HospitalInspections.org

Based on review of facility documents, policies and procedures, medical records (MR), observations and interview with staff (EMP), it was determined the Governing Body failed to ensure compliance with the Patient Rights Condition (A-115), failed to ensure Notice of Rights (A-0117), failed to ensure Admission Status notification (A-0133), failed to ensure the right to care in a safe setting (A-0144), failed to ensure that each use of restraint was in accordance with a written modification to the patient's plan of care (A-0166), failed to ensure compliance with QAPI Condition (A-263), failed to ensure Patient Safety (A-286), failed to protect patient records (A-441), failed to ensure compliance with Physical Environment Condition (A-700), failed to ensure the maintenance of the physical plant (A-701), failed to ensure the proper disposal of trash (A-713), and failed to ensure supplies were properly maintained (A-724).

Findings include:

Review on January 26, 2017, of facility document "Rules and Regulations of the Governing Board of Hahnemann University Hospital, dated November 2016," revealed "Purpose: The purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, provide for organizational management and planning of the Hospital. The Governing board has ultimate responsibility and legal authority for safety and quality of care, treatment and services rendered in the Hospital."




Cross Reference with:
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility document, review of facility policies and procedures, review of medical records (MR) and interviews with staff (EMP), it was determined the facility failed to ensure patient's Notice of Rights (A0117), failed to ensure patient's Admission Status Notification (A-133), failed to ensure the patient had the right to care provided in a safe setting (A-0144), and failed to ensure modification for patient's plan of care for restraint usage (A-166).



Cross Reference:

