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Based on record review and interview, the facility failed to ensure all orders, including verbal and telephone orders were authenticated promptly by the ordering practitioner or by another practitioner who was responsible for the care of the Patient in accordance with State law, Hospital policies, and medical staff by laws, rules, and regulations for 5 of 21 patient records reviewed (#1, #2, #3, #9, and #12).

This deficient practice could affect the authenticity and accuracy of Patients verbal and telephone orders taken and transcribed by others that require authentication by physician signature.


Findings included:

Review of the facility's Medical Staff By Laws approved 05/31/13, and Medical Staff Rules and Regulations revealed the following: , "Telephone/Verbal orders must be authenticated within 48 hours" from the time of order.


Patient #1

Record review on 10/28/15 of Patient #1's records revealed he had Telephone/Verbal Physician Orders for medications, g-tube feedings, and discharge orders, during his admission of 09/17/15 to 09/20/15, that were not signed or authenticated by a physician until 10/23/15.

Patient #2

Record review on 10/28/15 of Patient #2's records revealed he had Telephone/Verbal Physician Orders for admission to the facility, a beside swallow test, a cardiac diet, case management consult, occupational therapy and physical therapy evaluations, and medications, during his admission of 08/07/15 to 08/09/15, that were not signed or authenticated by a physician until 08/27/15.

Patient #3

Record review on 10/28/15 of Patient #3's records revealed she had Telephone/Verbal Physician Orders for medications and emergency medications for agitation, during her admisson of 08/03/15 to 08/19/15, that were not signed or authenticated by a physician until 09/14/15.

Patient #9

Record review on 10/28/15 of Patient #9's records revealed he had Telephone/Verbal Physician Orders for Restraints, Emergency Medications, and Seclusion that had not been signed or authenticated by a physician as of 10/28/15. The following Restraint/Seclusion records were reviewed:
1.) On 10/10/15 at 20:40 Physician A was notified and a Verbal/Telephone Order was obtained for a Physical Restraint for Patient #9 at 20:40. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

2.) On 10/21/15 at 20:10 Physician B was notified and a Verbal/Telephone Order was obtained for a Mechanical Restraint (Restraint Chair) and Emergency Medications; Ativan and Benadryl to be administered to Patient #9. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

3.) On 10/22/15 at 1500 Physician C was notified and a Verbal/Telephone Order was obtained for a Physical Hold, Mechanical Restraint (Restraint Chair), and Emergency Medication of Benadryl to be administered to Patient #9. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

4.) On 10/23/15 at 15:00 Physician C was notified and a Verbal/Telephone Order was obtained for a Physical Hold, Mechanical Restraint (Restraint Chair), Seclusion, and Emergency Medication of Benadryl to be administered to Patient #9. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

5.) On 10/23/15 at 21:42 Physician C was notified and a Verbal/Telephone Order was obtained for a Physical Hold and Emergency Medication of Benadryl to be administered to Patient #9. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

6.) On 10/26/15 at 14:50 Physician B was notified and a Verbal/Telephone Order was obtained for a Physical Hold and Emergency Medication of Zyprexa to be administered to Patient #9. The Restraint/Seclusion Verbal/Telephone Order had not been signed in the area for Physician's Signature to include authentication.

Patient #12

Record review on 10/28/15 of Patient #12's records revealed he was admitted to the facility on 10/22/15. Patient #12's Admission Orders, Medication Orders, and Physician Certification dated 10/22/15 at 00:45 had not been signed or authenticated by a physician as of 10/28/15 (6 days past/144 hours).

Further review of Patient #12's Physician Orders revealed the following Telephone Order (TO) that had not been signed or authenticated by a physician as of 10/28/15:
10/22/15 at 00:45 TO for the following medications: Tylenol 325 milligrams (mg), Hydroxyzine HCL 25 mg, Loperamide 2mg, Lorazepam (Ativan)1mg, and milk of magnesium 400 mg.

