HospitalInspections.org

1. Based on observation, review of facility documentation, and interviews the facility failed to ensure that the contracted Dialysis Service accurately maintained water logs and/or equipment within the acute dialysis treatment room in such a manner as to promote the safety and well being of patients.

a. Review of the Reverse Osmosis logs for the period of 1/1/10 through 2/8/11 indicated that the logs failed to have "normal" parameters identified on the log. In addition review of the log indicated that under the delta pressures "N/A" , "0" and/or "1" was designated. Interview with the Regional Biomedical Staff from the contracted service on 2/8/11 indicated that parameters would be added to the log, and that h/she was unaware of what the normal results should be as dialysis nurse's and or technician's completed this task.

b. On 02/08/11 at 10:05 AM, while touring the Battell Hall Acute dialysis room with the Director of Fiscal Services & Plant Operations, the Chief of the Connecticut Valley Hospital Fire Department and Plant Facilities Staff, it was observed that dialysis machines # 4KOS-K059, J983 and K028 were past due for an annual electrical safety check due 01/31/11 and the Reverse Osmosis machines # 49453, # 49455 and # 49456 were past due for annual preventive maintenance. Interview with a representative from the contracted service identified that they were aware of the dates and would be in by the end of the day to complete all required maintenance.

Based on review of hospital documentation, hospital policies/procedures and interviews, hospital staff failed to provide consistent unit rules and/or access to patient bathrooms. The findings include:

A tour of the M4D unit was conducted on 2/8/11 at 11:30 AM with the Assistant Division Director of Psychiatric Services. Observations identified that the unit had two patient bathrooms that were located in different hallways and one of the bathroom's entryway could be visualized from the nursing station. The bathroom farthest from the nursing station was unlocked and had a sign posted on the bathroom door that directed the bathroom door be locked. The bathroom door closest to the nursing was observed locked and did not have a sign posted. Interview with Patient's #48 and #49 noted that the bathroom doors were inconsistently locked, patients were informed by staff that the bathrooms had to be locked or should not be locked and patients have had to wait for extended periods for staff to allow bathroom access to a locked bathroom. Interview with the Program Manager on 2/8/11 at 11:30 AM indicated that the bathroom farthest from the nursing station was locked when there was insufficient staff to monitor the bathroom and that the bathroom that could be visualized from the nursing station was never to be locked. Interview with the Assistant Division Director of Psychiatric Services on 2/8/11 at 11:30 AM identified that bathroom doors were not to be locked except temporarily in an emergency situation and that if additional staffing was needed then the staffing would be provided. The Assistant Division Director of Psychiatric Services subsequently directed that signs be posted on the M4D bathroom doors that the doors were not to be locked (routinely). The Assistant Division Director of Psychiatric Services further indicated that the unit did not have a policy/procedure for doors to remain locked on the M4D unit.

Based on medical record reviews, review of facility documentation, facility policy and interviews for one patient who had a history of elopement (Patient #46) and/or one of two patients who had low body weight (Patient #48) staff failed to provide adequate supervision and/or weight monitoring in accordance with facility policy and/or the physician's order. The findings include:

a. Patient #46, with diagnoses of schizoaffective disorder and polysubstance abuse, was probated to the hospital following a physician's emergency confinement order (1/20/07). The annual psychological assessment dated 1/10/11 identified that the patient had delusional beliefs in a hostile manner toward others with frequent episodes of anger and agitation. Physician orders dated 1/6/11 directed level 3-observation status with 1: 4 staff and fresh air breaks if the patient's behavior was appropriate. The integrated treatment plan (ITP) dated 2/1/11 indicated that the patient was at risk for unauthorized leave and interventions included RN assessment of the patient when the patient appeared increasingly anxious, as exhibited by discussions regarding leaving the hospital and complete a mental status exam prior to the patient leaving the unit. The RN assessment dated 1/7/10 identified that the RN assessed the patient at 8AM as appropriate for off- unit activities. The Social Worker narrative dated 2/7/11 at 10:30 AM (after the RN assessment) noted that the patient stated h/she was ready for discharge today and became angry when informed that discharge planning takes time. The narrative by the mental health assistant (MHA) dated 2/7/11 at 12:15 PM identified that the patient was on a fresh air break at 12 PM with a group of patients, the MHA was assisting other patients with the vending machines and the patient could not be located at 12:15 PM for the group to return to the unit. The narrative by the MHA dated 2/7/11 at 1:45 PM noted that agency police returned the patient to the unit at 1:15 PM after the patient was found off hospital grounds. Physician progress notes dated 2/7/11 at 2:15 PM indicated that this was the patient's second elopement since 5/20/10. Interview with RN #11 (M3D Unit Supervisor) on 2/8/11 at 10:20 AM noted that the MHA was in charge of supervising Patient #46 and three other patients for the fresh air break on 2/7/11. The hospital policy for levels of observation/freedom of movement identified that privilege level 3 patients require staff supervision on and off- grounds (1 staff to four patients) and must be under the direct supervision of hospital staff.

