HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and Governing Body bylaws, the Governing Body failed to develop and maintain effective systems that ensured that patients received high quality healthcare that met their needs in a safe environment.

Failure to ensure patients are provided with care that meets acceptable standard of practice and meets the patient's healthcare needs in a safe environment risks deterioration of the patient's condition and poor healthcare outcomes

Findings included:

1. The hospital's Governing Body bylaws (January 2017) showed that the Governing Body's purpose is to establish an organized medical staff and other hospital departments whose responsibility would be to ensure high quality patient care. The bylaws showed that Governong Body will establish and implement an effective program for improvement of performance throughout the hospital.

2. Observation, interviews, record review, review of hospital policies and procedures, and review of the hospital's quality and Utilization Management program showed the following:

a. The Governing Body failed to ensure that medical care providers were considered an integral part of the patient's health care team; to review professional services as part of the utilization review process; and to include medical care outcomes as part of the hospital's quality program.

Cross Reference: A0049, Item #1

b. The Governing Body failed to ensure that the hospital developed and implemented an effective process for referring patients to health care consultants and for considering and acting on recommendations made by consultants as part of the treatment planning process.

Cross Reference: A0049, Item #2

c. The Governing Body failed to ensure that medical staff members developed and implemented care plans for patients with physical rehabilitation needs

Cross Reference: A0049, Item #3

d. The Governing Body failed to ensure that medical staff members developed and implemented care plans for patients with nutritional needs

Cross Reference: A0049, Item #4

3. On seven occasions during the survey, surveyors determined that conditions existed at the hospital that posed Immediate Jeopardy to the health and safety of patients.

Due to these findings and the scope and severity of deficiencies detailed under 42 CFR 482.13 Condition of Participation for Patient Rights; 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement; 42 CFR 482.23 Nursing Services; 42 CFR 482.26 Condition of Participation for Radiological Services; 42 CFR 482.30 Condition of Participation for Utilization Review; 42 CFR 482.41 Condition of Participation for Physical Environment; and 42 CFR 56 Condition of Participation for Rehabilitation Services, the Condition of Participation for Governing Body was NOT MET.

Cross Reference: Tags A0115, A0263, A0385, A0528, A0652, A0700, A1123
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Based on observation, interviews, document reviews, and review of hospital policies and procedures, the hospital failed to protect and promote patient rights.

Failure to to protect and promote each patient's rights risks the patient's loss of personal freedom, privacy, dignity, and psychological harm.

Findings included:

1. The hospital failed to ensure patients receive care in a safe setting which safeguards vulnerable individuals from self-harm and harm from others;

2. The hospital failed to to release patients from seclusion or restraints at the earliest possible time when documented behavior reflected no imminent risk of danger;

3. The hospital failed to to monitor the patient in restraints or seclusion as directed by hospital policies and procedures;

4. The hospital failed to to communicate the results of patient complaints prior to closure of the complaint;

5. The hospital failed to to maintain confidentiality of patient medical records.

The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient safety and protect patient rights.

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

Cross-Reference: Tags A0123, A0144, A0145, A0146, A0174, A0175
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Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop a hospital-wide quality assessment and performance improvement (QAPI) plan to monitor, evaluate, and improve the quality of patient care services through systematic data collection and analysis.

Failure to systematically collect and analyze hospital-wide performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. The hospital failed to develop and implement a QAPI program that measured meaningful quality indicators for all departments and services.

Cross Reference: Tag A0273

2. The hospital failed to develop and implement an effective QAPI program that included systems for ensuring the patient care environment is free from safety hazards, including plans for implementing a fire watch due to an impaired fire suppression system.

Cross Reference: Tags A0700, A0710 (Fire/Life Safety Statement of Deficiencies)

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.21, Quality Assurance and Performance Improvement was NOT MET.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff members provided nursing care in accordance with the patient's health care needs.

Failure to provide nursing care based on patient assessments and recommendations of health care consultants risk deterioration of the patient's health status and poor health care outcomes.

Findings included:

1. The hospital failed to ensure that nursing staff developed and implemented care plans for patients at high risk for falls,

2. The hospital failed to ensure that nursing staff members developed and implemented care plans for patients with nutritional needs.

3. The hospital failed to ensure that hospital staff members had an effective system to communicate patient care recommendations made by health care consultants.

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.23, Nursing Services was NOT MET

Cross Reference: A0396
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Based on observation, interview, document review, and policy and procedure review, the hospital failed to ensure that radiologic services was properly operated and maintained.

Failure to properly operate and maintain radiologic services places staff and patients at risk of injury and patients at risk for inadequate care.

Findings included:

1. The hospital failed to ensure the department was supervised by a radiologist.

2. The hospital failed to update policies and procedures to ensure they comply with current standards of practice.

3. The hospital failed to provide regular staff training for radiology department staff members.

4. The hospital failed to conduct staff competency evaluations at regular intervals.

5. The hospital failed to ensure shielding equipment is tested at regular intervals.

Due to the scope and severity of deficiencies cited under 42 CFR 482.26, the Condition of Participation for Radiologic Services was NOT MET.

Cross Reference: Tags A0535, A0536, A0546
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Based on interview and document review, the hospital failed to implement it's utilization review plan for services provided to hospital patients.

Failure to develop and implement a plan for review of care provided to patients limits the hospital's ability to improve healthcare services and risks poor patient outcomes.

Findings included:

Interviews with quality program and Utilization Management (UM) staff members; and review of the hospital's Utilization Management Plan (Effective October 2015) and quality program data revealed the following:

1. UM managers did not aggregate and submit data regarding the quality of care provided as directed by the hospital's Utilization Management Plan, including medical necessity of admissions, duration of hospital stays, discharge planning, and efficacy of professional services .

2. The Utilization Management Committee did not review professional services as part of the utilization review process.

Cross Reference: A0273, A0658
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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to provide a safe and secure environment for patients.

Failure to maintain a safe and secure environment risked serious injury or death for patients, staff, and visitors in the hospital.

Findings included:

The hospital failed to maintain a safe and secure patient care environment that included the following:

1. Systems for ensuring the patient care environment is free from safety hazards, including implementation of a fire watch due to inaccessible exits and inaccessible fire extinguisher cabinets; failure to maintain compliance with NFPA 101-2012 guidelines for fire drills; failure to maintain compliance with NFPA-25 for the hospital's fire sprinkler system; and failure to maintain compliance with NFPA 72 standards for the hospital's fire alarm system.

2. Systems for ensuring supplies were available, ready to use and not expired.

3. Systems to maintain air pressure relationships within industry standards in appropriate areas.

4. Systems to ensure that items used in the patient environment are maintained in good repair.

5. Systems to ensure the physical facility is maintained for patient safety.

Cross Reference: Tags A0710 (Fire/Life Safety Statement of Deficiencies) , A0724, and A0726

Due to the scope and severity of deficiencies identified during the survey, the Condition of Participation for Physical Plant and Environment was NOT MET.
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Based on observation, interview, document review, and policy and procedure review, the hospital failed to ensure that rehabilitation services were organized and staffed to ensure the health and safety of patients.

Failure to organize, staff, and operate the rehabilitative services according to acceptable standards of practice places patients at risk for inadequate or delayed care.

Findings included:

1. The hospital failed to organize the scope of services and adequately staff the physical therapy department to ensure patient needs were met.

2. The hospital failed to employ a director for occupational therapy services.

3. The hospital failed to ensure that physical therapy services were ordered before scheduling therapy sessions.

4. The hospital failed to ensure physical therapy services were documented in patient medical records.

5. The hospital failed to ensure staff performed rehabilitative services according to the patient's treatment plan.

Due to the scope and severity of deficiencies cited under 42 CFR 482.56, the Condition of Participation for Rehabilitation Services was NOT MET.

Cross Reference: Tags A1124, A1125, A1132, A1133, A1134
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Item #1 - Medical Care Quality Assessment and Interdisciplinary Team (IDT) Integration

Based on interview and review of the hospital's quality program, the Governing Body failed to ensure that medical care providers were considered an integral part of the patient's health care team; and to include medical care outcomes as part of the hospital's quality program.

Failure to include the medical care provider as an integral part of the IDT and to include medical care as part of the hospital's quality program risks delivery of substandard care and poor health care outcomes.

Findings included:

1. On 5/17/2017 at 9:15 AM, Surveyors #5, #6, #7, #8, #9, and #10 interviewed the Chief Medical Officer (Staff Member #M11), the Chief Nursing Officer (Staff Member #M12), the Deputy of Hospital Operations (Staff Member #M9), and the Chief of Quality (Staff Member #M4) regarding how medical physicians interface with the psychiatric care providers. The CMO stated that medical physicians were considered "consultants" and were not part of the psychiatric care team unless they were "invited". He stated each physician practices independently. Peer review was conducted for individual hospital cases but there were no medical outcome indicators for the patient population.

2. Review of the hospital's quality program and Utilization Management program confirmed the findings above.

Cross Reference: A0273, A0658


Item #2 - Referrals to Health Care Consultants

Based on observation, interview, and record review, the Governing Body failed to ensure that the hospital developed and implemented an effective process for referring patients to health care consultants and for considering and acting on recommendations made by consultants as part of the treatment planning process.

Failure to consider patient care recommendations made by health care consultants in the patient's treatment planning process risks deterioration in the patient's health status and poor health care outcomes.

Findings include:

1. On 5/11/2017 at 2:10 PM, Surveyors #5, #6, and #7 interviewed the Chief Executive Officer (Staff Member #M14) , the Chief Medical Officer (Staff Member #M11) the Deputy of Hospital Operations (Staff Member #M9), and the Chief of Quality (Staff Member #M4) about the medical referral process. The CMO stated the medical consultation process relies on "referral by exception", i.e. no automatic consults based on protocol or standard. He stated that the medical staff relies on issues identified by the nursing staff or medical problem concerns voiced by patients for referrals to be initiated.

2. On 5/17/2017 at 9:15 AM, Surveyors #5, #6, #7, #8, #9, and #10 interviewed the Chief Medical Officer (Staff Member #M11), the Chief Nursing Officer (Staff Member #M12), the Deputy of Hospital Operations (Staff Member #M9), and the Chief of Quality (Staff Member #M4) regarding how referrals to health care consultants are tracked. The CMO stated that referrals were currently not being tracked.

3. Observations, interviews, and medical record review confirmed that the hospital did not have an effective process that ensured health care consultant recommendations were part of the patient's treatment plan.

Cross Reference: A0049 Items #3 and #4, A0396, A1134


Item #3 - Medical Screening and Referral for Rehabilitation Services

Based on observation, interview, record review, and review of hospital policies and procedures, the Governing Body failed to ensure that medical staff members developed and implemented care plans for patients with physical rehabilitation needs, as demonstrated by Patient #KM1.

Failure to identify patients with physical rehabilitation needs and develop and implement treatment plans to meet those needs risks deterioration of the patient's health and prolonged hospitalization.

Findings included:

1. The hospital's policy and procedure titled, "Management of the patient at risk for falls" (Nursing Standard Protocol #339; Revised March 2017), under the heading: Area of Responsibility", read: "D. Physical Therapy Referral if needed ... "4. Refer for PT eval [evaluation] if: A. High Fall Risk (Tinetti score 0-19). B. Pt is non-ambulatory upon admit or with change of condition affecting ambulation".

Under the heading "F. Interdisciplinary Management Interventions", the policy read: "9. Consult with physical and occupational therapy to plan a program to increase patient's endurance and strength."

2. The hospital's policy and procedure titled "Medical Records Procedures Procedure: Rehabilitative Services Consult Referral" (WSH 23-59; Revised January 2013) read: " ...5. Possible Criteria for Referral: ...E. Physical Therapy deficit in: i. Range of Motion; ii. Muscle Strength; iii. Mobility (Transfers/Ambulation); iv. Neuromuscular or Musculoskeletal conditions".

