HospitalInspections.org

Based on review of policies and procedures and medical records and interviews with staff and patients, it was determined that the hospital staff failed to protect the patients' rights as evidenced by the following citations:

A 0117 for the failure to provide interpreter services to a Spanish speaking patient;

A 0131 for the failure to provide the Important Message to patients; and

A 0206 for the failure to have all staff trained in CPR who may be involved in seclusion or restraint.

Based on review of nursing personnel files, it was determined that the hospital failed to be in compliance with State and local law and policy and procedure.

The surveyor reviewed 6 nursing personnel files including 3 RNs, 1 LPN, 1 Residential Care Coordinator, and 1 Unit Secretary, who was cross trained as a PT or psychiatric technician. The personnel files per hospital policy #HR-36 for screening applicants states under procedure #2, "The Human Resource representative will utilize the company's designated vendors to process the screening measures required for the particular job. The specific measures required will vary, based on the job and applicable laws, regulations, and standards, but may include any of the following, and may not be limited to the following:
Verification of previous employment data
Professional references from previous employers
Other professional references
Verification of education
Verification of license and certification
Driving record
Criminal investigation
Credit report"

Based on the review of the records it was determined that 1 out of 6 (Residential Care Coordinator) personnel files did not have a current CPR card, which had expired in April 2012. The employee was participating in a CPR class on the last day of the survey 2/20/13. In addition, 2 of the 3 RNs personnel files had no references. Although evaluations are due yearly 4 out of 6 personnel files had no current evaluation which were due in January 2013.

Based on review of 30 open medical records, it was determined that in 1 out of 30 medical records reviewed, the hospital failed to provide patient #30 with notification of her discharge rights via the Important Message from Medicare (IM).

Patient #30 was admitted to the hospital on 1/4/13. Review of the medical record revealed the patient received the first IM on 1/7/13 and at discharge did not receive the second message. The hospital is not in compliance with the regulation since it did not provide the patient her IM within two days of admission nor did it provide the second IM prior to discharge.

Based on interview, review of policy and 1 of 19 open records, the hospital failed to obtain interpreter services for patient #1, and failed to give patient #1 her rights in a manner that patient #1 could understand during the first two days of admission.

Hospital policy RI-08, " Communications Mechanisms for Persons with Speech/Hearing Impairment or Primary Language Other Than English " which was reviewed by the surveyor, states in part, " Communication needs will be assessed and coordinated prior to admission when possible or by needs assessment upon admission by a social worker on the inpatient unit."

It further states "Interpreter services will be obtained promptly as requested by the patient or upon assessment. Interpreter services can be arranged though needs assessment or the Social Work or Nursing supervisors."

Patient #1 is a 31-year-old admitted to the unit following an overdose. An initial nursing educational assessment revealed that patient #1's spoken language as "English" and "Spanish", that patient #1 is able to read, and that there are "No" barriers to learning. Additionally, that patient #1's highest grade completed is the "4th grade."

Interview with a hospital administrator revealed that the facility has some consents written in Spanish. However, none of these Spanish written documents are found in the record of patient #1. Based on the educational assessment, patient #1 may have required help with reading in Spanish had Spanish interpreted documents been used, though no further assessment was documented.

Specifically, on the first two days of admission, patient #1 signed documents written in English that included Application for Voluntary Admission, Notification To Individual of Admission Status and Rights, Group Contract, an affirmation of no active health insurance, A Consent for Treatment, a Self Determination Act form, and Authorizations for Release of Information. None of these documents indicate that patient #1 signed them with the interpretive services of a translator. The Psychiatric Admission note reveals that "interview through SW (social work) ___. " The Psychosocial Assessment revealed "Speaks some English." All assessments were completed during the first two days of admission.

A group therapy note revealed "Pt did not share due to language barrier - asked to pass when prompted by SW." A nursing note of the same day reveals in part, "Pt was mostly in __ room this shift. (Patient #1) has a language barrier b/c (because) (patient #1) doesn't speak English. (Patient #1) did speak (with) another Spanish speaking patient on the unit .... "

On the third day of admission, a social worker note revealed "Called (translation service) to set up a Spanish Interpreter may be able to be at the unit two hours today then 4 hours every day until pt is discharged, and two hours Sat. and Sun. " A second social worker note ten minutes later revealed that a family meeting was held during which patient #1's Spanish speaking family has attended, and was aided by a social worker for interpretation.

Interpreter assisted interview with patient #1 by the surveyor revealed affirmation of patient #1's signature on the consents. Following interview, patient #1 received rights information again, this time with a certified Spanish interpreter. The hospital failed to inform patient #1 of her rights prior to providing care.

