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Based on record review and interview the hospital process for resolution of grievances failed to include a written notice of its decision that contains the following items when it is determined the grievance is not confirmed:
- The name of the hospital contact person;
- The steps taken on behalf of the patient to investigate the grievance;
- The results of the grievance process; and
- The date of completion.

The facility census was 60.

Findings included:

1. Record review on 12/01/11 for the policy titled, "Complaint/Grievance"; Policy Number 2.6; Effective Date: 07/06/98; Latest Revision Date: 08/31/11; Item #13 included:
-Document resolution of a complaint, if confirmed, which should include the following in a written response to the complainant:
a. Name of the hospital contact person;
b. Steps taken to investigate the complaint;
c. Results of the process;
d. Date of Completion; and
e. Any internal system change made to prevent any further occurrence, when appropriate.

The policy limited a written response to the complainant to only when the grievance is confirmed.
The policy failed to include that the complainant will be notified in writing when the grievance is not confirmed.

2. During an interview on 12/10/11, at approximately 2:00 PM, with Staff Z, Director of Performance Improvement/Risk Management, Staff Z stated:
-There have been no grievances made so there are no grievances to review;
-A complainant would not receive a written response to a grievance unless it is determined the grievance is confirmed;
-If the grievance is not confirmed Staff Z would talk with the guardian about the outcome of the investigation; or
-If the patient is no longer in the hospital Staff Z would call the guardian about the outcome of the investigation.
The hospital practice failed to provide written responses to complainants in the event it is determined the grievance is not confirmed.

Based on observation, interview and record review the hospital failed to provide a safe setting to suicidal patients when:
-Six blood pressure cuffs were found in Unit 4-South in an unlocked drawer in a patient area.
This has the potential to affect all suicidal patients on Unit 4-South. The facility census was 60.

Findings included:

1. Record review on 12/01/11 of the policy titled, "Contraband, Search for Disposition of"; Policy Number 7.2.13; Effective Date: 04/14/93; Latest Revision Date: 09/02/11; included:
-Searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient/resident may possess an item which is potentially hazardous;
-Contraband: Includes items that can be used to harm self, other, or damage property;
-Suffocation/Asphyxiation/Hangings/Strangling, Examples include, but are not limited to:
Scarves;
Window blind cords;
Drawstrings from clothing/bags, long, heavy-duty shoe/boot laces;
Straps from purses/luggage;
Electric cords; and
Belts.

2. During an observation on 12/01/11 at 2:45 PM, on Unit 4-South, six blood pressure cuffs were found in an unlocked drawer in the patients' day room with patients present in the day room.

3. During an interview on 12/01/11 at 2:45 PM with Staff E, Chief Nursing Officer, Staff E confirmed:
- Six blood pressure cuffs were found in an unlocked drawer in the patients' day room; and
-Unit 4-South does and has admitted suicidal patients.
Staff E stated he was not aware the blood pressure cuffs were kept in an unlocked drawer in a patient area and the blood pressure cuffs should not be in a patient area unsecured.

4. During an interview on 12/01/11 at 3:45 PM Staff H, RN manager from Unit 4-South, stated that the blood pressure cuffs have been in the unlocked drawer in the day room for one year or more. Staff H stated that currently there are no suicidal patients on 4-South, but suicidal patients have been admitted in the past year.

The facility failed to recognize that patient access to blood pressure cuffs can aide a suicidal patient in suffocation when the blood pressure cuff is placed around the patient's neck and the cuff is inflated.

The facility failed to follow its own policy regarding removal of items that can be potentially hazardous and can be used to harm self or others.

Based on observation and staff interview, the facility failed to have sufficient safeguards to ensure the access to all information regarding patients was limited only to those individuals who cared for the patients by allowing security to have access to the room where patients completed medical records were stored and by allowing non-employees access to the patients' medical record without proper training and signing the Health Insurance Portability and Accountability Act (HIPAA), which is a national standard that protects the privacy of patients' health information, and Confidentiality agreements. The facility census was 60.

