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Based on observation, interview, and record review, the Governing Body failed to effectively discharge its oversight responsibilities in the total operation of the hospital.

The hospital failed to meet the requirements of the Conditions of Participation for : Patient Rights; Food & Dietetic Services; and Physical Environment.

Findings included:

Patient Rights:.

The facility failed to meet the requirements of the Condition of Participation for Patient Rights:

The facility failed to ensure :

a) the fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas;

b) seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A);

c) Prohibited items (Contraband) were not accessible to patients on 2 of 3 units (100 and 200 hallways);

d) patients' right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons.

e) patient's right to personal privacy as shown by the absence of bathroom door curtains and shower curtains ; and also during a Group Therapy session.

[Cross refer to Tags A-0143 and A-144]

Food & Dietetic Services:

The facility failed to meet the requirements of the Condition of Participation for Food & Dietetic Services:

a) The facility's walk-in freezer was not in a safe working order, allowing ice build-up on the freezer floor, shelves, and the food products and the facility did not secure foods stored outside the kitchen, placing patients at nutritional risk from degraded foods, and food borne illness from spoiled or tampered food products.

b) The kitchen's hot food production area had copious amounts of a black, fuzzy, substance attached to the overhead ceiling tiles and frames, placing patients at risk of cross-contamination and gastrointestinal illness from biological contaminants.

c) The facility's high temperature sanitizing dishware washer was not being monitored according to the manufacturer's instructions for adequate temperatures, placing patients at risk of food borne illness from uncleaned dishware.

d) The facility's kitchen had copious amounts of food debris and dust on the shelves and floors throughout the kitchen, and the exterior door had daylight gaps, providing and entrance for pests, placing patients at risk of food borne illness from environmental contaminates.

e) The facility's Registered Dietitian, did not provide individualized diet plans for persons on Therapeutic diets, placing patients at risk of inadequate nutritional intake and hypo/hyperglycemia.

[Cross refer: A0620, and A0621]

Physical Environment :

The facility failed to meet the requirements of the Condition of Participation for Physical Environment

a) The facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers [ refer to TAG A-701 ].

b) The facility failed to comply with Life Safety Code [ National Fire Protection Association] and the Texas Adminstrative Code related to fire protection.The facility failed to develop a current Life Safety Plan that included: clear identification of all smoke compartments and identification of all "fire-rated" walls.[ refer to TAG A-710 ].

c) The facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire [Refer to Tag A-0714]

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility to ensure fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas.

The facility failed to ensure seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A).

The facility failed to ensure prohibited items (Contraband) were on 2 of 3 units (100 and 200 hallways).

The facility failed to ensure the patients' right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons.

The facility failed ensure the patient's right to personal privacy as shown by the absence of bathroom door curtains and shower curtains.

The facility failed to ensure the patient's right to personal privacy during a Group Therapy session.

Refer to Tags A-0143 and A-144

Based on observation, interview, and record review, the facility failed to meet the conditions of participation for Dietary when,

o The facility's walk-in freezer was not in a safe working order, allowing ice build-up on the freezer floor, shelves, and the food products and the facility did not secure foods stored outside the kitchen, placing patients at nutritional risk from degraded foods, and food borne illness from spoiled or tampered food products.

o The kitchen's hot food production area had copious amounts of a black, fuzzy, substance attached to the overhead ceiling tiles and frames, placing patients at risk of cross-contamination and gastrointestinal illness from biological contaminants.

o The facility's high temperature sanitizing dishware washer was not being monitored according to the manufacturer's instructions for adequate temperatures, placing patients at risk of food borne illness from uncleaned dishware.

o The facility's kitchen had copious amounts of food debris and dust on the shelves and floors throughout the kitchen, and the exterior door had daylight gaps, providing and entrance for pests, placing patients at risk of food borne illness from environmental contaminates.

o The facility's Registered Dietitian, did not provide individualized diet plans for persons on Theraputic diets, placing patients at risk of inadequate nutritional intake and hypo/hyperglycemia.

Cross refer: A0620, and A0621

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Physical Environment. This failure had the potential to affect all patients receiving services in the hospital ; and staff and visitors.

a) The facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers [ refer to TAG A-701 ].

b) The facility failed to comply with Life Safety Code [ National Fire Protection Association (NFPA] and the Texas Admintsratve Code related to fire protection. The facility failed to develop a current Life Safety Plan that included: clear identification of all smoke compartments and identification of all "fire-rated" walls. [ refer to TAG A-710 ].

c) The facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire. [Refer to Tag A-0714]

Based on observation, interview, and reccord review, the facility failed to:

1. Ensure the patient's right to personal privacy as shown by the absence of bathroom door curtains and shower curtains in 6 of 33 patient rooms (Rooms 111, 117, 120, 213, 216 &316) affecting 11 patients (Patient #'s 16, 21, 23, 27, 32, 33, 34, 35, 36, 37 & 38);

2. Ensure the patient's right to personal privacy during a Group Therapy session, as shown by the Group therapist asking personal, private psychiatric questions to 8 of 8 patients in the presence of other group members.