In addition, Patient #46's nursing narrative noted that items were turned over to nursing staff by police upon the patient's return from the unauthorized leave on 2/7/11. Nursing narratives lacked documentation that staff had taken measures to ensure that the patient did not have additional items/contraband. Progress notes and/or facility documentation dated 2/8/11 indicated that at 1 AM the patient exited from the bathroom, strong cigarette fumes were observed by a staff member and the patient denied that h/she had smoked.
Although nursing narratives dated 2/8/11 noted that the patient later admitted to having possessed 1 cigarette and matches that h/she had flushed down the commode, the patient's record lacked documentation that a search had been conducted for the presence of additional smoking contraband. Interview with RN #11 on 2/8/11 at 10:30 AM noted that if staff had conducted a search, the search would be documented in a progress note. The hospital policy for patient searches identified that it was the policy of the hospital to maintain a safe environment. The policy indicated that an emergency search may be conducted immediately only when there was serious concern for patient welfare and safety or facility security. The policy also noted that staff might conduct an individual search of patient property when there was reason to believe that the patient's property contained non- permissible/prohibited material that may threaten the health and safety of the patient, other patients or staff.


b. Patient #48 was admitted to the hospital on 8/19/10 with a diagnosis of anorexia nervosa. Physician orders dated 9/2/10 directed to discontinue daily weights and weigh every Monday starting 9/6/10. Physician orders dated 1/19/11 also directed to weigh every Monday. The treatment records from November and December 2010 and January 2011 identified that the patient was weighed once a month and the patient weighed 85 pounds in November, 86 pounds in December and 88 pounds in January. Interview with MD #12 on 2/8/11 at 1:30 PM noted that the patient should be on weekly weights. Interview with the M4D nursing staff on 2/8/11 at 1:35 PM identified that the patient's weight had stabilized, h/she was becoming fixated on his/her weight and to weigh the patient weekly would have caused the patient more distress. Interview with the Assistant Division Director of Psychiatric Services on 2/8/11 at 1:37 PM indicated that staff would need to speak with the physician to change the frequency of weight monitoring and should follow the physician's order.



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Based on review of the clinical record and interview, the facility failed to ensure that one patient (Patient #27) with skin breakdown had been assessed. The finding includes the following:

a. Review of the clinical record indicated that Patient #27 had diagnoses that included dementia and was receiving hospice services. The clinical record indicated that on 10/19/10, a 3 cm, stage 2-pressure ulcer was identified on the left hip. The flow sheet failed to identify if the 3 cm was length/width or depth. The wound flow sheets for the period of 10/19/10 through 10/25/10 indicated that on 10/19/10, 10/20/10 and 10/22/10 the wound was 10% necrotic however on 10/24/10 the wound was 100% necrotic. The flow sheets and/or the progress notes failed to identify comprehensive assessments of the pressure ulcer.

b. Review of the wound flow sheets for the weeks of 10/27/10, 11/19/10, 11/26/10, 12/3/10, 12/10/10, 12/18/10 and 1/25/11 failed to identify that the left hip pressure ulcer had been measured and /or assessed. Although the flow sheets for the weeks dated 11/2/10 and 11/12/10 identified that the pressure ulcer was 2 cm in length and 1 cm in width, the depth had not been assessed.

c. The flow sheets for the period of 10/24/10 through 12/16/10 identified that the pressure ulcer contained 100 % eschar. The flow sheet dated 12/18/10 identified that the pressure ulcer was 75% eschar. The progress notes and/or the flow sheets failed to contain comprehensive assessments of the pressure ulcer. In addition the wound care flow sheets for the period of 12/25/10 through 1/24/11 were unable to be located. The flow sheet dated 1/26/11 indicated that the pressure ulcer had 100 % granulation.

