HospitalInspections.org

Based on a tour and staff interview, it was determined that the facility failed to ensure that patient's receive care in a safe environment.

Findings include:

1. During a tour of the Psychiatric Unit on 2/28/18 at approximately 10:30 AM, in the presence of Staff #2, it was observed that the wall light fixtures in all the patient rooms, with the exception of one light fixture, were not ligature resistant.

a. Staff #2 and Staff # 16 agreed with the above, and indicated that the one ligature resistant fixture was a "trial" of a ligature resistant light fixture to perhaps replace the existing ones in the future.

Based observation, document review, and staff interview conducted on 3/1/18, it was determined that the facility failed to ensure that medications are administered in accordance with facility policies.

Findings include:

Reference: Facility policy titled "Medication Administration" states, "...IX. Right To Refuse: 1. The patient has a right to refuse medication. Determine the reason for refusal, when possible. ...3. Medication refusals should be documented immediately. 4. Notify the attending LIP when patients consistently refuse medications."

1. Review of Medical Record #4 indicated that Thiamine 100 mg (milligram) IM QD (intramuscularly daily) was ordered on 2/24/18 to 3/2/18.

a. It was noted that the patient had refused this medication on 2/24/18, 2/25/18, 2/26/18, and 3/1/18.

b. Upon interview, Staff #14 confirmed that there was no notification to the LIP (licensed independent practitioner) of the patient's refusal of his/her medication and there was no documentation of the reason for refusal in the nursing notes.

2. The above finding was confirmed by Staff #14.

Based on observation, staff interview, and document review, it was determined that the facility failed to develop and implement policies and procedures to ensure that vaccines are stored according to CDC (Center for Disease Control) guidelines.

Findings include:

Reference:CDC Vaccine Storage and Handling Toolkit, https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, states,"... check and record the current temperature a minimum of 2 times (at the start and end of the workday) This should be done even if there is a temperature alarm A temperature monitoring log sheet should be placed on each storage unit door (or nearby)..."

1. On 3/1/18, in the Medication Room, the medication refrigerator contained Fluvirin influenza vaccine.

a. The staff documented one (1) temperature reading per day on the refrigerator temperature log sheet instead of two (2).

2. This was confirmed by Staff #1.

Based on observation, document review, and staff interview conducted on 3/1/18, it was determined that the facility failed to ensure implementation of policies and procedures that outdated or otherwise unusable drugs are not available for patient use.

Findings include:

Reference: Facility policy titled "Multi-dose Vial Expiration Dates" states, "Procedure: On initial opening of a multi-dose vial, the nurse will initial the label and affix the revised expiration date and time on the label, which is 28 days from the opening."

1. At 9:32 AM, one (1) opened and multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was found in the medication refrigerator in the Medication Room. There was no indication of when the vial had been opened. The beyond-use date could not be determined.

2. At 9:32 AM, twenty-seven (27) unit-dose vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, labeled "use by 2/12/18" were found in the medication room.

3. The above findings were confirmed by Staff #12 and Staff #14.

Based on document review and staff interview, it was determined that the facility failed to ensure that the two independent physicians on the Utilization Review (UR) committee are regularly attending the UR committee meetings.

Findings include:

Reference: The facility's Utilization Review Plan states, "The EMH Utilization Review Committee is composed of two Physicians ... The EMH Medical Director will be invited to attend ..."

1. The minutes of the Utilization Review Committee for the 2/23/2017, 6/7/2017, 8/24/2017 and 1/11/2018 meetings revealed that one physician was excused for three of the four meetings.

a. There was no name of a second physician listed in any of the above meetings minutes.

2. This was confirmed by Staff #1.

Based on interviews and a tour conducted on 2/28/18, it was determined that condition of the physical plant and the overall hospital environment is developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

1. Emergency Response Equipment Room:

a. The drawers of a metal cabinet had salt and pepper spillage, grit, dust, and other refuse inside of them.

b. There was dust, grit, a drinking straw, potato chip pieces, popcorn pieces, and paper scraps on the floor beneath and behind the shredder box and the emergency kit. Also, an uncovered tin container with powdered sugar in it, was on the floor under a chair.

c. There was dust hanging from the edge of a ceiling tile that did not fully fit in the metal grid.

d. There was tape and tape residue on the walls.

e. A ceiling tile was stained.

f. There was a tacky raised stain on the wall above a metal shelf.

g. A portable cart with emergency equipment on it had grit, paper scraps, dust, a feather, string, and pieces of broken plastic on it. There was dust atop the suction canister and in the folds of the AED (Automated External Defibrillator) bag on the cart.

h. There was tape, tape residue, and dust atop a pigeonhole cabinet.

i. There was heavy dust, grit, cellophane atop a black, metal floor cabinet.

j. Telephone jacks on the wall behind the black, metal cabinet had a heavy accumulation of dust and grit on them.