Findings included:

1. Lack of privacy curtains:

Review of facility policy titled "Daily Room Cleaning", #VIC.1.15 effective 8/1/22, showed that the Environmental Services technician will inspect the privacy curtains in the patient bathrooms and replace them if damaged, clean them when soiled, replace them if unable to clean and/or replace them every 6 months.

Observation on 5/7/24 at 9:15 am-11:00 am of facility's 200 and 300 units showed the following: Rooms 213, 216, and 316 did not have bathroom door curtains for patient privacy. Room 310 did not have a shower door curtain for patient privacy and comfort.

Further observation revealed that it was possible for others to visualize a patient inside their bathroom when walking in the unit hallways as well as while walking inside the patient room.

In an interview at the time of findings, Corporate Clinical Director-Staff #F, who was present during observation, acknowledged that the curtains were missing and should have been present in these rooms.

Observation the following day on 5/8/24 at 9:30 am of facility's 100 unit showed that Room 112 did not have a bathroom door curtain for privacy.

In an interview on 5/8/24 at 9:35 am, Patient #32, who was housed in Room 112, stated she had been in the facility since 5/3/24 and never had a bathroom curtain. She also stated that she had asked "the people at the desk" (staff at the unit's nursing station) to please provide a curtain door, but they had not done so yet. Patient #32 then stated that whenever she used the toilet, she would move her roommate's wheelchair to barricade the room's main entrance door because she was embarrassed that people saw her on her toilet while walking in the hallway. She also stated that she had been embarrassed that her roommate could see her too but did not know what to do to prevent this.

In an interview immediately after the patient interview, Regional Corporate Clinical Director-Staff #G, who was present in the unit hallway, acknowledged there was no curtain and was asked to please provide this for the two patients in Room 112.

Further observation of unit 100 showed there were no shower curtains present in Rooms 111 and 129.

*Note: this same issue was previously cited during a survey on 10/10/23-10/11/23.

2. Group Therapy confidentiality:


Review of facility policy titled "Privacy & Security", # VIM.1.01, effective 8/1/22 showed that the policy of Voyages Behavioral Health is to protect the privacy of patient information.

In addition, review of facility policy titled "Patient Rights", #VR1.1.01, effective 8/1/22, showed that the facility shall respect, protect and follow the Patient Bill of Rights outlined in 25 TAC 404.154, which includes treatment in an environment that ensures the protection of privacy.

Observation of a Group Therapy session on 5/8/24 at 9:50 am on facility's unit 100 led by SW-Staff #GG revealed the following: There were 8 patients present sitting in the unit's 'quiet room', which was used for the therapy session that day, called a Process Group. The patients were all sitting in a semi-circle and all were participating.

During the session, Staff #GG was holding and filling out 8 pages of paper; one for each patient, asking patients questions one at a time in front of the entire group.

Many of these questions consisted of personal and confidential health information, including "Are you suicidal today? If yes, how much on a scale of 1-10?" Also, "Are you depressed today? If so, how much on a scale of 1-10?" Another question was "Are you anxious today? If so, how much on a scale of 1-10?"

Review of clinical records for the patients who had participated in the Group Therapy session showed most patients had history of depression, anxiety, and/or suicidal ideation.

Based on observation, interview, and record review, the facility failed to provide an environment that protected patients, staff and the public from harm (safe setting) by:

a) Failing to ensure fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas.
b) Failing to ensure seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A).
c) Failing to ensure prohibited items (Contraband) were on 2 of 3 units (100 and 200 hallways)

Findings included:

a) Fire Safety Plan

Observation on the 300 Hallway on 5/7/2024 at 1:45 PM showed the far end exit doors to be locked.

Interview with DON (D) at the time of observation when asked if the door become demagnetized and unlocked during activation of the fire alarm, she stated "yes." She was asked if this was just specific to the hallway where the alarm was activated or do all doors become demagnetized/unlocked and she stated that the are all connected and all will unlock throughout the facility.

Record review of facility document title" Fire Safety Management Plan," dated 1/2/22 showed the following information:

I. Scope.

The Fire Safety Management Plan describes the methods for minimizing the potential for a fire through the use of building systems, equipment, and training. The fire safety management plan is designed to assure appropriate, effective response to fire emergency situations that could affect the safety of patients, staff, and visitors, or the environment, and protect building occupants from fire and the products of combustion. The plan is also designed to assure compliance with applicable codes and regulations, as applied to the buildings and services provided.

The Fire Safety Management Plan does not address the safety measures to protect patients, staff or public during the demagnetization/unlocking of doors within the facility or exit doors to exterior unsecure areas.

b.) Seclusion Room Door

Observation on 5/7/2024 at 12:30 pm the survey team entered seclusion room B via facility provided security badge. Once inside the seclusion door closed behind the surveyors. Upon attempting to exit the seclusion room via the same badge access, the badge reader did not work allowing exit. Upon calling administration to have someone come let us out, the DON arrived and opened the door. In attempt to reenact to demonstrate what had happened, the door then did not close and latch automatically two times without being manually pushed to engage latching mechanism.

