HospitalInspections.org

Based on review of policy, list of medication errors for October, November and December 2018, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that two (#1 and #2) of three (#1-#3) incidents of a medication error were not documented in the chart of the patient that received the medication in error. By not documenting the medication errors, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:
A. Record review of the facility's policy titled, "Medication Variance," revised on 03/2006, showed the nurse was to enter the medication as administered in the medical record.
B. Review of medication errors for wrong medication given showed the following:
1. Event #1 showed Patient #34 received Melatonin 3 mg at 8:00 PM; and
2. Event #2 showed Patient #35 received a dose of Controlled Release medication at noon instead of an Immediate Release that was ordered for noon.
C. Review of clinical record showed the following:
1. Event #1 showed Patient #34's clinical record did not have an order for Melatonin nor documentation the patient received it; and
2. Event #2 showed Patient #35's clinical record showed the patient received the Immediate Release form at noon instead of the Controlled Release form.
D. During an interview on 02/05/19 at 3:19 PM, the Director of performance Improvement / Health Information Mangaement verified the findings at B and C.

Based on review of policy, observation and interview, it was determined the facility was not following acceptable standards of practice in that two licensed nurses did not always sign the medication wastage log per policy for three (1st, 2nd and 4th) of four (1st, 2nd, 3rd and 4th) floors toured. By not having a second nurse witness and sign the medication wastage log, the facility could not assure the medications were properly controlled. The failed practice had the likelihood to affect all patients admitted into the facility. Findings follow:
A. Record review of the facility's policy titled, "Medication Administration and Disposal," revised on 02/2016, showed two licensed nurses signatures were required to dispose of unused or leftover medication.
B. Record review of Floor Stock Usage/Waste Logs for 01/01/2019 through 02/03/2019 showed the following:
1) 1st floor wasted 14 doses of medications and 6 of them were not witnessed by a second nurse;
2) 2nd floor wasted 14 doses of medication and 4 of them were not witnessed by a second nurse; and
3) 4th floor wasted 3 doses of medication and 1 of them was not witnessed by a second nurse.
C. During an interview on 02/05/19 at 10:30 AM, the Director of Pharmacy verified the findings at A and B.

Based on Refrigerator and Freezer Temperature Log review for 11/01/18 through 01/31/19 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that freezer temperatures for three of three (2nd Floor, 3rd Floor, 4th Floor) nourishment area freezers were not below zero degrees 208 out of 270 times documented. Failure to maintain freezer temperatures below zero degrees created the potential for unwanted thawing in freezer foods; and could affect any patient receiving meals from those freezers. Findings follow.

A. Review of Table 9 showed Freezers must be less than or equal to zero degrees Fahrenheit. Review of Freezer temperature logs for 11/01/18 through 01/31/19 showed freezer temperatures were documented as above zero degrees 208 out of 270 times documented.
B. During an interview on 02/06/19 at 10:05 AM, the Certified Dietary Manager confirmed the freezer temperatures were above zero degrees.

Based on Refrigerator and Freezer Temperature Log review for 11/01/18 through 01/31/19 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that freezer temperatures were not documented three times per day for one (Ice Cream Freezer) of two (Walk in Freezer, Ice Cream Freezer) freezers. Failure to document temperatures three times per day created the likelihood for a freezer malfunction to go unnoticed, and could result in unwanted thawing of frozen foods. The failed practice had the potential to affect any patient receiving foods from that freezer. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.12 required temperatures of all refrigerators and freezers in the kitchen to be recorded three times per day. Review of Ice Cream Freezer temperature log for 11/01/18 through 01/31/19 showed temperatures were only recorded once per day for 92 out of 92 days.
B. During an interview on 02/06/19 at 10:00 AM, the Certified Dietary Manager confirmed the temperatures were only being documented once per day.

