HospitalInspections.org

Based on document review and interview the facility failed to:


A. recognize antipsychotic medications given IM for behavioral emergencies was a restraint in 3 (#2, #3, and #4) of 3 patient charts reviewed. The facility failed to ensure the staff administering the medications were properly trained and educated. The facility failed to document any assessment or reassessment of the patient before or after administering antipsychotic medications, perform de-escalation techniques before a restraint, perform and document a face to face, and failed to monitor the use of chemical restraints through the Quality Assessment Performance Improvement Process (QAPI).

Refer to Tag A0144



B. ensure that medications given IM (intramuscular) and used as behavioral restraints were not ordered PRN (as needed basis) in 7 (Patient #1, #2, #3, #4, #5, #6, and #10) of 8 patient records reviewed.

Refer to A0169


C. ensure a Face to Face by the provider, or a trained RN was completed within one hour of administration of the chemical restraint.

Refer to Tag A0179



The deficient practices were identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on document review and interview the facility failed to recognize antipsychotic medications given IM for behavioral emergencies was a restraint in 3 (#2, #3, and #4) of 3 patient charts reviewed. The facility failed to ensure the staff administering the medications were properly trained and educated. The facility failed to document any assessment or reassessment of the patient before or after administering antipsychotic medications, perform de-escalation techniques before a restraint, perform and document a face to face, and failed to monitor the use of chemical restraints through the Quality Assessment Performance Improvement Process (QAPI).

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Patient #2
Review of Patient #2's chart revealed she had been in the hospital with a urinary tract infection and developed sepsis. She was treated but sent to the rehab due to deconditioning at home and frequent falls. Review of the history and physical the patient was independent at home, was driving, and receiving ADL assistance from home health.
Rehabilitation diagnosis: "Generalized weakness and functional decline secondary to UTI complicated by sepsis. Mixture of Infectious and metabolic encephalopathy secondary to UTI complicated by sepsis and lactic acidosis."
Review of Patient #2's chart revealed there was a physician order for haloperidol (HALDOL) ordered on 9/10/2022 at 21:05 (9:05 pm). The order read, "Order Details: 1 mg = 0.2 mL, Indication: Agitation, Soln-Inj, Intramuscular, q2hr PRN Agitation, Start date 9/10/22 9:04:00 PM CDT."

Review of the chart revealed that a Licensed Vocational Nurse did rounds and the shift assessment at 2100 (9:00 pm). There was no documentation in the shift assessment of the patient having any agitation or a behavioral emergency.

Review of the nurses' notes dated 9/11/22 at 00:47 the LVN documented, "Patient got out of bed and hit the Mirror above the sink with the wheelchair leg rest when staff arrived to bed alarm. Patient stated, "Someone is trying to kill her in me in my sleep and have already killed my brother and sister in law". Patient was very agitated. Attempted to get pt to sit in w/c or get back into bed and provided reassurance that she was safe. Pt states staff was "showing pictures of pt drowning in a swimming pool" Attempted to hit staff member pt became more combative and tried to rip seatbelt from w/c and shoved w/c. pt unsafe and unsteady on feet. staff provided safety and MD notified and new order noted."

There was no documentation that the patient was assessed by the RN. There was no documentation of a nursing assessment after chemical restraints were given. There was no documentation of patient behavior, effectiveness of the medication, or patient's physical status after the administration of the chemical restraint. There was no face to face, no documentation from the physician concerning the Haldol, and no documentation on the treatment plan for behaviors and medication administration. There was no found documentation of other alternatives attempted to help the patient to deescalate before the administration of a chemical restraint. There was no documentation that the physician or family was notified.