2. Medication Room:

a. A drawer beneath the counter had dust, grit, paper scraps, and other refuse inside of it.

b. A wall cabinet containing narcotics had a heavy accumulation of dust atop the "Schedule II" box within the cabinet. There was tape and tape residue on the interior of the cabinet.

c. There was dust atop the safe and the green metal cabinet containing stock medications.

d. There was an accumulation of heavy dust, grit, paper clips, and scraps of paper beneath and behind the medication refrigerator. There was heavy dust on the floor beneath and behind a table.

e. There heavy tape and tape residue on the walls.

f. A cabinet beneath the counter had a crystal-like substance on the top shelf.

g. The "High Alert Medications" cabinet had dust on the shelves.

h. There was heavy dust and grit on an unfinished wood table under the food refrigerator. There was heavy tape residue inside of the refrigerator.

3. Nurses Station:

a. There was exposed raw wood, an uncleanable surface, under the counter near the hallway.

b. Wall shelves had dust, tape, tape residue, and torn stickers on them.

c. A wooden wall shelf holding a stereo had dust, tape, tape residue, and exposed raw wood (uncleanable surface) where the shelf was broken and/or worn.

d. A pharmaceutical waste receptacle on a wall had dust atop it.

e. There was heavy dust on a counter beneath and behind a copier machine.

f. There were clumps of dust, medication wrappers, grit, pieces of metal and other scraps of paper on the floor beneath and behind a large copier machine in the Nurses Station.

4. Seclusion Room #QA1:

a. There was dust hanging from the edge of unfinished gypsum board on the ceiling near the window.

b. There were cobwebs on the top of the screen in front of the window.

c. The gypsum board on the ceiling near the window was jagged at the edge.

5. There were broken floor tiles at the entrance to the Custodian Closet.

6. Hallway: There were strands of dust hanging from the ceiling tiles outside of the Supplies and Linen closets.

7. There was very heavy dust behind the metal louvers and on the walls in the Mechanical Room as observed from the hallway, across from the Supplies and Linens closets.


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8. Throughout the patient bathrooms, spackle was observed where wall tile was missing.

9. Several door entrances to patient rooms were stained.


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10. During a tour conducted on 3/2/18 at 10:30 AM, in the presence of Staff #1, the ceiling tiles installed in the hallway adjacent to Seclusion Room #1 and Seclusion Room #2 were found stained and surface worn rendering them uncleanable.

a. This finding was confirmed by Staff #1.

Based on observation and staff interview, it was determined that the facility failed to ensure adequate facilities are maintained for the services it provides.

Findings include:

Reference #1: "Guidelines for Design and Construction of Hospitals and Outpatient Facilities, 2014 edition, published by the Facilities Guidelines Institute, states ...
2.5-2.2.2" states, "Patient Bedroom Each Bedroom shall meet the following standards: ... 2.5-2.2.2.6 Patient toilet rooms ... (4) Toilet room doors (a) Where indicated by the safety risk assessment, toilet room doors shall be equipped with keyed locks that allow staff to control access to the toilet room. (b) If a swinging door is used, the door to the toilet room shall swing outward or be double-acting ...
2.5-8.1 General. For building system requirements for psychiatric hospitals, see Section 2.1-8 (Building Systems) and additional requirements in this section" states, " ... 2.1-8.2.1.2 Ventilation and space-conditioning requirements ... (2) Although natural ventilation for nonsensitive areas and patient rooms (via open windows) shall be permitted, mechanical ventilation shall be provided for all rooms and areas in the facility in accordance with Part 4 (ANSI/ASHRAE/ASHE 170 ... Table 7.1 Design Parameters ... Inpatient Nursing ...Toilet Room Pressure Relationship to Adjacent Area (s) Negative ..."

1. During a tour conducted on 2/28/18 at approximately 11:00 AM, the following was noted:

a. In Patient Room #615, a thick, not see through, curtain was hanging at the entrance to the bathroom/shower. The curtain was being utilized, instead of a door, as a "pilot" in order to provide additional anti-ligature measures, as indicated by Staff #16.

b. The above referenced guidelines are not being met without the use of a toilet room door.


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2. During a tour conducted on 3/2/18 at 10:30 AM, the following was noted:

a. Seclusion Room #2 did not have a window or door to the outside.

(i) A mattress was placed on the floor.

(ii) There was a pillow and blanket on the mattress.

(iii) Patient #7's belongings were on the floor next to the mattress. No clothes container/shelving was located in the room.

b. Staff #1 confirmed that Seclusion Room #2 was being utilized as a sleeping room since Patient #7 was admitted on 3/01/18.

