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Based on observation, interview, record review and policy review, the facility failed to ensure:
- Staff provided a safe environment for one current patient (#5) out of two current patients reviewed that were on one on one observation (1:1, continuous visual contact with close physical proximity). Patient #5 engaged in self-injurious behaviors (SIB, behaviors that result in physical injury to an individual's own body) that included insertions of various objects into her urethra (tube that carries urine out of your bladder) that resulted in multiple trips to a local emergency department (ED) for medical intervention. Refer to A-0144 for additional information.
- Protect the rights of four current patients (#4, #5, #6 and #27) and seven discharged patients (#20, #24, #28, #29, #30, #31 and #32) out of 11 patients reviewed that were placed in locking four point walking restraints (restrains on both arms and legs with a locking device that required a key for release of the restraints). Refer to A-0154 for additional information.
- Staff provided a safe environment on the adolescent and children's units by not removing non-psych safe screws (tamper resistant) present in multiple areas and repairing one bathroom wall on the adolescent unit damaged with chipped cement. Refer to A-0144 for additional information.
- Staff were trained in first aide training related to restraint use that included non-nursing staff that were responsible for patients while in restraints. Refer to A-0206 for additional information.

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at an increased risk for their safety. The facility census was 13.

The severity and cumulative effects of these systemic practices resulted in the overall non-compliance with CFR §482.13, Condition of Participation (CoP): Patient's Rights.

Refer to the 2567 for additional information.

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Staff assessed and reassessed one current patient (#5) out of two current patients reviewed that were on one on one observation (1:1, continuous visual contact with close physical proximity). Staff failed to assess/reassess Patient #5 after she engaged in multiple self-injurious behaviors (SIB, behaviors that result in physical injury to an individual's own body) that included insertions of various objects into her urethra (tube that carries urine out of your bladder) that resulted in multiple trips to a local emergency department (ED) for medical intervention.
- Staff provided oversight for the laboratory area and/or procedures for labeling test tubes used to draw blood that included staffs' initials, date and time when blood was collected for four current patients (#7, #10, #11 and #14) out of four current patients' medical records reviewed for blood collection.
- Staff dated two multi dose drug vials after being opened.
Refer to A-0395 for additional information.

These failures created an unsafe environment and had the potential to place all patients at increased risk for their health and safety. The facility census was 13.

The severity and cumulative effects of these systemic practices resulted in the overall non-compliance with CFR §482.23, Condition of Participation (CoP): Nursing Services.

Refer to the 2567 for additional information.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Ensure refrigerated food was dated to provide notice of when to discard, in the cook's refrigerator in the kitchen.
- Ensure frozen food was dated to provide notice of when to discard, in the main freezer in the kitchen.
- Maintain a sanitary environment in the Kitchen by not removing rust (a source of contaminant that transmits infections) from a can opener and door tracks of a food serving station.
- Ensure that the Physician's Exam Room was sanitary.
These accumulated failures increased the risk of cross contamination through lack of maintaining a sanitary environment in the Kitchen and the Physician's Exam Room and storing foods in a sanitary manner to protect from spoilage. This placed all patients, visitors and staff at risk for the spread of infection.

Please refer to A-0749 for additional information.

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Staff provided a safe environment for one current patient (#5) out of two current patients reviewed that were on one on one observation. Patient #5 engaged in SIB that included insertions of various objects into her urethra (tube that carries urine out of your bladder) that resulted in multiple trips to a local ED for medical intervention.
- Staff provided a safe environment on the adolescent and children's units by not removing non-psych safe screws (tamper resistant) present in multiple areas and repairing one bathroom wall on the adolescent unit damaged with chipped cement.
These failures by the facility created an unsafe environment and had the potential to place all patients admitted to the facility at an increased risk for their health and safety.The facility census was 13.

Findings included:

1. Review of the facility's document titled, "Summary of Your Rights as Consumers at Hawthorn, dated 11/2011, showed that Consumers (patients) have the right to receive care in a safe setting.

Although requested, there was no policy related to environmental safety.