Interview with DON (D) at the time of observation confirmed the findings and acknowledged that the door and badge reader was not working correctly.


c.) Contraband

Record review of facility policy titled "Contraband and restricted Articles," dated 8/1/22 showed the following information:

POLICY

Contraband is prohibited in order to protect the therapeutic milieu of the hospital and to clearly establish for patients the behavioral requirements of their continued treatment.

PROCEDURE

Contraband is any item that is deemed a potential threat to client, staff, and visitor safety and/or privacy, or is illegal. Examples include drugs, unidentified substance or powder, liquids containing alcohol, knives, guns, mirrors, jewelry with sharp edges, mobile telephones, clothing items such as belts or shoelaces, or metal objects designed as weapons or potential weapons.

Patients are informed in writing on admission that the use or possession of contraband is not allowed. Contraband is removed when identified by staff.

Observation on 5/7/ 24 at 1:00 PM and again on 5/8/24 at 10:30 am on the 100 and 200 hallways, in the day rooms, Styrofoam cups with plastic bag sheaths were observed.

Interview with staff RN (W) on 5/8/2024 at 11:30 AM acknowledged that the plastic bag sheaths should not be allowed on the unit and could cause harm to patients.


38015

Based on observation, interview, and record review, the facility failed to ensure the patients' right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons.

Findings included:

Review of facility policy titled "Patient Rights", #VR1.1.01, effective 8/1/22, showed that the facility shall respect, protect and follow the Patient Bill of Rights outlined in 25 TAC 404.154, which included treatment in a safe environment that ensured protection from harm.

Observation on 5/7/24 at 9:30 am of facility's outside patient courtyard showed the presence of 11 solid plastic chairs for patient use. These chairs, which were all identical, were able to be lifted by the average person and had the potential to cause injury to patients if used in physical altercations.

In an interview at the time of findings, Corporate Clinical Director-Staff #F who was present during observation, acknowledged that the chairs could be used to hurt others if thrown or swung, and were not weighted-down as they should be in psychiatric facilities.

Observation on 5/8/24 at 9:35 am revealed there were 7 more of these same plastic chairs for patient use, located in another courtyard outside the facility cafeteria.

Based on observation, interview, and record review, the facility :

Failed to initiate several important first-steps of an investigation related to a recent serious "near-miss" event. Patient # 13 obtained a fire extinguisher and sprayed several staff with fire extinguisher expellent; then pulled a fire alarm on the nursing unit. He was then able to exit through 2 sets of double doors into the front hospital lobby before he was detained.

-None of the hospital leadership or Director of Plant Operations had viewed the camera surveillance of the incident or begun interviews with staff present during the incident.

On Day 1 of survey, 5/07/2024 , the cabinet of the fire extinguisher used in the near-miss incident was observed unlocked and accessible to all patients.

Findings Included:

Record review of facility policy titled "Incident Reports," dated 8/01/2022, showed the process for completing incident reports, as well as established timeframes for reporting. Incident reports must include: a brief description of event, any witnesses to the event, and notifications to hospital leadership.

Incident investigation includes the following steps:

1. secure and review all available surveillance video of footage of the incident and leading up the incident.
2. Review medical record for information pertaining to the incident..
3. Interview staff members, patients, and witnesses ,as applicable.
4. Report investigatory findings to immediately to CEO.

The facility policy on Incident Reports did not include a timeframe for the completion of the investigation.