A. Based on document review and staff interview conducted on 3/1/18, it was determined that the facility failed to ensure that an ongoing Infection Control program designed to prevent, control, and investigate infections and communicable diseases is implemented.

Findings include:

Reference #1: CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 states, " All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. After baseline testing for infection with M. tuberculosis, HCWs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCWs with baseline negative test results). "

Reference #2: CDC Recommendations and Reports: Measles, Mumps, and Rubella- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practices states that, "...All persons who work in health-care facilities should be immune to measles and rubella. Because any health-care worker (i.e., medical or nonmedical, paid or volunteer, full- or part-time, student or nonstudent, with or without patient-care responsibilities) who is not immune to measles and rubella can contract and transmit these diseases, all health-care facilities (i.e., inpatient and outpatient, private and public) should ensure that those who work in their facilities are immune to measles and rubella."

1. Review of nine (9) health files revealed that six (6) of the health files lacked evidence of staff immunization status evaluations as follows:

a. The health files for Physician Staff #5, #6 and #9 were not provided despite multiple requests from Staff #2.

b. The employee health file for Staff #14 and Staff #17 lacked evidence of:

(i) Rubella immunity status

(ii) Rubeola immunity status

c. The employee health file for Staff #7 (physician) lacked evidence of an annual TB testing due in January 2018.


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B. Based on observation, interview and document review, it was determined that the facility failed to develop and implement policies and procedures to ensure that their glucometer is cleaned and disinfected according to the manufacturer's instructions for use.

Findings include:

Reference #1: The Precision Xceed Pro Monitor manufacturer's instructions for use states," It is recommended to clean after each patient for infection control... Recommended solutions are Sani-Cloth HB, Sani-Cloth Plus, and Super Sani-Cloth."

Reference #2: Facility policy titled Fingerstick Test for Blood Glucose states," Daily cleaning of the exterior surface of the meter using a water moistened cloth or mild detergent is recommended."

1. Facility policy does not state the need for cleaning and disinfecting the glucometer after each patient use or the need for using the manufacturer's recommended EPA registered disinfectant.

a. On 3/1/18 during interview, Staff #14 described cleaning the glucometer with one Sani-Cloth Plus wipe. Staff #14 did not mention the need to disinfect the meter with a second wipe.

Based on interview, it was determined that the facility failed to ensure that its discharge planning process is reassessed on an on-going basis.

Findings include:

1. Upon request, Staff #1 and Staff #2 were unable to provide evidence that the facility's discharge planning process was reassessed on an on-going basis.

Based on review of facility policy and procedure, review of the medical record of one patient who expired at the facility, and interview with administrative staff, it was determined that the facility failed to notify the OPO (Organ Procurement Organization) of a patient's death in the hospital.

Findings include:

Reference: Facility policy and procedure titled "Organ and Tissue Donor Protocol" stated: ".....
* Any deaths at East Mountain Hospital [EMH] require the notification of the Administration team: Executive Director, Chief Medical Officer, Director of Nursing, in order to assess needs of the hospital/staff and assist with possible donor protocol and autopsy requirements.
PROCEDURE
*Suitability for Donation
- Any patient on EMH would be considered for organ/tissue donation.
.....
* New Jersey Organ and Tissue Sharing Network
- East Mountain Hospital has entered into an agreement with the NJ Organ and Tissue Sharing Network for the procurement of tissue donations when feasible.
.....
- A procurement coordinator is available for consultation to the hospital 24 hours per day to assist in and coordinate all aspects of the tissue donation request and recovery. The Network's telephone number is 1-800-___-____.
- The Potential Organ/Tissue Referral Form should be completed as documentation of communication with the Network. The form becomes a permanent part of the medical record.
....."

1. Review of the medical record of Patient #1 revealed the following entries:

a. "- Hospital Course
"Course of Treatment:
The patient was scheduled for transfer to --- 6/28. On 6/27 the patient did not report increase in depression or feeling suicidal, but approximately 4:40 was found on floor in bathroom with shoelaces tied around neck. CPR was started, code team and rescue squad called, but patient did not respond to resuscitation.
Diagnosis and Disposition
- Discharge Summary
Condition at Discharge:
deceased
....."

b. "**ADDENDUM**
Patient declared dead and medical examiner called--I notified father."

c. An "ADDENDUM" authenticated by the physician on 6/27/17 at 5:22 PM stated: "Patient found by staff laying in bathroom behind closed door with shoelaces tied around neck, appearing blue. Shoelaces cut off, CPR started, 911 called and rescue squad came. So far no response to CPR after about 10-15 minutes, and now continued with ambulance squad.
Per staff last conversed with patient about 4:35, found about 4:40, code team came 1-2 minutes later. I spoke with patient's father _____ ______, (phone number) about 5:15, informed him of incident, that paramedics were doing CPR at this time."