Review of the facility's polity titled, "Precautions and Levels of Supervision for Inpatient and Residential," dated 08/15/2019 showed:
- 1:1 Supervision is one staff member to one particular patient. This level of supervision may be increased to 2:1, two staff for a particular patient (or higher if deemed clinically necessary) and all provisions of 1:1 Supervision would apply for the higher ratios of supervision (2:1, 3:1, ect.)
- Close Observation (CO) as defined by a ratio of one staff member to every three patients.
- Standard Observation (SO) as defined by a ratio of one staff member to every four patients.
- 1:1 staff supervision and/or higher staff supervision requires for the staff member(s) to remain within one arm's length of the patient at all times except: During toileting or showering, staff may supervise at the bathroom door with the door being slightly ajar but must maintain continual observation of the patient at all times. During naps or at hours of sleep the staff member(s) may remain at the patient's doorway.
- At the time an order for either 1:1 or CO is received, the patient shall participate in a patient safety search with the patient's belongings and bedroom being checked for hazardous items and the room check shall be documented in the progress notes. Nursing staff shall conduct these room and belonging searches on a daily basis.

Observation on 09/30/19 at 3:10 PM on the Adolescent Unit, showed non-psychiatric safe screws and one damaged wall in the following areas:
- Four screws in the bathroom mirrors for two bathrooms;
- Wall damage with chipped cement to the left of the sink in bathroom #407;
- 37 screws and one screw half-way out of the wall in the day room;
- Six screws in the seclusion/restraint room window; and
- Four screws in the Art room bathroom around mirror.

Observation on 10/01/19 at 1:25 PM on the Children's Unit, showed four non-psychiatric safe screws in the bathroom mirror for one bathroom and seven non-psychiatric safe screws in the day room.

2. Review of the facility's policy titled, "Precautions and Levels of Supervision for Inpatient Program," showed that 1:1 was one staff to one patient and Close Observation was defined by a ratio of one staff to three patients.

Review of the Inpatient Daily Clinical Flowsheet, on the Children's Unit, showed that Patient #11 was on Close Observation for psychosis (a disorder characterized by false ideas about what is taking place or who one is), aggression and self-injurious behavior and Patient #15 was on Close Observation for aggression and suicidal gestures.

Review of the Inpatient Daily Clinical Flowsheet, o precaution levels on the Adolescent Unit showed the following patients :
- Patient #1 was on Close Observation for suicidal ideations and psychosis.
- Patient #2 was on 1:1 for self-injurious behaviors and aggression.
- Patient #5 was on 1:1 for self-injurious behaviors.
- Patient #6 was on Close Observation for self-injurious behaviors.
- Patient #26 was on Close Observation for self-injurious behavior and suicidal attempts.
- Patient #27 was on 1:1 for developmental delays.

Review of Event Report dated 04/07/19 for Patient #5 showed that the patient found a screw in the day room under a table.

Review of Event Report dated 04/21/19 for Patient #24 showed that the patient found three screws behind a desk.

Review of Event Report dated 04/18/19 for Patient #25 showed that the patient in the Adolescent seclusion room, banged on the doors and plexi-glass that caused an abrasion (this was the room that had six non-psychiatric screws in the plexi-glass window).

During an interview on 10/01/19 at 1:35 PM on the Children's Unit, Staff B, Registered Nurse (RN), stated that they call maintenance for any environmental safety issues.

During an interview on 10/03/19 at 8:50 AM, Staff Q, Physical Plant Supervisor, stated that the nurses called him if it was emergent, sent emails or put work orders in. He stated that he has never been contacted regarding the non-psychiatric safe screws and didn't perform periodic safety rounds.

Review of the facility's document titled, "Work Orders," printout for dates 07/01/19 through 10/01/19 showed no work orders placed for the non-psychiatric safe screws and the damaged wall.

The failures to perform environmental safety rounds placed this vulnerable population of patients at risk for injury to themselves or others.

Review of Patient #5's medical chart showed she was readmitted for inpatient care and treatment from the residential program on 11/04/18 for complaints of aggressive behaviors and SIB that included multiple trips to a local ED for needed care and treatment as a result of the SIB.

Review of the facility's document titled "Incident Logs" showed that from 04/26/19 through 9/22/19, the patient had 20 episodes of SIB that included insertions of various objects into her urethra with 10 incidents that required the patient to be transported to a local ED for medical interventions for the SIB. The patient had inserted the following items into her urethra over the past five months that required emergency interventions:
- On 04/18/19 urology (branch of medicine that specializes in the urinary system) removed a pencil;
- On 04/27/19 urology removed two small pieces of plastic;
- On 04/30/19 urology removed two wood slivers;
- On 06/14/19 urology removed a metal screw;
- On 07/12/19 urology removed a felt tip of a marker;
- On 07/22/19 urology removed two pencil halves;
- On 08/31/19 urology removed plastic spoon piece;
- On 09/04/19 urology removed a rolled up metallic sticker;
- On 09/13/19 urology removed a pencil; and
- On 09/14/19 urology removed a plastic straw.