Joint Commission (JC) definition of a "near- miss" is "any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome." [This facility is accredited by JC.]

~~~~~~~~~~~~~~~~~~~~~~
Record review of the medical record of Patient # 13 showed the following:

Nursing progress note dated 5/4/2024 (6:18 PM) read :"patient heard shouting and agitated to have the phone to make calls while another patient was using the phone. He was advised to wait for the other patient to finish making the call but he refused. He became infuriated, all attempts for de-escalation failed. Patient broke out through the door into the nursing station threatening to hurt the staff and overpowering everybody. The patient activated the fire alarm system which was going off. He grabbed the fire extinguisher the entrance of the 100 hall and started spraying it at the faces of all the staff and all over the nursing station. The patient went trough the main entrance . Dr- II was informed and emergency medication was ordered... and given in the presence of the police officers. Seclusion order was made and patient placed in seclusion."

Observation by two surveyors in the Nursing Station area on 05/07/2024 at 11:45 AM, showed the fire extinguisher cabinet outside the 100 hallway was unlocked. The fire extinguisher was accessible to the Life Safely surveyor on-site who opened the cabinet and acessible to all of the current patients. It is unknown how long this fire extinguisher cabinet had been unlocked.

Interview : Staff -E, Director of Plant Operations (DPO)

During an interview on 05/09/2024 at 1:20 PM with Staff E, DPO, he was asked if he was aware of an incident that occurred on Saturday, 5/4/2024. He said between 6 and 8 PM that evening he got a call that a patient had gotten ahold of a fire extinguisher and pulled the fire alarm. Staff -E called the fire alarm company to notify it was a false alarm. He called his environmental staff to clean up the unit as the patient had sprayed the fire extinguisher all around the unit. Staff-E said he was was responsible for the surveillance camera footage. Staff -E said he had not viewed the footage from that night.

Surveyor and Staff E review of the camera footage for 5/4/2024 from 5:15 PM to 5:48 PM [timestamps on video monitor] showed the following (not all inclusive) :

Between video timestamps of 5:33 PM and 5:46 PM, the following was observed :
- Patient # 13 exited the 300 hallway doors and began walking around the area in front of the nursing station.

- the patient opened the fire extinguisher cabinet outside the 100 hallway and obtained the extinguisher. He continued walking around, appeared to be attempting to operate the fire extinguisher. Several staff were seen following him, at a distance.

- ( 5:37 PM) patient began spraying the extinguisher directly at several staff members and all around the nursing unit. The video showed a dense "greenish" fog. Some staff were observed to have masks on; some not.

- ( 5:39 PM) Patient # 13 rounded the corner by the nursing unit and pulled the fire alarm; strobe lights were visible in the video through the fog.

- patient walked past the cafeteria to the left and walked down the hall. He was seen trying to open the first set of double-doors out of the unit. He turned around and walked back toward the nursing station.

- patient is seen again near the cafeteria doors; he began walking very rapidly down the hall. He was seen exiting through the first set of double doors (right side). He quickly moved toward the 2nd set of double- doors and was seen exiting these doors and into the main lobby of the hospital. Camera review of lobby area showed he did not make it through the front door exit to the outside.

During continued interview with Staff -E, he said any time the fire alarm was pulled, all of the exit doors in the hospital were de-magnetized. He said he was always reminding staff of this safety issue. He was unsure if this was officially in the fire plan or staff training. Staff-E acknowledged that Patient #13 could have completely exited the building through the main doors had he not been stopped.

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Interview with Staff-A, Chief Executive Officer (CEO)

During an interview on 05/09/2024 at 2:15 PM with Staff A, CEO, he said he first got a report on Saturday (5/4/2024) that a patient had grabbed a fire extinguisher and sprayed the staff. He had not watched the video yet. The CEO was unsure if the exterior hall exits on the 3 patient units were covered by staff when the doors became de-magnetized during the fire alarm activation. The CEO said he knew that Staff -P, Chief Nursing Officer (CNO ) had started looking into this incident.

Interview with with Staff-D, CNO:

During a telephone interview on 05/09/2024 at 2:35 PM with Staff D, CNO, she stated she had made some notes; started notes on timestamps (video).

The CNO had not viewed the entire video as yet. She said that maintenance had contacted the locksmith company to come out and inspect / repair the magnetic lock on the 300 hallway.

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Record review of facility incident report , dated 5/4/2024 ( incident time 6:30 PM) , showed the description of the incident was consistent with the nursing progress note at time of incident. [The only discrepancy noted was the review of the video showed the patient sprayed the fire extinguisher before he pulled the fire alarm.]

Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) was physically on the unit available to provide patient care at all times in 1 of 3 patient care units (100 Hallway).

Findings include:

Record review of facility's 2024 Nurse staffing plan showed the following information:

The nursing services department have voyages behavioral health hospital of Sugarland supports the provision of patient care in a safe, cost-effective manner by appropriately using qualified and skilled personnel. The staffing plan is determined by the budgetary process based on historical data; projections for future program development and expansion; analysis of clinical practice patterns; and staff input into the needs of patients, unit, and staff.
The hospital shall adopt, implement, and enforce a written staffing plan as outlined Texas Administrative Code Title 25, Part 1, Chapter 133, Subchapter C, Rule 133.4 (o) ...
*Licensed Nurse-physically present on each hallway 24/7.