Findings included:

1. Record review of facility's policy titled "Security of Information," Policy No. 1.5.6, Patient Care Manual, dated 11/01/11, showed the following:
-All information will be protected against loss, defacement, tampering or use by unauthorized individuals.
-Purpose: To ensure the protection of all information/data.
-Provide intake, Nursing Supervisors and Security Department with access to the Health Information Management Department for after hours and emergency needs.

During review on 11/30/11 at 1:55 PM of the Health Information Management (HIM) Department, Staff Q, Director of HIM stated that the hours of operation for the department were from 8:00 AM to at least 4:30 PM daily, Monday through Friday.

2. During interview on 11/30/11 at 3:00 PM, Staff Q stated that the Security Department staff had keys to access the HIM department and the clinical records storage area. Staff Q stated that the security staff needed access to the clinical records storage area in the event of a fire or water damage in the area.

Observation on 11/30/11 at 4:15 PM of the clinical records storage room showed the room contained shelves with patients' completed clinical records on them. The records were easily accessible on the shelves to anyone who accessed the room.

During a phone interview on 12/14/11 at 8:35 AM, Staff Q stated that the HIM department maintains a log on who entered the department. She/he stated that the Intake Staff (Admission's Staff) pulled approximately 30 patients' medical records after hours within the past three months. He/she stated that only the Intake Staff had entered the department after hours, but there was a potential that other staff could enter the department after hours to pull patients' medical records.

Staff Q stated that the facility's security staff performed dual roles. He/she stated that the facility employed three maintenance staff during the day shift from 7:00 AM to 3:30 PM and those three maintenance staff also performed security duty for the facility. Staff Q stated that the facility employed one Housekeeper who also performed the duty of a security guard on the evening shift from 2:00 PM to 10:30 PM and another one on the night shift from 10:30 PM to 7:00 AM. Staff Q stated that he/she may not be accurate on the starting and ending times of the shifts.

3. Record review of facility's policy titled "Information Management," Policy No. 1.5.1, Patient Care Manual, dated 02/25/10, showed the following:
-The goal of the Hospital Information Management Plan is to ensure ongoing education and compliance with HIPAA standards.
-The objectives are to establish and maintain mechanisms for confidentiality, security and integrity of the Information system.
-Security and confidentiality of information pertains to printed materials (medical records, reports, etc.), electronic media (computers) and verbal communication.
-Only those individuals involved in the care of the patient should have access to the record.

4. Observation on 11/29/11 at 3:15 PM of the 2 South Unit showed Staff A, Contracted Registered Dietitian (RD), and Sub-contracted Staff W, RD's assistant gathering information from a patient's opened medical record in order for the RD to conduct an assessment of the patient's nutritional status.

Review of Staff A's personnel record showed the facility failed to cover the HIPAA laws and patients' confidentiality with him/her. Staff W's personnel file showed he/she had unsigned and undated copies of the HIPAA agreement in his/her personnel file.

5. During an interview on 12/01/11 at 2:13 PM, Staff Q, Director of Health Information Management, stated that he/she did not provide HIPAA training and Patient Confidentiality to contract staff, but she/he knew there was a video they had to watch and a test they had to take. He/she thought Staff Y, Director of Human Resources was responsible for ensuring that was covered with contract staff.

During an interview on 12/01/11 at 2:25 PM, Staff Y stated that he/she did not know Staff A had not gone through the facility's HIPAA and Confidentiality training nor did he/she know Staff A did not have signed copies of the agreements available in his/her personnel file.

During the interview, Staff Y stated that Staff W received the generic/basic in-service that covered HIPAA and confidentiality of patients' information. He/she stated that Staff W received the training by watching videos and taking a test on the information on 11/29/11. He/she stated that he/she thought most contract staff got some form of HIPAA training, but could not be sure if each had signed agreements in their files.

Record review showed that Staff A signed a contract with the facility on 11/07/11 and had been accessing the patients' information since the signing of his/her contract.

During an interview on 11/28/11 at 1:35 PM, Staff A stated that Staff W assisted him/her with accessing patients' medical records and gathering information to conduct nutritional assessments of patients nutritional status.

