HospitalInspections.org

Based on interview, review of facility grievances, and policy review, the facility failed to provide written notice with the name of the facility contact person, the steps taken to investigate a grievance and the date of completion for five of five grievance files reviewed. This failure affects all patients and/or patient's representatives who filed a grievance by denying them needed information regarding their grievances. The facility census was 22.

Findings included:

1. Record review of the facility policy titled, "Grievance Procedures," dated 07/18/14, showed that if a grievance is resolved the Treatment Coordinator shall document the resolution on the Grievance Form, discuss the resolution with the consumer [patient] and have the patient sign the Grievance Form indicating he/she agree with the resolution.

Record review of the facility grievance log showed an average of five grievances filed per month for the past six months.

Record review of five Grievance Forms showed the forms did not contain the name of the facility contact person, the steps taken to investigate the grievances or the date of completion of the grievances.

2. During an interview on 02/11/15 at 10:30 AM, Staff FF, Utilization Review Manager, stated that she is a member of the facility Grievance Committee and she tracks the facility grievances. Staff FF stated that a Grievance Form was given to any individual who wants to file a grievance and the form was used to track the grievance and document the resolution of the grievance. Staff FF stated that when a grievance was resolved, a copy of the Grievance Form was given to the person filing the grievance. Staff FF stated that no letter was sent to the person filing the grievance. Staff FF acknowledged the Grievance Form does not document who the facility contact person is, any steps taken to investigate the grievance or the date of completion of the grievance.

Based on observation, interview and record review, the facility failed to ensure patient privacy for two (#23 and #14) of two patients who were assigned to a room without a door. This had the potential to affect all patients assigned to a room without a door by preventing them from having personal privacy to rest or sleep. The facility census was 22.

Findings included:

1. Record review of the facility policy titled, "Consumer Privacy," dated 08/11/14, showed staff should respect the right of clients to privacy. Staff shall consider each consumer's [patient's] room and bathroom as their private area and afford patient's privacy by seeking patient's acknowledgment of their intent to enter their room.

Record review of, "Summary of Rights for Consumers in State-Operated Facilities," dated 11/2011, showed patients are entitled, by Missouri law, to have personal privacy.

2. Observation on 02/09/15 at approximately 10:30 AM on the Adolescent Unit, showed room 421 was directly across from the nurses' station. The room had no door and the door opening was visible to the corridor and the nurse's station.

During an interview on 02/09/15 at approximately 10:35 AM, Staff I, Day Charge Nurse, stated that a patient had damaged the door sometime in January. Staff I stated that no patients had been assigned to room 421 since the door was taken down to be replaced.

During an interview on 02/09/15 at approximately 11:00 AM, Staff O, Plant Manager, stated that the door was damaged by a patient and removed for replacement on 01/06/15.

3. Record review of the midnight census patient status report for January 2015 and February 2015 showed Patient #23 was assigned to room 421 from 01/10/15 through and including 01/19/15. The report showed Patient #14 was assigned to room 421 from 01/20/15 through and including 01/22/15 and also on 01/26/15 and 01/28/15.

Room 421 had no door to assure any patient privacy and patients were assigned to the room for a total of 15 nights.

4. During an interview on 02/11/15 at approximately 11:15 AM, Staff AA, Director of Medical Records and Privacy Officer, acknowledged patients had been assigned to a room (room 421) that did not have a door.

Based on interview, record review and policy review, the facility failed to ensure a safe environment for patients when they allowed one staff member (Staff W) to work on a patient care unit before being placed on administrative leave for an investigation of possible abuse of a patient. This failure had the potential to expose other patients to possible abuse. The facility census was 22.

