HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure patients received care in a safe setting for 71 out of 71 patients when:

1. Landscaping plants in four of six courtyards included one plant variety that is poisonous if eaten.

This failure had the potential to put all patients who have access to the courtyards at risk of poisoning.

2. Three of four sampled employee records did not contain proof of an annual abuse prevention (proactive steps to create safe environments and prevent harm to vulnerable populations) and reporting (when a person either knows or has a reasonable suspicion a person is being or has been abused and reports to the proper authorities) education completion.

This failure had the potential to place all patients at risk for unreported abuse.

Findings:

1. During a concurrent observation, interview, and document review on 4/10/25 at 9:00 a.m. in courtyard 1 with the Director of Plant Maintenance (DPM) and the Chief Executive Officer (CEO) the courtyard was observed as an outdoor area surrounded by hospital buildings, creating an enclosed outdoor space for patients to sit or engage in activities. The central area of the courtyard was concrete, and around the perimeter there were landscape plants. Six Nandina domestica shrubs (Nandina, often called heavenly bamboo or sacred bamboo, is a common shrub used in landscaping that produces bright red berries) were noted. The shrubs were not in bloom or producing berries at the time of the observation. The DPM was provided a print-out of reference from https://en.wikipedia.org/wiki/Nandina#:~:text=Nandina%20can%20take%20heat%20and,off%20by%20hand%20in%20spring for review. The reference indicated, " ... Toxicity: All parts of the plant are poisonous, containing compounds that decompose to produce hydrogen cyanide, and could be fatal if ingested." The DPM observed the bright berries in the picture of the shrub, and stated he could see that the berries on the plant looked like cherries and could be tempting to children and adults. The CEO stated she was not familiar with the plant. During a tour of courtyards 2, 3, and 4, the courtyards were identical with the same landscape plants, including Nandina. During a tour of courtyards 5 and 6, the areas were noted to be smaller and did not contain Nandina shrubs.

During an interview on 4/11/25 with the Chief Nursing Officer (CNO), the CNO stated she was not familiar with Nandina bushes, and stated, "We don't want anyone to get poisoned."

During a review of hospital policy titled, "Patient Rights and Responsibilities" dated 6/2024, the policy indicated, " ...1. Humane Psychological and Physical Environment: Each patient at [name of hospital] has the right to a humane psychological and physical environment. The facility has been, and shall continue to be, designed to positively contribute to patient treatment by affording patients with comfort and safety ..."

During a review of an article from Human and Experimental Toxicology titled, "Pediatric Nandina domestica ingestions reported to poison centers" dated April 19, 2018, retrieved from https://pubmed.ncbi.nlm.nih.gov/28421827/#:~:text=Abstract,outside%20of%20a%20healthcare%20facility, the article indicated, " ... Nandina domestica is grown as an ornamental plant in the United States but has also been reported as an invasive plant in a number of states. Parts of the plant, particularly the berries, contain cyanogenic glycosides that convert to hydrogen cyanide when ingested ..."

During a review of an article titled, "A Comprehensive Guide To Hazardous & Poisonous Plants In Therapeutic Settings" (undated) retrieved from https://rootinnature.ca/growth-network/ the article indicated, " ... An integral part of creating this therapeutic environment is ensuring the garden's safety. It is not merely about preventing inadvertent brushes with poison ivy or the prick of a thorny rose. It is about safeguarding the sanctity of the garden experience ..."


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2. During a concurrent interview and record review on 4/11/25 at 10:00 a.m. with the Director of Human Resources (DHR) and the CNO, House Supervisor (HS) 1's "Education History (EH)", dated 2024-2025, was reviewed. The DHR stated she was not able to locate documentation of abuse prevention and reporting education completed by HS 1 within the previous year. The CNO stated HS 1 received repeat training in Crisis Prevention Institute (CPI, a de-escalation and crisis intervention program for staff working with individuals with mental health needs) after a recent video camera review of an incident of a patient encounter on a patient care unit.

During a concurrent interview and record review on 4/11/25 at 10:10 a.m. with the DHR, the DHR reviewed Milieu Specialist (MS, a specialist in maintaining a safe and therapeutic environment for mental health patients) 1's "EH", dated 2024-2025. The DHR stated she could not locate documentation of abuse prevention and reporting education completed by MS 1 in the previous year.

During a concurrent interview and record review on 4/11/25 at 10:40 a.m. with the DHR, the DHR reviewed the CNO's "EH", dated 2024-2025. The DHR stated she could not locate documentation of abuse prevention and reporting education completed by the CNO in the previous year.