3. On 05/08/17 at approximately 2:30 PM, Surveyor #9 observed patient #KM1, a 58 year old admitted on 04/26/17 for competency restoration, sitting in a wheelchair that was too small for the patient. The patient's feet were located on the foot pedals causing his knees to be bent at chest level. The patient's hands were placed on the wheels to propel the wheelchair, as a result, the patient's arms were bent and angled outward and elbows were above shoulder level.

4. Review of #KM1's medical record revealed the following:

a. On 04/08/17 while in jail, Patient #KM1 began exhibiting symptoms of left sided numbness, and weakness. The patient was evaluated by the jail nurse and found to have slurred speech, nystagmus (double vision), and his left pupil was larger than the right pupil. Patient #KM1 was transferred to an acute care hospital where he was diagnosed with an acute thromboembolitic cerebellar stroke. Review of the hospital chart revealed that the patient was referred for inpatient physical rehabilitation on 04/12/17.

The hospital discharge summary dated 04/22/17 read: "Patient seen in AM rounds. Still can't close right eye or puff up right cheek. But ambulating fine in the hallways. Medically stable to discharge." The patient KM#1 was returned to jail.

b. On 04/26/17, the patient was admitted to Western State Hospital for competency restoration. The Admission History and Physical Examination (Form WSH 23-55C) completed on 04/26/17 (signed by the physician on 05/03/17) read: "B. History of present illness ... History recent CVA [stroke] with left side paresthesia, dysphagia, and right facial weakness." On Page 4, the history and physical read: " ....decreased sensory on left side of body and face ....unable to test gait secondary unsteady gait". The medical record did not include a physician order for a Physical Therapy Referral/Consult or Speech Therapy consult as directed by hospital policy.

c. The Initial Nursing Assessment (Form WSH 23-60A) completed on 04/26/17 read: "Safe patient handling and movement assessment: ...2. Patient Level of Assistance: Stand-by-assist; 3. Weight bearing capability: ...partial; ...5. Applicable conditions likely to affect transfer/repositioning techniques ... paralysis/paresis; 6. Assistive Devices ...Wheelchair; Tinetti Test (Fall Risk Index): Balance and Gait score 16". A Tinetti Score of less than 20 indicated that patient was at high risk for falls. The medical record did not include a nursing referral for physical therapy consult based a Tinetti Score less than 20, per hospital policy.

5. On 05/08/17 at approximately 3:15 PM, Surveyor #9 interviewed Patient #KM1. At the time of the interview Patient #KM1 stated that both of his legs were numb, and that nothing works on his right side. The patient stated that he had been walking every day at the previous hospital with the help of staff or with a walker. He stated that he had not been walking since he came here.

6. On 05/08/17 at approximately 3:00 PM, Surveyor #9 interviewed Staff Member #KM 1. At the time of the interview, Surveyor #9, asked Staff Member #KM1 to look at the patient in the wheelchair. Staff Member KM#1 verified the wheelchair was too small for the patient. During the interview, Staff Member #KM1 revealed that Patient #KM1 had been using a walker on admission. Staff Member #KM1 stated that walkers were not allowed because they could be used as a weapon. Because of that, Patient #KM1 was given a wheelchair. Staff member #KM1, stated Patient #KM1 had not been walking since he had been admitted to the hospital.

Staff Member #KM1 confirmed that hospital staff members had not conducted a wheelchair assessment for this patient. The staff member stated there was only one wheelchair on the ward and all patients used that wheelchair. At the time of the interview, Staff Member #KM1 contacted the Equipment Manager (Staff Member #M10), and the patient received a larger wheelchair.

Staff Member #KM1 confirmed that there was no physical therapy consult ordered for Patient #KM1 by medical or nursing staff members.


Item #4 - Medical Orders for Nutritional Care

Based on interview and record review, the Governing Body failed to ensure that medical staff members developed and implemented care plans for patients with nutritional needs, as demonstrated by Patient #JW2.

Failure to identify patients with impaired nutrition and develop and implement treatment plans to meet the patient's nutritional needs risks deterioration of the patient's health and prolonged hospitalization.

Findings include:

On 05/16/17 at 2:30 PM, Surveyor #10 reviewed the medical records of Patient #JW2 and interviewed the Ward Administrator for the patient's treatment unit (Staff #JW6). This record review and interview showed the following:

1. The patient had a long history of refusing to eat. On 03/07/17, the patient underwent a surgical procedure for insertion of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted through the patient's abdominal wall into the patient's intestine) as an access for supplemental feeding.

2. On 03/10/17, a registered dietician (Staff Member #JW3) performed a dietary consult for the patient. She recommended that the PEG tube feedings be increased from four cans of dietary supplement a day to six cans per day to maintain nutritional and caloric needs. The dietician also noted that the patient was dehydrated and recommended increasing the amount of "free water" (additional water given during feedings) to 450 ml per day. On 04/07/17, the patient's physician (Staff Member #JW4) ordered PEG tube feedings four cans a day with no additional free water. On 04/13/17 a different physician (Staff Member #JW5) wrote an order that stated, "Refer to Dietary for PEG tube feeling adjustment. Weekly weight and chart."

3. On 04/24/17, the dietician (Staff Member #JW3) wrote a nutritional follow up note. She wrote that patient had lost 9.8 lbs. and recommended that the PEG tube feedings be increased to six cans of supplement a day. She wrote, "Refer to progress noted dated 03/10/17 by this writer for details, current fdg [feeding] amount not sufficient."

4. On 05/16/17 at 3:25 PM the Ward Administrator (Staff Member #JW6) and a registered nurse (Staff Member #JW7) confirmed that the registered dietician recommendations were not implemented and that the updated order had not been placed on the treatment orders to alert staff to increase the PEG tube feedings.
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Based on interviews, document review, and review of hospital policies and procedures, the hospital failed to ensure the results of the grievance investigation were shared with the patient for 3 of 4 grievances reviewed (Patients #K14, #K15, #K16).

Failure to inform the patient of the results of the grievance investigation violates their right to be informed and risks patient safety for unmet care needs.

Findings included:

1. The hospital policy and procedure titled, "Patients, Comments, Grievances, and Resolution" (Policy 10.07, Effective Date May 1, 2017) read: "Policy: ...WSH provides timely response to patient complaints, including allegations of patient rights violations, ensuring the patient receives fair and courteous treatment ...G. Grievance Process..2. If the grievance cannot be resolved within 7 days, the PRG [Patient Rights and Grievances] [department] sends a letter to the patients that states the anticipated date when the grievance response will be complete..3. The PRG Director will provide the investigation results in a closure letter to the patient within 30 days of receipt of the grievance. The closure letter includes: a. The hospital's decision; b. Name of the hospital contact person; c. Steps taken on behalf of the patient to investigate the grievance; d. Results of the grievance process; and e. Date of completion."

2. Surveyor #7 selected four patient complaints for review of process and resolution. Sources included the patient grievance log. Each complaint was reviewed for evidence of receipt, hospital review, investigation, findings, and resolution of the grievance issue with the findings reviewed with the patient who filed the grievance.

3. On 05/23/17, Surveyor #9 reviewed the charts of two patients (Patient #K14 and Patient #K15) who filed grievances that were then forwarded to Clinical Risk Management (CRM) for investigation. Surveyor #9 noted the following:

a. Patient #K14 filed a letter of complaint on 05/02/17 making allegations of staff abuse and neglect of a peer patient. A review of the grievance log indicated the complaint was closed.

Review of the grievance file showed a letter dated 05/03/17 from the Patient Rights Investigator (Staff Member #K12) had been sent to the patient informing the patient the grievance had been forwarded to the Clinical Risk Management for review. A second letter dated the same day from the Director of Patient Rights and Grievances (Staff Member #K13), was sent to the patient informing her the allegations had been forwarded to Clinical Risk Management to investigate and stated "No further action will be taken."

b. Patient #K15 filed a letter of complaint on 04/20/17 making allegations of staff harassment and abuse. A review of the grievance log indicated the complaint was closed.

Review of the grievance file showed a letter dated 04/20/17 from Staff Member #K12 had been sent to the patient informing the patient the grievance had been forwarded to the Clinical Risk Management for review. A second letter dated 04/21/17 from Staff Member #K13, was sent to the patient informing her the allegations had been forwarded to Clinical Risk Management to investigate and stated "No further action will be taken."

4. On 05/23/17, Surveyor #7 reviewed the charts of two patients who filed grievances that were then forwarded to Clinical Risk Management (CRM) for investigation. Surveyor #7 noted the following:

a. Patient #K16 filed a letter of complaint on 04/22/17 making allegations of staff abuse. A review of the grievance log indicated the complaint was closed.

b. Review of the grievance file showed a letter dated 04/24/17 from Staff Member #K12 had been sent to the patient informing the patient the grievance had been forwarded to the Clinical Risk Management for review. A second letter dated 04/25/17 from Staff Member #K13, was sent to the patient informing her the allegations had been forwarded to Clinical Risk Management to investigate and stated "No further action will be taken."

5. On 05/23/17 at 9:00 AM, Surveyors #7 and #9 interviewed the Director of Patient Rights and Grievances (Staff Member #13) about the hospital's complaint and grievance process. The discussion included how patients are provided a written notice of steps taken to investigate their grievance and how the results of the investigation are then communicated with the patient. For Patients #K14, #K15, and #K16 there was no action documented indicating the patients concern had been addressed or resolved. Staff Member #K13 indicated that grievances or allegations of abuse are referred to CRM for investigation and the grievance is closed. She was unsure who informed the patient about the results of the investigation once it was referred to CRM. Staff Member #K13 acknowledged that their office did not receive a copy of the CRM investigation report.

6. On 05/23/17 at 11:05 AM, Surveyors #7 and #9 interviewed the Director of Clinical Risk Management (Staff Member #K11) about the hospital's process for providing patients written notice of steps taken to investigate their grievance and how the results of the grievance investigation by the Clinical Risk Management Department is disseminated. Staff Member #K11 indicated that the results of the investigation are shared with the Center Director and the Center's Senior Nurse Leader but was uncertain if those results are then shared with the complainant. The Director of Clinical Risk Management acknowledged that no formal investigation report is sent to the Grievance Coordinator for closure with the patient.
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Item #1 - Security

Based on observation, interview, and review of hospital policies and the manufacturer's instructions for use, the hospital failed to develop policies and procedures for use of a hand-held metal detector that reflected the manufacturer's instruction for use; and to educate staff regarding use of the detector.

Failure to ensure that staff used the hand held metal detector according to the manufacturer's directions for use places patients and staff at risk of injury or harm from contraband (prohibited items) brought into patient care units.

Reference: Garrett Metal Detector Super Scanner User's Manual: "The Audio Alert also indicates battery condition. When approximately 10% of battery life remains, the sound when metal is detected changes from a warble to a steady tone...When approximately 10% of battery life remains, the Amber Alert Light will turn on, indicating the battery needs to be replaced or recharged."

Findings included:

1. Review of hospital's policy and procedure titled, "Wanding - Use of Hand-Held Metal Detector Wand" (Approved Date 1/17) read: "The wand has a simple on/off switch. A green light indicates the scanner is on... When the green light no longer appears and alarms no longer sound, the battery must be changed." The policy and procedure was not written in accordance with the manufacturer's directions for use.

2.On 05/10/17 at 10:30 AM, a security officer (Staff Member #A5) scanned Surveyor #1 using the unit's metal detector wand prior to entering unit E2. When the security officer turned on the metal detector wand, the detector immediately started beeping, and amber and red lights started flashing. An interview with the security officer at the time of the observation showed the officer did not know that the batteries in the wand needed to be replaced or recharged.


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Item #2 - Environmental Safety

Based on observation, interview and review of hospital's policy and procedures, the hospital staff failed to maintain a safe patient care environment by effectively conducting environmental safety rounds and observing patients as directed by hospital policy.