During an interview on 10/29/15 at 10:40 AM with the facility's Chief Nursing Officer (CNO) and Director of Risk Management confirmed the following Patient records (# 1, #2 #9, and #12) had Verbal/Telephone Orders that had not been signed or authenticated. The CNO stated that Verbal/Telephone Orders had to be signed within the facility's Policy; By Laws; which was 48 hours from the time of the order. The Director of Risk Management stated that the Psychiatrist would sign their own Restraint/Seclusion Verbal/Telephone Orders when doing rounds and reviewing charts. The Director of Risk Management confirmed that Patient #9 had 6 Restraint/Seclusion Verbal/Telephone Orders that had not been signed or authenticated. The Director of Risk Management stated there were 3 different Doctors with outstanding Verbal/Telephone Orders and confirmed there was no other method to authenticate other than their signatures.

Based on observation, interviews and record reviews the facility failed to ensure drugs listed in schedules II, III, and V of the Comprehensive Drug Abuse Prevention and Control Act were kept locked within a secure area.

Findings include:

Observations conducted on 10/27/15 from 9:30 a.m. to 12:00 p.m. at the facility ' s specialty psychiatric hospital revealed the following:
· An open top red container which was approximately 2 to 3 feet tall was observed in the medication preparation area next to the door leading out to the nurse's station. The medication room door was open/ unlocked. The container was 2/3 full of various sharps (needles, syringes with liquid in them, suture removal kits, ect ...) and unidentified medications (pills). On the wall behind the container was a hand written note which stated "Not a waste can" .
In an interview conducted on 10/27/15 at 10:30 a.m., LVN-A stated that she (LVN-A) has voiced concern about the open top container with her manager, because she "got tired of people throwing trash in there (container)." During further interview, LVN-A further revealed that nursing staff were also disposing of unused narcotic medications in the same open top container.

In an interview conducted on 10/27/15 at 10:40 a.m., the Executive Director of the specialty psychiatric hospital confirmed the above findings.

Record review of the facility policy entitled Pyxis Drug Administration, Returning, & Wasting, dated November 2003 revealed in part the following:
· Controlled substances not used must be placed in locked return bin in medstation. If the package is opened, it should be wasted.
· If the contents of a controlled drug vial or ampule are drawn up and not administered, or partially administered, the contents must be wasted at the pyxis unit and witnessed by another licensed nurse or pharmacist.
· Wasted controlled medications will be documented via the medstation, flushed in a sink or drain and witnessed by a licensed nurse or pharmacist.

Record review of the facility policy entitled Controlled Drugs- Disposition/ Destruction revealed in part the following:
· When controlled drugs must be returned, a licensed contract service shall be utilized for the return of products.
· When controlled drugs cannot be returned to the manufacturer, distributor, or other source of supply, the Director of Pharmacy or designee shall destroy or dispose of these drugs in accordance with current destruction or disposition procedure of the DEA and this state.

Based on observations and interviews, the facility failed to ensure the condition of the overall hospital environment was maintained for the safety and well-being of the patients.

The findings include:
Observations conducted on 10/27/15 from 9:30 a.m. to 12:00 p.m., at the facility ' s Specialty Psychiatric Hospital revealed that the patient bathrooms contained sink faucets with long metal handles.
In an interview conducted on 10/27/15 at the time of discovery, the Executive Director of Psychiatric Services revealed that the sink faucets in the facility were not breakaway faucets.

On 10/28/15 at 11:15 a.m., observations in the pharmacy revealed:
-The pharmacy work counter had chipped paint and exposed plywood, ensuring the counter was no longer a wipe able surface. The face of one cabinet drawer was held together by clear tape. Several of the drawer handles were either missing or loose.
-What was described to the surveyor as a " portable air conditioning " unit, when the unit is turned on, pools water on the floor.
- The medication refrigerator had a thick accumulation of dust and debris underneath, with mold observed in the condensation drainage area.
Interview with the Director of Pharmacy (DOP) on 10/28/15 at 11:25 a.m. revealed the pharmacy needs a new work counter. The DOP also revealed the water pooling on the floor from the portable air conditioning unit is a problem as it causes mold and a slipping hazard.



29242

29242


Based on observation, interview and record review, the facility failed to develop, and implement a system for identifying and controlling infections and communicable diseases within the hospital. The facility failed to:
1.) Ensure staffs were knowledgeable in the use of disinfectant wipes used to disinfect equipment being removed from isolation rooms and
2.) Ensure staffs at the specialty psychiatric hospital disposed of sharps in approved closed top sharps containers for disposal and
3,) Ensure staffs consumed food and/or drinks in approved areas outside the patient care area.