During an interview on 4/11/25 at 3:36 p.m. with the CNO, the CNO stated Abuse prevention and reporting education is important because abuse of a patient was more likely to occur with patients with mental health issues.

During a review of the hospital's policy and procedure titled, "Staff Competency and Training (SCT)", dated 6/2024, "SCT" indicated, " ... Purpose: To assure compliance with all laws, rules and regulations relating to federal and state health care programs ... Annual Retraining ... On an annual basis, each employee is required to complete refresher training on the following topics ... Abuse/Neglect Identification and Reporting ...".

During a review of a professional reference titled, "Patient safety in inpatient psychiatry: a reaming frontier health policy (PS)", dated 5/2/23, "PS" indicated, " ... Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence ... sexual assault, inappropriate medication use ... inappropriate restraint and seclusion ... Several processes must be in place to ensure safety within psychiatric facilities. Safe environments require that staff members be proactive and intervene quickly in tense and escalating situations. Their ability to notice and mindfully intervene at these flash-point moments can result in the reduced use of containment measures (that is, chemical and physical restraint and close-door seclusion) that in some instances can be harmful to patients ...".

Based on observation, interview, and record review, the hospital failed to ensure nurses followed policies and procedures (P&P) when:

1. Licensed Nurses (LNs) did not ensure 1 of 4 emergency carts (a mobile, portable cabinet containing essential medical equipment and medications needed for treating emergencies like cardiac arrest [when the heart stops beating suddenly] or respiratory distress (trouble breathing) was locked on unit 2.

2. LNs did not complete the daily inspection of one (1) of four (4) emergency carts on unit four (4).

3. LNs did not ensure the portable oxygen tank (large metal cylinders that store oxygen under pressure [compressed oxygen]) stored on the crash/emergency cart in unit 1 was filled to/or greater than 500 psi (PSI-pounds per square inch- unit of pressure measurement that indicates the force exerted per square inch of an area) per facility P&P.

These failures had the potential for essential supplies and equipment to be unavailable or malfunctioning in a medical emergency, and possibly not address the emergent needs of patients.

Findings:

1. During a concurrent observation and interview on 4/8/25 at 2:41 p.m., with Chief Nursing Officer (CNO) on unit four (4) the, "Emergency Medical Equipment Daily Checklist", dated April 2025 had not been completed for 4/7/25. CNO stated her expectation is that LNs ensure the emergency cart is inspected daily during the night shift.

2. During a concurrent observation and interview on 4/8/25 at 3:22 p.m., with CNO on unit two (2) the emergency cart was observed to be unsecured. CNO stated her expectation is that LNs ensure the emergency cart is kept secured to prevent unauthorized access.

3. During a concurrent observation and interview on 4/8/25 at 3:44 p.m., with CNO on unit one (1), the oxygen tank on the emergency cart was below the 500-psi level, at "443." CNO stated her expectation is that staff ensure the oxygen tanks are full. CNO clarified a display of any level "below 500 [psi] is considered empty."

During a review of the hospital P&P titled, "Medical Gas Cylinders" dated 1/2025, the P&P indicated " ... PROCEDURE: ... 5. Empty cylinders shall be labelled as being empty. If cylinders have an integral pressure gauge, your facility must define, by policy, the threshold at which they are considered empty. River Vista policy defines 500 PSI as empty. 6. Partially used cylinders are considered empty and must be treated as such..."

A policy for the secure storage of crash carts was requested and was not provided by the end of the survey.

During a review of a professional reference titled, "Quick Safety 32: Crash-cart preparedness" (retrieved from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-32-crashcart-preparedness/crashcart-preparedness/, on 4/18/25, "...Medical emergencies have the tendency to create an uneasiness and a sense of chaos during the event. These feelings may be magnified if the emergency equipment used to rescue the patient is not readily available. The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency... Contributing factors to patient safety events related to crash carts include, but are not limited to: ...Missing, expired, damaged, contaminated, and unavailable equipment or medications, Empty oxygen tanks...Unsecured carts or carts that have been tampered with, Carts not checked or inspected according to policy and procedure...Some of these issues may appear minor, but alone or in combination, they may produce delays in providing care, thereby creating a patient safety risk... The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency..."

Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures and clinical standards of practice for infection control when:

1. Dust and debris were visible on slanted ledges at least 25 feet above the floor in the gym where patients were playing basketball.

This failure had the potential of triggering respiratory illnesses, allergies and asthma (a severe respiratory disease causing narrowing and inflammation of the airways).

2. Three of four sampled employee immunization records had declination forms (documents an individual signs when they refuse a vaccination) and titers (essential blood tests used in healthcare to determine if someone has immunity to specific diseases) that were not completed.

