HospitalInspections.org

Based on observations and staff interviews, the hospital failed to ensure patients received care in a safe environment by failing to ensure electrical wires with 110 volts of electricity flowing through them were not accessible to psychiatric patients.

Findings:

A tour of the Psych Unit revealed a white and black electrical wire with electrical wire nuts covering the exposed wire ends hanging approximately 7 inches from the ceiling in a hall way.

On 10/22/2020 at 10:40 a.m. S1Adm stated the wires were for an Exit sign that a patient had broken but she was not sure of the exact date it was broken.

On 10/22/2020 at 10:45 a.m. in an interview S5Main verified the hanging wires were 110 volts for an Exit sign and electricity was still flowing to said wires. He further stated that a psych patient broke 2 days prior. S5Main also verified if someone grabbed both wires and pulled the wire nuts off they be shocked with the 110 volts.

Based on record reviews and interviews the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure to ensure all patient admission orders were followed for 5 of 5 (#1, #2, #3, #4, #5) of 5 sampled patients; and
2) failure to ensure complete and accurate skin and wound assessments of a patient was documented by nursing for 1 of 5 (#2) sampled patients; and
3) failure to document patient medication administration as ordered for 1 of 5 (#2) patient's medical records reviewed for medication administration documented as ordered.

Findings:

1. Failure to ensure all patient admission orders were followed for obtained from a licensed provider for 5 of 5 (#F1, #F2, #F3, #F4, #F5) of 5 sampled patients.

A review of Patient #1, #2, #3, #4 and #5's admission orders reveal the box checked "Yes" next to PT, evaluate OT, evaluate. Further review failed to reveal any documented OT evaluation or documentation canceling the order for OT to evaluate.

On 10/21/2020 at 11:20 a.m. S4PTA confirmed no patient has received an OT evaluation as today. He stated the hospital nor the contracted service has an OT who is coming to complete the ordered OT evaluations.

On 10/21/2020 at 12:58 in an interview S1Adm verified the hospital does not have an OT or ST.

2. Failure to ensure complete and accurate skin and wound assessments of a patient was documented by nursing for 1 of 5 (#2) sampled patients.

A review of Patient #2's medical record revealed on 10/09/2020 and 10/10/2020 nurse documented wound Right labia but failed to document a complete skin/ wound assessment.
On 10/22/2020 at 3:10 p.m. in an interview S2DON and S1Adm verified the nurse failed to document a skin/ wound assessment.

3) Failure to document patient medication administration as ordered for 1 of 5 (#F2) patient's medical records reviewed for medication administration documented as ordered.

A review of the hospital policy titled Skin Care Protocol effective date 09/2017 revealed in part:
vi. Institute measures to contain fecal and/ or urinary continence and protect the skin from incontinence.

Review of the physician orders revealed the following orders: Clean right Labia with wound cleanser, pat dry, apply Calmoseptine cream daily and PRN with each soiled brief change.
Further review revealed the following adult brief changes due to urine and stool:
- 10/07/2020 urine x 5
- 10/08/2020 urine x 6, stool x1
- 10/09/2020 urine x 5, stool x 2
- 10/10/2020 urine x 6

A review of Patient #2's medical record from 10/07/2020 through 10/11/2020 at the time if transfer failed to reveal any documentation of the Calmoseptine cream ever being applied to the patient as ordered.

On 10/22/2020 at 4:00 p.m. in an interview S2DON verified the above medication was never documented as ordered.

Based on record review and interview, the facility failed to ensure all information needed to provide appropriate care was contained in patients' medical records. This deficient practice was evidenced by not having completed Physical Therapy evaluations and treatment plans, signature of the Physical Therapist completing the evaluation or date for 4 (#2, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) patient records reviewed receiving rehab services.

Findings:

A review of the hospital policy titled Assessment and Reassessment effective date 09/2017 revealed in part:
B. Therapy Documentation:
1. If the Physician ordered, Physical Therapy, Occupational Therapy and/ or Speech Pathology will complete their portion of the Interdisciplinary Patient Assessment within 72 hours.
The assessment includes:
a. Functional assessment of strength, endurance, locomotion, posture, coordination, sensation, swallowing, comprehension, expression, cognition, leisure activities, hobbies, psychosocial/ neurological status, daily living skills, and home and community skills.
b. Indication and contradictions for treatment.
c. Treatment goals based on the findings of the functional assessment.
2. The therapist's signature should be included in the appropriate section of their assessment.
3. Dates and times should also be entered into the documentation.

An observation of Patient #2's PT EMR revealed the record was initiated on 10/08/2020 and watermark identifying the record as incomplete. Further review failed to reveal a completed Plan of Treatment.

An observation of Patient #3's PT EMR revealed the record was initiated on 10/14/2020 and watermark identifying the record as incomplete. Further review failed to reveal a completed Plan of Treatment.

An observation of Patient #4's PT EMR revealed the record was initiated on 10/20/2020 and watermark identifying the record as incomplete. Further review failed to reveal a completed Plan of Treatment.

An observation of Patient #5's PT EMR revealed the record was initiated on 10/14/2020 and watermark identifying the record as incomplete. Further review failed to reveal a completed Plan of Treatment.