482.12 Governing Body
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on observations, review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure results from a Quality Safety Audit were reported to the Governing Body and failed to develop an action plan to correct the identified safety concerns.
Findings include:
Review on January 27, 2017, of facility policy "Psychiatric Medical Care Unit Performance Improvement Plan," dated November 2016, revealed "III A. The Board of Governors has the ultimate authority for the quality of patient care delivered at the hospital. C. The Department implements a continuous, systematic and coordinated approach to plan, design, measure, assess, and improve its structural and clinical processes. D. 5. Taking effective action when improvement is required or recommended, E. Additional Goals of our PI process include: 1. Collaboration and coordination among departments and disciplines ... 3. Prioritization of areas selected for improvement ... II. Key Assumptions ... G. Tenet performs yearly Quality Management Audit to ensure that all standards are followed adequately.
Review of facility document "Hahnemann University Hospital Performance and Improvement Plan," revealed "Purpose: The Performance Improvement Plan supports the mission of Hahnemann University Hospital by providing a systematic well organized approach to performance improvement ... Authority: The Board of Governors has ultimate authority for the quality of patient care delivered at the hospital. It has delegated to the Medical Staff Committee (MEC) responsibility for oversight and coordination of Performance Improvement Program ... A. Medical Executive Committee (MEC) The MEC ... it assures that each Care Center Performance Improvement Council effectively identifies and addresses opportunities for improvement and coordinates activates among the councils to avoid redundancy and to foster interdepartmental communication and cooperation ... B. Chief Executive Officer (CEO) is responsible for assuring that all hospital services are well planned defined and implemented to meet the needs of the patients ...The CEO through recommendations from the MEC assures that adequate resources are allocated to realize improvement for patient care and services ... C. Performance Improvement Coordinating Council: The membership of this Council includes, a Board representative, the Hospital Administrators (CEO, COO, CNO and CFO), President of the Medical staff,, Chairs of each Care Center Council and the Risk Manager.
Review on January 26, 2017, of facility document, "Executive Summary for Tenet Quality Management Audit" conducted on March 22, 2016," revealed "All findings and recommendations assessed as "high" must have an action plan for correction completed and submitted via Compliance Central within then (10) days of when you are notified that the full audit report is accessible in Compliance Central. A comprehensive action plan which addresses all items assessed as requiring action must be submitted via compliance Central within thirty (30) days of when you are notified that the full audit report is accessible in Compliance Central.
A request was made on January 24, 2016, at 4:00 PM of EMP2 for the Tenet Quality Management Audit Action Plan for the recommendations assessed during the audit. None provided.
1. Review on January 27, 2017, of facility document "Psychiatric Care Center Performance Improvement Council Meeting Minutes" dated January 19, 2016, through December 20, 2016, revealed no documented evidence the results from environmental safety audit dated March 22, 2016, were discussed at the meeting.
Interview on January 26, 2017, at 3:00 PM with EMP1 confirmed the Psychiatric Quality Improvement Council meets twice a year with the Medical Executive Committee to present the minutes from the Psychiatric Independent Council meetings and confirmed there was no documented evidence the results of the March 22, 2016, audits were discussed.
2. Review on January 27, 2017, of facility documents "Medical Executive Committee (MEC) Meeting Minutes" revealed the Psychiatric Council reported to the committee on May 3, 2016, and July 5, 2016. Further review revealed no documented evidence safety concerns on the PCMU were reported to the MEC regarding the environment observations.
Interview on January 27, 2017, at 9:36 AM with EMP13 confirmed there was no documented evidence the environmental quality reports and audits for the PMCU were reported to the Governing Board at the May 3, 2016, or July 5, 2016 meeting.
3. Review on January 24, 2017 of facility document "Hahnemann University Hospital, Board of Governor, Reporting Schedule 2016," revealed Patient Safety Relations: EOC (Environment of Care), is reported bi-annually in March and November "
Review of facility document "Governing Body Meeting Minutes, dated January 1, 2016 thru December 31, 2016, revealed no documented evidence the environmental survey results or action plan from the Tenet Quality Management Audit of the PMCU were reported at the March and November meetings.
Interview on January 26, 2017, at 10:45 AM with EMP10 confirmed there was no documented evidence the safety concerns on the PMCU were reported to the Governing Board.
4. Review on January 27, 2017, of facility documents "Patient Safety Meeting Minutes," dated January 19, 2016, through September 20, 2016, revealed no documented evidence the environment of care safety audit dated March 22, 2017, was reported at the meeting.
