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Based on document review and interview, it could not be determined that medical staff was accountable to the Governing Board for 4 of 4 Nurse Practitioners credential files reviewed. (NP1, NP2, NP3, and NP4).

Findings include;

1. Medical Staff Bylaws indicated under Appendix A: Credentialing Policy and Process, a. Basic Responsibilities and Requirements: 1. As a condition of the Medical Staff or Allied Health Staff membership, every applicant and member specifically agree to the following as applicable: ii. To abide by the bylaws and policies of the Hospital and Medical Staff and any revisions or amendments.

2.
a. Review of staff members NP1 credential files indicated on the reappointment dated 01/24/2023 lacked signed documentation of abide by Medical Staff Bylaws.

b. Review of staff members NP2 credential files indicated on the reappointment dated 10/24/2023 lacked signed documentation of abide by Medical Staff Bylaws.

c. Review of staff members NP3 credential files indicated on the reappointment dated 02/28/2023 lacked signed documentation of abide by Medical Staff Bylaws.

d. Review of staff members NP4 credential files indicated on the reappointment dated 03/28/2024 lacked signed documentation of abide by Medical Staff Bylaws.

3. On 1/23/20 at approximately 1500 hours, staff A1 (Chief of Quality and Compliance) was interviewed and confirmed that NP1, NP2, NP3, and NP4 did not have a signed abide by rules for the reappointed dates.

Based on document review and interview, the facility failed to maintain a list of all contracted services.

Findings include:

1. The facility lacked or failed to produce documentation of a list of contracted services.

2. On 11-07-2024 at 1350 hours, staff A1 (Chief of Quality and Compliance) confirmed that they did not have a list of contracted services and no documentation was provided by the end of survey.

Based on document review and interview facility failed to maintain documentation of providing Patient Rights to consumers seeking treatment in 14 of 30 Medical Records reviewed. (P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28)

Findings include:

1. Policy titled Rights of Service Recipients, Policy No.: CCBHC.04.04.00.00, Last R/R Date: 05/2024, indicated under Page 2, A. 6. A written statement delineating client rights shall be provided to all who seek services as well as a verbal explanation of his/her rights.

2. Review of Medical Records on 11/6/24 at 1430 hours and on 11/7/24 at 0800 hours with A2 (Chief of Crisis Services), indicated a lack of documentation of patient rights provided to P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28.

3. In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of providing patient rights to consumers upon admission to facility in 14 of 30 Medical Records reviewed.

Based on document review and interview facility failed to maintain documentation of notifying consumers of facility advanced directive policy at the time of admission for 14 of 30 Patient Medical Records reviewed. (P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28)

Findings include:

1. Facility policy titled Policy Rights of Service Recipients, Policy No.: CCBHC.04.04.00.00, Last R/R date 05/2024, indicated under Page 4, Under Policy Components B. The following guidelines are established for the protection of client rights: The right to make informed decisions regarding care.

2. Review of Medical Records on 11/6/24 at 1430 hours and on 11/7/24 at 0800 hours with A2 (Chief of Crisis Services), indicated a lack of documentation of advanced directive policy to make informed consent provided to P5, P6, P7, P8, P13, P14, P15, P16, P17, P19, P20, P21, P25 and P28.

3. In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of providing patients with advanced directive policy upon admission to facility in 14 of 30 Medical Records reviewed.

Based on document review and interview facility failed to maintain follow-up reports on 2 of 30 incident reports reviewed. (P6 and P7)

Findings Include:


1. Facility policy titled Internal Event & Incident Reporting, Policy No.: EC.12.07.00.00, Last R/R Date: 07/2024, indicated under Policy, A. Facility staff complies with incident reporting requirements set forth by federal, state, and local regulatory agencies and accrediting bodies. 1. Staff reports all incidents and/or events involving employees, consumers and visitors including, but not limited to: a. Potentially injurious events; b. Accidents and injuries; c. Bloodborne exposures; d. Buildings, property and emergency responses; e. Equipment; and f. Medication. C. Staff completes the online facility Incident Report Form within 24 hours of and event or of becoming aware of an event. Follow-up reports are completed online for medication/treatment/procedures. Incident Reports are reviewed and as necessary, follow-up reports may be directed to the supervisor.