Based on observation, record review and interview the facility failed to have documented evidence the patients were monitored according to physician orders in 36 (#1, #2, #3, #4,
#5, #9, #10, #11, #12, #13, #15, #16, #17, #19, #20, #21, #22, #23, #24, #26, #28, #29, #30, #31, #32, #33, #36, #37, #38, #39, #40, #41, #42, #43, #44 and #45) of 36 records reviewed. The facility census was 60.

Findings included:

1. Review of the clinical records showed the facility failed to have documented evidence it followed physician admission orders for "Observation every 15 minute checks" when observation documentation failed to be in the clinical records for the following patients: #1,
#2, #3, #4, #5,#9, #10, #11, #12, #13, #15, #16, #17, #19, #20, #21, #22, #23, #24, #26, #28, #29, #30, #31, #32, #33, #36, #37, #38, #39, #40, #41, #42, #43, #44 and #45.

2. Observation on the 4 south unit on 11/29/11 at 10:20 AM showed a Behavioral Health Technician (BHT) sitting behind a desk in the open day room area and a BHT sitting behind a desk at the end of the hallway. The BHT's were observing and documenting (on a combined form) the 15 minute checks on all 20 patients located on the 4 south units.

3. During an interview on 11/29/11 at 10:35 AM, Staff H, Registered Nurse (RN) Manager stated that the combined form with all the patient's 15 minute checks are kept in a separate book and are not part of the patient's record.

4.During an interview on 11/29/11 at 3:45 PM, Staff I, Registered Nurse (RN) Manager for 2 South Unit stated that the facility did not keep the rounding sheets as part of the patients' medical record because the sheet contained the names of all the patients on the Unit.

5. During an interview on 12/01/11 at 1:18 PM with Staff E, Chief Nursing Officer, Staff E stated:
-The patient rounding sheets (where it is documented the patients were observed for precautions levels ordered by the physician) are not filed in the clinical records;
-The rounding sheets are kept separate due to the rounding sheets having the names of all the patients on the unit on the same rounding sheet.

6. During an interview on 12/01/11 at 1:30 PM with Staff V, Health Information Management Director, Staff V stated:
-The reason the rounding sheets are not kept in the patient's clinical record is because multiple names of patients are on the same rounding sheet;
-There is no policy that addresses the rounding sheets being separated from the from clinical records;
-The rounding sheets go to the nurse manager. Once a year the nurse manager will box up the rounding sheets and a maintenance worker will take the box up to the fifth floor for storage;
-The rounding sheets do not come through the Information Management department;
-The Information Management department does not track or record where the rounding sheets are stored;
-There is not a method for retrieval of the rounding sheets other than going to the fifth floor and start opening boxes and looking for the rounding sheet needed;
-There are about 10 years worth of boxes stored on the fifth floor and it would be a big job to find the rounding sheets;
-The rounding sheets are not considered part of the clinical record if the record is requested;
-The rounding sheets would not be sent in response to a clinical record request unless the request specifically stated the rounding form by name in addition to requesting the clinical record.

The facility's clinical records failed to show physician ordered observations for precautions were completed as ordered.

The facility failed to maintain complete clinical records for its patients.






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Based on observation, interview and record review the facility failed to ensure unlabeled drugs were not available for patient use in five of five prescription strength tubes of medications affecting two (#11 and #41) of two patients. The facility census was 60.

Findings included:

1. Record review on 11/29/11 for the policy titled, "Medication Dispensing"; Policy number 10.2.1; Effective Date: 07/13/92; Last Review Date: 09/17/08; Item #13 showed the following direction: Label all medications with the following:
a. Drug name;
b. Strength;
c. Amount (if not apparent from the container);
d. Expiration date when not used within 24 hours;
e. Expiration time when not used within 24 hours; and
f. Indication if a look-alike/sound-alike drug.

2. During an observation on 11/29/11 at 1:50 PM, Staff K, Registered Nurse (RN), applied Mupirocin Ointment 2% (an antibacterial ointment) to the nose of Patient #11. The manufacture labeled the medication as dispense by prescription only. The medication failed to have a dispensing label from the pharmacy and is not labeled with the patient's name. The medication was stored among the stock medication in the bottom drawer of the medication cart on 2-South.