During an interview on 10/03/19 at 12:55 PM, Staff E, RN, Interim Director of Nursing (DON), stated that when a patient was placed on 1:1 supervision, the intent was not for staff to prevent the behavior of the patient but to be able to intervene and/or alert staff when a patient did the behavior that required monitoring by staff. Staff E stated that 1:1 supervision was not a 100% act to prevent but for staff to be a "gate keeper" to hinder the act by the patient if at all possible.

During an interview on 10/03/19 at 3:05 PM, Staff I, Chief Operating Officer (COO), stated that she expected staff when providing 1:1 supervision for patients, was to prevent the behavior for the reason the patient was placed on 1:1.

During an interview on 10/08/19 at 2:50 PM, Staff CC, Behavioral Health Technician (BHT), stated that the patient has been at the facility for approximately two and a half years and was very familiar with the routine on the unit and what staff she could get by with various behaviors. Staff CC stated that the patient had become very creative in hiding objects from staff and that she picked the days she engaged in SIB when staffing on the unit was not as fully staffed as at other times.

During an interview on 10/08/19 at 4:00 PM, Staff DD, Psychiatrist, stated that:
- Staff did not always give 100% of their attention to the patient when they provided 1:1 supervision.
- The patient was very aware of when staff did not provide their undivided attention to her during 1:1 supervision.
- The patient has been discussed many times during rounds and multi-disciplinary team meetings and had even been placed on 2:1 supervision.

During an interview on 10/08/19 at 4:25 PM, Staff U, RN, Senior RN, stated that her expectation of staff when they provided 1:1 supervision, was that staff provided constant visualization of the patient and were at arms' length at all times. Staff U stated that there were times when she had to address staff when they became distracted when they were supposed to provide 1:1 supervision for a patient. Staff U stated that the patient would do more staff "pushing" of limits when the unit had less staff and that the patient would create "chaos" with her peer.

During an interview on 10/08/19 at 4:45 PM, Staff EE, BHT, stated that:
- She knew the patient and had provided 1:1 supervision for her.
- When she provided 1:1 supervision for the patient she was responsible to provide: Visual observation of the patient, be at arms' length of the patient with visualization when she was out of her room and not to talk to others but constantly watch the patient.
- The patient had become very cleaver on how she obtained objects to self-insert and was very "slick" in how she covered up her ability to get objects to self-insert.

During an interview on 10/08/19 5:10 PM, Staff FF, BHT, stated that:
- The patient was very "crafty" with SIB incidents and the incidents had occurred when the patient was on CO.
- The patient has been on 2:1 supervision and still able to obtain objects to self-insert.
- The patient needed to have her hands and feet visualized at all times because the patient has learned how to pick up objects with her feet by grasping objects in her toes.
- New staff did not realize how the patient had the ability to obtain objects and did not know her "tricks".
- Sometimes staff do not observe the patient, for example when they become distracted when they provided 1:1 supervision.

During interview on 10/09/19 at 9:00 AM, Patient #5 stated that staff were not "watching" me when I inserted objects, for example, some staff were on their phones and that was when I took the opportunity to insert. Patient #5 stated when I'm on 1:1 observation, staff are supposed to watch me at all times but sometimes staffs' attention was diverted and when they are not watching me, I take that opportunity to self-insert objects.

During an interview on 10/09/19 at 9:10 AM, Staff AA, BHT, stated that:
- She was providing 1:1 supervision for the patient today.
- While providing 1:1 supervision, she was responsible to provide: Direct eye contact on the patient at all times to ensure that the patient was safe, provide emotional support, do not leave the patient alone and always be with the patient at all times.
- She has worked with the patient in the past and she was unsure how the patient was allowed to engage in SIB when staff were to provide 1:1 supervision for the patient.

These failures by the facility placed all patients admitted to the facility at increased risk for their health and safety.