Findings included:

1. Record review of the facility policy titled, "Clients Rights, Investigation Procedures," dated 12/01/13 showed:
- Procedures for reporting, investigation and processing reports and complaints of abuse, neglect and misuse of funds.
- The policy defines physical abuse as handling a consumer [patient] with any more force than is reasonable for a consumer's proper control, treatment or management.
- Complaints shall be immediately reported to the head of the facility or designee by any person including department employees, contract employees, or any other mandatory reporter who knows through direct or indirect means that abuse or neglect has occurred, or suspects such has occurred or receives a complaint.
- Pending completion of the inquiry or investigation of an incident, the head of the facility may place the employee accused of any prohibited conduct on administrative leave or assign the person to work in an area away from consumer contact, if such is available.

Record review of an inquiry report dated 12/29/14 showed:
- On 12/28/14 Patient #23 complained that Staff W, Psychiatric Technician (Psych Tech) slammed his head into a wall during a restraint (any manual method, physical or mechanical device that immobilizes or reduces the ability of an individual to move his/her arms, legs or body freely) episode.
- A nursing supervisor moved Staff W to another unit.
- On 12/29/14 Staff A, Chief Operating Officer (COO), reviewed video footage of the incident and reported the allegations of physical abuse to the Children's Division hotline for further investigation.

Record review of a letter dated 12/30/14 to Staff W showed that Staff A placed Staff W on administrative leave pending the outcome of an investigation into allegations of possible patient abuse or neglect.

2. During an interview on 02/10/14 at approximately 11:00 AM, Staff A, COO, stated that the nursing supervisor had not contacted her on 12/28/14, at the time of the incident. Staff A stated that the nursing supervisor and the Medical Director, Staff N, decided to move the Psych Tech to another patient care unit for the remainder of the shift. Staff A stated that Staff W, Psych Tech, worked from approximately 5:00 PM until 11:00 PM on another patient care unit on 12/28/14. Staff A stated that Staff W remains on administrative leave because the investigation is not complete.

During a telephone interview on 02/18/15 at 1:00 PM, Staff A, COO, stated that on 12/28/14 Staff W was moved to the Children's Unit to work. Staff A stated that the census on the Children's Unit was five.

Based on interview, record review and policy review, the facility failed to ensure that care plans were modified to include goals and interventions related to restraint (any manual method, physical or mechanical device that immobilizes or reduces the ability of an individual to move his/her arms, legs or body freely) or seclusion (involuntarily placed in a monitored, secluded room for the safety of self or others), for four patients (#1, #2, #6 and #7) of four patients who were restrained/secluded. This had the potential to affect all patients who were restrained or placed in seclusion by failing to ensure that the patients' physical and psychological needs were met and to potentially prevent future restraint/seclusion use. The facility census was 22.

Findings included:

1. Record review of the policy titled, "Nursing Plans of Care," dated 12/2013, showed the following directives for staff:
- All patients admitted to the facility shall be assessed for behavioral and medical needs that require nursing planning, intervention, treatment and reassessment on an ongoing basis.
- All patients who demonstrate an active behavioral, medical or nursing diagnosis shall have an appropriate Individual Problem Plan completed at the time the behavioral, medical or nursing diagnosis is made by the nurse.
- The Nursing plan of care shall be documented in the Master Treatment Plan (treatment plan developed by multiple disciplines) section of the patient's electronic medical record.
- The nurse identifies the goal to be achieved during the nursing interventions.
- The nurse enters the specific interventions that nursing staff will be responsible for until the patient meets the identified objectives.

2. Record review of Patient #1's orders for special procedures (restraint and seclusion order) and nursing care plan showed nine episodes of a manual hold/seclusion from 12/30/14 to 02/01/14 with no modifications made in the nursing care plan. Record review of the Master Treatment Plan showed no modifications after each restraint/seclusion.

3. Record review of Patient #2's orders for special procedures and nursing care plan showed three episodes of a manual hold/seclusion from 12/19/14 to 01/16/15 with no modifications in the nursing care plan. Record review of the Master Treatment Plan showed no modifications after each restraint/seclusion.

During an interview on 02/09/15 at 11:35 AM, Staff F, Registered Nurse (RN), stated that she did not ever add a care plan for restraint and seclusion.