Review of Patient #2's chart revealed she was administered Haldol 1 mg IM. Admin Date/Time: 9/11/2022 10:27. Review of the chart revealed the RN did rounds on 9/11/2022 10:39. The patient's glucose was checked, and the nurse documented "Agitated, Anxious, Impulsive" at 11:11AM. There was no documentation of a nursing assessment after chemical restraints were given. There was no documentation of patient behavior, effectiveness of the medication, or patient's physical status after the administration of the chemical restraint. There was no face to face, no documentation from the physician concerning the Haldol, and no documentation on the treatment plan for behaviors and medication administration. There was no found documentation of other alternatives attempted to help the patient to deescalate before the administration of a chemical restraint. There was no documentation that the physician or family was notified.

Review of Patient #2's chart revealed she was administered Haldol 1 mg IM Admin Date/Time: 9/11/2022 20:41(8:41 pm). Review of the IVIEW notes revealed the RN documented, "agitated" at 9/11/2022 20:40 (8:40 pm). The first vital signs documented after the medication administration were taken 9/12/2022 06:36, 10 hours later. There was no documentation of a nursing assessment after chemical restraints were given. There was no documentation of patient behavior, effectiveness of the medication, or patient's physical status after the administration of the chemical restraint. There was no face to face, no documentation from the physician concerning the Haldol, and no documentation on the treatment plan for behaviors and medication administration. There was no found documentation of other alternatives attempted to help the patient to deescalate before the administration of a chemical restraint. There was no documentation that the physician or family was notified.

Review of Patient #2's chart revealed she was administered Haldol 1 mg IM Admin Date/Time: 9/12/2022 20:14. There was no documentation of a nursing assessment after chemical restraints were given. There was no documentation of patient behavior, effectiveness of the medication, or patient's physical status after the administration of the chemical restraint. There was no face to face, no documentation from the physician concerning the Haldol, and no documentation on the treatment plan for behaviors and medication administration. There was no found documentation of other alternatives attempted to help the patient to deescalate before the administration of a chemical restraint. There was no documentation that the physician or family was notified.

A review of the facility policy titled, "Use of Restraints Policy #10" with a last review date of 8/25/2022 revealed that there was instruction for physical restraints, face to face, assessment of the patient in physical restraints, but there was no instruction found for assessments frequency and/or instruction for documentation in the policy and procedure.

An interview was conducted with Staff #4 on 9-19-22. Staff #4 stated that she was not aware that of the black box warnings for Haldol nor was she aware that there was no specific antidote, and supportive treatment (airway maintenance/metabolism) would be the mainstay of haloperidol toxicity. Staff #4 stated that the physicians had ordered the medications and the staff had not considered the medications as restraints until now.

According to /www.ncbi.nlm.nih.gov/books/NBK560892/revealed the following:
"HALDOL (haloperidol) Haloperidol is the first of the butyrophenone series of major antipsychotics that is indicated for use in the treatment of schizophrenia.

Box Warning
There is an increased risk of mortality (1.6 to 1.7 times) in elderly patients with dementia-related psychosis. In seventeen placebo-controlled controlled trials, patients using atypical antipsychotic drugs for 10-weeks, death was reported in 4.5% of patients for drug-treated patients compared to 2.6% in the placebo group. Hence haloperidol is not FDA-approved for the treatment of patients with dementia-related psychosis ... there is no specific antidote, supportive treatment is the mainstay of haloperidol toxicity.

HALDOL (haloperidol) should be administered cautiously to patients: with severe cardiovascular disorders, because of the possibility of transient hypotension and/or precipitation of anginal pain. Should hypotension occur and a vasopressor be required, epinephrine should not be used since HALDOL may block its vasopressor activity and paradoxical further lowering of the blood pressure may occur. Instead, metaraminol, phenylephrine or norepinephrine should be used. When HALDOL is used to control mania in cyclic disorders, there may be a rapid mood swing to depression.