Failure to protect patients from self-harm and harm by other patients poses a serious threat to the health and safety of all patients, which may result in serious injury and death.

Findings included:

1. Review of hospital policies, procedures, and directives showed the following:

a. The hospital policy titled, "Management of the Patient Exhibiting Potential for Suicide (Suicide Watch)" (Standard Protocol 305; Revised March 2017) states in part: "A patient at risk for life-threatening self-injurious behavior may also place on constant or close suicide watch. ...Close Suicide Watch: A patient is assessed to be a moderate risk for suicide. ...The RN assigns staff member to maintain view of the patient by direct visual observation at all times and be within close enough proximity for immediate intervention.

b. The hospital policy titled, "Specialized Staffing" (Policy 8.03; Effective March 15, 2017) read: "Specialized staffing is allowed for the following reasons: ...Danger to Self (DTS): 1:1 or 2:1 coverage ordered by a physician to help the patient refrain from self-injury. ...Employees providing monitoring for all patients will: 1. Know why the patient requires monitoring and what specific behaviors are expected of the staff. ...4. Know how to intervene to prevent patient harm." ..."Specialized staffing includes the following staffing ratios and monitoring parameters: One to One (1:1): Requires staff to be within arm's length to the patient at all times; One to One Behavioral (1:1) requires staff to watch the patient at all times while about 5 feet away for safety; and Line of Sight (LOS): Requires staff to see the patient at all times."

c. The policy and procedure titled, "Patient and Environmental Safety Rounds" (Nursing Standard: Procedure 204; Revised June 2014) showed that staff were to observe all areas of the ward accessible to patients. Staff were to assess for environmental and physical hazards that may contribute to an unsafe or unhealthy patient environment.

d. The hospital policy titled, "Searches" (Policy 13.06; Effective Date: April 5, 2017) read: "Policy: "WSH (Western State Hospital) has a responsibility to provide for the safety and protection of patients, staff, visitors and the community, as well as providing a safe environment under which hospital staff may conduct searches. ...F. All staff members are required to continuously observe the environments for contraband [prohibited items], restricted items, safety hazards and potential weapons ...H. When searches may be warranted ...4. Previous behavior concerning contraband or restricted items."

e. On 05/12/17 at 12:00 PM, a nurse manager (Staff Member #K3) provided Surveyor #9 with a copy of the staff guide for sharps and flex pens from the Center for Forensic Services procedure manual (no title, no date). The document read: "Flex pens are available at all times for your personal use on the ward and in the TRC. Staff must approve the use of any other drawing materials and if approved, they must be checked out and in at the end of the shift. Patients who misuse or modify flex pens may be required to use pens under supervision. No pens or pencils are allowed on the ward or in the TRC without supervision.

2. Staff interviews and review of the medical records of patients housed on F1 in the Center for Forensic Services showed the following:

a. On 05/10/17 at approximately 10:45 AM, Surveyor #9 reviewed the medical record of Patient #K4. The review showed that the patient had an extensive history of assaultive behavior and was a danger to others.

1) Documentation in the patient's record showed that on 04/05/17 the patient attempted to assault staff with a sharpened toothbrush. Review of environmental safety round documentation dated 4/5/2017 showed unit staff members had found no additional harmful objects in the patient's room after the assault.

2) Documentation dated 04/06/17 on the patient's treatment plan showed that the patient had a history of assaultive behavior without warning or provocation, and that he had assaulted another hospital staff member in August 2015 with a sharpened toothbrush.

3) At the time of the record review, Surveyor #9 discussed the findings with the unit's nurse manager (Staff Member #K3). Staff Member #K3 verified that no interventions had been implemented to prevent the patient from making weapons when the patient was admitted on 3/16/2017.

b. On 05/12/17 at 10:30 AM, Surveyor #7 reviewed the medical record of Patient #K12 who was admitted on 4/7/2017. The admission psychiatric evaluation dated 4/7/2017 and nursing admission history showed that the patient had a history of engaging in self harming behaviors including swallowing foreign objects.

1) On 04/07/17, physician admission orders were written for 1 to 1 line of sight monitoring at all times secondary to swallowing foreign objects. On 4/17/2017, specialized monitoring (1 to 1 line of sight monitoring) was discontinued. On 5/2/2017, the patient was transferred to local acute care hospital after self-reporting ingestion of a flex pen and a "spork" (a plastic eating utensil that combines the attributes of a spoon and a fork).

2) On 05/03/17, the patient was transferred back and placed on 1 to 1 Close Suicide Watch monitoring. On 05/11/17 at 11:00 AM, physician orders were written to "Continue close monitoring for DTS" (danger to self). The behavior observational record dated 5/11/17 for the evening shift showed that the patient was on Close Suicide Watch due to his history of swallowing foreign objects and included a summary of behaviors to watch for. The evening assignment of patient care sheet for 5/11/2017 confirmed that Patient #K12 was on close suicide watch.

3) The evening/night shift nursing unit inter-shift report for 05/11/17 indicated that patient reported to staff that he had swallowed one pen, one spoon, and one toothbrush and was now complaining of abdominal plan. The patient was sent to a local acute care hospital for treatment.

c. On 05/12/17, at 11:35 AM, Surveyor #9 reviewed the medical record for Patient #K13. The record showed that the patient had a history of assaultive behavior and of obtaining and hiding contraband. The patient's treatment plan dated 4/25/2017 indicated that staff found two batteries hidden in the patient's sock and crayons in the patient's room.

1) On 05/09/17 beginning at 10:30 PM, entries in the patient's record showed that the patient had swallowed a spoon. The patient was sent to a local acute care hospital for treatment.

2) At the time of the review, the nurse manager (Staff Member #K3) told Surveyor #9 that prior to the event on 05/09/17 Patient #K13 was not on any kind of special watch or monitoring for contraband or ingesting foreign objects. Staff Member #K3 stated that patients do not have to return sporks, toothbrushes and flex pens until after an adverse event occurs, even if they have a history of ingesting foreign objects.

3. Observations in the Center for Forensic Services unit showed the following:

a. On 05/10/17 at 3:40 PM, during an inspection of clinical unit F6, Surveyor #7 observed two flex pens lying on the floor between rooms 19 and 24. This observation occurred after the on-coming staff had completed their environmental checks.

b. On 05/12/17 at 11:30 AM on unit F1, Surveyor #1 observed a Patient Safety Assistant (PSA) (Staff Member #A1) during a 15-minute patient safety/environmental round check. While making the rounds with the PSA, Surveyor #1 found an external cover of a flex pen wrapped in plastic stored behind a book on the window seal that the PSA had missed. Surveyor #1 asked what happens when something is found. The PSA stated that he notifies the nurse; the nurse notifies security, security takes a picture of the item, and then the item is confiscated. The surveyor asked the nurse on duty (Staff Member #A2) if any additional actions were to be taken to find the missing inside mechanism of the pen. The nurse stated, "No". Unit staff members did not follow the policy and procedure for conducting environmental safety rounds as required.

c. On 05/12/17 at 11:58 AM, Surveyor #7 interviewed an institutional counselor (Staff Member #K10) on unit F1 about how environmental safety rounds are conducted. Staff Member #K10 indicated they occur primarily during shift change. She acknowledged that it was common to find flex pens on the floor during environmental and patient census rounds.

d. 05/12/17 at 12:15 PM on unit F1, Surveyor #1 observed Patient #A1 hiding an item underneath their clothing. The surveyor brought it to the attention of the Ward Administrator (Staff Member #A3) who then asked a registered nurse (Staff Member #A4) to remove the item. The nurse confiscated five slices of bread from the patient. The nurse identified the patient as being extremely dangerous and was on 1:1 monitoring status at the time of the observation. Staff Member #A4 indicated that the patient should have been observed at all times by the assigned staff member to prevent such an occurrence. Unit staff members did not follow the specialized staffing policy and procedure.



35594


Item #3 - Contraband (Prohibited Items)

Based on observation, interview and review of hospital policies and procedures, the hospital failed to develop effective processes to protect patients from contraband brought into the facility by visitors.

Failure to develop and implement effective protocols that prevent visitors from bringing prohibited items into the facility risks harm to patients, staff members, and other visitors.

Findings included:

1. The hospital's policy titled "Patient Visitation" (Policy #12.05, Effective 11/11) read: "#6. Visitors may not bring prohibited items into the hospital. Prohibited items include illegal items and patients are prohibited to have in their possession, including, but not limited to, the following: a. Any medication ...b. Intoxicating substances...c. Controlled drugs or illegal drugs . "All visitors must show photo ID [identification] ... 6 ...Visitors must sign in and out on the log."

2. On 5/12/17 at 9:15 AM, Surveyor #8 reviewed the medical record and visitor log for Patient #CS15 on Ward C8. The medical record showed that the patient had three visitors on 05/11/17. Only two of the visitor's log names were on the log. Additionally, the log failed to show evidence that the visitors presented photo ID to hospital staff members. None of the visitors documented their time in or out.

3. On 05/12/17 at 9:30 AM during an interview with Surveyor #8, the Nurse Manager (Staff Member #CS8) stated that shortly after the two visitors left Patient #CS15 on 05/11/17, the patient was slurring his words, appeared pale and gray in color, and had "pin-point" (constricted) pupils. Staff members searched the patient's room and found three liquid-filled syringes and one empty syringe. Hospital staff members determined the syringes contained heroin. This was confirmed by the patient.

4. On 05/24/17 at 9:15 AM, Surveyor #2 examined visitor logs on Ward S7. The form titled "Visitor's Register" had one entry dated 5/20/2017. The section titled "Time Out" did not have a time recorded per policy. The Ward Administrator (Staff Member #TH21) confirmed the finding.
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Based on observation, interview, and review of hospital documents, policies, and procedures, the hospital failed to develop and implement effective policies, procedures, and interventions to protect patients from harm due to patient-to- patient assaults, as demonstrated by six patients reviewed (Patients #KM12, #KM16, #KM17, #KM18, #JW4, #JW5 )

Failure to ensure effective processes are in place to protect patients from abuse and harassment risks serious harm to patients due to physical and psychological injury.

Findings included:

1. Review of the hospital policy titled "Specialized Staffing" (Policy 8.03; Issued 3/17) showed the following:

a. Specialized staffing is allowed for "Danger to Others" (DTO), "Danger to Self "(DTS), and "Unpredictable Behavior" (UPB). One staff member per patient (1:1) or two staff members per patient (2:1) coverage is ordered by a physician when monitoring is needed to keep the patient from engaging in dangerous behaviors toward others.

b. Specialized staffing includes the following staffing ratios and monitoring parameters: One to One (1:1): Requires staff to be within arm's length to the patient at all times; One to One Behavioral (1:1) requires staff to watch the patient at all times while about 5 feet away for safety; and Line of Sight (LOS): Requires staff to see the patient at all times

c. The physician's order for specialized staffing must state the specific action needed by the monitoring staff to keep patients safe (e.g., patient must be within arm's reach; 1:1 only during mealtimes; LOS (Line of Sight) at all times, etc.

2. Review of the hospital's policy and procedure titled "Management of the patient exhibiting potential for suicide (Suicide Watch)" (Standard Protocol 305, Revised April 2016) showed that when a patient required "Close" suicide watch, the RN was to assign a staff member to maintain view of the patient by direct visual observation at all times.

3. Review of the medical records for Patient #KM12 showed the following:

a. The records included "Physician/Pharmacy" notes dated 04/10/17 at 7:15 PM that showed the patient had been in seven different physical altercations with other patients during the previous two weeks. Treatment and recovery plan addendums dated 04/04/17, and 04/08/17 included interventions for patient education, reorientation and medication administration to decrease agitation and aggression.

b. On 05/04/17, Patient #KM12 assaulted two patients (Patients #KM17 and #KM23). On 05/09/17, Patient #KM12 assaulted another patient. The record did not contain physician orders for additional interventions to prevent the patient from assaulting other patients.