3. During an observation on 11/29/11 at 1:50 PM, five prescription strength medications were found among the stock medications in the bottom drawer of the medication cart on 2-South and each failed to have a dispensing label from the pharmacy as follows:
-Two prescription strength tubes of Mupirocin Ointment 2%;
-One prescription strength tube of Triamcinolone Acetonide Cream 0.1% (used to treat swelling, inflammation, and itching of skin conditions such as eczema, dermatitis, rashes, insect bites, poison ivy, allergies and other irritations) ; and
-Two prescription strength tubes of Hydrocortisone 2.5% (used to treat inflammation conditions of the skin).

4. During an interview on 11/29/11 at 1:50 PM, Staff K confirmed the Mupirocin Ointment is labeled from the manufacturer as a prescription only medication. Staff K also confirmed that:
-The Mupirocin Ointment 2% tubes (two tubes) do not have a dispensing label from the pharmacy;
- The medications do not have the patient's name on them; and
- There are not medication boxes with a prescription label in the medication cart for the medications.
Staff K stated that she just knew the medications belonged to Patient #11 even though the medications failed to have a pharmacy label with the patient's name.

5. During an interview on 11/29/11 at 1:50 PM, Staff K, RN, stated the tube of Triamcinolone Acetonide Cream 0.1% belonged to Patient #41 and confirmed the medication failed to have a prescription label from the pharmacy. Staff K confirmed there are five tubes of prescription strength medications that failed to have a dispensing label from the pharmacy and there are no medication boxes with prescription labels for the following medications:
-Two prescription strength tubes of Mupirocin Ointment 2%;
-One prescription strength tube of Triamcinolone Acetonide Cream 0.1%;
-Two prescription strength tubes of Hydrocortisone 2.5%.
Staff K stated she didn't know which patient the Hydrocortisone 2.5 % belonged to.

6. During an interview on 11/29/11 at 2:16 PM, Staff J, hospital pharmacist, stated that the following medications are prescription strength medications and each are found without a pharmacy prescription label in the bottom drawer of the medication cart on 2-South:
-Two prescription strength tubes of Mupirocin Ointment 2%;
-One prescription strength tube of Triamcinolone Acetonide Cream 0.1%;
and
-Two prescription strength tubes of Hydrocortisone 2.5%.
Staff J also confirmed:
- The medications should have prescription labels;
- There are no medication boxes with a prescription label found in the medication cart for these medications; and
-The medications were found among the stock medications in the bottom drawer of the medication cart.

Based on observation, record review and staff interviews, the facility failed to employ a qualified full-time person to oversee the operations of the dietary department. The facility census was 60.

Findings included:

1. Observation on 11/29/11 at 10:15 AM showed the facility had no one in the dietary department providing directions to the dietary employees. Observation showed the dietary employees preparing patients' food without guidance to use standardized recipes.

2. During an interview on 11/28/11 at 2:15 PM, Staff B, Chief Financial Officer (CFO), stated that he/she provided leadership and guidance to the Dietary Department staff. He/she stated that Staff U, Dietary Cook, took on increased responsibilities and the lead role of the department by ordering food and preparing the work schedules. When told the person in charge of the Dietary Department should be a full-time person qualified by training and experience in organization and administration of food service, Staff B stated that Staff A, Registered Dietitian (RD), spent a great deal of time in the department and could serve in that position. Staff B was reminded that Staff A could not serve as the director of the department since the facility did not employ him/her as an employee and Staff A was not full-time.

During the interview, Staff B stated that Staff U did not have training and experience in organization and administration of food service. He/she stated that he/she thought Staff U would be good in the position, but he/she also wanted to hire a full-time RD to manage and supervise the department. Staff B stated that he/she interviewed perspective staff for the position, but he/she had not made a decision on hiring anyone nor did he/she know when the position would be filled.

3. Review of Staff A's contract with the facility indicated the facility contracted with him/her to provide services on a part-time basis. Review of the contract also showed he/she did not meet the criteria to be director of the department.

During an interview on 12/01/11 at 11:08 AM, Staff A stated that he/she did not spend very much time in the kitchen because he/she felt Staff U was very good in performing his/her duties and taking on the lead role of the department. Staff A stated that he/she did not know the cooks did not use the standardized recipes when preparing food items on the new menus. He/she stated that he/she did not provide guidance to staff on the use of the menus and recipes.