Observation and interview on May 8, 2024, at 11:09 am staff nurse (S) was seen exiting the 100 Hallway unit. 8 patients were in the day room attending group, the remaining patients were in other areas of the hallway or in their rooms. Surveyors unsuccessfully tried to identify another RN on the unit. At 11:14 am the Director of Nursing (D) arrived on the unit. She was asked at that time who the RNs assigned to the unit were and if she was aware that there was no RN currently on the unit. She stated that she was not aware they were not on the unit. She went on to say that a nurse is supposed to be on the unit at all times.

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the care of 2 of 2 sampled patients (Patients # 9, 31):

-Two (2) patients were not placed on assault precautions following a significant patient to patient altercation (Patients # 9, 31)

- One (1) patient failed to have multiple "patient observation forms" completed (Patient # 31).

Findings included:

a) Failure to place patients on assault precautions following a patient/patient assault:

Record review of facility policy titled "Patient Safety Peculations," dated 8/01/2022, showed: To promotes a safe environment and decrease the possibility of harm, facility precaution levels include: homicide/assault (not all inclusive). Precautions are documented in the observation record with on-going assessments necessary during hospitalization. RN may initiate precautions; however a physician must be notified and write an order for the precaution.

Record review was conducted with Staff -W, RN on 5/9/2024 at 11:45 AM. Review of Patient # 9''s clinical record record showed a NP progress note, dated 1/30/2024 that showed: " Patient got into a physical altercation with another patient overnight... Patient stated another patient jumped her and clawed her face..." The other patient was identified in the record as Patient # 31.

Continued review of Patients' # 9 and 31 medical records failed to show that either patient had been placed on assault precautions following the altercation.

During an interview at the time of review, Staff-W said all patients are required to be placed on assault precautions following a physical altercation. It is nursing responsibility to inform the provider and obtain the order.

b) Incomplete patient observation forms:

Record review of facility policy titled "Patient Observation," dated 8/01/2022, showed: Policy: to establish levels of observation and monitoring that provides a safe patient environment and decrease the possibility of harm to self or others All patients will be monitored via time intervals as identified though assessments and presenting behaviors. Levels of observation will be ordered by the patent's practitioner and implemented by nursing staff with subsequent documentation.

Review of Patient #31's "Patient Observation Forms" with Staff -W, RN showed:

a) no observation levels or precautions documented : January 20, 21, 23 , 24

b) no dates , no observation levels, or precautions were documented : 6 shifts .

The above information was verified by Staff-W, RN who said the forms should be documented completely. It is nursing responsibiliy to provide oversight of Mental HealthTech's (MHT) documented work .

Based on observation, interview, and record review, the facility failed to provide an organized Dietary Service when the Director of Food Service did not establish, maintain, supervise work performance, and ensure appropriate Policy and Procedures were available for the Dietary Services.

- Unsecured chemicals were being stored in the facility's main dining room which is not kept locked and the locking kitchen door was observed propped open, allowing access into the kitchen where knives are stored.
- The kitchen's SDS (Safety Data Sheet) manual did not include items used in the department.
- The kitchen floors, shelving, and equipment had food debris on its surfaces and a mold like substance was noted on the ceiling tiles and vents above the food production areas.
- The facility's dish washer was not being monitored to ensure an appropriate high temperature was reached to verify items being washed had been sanitized.
- The exterior kitchen door had several gaps where daylight shone through, enabling pests access to the kitchen.
- An unattended dirty mop was sitting in a bucket of gray water, creating an environment for bacterial growth.
- The facility's walk-in freezer had three different temperature gauges showing three different temperatures with a large variance; one exterior temperature read 0 degrees Fahrenheit and an interior thermometer showed the walk-in freezer was at 40 degrees Fahrenheit, and there was water dripping from the ceiling onto the food product and floor. The food had been thawing, freezing, and thawing, and freezing.
- The temporary freezer truck, located outside the facility, was observed to be unlocked, and accessible to anyone wanting to tamper with the food items.

These failures places all patients receiving meals at the facility, at risk of gastrointestinal pain, diarrhea, and possible death from cross-contamination from, environmental, bacterial, and chemical contaminates.

Findings include:

Observations made on the morning of 05/07/24, while accompanied by Staff #H, Director of Food Service, revealed the entrance door to the patient dining room was not locked. When asked why it is not secured, Staff #H stated, "The administration decided to leave them unlocked, there is no way for the patients to get into the kitchen and there isn't anything out here that can hurt them."

Further observation on 05/07/24, of the dining room revealed, a bottle of Ecolab Lime-away (used to remove calcium build-up), Pine Sol disinfectant, and Awesome Window cleaner located under the hand sinks located behind the hot food tables. Staff #H removed the chemicals.

Review of the facility provided "SDS"Safety Data Sheet, used to identify and instructions for use and safety risks, for all chemicals used in the departments, revealed the facility did have a SDS for the Lime-A-Way or the Pine Sol disinfectant.

Review of the facility provided material safety data sheet reflected the following:
Lime-A-way: Potential Health Effects
Eyes : Causes serious eye damage.
Skin : Causes severe skin burns.
Ingestion: Causes digestive tract burns.
Inhalation: May cause nose, throat, and lung irritation.



An observation on the morning of 05/08/24, in the facility's dining room, revealed approximately 25 patients and family in the dining room, the facility's locking kitchen door was propped open with a door jam. The surveyor was able to enter the kitchen without intervention; there was no one watching the door.