4. On 05/15/17 at 11:00 AM, Surveyor #9 observed 1:1 monitoring for Patient #KM17. The staff member assigned to monitor Patient #KM17 (Staff Member #KM8) was located approximately 25 feet from the patient.

At the time of the observation, Staff Member #KM8 told Surveyor #9 that line of sight monitoring meant staff should be able to visibly see the patient. At 11:25 AM a registered nurse working in the unit (Staff Member #KM3) told the Surveyor #9 that line of sight monitoring meant staff should be close enough to intervene.

5. Review of the medical records for Patient #KM17 showed documentation of a pattern of unprovoked assaultive behavior on staff and other patients.

a. On 03/10/17, Patient KM#17 tore an exit sign off the wall and assaulted staff member. On 05/09/17, Patient KM#17 tore a metal table leg off a table located in the patient's room and threatened staff which resulted in a lock down of the ward. The police were called and the patient was arrested.

b. On 05/10/17, Patient KM#17 was readmitted to the hospital. The patient treatment and recovery plan and physician orders showed the patient was placed on 1:1 for DTO/DTS ("Danger to Others" and "Danger to Self") at all times for safety. On 05/12/17, a new physician order showed the patient was placed on 1:1 "Line of Sight" observation.

c. On 05/13/17, while on 1:1 line of sight monitoring, Patient KM#17 committed an unprovoked assault of another patient.

6. Review of the medical records for Patient #KM18 showed that physician orders were written on 05/13/17 for "Close" suicide watch. On 05/14/17 at 3:55 PM while on "Close" suicide watch, Patient KM#18 was assaulted by another patient (Patient KM#16) who had a pattern of assaultive behavior.

7. Review of the medical records for Patient #KM16 showed the patient had a pattern of unpredictable, unprovoked, and aggressive assaults of staff and other patients. Treatment and recovery plan addendums for staff and patient assaults were initiated on 01/16/17, 02/12/17, 03/02/17, 03/11/17, 04/04/17, 05/10/17 and 05/17/17. Physician orders for 1:1 DTO (Danger to Others) monitoring or WOOR (While out of Room) 1:1 monitoring were dated 02/07/17, 02/15/17, 03/10/17, 03/13/17, 03/16/17, 03/20/17, and 04/04/17. No physician orders for 1:1 monitoring for behavioral or assaultive behavior were located in the chart after 04/04/2017.

On 05/14/17 at 3:55 PM, Patient KM#16 assaulted another patient (Patient KM#18). On 05/17/17 at 6:40 PM, Patient KM#16 again assaulted another (Patient KM#20).

8. On 05/18/17 at 2:00 PM, Surveyor #9 interviewed a psychiatrist (Staff Member KM#9) regarding Patient KM#16 and the assaults that occurred on 05/14/17 and 05/17/17. The surveyor asked about the lack of physician-ordered assault prevention interventions. The psychiatrist stated that Patient KM#16 was fully competent and these acts were fully volitional. The psychiatrist stated that it did not make a difference if the patient was on 1:1 staffing or not.

9. Review of the medical records of Patient #JW4 showed the following:

a. Documentation in the patient's medical records showed that on 04/25/17 the patient was placed in restraints and seclusion (R/S) following assaults of another patient and a staff member. Following release from R/S the patient was placed on 1:1 DTO monitoring by a nursing order.

b. On 04/28/17, Patient #JW4 assaulted another patient and was placed in seclusion.

c. On 05/06/17, the on-call psychiatrist (Staff Member #JW10) documented that Patient #JW4 had assaulted another patient. The psychiatrist wrote, "Patient is on one to one monitoring, 2:1 monitoring was relaxed to 1:1 on 05/05/17. Patient also assaulted staff today. Plan... Start 2:1."

d. On 05/08/17, the psychiatrist (Staff Member #JW5) wrote orders for Patient #JW4 to remain on 2:1 when the patient was out of his room for DTO (Danger to Others). The psychiatrist wrote in the patient's progress notes, "This patient must remain under close supervision to reduce his DTO. However, this patient does not belong to this milieu any longer. He should be removed to another setting where his criminal behavior can be addressed."

e. On 05/11/17, Patient #JW4 assaulted two other patients and was subsequently transferred to a forensics ward. The psychiatrist orders did not specify distance the staff monitor was to maintain from the patient on the new ward.

f.

10. Review of the medical records for Patient #JW5 and an interview with a hospital staff member showed the following:

a. The patient was in and out of R/S four times from 05/01/17 to 05/04/17 due to aggression toward staff, delusion, and threats of self-harm.

b. On 05/07/17, a psychiatrist (Staff Member #JW12) wrote an order to continue to monitor for DTO/DTS (Danger to Self) for 24 hours.

c. On 05/08/17, the patient was placed into seclusion due to an altercation with another patient. The psychiatrist (Staff Member #JW13) wrote an order for 2:1 monitoring for 72 hours. The patient remained on 2:1 monitoring until he attempted to strike another patient on 05/15/17 and was placed in restraints. The psychiatrist orders did not specify the distance the staff monitor was to maintain from Patient JW#13.
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Based on observation and interview, the hospital failed to store medical records in a secure location that was not subject to unauthorized access.

Failure to safeguard patient records violated patients' rights to privacy and confidentiality of records.

Findings included:

On 05/11/17 at 11:40 AM, during a tour of Ward S9 with the S9 Ward Administrator (Staff Member #RM1) and the Ward Clerk (Staff Member #RM2), Surveyor #4 observed some loose patient records and a 4-inch binder notebook containing several patients' medical records lying on a shelf in room #430. Staff RM-1 explained that the medication room (room #430) was not currently being used by staff due to an in-progress heating ventilation and air conditioning (HVAC) project. The staff member also stated that the construction contractors had access to room #430 during the course of the project.

Staff Member #RM2 immediately collected the patient records and said she would remove them to a secure location.
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Based on record review and review of hospital policies, procedures and documents, the hospital failed to ensure that patients were removed from seclusion or restraint at the earliest possible time for 7 of 10 patients reviewed (Patient #K1, #K2, #K3, #K4, #K5, #K6, #K7 ).

Failure to remove patients from seclusion or restraint at the earliest possible time puts patients at risk for psychological harm, loss of dignity, and personal freedom.

Findings included:

1. Review of hospital policies, procedures, and documents showed the following:

a. The hospital policy and procedure titled "Management of the Patient in Seclusion and Restraint", (Standard Protocol 302; Revised January 2017) read: "Release from seclusion or restraint when behavior that necessitated seclusion or restraint is no longer in evidence and the release criteria stated in MD order is attained."

b. The Behavioral Health Administration Inter-Hospital Policy titled "Seclusion and Restraint" (Policy No. 1.7; Effective January 30, 2017) states in part: "Seclusion and/or restraint will be discontinued as soon as safely possible at the earliest possible time, regardless of the scheduled expiration of the order. E.g. as soon as the imminent risk to self or others is no longer present or the patient's need can be addressed using less restrictive measures."

c. The seclusion/restraint monitoring flowsheet (WSH 23-116Bb; Revised 03/17) under observable behavior(s) directs staff to "Notify RN when release criteria are met, or if patient is quiet/sleeping more than one 15 minute segment."

2. On 05/08/17 at 9:00 AM, Surveyor #7 reviewed the medical record of Patient #K1 who was placed in restraints on 05/07/17 at 5:30 PM after assaulting another patient. Patient #K1 was released from restraints on 05/08/17 at 9:00 AM, a period of 15.5 hours. Surveyor #7 noted the patient's observed documented behavior of "mute/unresponsive" or "quiet/appears asleep" for the following periods:

a. From 05/07/17 at 7:00 PM until 7:45 PM, a period of 45 minutes.

b. From 05/08/17 at 12:45 AM until 3:00 AM, a period of 2 hours and 15 minutes.

3. On 05/10/17 while on clinical unit F1, Surveyor #7 reviewed the medical record of Patient #K2 who was placed in seclusion on 04/12/17 at 12:30 PM after assaulting another patient. Patient #K2 was released from seclusion on 4/14/2017 at 4:30 AM, a period of 36 hours. Surveyor #7 noted the patient's observed documented behavior was described as "unwilling to communicate with staff","sitting on the bed","asleep", or "resting on bed","sitting at desk or reading/writing" and continued in seclusion for the following periods:

a. From 04/12/17 at 6:00 PM until 6:45 PM, a period of 45 minutes.

b. From 04/12/17 at 7:30 PM until 10:15 PM, a period of 2 hours and 45 minutes.

c. From 04/12/17 at 10:45 PM until 4/13/2017 at 2:45 AM, a period of 4 hours.

d. From 04/13/17 at 3:00 AM until 4:45 AM, a period of 1 hour and 45 minutes.

e. From 04/13/17 at 6:00 AM until 10:45 AM, a period of 4 hours and 45 minutes.

f. From 4/13/2017 at 1:15 PM until 5:00 PM, a period of 3 hours and 45 minutes.

g. From 04/13/17 at 7:15 PM until 4/14/2017 at 12:45 AM, a period of 5 hours and 30 minutes.

h. From 04/14/17 at 3:00 AM until 4:30 AM, a period of 1 hour and 30 minutes.

4. On 05/10/17, at 9:10 AM, Surveyor #9 reviewed the medical record of Patient #K3, who was ordered into seclusion on five separate occasions between 4/26/2017 and 5/9/2017. The documentation on the seclusion/restraint monitoring flowsheet indicated the patient was "calm", "quiet" or "sleeping" and continued in seclusion for the following periods:

a. From 04/27/17 at 1:15 AM to 7:30 AM, a period of five hours and 15 minutes.

b. From 05/09/17 at 8:30 PM until 9:30 PM, a period of 1 hour.

5. On 05/10/17, at 10:45 AM, Surveyor #9 reviewed the medical record of Patient #K4, who was placed in seclusion on 04/06/17 at 7:40 AM and released from seclusion on 04/07/17 at 5:30 AM. The documentation on the seclusion/restraint monitoring flowsheet indicated the patient was resting, quiet or sleeping and continued in seclusion for the following periods:

a. From 04/06/17 at 10:15 AM to 11:30 AM, a period of 1 hour and 15 minutes.

b. From 04/07/17 at 1:45 AM to 5:00 AM, a period of 3 hours and 15 minutes.

6. During record review, Surveyor #6 reviewed 4 medical records of patients who were placed in restraints and noted the following:

a. Patient #K5 was restrained on 04/18/17 from 11:05 AM until 12:12 PM, a period of 1 hour and 7 minutes. No documentation of the patient's behavior was recorded for the first 45 minutes of the restraint episode. The remaining 22 minutes of the restraint period was described as "sleeping on and off".

b. Patient #K6 was restrained on 04/13/17 from 4:45 PM to 6:45 PM, a period of 2 hours. The patient's behavior was documented as "mute/unresponsive" from 5:30 PM to 6:30 PM and "Quiet/Appears Asleep" at 6:45 PM.

c. Patient #K7 was restrained on 04/16/17 from 9:30 PM to 04/17/17 at 1:00 AM. Documentation indicates the patient was "Mute/Unresponsive" and/or "Quiet/Appears Asleep" between 10:00 PM and 1:00 AM, a period of 3 hours.
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Based on record reviews, interviews, and review of hospital policies, procedures, and documents, the hospital failed to ensure hospital staff monitored patients placed in seclusion or restraints according to hospital policy for 9 of 10 patients reviewed (Patients #K1, #K3, #K4, #K5, #K6, #K7, K9, #K10, #K11).

Failure to monitor patients who are restrained or secluded puts them at risk for injury or decline in status.