Based on observation, policy and procedure review, and interview, it was determined the facility failed to ensure a safe environment for the wellbeing of patients in that surfaces of the plastic charis were not cleaned with a cleaning solution in one of one ( Third Floor) Patient Day Room. Failure to clean surfaces of the chairs did not assure they were free of sources of infection that could potentially be transmitted. The failed practice affected all patients on Patient care Unit Three South. Findings follow:
A. Review of policy and procedure titled "Surface Cleaning Furniture," received on 02/05/19, showed the following:
1. Method
a) Do entire surface with a damp cloth;
b) Saturate cloth with cleaning solution. Rub over all surfaces using up and down and side to die strokes;
c) Rinse with a clean cloth;
d) Polish with a dry cloth;
e) Arrange furniture as found; and
f) Clean equipment.
2. Frequency- Daily
B. Observation of daily cleaning of Patient care Unit Three South Day Room at 8:23 AM on 02/06/19 showed Housekeeping Employee #1 did not surface clean the Day Room plastic sitting chairs. During the room cleaning process, the chairs were stacked up on top of one another, the area was cleaned, and the chairs were placed back under the tables.
C. The findings in B were verified with Housekeeping Employee #1 at 8:45 on 02/06/19. Surveyor #1 asked "Do you wipe down the chairs when you clean daily" Housekeeping Employee #1 stated "no, we pressure wash them about once a month."
D. The findings in A were verified during an interview with Director of Plant Operations/ Emergency Preparedness at 1:30 PM on 02/07/19, he stated that the policy for surface cleaning the plastic chairs is to clean them daily. He stated that there was no policy regarding pressure washing the plastic chairs.

Based on observation and interview, it was determined the facility failed to assure 10 (First Floor: Room 143B, Second Floor: Dirty Supply Closet and Seclusion Room, Third Floor: Patient room # 312, East Day Room, and Tub Room, and Fourth Floor: Day Area, Seclusion Room, and Dirty Supply Closet) units/patient areas were cleaned to protect the well-being of patients in that chairs were not cleaned, trash was not thrown away in a receptacle, peeling paint, and sticky substance on the outside of a door. The failed practice did not assure the physical environment was safe for patients. The failed practice had the potential to affect any patient whose care was rendered and received in any of the areas listed above. Findings Follow:
A. First Floor:
1) Observation in Room 143B (Patient Day Area) at 2:45 PM on 02/04/2019 showed 17 plastic chairs with brownish black area on the seats and black markings on the legs. Six of Six tables with taped numbers on the center of each table with black area on each piece of tape of tape. The findings were verified by the Administrator/ Chief Executive Officer (CEO) on 02/04/19 at 2:45 PM.
B. Second Floor:
1) Observation of the Dirty Supply Closet at 2:15 PM on 02/04/19 showed brownish black areas and stains in the sink. Observed in this same room was an uncovered pillow, a pair of shoes, and a pair of sox on top of the biohazard containment bin. Also, there were accumulation of dust t particles on the floor and in the corners of the room. The findings were verified by Registered Nurse (RN) House Supervisor #1 at 2:18 PM on 02/04/19.
2) Observation at 2:20 PM on 02/04/19 of the Seclusion Room showed two opened band aids on the floor of the entry way of the Seclusion Room. Findings were verified at 2:26 PM on 02/04/19 by RN House Supervisor #1
3) Observation on 02/05/2019 at 8:35 AM, in Patient Room # 312, showed a large area of paint peeling and chipping from the wall approximately 9 to 10 inches wide and 6 to 7 inches tall at the head of bed A. The findings were verified by Registered Nurse (RN) House Supervisor #1 at 8:38 AM on 02/05/19.
C. Third Floor:
1) Observation of the East Day Room at 1:43 PM on 02/04/19 showed visual accumulation of dust and debris and particles of paper on the floor. Observation in the same room were two Styrofoam containers filled with food on two of the tables and one milk container open on one table. The findings were verified by the Administrator/ CEO at 1:45 PM on 02/04/19.
2) Observation of the Tub Room on 02/04/19 at 2:00 PM showed visible brownish black staining in the bottom of the bathtub and visible clumps of dirt and lint on the floor. Findings were verified by RN House Supervisor #1 at 2:00 PM on 02/04/19.
D. Fourth Floor
1) Observation of the Day Area at 1:02 PM on 02/04/19 that was unoccupied by patients showed visual dirt and particles of paper on the floor. One medication cup on one table, three drinking cups on three tables, and one half of a sandwich in the window seal. Findings verified at 1:03 PM on 02/04/19 by Administrator/ CEO.
2) Observation of the Seclusion Room at 1:04 PM on 02/04/19 showed an area inside the window with an unidentified brown soiled area that was approximately 2 by 3 inches. Findings were verified by the Administer/ CEO at 1:04 PM on 02/04/19.
3) Observation of the Dirty Supply Closet at 1:35 PM on 02/4/19 showed on the outside of door were three strips of a sticky material with each approximately 4 to 5 inches long, and 1 piece with a strand of hair attached to it. Observation in the same room there was visual dirt and stains in the bottom of the sink. Findings were verified at 1:39 PM on 02/04/19 by RN House Supervisor.