On 10/22/2020 at 1:25 p.m. in an interview the S1Adm stated PT evaluations should be completed within 72 hours.

On 10/21/2020 at 2:20 p.m. in an interview S4PTA verified the PT evaluations were incomplete and not within the paper patient charts.

Based on observations, record review and the hospital failed ensure a system for controlling infections and communicable diseases of patients and personnel were established during a national pandemic of Covid-19. This deficient practice was evidenced by the hospital's:
1) failure to ensure used PPE was properly stored or disposed of;
2) failure to ensure all opened medications which were available for patient use were properly labeled and dated and or not expired; and
3) failure to ensure opened food was not stored in the medication refrigerator.

Findings:

1) Failure to ensure used PPE were properly stored or disposed of.

On 10/20/2020 at 11:15 a.m. a tour of the hospital revealed the blue plastic PPE gowns with the waistband tied in a knot and the band torn blue plastic PPE gowns: 2 used gowns hanging on storage door hinges in the hallway near the nurse's station, 1 used gown hanging on the patient scale near the nurse's station and 1 used gown hanging on a screw on the wall below the Exit sign in the hall near the nurse's station.

On 10/20/2020 at 11:15 a.m. DON verified they were used and should have been hanging in those locations.
An observation of the medication room revealed a used N95 mask hanging on the IV Piggyback wall next to premixed patient IV medications. The N95 mask's metal nose piece was bent to fit and the inside of the mask contained brown spots.

On 10/20/2020 at 11:55 a.m. in an interview DON verified the dirty N95 mask and confirmed it should not have been hanging there.

2) Failure to ensure all opened medication available for patient use were properly labeled and dated and or not expired.

A review of the hospital policy titled Multiple- Dose Medications effective date 09/2017 reads in part:
The Manufacturer's Expiration Date is applicable of the container is unopened and stored per recommendations. Once the container is opened, a beyond- used date must be applied to it. The following guidelines should be followed.
A. The Healthcare Professional first puncturing or opening the medication container must initial the vial/ medication container, and place the date of the first use of the container.

Multiple- dose medication vials may be used up to 28 days after initial entry, unless the Manufacturer recommends a shorter time.

An observation of the Psyc. Unit medication refrigerator revealed open undated and or expired medications.
- 1% Lidocaine 100 mg per 10 ml opened and not dated;
- 1% Lidocaine 200 mg per 20 ml opened and not dated with a manufacture expiration date of 08/01/2020.

On 10/22/2020 at 10:30 a.m. in an interview S6RN verified the open undated and or expired medication.

An observation of the LTAC Unit medication refrigerator revealed following opened undated and or expired medications:
- Acetycyst 20% Sol opened and not dated,
- Tuberculin Purified Protein Derivative (Mantoux) opened and not dated with a manufacture expiration date of 05/22/2020.

On 10/22/2020 at 11:40 a.m. in an interview S7RN verified the opened undated and expired medication.

3) Failure to ensure opened food was not stored in the medication refrigerator.
An observation of the patient nourishment refrigerator revealed 4 opened and not dated containers of ice-cream as well as a Wendy's Vanilla Frosty.

On 10/20/2020 at 11:50 a.m. in an interview S2DON verified the opened and undated ice-cream and frosty.

Based on record reviews and interviews, the hospital failed to ensure that all rehabilitation (rehab) services provided were documented in the patient's medical records in accordance with requirements at §482.24 as evidenced by failing to have documentation of the speech therapy (ST) signature or date for 4 (#2, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) patient PT evaluation records reviewed receiving rehab services.

Findings:

A review of the hospital policy titled Assessment and Reassessment effective date 09/2017 revealed in part:
B. Therapy Documentation:
1. If the Physician ordered, Physical Therapy, Occupational Therapy and/ or Speech Pathology will complete their portion of the Interdisciplinary Patient Assessment within 72 hours.
The assessment includes:
a. Functional assessment of strength, endurance, locomotion, posture, coordination, sensation, swallowing, comprehension, expression, cognition, leisure activities, hobbies, psychosocial/ neurological status, daily living skills, and home and community skills.
b. Indication and contradictions for treatment.
c. Treatment goals based on the findings of the functional assessment.
2. The therapist's signature should be included in the appropriate section of their assessment.
3. Dates and times should also be entered into the documentation.

An observation of Patient #2's PT EMR revealed the record was initiated on 10/08/2020 and watermark identifying the record as incomplete. Further review failed to reveal S8PT's signature or date.

An observation of Patient #3's PT EMR revealed the record was initiated on 10/14/2020 and watermark identifying the record as incomplete. Further review failed to reveal S8PT's signature or date.

An observation of Patient #4's PT EMR revealed the record was initiated on 10/20/2020 and watermark identifying the record as incomplete. Further review failed to reveal S8PT's signature or date.

An observation of Patient #5's PT EMR revealed the record was initiated on 10/14/2020 and watermark identifying the record as incomplete. Further review failed to reveal S8PT's signature or date.

On 10/22/2020 at 1:25 p.m. in an interview the S1Adm stated PT evaluations should be completed within 72 hours.

On 10/21/2020 at 2:20 p.m. in an interview S4PTA verified the missing signatures and dates.