Findings included:
1.) Observations conducted on 10/27/15 from 12:30 p.m. to 5:30 p.m. of the medical/ surgical floors revealed the following:
· Clorox germicidal disinfectant wipes (used for C- Difficille toxin) were not available on the patient care floors for staff use.
In an interview conducted on 10/27/15 at 4:15 p.m., Registered Nurse (RN)-A stated that if they (staff) receive a patient with C- Difficille (C-Diff) they have to contact housekeeping services to obtain Clorox germicidal disinfectant wipes, as they are not kept on the floor for use. When asked how long staff waited to remove equipment, which was disinfected with the Clorox wipes, from isolation rooms RN-A stated " Im not sure. "

In an interview conducted on 10/27/15 at 4:30 p.m., the facility Chief Nursing Officer (CNO) stated that facility staff should be using Virex wipes to disinfect equipment used in C-Diff isolation rooms.

In an interview conducted on 10/27/15 at 4:45 p.m., the facility Infection Control Practitioner revealed that staffs were supposed to be using germicidal Clorox wipes to disinfect C-Diff isolation rooms, with a wait time of 10 minutes before removing any disinfected equipment from isolation rooms.

In an interview conducted on 10/27/15 at 5:00 p.m., Certified Nurse ' s Aide- A (CNA) stated he routinely disinfects isolation equipment with bleach, but he was not sure how long to wait before removing equipment from the isolation rooms. He further revealed that Clorox wipes were not kept on the patient care floors, and that they (Clorox Wipes) must be brought to the floor by housekeeping.

In an interview conducted on 10/27/15 at 5:20 p.m. Licensed Vocational Nurse (LVN)-B stated that he was unsure how long to wait before removing equipment from isolation rooms that had been disinfected with the Clorox germicidal wipes. He further stated, " I know it ' s less than an hour. "

Record reviews of the facility ' s Infection Control Program Plan, dated 2015, revealed in part the following:
· VI- Education and Training: Education and training of healthcare workers in infection control interventions that interrupt disease transmission and reduce healthcare associated infection rates.
· All new employees received education and training in infection control during general hospital orientation.
· Current employees will receive education and training in infection control annually.
· The responsibility for staff education falls on the Department Director in close collaboration with the Infection Control Preventionist.

2.) Observations conducted on 10/27/15 from 9:30 a.m. to 12:00 p.m. at the facility's specialty psychiatric hospital revealed the following:
· An open top red container which was approximately 2 to 3 feet tall was observed in the medication preparation area next to the door leading out to the nurse ' s station. The medication room door was open/ unlocked. The container was 2/3 full of various sharps (needles, syringes with liquid in them, suture removal kits, ect ...) and unidentified medications (pills). On the wall behind the container was a hand written note which stated " Not a waste can " .
In an interview conducted on 10/27/15 at 10:30 a.m., LVN-A stated that she (LVN-A) has voiced concern about the open top container with her manager, because she " got tired of people throwing trash in there (container). " During further interview, LVN-A further revealed that nursing staff were also disposing of unused narcotic medications in the same open top container.

In an interview conducted on 10/27/15 at 10:40 a.m., the Executive Director of the specialty psychiatric hospital confirmed the above findings.

3.) On 10/27/15 at 10:40 a.m. during a tour of the facility's specialty psychiatric hospital , a facility staff member was observed "squatting" in the work area hallway eating what was observed to be a candy bar. Several patients were walking around the staff member.

Interview on 10/27/15 at 11:30 a.m. with the facility Vice President of Clinical Services of Behavioral Services confirmed the facility staff member was employed by the facility. The staff revealed to her "he was eating a breakfast bar, not a candy bar." Further interview confirmed the staff should not have been eating in the hallway.

When asked if the facility had a policy in regards to staff not eating or drinking at their work stations, the facility stated they did not have a policy. But handed the surveyor the following print out from Occupational Safety and Health Administration (OSHA) regulations:

" OSHA/Blood Borne Pathogen Regulations Policy 1910.1030" stated in part "OSHA's blood borne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material place, or where the potential for contamination of work surfaces exist."