2. Review of Incident Report for P6 indicated the following:
a. Incident Report on 1/18/2024 at 2030 hours indicated P6 was agitated and called the police. Staff had to turn the phone off because P6 was trying to call 911 and he/she became engraged, screaming and cursing, banging his/her fists on the walls and counters as he/she paced back and forth from his/her room to the dining area. Once P6 was at the medication room window banging his/her fists screaming at the medication nurse. Physician was notified and a decision was made to call Rapid Response when P6 refused to take as needed medications by mouth.
b. Incident Report as well as MR lacked documentation of follow-up after Rapid Response was called.

3. Review of Incident Report for P7 indicated the following:
a. Incident Report on 2/16/2024 at 1300 hours indicated P7 hit a wall in his/her room causing a dent in the wall, left hand resulting in an Abrasion/Scratch to left hand.
b. Incident Report as well as MR lacked documentation of follow-up on P6 injury to left hand.

4. In interview on 1/6/24 at approximately 1200 hours with A2 (Chief of Crisis Services), he/she confirmed lack of follow-up documentation on Incident Reports for P6 and P7.

Based on document review and interview, the governing body had not approved current medical staff bylaws.

Findings Include:

1. Review of the Medical Staff Bylaws indicated a lack of documentation of an approval date that the medical staff operates under current bylaws, rules and policies that have been approved by the governing board nor that any revisions or modifications in the medical staff bylaws, rules and policies had been approved by the medical staff and governing board, annotated with date of last review and initialed by persons responsible.

2. On 11-07-2024 at 1400 hours in interview with staff member A1 (Chief of Quality and Compliance), it was indicated that medical staff bylaws and rules and regulations had not been approved by the governing board.

Based on document review and interview nursing services failed to complete documentation of consumer and/or staff debriefment following use of restraint/seclusion in 2 of 30 patient medical records reviewed. (P6 and P7)

Findings include:

1. Facility policy titled Procedure: Use of Physical Restraints, Procedure No: IPU.08.03.01.00, Last R/R Date: 03/2024, indicated on Page 4, 3. RN documentation will include: g. The RN (Registered Nurse) will complete both IPU.08.03.01.06 consumer debriefing form and IPU.08.03.01.07 staff debriefing forms. Page 5, Under G. Debriefing, 1. Within two hours following the restraint episode, the RN will conduct a debriefing with the consumer. The debriefing will include exploration of alternatives that could be employed in response to future episodes of escalating emotions/behavior.Page 6, 2. A debriefing will also take place for the staff involved in the restraint procedure within two hours of the restraint episode. Discussion will include consideration of : a. What were the events leading up to the restraints?; b. What other strategies could have been used to handle the situation?; c. What alternative interventions might have been used?; d. Did the procedure go smoothly?; and e. Were there any injuries/ How could these have been prevented.

2. Review of P6 MR indicated the following:
a. P6 was placed in restraints on 1/18/24.
b. MR lacked documentation of patient and staff debriefing following use of restraints.

3. Review of P7 MR indicated the following:
a. Patient was placed in restraints on 2/16/24.
b. MR lacked documentation of patient debriefing following use of restraints.

4.In interview on 11/7/24 at approximately 1200 hours with A2, he/she confirmed medical records lacked documentation of consumer and staff debriefing following use of restraints for P6 and consumer debriefing following use of restraints for P7.

Based on document review, observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9; failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate; failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1; failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters; failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period; failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1; failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds; failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility's diesel powered generator; and failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks.