4. Record review of Patient #6's orders for special procedures and nursing care plan showed a manual hold by staff on 02/07/15 with no modifications made to the nursing care plan. Record review of the Master Treatment Plan showed no modifications for restraint/seclusion.

5. Record review of Patient #7's orders for special procedures and nursing care plan showed a manual hold by staff on 02/03/15 with no modifications made to the nursing care plan. Record review of the Master Treatment Plan showed no modifications for restraint/seclusion.

During an interview on 02/09/15 at 2:45 PM, Staff D, Chief Nursing Executive (CNE), stated that updating the nursing care plan was a problem in their electronic medical record system. She stated that the nursing staff could not update the nursing care plan until the Master Treatment Plan meetings (a multidisciplinary meeting, which usually includes nursing, social services, physician, dietary and therapists) are held, which are once a week.





29117

Based on interview and record review the facility failed to ensure medication administration policies and procedures were approved by medical staff. This failure increased the risk for inappropriate medication administration for all patients who received medication. The facility census was 22.

Findings included:

1. Record review of the facility's document titled, "Rules and Regulations of Medical Staff," revised 12/29/14, showed no approval of medication administration policies or procedures.

Record review of the facility's document titled, "Nursing Service Procedure, Medication Administration," dated 09/2012, showed no approval by medical staff.

2. During an interview on 02/11/15 at 10:10 AM, Staff D Chief Nursing Executive stated that medical staff did not approve who could administer medication because the facility followed state and federal laws.

During an interview on 02/11/15 at 10:50 AM, Staff A, Chief Operating Officer stated that medical staff did not approve the medication administration policies.

Based on observation and interview, the facility failed to maintain one of one deep fat fryer to prevent cross-contamination and harborage of pests and vermin. Failure to thoroughly clean and maintain cooking equipment after use creates a food source that draws pests and could affect all staff and patients who eat in the cafeteria. The facility census was 22.

Findings included:

1. Observation on 02/09/15 at 9:40 AM, showed a deep fat fryer located at the edge of the cook line, under the kitchen range hood. The burner, gas line and metal base inside the cabinet were caked with accumulated yellow and brown grease.

2. During an interview on 02/09/15 at 9:40 AM, Staff Q, Dietician, acknowledged the finding and stated that they were trying to go to more healthy diets and did not use the deep fat fryer.

During an interview on 02/19/15 at 10:45 AM, Staff Q stated that the cleaning procedure for the fryer did not include instructions or a directive to clean around the burner and the interior of the fryer cabinet.

Based on observation, interview, and policy review, the facility failed to thoroughly clean and maintain walls and floors of patient bedrooms, classrooms, dayrooms, showers and toilets in the 8-bed Children's Unit, 12-bed Adolescent Unit and 8-bed Cottage E. The facility also failed to ensure three of three refrigerators and one of one oven in patient care areas were clean and free of debris.
Lack of attention to detail and consistent enforcement of established housekeeping policies for cleaning rooms and commonly used areas in a health care setting directly impacts the health and well-being of the patient population. The facility census was 22.

Findings included:

1. Record review of the facility manual titled,"Regional Housekeeping Department Manual, Standard Operating Procedures Manual," revised 02/05/14, showed:
- "There will not be any visible dust or litter on the floor or baseboards."
- "The floors will not have any dry spills or wet spills, the corners and edges will be free from dirt build up, and baseboards free from dirt."
- "The floors are stripped properly when there is no visible finish on the floor after it has been stripped and dried."
- "The floor has been refinished properly when there is a clean shining floor without any mop marks, air bubbles or streaks."
- "The carpet is adequately vacuum cleaned when there is no visible dust or debris on the carpet."
- "The carpet has been adequately shampooed when it looks clean and has no spots."

The Regional Housekeeping Department Manual stated that Custodial Workers are responsible for dust mopping, wet dusting, buffing, stripping, vacuuming and shampooing. It stated that Custodial Work Supervisors are responsible for checking progress and setting up scheduled cleaning of the specific type and frequency necessary to "Maintain the hospital facilities in a clean, sanitary, orderly and attractive condition...to provide a suitable environment of care of patients and for the work of the hospital staff and employees."