Findings included:

1. Review of hospital policies, procedures, and documents showed the following:

a. The hospital policy and procedure titled "Management of the Patient in Seclusion and Restraint", (Standard Protocol 302; Revised January 2017) states in part, "E. Monitor physical, emotional and safety needs... RN assigns staff member to engage patient, perform care and need interventions, and document behavior response to seclusion or restraints at least every 15 minutes. ...Check breathing...skin color, circulation...Proper positioning of restraint devices(s) to prevent restriction of circulation...Assess circulation, reposition and perform ROM at least every two hours."

b. The seclusion/restraint monitoring flowsheet (WSH 23-116Bb; PILOT Revised 03/17) under observable behavior(s) directs staff to "Check the appropriate Observable Behavior box every 15 minutes and initial at the bottom."

2. On 05/08/17 at 9:00 AM, Surveyor #7 reviewed the medical record of Patient #K1 who was placed in restraints on 5/7/2017 at 5:30 PM and was released from restraints on 5/8/2017 at 9:00 AM, a period of 15.5 hours. There was no documentation on the seclusion/restraint flowsheet to indicate that staff members assessed the patient's circulation or checked for "Signs of Injury/Skin Integrity" for the following periods:

a. From 05/07/17 at 5:30 PM until 9:00 PM, a period of 3 hours and 30 minutes.

b. From 05/07/17 at 9:15 PM until 10:15 PM, a period of 1 hour.

c. From 05/08/17 at 3:15 AM until 5:00 AM, a period of 1 hour and 45 minutes.

d. From 05/08/17 at 7:30 AM until released at 9:00 AM, a period of 1 hour and 30 minutes.

3. On 05/09/17 at 1:30 PM, Surveyor #7 reviewed the medical record of Patient #K9 who was placed in 5 point restraints on 5/8/2017 at 10:40 AM and was released from restraints on 5/10/2017 at 1:30 PM, a period of 49.5 hours. There was no documentation on the seclusion/restraint flowsheet to indicate that staff members assessed the patient's circulation or checked for "Signs of Injury/Skin Integrity" for the following periods:

a. From 05/08/17 at 1:00 PM until 7:30 PM, a period of 6 hours and 30 minutes.

b. From 05/08/17 at 9:15 PM until 10:15 PM, a period of 1 hour.

c. From 05/09/17 at 4:45 AM until 5:30 AM, a period of 45 minutes.

d. From 05/09/17 at 10:00 AM until 11:30 AM, a period of 1 hour and 30 minutes.

e. From 05/09/17 at 3:30 PM until 7:30 PM, a period of 4 hours.

f. From 05/09/17 at 9:00 PM until 05/20/17 at 12:45 AM, a period of 3 hours and 45 minutes.

g. From 05/10/17 at 2:45 AM until 3:30 AM, a period of 45 minutes.

4. During record review, Surveyor #6 reviewed 4 medical records of patients who were placed in restraints and noted the following:

a. Patient #K5 was restrained on 04/18/17 from 11:05 AM until 12:12 PM, a period of 1 hour and 7 minutes. No documentation of circulation checks or checks for injury/skin integrity were recorded from 11:05 AM to 12:05, a period of 1 hour.

b. Patient #K6 was restrained on 04/13/17 from 4:45 PM to 6:45 PM, a period of 2 hours. No documentation of checks for signs of injury/skin integrity, offering food/fluids, or psychological or physical comfort from 4:45 PM to 6:45 PM were recorded, a period of 2 hours.

c. Patient #K7 was restrained on 04/16/17 from 9:30 PM to 04/17/17 at 1:00 AM. No documentation of checks for injury/skin integrity from 9:30 PM to 1:00 AM were recorded, a period of 3 hours and 30 minutes. The surveyor also found no checks for circulation from 9:30 PM to 10:30 PM, a period of 1 hour.

d. Patient #K10 was restrained on 04/16/17 from 4:45 PM to 6:30 PM, a period of 1 hour and 45 minutes. No documentation of checks for signs of injury/skin integrity from 5:00 PM to 6:00 PM were recorded, a period of 1 hour.

5. On 05/10/17 at 9:10 AM, Surveyor #9 reviewed four episodes of seclusion being ordered for Patient #K3. The surveyor noted there was no documentation on the seclusion/restraint monitoring flowsheet to indicate that staff members assessed the patient's circulation and respiration for the following periods:

a. From 04/26/17 at 7:30 PM to 8:15 PM, a period of 45 minutes.

b. From 04/26/17 at 9:45 PM then released from seclusion on 04/27/17 at 9:30 AM, a period of 11 hours and 45 minutes.

c. From 05/03/17 at 7:45 PM to 11:45 PM, a period of 4 hours.

d. From 05/04/17 at 1:00 AM to 2:15 AM, a period of 1 hour and 15 minutes.

e. From 05/04/17 at 2:30 AM to 3:15 AM, a period of 45 minutes.

f. From 05/04/17 at 4:00 AM to release on 5/4/2017 at 4:45 AM, a period of 45 minutes.

g. From 05/04/17 at 9:50 AM through 4:45 PM, a period of 6 hours and 55 minutes.

h. From 05/09/17 at 7:30 PM through 11:15 PM a period of 3 hours and 45 minutes.

i. From 05/10/17 at 1:30 AM through 5/10/2017 4:30 AM, a period of 3 hours.

6. On 05/10/17 at 10:45 AM, Surveyor #9 reviewed the medical record of Patient #K4, who was placed in seclusion on 04/06/17 at 7:40 AM and released from seclusion on 04/07/17 at 5:30 AM. There was no documentation on the seclusion/restraint monitoring flowsheet to indicate that staff members assessed the patient's circulation and respiration for the following periods:

a. From 04/06/17 at 7:45 AM to 8:45 AM, a period of 1 hour.

b. From 04/06/17 at 9:00 AM to 2:45 PM, a period of 5 hours and 45 minutes.

c. From 04/06/17 at 5:15 PM until released from seclusion on 04/07/17 at 5:30 AM, a period of 12 hours and 15 minutes.

7. On 05/10/17 at 2:15 PM, Surveyor #9 reviewed four episodes of restraints being ordered for Patient #K11. The surveyor noted there was no documentation on the seclusion/restraint monitoring flowsheet to indicate that staff members assessed the patient's circulation and respiration for the following periods:

a. From 04/28/17 at 3:40 PM then released from seclusion at 4:45 PM, a period of 1 hour and 5 minutes.

b. From 05/02/17 at 10:40 AM then released from seclusion at 11:40 AM, a period of one hour.

c. From 05/04/17 at 4:50 PM then released from seclusion at 5:50 PM, a period of one hour.

d. From 05/05/17 at 3:45 PM then released from seclusion on 5/5/2017 at 5:45 PM, a period of 2 hours.

8. On 05/10/17 at 9:44 AM, Surveyor #9 interviewed a nurse manager (Staff Member #K3) about monitoring and recording on the seclusion/restraint flowsheet. Staff Member #K3 confirmed that 15 minute checks for circulation and respiration should have been completed on the flowsheet per hospital policy.

9. On 05/23/17 at 10:35 AM, Surveyors #7 and #9 interviewed the hospital restraint and seclusion training team (Staff Members #K4, #K5, #K6, #K7, #K8) about how patients are monitored in seclusion and restraints. Staff Member #4 indicated that breathing and circulation checks are to be performed and documented every 15 minutes on the seclusion/restraint monitoring flowsheet.
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Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop, implement, and maintain a hospital-wide, integrated Quality Assessment Performance Improvement (QAPI) program that included selection of meaningful quality indicators for all departments and services.

Failure to select meaningful quality indicators, to systematically collect and analyze performance data, and to formulate action plans for improvement reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. The hospital's quality program plan titled "Quality Assessment and Performance Improvement Plan 2016-2018"
showed that the plan was to provide the hospital with mechanisms to identify opportunities for performance improvement and a process to improve identified deficiencies. The plan identified a collaborative hospital-wide approach for sustaining performance improvement in patient care outcomes and enhancement of the quality of the practice of the health care professionals who provide that care. The plan showed data collection was to focus on processes, outcomes, targeted areas of study, comprehensive performance measures, client's needs, expectation and feedback, results of ongoing infection control activities, safety of the environment, quality control and risk management findings, and dimensions of performance.

2. On 05/09/17 from 9:30 AM to 4:00 PM, Surveyor #6 interviewed the Chief of Quality (Staff Member #M4); the Quality Director (Staff Member #M5); the "Lean" Program Director (Staff Member #M6); the HIM Director (Staff Member #M7); and the Performance Improvement Manager (Staff Member #M8). During this interview, the meeting participants reviewed the hospital's QAPI plan, quality committee meeting minutes, quality indicators, and performance improvement plans and documents.

During this interview and a subsequent interview with the Chief of Quality and the Deputy of Hospital Operations (Staff Member #M9) on 05/23/17 from 11:05 AM to 2:00 PM, Surveyor #6 determined the following:

a. Utilization Management (UM): Service managers reported numbers of patient records reviewed and certifications completed. UM managers did not aggregate and submit data regarding the quality of care provided as directed by the hospital's Utilization Management Plan (Effective October 2015), including medical necessity of admissions, duration of hospital stays, discharge planning, and efficacy of professional services .

Cross Reference: Tag A0652

b. Nutritional Services: Service managers submitted quality control data including food temperatures. There were no indicators that measured the quality of nutritional services provided for patients.

Cross Reference: Tag A0049, Item #2

c. Physical Therapy, Dental Services, Radiological Services: Service managers submitted data regarding the numbers of procedures performed. There were no indicators that measured the quality of services provided for patients.

Cross Reference: Tags A0528, A1123

d. Referrals for consultative services: The QAPI program did not include quality indicators for patient referrals for consultative services such as nutritional services, physical therapy, wound care, and orthotic services.

Cross Reference: Tag A1134

e. Emergency Services: Service managers submitted data regarding response to medical emergencies. There were no action plans for improvement for problems identified during emergency response incidents.

f. Pain Management: Service managers submitted data regarding the numbers of patients referred for palliative care and pain control services. There were no indicators that measured the quality of the services provided.

g. Infection Prevention and Control: The infection preventionist submitted data regarding the numbers and types of hospital-associated infections. There were no action plans for reducing incidents of infections.

h. Active Treatment: Service managers submitted the number of hours of psychiatric, psychological, and mental health treatment provided per patient. There were no indicators that measured the quality of the treatment provided and whether this treatment resulted in improved health outcomes.

i. Patient Grievances: Service managers identified the numbers of patient complaints and grievances, the timeliness of response to patients, and types of complaints. There were no action plans that addressed complaint issues.
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Item #1- Fall Prevention Care Plan

Based on interview and review of hospital policies and procedures, the hospital failed to ensure that staff developed and initiated care plans for patients at high risk for falls, as demonstrated by four patients reviewed (Patients #KM1, #KM2, #KM3, #KM4).

Failure to identify patients who are at high risk for falls and develop care plans to prevent falls places patients at risk of injuries.

Findings included:

1. The hospital's policy and procedure titled "Management of the Patient at Risk for Falls" (Revised March 2017) stated, "Area of Responsibility... D. Physical Therapy Referral if needed... 4. Refer for PT eval [Physical Therapy evaluation] if: A. High Fall Risk (Tinetti score 0-19). B. Pt. is non-ambulatory upon admit or with change of condition affecting ambulation... F. Interdisciplinary Management Interventions... 9. Consult with physical and occupational therapy to plan a program to increase patient's endurance and strength."

2. On 05/10/17 at 2:00 PM, Surveyor #9 reviewed the medical record for Patient #KM1, reviewed the nursing shift report, and interviewed a registered nurse (Staff Member #KM1). The review and interview showed the following:

a. The Initial Nursing Assessment (Form WSH 23-60A) completed on 04/26/17, under subsection: "Safe patient handling and movement assessment" read: "...2. Patient Level of Assistance: Stand-by-assist. 3. Weight bearing capability: ...partial. ...5. Applicable conditions likely to affect transfer/repositioning techniques ... paralysis/paresis 6. Assistive Devices ...Wheelchair". Under Subsection: "Tinetti Test (Fall Risk Index): Balance and Gait score 16".

b. According to the Tinetti Fall Risk Index, a Tinetti Score of less than 20 means the patient is at high risk for falls. A physical therapy consult had not been initiated as directed by hospital policy. The medical record did not include a care plan or treatment plan addendum that identified the problem "High Risk for Fall", goals and interventions.

c. The nursing report sheet did not identify Patient #KM1 as a high fall risk.

d. Staff member #KM1 confirmed the findings above and stated, "If a patient is a high fall risk it should be on the report sheet."