Haloperidol is one of the most commonly used antipsychotics in this world. However, since the drug can cause several side effects and is related to several toxicities after initiation, the healthcare workers must be familiar with its pharmacology, signs, and symptoms of toxicity, and management of adverse effects. In addition, a proper history and physical examination are necessary before the initiation of haloperidol in any patient. Therefore, recommended course of action when prescribing haloperidol is as follows:
The clinicians (MD, PA, NP) prescribe haloperidol for appropriate indication.
Psychiatrists are responsible for the overall care of patients on haloperidol therapy.
Pharmacists should ensure proper dosing and report back to clinicians if there are potential drug interactions.
Specialty-trained nurses should review the medicine administration record to ensure there were no administration errors.
Emergency department physicians and triage nurses are the first to respond in case of acute haloperidol overdose.
Intensivist ensures proper ICU care and monitoring while in hospital.
Severe cases of haloperidol toxicity require the consultation of a medical toxicologist."




40989

Findings:

Patient #3

A review of the medication order dated 8/19/2022 at 8:54 PM by Staff #14 was as follows:
"Geodon (Psychotropic/Antipsychotic medication) 10mg Intramuscular (IM) q (every) 2 hrs PRN agitation"

A review of Patient #3's medical record with Staff #4 revealed the following:


8/19/2022
A review of the Medication Administration Record (MAR) dated 8/19/2022 revealed Patient #3 received an IM injection of 10 mg Geodon to Right Arm at 11:23 PM by Staff #24 for agitation.

A review of the RN nursing assessment documented by Staff #24 on 8/19/2022 at 7:45 PM revealed Patient #3 was alert, oriented to person, agitated, and impulsive.

Staff #4 confirmed Patient #3 had a nursing assessment by Staff #24 on 8/19/2022 at 7:45 PM and the next nursing assessment was documented on 8/20/2022 at 7:09 AM by Staff #32. This was greater than 7 hours after the chemical restraint was administered for agitation.

A review of the progress note dated 8/20/2022 at 12:00 AM by Staff #24 was as follows:
"Patient became very aggressive and combative with staff and roommate. She was yelling in roommates face and cursing. She was cursing at staff as well. She was impulsive and kept trying to leave the building. Doctor was notified and Geodon was ordered. It was given and patient calmed down and went to sleep."


8/22/2022
A review of the Medication Administration Record (MAR) dated 8/22/2022 revealed Patient #3 received an IM injection of 10 mg Geodon to left upper abdomen quad at 12:54 AM by Staff #26 for agitation.

A review of the nursing assessment documented by Staff #33 on 8/21/2022 at 10:42 PM revealed Patient #3 was alert, oriented to person, agitated, and impulsive.

Staff #4 confirmed Patient #3 had a nursing assessment documented by Staff #33 on 8/21/2022 at 10:42 PM and the next nursing assessment was documented on 8/22/2022 at 6:15 AM by Staff #34. This was greater than 5 hours after the chemical restraint was administered for agitation.


8/26/2022

A review of the Medication Administration Record (MAR) dated 8/26/2022 revealed Patient #3 received an IM injection of 10 mg Geodon to the left arm at 10:17 PM by Staff #24 for agitation.

A review of the nursing assessment documented by Staff #24 on 8/26/2022 at 7:00 PM revealed Patient #3 was alert, appropriate, calm, cooperative, and oriented to person.

Staff #4 confirmed Patient #3 had a nursing assessment documented by Staff #24 on 8/26/2022 at 7:00 PM and the next nursing assessment was documented on 8/27/2022 at 7:00 PM by Staff #35. This was greater than 20 hours after the chemical restraint was administered for agitation.




Patient #4

A review of the medication order dated 5/26/2022 at 1:15 AM by Staff #13 was as follows:

"Haloperidol (Haldol-Psychotropic/Antipsychotic medication) 1mg Intramuscular (IM) q (every) 4 hrs PRN agitation"

A review of Patient #4's medical record with Staff #4 revealed the following:

5/26/2022
A review of the Medication Administration Record (MAR) dated 5/26/2022 revealed Patient #4 received an IM (intramuscular) injection of 1mg Haldol to the left deltoid at 7:47 PM by Staff #17 for agitation. Further review of the MAR revealed Staff #17 documented at 8:45 PM the IM Haldol given for agitation was ineffective.