2. Observation of the Children's Unit on 02/09/15 at 10:38 AM showed:
- Black mold-like substance embedded in the grout and perimeter base tiles of the walk-in shower floor (rooms 502 and 511).
- Plastic surrounding the shower control fixture in room 511 was cracked and exposed the interior of the wall.
- Dirt, accumulated dust and some waxed over dirt darkened the perimeters of the vinyl-tiled floors, thickened in the corners at door frames, and extended along the cove base that lined the edges of the main corridors, common classroom (room 500), in eight of eight patient rooms and five of five toilet rooms.
- Metal doorframes were rusted through at the bottoms and exposed rusted interior framework to the concrete block and cement wall of areas exposed to water.
-Thresholds of patient room entrance doors, closets and a time-out room (506) were stained and marked where a portion of the corridor floor had been stripped, buffed and re-waxed without opening the door and also cleaning the threshold or floor of the connecting room.
- The edge of the vinyl tiled corridor was discolored brown with scratches, general wear and soils where it joined the carpet of the day room (509), and extended the full width of the opening between the day room and the corridor.
- Room 503 (laundry) had a deposit of lint and fuzz about two inches deep on the floor along the wall behind the washer and dryer.

3. Observation with concurrent interview on 02/09/15 at approximately 1:30 PM to 2:20 PM of the Children's Unit in rooms 515, 517, and 518 showed:
- The outside of each room door had chipped areas in the doors and adhesive residue.
- The door that went into the bathroom had chipped areas and adhesive residue.
- The walls had multiple areas of chipped paint.
- Room 515 had three dime sized holes in the south wall.
- Room 517 had two pea sized holes in the north wall.
- During an interview Staff C, Quality Assurance Specialist, and Staff K, Quality Management Director, confirmed the findings.

4. Observation of the Adolescent Unit on 02/09/15 at 10:50 AM showed the following:
- Large area of stained or soiled grout 12 inches wide by 12 inches deep by 12 inches long, under the entrance door of tub room (416).
- Dark mold-like stains were embedded in the pits and surface deformities of the bottom layer of the painted concrete block wall and corners of the poured floor, and the door frame was rusted out at the base in common shower room (417).
- Dark stain of what looked like dried stripper or waxed over soil extended across the threshold of the time out room (419)
- Dirt, accumulated dust and some waxed over dirt darkened the perimeters of the vinyl-tiled floors, thickened in the corners at door frames, and extended along the cove base that lined the edges of the main corridors, common classroom, in eight of eight patient rooms and seven of seven toilet rooms.
- A two-inch wide band of black colored, unidentified residue had been worn or pressed into the carpet of the day room (400) and extended the full width of the opening between the day room and the corridor.
- Metal doorframes were rusted through at the bottoms and exposed rusted interior framework to the concrete block and cement wall of areas exposed to water.
-Thresholds of patient room entrance doors and closets were stained and marked where a portion of the corridor floor had been stripped, buffed and re-waxed without opening the door and also cleaning the threshold or floor of the connecting room or closet.
- Room 421 had a missing entrance door and pieces of the vinyl tiled floor had been torn away and was missing.
- Peeled and missing cove base in rooms 409, 417, 421, and 427 exposed strips of glue residue that was stuck to the painted cinder block wall.
- Room 401 (laundry) had significant (about two inches deep) deposit of lint and fuzz on the floor along the wall behind the washer and dryer.

5. During an interview on 02/09/15 at 11:00 AM, Staff O, Physical Plant Supervisor, stated that the door to room 421 had been damaged by a patient and presented a hazard to others. He stated that it was temporarily removed on 01/06/15 until a suitable replacement door could be ordered and purchased.