36473

Based on interview, record review and policy review, the facility failed to protect four current patients (#4, #5, #6 and #27) and seven discharged patients (#20, #24, #28, #29, #30, #31 and #32) out of 11 patients reviewed that were placed in locking four point walking restraints (restraints on both arms and legs with a locking device that required a key for release of the restraints). These failures placed all patients in need of restraints at the facility at risk for safety for emergencies. The locked restraints required keys that were not easily removed and inappropriate for a hospitalized patient. The facility census was 13.

Findings included:

1. Review of the facility's policy titled, "Special Procedures: Restraint and Seclusion," showed that Four-point walking restraints were padded cuffs locked to the wrist and ankle that limited limb movement.

Observation on 10/09/19 at 1:00 PM of the locking four point walking restraints showed there were five keyed locks (both ankles, both wrists and one at the waist).

Review of the facility's printout of patients on the Adolescent Inpatient Unit that were placed in four point walking restraints between 04/01/19 and 10/01/19 showed the following:
- Current Patient #4 on 10/04/19 and 10/05/19;
- Current Patient #5 on 04/25/19;
- Current Patient #6 on 07/03/19, 07/05/19 and 07/09/19;
- Discharged Patient #20 on 09/03/19;
- Discharged Patient #24 on 04/03/19;
- Current Patient #27 on 09/24/19;
- Discharged Patient #28 on 04/05/19;
- Discharged Patient #29 on 04/16/19;
- Discharged Patient #30 on 05/12/19;
- Discharged Patient #31 on 05/22/19; and
- Discharged Patient #32 on 08/15/19.
The patients at this acute inpatient facility came seeking medical treatment and when they were placed into four point walking restraints it crossed over into law enforcement tactics. These patients are a vulnerable youth population that were in need of care not law enforcement.

During an interview on 10/09/19 at 1:30 PM, Staff I, Chief Operating Officer, stated that she was unaware that the four point walking restraints were inappropriate.

The use of devices such as locked padded cuffs are considered a law enforcement restraint device and the expectation was for a more appropriate intervention for a hospital setting. Patient's rights were not taken into account when they placed these adolescent children into four point restraints.

Based on interview, record review and policy review, the facility failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) training related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), that included non-nursing staff that were responsible for patients while in restraints, for four staff (E, M, U and FF) personnel files of six staff personnel files reviewed. This failure had the potential for serious injury or death to any patients that required restraints in the facility. The facility census was 13.

Findings included:

1. Review of facility policy titled, "Use of Seclusion and Restraints," revised 07/01/19 showed that all direct care staff and other staff involved in the use of restraint and seclusion should receive education and training with first aid procedures.

Review of the facility document titled, "Seclusion and Restraint Log," showed 17 entries of the application of restraints over the previous six months.

Review of four personal records for Staff E, Interim Director of Nursing (DON), Staff M, Behavioral Health Technician (BHT), Staff U, Registered Nurse (RN) and Staff FF, BHT showed no restraint first aid training.

During an interview on 10/07/19 at 10:32 AM, Staff X, RN, Nurse Educator stated that the restraint training provided to staff did not include restraint first aid training.

During an interview on 10/08/19 at 2:44 PM, Staff AA, Training Technician II stated that the restraint training provided to staff did not include restraint first aid training. She stated that bi-annually nursing staff were provided a general first aid course but it wasn't in direct relation to the use of restraints and that it was only provided to the nursing staff and not all of the staff that were trained in the use of restraints.

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Staff assessed and reassessed one current patient (#5) out of two current patients reviewed who were on one on one observation (1:1, continuous visual contact with close physical proximity). Staff failed to assess/reassess Patient #5 after she engaged in multiple self-injurious behaviors (SIB, behaviors that result in physical injury to an individual's own body) that included insertions of various objects into her urethra (tube that carries urine out of your bladder) that resulted in multiple trips to a local emergency department (ED) for medical intervention.
- Staff provided oversight for the laboratory area and/or procedures for labeling test tubes used to draw blood that included staffs' initials, date and time when blood was collected for four current patients (#7, #10, #11 and #14) out of four current patients' medical records reviewed for blood collection.
- Staff dated two multi dose drug vials after being opened.
These failures by the facility to provide patients with proper assessment/re-assessment, evaluation and supervision of their safety needs had the potential to negatively affect all patients' treatment, health and safety while admitted to the facility. The facility census was 13.

