at 2:40 PM due to a danger to self or others. The note identified the patient was hitting, biting, and yelling.

Review of the restraint/seclusion observation form dated 10/14/23 noted the patient's behaviors were monitored every fifteen minutes while the patient was in the restraint chair. Further review of the observation form noted from 3:10 PM until the time the patient was released from the restraint chair at 3:55 PM (45 minutes) the patient was calm, cooperative, and easily redirected.

Interview with LPN #1 on 10/25/23 at 1:35 PM stated that the patient is to be removed from the restraint chair when the behaviors stop. Further interview with LPN #1 and review of the restraint/seclusion observation form stated the patient should have been removed from the restraint chair at 3:10 PM when the patient was calm and easily redirected.

Review of the hospitals policy for restraint/seclusion identified when a patient is in the seclusion room the patient's behaviors will be monitored every 15 minutes. The policy further identified when a patient is in the restraint chair staff will do continuous observation of the patient and when the patient is assessed by a medical provider or nurse to not be a danger to self or others, the restraint chair will be discontinued.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 sampled patients reviewed for restraints (Patient #10 and #11) the hospital failed to ensure a face-to-face evaluation was completed within one hour after the initiation of a restraint. The findings include:

a. Patient #10's diagnoses included dementia and restlessness. A nurse's note dated 10/7/23 at 11:05 PM noted the patient was placed in the SOMA bed at 9:15 PM. Review of the clinical record with LPN #1 on 10/25/23 at 11:50 AM failed to identify a face-to-face evaluation was completed when the patient was placed in a soma bed on 10/7/23 at 9:15 PM.

b. Patient #11's diagnoses included delusions and confusion. A nurse's notes dated 10/14/23 at 2:54 PM noted the patient was hitting, biting, and yelling at staff and was placed in the restraint chair at 2:40 PM.

Review of the APRN face to face evaluation dated 10/14/23 noted the evaluation was documented at 4:03 PM, an hour and 23 minutes after the patient was placed in the restraint chair.

Interview with the Nurse Practitioner on 10/25/23 at 12:00 PM identified that the face-to-face evaluation is to be completed within one hour of the initiation of the restraint.

Review of the hospital policy for restraints/seclusion noted a medical provider must complete a face-to-face evaluation of the patient within one hour of the initial order.

Based on review of facility documentation, staff education records, interviews, and review of job descriptions, the Hospital failed to ensure Patient Care Associates (PCAs) maintained current CPI certification or the approved comparable education in accordance with their job description. The finding includes:

Review of the staff list provided by the Hospital identified 25 of the 32 Patient Care Associates (PCA) actively employed by the hospital had not completed the required Crisis Prevention Intervention (CPI) training (15 of which had no documentation of having previous CPI certification) or had expired CPI certification.

Interview with Director #4 on 10/25/23 at 12:20 PM identified the Hospital last offered CPI training in April of 2023 and switched to De-escalation training which started in October of 2023 (6 months gap in education offering). The Director identified that new employees were not certified and some staff CPI certification had expired.
Review of the hospital documentation identified a De-escalation class was completed by 10 staff on October 10, 2023. Director #4 identified additional classes were scheduled for November 20, November 27 and December 12, 2023.

The hospital failed to ensure PCA staff had the required education to meet the requirements of their job description.

The Patient care associate (PCA) job description identified Safety and security as an essential job function and identified the standard of performance to include, demonstrate use of Crisis Prevention Intervention techniques when caring for agitated or violent patients and to maintain current CPI certification.

Based on observation, clinical record review, staff interviews, and policy review, for 1 of 3 sampled patients reviewed for therapeutic diets and weekly weights, (Patient #4) the hospital failed to ensure the patient was provided the correct diet and failed to ensure weights were completed as ordered. The findings include:

a. Observation of Patient #4 on 10/24/23 at 12:10 PM during the mid-day meal identified Patient Care Tech (PCT) #1 ladled soup from a prepared vat of soup and gave it to the patient, which the patient ate. The PCT then scooped vegetables onto the plate with other foods and gave it to the patient. Approximately one minute passed and the PCT took Patient #4's plate, removed a large center core of cauliflower off the plate and returned it to the patient with smaller cauliflower and other vegetables. Observation of the returned plate identified that the cauliflower serving also included string beans, some of which were 1.5 to 2 inches in length, and the patient ate it. In addition, the patient was served pudding.