This failure had the potential to spread disease causing harm or death.

3. The facility failed to clean and maintain four out of four intake rooms (area located in each, where new patients get interviewed by the nurse and change into appropriate clothing/scrubs).

4. Paper signs posted with scotch tape were found on all patient care units.

5. 85 cardboard boxes of emergency food were stacked directly on the floor in a clean supply room and dust clumps and debris were noted on the floor of the room.

These failures had the potential to cause cross contamination (transmission of disease from one patient to another) from the intake rooms not being cleaned after each use.

Findings:

1. During a concurrent observation and interview on 4/8/25 at 3:05 p.m. with the Chief Nursing Officer (CNO) in the gym, dust and debris were visible on slanted ledges at least 25 feet above the floor. Marks in the dust were also visible where items had moved the dust around. When asked who cleaned the ledges, the CNO stated we would have to ask the Director of Plant Operations (DPO).

During an interview on 4/8/25 at 3:10 p.m. with House Keeping Worker (HKW) 1, HKW 1 stated he knew about the dust in the gym, but did not have the tools to clean that high. HKW 1 stated housekeeping staff have a list of what to clean on every patient unit, but not for the gym.

During an interview with the DPO, the DPO stated he did not have staff, until a few days ago, that could get on a ladder to assist the DPO in cleaning the gym's ledge. The DPO stated the Environmental Services (EVS) personnel were not allowed to get on a ladder.

During an interview on 4/11/25 at 2:15 p.m. with the Infection Prevention Registered Nurse (IPRN), the IPRN stated the dust on the ledge of the gym was a risk for patients, as it could contain dust mites (very small, insect-like pests that feed on dead human skin cells and thrive in warm, humid settings, causing respiratory symptoms and rashes to individuals exposed to them) and could fall down triggering allergies and asthma in patients and staff.

2. During a concurrent interview and record review on 4/11/25 at 9:55 a.m. with the Director of Human Resources (DHR), House Supervisor (HS) 1's "Immunization Record (IR)" (undated) was reviewed. HS 1's "IR" indicated HS 1 declined a Measles, Mumps and Rubella vaccine (MMR, three highly contagious and serious viral infections) and the varicella (chicken pox, highly contagious viral infection) vaccine. The DHR stated the "IR" had no documentation of measles, mumps, rubella, or varicella titers.

During a concurrent interview and record review on 4/11/25 at 10:00 a.m. with the DHR, Milieu Specialist (MS, a specialist in maintaining a safe and therapeutic environment for mental health patients) 1's "IR" (undated) was reviewed. The "IR" indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B (viral infection in the liver), and tDAP or Tdap (a vaccine against three bacterial infections: tetanus [lockjaw], diphtheria [life threatening infection], and pertussis [whooping cough]). The DHR stated the "IR" had no documentation of titers for the previously mentioned diseases.

During a concurrent interview and record review on 4/11/25 at 10:25 a.m. with the DHR, the CNO's "IR" (undated) was reviewed. The "IR" indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B, and tDAP. The DHR stated the "IR" had no documentation of Hepatitis B or tDAP titers.

During an interview on 4/11/25 at 2:12 p.m. with the IPRN, the IPRN stated employees are asked to provide a copy of their immunizations, and the hospital recommends immunizations. The IPRN stated the hospital offers vaccination to employees but does not draw titers. The IPRN stated she was not aware of the Center for Disease Control & Prevention (CDC, the nation's leading science-based, data-driven service organization) recommendations for health care workers vaccination, titer guidelines.

During a review of the hospital's policy and procedure titled, "Pre-Placement Health Screening (On-boarding) (PHS)" dated 6/2024, the "PHS" indicated, " ... Infection Prevention/Employee Health (IP/EH) will provide preventative and healthcare related services ... assures up-to-date health screening for every employee ... pre-employment physical screening is completed for all newly hired staff ... The physical screening includes ... HBV [Hepatitis B Vaccination] screen, MMR vaccination history ... communicable disease and drug screen ... immunization history will be taken from the newly hired employee ... It is recommended that employees should have had at least one (1) Tdap on file ...All immunizations are documented in the employee health file ... Measles, Mumps, and Rubella Screening ... All employees are screened for immunization history at the time of hire ...Patients/Resident must have history of current immunizations at time of admission ...Varicella and Pertussis Screening ... All employees are screened for immunizations at time of hire ...".

During an interview on 4/11/25 at 1550, the CNO stated it was her expectation for hospital policy to follow CDC guidelines.