A review of the nursing assessment documented by Staff #17 on 5/26/2022 at 7:45 PM revealed Patient #4 was alert, oriented, agitated, and impulsive.

Staff #4 confirmed Patient #4 had a nursing assessment by Staff #17 on 5/26/2022 at 7:45 PM and the next RN assessment was completed on 5/27/2022 at 8:46 AM by Staff #18. This was greater than 13 hours after the chemical restraint was administered for agitation.

6/01/2022
A review of the Medication Administration Record (MAR) dated 6/1/2022 revealed Patient #4 received an IM injection of 1mg Haldol to the left arm at 3:54 PM by Staff #18 for agitation. Further review of the MAR revealed Staff #17 documented at 4:42 PM the IM Haldol given for agitation was effective.

A review of the nursing assessment by Staff #18 was documented on 6/1/2022 at 8:55 AM. The next nursing assessment was completed at 6:50 PM by Staff #20.

Staff #4 confirmed there was no RN assessment, progress note, or monitoring of the patient in the medical record after the chemical restraint was administered for greater than 9 hours.

6/08/2022
A review of the Medication Administration Record (MAR) dated 6/8/2022 revealed Patient #4 received an IM injection of 1mg Haldol to the left deltoid at 8:11 PM by Staff #21 for agitation. Further review of the MAR revealed Staff #21 documented at 8:41 PM the IM Haldol given for agitation was effective.

A review of the nursing assessment by Staff #21 was documented on 6/8/2022 at 8:10 PM. The next nursing assessment was documented on 6/09/2022 at 6:40 AM by Staff # 22.

Staff #4 confirmed there was no RN assessment, progress note, or monitoring of the patient in the medical record after the chemical restraint was administered for greater than 10 hours.

6/11/2022
A review of the Medication Administration Record (MAR) dated 6/11/2022 revealed Patient #4 received an IM injection of 1mg Haldol to the left deltoid at 11:30 PM by Staff #23 for agitation. Further review of the MAR revealed Staff #23 documented at 12:00 AM the IM Haldol given for agitation was effective.

A review of the nursing assessment by Staff #19 was documented on 6/11/2022 at 7:00 AM. The next nursing assessment was documented on 6/12/2022 at 7:00 AM by Staff # 19.

Staff #4 confirmed there was no RN assessment, progress note, or monitoring of the patient in the medical record after the chemical restraint was administered for greater than 7 hours.

A review of the nursing progress note by Staff #23 was as follows:

"6/11/2022 23:30 (11:30 PM) Patient was repeatedly getting out of bed. After several attempts to keep him in bed he was placed in a chair. He was yelling at staff and tried to not let the tech around and had her stuck between him and the beds. Placed patient in the chair. He would not stay in the chair kept undoing the seat belt. He was being aggressive with staff and was in danger of falling. Patient was given a PRN dose of Haldol. Patient calmed down after a while and was able to be placed back in bed."

6/14/2022
A review of the Medication Administration Record (MAR) dated 6/14/2022 revealed Patient #4 received an IM injection of 1mg Haldol to the right arm at 8:15 PM by Staff #24 for agitation. Further review of the MAR revealed Staff #24 documented at 8:45 PM the IM Haldol given for agitation was ineffective.

A review of the nursing assessment by Staff #24 was documented on 6/11/2022 at 7:00 PM. The next nursing assessment was documented on 6/15/2022 at 7:30 AM by Staff # 25.

Staff #4 confirmed there was no RN assessment, progress note, or monitoring of the patient in the medical record after the chemical restraint was administered for greater than 12 hours.

A review of the progress note by Staff #24 was as follows:

"6/15/2022 3:15 AM Patient became combative and aggressive. Started hitting staff and kicking other patients. Gave patient Haldol per order and called family. Son came and stayed with patient until he went to sleep."


