HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure patient's received care in a safe setting related to not having shatterproof glass in a door in a patient care area for 1 of 3 units (Unit 300); and closet/locker doors not locking and being able to be opened by patients for 3 of 12 (202, 203 and 303) patient rooms; and lack of showerhead and bathroom sink without running water in 1 of 12 (304) patient rooms; and lack of a clean and sanitary environment for 1 of 3 Units (Unit 300); and lack of monitoring HK personnel performance for 2 of 2 (HK1 and HK2) HK personnel files reviewed.

Findings Include:

1. Review of policy and procedure titled, "Patient Rights and Responsibilities", last revised 09/2021, indicated patients have the right to receive care in a safe setting.

2. Staff P4 (Chief Executive Officer) was interviewed on 12/14/2022 at approximately 1:13 p.m., and stated tempered glass that was in the door in the Nurse's Station that was shattered by two aggressive patient's was not shatterproof.

3. Review of policy and procedure titled, "Housekeeping Safety", last revised 01/2020, indicated spills and broken objects are promptly and safely removed...Debris of all varieties is removed immediately when reported or observed.

4. Review of personnel files for staff HK1 and HK2:
a. HK Job Description stated, HK cleans and services the Hospital and outlying areas...and performs a variety of heavy cleaning duties in order to maintain the Hospital in an orderly and sanitary condition...Adheres to housekeeping guidelines for frequency and location of cleaning.
b. Lacked documentation of education related to housekeeping duties/tasks and/or monitoring of performance.

5. While on tour of Unit 300 on 12/14/2022 at approximately 11:59 a.m., the following was observed:
a. Door from the Nurse's Station out to the unit was boarded up with thick wood where tempered glass once was.
b. Room 303 - right side door on closet/locker was not locked and able to be opened by Surveyor.
c. Room 304 - was occupied by a patient who was lying in bed during the tour and bathroom lacked a shower head and there was no running water in the bathroom sink.
d. Soiled Utility Room - linen carts were in the way of access to the sink and hand washing soap, a large garbage can was in the way of access to the hopper, a non-functional Eco Lab Hand Sanitizer dispenser was laying on the counter to the right of the sink.
e. Clean Utility Room - one blue pillow and one white pillow were on laying on the counter to the left of the sink and both had visible holes in them. One white pillow was laying on the counter to the right of the sink, unable to tell if it was dirty or clean. Eco Lab Hand Sanitizer dispenser was laying on the counter to the left of the sink.
f. Clean Linen Room - disheveled, empty plastic bags laying on open shelves with the zippered linen cart covers unzipped and wide open. One pillowcase laying on a shelf all crumpled up and one bundle of towels was open laying on the shelf.
g. Medication Room - disorganized patient care items on the counter and some small paper scraps on the floor.
h. Seclusion Room - bathroom sink counter dirty with brown ring stain and orange liquid substance, hairs, and sharp piece of what looked like the tine of a plastic fork (approximately 1 inch long). Wall mounted garbage can full of garbage, floor dirty and no paper towels.

6. While on tour of Unit 200 on 12/14/2022 at approximately 2:15 p.m., the following was observed:
a. Room 202 - left side door on closet/locker was not locked and able to be opened by Surveyor.
b. Room 203 - right side door on closet/locker was loose and locked, but able to be jiggled slightly open by Surveyor.

7. Staff HK1 (Housekeeper) was interviewed on 12/14/2022 at approximately 1:58 p.m., and stated he/she does not clean the Seclusion Room or look in it when cleaning the 300 unit because no one ever uses it.

8. Staff P8 (Plant Operations Director) was interviewed on 12/14/2022 at approximately 1:11 p.m., and stated:
a. The Seclusion Room is cleaned three times per week.
b. The locks on the closets/lockers in patient rooms are supposed to be locked and only accessible by staff.
c. Patient bathrooms should have a showerhead and running water in the sink.

Based on document review and interview, the facility failed to ensure adequate numbers of nursing staff and other personnel to provide nursing care to patients per facility policy for 3 of 3 units (100, 200 and 300).

Findings Include:

1. Review of Nursing staffing pattern and census for Units 100, 200 and 300 for 11/20/2022 to 12/14/2022 indicated facility did not meet its guidelines as follows:
a. Unit 100 - 12/4/2022, patient census 14; staffing was 1 RN (Registered Nurse) and 1 BHA (Behavioral Health Associate) for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.
b. Unit 100 - 12/11/2022, patient census 13; staffing was 1 RN and 1 BHA for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.
c. Unit 100 - 12/14/2022, patient census 14; staffing was 1 RN and 1 BHA for day shift and 1 RN and 2 BHAs night shift; lacked 1 Nurse and 1 BHA for day shift and lacked 1 Nurse for night shift.
d. Unit 200 - 12/4/2022, patient census 15; staffing was 2 RNs and 1 BHA for day shift and 1 LPN (Licensed Practical Nurse) and 1 BHA night shift; lacked 1 BHA for day shift and 1 Nurse and 1 BHA for night shift.
e. Unit 200 - 12/11/2022, patient census 15; staffing was 1 RN and 1 BHA for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.
f. Unit 200 - 12/12/2022, patient census 16; staffing was 1 RN and 1 BHA for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.
g. Unit 300 - 11/23/2022, patient census 15; staffing was 1 RN and 1 BHA for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.
h. Unit 300 - 12/14/2022, patient census 14; staffing was 1 RN and 1 BHA for day shift and night shift; lacked 1 Nurse and 1 BHA for each shift.

2. Staff P3 (Vice President of Quality and Compliance) was interviewed on 12/14/2022 at approximately 11:25 a.m., and stated Unit 100 has 14 beds and staffing should be 1 RN, 1 LPN or Nurse and 2 BHAs for 14 patients on day shift and night shift. Unit 200 has 16 beds and staffing should be 1 RN, 1 LPN or Nurse and 2 BHAs for 16 patients on day shift and night shift. Unit 300 has 15 beds and staffing should be 1 RN, 1 LPN or Nurse and 2 BHAs for 15 patients on day shift and night shift.