Review of the patient's diet slip accompanying the meal identified "mechanical soft" diet and "aspiration precautions", ground chicken soup, soft cauliflower, and soft canned fruit for dessert.

Interview with PCT #1 on 10/24/23 at 12:10 PM identified that she had not reviewed Patient #4's diet slip and was not aware of the special diet requirements for this meal.

Interview with the Food Service Supervisor on 10/24/23 at 1:00 PM identified that staff in the dietary department should have provided direction and/or alternate foods to accommodate Patient #4's dietary requirements. In addition, because nursing staff are serving the food, they should have additional training on following the diet slip specifications.

Interview with the Infection Preventionist on 10/24/23 at 1:00 PM identified that the hospital did not have a policy or formal training for nursing staff on how to serve patient meals.

b. Review of Patient #4's clinical record noted the patient was admitted on 9/18/23. Review of the nursing admission assessment dated 9/18/23 failed to identify the patient's admission weight.

Review of the nutritional assessment dated 9/28/23 identified abnormal weight loss and a history of muscle wasting. The note further identified there is no documented weight in the patient's chart or weight book.

Review of the weight book noted Patient #4's weight was completed on 10/9/23 (21 days after admission) and was recorded at 102.4 pounds.

Interview with LPN #1 on 10/25/23 at 10:10 AM indicated patients are to be weighed on admission and then weekly.

Review of the Nursing assessment policy identified weights are to be completed on admission and one time per week.

Based on observations, review of facility documentation, interviews, and policy review, for the review of medication storage and diabetic testing supplies, the Hospital failed to ensure an expired medication was removed from the general medication storage and failed to ensure glucometer control reagents were dated at the time of opening. The findings include:

Tour of the A unit medication room on 10/24/23 at 9:45 AM with Director #2 and Director #3 identified the following:
a. Stock medication Azelastine HCL nasal spray with an expiration date of 7/2023.

In an Interview with Pharmacist #1 on 10/24/23 at 9:50 AM, Pharmacist #1 identified she was responsible for checking the medication storage monthly. Pharmacist #1 stated that medications were removed from the medication storage cabinet when expired and was unable to identify the reason the expired Azelastine HCL nasal spray was not removed from the medication storage at the time it was expired.

Subsequent to the Surveyor's inquiry, Pharmacist #1 removed the expired medication from the medication storage.

Review of the Hospital's Unusable Medications Policy directed, unused medications include those that are expired (outdated). The policy further identified unusable medications should be returned to the pharmacy for proper disposition.


b. Two opened vials of glucometer control testing reagents were identified in the storage cabinet of the medication room without the benefit of a discard or opened date documented

Review of the daily glucometer monitoring testing log for 10/2023 identified the low reagent testing was out of range for 11 of the 25 days tested.

Interview with RN #1 identified staff on the night shift was responsible for completing the reagent testing daily.

Interview with Director #3 on 10/24/23 at 9:55 AM identified glucose control reagents should be labeled according to the protocol and reagent testings repeated if results are out of range.

The Hospital's Blood Glucose Monitoring equipment quality control Testing policy directed control solutions must be dated upon opening with the discard date. Control solutions are to be discarded 90 days after opening or at the expiration date on the bottle whichever comes first.

Based on observation, review of hospital documentation and staff interview, the hospital failed to ensure the kitchenette was maintained in a clean and sanitary manner. The findings include:

Observations during a tour of the "B" unit kitchenette on 10/24/23 at 10:00 AM noted the patients' refrigerator/freezer had dried on liquids and foods on the shelves, doors, and walls. The patients' toaster was noted to be heavily soiled with burnt on toast and breadcrumbs on the top and bottom of the toaster.

Further observations of the "B" unit noted a recliner chair in the TV room had two tears in the fabric of seat rendering an inability to effectively sanitize.

Interview with Infection Preventionist (IP) at that time indicated that environmental service is responsible to clean the kitchenette and it is cleaned "all the time". The IP further stated environmental rounds are done monthly on each unit.