An interview was conducted with Staff #4 on 9/19/2022 after 11:30 AM. Staff #4 was asked if the RN administering the IM injections were completing an assessment post injection. Staff #4 replied, "The techs, LVN's or themselves do patient rounding but, they do not complete a full assessment on the patient after the IM injection." Staff #4 confirmed patient rounding included patient position, Intakes and outputs, basic needs, and safety precautions in place at the time of the rounds.


A review of the facility policy titled, "Assessment, Re-assessment Policy #3" with a review date of 8/25/2022 was as follows:

" ...PURPOSE
To set guidelines for the assessment/re-assessment of patients across all disciplines.
...
POLICY
I. All patients admitted to the hospital will be assessed upon admission as described below
...
2. Nursing-RN assessment is initiated as soon as possible, but within the first 8 hours of admission. The assessment, including a functional assessment, is completed within 24 hours.
...

II. Reassessments are performed by each discipline according to the patient's vital signs, laboratory results, status or condition in accordance with the professional's scope of practice. RN's conduct daily reassessments of the patient's condition as documented in the medical record.
...

IV. Reassessment across all disciplines is ongoing and occurs at designated intervals during the patients stay/treatment to determine the response to and effectiveness of certain care, treatment, and services received.

V. Reassessment provides ongoing data about the patients biophysical, psychological, spiritual, and social needs.

VI. The scope and intensity of the reassessment are based on the patients diagnosis, care setting, and patients response to previous care.

VII. When there is significant change in the patients condition, a full reassessment is performed. Such as but not limited to:
There is change in the level of consciousness
Significant changes in vital signs or lab results
Functional level declines significantly
To determine response to a certain treatment
Patient/family requests reassessments
As ordered by a physician ..."


Staff #1, #4, and #16 confirmed the findings.

Based on review of record and interview, the facility failed to ensure that medications given IM (intramuscular) and used as behavioral restraints were not ordered PRN (as needed basis) in 7 (Patient #1, #2, #3, #4, #5, #6, and #10) of 8 patient records reviewed.


Findings:


Patient #1

A review of the medication orders written for Patient #1 was as follows:

1/22/2021 at 10:12 PM by Staff #11 Geodon (antipsychotic medication) 10mg IM q (every) 2 hours PRN agitation.
1/28/2021 at 7:24 PM by Staff #12 Geodon 10mg IM q 4 hours PRN agitation
2/2/2021 at 8:18 PM by Staff #12 Geodon 10mg IM q 2 hours PRN agitation
2/2/2021 at 8:20 PM by Staff #12 Geodon 20 mg IM q 4 hours PRN agitation


Patient #2

A review of the medication order written for Patient #2 was as follows:

9/10/2022 at 11:05 PM by Staff #13 Haloperidol (antipsychotic medication) 1mg IM q 2 hours PRN agitation



Patient #3

A review of the medication order written for Patient #3 was as follows:

8/19/2022 at 8:54 PM by Staff #14 Geodon 10mg IM q 2 hours PRN agitation



Patient #4

A review of the medication order written for Patient #4 was as follows:

5/26/2022 at 1:20 AM by Staff #13 Haloperidol 1mg IM q 4 hours PRN agitation


Patient #5

A review of the medication order written for Patient #5 was as follows:

Haloperidol 1mg IM q 2 hours PRN agitation written by Staff #13.


Patient #6

A review of the medication order written for Patient #6 was as follows:

6/16/2022 at 11:02 PM by Staff #13 Haloperidol 1mg IM q 2 hours PRN agitation



Patient #10

A review of the medication order written for Patient #10 was as follows:

Geodon 10mg IM q 4 hours PRN agitation written by Staff #11.




An interview with Staff #1 and Staff #4 on 9/13/2022 after 1:00 PM confirmed the medications Haloperidol and Geodon administered IM to Patients #1, #2, #3, #4, #5, #6, and #10 were administered due to a behavioral emergency and should have been documented and monitored as a chemical restraint.