Interview on January 26, 2017, at 3:00 PM with EMP1 confirmed the results environmental safety audit of the PMCU conducted March 22, 2016, was not discussed in the Patient Safety Committee.
A request was made on January 24, 2017, at 4:40 PM to EMP11 for the action plan that was submitted to the CEO and the CFO to request funding for the environmental safety concerns on the PMCU. None provided.
Interview with EMP12 on January 27, 2017, at 10:45 AM confirmed the initial request for funds to complete upgrades for the physical environment on the Psychiatric Medical Care Unit was not made until January 26, 2017.
Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility documents, observations and interviews with staff (EMP), it was determined the facility failed to maintain a safe environment for patients on the Psychatric Medical Care Unit.
Findings include:
Review on January 24, 2017, of facility policy "Safety Guidelines for Psychiatric Unit, dated December 2016," revealed "II. Procedure ... A. These are general guidelines that are not all inclusive and workers should always check in and out with the charge nurse regarding specific work to be done ... 9. Only tamper-proof screws can be used when making repairs ... 10. No hooks or hardware should be installed for hanging items such as clothing, shower curtains or window curtains unless there are certified as breakaway ... 11. The height and accessibility of plumbing, electrical work, etc., must never be such that it can be used as a base for self harm or suicide ... 14. Any materials installed for shelving or holding supplies, including tooth brushes, etc. must not have sharp edges that can be used to harm self or others ... 16. All installations must be in accord with licensure codes for psychiatric inpatient units ..."
Review of facility policy on January 24, 2017, "Hazardous Surveillance Rounds," undated revealed " ... as part of an ongoing safety program, the Environmental and Safety Department shall coordinate the performance of all hazardous surveillance rounds of the facility known as 'environment of care' rounds, to accrue and evaluate information concerning safety practices, hazardous conditions, exposure monitoring and staff knowledge' ... 18. immediate actions should be made to correct those unsafe conditions that are within the capabilities of the department director or staff. NOTE: Should conditions or hazards pose an immediate threat to life, health, or safety the situation must be immediately and appropriately addressed and reported to the Patient Safety Officer."
Review of facility document on January 24, 2017, "Executive Summary for Tenet Quality Management Audit" conducted on March 22, 2016, revealed " ... All findings and recommendation assessed as "high" must have an action plan to correction completed and submitted via Compliance Central within then (10) days of when you are notified that the full audit report is accessible in Compliance Central. A comprehensive action plan which addresses all items assessed as requiring action must be submitted via compliance Central within thirty (30) days of when you are notified that the full audit report is accessible in Compliance Central. This Executive Summary is not inclusive of all the deficiencies identified in the QM Audit, only those with actual/potential high risk or significant negative outcome related to compliance, patient safety, Tenet policy, regulatory, licensing and accrediting agency requirements." Further review of the document revealed " ... 5 EC-Life Safety Findings: sinks are not push button water control type, handles and faucet would support a nose. Priority: high-Provides an anchor point for ligature device. Recommendation: Replace the sinks with hardware without anchor points. Findings: The bathroom doors and the doors into the hallway would support a knotted sheet that could be used as a noose. There is no alarm system on the doors. Priority: High- Provides an anchor point for a ligature device. Recommendation: Replace the bathroom doors with ones that do not provide an anchor point (soft suicide prevention door, remove the door) ... Doors into the hallway need a system to prevent the use of a ligature device ... Findings: Patient room doors are at risk of barricading. Priority: High - Delays immediate access in an emergency Recommendation: Ensure the door cannot be barricaded. Finding: Bedside tables are not bolted down and have drawers. Priority: High . Drawers can be pulled out and used as a weapon. Table can be used to help barricade the patient room door. Recommendation: Replace the bedside table with one open shelves that can be bolted to the floor. Findings: Patient rooms doors do not lock. Priority: High- Patients can enter vacant rooms. Reduces ability to monitor patients. Recommendation: Ensure all patient rooms can be locked. Finding: There is a chest in the patient room with drawers that could be pulled out and used as a weapon. Priority: High - Drawer could be used as a weapon. Recommendation: Remove the drawers. Findings: In the patient room bathroom, there is a light cover that can be removed, allowing for access to the globe. Priority: High - the globe can be broken into a sharp object. Recommendation: Replace the light cover with a barrier that cannot be removed." Continued review of this document revealed a distribution list of these findings to employees that included EMP1, EMP6, EMP10, EMP14, EMP12, EMP15, EMP16 and EMP17.