During an interview on 12/01/11 at 11:28 AM, Staff U stated by phone that he/she did not provide in-service training to the dietary staff regarding the use of the new recipes.

Based on observation, interview and record review the facility staff failed to ensure appropriate measures were followed to prevent the spread of infection for one (#20) of one patient identified with signs and symptoms of strep (Streptococcus bacterial infection spread by person-to-person contact with nasal secretions or saliva); failed to ensure approved alcohol-based hand sanitizer was utilized by staff during medication administration for 14 (#15, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) of 14 patients observed on 4 south unit; and the facility failed to provide a clean environment in the hospital pharmacy which could lead to infection control issues because the dirty area was directly over top where medication was repackaged into unit dose containers. The facility census was 60 and the census on 4 south was 20.

Findings included:

1. Record review of the facility's policy titled "Isolation, Patient's with Known or Suspected Infection Disease", dated 09/25/95 and revised 04/04/11 showed that nursing staff was responsible to isolate any patient exhibiting signs/symptoms of highly communicable disease in a private room and ensure the patient remained in isolation until assessed by physician and appropriate level or care was determined.

Review of the facility's written guidelines titled "Strep Throat Identification, Treatment, and Prevention Guidelines for Physicians, Nursing Staff and Intake", (no date) instructed nurses to assess for complaint of sore throat and fever and notify physician when patient has fever or a sore throat and restrict patient to room until examined by physician. Instructions for room restriction included the following:
Patients must eat in their room;
Cohort patients with strep throat in rooms together;
Place patient in a room by self when possible; and
Continue restriction for 24 hours after first dose of antibiotic started.

2. Review of Patient #20's medical record showed she/he was admitted to the facility on 11/29/11 at 4:20 AM with an admitting diagnosis of Mood Disorder.

Review of the nursing admission assessment completed on 11/29/11 at 4:30 AM showed the patient was exposed to an infectious disease "strep in 2011".

Review of the physician's history and physical exam completed on 11/29/11 and documented at 9:40 AM showed the patient was exposed to the communicable disease strep by drinking after someone with the disease; had a past medical history of strep throat; and noted two weeks of a sore throat. The physician's order sheet dated 11/29/11 at 9:17 AM showed an order for strep screen now due to "strong exposure last Tuesday and a sore throat now". The physician ordered Amoxil (an antibiotic) 500 milligrams (mg) one tablet PO (by mouth) three times a day for seven days and to stop if culture was negative for strep.

Review of the patient's medication treatment plan dated 11/29/11 (no time documented) showed the strep culture was obtained and sent to a local laboratory.

Review of an Infection Control Report completed on 11/29/11 (no time documented) for Patient #20 showed there were signs and symptoms of infection "sore throat" present on admission and a strep screen had been ordered.

During an interview on 11/30/11 at approximately 8:45 AM, Staff P, Registered Nurse (RN) stated that she gave Patient #20 Amoxil 500 mg for possible strep. Staff P stated that the patient had been tested for strep but the results had not been received. When questioned, Staff P stated that the protocol would be to place such patients on room restriction for 24 hours and continue the course of antibiotics until they received the results of the strep screen. Staff P stated that she thought maybe the physician opted not to put Patient #20 on room restriction due to a complaint of sore throat but no redness or fever. Staff P stated that she had not talked to the physician and there was no documentation or physician order not to restrict the patient.

During an interview on 11/30/11 at 9:10 AM, Staff Y, RN stated that Patient #20 did not have a fever this morning but still complained of a sore throat.

Observation on 11/30/11 at 9:35 AM showed Patient #20 sitting in a circle in an enclosed (locked) group classroom (room size was approximately 10 feet by 12 feet) with approximately ten other patients, all within close proximity to Patient #20.