Findings Include:
The cumulative effect of these systemic problems resulted in the facility's inability to ensure it had implemented a systemic plan of correction to prevent recurrence, therefore failing to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either be continuously in operation or shall be capable of repeated automatic operation without manual intervention; failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction; failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds; failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility's diesel powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards; and failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction.


Findings Include:

Based on observation with the Director of Operations at 3:25 p.m. on 11/06/24, the battery operated emergency light at the diesel generator failed to function when its respective test button was pushed five times. Based on interview at the time of the observation, the Director of Operations stated battery operated lights in the facility are tested monthly and confirmed the aforementioned battery operated emergency light failed to function when its respective test button was pushed.
Based on record review on 11/06/24 at 1:10 p.m. with the Director of Operations, the Battery Operated Emergency Light monthly testing was incomplete. The monthly 30 second testing was documented as being complete, but were not identified and itemized by location in the facility. Based on an interview at the time of record review, the Director of Plant Operations indicated the facility has battery operated emergency exit lights throughout the facility that are tested monthly by the Security staff, but the testing documentation is not itemized by location.

Based on record review on 11/06/24 at 1:55 p.m. with the Director of Operations, the Monthly Preventative Maintenance for Emergency Generator log sheets were reviewed over the past year and lacked the transfer time from normal power to emergency power. Based on interview at the time of record review, the Director of Operations confirmed the transfer time is not written on the Monthly Preventative Maintenance log sheets monthly when the load test is conducted.

Based on record review with the Director of Operations on 11/06/24 at 12:20 p.m., documentation of an annual fuel quality test results for the diesel generator was dated 02/09/24. The result report stated 'Action Required' and that 'iron corrosion is highly elevated. Sulfur level of this fuel is slightly above the ultra-low sulfur diesel range. We suggest to polish the fuel to restore the quality and reduce the existing particles. Resample in 3 months to monitor.' Based on interview at the time of records review, the Director of Operations stated the facility does have a diesel generator and that additional documentation to show the fuel quality issues were addressed was not available for review at the time of the survey.
Based on record review with the Director of Operations on 11/06/24 from 9:30 a.m. to 2:30 p.m., documentation for seven weeks of weekly generator testing was not available for review. Those weeks are 01/14/24, 05/19/24, 05/26/24, 06/23/24, 08/11/24, 09/01/24 and 10/06/24. Based on an interview at the time of record review, the Director of Operations confirmed additional weekly generator testing documentation for the above-mentioned weeks was not available for review at the time of the survey.

Based on record review, observation, and interview, the facility failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1. Section 14.2.1 states, "except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material; failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters; failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period; failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Findings include:

Based on record review with the Director of Operations on 11/06/24 at 11:30 a.m., the annual sprinkler system inspection dated 08/21/24 indicated a 5 year internal pipe inspection was conducted 2023. Based on an interview with the Director of Operations at the time of record review, he stated inspection documentation for the most recent 5 year internal obstruction investigation was not available for review at the time of the survey.

Based on review of the facility's fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, the facility lacked fire drill documentation for the first shift (day) of the second quarter (April, May, and June) of 2024. Based on interview at the time of record review, the Director of Operations said there was no other documentation available for missing fire drills during the previously mentioned shift and quarter of 2024.

Based on review of the facility's fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, all 11 documented fire drills performed during the past 12 month period did not include the transmission of signal of the fire drills. Based on interview at the time of record review, the Director of Operations said there was no other documentation available to show the transmission of the fire alarm signal for each fire drill during the past 12 month period.
Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations present, no annual inspection of the fire door assemblies were available for review. Based on observations during the tour of the facility between 2:30 p.m. and 3:35 p.m., there were labeled fire door assemblies noted throughout the building that were fire-rated and non-fire rated wall assemblies. Based on interview at the time of records review, the Director of Operations stated annual inspection documentation for the fire door assemblies during the past 12 month period was not available for review, and confirmed the doors in the facility were labeled 90-minute and 45-minute assemblies.