Review of the Wound Care flow sheet indicated that staff should document daily until the wound is healed and the wound should be measured daily. Interview with facility staff on 2/9/11 at 2:00 PM indicated that the facility does not have a skin assessment policy.

Based on review of clinical records and interviews, the facility failed to ensure that bed/chair alarms were implemented as ordered.
a. Review of the clinical record for Patient #29 identified that the patient was a fall
risk. The clinical record identified an order dated 1/31/11 for a chair and bed alarm.
Tour of the unit failed to identify that the chair and bed alarms had been utilized.
Interview with staff on 2/7/11 indicated that the alarms were not available at tha
time. Staff indicated that the alarms are installed by physical therapy and as of 2/7/1
had not been installed.

Based on clinical record reviews, interviews with staff, and review of policies for 2 patients (Patients #30 and #32) who had physician orders for the use of CPAP machines while sleeping, the Hospital failed to ensure that staff documented each patient's daily use and responses to the treatment. The findings include:

Patient #30 had a diagnosis of sleep apnea. A physician order dated 10/20/10 directed for the patient to use CPAP. Patient #32 had a diagnosis of sleep apnea. Physician orders dated 12/15/11 and 1/13/11 directed for the patient to use CPAP with a pressure of 12 cm and warm humidification at bed time, and for staff to document the degree of patient compliance. Treatment records of Patients #30 and #32 were reviewed with the Nurse Manager on 1/9/11 at 10 AM and the Director of Regulatory compliance on 1/9/11 at 1 PM. The treatment records failed to reflect each patient's daily use of the CPAP. In addition, the hospital did not have a policy to address the use and documentation of CPAP.


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Based on medical record reviews, review of facility information and interviews for one of two psychiatric patients who resided on the M2DE unit (Patient #45), the facility failed to ensure that the patient had the opportunity to attend group meetings per the patient's Integrated Treatment Plan (ITP). The findings include:

Patient #45 was admitted to the M2DE unit on 1/5/11 with a primary diagnosis of opioid dependence and a diagnosis of depressive disorder. The patient's unit program schedule was developed by the treatment team and identified groups that the patient should attend and included attendance at the Co-Occurring group until discharge. Hospital documentation indicated that the Co-Occurring group was held on a weekly basis on 1/11/11, 1/18/11, 1/25/11 and 2/1/11 and Patient #45's name was not written on the Co-Occurring group list. Interview with SW #11 on 2/7/11 at 2:30 PM noted that patients whose names appeared on the list were the only patient's invited by staff to attend the group and Patient #45 was never invited. Interview with MD #11 on 2/7/11 at 2:40 PM identified that because Patient #45 had the coexisting psychiatric diagnosis of depressive disorder, the patient should have attended the group and the patient would be invited to attend future group sessions beginning 2/8/11.


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Based on review of the clinical record, interview and review of the facility policy the facility failed to ensure the Treatment Plan (TP) had been updated, reviewed and/or revised when one patient (Patient #31) was unable to attend groups. The finding includes the following:

Review of Patient #31's clinical record on 2/8/11 indicated a history of cancer and was receiving hospice care. Review of the MTP indicated that the interventions for the patient centered on attending daily groups. Review of the group notes for the period of October 2010 through February 9, 2011 indicated that the patient had been excused and/or unable to attend groups related to medical issues. The TP failed to be updated to reflect new interventions based on the patient's inability to attend group.

Review of the facility policy indicated the plan is a living document and should be used to guide the individuals course of treatment while in the hospital. The plan should integrate and coordinate all services and treatments provided to the individual.

Based on review of the clinical record and interview the facility failed to ensure that the medical record for one patient (Patient #27) was complete. The finding includes the following:

Review of the clinical record indicated that Patient #27 developed a stage-two pressure ulcer of the left hip on 10/19/10. The clinical record contained flow sheets for the period of 10/24/10 through 12/24/10, however, could not be located during the period of 12/25/10 through 1/24/11.