During an interview on 11/30/11 at 9:45 AM, Staff H, RN Manager stated that the unit was running full capacity and they did not have a private room for Patient #20. Staff H confirmed that the patient shared a room during part of the night (since admission at approximately 4:30 AM) with another patient, ate breakfast with the group, attended group therapy and group classroom this morning with other patients. Staff H stated she was not aware the patient had been suspected of possible strep and stated that they should have followed the protocol to restrict the patient in her room until examined and cleared by the physician or obtained a physician's order that the restriction was not necessary.

During an interview on 11/30/11 at 10:05 AM, Staff O, Infection Control RN stated that the facility had worked very hard over the last year to keep infections down. She said, "Strep was running high last winter so we developed the written guidelines and treatment plans to help keep this down. Staff needed to follow the written guidelines to obtain a physician's order and/or documentation from the physician on why it did not need to be followed." Staff O said, "Staff should have restricted the patient to a private room until examined by the physician per written guidelines."

According to the Center for Disease Control and Prevention (CDC) guidelines, streptococci bacteria are spread through direct contact with mucus from the nose or throat of infected persons. Treating an infected person with an antibiotic for 24 hours or longer generally eliminates their ability to spread the bacteria. The spread of infection can be reduced by good hand washing, especially after coughing and sneezing and before preparing foods or eating.

3. Record review of the facility's policy titled "Hand washing Guidelines", dated 11/89 and revised 02/25/08, showed the policy was for "Staff engaged in direct patient contact shall adhere to the following guidelines regarding hand-hygiene practices":
The purpose was "To provide guidelines to promote hand-hygiene practices and reduce transmission of infectious agents by staff to patients";
The guidelines showed "In addition to traditional hand-washing with soap and water, the CDC is recommending the use of alcohol-based hand rubs (if hands are not visibly soiled, an alcohol-based hand rub may be used to decontaminate hands)"; and
The procedure instructed staff to "Wash hands with soap and water or use an alcohol based hand rub before handling medication or preparing food".

Observations on 11/30/11 from 8:00 AM through 8:55 AM showed Staff P, RN administered a total of 29 PO medications to patient's #15, #18, #20 (the patient who was being tested for strep bacteria), #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31. Observations showed that Staff P did not wash hands with soap and water, but instead used hand rub labeled "alcohol free" before and after each individual patient's medications were given.

During an interview on 11/30/11 at 9:00 AM, Staff P stated that the alcohol free rub was less drying to her skin. She stated that she was not sure if it was okay to use in place of the alcohol based hand rub.

During an interview on 12/01/11 at 2:00 PM, Staff O, Infection Control RN stated that "undercover staff" performed occasional hand washing surveillance but was not aware that any staff used alcohol free hand rub. Staff O said, "Alcohol free hand rub is not approved by CDC and is not to be used by staff in the facility."

During interviews on 12/01/11 at 2:10 PM, Staff H, RN Manager and Staff E, Director of Nursing both stated that the alcohol free hand rub was not to be used in the facility. They found the hand rub in a cabinet above the medication cart and it was labeled with Staff P's name. Staff H stated that it must have been purchased by Staff P and that it was not approved for facility use therefore, she would not be allowed to continue to use it.

4. Observation in the hospital pharmacy on 11/30/11 at 10:25 AM showed a ceiling vent that was visibly soiled with dirt and dust. The ceiling tile in the grid alongside the vent had a four inch by four inch area of gray and black discoloration. The area appeared to be moldy as if it had previously been wet. It was not currently wet. The area of the ceiling vent and tile were directly over top the table where medication is repackaged into unit dose containers.

Review of facility policy 7.10.4 titled "Non Patient Areas, Cleaning of" dated 03/01/10 showed direction to staff to maintain a clean hospital environment and decrease the transmission of infection. In addition the policy states that staff should clean entrances, walls, lobbies, waiting rooms, halls, walls, railings, floors and surface areas with appropriate cleaning solutions daily and as needed. The policy does not reference ceiling vents.

During an interview on 11/30/11 at 10:35 Staff J, Director of Pharmacy, stated that housekeeping does come in and clean the Pharmacy but they must have missed the vent. Staff J stated that he was not sure what stained the ceiling tile or when it occurred.

During an interview on 11/30/11 at 1:25 PM Staff O, Infection Control Nurse, stated that she does not do regular rounding in the Pharmacy



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