Based on policy and procedure review and observation, it was determined the facility failed to assure the well-being of patients in that two of two ( Third and Fourth Floor) patient weight scales showed brownish black discolored areas on the glass reading portion of the scales and where the feet were placed. Failure to assure patient care equipment was clean did not ensure patient weight scales where clean, ready for use, and were accurate. The failed practice had the potential to affect any patient who required use of the weight scales on the third and fourth floor. Findings follow::
A. Review of the policy and procedure titled "Cleaning/Disinfecting Multi use Equipment," received on 02/04/19, showed the following:
1) Portable Equipment (i.e. wheelchairs, assistive device, mats etc. ...) would be cleaned between each patient, as needed, and at least daily when in use.
B. Observation of the patient scales in the Nurse's Station at 2:00 PM on 02/04/19 of the Third Floor showed brownish black discolored area over the top clear portion of the scales causing the reading to be difficult to visualize and verify the weight. Also, the area where the patient would place their feet was dirty. The Registered Nurse (RN) House Supervisor #1 verified the findings at 2:01 PM on 02/04/19.
C. Observation of the patient scales in the Nurse's Station of the Fourth Floor at 1:15 PM on 02/04/19 showed a brownish black discolored area over the top clear portion of the scales causing the reading to be difficult to visualize and verify the weight. Also, the area where the patient would place their feet was dirty. The RN House Supervisor verified the findings at 1:16 PM on 02/04/19.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to ensure safety and quality of one (Residential Unit) of four point of care blood glucose testing devices by not documenting open dates of the glucose control solution bottles. The failed practice did not ensure that the control solutions were effective in measuring the quality of the glucose test strips prior to patient use. Findings follow:
A. Review of the manufacturer's recommendation for the Contour Glucose Control Solutions showed "it was important not to use the control if the expiration date printed on the bottle label and carton had passed or it had been six months since you first opened the bottle. The six month date was to be written on the label in the area provided when opened
B. During tour of the medication room of the Residential Unit on 02/04/19 at 2:48 PM, two of two Contour Glucose Control Solutions were found without the date of opening or discard date written on the bottles..
C. During interview with the House Supervisor #1 on 02/04/19 at 2:50 PM, the findings in A and B were verified.

Based on review of policy, review of Healthcare Workers and volunteers' TB (Tuberculosis) records, and interview, the Infection Control Officer failed to identify that one of one (#1) Physical Therapist (PT); one of one(#1) Speech Language Pathologist (SLP); and one (#2) of two (#1 and #2) Pet Handlers were not being screened annually for TB. By not assuring the Healthcare workers were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees, volunteers and patients in the facility. Findings follow:

A. Record review of the policy titled, "Employee Health Program Description," revised 04/2002, showed all employees were to be tested and or screened for TB upon hire and annually thereafter.
B. Review of the Healthcare Workers' Tuberculosis records showed the following:
1) PT #1 was last tested/screened on 01/25/18 and was due for testing/screening on 01/25/2019;
2) SLP #1 was last tested/screened on 04/29/16 and was due for testing/screening on 04/29/2017; and
3) Pet Handler #2 was last tested/screened 10/22/2016 and was due for testing/screening on 10/22/2017.
C. During an interview on 02/05/2019 at 1:36 PM, the Director of Performance Improvement / Health Information Management verified the findings at A and B and clarified that although the policy states "employees", it applies to contract workers and volunteers also.