An observation, on 05/07/24, inside the facility's kitchen revealed, copious amounts of food debris, dust, unidentified debris, a dirty food apron on the kitchen's floor, and shelves. (3) Three food baking sheets had a greasy feel and had baked on food residue, a large plastic bin had multiple green/brown fuzzy debris on the exposed bottom and on the sink pipes in the clean dish storage area. The food exhaust hood, directly above the stove top, had signs of where a dark liquid had dripped, pooled, and dried. The exhaust hood had condensed water, which was running down the inside, down to the stove, where food was on the burners. The steamtable, (where the hot food is held for service) had two wells with dirty water and food debris from the previous meal.

An observation on 05/07/24, of the facility's walk-in freezer at 10:01 am revealed an outside thermometer temperature of 0 degrees. The internal freezer revealed a temperature of 42 degrees Fahrenheit. An observation of the facility's walk-in freezer at 2:21 pm revealed an outside thermometer temperature of -1.2 degrees Fahrenheit, the facility provided, infrared thermometer reading revealed 13.9 degrees Fahrenheit. Staff #HH, Regional Facilities Manager, operated the infrared thermometer and confirmed the differing temperatures.

An observation, on the morning of 05/07/24, in the kitchen's dishwashing room, revealed an automatic dishwasher. A sanitizing solution record log was located on the wall next to the dish machine. The days 1 through 5 had been marked through, with the note, "was instructed by my corporate person to add this temp log back." The sanitation log did not reflect any dishwashing temperatures had been recorded on the record. The facility was unable to provide the temperature logs for the dish machine.

During an interview, on the morning of 05/07/24, in the kitchen's dishwashing room, when asked if the dish machine was a chemical or high temperature sanitizing machine, Staff #H stated, "It's a chemical sanitizer,"

Review of the facility provided manufacturers operation manual, and the dish machine's manufacturer installed date plate reflected it was a DynaStar®VER, Door-type machine; electrically heated, high-temp, hot-water sanitizing, with booster heater and VER heat recovery system. The instruction manual reflected the following instructions,
"Water temperature is an important factor in ensuring the machine functions properly. The machine's data plate details what the minimum temperatures must be for the incoming water supply, the wash tank, and the rinse tank. If minimum requirements are not met, it's possible that dishes will not be clean or sanitized. Instruct operators to observe the required temperatures and to report when they fall below the minimum allowed. A loss of temperature can indicate a larger problem."

The surveyor requested all work orders placed for the facility's walk-in freezer; the facility provided the
following outside contractor, walk-in freezer repairs, not the Facility's requisition log:

8/4/23, WIF (Walk-in freezer) is not maintaining temp, temp is staying at 32°. Located in the kitchen. Brand: US Cooler Found both evaporator fan motors shorted out. Went to supply house picked up 2 motors. Replaced both motors."

2/27/24, "Called about the walk-in freezer in the kitchen is icing up and not going into defrost and the display on the evap (evaporator) is not coming on (not displayed) and the heat strip around the door is not hot. Evaporators#E202101001. Found Emerson temperature controller is shorted out. Found water inside control box. Checked incoming power for controller getting 208v. Also found door heater has a short. Right side door frame has ice buildup and left side."

3/5/24: Went to kitchen and removed temperature controller and replaced with new temperature controller. Wired in and ran probe. Adjusted set point to -5. Controller checked out ok. Shut off power and removed door trim, heaters, and gasket. Ran new heater around door frame. Wired it into lights for box. Also installed new door gasket. The door trims and defrost timer didn't use. Timer is still good. Also spoke with Staff #E, Director of Plant Operations about his door closure, wasn't closing door all the way. He will have to wait to fix that. Freezer box coming down to temp ok.

During an interview on the morning of 05//9/24, Staff #A, CEO (Chief Executive Officer) stated the facility was aware the freezer required multiple repairs. The CEO ordered a freezer truck to be placed next to the kitchen for use until the walk-in freezer could be fixed.

An observation, on the morning of 05/09/24, revealed the temporary freezer truck had three doors to access the food truck, all three door had locks that were in the open position. The freezer truck was parked behind the kitchen and is not within view of the dietary staffs. Staff #HH, was informed, and stated, "Those are not our locks, we didn't close them because we don't have the keys.

Based on record review, and interview, the facility's dietitian failed to ensure the nutritional needs of 2 out of 4 patients requiring a theraputic diet when the facility's menus required a specialized menu but did not recieve one, this failure places any patient being admitted on a specialized diet at risk of malnutrition, worsening cardiac disease, and hypo/hyperglycemia. (Patients #24, and #25)

Findings include:

Review of Patient #24's diet order listing for 05/08/24 revealed Regular, Note: Diabetic diet.
Review of Patient #25's diet order listing for 05/08/24 reflected, Cardiac Diet.

Review of the facility provided eat right Nutrition Care Manual, (dated 12/22/22) reflected, "Consistent Carbohydrate Diet
Definition: A consistent carbohydrate diet provides the same amount of total carbohydrate daily,
distributed evenly across all meals and snacks. A consistent amount of carbohydrate at each daily
meal is the goal. The exact amount and type of carbohydrate served is individualized by the
registered dietitian nutritionist (RDN).

Indication: A consistent carbohydrate diet is indicated for individuals diagnosed with diabetes, prediabetes, or obesity. This diet may also be ordered to accommodate those who choose to follow a controlled or lower-carbohydrate meal pattern or for people who experience temporary elevated blood glucose levels related to acute medical conditions.

Heart-Healthy (Cardiac) Diet
Definition: The heart -healthy diet limits the amount of saturated fat (5% to 6% of total energy),