Review of facility document on January 24, 2017, of facility document "Behavioral Health Risk Assessment," dated October 2016, revealed " ... High Alert! Light fixtures in the bathroom do not meet regs due to patient able to access the globe ... All electrical device (switches, outlets, etc.) cover plates must be attached with tamper resistance screws ... Patient room to corridor doors present the possibility of patients barricading themselves in their rooms to delay staff members' access ... The top of all tight-fitting doors provides a pinch point that allows a patient to tie a knot, place it over the top of the door and close the door. This provides a hanging device ... It is highly desirable to keep vacant patient rooms locked at all times to avoid other patients entering these rooms without staff 's knowledge ... All lavatory waste and supply piping must be enclosed and should not be accessible to patients ... High Alert!!! Sink faucets are a high suicide risk due to use of gooseneck and long handles. Need replacement ASAP ... Open nurses station patients able to get into area ... Computers are behind nurses station but we have had past incidents where patients have gotten into nurses' station."
Review on January 26, 2017, of facility document "EOC (Environment of Care) Update," dated September 30, 2016, revealed " ... Sinks are not push button water control type, handles would support a noose. Replace the sinks with hardware without anchor points ... The bathroom doors and doors into hallway would support a knotted sheet that could be used as a noose ... Patient room doors are at risk of barricading ... In the patient room bathroom, there is a light cover that can be removed, allowing access to the globe."
Observation of the Psychiatric Medical Care Unit (PMCU) on January 24, 2017, between 11 AM and 12:15 PM revealed a 20 bed psychiatric patient care adult unit. Further observation of the PMCU revealed the following:
1. Nine out of 11 patient rooms (Room number 1122, 1121, 1118, 1109, 1110, 1111, 1117, 1116, 1115) contained the following: Standard and Phillips screws were being utilized, piano hinges with loopable attachment points at top, three windows were in all of these rooms had two loopable locks on each window, bathrooms had loopable sink faucets, loopable faucet handles, loopable exposed plumbing, loopable light fixture over the sink with breakable plastic covering exposing light bulb.
2. Outside of all 20 patient rooms had sharp/metal patient information clips attached on the hallway wall.
3. Rooms 1106 and 1121 ceiling vent in the bathroom was hanging down.
4. Rooms 1111, 1116, 1117, 1118, 1122 and 1121 had loopable towel dispensers.
5. Rooms 1109, 1120, 1122 had Oxygen storage boxes attached to the wall that were protruding out about 3 inches. Metal face plates that housed Oxygen connections had been tampered with.
6. Room 1111 contained a mechanical closet with a loopable three pin-hinged door. The face plate for the call bell in this room was damaged with sharp edges and was also loopable. The ADA sink was loopable.
7. Room 1115 had a loopable thermostat in the bathroom.
8. All patient bedroom doors opened inward creating a risk for barricading.
9. The community shower had loopable a call bell, rust on the door, the door handles, missing grout and a black substance on the floor.
10. Hallway alcove across from Room 1108 contained a wall mounted fire alarm with a electrical cord that extended from the alarm to the ceiling that was loopable, an environmental closet with loopable pin type hinges, a fire extinguisher cabinet/case with two wooden brackets that secured the doors covering the plexiglass creating a ligature point.
11. The main hallways had three loopable thermostat cages.
12. The main hallway ceiling vents not flushed with ceiling.
13. The main hallway and dayroom safety mirrors had loopable extension brackets.
14. The Activity Room contained the following: a three pin-hinged entrance door, the back of the door had a door closure device that could be loopable, the interview room alcove room could not observable from nurse's station and had a loopable door knob, a piano with the top accessible with exposed wiring and sharp hardware, the dry erase board with sharp/metal ledge.
15. Observation of the of Nurses' Station between 11:40 AM and 11:50 AM, revealed there was no staff consistently monitoring the video safety cameras during this time. Further observation revealed the potential for patients to enter this unsecured area to access unsafe office tools such as computer cables, hole punchers.
On January 24, 2017, surveyor made a request to EMP6 at 3:30 PM and EMP2 at 5:30 PM for previous environment of safety monitoring audits and any associated meeting minutes that discussed the environmental risk assessment at the Quality Assurance Performnce Improvement Meeting, Risk Management Meeting, and Patient Safety Meetings for the PMCU. EMP2 and EMP6 confirmed there was no documented evidence the results of the survey were reported or discussed at the above meetings.
Interview on January 24, 2017, between 11 AM and 12:15 PM, with EMP6 and EMP11 confirmed the above findings and confirmed upgrades to meet patient safety standards were only completed for 2 out of 11 rooms due to funding.
Interview with January 24, 2017, at 3:22 PM with EMP18 confirmed staff was not assigned to monitor the video monitoring camera at the nurses station.