3. On 05/16/17 at 10:00 AM, Surveyor #9 reviewed the medical records for Patient #KM3 and interviewed a registered nurse (Staff Member #KM2). The review and interview showed the following:

a. The patient was admitted on 04/28/17 for treatment of competency restoration. The Initial Nursing Assessment Tinetti Score indicated the patient was not at risk for falls. On 05/03/17, Patient #KM3 experienced a seizure resulting in a fall to the floor. Physician/Pharmacy and Nursing Notes documentation showed Patient #KM3 exhibited additional seizure like activity that resulted in falls to the floor on 05/04/17, 05/06/17, 05/07/2017 and 05/09/17. No physical therapy consult was initiated. The medical record did not include a care plan or treatment plan addendum that identified the problem "High Risk for Falls."

Subsequent review of the patient's medical record on 5/16/207 at 9:30 AM revealed additional seizure activity resulting in a fall to the floor on 05/10/17. A treatment and recovery plan addendum identifying the patient as high Risk for Falls was not initiated until 05/12/17 at 3:50 PM.

b. Surveyor #9 asked the nurse about the delay in adding "High Fall Risk" to the Patient Treatment and Recovery Plan. The nurse stated that she had not thought about performing a fall risk assessment until someone called her during the survey and told her to do one.

4. On 05/16/17 at 10:40 AM, Surveyor #9 reviewed the medical records for Patient #KM2, reviewed and nursing shift report, and interviewed a registered nurse (Staff Member #KM2). The review and interview showed the following:

a. The Initial Nursing Assessment (Form WSH 23-60A) completed on 04/11/17 showed under subsection: "Safe patient handling and movement assessment: ...2. Patient Level of Assistance: Stand-by-assist; 3. Weight bearing capability: ...partial; ...5. Applicable conditions likely to affect transfer/repositioning techniques: ... severe osteoporosis; 6. Assistive Devices: ...Wheelchair; ...Staff assist with transfer'". Under subsection: "Tinetti Test (Fall Risk Index): Balance and Gait score 18".

b. According to the Tinetti Fall Risk Index, a Tinetti Score of less than 20 means the patient is at high risk for falls. A physical therapy consult had not been initiated as directed by hospital policy. The medical record did not include a care plan or treatment plan addendum that identified the problem "High Risk for Falls"

c. The nursing report sheet did not identify Patient #KM2 as a high fall risk.

d. Staff Member #KM2 confirmed the above findings.

5. On 05/25/17 at approximately 12:20 PM, Surveyor #9 reviewed the medical records for Patient #KM4, reviewed the nursing shift report, and interviewed a registered nurse (Staff Member #KM1). The review and interview showed the following:

a. The Initial Nursing Assessment (Form WSH 23-60A) completed on 05/22/17 read: "Safe patient handling and movement assessment: ...2. Patient Level of Assistance: Assistive devices
should be used for some lifting and moving tasks; ...3. Weight bearing capability: ...none; 5. Applicable conditions likely to affect transfer/repositioning techniques: ...(No documentation); 6. Assistive Devices
...Wheelchair." Under "Tinetti Test (Fall Risk Index)" the balance and gait score was not completed as the patient was assessed as non-ambulatory. No fall risk assessment was completed. A physical therapy
consult had not been initiated as directed by hospital policy.

b. Documentation in the nursing notes stated: ""Pt [patient] displays severe memory deficit ....Pt wheelchair bound." The Admission History and Physical Examination (Form WSH 23-55C) completed on 05/23/17 read: "Admission Physical Exam... Decreased ROM (Range of Motion) LE (Lower Extremity)... amb [ambulates] stiffly with walking." Under Subsection: "Diagnosis/Plan... Uses walker/wheelchair to get around."

c. The medical record did not include a care plan or treatment plan addendum that identified the problem "High Risk for Falls" nor goals and interventions to prevent falls.

d. The nursing report sheet did not identify Patient #KM4 as a high fall risk.

e. As the result of survey findings, a physician initiated a Rehabilitation Service Consultant Referral on 05/24/17. The referral read: "Current diagnosis or signs/symptoms to be treated: Multiple back surgery years ago has chronic back pain with difficulty to walk. In w.c. [wheelchair] now ...2. Patient functional limitations: Unable to ambulate, was using cane ...Patient prior level of functioning ...limited ambulation."

f. During the interview the nurse stated that Patient #KM4 used a walker when he arrived to the unit, and that walkers were not allowed on the unit. The surveyor asked the nurse about how fall risk assessments are performed for patients who are immobile and not eligible for the Tinetti Assessment (Fall Risk Index). The nurse told the surveyor that the hospital had no other method for assessing fall risk. The nurse confirmed that a physical therapy evaluation of the patient had not been initiated on 05/22/17 as directed by hospital policy.


Item #2 - Nutritional Care Plan

Based on observation, interview, and record review, the hospital failed to ensure that nursing staff members developed and implemented care plans for patients with nutritional needs, as demonstrated by 5 patients reviewed (Patients #K8, #JW1, #JW2, #JW3, #M1).

Failure to identify patients with impaired nutrition and develop care plans to meet the patient's nutritional needs risks deterioration of the patient's health and prolonged hospitalization.

Findings included:

1. The hospital's policy and procedure titled "Vital Signs/Daily Care Flowsheet (Procedure #9.4; Revised 01/16) showed that when daily weights were ordered by a doctor or nurse, the patient's weight would be documented on a Vital Signs/Daily Care Flowsheet in the weight column on the line corresponding with the current date and time.

2. On 05/08/17 at 10:00 AM, Surveyor #10 reviewed the medical records of Patient #JW1 and interviewed the Ward Administrator for the patient's treatment unit (Staff #JW2). This record review and interview revealed the following:

a. The patient had a cerebrovascular accident (stroke) in October 2016. The patient developed a stage II pressure ulcer on the buttocks and was receiving ongoing wound care. On 02/01/17, the patient's physician (Staff Member #JW1) ordered the following nutritional supplements: Two cans of Ensure Plus four times a day and protein powder three times a day.

b. On 02/01/17, the physician ordered that the patient was to be weighed weekly. The first weight recorded on the vital sign/daily care flowsheet was dated 02/11/17. No weights were recorded between 02/11/17 and 03/02/17. On 03/02/17, the patient's physician (Staff Member #JW1) repeated the order for weekly weights. The next recorded weight was dated 03/12/17. There were no recorded weights or refusals to be weighed between 03/12/17 and 03/30/17. On 0/30/17, the physician repeated the order for weekly weights. Documentation in the patient's record indicated the patient refused to be weighed on 04/01/17. On 04/02/17, the patient's weight was recorded. No further weights were recorded until 04/29/17.

c. During an interview with Surveyor #10 at the time of the record review, the Ward Administrator (Staff Member #JW2) confirmed that based on review of patient records, the patient had not been weighed daily as ordered.

3. On 05/08/17 at 1:40 PM, Surveyor #6 reviewed the medical record of Patient #M1 and interviewed a registered nurse who provided care in patient's treatment unit (Staff #M1). This record review and interview revealed the following:

a. The patient had a neurodevelopmental and metabolic disorder that required a 6000 calorie per day diet. The patient had a gastrointestinal tube (a tube surgically inserted through the patient's abdominal wall into the patient's intestine) as an access for supplemental feeding.

b. On 12/21/16, the patient's physician (Staff Member #M2) ordered the following dietary supplement: "Peptamen 1.5 - Give 1000 cc overnight through feeding tube; Run it at 125 cc/hr.". On 12/29/16, the physician ordered the following nutritional supplement: "Give Boost Plus five cans daily".

c. There was no documentation in the patient's medical record that hospital staff members infused 1000 cc of Peptamen 1.5 through the patient's feeding tube for 4 of 38 nights between 04/01/17 and 05/08/17.

d. There was no documentation in the patient's medical record that hospital staff members offered Boost Plus to the patient for 80/180 cans prescribed between 04/04/17 and 05/08/17.

e. On 05/08/17 1:55 PM. the registered nurse (Staff Member #M1) confirmed that documentation in patient's record did not reflect that the patient received 1000 ml of Peptamen 1.5 nightly as ordered; and that the patient had been offered "Boost" nutritional supplement five times daily as ordered.

4. On 05/16/17 at 9:00 AM, Surveyor #7 reviewed the medical record of Patient #K8. A nutrition risk assessment completed on 04/25/17 by a dietician (Staff Member #K1) identified the patient as a moderate nutritional risk with altered nutrition-related laboratory values. A follow-up nutrition consult was ordered because the patient had lost weight as a result of refusing meals during the previous two weeks. The consult (dated 05/10/17) indicated the patient had a weight loss of 16 pounds or 10.8 percent of his/her total body weight within the past month. The patient's current treatment plan (dated 05/09/17) nor the previous treatment plan dated 4/25/2017 identified any treatment plan problems related to nutritional deficiencies.

On 5/16/2017 at 2:30 PM, Surveyor #7 had a follow-up interview with a nurse manager (Staff Member #K2). The manager acknowledged that the Patient #K8's treatment plan should have included a problem related to inadequate nutrition.

5. On 05/16/17 at 10:00 AM, Surveyor #10 reviewed the medical record of Patient #JW3 and interviewed a registered nurse who provided care in patient's treatment unit (Staff Member #JW9). This record review and interview revealed the following:

a. The patient has a history of poor oral intake. On 04/10/17, the patient's physician (Staff Member #JW8) wrote orders for patient care staff members to document the patient's oral intake. On 04/13/17 the physician repeated the order to document oral intake. Based on medical record review, documentation of oral intake was not initiated until 04/18/17.

b. An interview with the registered nurse (Staff Member #JW9) confirmed that oral intake had not been documented as ordered

6. On 05/16/17 at 2:30 PM, Surveyor #10 reviewed the medical records of Patient #JW2 and interviewed the Ward Administrator for the patient's treatment unit (Staff #JW6). This record review and interview revealed the following:

a. The patient had a long history of refusing to eat. On 03/07/17, the patient underwent a surgical procedure for insertion of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted through the patient's abdominal wall into the patient's intestine) as an access for supplemental feeding.

b. The patient's weights recorded on a monthly vital sign form dated February 2017 through May 2017 indicated the patient weighed 162 lbs. in February 2017 and 147.5 lbs. in May 2017. Documentation on the patient's treatment form dated May 2017 indicated monthly weights were discontinued on 05/13/17. There was no physician order found to support discontinuance of weights.


Item #3- Referrals to Health Care Consultants

Based on observation, interview, and record review, the hospital failed to ensure that hospital staff members had an effective system to communicate patient care recommendations made by health care consultants, as demonstrated by Patient #CS12.

Failure to consider and implement recommendations made by health care consultants risks patient injury and harm.

Findings included:

1. On 05/18/17 at 2:30 PM, Surveyor #8 reviewed a podiatry consult for Patient #CS12, a 54 year old female with a history of diabetes with neuropathy and pain in both feet. The consult dated 05/15/17 noted that the patient had been given new shoes with specific instructions to break in wearing the shoes over the following 1-2 days. The patient was not to wear the shoes continuously until the breaking-in period had been completed.

2. During an interview with Surveyor #8 at the time of the record review, a registered nurse (Staff Member #CS14) reported that the staff had not received the information about when the patient's shoes would arrive. Upon further investigation, the patient reported that she was wearing them.

3. The charge nurse (Staff Member #CS13) interviewed unit staff and reported that the consultative summary and instructions for breaking in the shows had been placed into the patient's attending physician's mailbox by the staff member who had escorted the patient to get her shoes. The nurses had not been informed that the shoes had been received and the process for breaking in the shoes.