cholesterol (<200 mg per day), and sodium (2000-3000 mg per day) and encourages foods containing unsaturated fats and unprocessed foods low in added sugars (AHA, 2021; EAL, 2017,Jacobson, 2015).
The registered dietitian nutritionist (RDN) should individualize the sodium intake (EAL, 2017).
Foods with trans fats are eliminated or limited as much as possible (USDA, 2020).
A heart-healthy diet encourages vegetables, fruits, legumes, nuts, whole grains, low-fat or fat-free dairy, and fish (Lichtenstein, 2021; Arnett, 2019; Jacobson, 2015). A heart-healthy diet includes 22- 38 g total fiber per day and 5-10 g viscous fiber per day (USDA, 2020; Jacobson, 2015).

Indication: The heart-healthy diet is indicated for individuals with cardiovascular disease such
as coronary artery disease, coronary artery bypass graft, myocardial infarction, stroke,
dyslipidemia, and heart failure. This diet should be individualized by the RDN."

During a telephone interview, on the afternoon of 05/08/24, when asked if patients with Constant Carbohydrate and Cardiac diets had an individualized diet plan, Staff #L, RDN, stated in part, No, Staff #H was to be coordinating the menus with the company that provides the menus."

Based on observation and interview, the facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers (Rooms 109, 111, 112, 114, 115, 118, 214, 216, 218, 309, 312, 316, 314, 317 and 319).

Findings included:

Review of facility policy titled "Daily Room Cleaning", #VIC.1.15 effective 8/1/22, showed that after a housekeeper is done cleaning the patient's room, they will note any damage and report it to the Director of Plant Operations.

Observation on 5/7/24 at 9:15 am-11:00 am of facility's 200 and 300 units' patient showers showed the following: Rooms 214, 216, 218, 309, 312, 316, 314, 317 and 319 all had varying degrees of paint peeling and chipping on the walls of the showers, along with numerous holes in the sheetrock. Most of the showers also had the presence of air pockets under the paint on the sheetrock walls which protruded out and were saturated with water, allowing the paint to be easily peeled away. The dried areas of the paint that were peeling could easily be further peeled away from the walls as well as from the numerous holes in the sheetrock. The largest hole observed was in room 312 and was approximately 8" x 6".

These findings posed safety hazards for patients who might engage in self-harm by swallowing the paint, and, were also infection control issues due to mold and bacteria accumulation. In addition, they were unsightly and undignified for patients housed in these rooms.

In an interview at the time of findings, Corporate Clinical Director-Staff #F, who was present during observation, acknowledged that the showers had paint peeling and numerous holes in the walls and should not have been present.

Observation the following day on 5/8/24 at 9:30 am of facility's 100 unit showed that Rooms 109, 111, 112, 114, 115 and 118 had the same issues as the 200 and 300 units; all had varying degrees of paint peeling and chipping on the walls of the showers along with numerous holes in the sheetrock.

Based on observation, interview and record review , the facility failed to comply with Life Safety Code [ National Fire Protection Association (NFPA) Codes and the Texas Adminstrative Code {TAC] related to fire protection. The facility failed to develop a current Life Safety Plan that included:

a. identification of all smoke compartments;

b. identification of all "fire-rated" walls and barriers .

Findings included :

Record review of NFPA Codes showed :

NFPA 5000, Building Construction and Safety Code (2024):

Wall Marking and Identification. For other than existing assemblies, where there is an accessible concealed floor, floor/ceiling, or attic space, fire walls, fire barriers, smoke barriers, and smoke partitions shall be permanently identified with signs or stenciling in the concealed space and shall comply with all of the following: (1) Be located in accessible concealed floor, floor/ceiling, or attic spaces (2) Be located within 15 ft (4572 mm) of the end of each wall and at intervals not exceeding 30 ft (9144 mm) measured horizontally along the wall or partition (3) Include lettering not less than 3 in. (76 mm) in height with a minimum 3 ?8 in. (9.5 mm) stroke in a contrasting color (4) Identify the wall type and its fire resistive rating as applicable

NFPA 101 [ 2003, 8.3.5.1] :

a ) Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

Review of TAC 133.162 [Physical Plant & Constriction Reqquiments] showed:

§133.162(d)(1)(A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter.
_____________

Review of facility policy titled : "Fire Safety Management Plan," dated 1/02/2022, showed : "The hospital is maintained in compliancee with Life Safety Code ( NFPA 101, 2012 edition)."

Review of facility's current LIfe Safety (LS) Plan, dated 5/27/2020 showed the required LEGENDS: colored line markings for smoke partitons; 1 hour smoke barriers; 1 hour fire barriers ; 1 hour bearing walls.
_______

Observations made on 5/072024 by Life Safety surveyor, accompanied by Staff-E, Director of Plant Operations (DPO), showed :

None of the 1 hr. smoke barrier and 1hr. fire barrier walls as indicated on Life Safety Plans were stenciled on site. It was very difficult to track the delineation of the noted smoke compartments and plan noted rated walls. Per NFPA, it is expected for the facility to track and stencil the smoke compartment walls as well as all other rated walls in the facility. While performing this task, seal and caulk any wall penetrations that are non-compliant.

During an interview with Life Safety Surveyor on 5/7/2024 at 2 PM, he stated he was unable to verify the facility's current Life Safety Plan; this included smoke compartments and ratings of fire-walls and barriers.

These findings were discussed with Staff-A, CEO during the exit conference held on 5/10/2023

Based on record review and interview, the facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire.

The current fire evacuation plan is based upon a Life Safety Plan that was not accurate / verifiable during survey ( refer to TAG- A-0710 ).

Findings included:

Review of facility policy tilted "Fire Evacuation," dated 8/1/2022, showed:

4 "....The hospital is designed to confine fire / smoke within various areas in order to reduce the need for immediate evacuation of the entire hospital because of fire and / or smoke.

5. Fire/smoke barriers wish 1 hour fire resistive construction are provided at no more than 150 foot intervals and can be identified in the fire safety drawings....".