Interview on January 25, 2017, at 10:45 AM with EMP2 confirmed 11 of 15 patients on the PMCU were on suicidal precautions.
Interview on January 26, 2017 at 2 PM with EMP10 confirmed they were aware of the environmental safety concerns within the Psychiatric Medical Care Unit's physical environment that were identified during the facility's "Behavioral Health Risk Assessment", through an "EOC Update," dated September 30, 2016 and the "Tenet Quality Management Audit," dated March 22, 2016.
Interview on January 27, 2017 at 10:43 AM with EMP12 confirmed request for funds to complete environmental safety concerns that were identified March 22, 2016, was requested until the Department was onsite


Cross Reference:
482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" within two days of admission and/or within two days prior to discharge for four of four medical records reviewed for IMM provided to Medicare beneficiaries (MR12, MR15, MR17, MR18).

Findings include:

Review on January 27, 2017, of facility policy "Hospital Coverage Notices For Medicare Inpatients (Including Important Message From Medicare)" effective August 8, 2016, revealed " ... V. Procedures ... b. The admission IMFM (Important Message From Medicare) must be given to the beneficiary as soon as possible within two (2) calendar days of admission, or at preadmission, but not more than seven (7) calendar days before admission ... 2. Follow-Up Notice ... b. The Follow-Up Notice must be given to the beneficiary as soon as possible before discharge, but no more than two (2) calendar days before discharge.

1) Review of MR12, MR15, MR17 and MR18 on January 27, 2017, revealed no documentation this Medicare beneficiary was provided with an IMFM within two days of discharge.

Interview with EMP5 on January 27, 2016, at 2:00 PM confirmed there was no documented evidence that MR12, MR15, MR17 and MR18 were provided with an IMFM within two calendar days prior to discharge.



482.12 Governing Body
482.13 Patient Rights Condition
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to their physician of the hospital admission and/or failed to document in the medical record if the patient requested or declined a family member or representative to be notified of the hospital admission including date, time and method of the requested notification in four of four medical records reviewed (MR12, MR13, MR15, MR17).

Findings include:

1) Review on January 26, 2017, of facility document "Rules and Regulations of The Medical Staff of Hahnemann University Hospital" revised November 1, 2016, revealed "Article II. General Conduct of Care ... 1. Responsibility of Care ... The patient's attending physician at all times maintains responsibility for communicating the condition of the patient to the referring practitioners and to the relatives of the patient ... "

2) Review on January 27, 2017, of MR12 revealed the patient was admitted to the facility on January 9, 2017. Further review of MR12 revealed no documented evidence in the medical record whether the facility asked the patient if they requested or declined notification to his/her own physician of the hospital admission or whether they requested or declined notification to his/her family member or representative of the hospital admission, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.

3) Review on January 27, 2017, of MR13 revealed the patient was admitted to the facility on December 21, 2016. Further review of MR13 revealed no documented evidence in the medical record whether the facility asked the patient if they requested or declined notification to his/her own physician of the hospital admission.

4) Review on January 27, 2017, of MR15 revealed the patient was admitted to the facility on December 21, 2016. Further review of MR15 revealed no document evidence in the medical record whether the facility asked the patient if they requested or declined notification to his/her own physician of the hospital admission or whether they requested or declined notification to his/her family member or representative of the hospital admission, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.

5) Review on January 27, 2017, of MR17 revealed the patient was admitted to the facility on December 14 2016. Further review of MR17 revealed no document evidence in the medical record whether the facility asked the patient if they requested or declined notification to his/her family member or representative of the hospital admission, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.

6) Interview with EMP5 on January 27, 2017, between 2:30 and 3:30 PM confirmed there was no documentation in the medical record for MR12, MR13, MR15, and MR17 of whether the patient requested or declined notification to the patient's own physician, and/or family member or representative, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.


Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility policies and procedures, review of facility documents, observations and interviews with staff (EMP). It was determined the facilty failed to ensure patients' rights to receive care in a safe setting.

Findings include:

Review on January 24, 2017, of facility policy, "PMCU Suicide/Self-Injury Patient Management, "revealed" ... Goals ... A ... To promote physical safety by maintaining a safe environment."

Review of January 24, 2017, of facility document, "Census-Tuesday January 24, 2017," revealed PT5, PT6, and PT7 were on suicidal precautions.

Observation of the Psychiatric Medical Care Unit's Activity Room on January 24, 2017, at 3:10 PM revealed PT5, PT6, PT7 were in the room without staff supervision.
Interview on January 24, 2017, at 12:10 PM, with EMP8 confirmed patients are not allowed to be alone in Activity Room unless they can be viewed from Nurse's station.
Interview on January 24, 2017, at 3:15 PM, with EMP7 confirmed PT5, PT6, and PT7 were alone in Activity Room with no staff supervision and they were not visible from Nurse's station.

Cross Reference:
482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that each use of restraint was in accordance with a written modification to the patient's plan of care for three of four medial records reviewed for restraint usage (MR12, MR14, MR23).