Based on observation and review of facility policy and procedures, the facility failed to follow guidelines for acceptable hygiene practices of food service personnel according to facilty policy. The findings include:

During tour of the kitchen and observation of the tray line on 2/9/2011 at 10:30 AM with Director of Food Services and Chief of Patient Care Services, one dietary staff member working on the tray line was observed to have his/her long hair tucked under a baseball cap only, without a hairnet. The dietary staff member was observed to still have strands of hair loose from the baseball cap and going down his/her neck and back. Review of facility policy titled Regulations for Dietary Uniforms and Dress Code in Kitchen and Dining Rooms directs that employees with long hair will be required to wear a hair net and a visor cap.

The facility failed to ensure that the Condition of Physical Environment was met.
Based on a tour of the inpatient psychiatric units, review of hospital documentation and interviews with staff, the Hospital failed to identify and ensure that the physical environment was safe.
See A 701 & A 724 and CMS form 2786R Life Safety Code Tags K17, 18, 20, 25, 27, 29, 50, 51, 62, 67, 69, 72,130, 155, and 147

Based on a tour of the hospital, the facility failed to ensure that the psychiatric living dorms and wings/units were maintained in such a manner as to promote the safety and well being of patients.

On 02/07/11, 02/08/11 and 02/09/11 at 09:00 AM and various times throughout the days, while touring Merritt Hall, Whiting Forensic, Dutcher Hall, Woodward Hall and Battell halls psychiatric units with the Director of Fiscal Services & Plant Operations, the Chief and/or Assistant Chief of the Connecticut Valley Hospital Fire Department and the Facilities Plant Engineering staff, the following was observed:
a. On 02/07/11 and 02/08/11 at 09:15 AM, it was observed that the patient beds and ancillary patient care medical equipment in the patient dorms throughout Merritt Hall, Woodward Hall and Battell Hall had power cords and control cords that were unsecure. The facility had previously instituted a directed plan of correction to identify and inventory all electric beds and to safely secure all electrical cords. Subsequent to these observations it was also identified that the facility would have to more permanently secure the cords for all medically necessary equipment, patient owned electrical devices and/or replace the beds with a hand crank or platform style bed to abate the suicide risk. During a meeting on 02/08/11to discuss these observations with the CVH Chief executive Officer, a representative of the licensing agency and the Director of Fiscal Services, the Facility Plant Engineer 3 stated he could assign personnel to monitor and complete this.

b. On 02/07/11 at 10:30 AM, it was observed that the Woodward Hall patient dorms had sunroom/solariums that contained openings that had 2 X 6 wooden rails mounted approximately 50 inches off the floor that could be used a ligature point for a patient to hang themselves and sinks adjacent to the openings that had sinks that were not of an institutional standard for suicide risk reduction. The TV lounge adjacent to the 2 South dorm had an unsecure TV Cabinet with a power cord run through the door opening, and subsequent interview of 2 south staff revealed that the cabinet should have been locked.


c. On 02/08/11 at approximately 9:30 AM, it was observed that the Battell Hall South 4 and 3 patient shower rooms were unlocked and subsequent staff interview revealed that when not being used shower rooms were to be locked.

d. On 02/08/11 at approximately 9:30 AM, it was observed that the Battell Hall South 4 shower room was being utilized by a patient. Interview of staff and documentation review of every- fifteen-minute environmental safety checks failed to reveal that the shower room was being utilized at 9:30 a.m. Subsequent interview with staff confirmed that the patient had been in the shower. Following use, the shower room was still not secured by floor staff and a facilities plant staff member secured the door prior to leaving the floor. Staff interview revealed that when not being used shower rooms were to be locked.


e. On 02/07/11 at 11:04 AM, it was observed that the hand towel and toilet tissue dispensers installed throughout Merritt Hall were constructed of a material (plastic) that had the potential to harm residents if broken or damaged and not suitable for institutional use.

f. On 02/09/11 at 10:06 AM, it was observed that the hand towel and toilet tissue dispensers installed throughout 500 Vine Street were constructed of a material (plastic) that had the potential to harm residents if broken or damaged and not suitable for institutional use.