A review of the facility policy titled, "Use of Restraint Policy #10" with a review date of 8/25/2022 was as follows:

" ...Content of Order/Renewal
Orders will contain the type of restraint, reason for the restraint, and time limitation for restraint. NO PRN or Standing restraint or trial release orders allowed ..."


Staff #1, #4 and Staff #5 confirmed these findings.

Based on document review and interview the facility failed to ensure a physician or qualified Registered Nurse (RN) completed a One Hour Face to Face on patients after a chemical restraint was administered in 5 (Patient #1, #2, #3, #4, and #6) of 5 patient records reviewed. The facility also failed to follow their own policy.

A review of medical records was conducted on 9/13/2022 and 9/19/2022 after 10:00 AM with Staff #4.


Findings:

Patient #1

Review of Patient #1's physician orders revealed she was ordered Geodon IM (a psychotropic/antipsychotic medication) 11 times for agitation. There was no written documentation found of a face to face performed by the physician or a trained RN within 1 hour of administration of the chemical restraint. Patient #1 was chemically restrained to treat a behavioral emergency on the following dates:

1/23/2021 at 12:22 AM Geodon 10mg IM to left deltoid by Staff #17 for agitation
1/25/2021 at 12:27 AM Geodon 10mg to right upper arm by Staff #20 for agitation
1/25/2021 at 8:33 PM Geodon 10mg IM to left upper arm by Staff #23 for agitation
1/28/2021 at 7:45 PM Geodon 10mg IM to right gluteus medius by Staff #31 for agitation
1/31/2021 at 3:10 PM Geodon 10mg IM to right arm by Staff #30 for agitation
2/1/2021 at 6:45 PM Geodon 10mg IM to right deltoid by Staff #29 for agitation
2/2/2021 at 6:53 PM Geodon 10mg IM to right arm by Staff #17 for agitation
2/2/2021 at 8:01 PM Geodon 10 mg IM to right deltoid by Staff #17
2/3/2021 at 9:59 AM Geodon 20mg IM to right deltoid by Staff #28 for agitation
2/3/2021 at 5:37 PM Geodon 20 mg IM to right deltoid by Staff #28 for agitation
2/5/2021 at 1:27 AM Geodon 20mg IM to left arm by Staff #27 for agitation

Patient #3

Review of Patient #3's physician orders revealed she was ordered Geodon IM (a psychotropic/antipsychotic medication) 3 times for agitation. There was no written documentation found of a face to face performed by the physician or a trained RN within 1 hour of administration of the chemical restraint. Patient #3 was chemically restrained to treat a behavioral emergency on the following dates:

8/19/2022 at 11:23 PM Geodon 10mg IM to right arm by Staff #24 for agitation
8/22/2022 at 2:54 AM Geodon 10mg IM to left upper abdomen quad by Staff #26 for agitation
8/26/2022 at 10:17 PM Geodon 10mg IM to left arm by Staff #24 for agitation


Patient #4

Review of Patient #4's physician orders revealed she was ordered Haldol IM (a psychotropic/antipsychotic medication) 5 times for agitation. There was no written documentation found of a face to face performed by the physician or a trained RN within 1 hour of administration of the chemical restraint. Patient #4 was chemically restrained to treat a behavioral emergency on the following dates:

5/26/2022 at 7:47 PM Haldol 1mg IM to left deltoid by Staff #17 for agitation
6/1/2022 at 3:54 PM Haldol 1mg IM to left arm by Staff #18 for agitation
6/8/2022 at 8:11 PM Haldol 1mg IM to left deltoid by Staff #21 for agitation
6/11/22022 at 11:30 PM Haldol 1mg IM to left upper arm by Staff #23 for agitation
6/14/2022 at 8:15 PM Haldol 1mg IM to right arm by Staff #25 for agitation



A review of the facility policy titled, "Use of Restraints Policy #10" with a last review date of 8/25/2022 was as follows:

" ...Guidelines
Violent/self-destructive
...
May be initiated by a RN with notification to LIP immediately
Within 1 hour a face to face evaluation will be conducted by the LIP (or specially trained RN with immediate notification of the LIP) ..."