Findings included:

1. Review of the facility's policy titled, "Precautions and Levels of Supervision for Inpatient and Residential," dated 08/15/19 showed:
- 1:1 Supervision is one staff member to one particular patient. This level of supervision may be increased to 2:1, two staff for a particular patient (or higher if deemed clinically necessary) and all provisions of 1:1 supervision would apply for the higher ratios of supervision (2:1, 3:1, etc).
- Close Observation (CO) as defined by a ratio of one staff member to every three patients.
- 1:1 staff supervision and/or higher, requires staff member(s) to remain within one arm's length of the patient at all times except during toileting or showering, when staff may supervise at the bathroom door with the door being slightly ajar but must maintain continual observation of the patient at all times; and during naps or at hours of sleep, the staff member(s) may remain at the patient's doorway. Patients with a history of self-harm are requested to keep their hands outside of the covers at all times and staff will remain in direct line of sight no further than the patient's doorway. At any time a patient refuses to keep their hands outside of the covers, staff will provide continued observation and check under the covers every 15 minutes to ascertain to the safety of the patient.
- At the time an order for either 1:1 or CO is received, the patient shall participate in a patient safety search with the patient's belongings and bedroom being checked for hazardous items, and the room check shall be documented in the progress notes. Nursing staff shall conduct these room and belonging searches on a daily basis.

Review of Patient #5's medical record showed she was readmitted for inpatient care and treatment from the residential program on 11/04/18, for complaints of aggressive behaviors and SIB that included multiple trips to a local ED for care and treatment.

Review of the facility's document titled "Incident Logs," showed that from 04/26/19 through 9/22/19, the patient had 20 episodes of SIB. The patient inserted various foreign objects into her urethra, which resulted in 10 incidents that required the following medical intervention at a local hospital:
- On 04/18/19 urology (branch of medicine that specializes in the urinary system) removed a pencil;
- On 04/27/19 urology removed two small pieces of plastic;
- On 04/30/19 urology removed two wood slivers;
- On 06/14/19 urology removed a metal screw;
- On 07/12/19 urology removed a felt tip of a marker;
- On 07/22/19 urology removed two pencil halves;
- On 08/31/19 urology removed a plastic spoon piece;
- On 09/04/19 urology removed a rolled up metallic sticker;
- On 09/13/19 urology removed a pencil; and
- On 09/14/19 urology removed a plastic straw.

Review of the patient's medical record showed the following related to the SIB incident dated 04/30/19:
- Progress Notes dated 04/30/19 at 2:00 PM, by the psychology therapist, documented that after she met with the patient, she believed the patient remained at high risk for additional insertions, and would insert soon, and reported this information to Staff U, Senior Registered Nurse (RN), on the Adolescent Unit.
- The Summary Note dated 04/30/19 at 5:00 PM by Staff DD, Psychiatrist, documented that the patient appeared in crisis mode again, had previously inserted on 04/26/19 and 04/27/19, and had inserted again on 04/30/19.
- The Summary Note dated 04/30/19 at 7:38 PM by Staff X, RN, documented that the patient reported just before her precaution change (from 1:1 to CO) that she found a small piece of wood approximately one inch long, inserted it into her urethra, and was currently bleeding. The patient's precautions were changed back to 1:1. The physician was notified and an order was obtained to send the patient to the local ED per emergency medical services (EMS, ambulance).
- The patient's Precautions Flowsheet dated 04/30/19, documented that the patient was on CO when she inserted the foreign object into her urethra, and staff failed to document if the daily patient safety search/room search was completed.

Staff failed to assess the patient after the psychology therapist reported to Staff U, RN, on 04/30/19 at 2:00 PM, that she was concerned that the patient remained at high risk for SIB and that the patient's precaution level needed to be adjusted from CO to 1:1 to provide a higher level of safety for the patient. Staff failed to recognize that Patient #5 had experienced two prior episodes of self-injurious behaviors on 04/26/19 and 04/27/19, and failed to document on the Precautions Flowsheet dated 04/30/19 that they had performed the daily patient safety search/room search to assist with keeping the patient and her environment safe.