(i) There was no documentation in the medical record that anyone on the Administration team was notified of the patient's death.

(ii) There was not a Potential Organ/Tissue Referral Form in the patient's medical record.

(iii) There was no documentation in the medical record that the Sharing Network procurement coordinator, or anyone from the Sharing Network was notified of the patient's death.

2. Administrator #2 agreed with the findings.

A. Based on review of policy and procedure, review of the medical record of one patient who expired at the facility, and interview with administrative staff, it was determined that the facility failed to ensure, in collaboration with the OPO (Organ Procurement Organization), that the family of each potential donor is informed of its options to donate organs, tissues, or eyes, or to decline to donate.

Findings include:

Reference: Policy and procedure titled "Organ and Tissue Donor Protocol" stated:
"PURPOSE
Establish procedures for procurement of organ/tissue donor.
.....
* Any deaths at East Mountain Hospital [EMH] require the notification of the Administration team: Executive Director, Chief Medical Officer, Director of Nursing, in order to assess needs of the hospital/staff and assist with possible donor protocol and autopsy requirements.
PROCEDURE
Suitability for Donation
* Any patient on EMH would be considered for organ/tissue donation.
.....
New Jersey Organ and Tissue Sharing Network
* East Mountain Hospital has entered into an agreement with the NJ Organ and Tissue Sharing Network for the procurement of tissue donations when feasible.
* Upon the death of a patient, or anticipated death of a patient with a Do Not Resuscitate (DNR) order, the physician, or other member of the treatment team should inquire of the family and conduct a search of the patient's effects, to determine whether the patient had intended, or the family desires, that tissue donation be arranged. The presence of any organ donor card in the patient's possession should specifically be noted.
* A procurement coordinator is available for consultation to the hospital 24 hours per day to assist and coordinate all aspects of the tissue donation request and recovery. The Network's telephone number is ..... .
* The coordinator should be called by the physician, and provided with the patient's medical record number, age, sex, race, religion, and cause and time of death.
* The Potential Organ /Tissue Referral Form should be completed as documentation of communication with the Network. The form becomes part of the medical record.
.....
In the event that the death falls under the jurisdiction of the Medical Examiner, in addition to the consent of the next of kin, it will be necessary to obtain consent from the Medical Examiner's Office for removal of specified organs and tissues. In order to ensure that the donation takes place in a smooth and timely manner, it is important that the Medical Examiner is involved early in the process. Obtaining such consent will be the responsibility of The Network or tissue bank recovery team and documented in the Physician Progress Note. Normal hospital protocol will be followed when reporting a death.
....."

1. Review of the medical record of Patient #1:

a. The "Hospital Course of Treatment" section stated: The patient was scheduled for transfer to --- 6/28. On 6/27 the patient did not report increase in depression or feeling suicidal, but approximately 4:40 was found on floor in bathroom with shoelaces tied around neck. CPR was started, code team and rescue squad called, but patient did not respond to resuscitation. The entry was authenticated by a physician on 6/28/17 at 8:22 AM.

b. An "ADDENDUM" authenticated by the physician on 6/27/17 at 5:22 PM stated: "Patient found by staff laying in bathroom behind closed door with shoelaces tied around neck, appearing blue. Shoelaces cut off, CPR started, 911 called and rescue squad came. So far no response to CPR after about 10-15 minutes, and now continued with ambulance squad.
Per staff last conversed with patient about 4:35, found about 4:40, code team came 1-2 minutes later. I spoke with patient's father _____ ______, (phone number) about 5:15, informed him of incident, that paramedics were doing CPR at this time."

c. An "ADDENDUM" authenticated by the physician on 6/27/17 at 5:28 PM stated: "Patient declared dead and medical examiner called -- I notified father."

(i) There was no documentation in the medical record that anyone in the patient's family was informed of his/her options to donate organs, tissues, or eyes, or to decline to donate.

(ii) Administrator #2 agreed with the findings.


B. Based on interview with administrative staff, it was determined that the facility did not have a QAPI (Quality Assurance Performance Improvement) mechanism to ensure that the families of all potential donors are informed of their options to donate organs, tissues, or eyes, or to decline to donate.

Findings include:

1. A request was made of Administrator #2 for evidence of a QAPI mechanism designed to ensure that the families of all potential donors are informed of their options to donate organs, tissues, or eyes, or to decline to donate. He/she stated that there was no such mechanism.

2. Review of the medical record of Patient #1 indicated that the patient expired at the facility. There was no documentation that the patient's family was informed of their options to donate organs, tissues, or eyes, or to decline to donate.