g. On 02/07/11 at 11:27 AM, it was observed that the 2 (two) electric, patient beds located in Bedroom # 14-Floor 3F at Merritt Hall were equipped with power cords that were excessive in length and had the potential to harm residents.

h. On 02/09/11 at 10:08 AM, it was observed that the patient bedrooms throughout 500 Vine Street were provided with window-mounted air conditioning units that were equipped with power cords that were excessive in length and had the potential to harm residents.


i. On 02/09/11 at 10:08 AM, it was observed that the patient bedrooms throughout 500 Vine Street were provided with wardrobe units that had piano-style hinges installed on them that had a gap at the top of the door that created the potential to harm residents.

The facility failed to ensure that the provisions of the "Life Safety Code" of the National Fire Protection Association (NFPA 101, 2000 edition) that are applicable to Health Care Occupancies were followed. These findings are based on observations and review of facility documentation.

See CMS form 2786R Life Safety Code Tags K17, 18, 20, 25, 27, 29, 50, 51, 62, 67 69, 72, 130, 155, and 147

Based on direct observation, the Hospital failed to ensure that laundry room doors remained locked when staff were not in attendence, per facility practice. The findings include:

A tour of units D3N and D3S were conducted on 2/8/11 at 10:55 AM with the Nurse Manager and/or Head Nurse. Laundry room doors were observed to be open and unattended by staff. Although laundry detergents were locked in a cabinet, electrical cords and laundry machine hoses were accessible. During a tour of the second floor unit in a Satellite Facility on 2/10/11 at 10 AM, a laundry room door was observed to be unlocked and unattended.


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29051

Based on review of facility documentation, staff interviews, and review of facility policy and procedure, the facility failed to maintain refrigerator temperature logs on inpatient units per facility policy. The findings include:

During tour of unit Batell 3 North on 2/7/2011 at 1:30 PM, the Refrigerator /Freezer monitoring form for the unit's patient refrigerator was not complete, with missing entries for 2/5/2011 and 2/6/2011. In addition, the Refrigerator/Freezer monitoring form for the unit's specimen refrigerator was not complete, with missing entries for 2/2/2011 and 2/4/2011. Interview with the unit's Head Nurse during tour indicated that the night shift staff is responsible for logging refrigerator temperatures daily. Review of facility policy titled Refrigerator Maintenance Procedures directs that nursing staff on the third shift will record unit refrigerator and freezer temperatures nightly on a designated temerature monitoring form.

Based on medical record reviews, review of hospital policies and interviews for two patients (Patient #53, #36) who required physical and/or occupational therapy (PT/OT), staff failed to ensure that the patient received the therapy as ordered. The findings include:

a. Patient #53 was admitted to the M4B unit on 1/20/11 with a diagnosis of alcohol dependence and a history of falls. The fall risk assessment dated 1/20/11 indicated that the patient had a fall within the last 3 months and was a medium risk for falls. Physician orders dated 1/20/11 directed a PT evaluation for gait instability and that the patient to ambulate with a walker. The physical therapy assessment dated 1/24/11 recommended that if the patient decided to stay, the patient would benefit from PT and would benefit from services in the community as well. The patient was transferred to the 2AB unit on 1/31/11. Physician progress notes dated 1/31/11 identified that the patient ambulated easier and no longer required the use of the walker. Although the patient remained in the hospital, the patient's record lacked documentation that the patient received additional PT services. Interview with the Chief of Patient Care for Addiction Services on 2/8/11 at 8:30 AM noted that it was a misunderstanding that the patient had not received PT, the patient remained at risk for falls and the covering physician believed the patient would still benefit from PT. The PT policy identified that based on the PT assessment, the patient's wants and needs and the physician's recommendations, a PT therapy treatment plan is created and initiated.


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b Review of the clinical record of Patient #36 identified an order dated 1/25/11 for an Occupational Therapy consult. Review of the clinical record on 2/8/11 failed to identify that the OT consult had been completed. Interview on 2/9/11 with The Director of OT indicated that consults should be completed within 10 days. The Director indicated that there are delays depending on the service line.