During an interview with Staff #1 and Staff #3 on 9/13/2022 after 10:00 AM it was confirmed the facility does not have the physician or a Registered Nurse complete a Face to Face when a chemical restraint was administered to control a patients behavior. Staff #1 and #3 also confirmed there are no Registered Nurses qualified or trained to complete a One Hour Face to Face.

Staff #4 confirmed the facility does administer medications for behavioral emergencies but did not consider this to be a restraint. She also confirmed the facility policy did not address the proper assessments, evaluations, or treatment of a patient that was administered an IM injection for a behavioral emergency. Staff #4 also confirmed the facility did not maintain a log for chemical restraints.

Staff #1, #3, and #4 confirmed the findings.

Based on observation and interview the facility failed to maintain a clean and sanitary environment to mitigate the spread of infectious diseases and hospital acquired infections in 3 (Central Supply,Pharmacy, and Gym #2) of 3 areas observed.

An observation tour was conducted on 9/13/2022 at 9:45 AM with Staff #1, #2, #4, and #8.

Findings:

Central Supply
This room was used to store patient supplies and equipment. Upon entering the room multiple pieces of equipment were noted to be covered with plastic bags. Staff #6 confirmed that the plastic bags were placed on the equipment to identify the equipment had been cleaned and sanitized and was ready for patient use. On the far wall, furthest from the entry door, was a storage of 24 IV poles draped in plastic bags. The floor was heavily soiled with dirt, trash, dust, and cobwebs. The rows of metal shelving used to store patient supplies was heavily covered with dust and debris. On the bottom shelf of the storage racks, a dead bug, resembling a large roach was seen. On the metal shelving, throughout the room, there were blue bins used to separate and store patient supplies. The inside of the blue bins were dirty with trash and dust. The floor underneath the shelving was soiled with dirt, dust, and trash.

An interview was conducted with Staff #6 on 9/13/2022 at 10:30 AM. Staff #6 was asked if this room was used to store all supplies for the facility. Staff #6 confirmed this room was the central supply area where all orders were received, and some supplies were also stored in this room. Staff #6 was asked if the temperature and humidity was monitored in the Central Supply Room. Staff #6 stated, "I do not document the temperature and humidity in this room." Staff #3 stated the facility has a monitoring system that is done electronically and will alarm if the temperature is outside of range but, he was unsure if the Central Supply area was a room that was included in the monitoring program. Staff #8 said that there is a Plant Operations employee that is on call 24/7 and the facility could set the alert up so that this room would be included on the monitoring and alert system.

Staff #1, #3, #6, and #8 confirmed the findings.



32143

A tour was taken in the facility on 9-13-22 at 9:49AM with Staff #1, #4 and #36. The findings are as follows;

Pharmacy

Patient home medications were brought in from home and stored with other pharmacy supplies and personal belongings.

Cardboard shipping boxes were found sitting on the floor in the middle of the clean pharmacy. Staff #5 was unable to describe what part of the pharmacy was clean and where dirty area was located.


GYM #2
The refrigerator holding the cold packs was caked in ice and unable to be properly cleaned.

2 sets of crutches were found sitting on the floor in a corner of the room. The floor beneath was covered in cobwebs and dead bugs.

The floor parallel bars were found to be heavily soiled with dirt, dust and hair. The base was missing paint and the bars were rusted at the base.

Dead bugs were found lying underneath the windows and floors.

The weight equipment was heavily soiled on the bottom with dirt, dust, hair and paper debris. The handle bars were heavily soiled with dirt and grime.

A dishwasher was found in the occupational room kitchen. The equipment was not hooked up for use. It was for patients to retrain on household skills. The dishwasher was opened and it was full of dirty coffee cups and had spilled dried and wet coffee all in the washer.