Review of the patient's medical record showed the following related to the SIB incident dated 09/14/19:
- A Precautions Flowsheet dated 09/14/19 documented that the patient was on CO when she inserted a foreign object (plastic straw half) into her urethra.
- A Summary Note dated 09/14/19 at 9:01 PM by Staff HH, BHT, documented that she was informed that the patient was "playing" with a straw while in the cafeteria, but staff reported that they made sure the straw was on the patient's tray (when it was returned). When the patient later used the multi-purpose room bathroom, the BHT redirected the patient when she observed the patient "digging" in her vagina. Staff HH overheard the patient tell a peer that she had inserted, and Staff HH informed Staff U, RN.
- A Summary Note dated 09/14/19 at 8:55 PM by Staff U, RN, documented that when Staff HH reported that the patient appeared to "dig" in her private area while in the multi-purpose bathroom, the patient was searched for contraband (items that are illegal, forbidden, or items that can be used to harm self or others), but nothing was found. The patient later reported that she broke the cafeteria straw in half, and hid half of it in the inside pocket of her tights, and inserted it into her vagina when she was in the multi-purpose bathroom. The patient stated that when she tried to remove the straw it was no longer in her vagina but in her urethra. An order was received by Staff GG, Psychiatrist, to send the patient to the ED per EMS transportation.

Staff failed to recognize the straw on the patient's tray was not intact, and that half of it was missing. Staff failed to assess/intervene when the patient was in the multi-purpose bathroom and was observed "digging" in her vagina.

During an interview on 10/08/19 at 2:00 PM, Staff X, RN, stated that
- The patient was on 1:1 supervision when she inserted the wood into her urethra.
- When staff provided 1:1 supervision for a patient and the patient was in their room, staff sat in a chair in the doorway of the patient's room to make their observations. If the patient was in bed, the patient's hands should be outside the covers and visible at all times to staff. If the patient refused to have their hands outside the covers, then staff were expected to pull back the covers and check the hands every 15 minutes. When the patient was outside of their room, the patient was to be in staff line of sight at all times, and when the patient ambulated, staff were to be within arm's length.
- The expectation of staff when they observed a patient engaging in SIB was for staff to say something to the patient and stop the behavior.
- She had observed staffs' attention diverted when they provided 1:1 supervision for the patient. For example, they would turn their head away and not provide 1:1 supervision as ordered by the facility's policy and procedure.

During an interview on 10/08/19 at 2:50 PM, Staff CC, BHT, stated that the patient has been at the facility for approximately two and a half years and was very familiar with the routine of the unit and what behaviors she could get by with staff. Staff CC stated that the patient picked the days she engaged in SIB, when staffing on the unit was not as fully staffed as at other times.

During an interview on 10/08/19 at 4:00 PM, Staff DD, Psychiatrist, stated that:
- Staff did not always give 100% of their attention to the patient when they provided 1:1 supervision.
- The patient was very aware of when staff did not provide constant 1:1 supervision.
- The patient was discussed many times during rounds and multi-disciplinary team meetings, and was previously placed on 2:1 supervision.

During an interview on 10/08/19 at 4:25 PM, Staff U, RN, Senior RN, stated that her expectation of staff when they provided 1:1 supervision, was that staff provided constant visualization of the patient and were at arm's length at all times. Staff U stated that there were times when she had to address staff when they became distracted, during 1:1 supervision of a patient. Staff U stated that the patient would do more staff "pushing" of limits when the unit had less staff and that the patient would create "chaos" with her peer.

During an interview on 10/08/19 at 4:45 PM, Staff EE, BHT, stated that when she provided 1:1 supervision for the patient, she was responsible for visual observation of the patient, to be at arms' length of the patient with visualization when she was out of her room, and not to talk to others but constantly watch the patient. The patient had become very cleaver on how she obtained objects to self-insert and was very "slick" in how she covered up her ability to get objects to self-insert.

During an interview on 10/08/19 5:10 PM, Staff FF, BHT, stated that:
- The patient was very "crafty" with SIB incidents and the incidents had occurred when the patient was on CO.
- The patient had been on 2:1 supervision and was still able to obtain objects to self-insert.
- The patient needed to have her hands and feet visualized at all times because the patient had learned how to pick objects up with her feet by grasping objects in her toes.
- New staff did not realize how the patient had the ability to obtain objects and did not know her "tricks."
- Sometimes staff did not provide constant 1:1 supervision, and would become distracted.