~~~~~~~~~~~

During an interview on 5/7/2024 at 2 PM, with Life Safety Surveyor on-site, he stated he was unable to verify smoke compartments and ratings of fire-walls as indicated on the facility Life Safety Plan architectural drawings. He went on to say that a facility's evacuation plan is based upon the Life Safety Plan drawings.

(Cross refer : TAG A-0710)

Based on observation, interview, and record review the facility failed to provide a sanitary environment to avoid sources and transmission for infections and communicable diseases in 1 of 3 seclusion rooms (A).

Findings include:

Observation on 5/7/24 at 12:12 pm in seclusion room A showed brown blood-like smear from unknown source on the door.

Review of facility policy titles "Housekeeping Cleaning Procedure," dated 8/1/22 showed the following:

PRUPOSE AND SCOPE
The housekeeping department shall provide the facility with safe and sanitary cleaning services in the interest of promoting an effective infection prevention program.

POLICY
Sanitation within the hospital environment depends upon cleaning thoroughness and frequency. There are procedures for cleaning walls, floors, windows, beds, furniture, draperies, carpet, waste containers, bathrooms, equipment, and other non-patient care areas.

5. Seclusion Rooms
a. Wipe and sanitize daily-or as needed due to patient use.
b. Dust and wet mop: floor.

Observation on 5/7/24 at 12:04 pm in seclusion room A showed large amounts of a black "splotchy " substance noted on the ceiling on all four sides of a sky light opening. The black splotchy areas looked to be mold. In addition, there were multiple drops of moisture noted on the air vent and ceiling; some water was observed on floor directly under the vent.

Interview with CNO (D) at the time of observations, acknowledged the above findings.

Both were cited previously on 7/24/23.

Based on a review of medical records, documentation, and interview, the facility failed to conduct appropriate discharge planning for patients per facility policies in 3 of 7 patients (IDs 25, 28 and 29).

Findings included:

Record review of facility policy titled "Discharge Planning," dated 8/1/22 showed the following information:
PURPOSE AND SCOPE

To provide clear guidelines and expectations concerning discharge planning and process.

POLICY
Discharge planning begins on admission and should include involvement of staff, patient, and legally authorized representative, when applicable, and planning activities and following the aftercare plan once the patient is discharged from the hospital ...

PROCEDURE
Component of the assessment and treatment planning process, aftercare treatment recommendations are formulated and should include members of the interdisciplinary treatment team, including the patient and their legally authorized representative, when appropriate. These recommendations include the various levels of care indicated to ensure that patients are treated at the appropriate level of care.

I. Discharge planning should include, at a minimum, the following activities ...
A. The patient's interdisciplinary team (IDT) recommending services and supports needed by the patient after discharge, including the placement after discharge.
B. staff will assist patient in arranging for these services supports recommended by the patients IDT as appropriate.
C. Discharge planning staff will provide counseling to the patient, the patient's legally authorized representative (LAR), and the patient's caregivers, as appropriate, to prepare them for post discharge care ...

II. The discharge plan should consist of:
A. a description of the individual's living arrangement after discharge that reflects the individual's preferences, choices, and available community resources ...

Interview with Director of Clinical services (X) on 5/9/24 at 0930, she explained the initial process for when discharge planning begins. She stated that the Collateral Contact Call is when we gather information from the patient's family or legally authorized representative (LAR) to see where the patient is going to be discharged to and formulate a plan. This process is to be completed within the first 72 hour of admission. The discharge notes/ safety plan from the therapist will state what the plan is for the patient for discharge.

Medical record review for patients (IDs 25, 28 and 29) on 5/9/24 failed to show evidence of this procedure.

Interview with VP of Clinical Services (Y) on 5/9/24 at 10:00, she confirmed process outlined by staff (X) and verified findings for patients (IDs 25, 28 and 29).