During a review of a professional reference titled, "CDC Immunization of Health-Care Personnel [HCP] (CDCI)", dated 11/25/11, the "CDCI" indicated, " ... Summary of main changes from 1997 Advisory Committee ... Infection Control Practices ...recommendations for immunization of health-care personnel (HCP) ... Hepatitis B ...in certain populations at high risk ... should be tested ... to determine infection status ... MMR ...History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella ...Pertussis ... HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap ... Tdap can now be administered regardless of interval since last tetanus or diphtheria-containing vaccine ... Varicella ...Criteria for evidence of immunity to varicella were established. For HCP they include ... written documentation with 2 doses f vaccine, laboratory evidence of immunity or laboratory confirmation of disease ...".

3. During an observation on 4/8/25 at 2:40 p.m. while in Unit 4 intake room, the patient exam table had crunched up paper across the exam table (indicating that someone had sat on the paper because it should be straight with no indents if it is cleaned).

During an observation on 4/8/25 at 2:58 p.m. while in Unit 3 intake room, the patient exam table had crunched up paper across the exam table.

During an observation on 4/8/25 at 3:25 p.m., while in Unit 2 intake room, the patient exam table had crunched up paper across the exam table.

During a concurrent observation and interview on 4/8/25, at 3:48 pm with the Chief Executive Officer (CEO) and the CNO, while in Unit 1's intake room, the patient exam table had crunched up paper across the exam table. The CEO and CNO stated the intake rooms should be cleaned after each patient use.

During an interview on 4/11/25, at 2:12 p.m., with the IPRN, the IPRN stated the exam rooms should have been cleaned immediately after they were used. IPRN stated, "If you don't have a clean exam room, there could be transmissible disease, lice ...".

During a review of a professional reference from the CDC titled, "Healthcare-Associated Infections (HAIs)" Considerations for Reducing Risk: Surfaces in Healthcare Facilities, dated 4/15/24 indicated, " ... Hospitals must maintain a clean environment and reduce germ exposure to keep patients, visitors and healthcare personnel safe. There are six Core Components to creating and sustaining a clean, safe environment ... 1. Integrate environmental services into the hospital's safety culture. 2. Educate and train all personnel responsible for cleaning and disinfecting patient care areas. 3. Select appropriate cleaning and disinfection technologies and products. 4. Standardize setting-specific cleaning and disinfection protocols. 5. Monitor effectiveness and adherence to cleaning and disinfection protocols. 6. Provide feedback on the adequacy and effectiveness of cleaning and disinfection to staff and stakeholders ... All personnel who clean and disinfect reusable patient care equipment and environmental surfaces in patient care areas must understand their roles and responsibilities ...".
https://www.cdc.gov/healthcare-associated-infections/hcp/infection-control/index.html

4. During an observation on 4/8/25 at 2:20 p.m. on Unit 4, multiple paper signs hung with scotch tape were posted in the medication room and hallways.

During an observation on 4/8/25 at 2:50 p.m. on Unit 3, multiple paper signs hung with scotch tape were posted in the medication room and hallways.

During an observation on 4/8/25 at 3:20 p.m. on Unit 2, multiple paper signs hung with scotch tape were posted in the medication room and hallways.

During an observation on 4/8/25 at 3:40 p.m. on Unit 1, multiple paper signs hung with scotch tape were posted in the medication room and hallways.

During an interview on 4/11/25 at 2:15 p.m. with the IPRN, the IPRN stated paper signage on the walls was a " ... no-no ..." because it " ... can't be cleaned ...". The IPRN stated acceptable signage should be laminated or kept in a clear sleeve that could be cleaned.

5. During a concurrent observation and interview on 4/8/25 at 2:55 p.m. with the CEO in a clean supply room, 85 cardboard boxes of emergency food were stacked on the floor and clumps of dust and debris were on the floor. The CEO stated the room was usually cleaned daily.

During an interview on 4/11/25 at 2:18 p.m. with the IPRN, the IPRN stated the cardboard boxes of food could harbor bugs and if the boxes got wet, the food could mold easily and cause a risk of infection if consumed. The IPRN stated the debris and dust clumps on the clean supply room floor was " ... definitely not clean ...".

During a review of a professional reference titled, "Why carboard boxes attract pests (CB)", dated 4/7/24, "CB" indicated, " ... Cardboard can absorb and retain moisture from the environment, which creates an inviting habitat for pests ... The corrugated structure of cardboard offers an ideal hiding spot for pests ... making it difficult to detect their presence until an infestation has occurred ... Cockroaches ... are attracted to the glue used in cardboard, which often contains starch, a food source for these pests ... Silverfish ... are particularly fond of damp cardboard, which provides both a food source and a humid environment ...".





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