Findings include:

Review on January 27, 2017, of facility policy "Guidelines for Restraint Use in Patient Care," revised March 2016 revealed " ... Section Two: Violent, or Self-Destructive Behavior Use of Restraints ... B. Authorization and Ordering of Restraint ... Document his/her assessment of an plan of care for the patient ... Section Three: Non -Violent or Non-Self Destructive Use of Restraints ... B. Documentation ... use of restraint must be addressed in the patient's modified plan of care ... "

Review of MR12 on January 27, 2017, revealed the patient was in non-violent or non-self-destructive restraints on November 28, 2016. Further review of MR12 revealed no documented evidence the patient's plan of care was modified for the use of restraints.

Review of MR14 on January 27, 2017, revealed the patient was in violent or self destructive restraints on June 27, 2016. Further review of MR14 revealed no documented evidence the patient's plan of was modified for the use of restraints.

Review of MR23 on January 27, 2017, revealed the patient was in restraints on July 10, 2016, for violent or self destructive behavior. Further review of MR23 revealed no documented evidence the patient's plan of care was modified for the use of restraints.

Interview on January 27, 2017, with EMP5 confirmed there was no documented evidence the patient's plan of care was modified for the use of restraints.

Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review facility documents and interview with staff (EMP), it was determined the facility failed to ensure a safe and secure environment was provided in the Psychiatric Medical Care Unit.

Finding include:

Review on January 24, 2016, of Faciltiy policy "Hazardous Surveillance Rounds," no date provided, revealed "2. Hahnemann University Hospital will conduct environmental tours at least every six months in areas where patients are served ... 5. Environment of Care Rounds (EOC) of all patient care areas of the facility will be performed on a semi annual basis ... 12. An EOC Rounds Report of all identified discrepancies shall be submitted to and addressed by the appropriate responsible parties which may include but not limited to: a. Director of Maintenance, b. Director of Environmental Services, c. Materials Management, d. Patient transportation, e. Department Director, f. Hospital administration, g. EOC Committee ... 13. Upon receipt of the EOC Rounds Report, the responsible Department Director/and or responsible person for corrective actions must respond to the Safety Officer in writing with a plan of corrective action within 30 days of receipt of request ... 16. As each identified hazard is corrected, the Safety Officer will update the original EOC Rounds Report."

1. A request was made on January 24, 2017, at 10:45 AM to EMP6 for the environmental rounds report, corrective actions related to the rounds conducted in 2016, and the None provided.

Interview on January 24, 2:00 PM with EMP6 confirmed there was no documentation that the environmental rounds were completed.

Based on review of facility polices and procedures, review of facility documents, observations and interview with staff (EMP), it was determined the facility failed to ensure confidentiality of patients' medical records on the Psychiatric Medical Care Unit (PMCU).

Findings include:

Review on January 26, 2017, of facility policy "Patient's Rights and Responsibilities," dated September 2014 revealed " ... Patient's Bill of Rights ... 4. A patient has the right to have all records pertaining to his/her medical care treated as confidential ..."

Review on January 24, 2017, of facility document "Behavioral Health Risk Assessment," dated October 2016, revealed "...we have had past incidents where patients have gotten into nurses' station."

Observation of the of PMCU Nurses' Station on January 24, 2017, revealed there were paper medical records were kept in this area and patients could access the nurses station through two unsecured swinging doors. Further observation of the Nurses' Station on January 24, 2017, between 11:40 AM to 11:50 AM revealed there was no staff continuously in this area to prevent unauthorized access to the paper medical records.

Interview on January 24, 2017 at 11:50 AM, with EMP6 and EMP11 confirmed there was no staff continuously present in this area during the above observation period to prevent unauthorized access to patient medical records.


Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on observation, review of policies and procedures, and interviews with staff (EMP), it was determined the facility failed to ensure a clean and sanitary environment in the clinical laboratory.
Findings include:
Observation on January 27, 2017, between 3 and 4 PM, of the clinical laboratory department revealed there were numerous dust bunnies (a ball of dust and fluff) and other dirty debris on the floors in the Hematology, Coagulation, Microbiology, and Human Leukocyte Antigen (HLA) areas of the department.
Review on February 7, 2017, of "Safety Policy: SM 201 Chemical Hygiene Plan", dated June 2016, revealed "... XVIII. Housekeeping Floors are cleaned regularly by Environmental Services."
Interview with EMP20 on January 27, 2017, at 3:43 PM, confirmed there were numerous dust bunnies and other dirty debris on the floors in the hematology, coagulation, microbiology, and Human Leukocyte Antigen (HLA) areas of the department.


Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(b)(6) Standard: Disposal of Trash
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on observation, and review of policies and procedures and interviews with staff (EMP), it was determined the facility failed to follow its own established policy by not having lids/covers on 18 of 18 garbage cans in the dietary department.

Findings include:

Tour of the Dietary department on January 27, 2017, at 2:50 PM, revealed 18 garbage cans that did not have lids or covers on them and were not all in continuous use.

Review on January 27, 2017, of policy "Garbage Holding and Covers", dated December 2016, revealed "... 4. Receptacle Covers: a Inside - Receptacles and waste handling units for refuse ... shall be kept covered inside the food establishment if the receptacles: i. Contain food residue and are not in continuous use ..."

Interview with EMP19 on January 27, 2017, at 2:50 PM, confirmed the 18 garbage cans did not have lids or covers on them and were not all in continuous use.



Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(c)(2) Standard: Facilities, Supplies, Equipment Maintenance

Based on review of facility policy and procedures, observation of patient care areas, and interview with staff (EMP), it was determined the facility failed to ensure disposable syringes and needles were maintained in secure areas with access available only to authorized personnel.

Findings include:

Review on January 27, 2017, of facility policy "Clean Supply Storage Guidelines," reviewed February 2016 revealed " ... III. Specific Guidelines ... 5. Syringes, needles, and kits containing these items shall be secured in a manner which prevents unauthorized access to these items during transport, storage, use, and disposal."

1) Observation on January 26, 2017, at 11:30 AM of the 4th Floor PCU patient care unit revealed two unlocked isolation/treatment carts located in the hallway outside of patient rooms. Further observation of Cart #79 located outside of Room 468 revealed it contained with two butterfly needles and Cart #72 located outside of Room 465 contained an IV start kit that contained a needle.

Interview with EMP3 on January 26, 2017, at 11:30 AM confirmed the two unlocked treatment/isolation carts located in the hallway contained needles.

2) Observation on January 26, 2017, at 12:30 PM of the Surgical Trauma Intensive Care Unit (STICU) - Zone 1 on the 8th Floor revealed two unlocked cabinets above the handwashing sink that included a supply various syringes and needles that included 3cc and 5 cc syringes, 18 and 22 gauge needles, insulin syringes, 25 gauge hypodermic needles, 14, 20 and 22 gauge IV catheter start kits.

Interview with EMP4 on January 26, 2017, at 12:30 PM confirmed the Zone 1 unlocked cabinet containing the various sizes of syringes and needles and unlicensed personnel had access to the area.

3) Observation on January 26, 2017, at 12:45 PM of the STICU - Zone 2 revealed two unlocked cabinets located over the handwashing sink that contained a supply of various sizes of syringes and needles that included ABG needles, insulin syringes, 18, 22 and 23 gauge needles.

Interview with EMP4 on January 26, 2017, at 12:45 PM confirmed the unlocked cabinets contained various sizes of syringes and needles and unlicensed personnel had access to the area.

Cross Reference:

482.12 Governing Body
482.13 Patient Rights Condition
482.13(a)(1) Standard:Notice of Rights
482.13(b)(4) Standard: Admission Status Notification
482.13 (c)(2) Standard: Care in a Safe Setting
482.13(e)(4)(i) Standard: Restraint of Seclusion
482.21 QAPI Condition
482.21(a),(c)(2),(e)(3) Standard: Patient Safety
482.24(b)(3) Standard: Protecting Patient Records
482.41 Physical Environment: Condition
482.41(a) Standard: Maintenance of Physical Plant
482.41(b)(6) Standard: Disposal of Trash