During an interview on 10/09/19 at 9:10 AM, Staff AA, BHT, stated that she was unsure how the patient was allowed to engage in SIB when staff provided 1:1 supervision for the patient.

During interview on 10/09/19 at 9:00 AM, Patient #5 stated that staff did not always watch her, and when their attention was diverted by their cell phones (for example), was when she would insert objects.

During an interview on 10/03/19 at 12:55 PM, Staff E, RN, Interim Director of Nursing (DON), stated that when a patient was placed on 1:1 supervision, the intent was not for staff to prevent the behavior of the patient but to be able to intervene and/or alert staff. Staff E stated that 1:1 supervision was not a 100% way to prevent, but to hinder the act by the patient if at all possible.

During an interview on 10/03/19 at 3:05 PM, Staff I, Chief Operating Officer (COO) stated that she expected that when staff provided 1:1 supervision for patients, it was to prevent the behavior for the reason the patient was placed on 1:1.

2. Review of the facility's undated policy titled, "Collecting Blood Work: A Competency Based Skill," showed the following direction for staff of items needed on a laboratory requisition form:
- Patient's surname (last name), first name and middle initial;
- Patient's ID number;
- Patient's date of birth and sex;
- Physician's complete name;
- Date and time of collection;
- Initials of the individual drawing the blood; and
- The test requested.

Review of the facility's undated policy titled, "Collecting Blood Work: A Competency Based Skill," showed the following direction for staff of items needed on the label of the tube sample:
- Patient's surname, first and middle;
- Patient's ID number;
- Both of the above must match the same on the requisition form; and
- Date, time and initials of the nurse drawing the blood must be on the label of each tube.

Review of the facility's policy titled, "Critical Test, Critical Values and Critical Results," dated 03/20/19, showed that the following laboratory blood tests were considered an urgent test and required the staff to draw the blood from patients within 30 minutes of receiving the order and contact the laboratory for pick up:
- Complete blood count (CBC, a lab used to measure the components of your blood) to include chemistries (a lab panel that was used as a general screening tool for physicians to evaluate overall health) that included electrolytes (minerals involved in essential processes in the body).
- Hematology that included CBC and white blood count (WBC, to detect infection); and
- Therapeutic that included Digoxin (Medication used to control heart irregularities with toxic levels creating life-threatening conditions.), Dilantin (Medication used to treat and prevent seizures with toxic levels creating life-threatening conditions.), Phenobarbital (Medication used to treat epilepsy with toxic levels creating life-threatening conditions) and Lithium.

Observation on 10/02/19 at 11:00 AM in the laboratory drop off room, showed a blood tube for Patient #7 in the box awaiting pick up. The blood tube had no time of the collection or the staff member's initials.

During an interview on 10/02/19 at 11:01 AM, Staff D, Senior RN, stated that the nursing process was to drop off the lab draws in the laboratory room and then they assumed that the contracted laboratory courier picked them up daily before 10:00 AM. She also stated that nobody followed-up to see if the lab draws were picked up.

Review of the laboratory requisition forms for Patients #7, #10, #11 and #15 showed no date, time or initials of staff who drew the lab.

During an interview on 10/02/19 at 1:55 PM, Staff B, RN, stated that when she drew labs, she had not been told to put her initials and time on the blood tubes.

During an interview on 10/02/19 at 3:15 PM, Staff E, Interim Director of Nursing, stated that it was a nursing failure when they failed to put their initials, and date and time of the blood draw, on the tube at the bedside.

Review of Patient #7's medical record laboratory orders showed a CBC and a CMP (Comprehensive Metabolic Panel that included chemistries) was ordered on 09/30/19 at 3:02 PM (which was inaccurate due to no time on lab blood tube). No results logged at time of survey.

Review of Patient #11's medical record laboratory orders showed a CBC and a CMP on 08/29/19 on 4:45 PM (which was inaccurate due to no time on lab blood tube), received at the contracted laboratory on 08/31/19 at 6:03 AM, with results reported on 09/04/19, and staff acknowledgement on 09/05/19 at 3:20 PM.

Review of Patient #15's medical record laboratory orders showed a CBC and a CMP created on 09/17/19 at 10:07 AM (which was inaccurate due to no time on lab blood tube), received at the contracted laboratory on 09/19/19 at 12:02 PM, with results received on 09/20/19 at 2:58 PM and staff acknowledgement on 09/23/19.