4. The registered nurse (Staff Member #CS14) caring for the patient who was wearing the shoes assessed the patient's feet and reported that there was a blister on the right big toe.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure all hospital staff members followed its procedure for identification of patients prior to medication administration, as demonstrated by 2 of 2 patients observed (Patients #KM14, #KM15).

Failure to follow the hospital's patient identification policy places patients at risk of injury or death.

Findings included:

1. The hospital policy, "Patient Identifiers Including Photograph" Policy #8.11 (Effective Date: 05/08/17) read: "A. All staff will use at least two patient identifiers when: 1. Administering medications... B. ...Acceptable identifiers include the patient's name, patient's medical record number, telephone number, date of birth, social security number and/or photograph."

2. On 5/17/2017 at 4:10 PM, Surveyor #9 observed medication administration for two patients (Patient #KM14 and patient #KM15). The surveyor observed that the Licensed Practical Nurse (Staff Member #KM7) failed to use two patient identifiers prior to administering their medication for 2 of 2 patients. In both cases, the staff member called the patients by their first name, rather than asking them to state their full name or other identifier per hospital policy.

3. During interview with the Licensed Practical Nurse immediately following the medication administration, the nurse told the surveyor that he knew the policy and should be following the policy.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure health care staff charted in medical records according to hospital charting requirements for 6 of 6 records reviewed (Patients #KM2, #KM6, #KM21, #KM22, #CS2, #CS8).

Failure to write accurate, legible, dated and timed medical record entries risks patient harm or injury by misinterpreted information and delay in treatment.

Findings included:

1. The hospital's policy and procedure titled "Medical Records Procedures, Charting Requirement" (Policy #1.4, Rev. 3/17) read: "Every Medical Record entry is to be dated and timed , ...the Author identified (signed) and when necessary, authenticated. All record entries must be accurate, complete and legible. ...All incorrect entries will be lined through, initialed, dated and marked "error" ... Do Not Use White Out ..."

2. On 05/24/17 at 9:45 AM, Surveyor #9 reviewed the record for Patient #KM2 and found two consultation reports with illegible initials of staff and without time or date of the acknowledgment of the report.

3. On 05/24/17 at 9:45 AM, Surveyor #9 reviewed the record for Patient #KM22 and found an oncology consultation without the time of initialing practitioner.

4. On 05/24/17 at 11:15 AM, Surveyor #9 reviewed the record for Patient #KM21, and found an imaging report with an illegible initial, without a time or date of initial. A registered nurse working on the patient's unit (Staff Member #KM1) stated the initial could be two different practitioners and was unable to confirm which physician had initialed the form.

5. On 05/24/17 at 11:30 AM, Surveyor #9 reviewed a dietitian consult for Patient #KM6. The consult was without a time of the initialing practitioner.

6. On 05/08/17 at 9:30 AM, Surveyor #8 reviewed the medical record for Patient #CS2 and found that white out had been used on a restraint and seclusion flow sheet dated 04/6/17. A registered nurse working on the patient's unit (Staff Member #CS4) confirmed the finding and stated that hospital policy prohibits use of white-out in a patient record.

7. On 05/09/17 at 11:00 AM, Surveyor #8 reviewed the medical record for Patient #CS8 and found three errors on a seclusion and restraint record dated 04/27/17. The errors had been scribbled over rather than following the hospital policy to line through, write "error" and initial. The physician's order for same event also showed scribbled-over writing. A registered nurse working on the patient's unit (Staff Member #CS6) confirmed the finding at the time of the observation.
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Item #1 - Policies and Procedures

Based on observation, document review, and interview, the hospital failed to ensure that policies and procedures for radiological services were periodically reviewed and revised to reflect current standards of practice.

Failure to review policies and procedures regarding radiological services places patients and staff at risk for unsafe care and injury.

Findings included:

1. On 05/16/17 from 9:15 AM to 10:35 AM, Surveyor #2 inspected the radiology department of the facility. During the inspection, the surveyor asked the imaging technician (Staff Member #TH16) to provide the policy and procedure manuals that guide work in the department. The technician provided policy manuals dated 2004 and a procedure manual titled "VA Decentralized Hospital Computer Program - Radiology" dated 1992.

2. The surveyor asked the technician if there were more current manuals on the hospital computer system. The technician stated that he was unaware if any updated policies or procedures exist. The most recent policy found in the hospital-wide database titled "Radiology Services: Oversight, Safety, and Maintenance" was last updated in 2011.

3. On 05/16/17 from 2:00 PM to 2:30 PM, Surveyor #2 interviewed the Radiology Department Manager (Staff Member #TH12). The manager stated that policies and procedures could not be updated in house because he was not a radiologist.


Item #2 - Training and Competency Evaluation

Based on policy and procedure review, document review, and interview, the hospital failed to ensure that staff performing ionizing radiology activities received ongoing training and competency evaluations.

Failure to regularly train staff and perform competency evaluations places patients at risk for unsafe care and risks staff safety due to unsafe technique.

Findings included:

1. The hospital's policy titled, "2.4.14 Radiology Services: Oversight, Safety, and Maintenance" (Rev. 5/2011) read: "Employee Training: The Radiology Supervisor ensures employees who use x-ray equipment receive ongoing training on equipment, safety, and operation."

2. A hospital document titled "Client Service Contract: WSH Radiology Services" (Expiration Date 06/30/17) stated in part, "Special Terms and Conditions: 4. Performance Work Statement. The Contractor shall provide services and staff, and otherwise do all things necessary for or incidental to the performance of work, as set forth below: b. Provide the following professional In-Patient services on a scheduled basis: (3) Provide professional education services for Hospital staff, as determined necessary by either party for providing needed updates and/or changes in radiology ..."

3. On 05/16/17 from 9:15 AM to 10:35 AM, Surveyor #2 inspected the hospital's radiology department. During the inspection, the surveyor asked the imaging technician (Staff Member #TH16) what types of training he receives from the facility regarding radiological services. The technician stated that no training was being conducted. The surveyor also asked how often competency evaluations are being conducted. The technician stated that competency evaluations were not being conducted because there was no other person on staff qualified to perform such evaluations.

4. On 05/16/17 from 2:00 PM to 2:30 PM, Surveyor #2 interviewed the Radiology Department Manager (Staff Member #TH12). The manager stated that he could not perform competency evaluations or training because he was not a radiologist.

5. The imaging technician (Staff Member #TH16) did not have any radiological services training documented in his clinical education files.
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Based on observation, policy and procedure review, and interview, the hospital failed to ensure that lead shielding vests were tested to ensure efficacy and safety as required by hospital policy.

Failure to ensure shielding equipment is effective and safe risks patient and staff exposure to ionizing radiation.

Findings included:

1. The hospital policy titled, "2.4.14 Radiology Services: Oversight, Safety, and Maintenance" (Rev. 5/11) read: "Radiation Protection and Safety: WSH Technologists test the integrity of lead aprons/gonadal-shielding equipment yearly and record and date the testing was completed on a label affixed on the aprons."

2. On 05/16/17 9:15 AM to 10:35 AM, Surveyor #2 inspected the radiology department of the facility. The surveyor inspected shielding equipment. One vest was dated 04/12/16, which indicated that this was the last inspection date.

3. At the time of the observation, the surveyor asked the imaging technician (Staff Member #TH16) how often the vests are tested for safety and efficacy. The technician confirmed that the vests should be tested annually and the date of the test written on the vest.
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Based on interview, policy and procedure review, and document review, the hospital failed to ensure that a radiologist supervised ionizing radiology services.

Failure to ensure that a radiologist supervises radiological services places patients at risk for unsafe care and staff members at risk for unsafe working conditions.

Findings included:

1. The hospital's policy titled, "2.4.14 Radiology Services: Oversight, Safety, and Maintenance" (Rev. 05/11) read: "Radiology Oversight: WSH (Western State Hospital) Radiology Services oversight is provided by a Radiologist credentialed and privileged by the organized Medical Staff."

2. The document titled "Client Service Contract: WSH Radiology Services" (Expiration Date 06/30/17) read: "Special Terms and Conditions: 4. Performance Work Statement. The Contractor shall provide services and staff, and otherwise do all things necessary for or incidental to the performance of work, as set forth below: a. Designate a qualified Radiologist to be director of ionizing radiology services for WSH. (1) The director shall have oversight of the safety of ionizing radiology services to patients and personnel. (2) The director shall review records of equipment maintenance and quality control data semi-annually."

3. On 05/16/17 from 2:00 PM to 2:30 PM, Surveyor #2 interviewed the Radiology Department Manager (Staff Member #TH12). The manager stated that he was assigned a managerial role over the radiology department in 2006 but was not a radiologist. He stated that he was a pathologist and only provides administrative responsibility over the department. He stated that the facility had previously had onsite consultation from the radiological services contractor (Tacoma Radiological Associates) when films were read onsite, but that oversight was reduced when film reading moved offsite.

4. On 05/18/17 at 8:35 AM, Surveyor #2 interviewed the Quality Director (Staff Member #TH13) regarding oversight of the radiology department. She stated that a physician (Staff Member #TH14) and consultant (Staff Member #TH15) from the radiology contractor came onsite twice a year to evaluate the facility and ensure equipment maintenance was completed. Those individuals did not provide direct oversight of day-to-day operations throughout the year.
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Based on observation, interview, and document review, the hospital failed to comply with the food safety requirements of the 2009 Federal Drug Administration Food Code.

Failure to implement food safety requirements put patients at risk for development of food borne illness.

Findings included:

Item #1 - Hand Hygiene

1. The hospital's Food and Nutrition Services Policy 11.10 (effective March 2017), under Procedures A. Handwashing, stated in part; "1. Employees will wash their hands frequently and always in the following situations: ... b. Before gloving and after gloves are removed; ..."

2. On 05/09/17 between 11:00 AM and 1:10 PM, Surveyor #4 observed lunch service from the service kitchen for Wards S8 and S10. The surveyor observed two Food Service Staff (Staff #RM6 and Staff #RM7) don and doff gloves eleven times without performing a hand wash as required.

Reference: 2009 FDA Food Code 2-301.14 (8)


Item #2 - Handwashing Sink Available for Use

1. The hospital's 2017 Ward Food Service Worker Handbook; Operational Guidelines for Ward Food Service (dated 1/1/2017), under Hygiene & Handwashing, "What should be provided for washing and drying hands at the hand washing sinks?" (page 22), stated in part, "... a suitable method of hand drying (e.g. paper towels from a dispenser, ...)."

The hospital's Food and Nutrition Services Policy 11.10 (effective March 2017), under Procedures A. Handwashing, #2 stated; "Do not wash hands in a pot sink or food preparation sink."

2. On 05/08/17 at 11:20 AM during lunch service for Ward F1, Surveyor #3 observed that a sanitizer bucket was located in the handwashing sink, thereby making the sink inaccessible for handwashing.

3. On 05/09/17 at 11:05 AM, in the service kitchen for Wards S8 and S10, Surveyor #4 observed that there were no disposable towels available within arm's reach of the handwashing sink. The surveyor asked one of the Food Service Staff (Staff Member #RM6) about the empty dispenser. Staff Member #RM6 said, "That's because we don't have a key."

4. On 05/12/17 at 11:30 AM, during lunch service for Wards C2 and C5, Surveyor #2 observed that a sanitizer bucket was located in the handwashing sink. The surveyor asked a Mental Health Technician (Staff Member #TH11) and a Food Service Worker (Staff Member #TH23) why a sanitizer bucket was stored in the handwashing sink when the kitchen also contained a service sink. They stated that the service sink had been turned off earlier in the day for maintenance and had not been turned back on at the time of food service. They acknowledged that the handwashing sink was dedicated for that function and removed the sanitizer bucket. Handwashing sinks must be accessible for handwashing and not used for any other purpose.