6. Observation on 02/10/15 at 11:05 AM of the Adolescent Unit showed two under the counter refrigerators located in a hallway outside the day charge nurses' office. Both refrigerators had unknown dried substances on the bottom of the inside of the doors and dried substances on both shelves.

During an interview on 02/10/15 at 11:10 AM, Staff I, Day Charge Nurse, acknowledged both refrigerators were not clean.

7. Observation of the Education Hall on 02/09/15 at 11:01 AM showed:
- Dirt, accumulated dust and some waxed over dirt darkened the perimeters of the vinyl-tiled corridor floors, thickened in the corners at door frames, and extended along the cove base that lined the edges of the main corridor and common classroom.
- The underside of the Recreational Therapy (RT) kitchen's vent hood above the 4-burner stove/oven was densely splattered with brown grease and greasy food residue.
- The oven had a mass of burned food residue on the bottom pan and chunks of burned food on the wire shelves.
- The pull-out drawer below the oven had burned-on brown grease residue on the top edge of the door and a burned and blackened spill in the bottom of the drawer.
- The toe kick area under the edge of the kitchen cabinets was soiled a brown color with dirt and food crumbs present and most noticeable in area where the partially peeled cove base prevented easy access for cleaning.

8. Observation of Group Cottage E on 02/09/15 at 1:50 PM showed:
- Deep pockets of accumulated dust and lint in the corners of patient room 104 and common toilet room 121.
- Blackened and burned food spills burned on the wire shelves and bottom of the cottage kitchen oven.
- Blackened food crumbs and spill in the bottom of the drawer below the oven.
- Dirt, food crumbs and dust/lint behind the kitchen's refrigerator and under the toe kick of the kitchen cabinets.
- Lint and fuzz behind the washer and dryer in the laundry room.

Observation on 02/09/15 at 10:30 AM in Cottage E in the girls and boys common bathroom showers showed black lines of soiled grout and caulk which looked like mold.

Observation on 02/09/15 at 11:00 AM in the kitchen of Cottage E showed multiple kitchen cabinet drawers and shelves behind cabinet doors which had unidentifiable debris and stains.

9. During an interview on 02/09/15 at 11:20 AM, Staff H, Housekeeping, stated that the cleaning of the inside of the cabinets and refrigerator was not a housekeeping responsibility.

During an interview on 02/09/15 at 11:40 AM, Staff G, Registered Nurse, stated that nursing was responsible for cleaning the refrigerator and refrigerator freezer. She stated that nursing should also clean inside the kitchen drawers and cabinets but that it was not on a schedule.

During an interview on 02/09/15 at 1:40 PM, Staff II, Psychiatric Tech, stated that patients used the kitchen for cooking classes during Recreational Therapy.

During an interview on 02/10/15 at 9:18 AM, Staff P, Housekeeping Supervisor, stated that housekeepers were responsible for cleaning patient rooms and common areas. He acknowledged the findings and stated that Housekeeping needed to put more effort into cleaning the perimeter areas of patient rooms and corridors, inside corners and behind doors and across thresholds. He stated that housekeeping staff were responsible only for cleaning the floors of the satellite cooking kitchens (Education Center, RT kitchen and Cottage E kitchen). He stated that direct care staff were responsible for cleaning the other equipment in the satellite kitchens.



19957




27727




29117

Based on interview and record review, the facility failed to ensure that Staff D, Infection Control Specialist (ICS), was qualified by experience, training, education or certification. This failure to provide training placed all patients at risk for inappropriate infection control compliance and protection. The facility census was 22.

Findings included:

1. Record review of the job description dated 09/30/10, for Staff D, showed duties and responsibilities of the position to include infection control monitoring of requirements and compliance.

Record review of personnel file for Staff D showed no prior experience or training for infection control, other than annual training that all staff received.

2. During an interview on 02/10/15 at 11:10 AM, Staff D, ICS, stated that she had attended no workshops on Infection Control and that she had had no additional training on Infection Control since being employed as the ICS. Staff D stated that she had no previous education or training on Infection Control to meet this job requirement.