Based on the review of 1 out of 6 personnel files, it was determined that staff did not have current cardiopulmonary resuscitation (CPR) certification in his personnel file.

The review of the personnel file of the residential care coordinator revealed that his CPR certification had expired in April 2012. The employee who is responsible for direct patient care was not certified in CPR for approximately 10 months. He was being certified on the last day of the survey on 2/20/13. The hospital failed to ensure that their staff had required education and training (CPR).

Based on interview, and review of three outpatient areas, no clear and ongoing performance improvement projects are in progress.
Interview with the managers of each outpatient area revealed informal performance measures of patient satisfaction and readmission. However, no data is formalized, nor is any informal quality measure shared with the hospital Quality/Performance Improvement Committee. Therefore, the Governing Body failed to ensure that hospital-wide priorities are set and evaluated for outpatient areas.

Based on review of 1 of 19 open and 1of 11 closed medical records for patients #3 and #4, a psychiatric assessment was not found for patient #2, and a discharge summary was not completed within 30 days of discharge for patient #3.

Review of patient # 2's open record revealed no psychiatric assessment 6 days after the patient's admission to the hospital.

Review of patient #3's closed record who was discharged on 10/16/2012, revealed a discharge summary dictated on 1/27/2013, and signed on 2/4/2013.

Based on these findings, the hospital failed to promptly complete two important medical record components for patients #3 and #4.

Based on observation of the facility on February 19, 2013, it was revealed that there were several examples of unattended maintenance care needs in evidence.
The findings included the following:
On February 19, 2013, an environmental health survey was conducted by this surveyor to determine if the physical plant was being maintained as needed to provide for a safe, sanitary and comfortable environment of care. During a tour of the facility, it was revealed that equipment and work areas used for food service production were not being maintained as required. Examples of disrepair and/or of maintenance needs included the following:
Main Kitchen, 14901 Building:
a. Within the walk-in refrigerator it was revealed that a section, formerly for frozen storage, had been converted to refrigerated storage. Unfortunately, the former indoor unit for cooling of the former freezer compartment had never been dismantled and instead was abandoned in place. Such a decision led to the presence of non-functioning equipment within a refrigerated storage unit where this equipment was allowed to accumulate moisture, dust and other debris and thus pose a potential for contamination of the food stored within.
b. The wall area above and below a hand washing sink within the dish washing area of the kitchen was found to be in need of repair and repainting and re-caulking. All wall, floors, and ceiling must be maintained in good condition and easily cleanable.
c. The booster heater to the low temperature sanitizing dish machine was in need of repair or replacement. One of the two supports to this device had broken away from the remainder of the unit, it was lying on the floor, and the power supply box attached to this support was also lying on the floor. The failure to repair this equipment subjected staff to an unnecessary electrical safety hazard.
d. Metal cooking pans as stored on a clean storage and drying rack were found to be stacked wet, one within another. All kitchenware must be washed, rinsed, sanitized, and air dried between uses.
e. The electrical cable connected to the tilt skillet was found to be coming apart at a coupling such that there was potential for stress or damage to the electrical wiring. As such, this condition was another example where staff was subjected to an electrical hazard.
All hospitals shall maintain the physical plant in a manner where it is safe, sanitary, comfortable and orderly for use by patients, staff and the general public.

Based on observation of the facility on February 19, 2013, it was revealed that the temperature of the dish machine was not properly maintained:
The findings included the following:
On February 19, 2013, an environmental health survey was conducted by this surveyor to determine if the physical plant was being maintained as needed to provide for a safe, sanitary and comfortable environment of care. During a tour of the facility, it was revealed that the low temperature sanitizing dish machine was found to be operating at a temperature between 104 and 110 degrees Fahrenheit. The minimum requirement for operational temperature shall be 120 degrees Fahrenheit. The specification plate for this dish machine was to have an operating temperature of 140 degrees Fahrenheit per the manufacturer.

Based on interview with the Infection Control Preventionist (ICP), it was determined that the hospital's infection control program does not monitor for hospital-wide compliance with policies and procedures, food sanitation and other infection control program requirements.

In interview with the ICP on 2/20/13, it was determined that the hospital does monitor hand hygiene and proper use of personal protective equipment by secret shoppers such as administrative staff, unit managers and the ICP on the day and evening shift but there is no monitoring on the night shift. In addition, the ICP makes environmental rounds with environmental services but when asked if this included the kitchen area the surveyor was told that the she does not make rounds in this area. The failure to monitor all staff compliance with policy/procedure and protocols and the sanitary environment within the kitchen indicates that the hospital infection control program is not hospital wide.