Based on review of Therapy Services Contract, Arkansas Rules and Regulations for Hospitals 2016, Section 23, review of Speech Language Pathologist's (SLP) personnel file and interview, it was determined one (#1) of one SLP did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per Therapy Services Contract. By not having evidence of these qualifications, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Speech Language Rehabilitation Services. Findings follow:
A. Record review of the Therapy Services Contract, dated 09/06/2016, showed SLPs were required to remain appropriately licensed/certified in the State of Arkansas.
B. Record review of the Arkansas Rules and Regulations for Hospitals 2016, Section 23, showed all SLPs shall maintain competency in life support measures.
C. Review of SLP #1's personnel file showed no evidence of a current CPR certification. The file did not contain any expired CPR certifications either.
D. During an interview on 02/05/19 at 1:36 PM, the Director of Performance Improvement / Health Information Management verified the findings at B and C.

Based on record review and staff interview it was determined that for six (6) of eight (8) active sample patients(Patients A3, A4, B1, B2, B3 and B4) the psychiatrist interventions on the Master Treatment Plans were generic discipline functions and lacked patient specificity. This failure resulted in no information being made available to other members of the multidisciplinary treatment team about what the psychiatrist was going to do for each patient, which would have resulted in an individualized Master Treatment Plan.

The findings include----

I. Record Review:

1. Patient A3: The Master Treatment Plan dated 1/31/19 stated as the sole psychiatrist intervention for this patient with the Problem "Depression with SI (suicidal ideation)," the statement "Educate patient regarding purpose, actions, risks & side effects of prescribed psychotropic medications." No information was given as to what type of "psychotropic medication" was selected or what the "actions" or the "risks & side effects" might be.

2. Patient A4: The Master Treatment Plan dated 1/28/19 stated as the sole psychiatrist intervention for this patient with the Problem "Aggression with SAO (sexual acting out) Behaviors" the statement "Educate (Patient A4) regarding purpose, actions, risks & side effects, symptoms of disruptive and aggressive behaviors and importance of compliance with treatment."

3. Patient B1: The Master Treatment Plan dated 1/25/19 stated as the sole psychiatrist intervention for the Problem "Aggression w/HI (with homicidal ideation)" the statement, "Educate (patient B1) regarding purpose, actions, risks & side effects, symptoms of labile mood and importance of compliance with treatment."

4.Patient B2: The Master Treatment Plan dated 2/05/19 stated as the sole psychiatrist intervention for the Problem "Mood Lability w/Aggression, Self-Harm, and Anxiety" the statement, "Educate (Patient B2) regarding purpose, actions, risks & side effects, symptoms of labile mood and importance of compliance with treatment."

5. Patient B3: The Master Treatment Plan dated 1/29/19 stated as the sole psychiatrist intervention for the Problem "Aggression," "Educate (Patient B3) on the importance of compliance with treatment."

6. Patient B4: The Master Treatment Plan dated 1/25/19 stated as the sole psychiatrist intervention for the Problem "Mood Lability with SI (suicidal ideation)" the statement, "educate (PatientB4) regarding purpose, actions, risks & side effects, symptoms of labile mood and importance of compliance with treatment."

II. Staff Interview:

On 2/05/19 at approx. 2:30 p.m. the Clinical Director was interviewed. A partial focus for the interview was the findings described in Section I, above. The Clinical Director agreed that the interventions were not descriptive of a patient specific need and were generic discipline tasks.

Based on record review and staff interview it was determined that for six (6) of eight (8) active sample patients (Patients A3, A4, B1, B2, B3 and B4) the Clinical Director failed to ensure that psychiatrist interventions were more than generic discipline tasks. This failure resulted in the absence of an individualized description of what the psychiatrist would be doing for these patients. Refer to B 122 for details

Based on record review and interview, the facility failed to provide activity therapy groups by CTRS (Certified Therapeutic Recreational Staff) seven days per week on evenings and weekends for all five inpatient units (3 adolescents and 2 children). This failure results in patients not receiving individualized and goal directed active treatment.

Findings include:

A. Record Review

The five (5) patient units listed above did not have any groups 7 days a week by CTRS for evenings and weekends on their unit schedules.


B. Interview

In an interview on 2/4/19 around 11:30 a.m. with RT#1, the lack of evening and weekend therapeutic activities 7 days a week was discussed. S/he did not dispute the findings.