These labs were considered urgent per the facility policy and had no time of the blood draw that created a break in the integrity of the blood. There was no oversight which resulted in inaccurate urgent laboratory results.

During an interview on 10/02/19 at 11:15 AM, Staff E, Interim Director of Nursing, stated that she didn't think any staff oversaw this process. She also stated that the nurses were supposed to date, time and put their initials on the requisition form.

There was no follow-up or a staff member that oversaw the laboratory process. This failure allowed a break in the integrity of the laboratory draws that could have delayed treatment for patients and had the potential to be detrimental to all patients in the facility receiving laboratory draws.

3. Review of facility's policy titled, "Medication Administration," dated 09/2017, showed that nursing was required to date and initial all multi-dose containers the time they were opened in order to track the beyond use date of 28 days.

Observation on 10/01/19 at 10:00 AM, in the medication room refrigerator, showed one multi-use vial of Tuberlin (medication used to test for Tuberculosis, an infectious disease that affects the lungs) opened with no date or initials.

Observation on 10/01/19 at 10:00 AM, in the medication room refrigerator, showed one multi-use vial of Flucelvax (medication used as a preventative for the flu) opened with no date or initials.

During an interview on 10/03/19 at 10:53 AM, Staff T, Infection Control Consultant, stated that all multi-use vials were to be dated at the time they were opened.

During an interview on 10/02/19 at 9:55 AM, Staff J, Pharmacist, stated that per policy the multi-use vials should have been dated at the time they were opened.



36473

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Ensure refrigerated food was dated to provide notice of when to discard, in the cook's refrigerator in the kitchen.
- Ensure frozen food was dated to provide notice of when to discard, in the main freezer in the kitchen.
- Maintain a sanitary environment in the Kitchen by not removing rust (a source of contaminant that transmits infections) from a can opener and door tracks of a food serving station.
- Ensure that the Physician's Exam Room was sanitary.

These accumulated failures increased the risk of cross contamination through lack of maintaining a sanitary environment in the Kitchen and the Physician's Exam Room and storing foods in a sanitary manner to protect from spoilage. This placed all patients, visitors and staff at risk for the spread of infection. The facility census was 13.

Findings included:

1. Review of the facility's policy titled, "Implementing Missouri Food Code Requirements," dated 09/06/19, showed that all opened, undated food items should be discarded every Sunday.

Review of the "United States Department of Health and Human Services Food Code," dated 08/2015, showed that once food has been opened, there should be a label with the date opened and the date of expiration.

Observation on 10/01/19 at 2:05 PM in the Kitchen at the food serving station, under the cold food bar, showed rust on the door tracks.

Observation on 10/01/19 at 2:07 PM in the Kitchen, showed rust on the large can opener.

Staff failed to remove the rust from the cooler door tracks and the large can opener that can cause bacteria. Rust promotes bacterial growth that can enter the bloodstream through any break in the skin. This had the potential to cause illness to staff, patients and visitors.

2. Observation on 10/01/19 at 2:10 PM in the Kitchen Cook's refrigerator, showed:
- Three pieces of chicken in an opened unlabeled bag;
- Three bunches of pancakes in an opened unlabeled bag;
- Two burritos in an opened unlabeled bag;
- Three waffles in an opened unlabeled bag; and
- One bag of corn dogs in an opened unlabeled bag.

Observation on 10/01/19 at 2:10 PM in the Kitchen's main freezer, showed one bag of egg rolls and one bag of veggie nuggets opened and unlabeled.

Staff failed to maintain wholesomeness and integrity of the food for human consumption.

During an interview on 10/01/19 at 2:50 PM, Staff A, Dietician and Kitchen Manager, stated that the items in the refrigerator and the main freezer should have been labeled. She also stated that the rust on the door tracks and the rust on the can opener should have been removed.

3. Observation on 09/30/19 at 3:15 PM in the Physician's Exam Room, showed dirt on the floors, sink, countertop (where the nurses drew up medications from multi-use vials) and dirty old tape on the blood pressure cuff machine.

During an interview on 10/03/19 at 10:53 AM, Staff T, Infection Control Consultant, stated that:
- Opened food should have been dated;
- No rust should have been in the Kitchen; and
- The Physician's Exam Room should have been cleaned.

This failure to maintain a clean physician exam room had the potential to cause contamination and illness to patients and staff.