HospitalInspections.org

Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure twenty-six of thirty patients were informed of the patient's rights prior to receiving care at the facility.

This had the potential to negatively affect all patient's served by this facility.

Review of the MR's of Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 7, PI # 8, PI #9, PI # 14, PI # 15, PI # 16, PI # 17, PI # 18, PI #19, PI # 20, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, and PI # 30 revealed there were no verbal or signed patient rights completed.

An interview was conducted on 12/12/24 at 11:17 AM with Employee Identifier (EI) # 4, Interim Chief Executive Officer who confirmed there were no verbal or signed patient rights completed.

Based on observations, facility policy, and interviews, it was determined the facility failed to ensure the Senior Behavioral Care Unit (SBCU) was free of ligature risks.

This deficient practice had the potential to negatively affect all patients admitted to this unit.

Findings include:

Facility Policy: Suicide Assessment and Preventions

Policy Number: Not Listed

Revised: 9/14/2017

Purpose: To outline the process for the timely assessment and reassessment of patient's suicide risk and to provide guidelines for safety interventions.

Policy: It is the policy of Mizell Memorial Hospital Senior Behavioral Care Unit to create an environment of care...and successful management of patients who are at an increased risk of suicide or self destructive behaviors...

Procedure:

7. Staff are to maintain a safe and therapeutic environment for all patients. Additional safety interventions are implemented for patients on suicide precautions...

Remove all potential ligatures...from the environment...

Safety and Environment Rounds:

1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times.

2. Safety and Environment Rounds are to be conducted at regular intervals...

3. ... all staff are to be continually aware of the environment and immediately correct or report any identified risks, damage, ... to their supervisor or Plant Operations personnel for immediate mitigation.

1. A tour of the SBCU unit was conducted on 12/10/24 at 9:45 AM with EI # 3, SBCU Manager. The following patient safety concerns were identified:

a. Each of the 14 beds on the 12 bed unit had side rails on the upper half of the beds that could be raised and used as ligature attachment.

b. The faucet in the Shower Room was constructed in a manner that could allow for a ligature to be attached.

Review of the daily SBCU Environmental Safety Rounds for December 2024 revealed no documentation of these safety risks being identified.

An interview was conducted on 12/12/24 at 11:00 AM with EI # 3, who confirmed the side rails and the shower faucet could be used as a ligature attachment.

Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and Health surveyors, it was determined the hospital was not constructed, arranged, and maintained to ensure patient safety.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Refer to tags: K-0133, K-0324, K-0362, K-0372, K-0521, K-0761, K-0918, K-0920, and health survey citation A-701, and A-724.

Based on observations, review of Maintenance Work Orders, facility policy and procedures, and interviews, it was determined the facility failed to ensure required maintenance of the physical plant was completed.

This deficient practice affected patient care areas on the Medical Surgical Unit and in the Dietary Department.

Findings include:

Facility Policy: Routine Work Request

Department: Plant Operations

Policy Number: 1001

Revised/Reviewed: 1/4/24

Purpose: To provide guidelines for submitting, receiving and scheduling routine work requests.

Policy: A work order request should be emailed/called in for any repair or maintenance needed.

a. Those that fall under Urgent/High priority will be handled as "Emergency Maintenance."

b. All others will be scheduled for accomplishment by Plant Operations by priority level as:

1. Low
2. Normal
3. Medium

Procedure:

...The employee entering the work order will be notified by email when the work order is received, assigned to a mechanic, in progress, placed on hold, and upon completion...

1. A tour of the Medical Surgical Unit was conducted with Employee Identifier (EI) # 9 on 12/11/24 at 9:03 AM.

The unit had 31 patient rooms with 36 available beds. Out of the 31 patient rooms, eight patient rooms had signs on the doors indicating the rooms were out of service. This impacted 16 beds.

The following patient rooms had signs on the door stating they were out of service due to maintenance issues including rooms 321 and 323.

An interview was conducted with EI # 6, Registered Nurse, who stated the rooms listed had been out of service for at least a year.

Review of the Maintenance Work Orders revealed:

Review of Work Order # 3795 revealed the work order was placed on 3/18/24 for repair of room 321 wall flange. The status was listed on the work order as resolved on 3/18/24.

Review of Work Order # 4129 revealed the work order was placed on 5/3/24 due to room 323 being hot. The due date was listed as 5/6/24 with comments, resolved.

An interview was conducted on 12/11/24 at 2:15 PM with EI # 9, Maintenance Supervisor, who stated Room 321 remained out of service due to a broken drill auger and Room 323 remained out of service due to coils in the air conditioner being clogged.

2. A tour of the Dietary Department, dishwashing area, was conducted on 12/11/24 at 11:45 AM with EI # 1, Chief Operating Officer. The following items were observed in need of repair:

Observation of the dishwashing area revealed the right side of the wall at the entry way were missing 33 four inch square tile pieces exposing the subwall. On the left side of the room, the lower section of the wall extending under the dish machine had peeling paint and broken drywall. Additionally, the three foot light casing on the ceiling had peeling paint and was rusted half way the length of the light casing.

The surveyor requested work orders for the dishwashing area repairs with none provided.

An interview was conducted with EI # 1, who confirmed the facility failed to ensure the required maintenance of the dietary area was completed.

Based on observations, and staff interviews, it was determined the facility failed to ensure expired supplies were not available for patient use.

This had the potential to negatively affect all patients served by the hospital.

Findings include:

1. A tour of the surgical suite was conducted on 12/10/24 at 10:05 AM with Employee Identifier (EI) # 8, Surgical Services Manager.

The following supplies were found to be expired and available for patient use:

Operating Room (OR) # 1 anesthesia cart:

One Melker Emergency Cricothyrotomy Catheter Set with an expiration date of 7/2015.

OR # 2 anesthesia cart:

Two Becton Dickinson (BD) Insyte Autoguard Shielded Intravenous (IV) Catheters with an expiration date of 8/31/23

One Rusch Endotracheal Tube Oral/Nasal 6.5 millimeter (mm) with an expiration date of 2/28/21.

OR # 2:

Eight Culturettes with an expiration date of 11/29/24.

The "Issue" (medical supply room ) Room:

Twelve Cautery Tip Polishers with an expiration date of 8/31/24 and four with an expiration date of 4/30/24.

OR Hallway:

Nine BD 20 gauge (g) x (by) 3.5 mm Spinal Needles with an expiration date of 8/31/24.

Six BD 25 g x 3.50 mm Spinal Needles with an expiration date of 9/30/24.

Crash Cart # 2:

Two green top laboratory tubes with an expiration date of 10/30/24.

Block Cart:

Two ICUmedical Extension Sets with an expiration date of 1/1/24.

Malignant Hyperthermia Cart:

One Bard Latex Free Foley Catheter Tray with an expiration date of 7/31/24.

An interview was conducted on 12/10/24 with EI # 8, Surgical Services Manager, who confirmed at the time of the tour, the above items were expired and available for patient use.

Based on review of the personnel files, and staff interviews, it was determined the hospital failed to ensure all staff completed Emergency Preparedness (EP) training initially upon hire and every two years.

This deficient practice did affect seven out of eight personnel files reviewed and had the potential to negatively affect all staff and patients served by the hospital.

Findings include:

A review of seven out of eight personnel files revealed no documentation of initial EP training upon hire in two out of eight files.

Further review of the personnel files revealed, no documentation of EP training every two years in five out of the eight files reviewed for the years 2019 through 2024, respectively.

An interview was conducted on 12/12/2024 with Employee Identifier (EI) # 5, Administrative Assistant, who confirmed there was no documentation the staff received EP training initially upon hire and every two years.