5. On 05/16/17 from 2:00 PM to 2:40 PM, Surveyor #4 and the Java Site manager (Staff Member #RM8), toured the Java Site (a coffee service shop for patients). The surveyor observed that the Java Site had been designed and constructed without a handwashing sink as required by state regulation. Staff Member #RM8 said that staff had been performing handwashing in the first compartment (a pot sink) of the three compartment warewashing sink. Staff Member #RM8 acknowledged the observation and stated he would requisition a handwashing sink immediately.

Reference: 2009 FDA Food Code 6-301.12; 2009 FDA Food Code 5-205.11 (2); 2009 FDA Food Code 5-230.11


Item #3 - Food Safety

1. The hospital's Food and Nutrition Services Policy 11.10 (effective March 2017), under Procedures B. Food Storage, step 6 stated, "Maintain prepared and perishable foods at a safe temperature until served. Use a calibrated thermometer to verify the temperature. Foods shall be maintained at an internal temperature of below 41 degrees Fahrenheit or above 140 degrees Fahrenheit to ensure food safety.

The hospital's 2017 Ward Food Service Worker Handbook; Operational Guidelines for Ward Food Service (dated 01/01/17), under Food Serving Procedure (page 53), #7 stated in part, "Use a sanitized calibrated thermometer to monitor the food temperatures..."

The 2017 Ward Food Service Workers Handbook; Operation Guidelines for Ward Food Service (dated 01/01/17) under Food Serving Procedure (page 53), #6 stated in part, "...sanitizing solution ... test the solution using test strip ..."

2. On 05/08/17 at 11:20 AM, during lunch service for Ward F1, the Food Service Staff (Staff Member #LM3) and Surveyor #3 used a thin-stemmed thermometer to assess the internal temperature of cooked fish arriving in an enclosed container from the main kitchen. The fish servings had internal temperatures between 119 and 132 degrees Fahrenheit, lower than the minimum hot holding temperature of 135 degrees Fahrenheit required by the food code.

Staff Member #LM3 reconditioned the fish servings by reheating to 165 degrees Fahrenheit in a microwave oven.

3. On 05/08/17 at 11:20 AM during lunch service for Ward F1, Surveyor #3 observed that the Food Service Staff (Staff Member #LM3) failed to sanitize a thin-stemmed thermometer between uses.

4. On 05/09/17 Surveyor #4 observed two Food Service Staff (Staff Member #RM6 and Staff Member #RM7) prepare food service for Wards S-8 and S-10. At 11:20 AM Staff Member #RM7 removed an analog stem thermometer from a drawer, rinsed it under running water, and dried it with a paper towel before piercing a stack of Reuben sandwiches.

At 11:55 AM Staff Member #RM6 rinsed the same analog stem thermometer under running water and dried it with a paper towel before piercing another stack of Reuben sandwiches.

Surveyor #4 asked Staff Member #RM6 and Staff Member #RM7 why the thermometer was not sanitized before use. Staff Member #RM6 replied, "I thought it's not good for the food."

On 05/10/17 at 11:20 AM, Surveyor #4 observed a Food Service Staff (Staff Member #RM10) prepare food service for Ward S7. Staff Member #RM10 rinsed an analog stem thermometer under running water and dried it with a paper towel prior to inserting the probe into a container of vegetable soup. Surveyor #4 asked Staff Member #RM10 why the thermometer was not sanitized before use. She replied, "I can't put bleach in the food."

5. On 05/09/17 at 1:00 PM in the service kitchen for Wards S8 and S10, and on 05/16/17 at 2:15 PM in the Java Site, Surveyor #4 observed that no sanitizer test strips were available to measure the concentration of sanitizer solution. A food service staff member (Staff Member #RM7) confirmed that the Ward S8 and S10 service kitchen did not have test strips; and Java Site manager (Staff Member #RM8) confirmed that the Java Site did not have sanitizer test strips.

Reference: 2009 FDA Food Code 3-01.16 (1)(a); 2009 FDA Food Code 3-701.11 (1); 2009 FDA Food Code 4-702.11; 2009 FDA Food Code 4-302.14


Item #4 - Equipment Installation

1. The Hobart Operation Manual LX Series manufacturer's directions for use read: "Plumbing Connections: Warning: Plumbing connections must comply with applicable sanitary, safety, and plumbing codes ...Drain: A drain hose is provided with a 3/4" pipe connection adapter. This should be securely plumbed into the sink drain. Use care not to kink the hose. Drain must have a minimum flow capacity of 10 gallons per minute."

2. The Hoshizaki DCM-270BAH ice machine manufacturer instructions for use read, "F. Water Supply and Drain Connections: Drain lines must have a 1/4" fall per foot (2 cm per 1 m) on horizontal runs to get a good flow..."

3. On 05/08/17 between 9:30 AM and 12:30 PM, Surveyor #1 observed that the dishwashers on Wards E2, E3, and E5 had been plumbed such that the drain lines did not slope to prevent water from pooling in the line, thereby allowing for stagnation.

4. On 05/09/17 from 2:00 PM to 3:00 PM, Surveyor #2 toured Ward E8. During the tour, the surveyor inspected a Hoshizaki DCM-270BAH ice machine in the service kitchen. The vinyl drain line had a U-shaped bend before it sloped to the floor drain. The bend in the drain line created a slight loop that could allow water to stagnate and does not follow manufacturer installation instructions.

5. On 05/16/17 at 2:35 PM, Surveyor #4 and the Java Site manager (Staff Member #RM8) observed the drain line from the Hoshizaki Ice Maker in the Java Site. The drain line was nearly horizontal for most of its length (estimated 4-feet) with an area of pooled water; and heavy, black growth. The drain line was not sloped sufficiently to allow it to completely drain to the floor sink where it discharged.

Reference: 2009 FDA Food Code 4-204.120; 2009 FDA Food Code 4-501.15
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Based on interview and document review, the hospital failed to review professional services as part of the Utilization Review program.

Failure to review professional services limits the hospital's ability to determine if services provided are medically necessary and effective.

Findings included:

1. The hospital's Utilization Management Plan (dated October 2015), under "Utilization Management Procedure Manual, Committee Charter" section "IV. Scope, Duties, and Responsibilities", read: "2. Review data for medical necessity of admissions, active treatment, continued stays, efficacy of professional services, discharge planning and duration of stays. 3. Recommend actions to improve utilization and to monitor the effectiveness and appropriateness of improvement strategies... 5. Review the effectiveness of the UM program annually and revise as appropriate."

2. Under the section titled "II. Scope: Review of Professional Services", the plan showed that the utilization management committee would select the topic of the annual Medical Care Evaluation (MCE) and oversee completion of this evaluation. The plan stated that the purpose of an MCE study was to promote more effective and efficient use of facilities and services, analyze the finding of the study, correct or investigate further any deficiencies or problems, and recommend more effective hospital care procedures.

Under the section titled "II. Scope: Functions of the Utilization Management Committee", the plan showed that the committee would review the medical necessity and efficacy of professional services.

3. On 05/17/17 at 3:00 PM, Surveyor #5 interviewed staff members who performed utilization review functions (Staff Members #E8, #E9, #E10, #E11, and #E12) on 05/17/17. The interview revealed that the Utilization Management Committee did not review professional services as part of the utilization review process. The hospital's MCE projects implemented in 2015 and 2017 were performance improvement projects involving smoking cessation and antibiotic stewardship and did not meet the definition of review and evaluation of professional services as required by 42 CFR 482.30(f).
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Based on observation, interview, and document review, the hospital failed to meet the requirements of the 2012 edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC).

Findings included:

Refer to the deficiencies written on the ACUTE CARE HOSPITAL MEDICARE LIFE SAFETY inspection report dated 06/01/17 .
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Item #1 - Expired Supplies

Based on observation, document review and interview, the hospital failed to ensure that patient care supplies did not exceed their designated expiration dates.

Failure to ensure patient care supplies do not exceed their expiration dates risks patient harm due to unsafe and unusable equipment.

Findings included:

1. The hospital document titled, "Chapter 8, Nursing Units - Infection Control Policy "(approved by the Infection Control Committee 3/21/2017), under IV. Procedure: D. Medical Supplies: 1. Storage, stated in part, "All Medical supplies shall be checked on at least a monthly basis for outdates ..."

2. On 05/08/17 at 11:45 AM in the F1 exam room, Surveyor #3 identified two containers of "Hibiclens" (a skin antiseptic) with expiration dates of 11/2016 and 02/2017. At the time of the observation, a ward patient safety nurse (Staff Member #LM1) confirmed the finding and discarded the items.

3. On 05/09/17 at 10:20 AM in the F6 environmental cabinet, Surveyor #3 identified 4 bottles of Metricide ( a high-level disinfectant). One bottle had an expiration date of 11/2014 and 3 bottles had an expiration date of 01/2015. A staff member removed the bottles at the time of the observation.

4. On 05/10/17 at 2:45 PM, Surveyor #4 identified an expired bottle of Metricide on Ward S8 of the Psychiatric Treatment and Recovery Center (PTRC). The bottle had an expiration date of 01/2015. A staff member removed the bottle at the time of the observation.

5. On 05/11/17 at 11:55 AM, Surveyor #4 identified an expired bottle of Metricide in the Dirty Utility room on Ward S9 of the PTRC. The bottle had an expiration date of 10/2014. The S9 Ward Administrator (Staff RM-1) removed the bottle at the time of the observation.


Item #2 - Insect Infestation

Based on observation and interview, the hospital failed to maintain shower rooms in a way to prevent infiltration of insects.

Failure to prevent insects from entering the patient shower area puts patients at risk from an unsanitary environment.

Findings included:

On 05/08/17 at 10:10 AM during a tour of the F3 shower room, Surveyor #3 observed small winged insects present in each shower stall. At the time of the observation, the F3 Ward Administrator (Staff Member #LM4) identified the insects as "drain flies", small flies that lay eggs and breed in sludge-based habitats.


Item #3 - Damaged Furniture

Based on observation and interview, the hospital failed to maintain furniture in the patient care area in a safe and easily cleanable condition.

Failure to maintain furniture in a safe and cleanable manner puts patients at risk of injury and infection.

Findings included:

1. On 05/08/17 between 9:20 and 10:20 AM during the tour of Ward C8, Surveyor #2 noted pillows stored in the clean utility room. One pillow had visible striated tears on the vinyl surface, making it difficult for staff members to properly clean it. The surveyor found a second torn pillow in the restraint room. The Ward Administrator (Staff Member #TH5) confirmed the findings at the time of the observation, and disposed of the torn pillows.

2. On 05/08/17 at 10:53 AM, Surveyor #2 observed a chair in room C2-352 with an approximately 3 inch diameter tear in the front. At the time of the observation, the Ward Administrator (Staff Member #TH6) confirmed the finding.

3. On 05/08/17 at 3:45 PM, Surveyor #2 toured the treatment mall for the C wards. The surveyor identified torn furnishings in room C9-320. At the time of the observation, the Therapy Supervisor (Staff Member #TH7) confirmed the finding.

4. On 05/10/17 at 9:20 AM, Surveyor #9 observed a chair located in the patient milieu on Ward F1 with torn and missing fabric on both arms. The hard plastic structure and the foam cushioning were exposed. The chair was not cleanable. Staff Member #KM5 confirmed these findings at the time of the observations.

5. On 05/10/17 at 2:15 PM , Surveyor #9 observed a chair located in the nursing station on Ward F6 with cracked and missing fabric on both arms exposing the foam. The arms of the chairs were taped over with clear tape, the internal foam could be visualized through the clear tape

6. On 05/10/17 at 4:00 PM, Surveyor #9 observed a cloth chair located in the medication room of Ward F6 with torn fabric on both arms. The foam cushioning was exposed through the torn fabric. The cloth fabric of the chair seat and back were noted to be dirty. The cloth fabric was not cleanable. Staff Member #KM6 confirmed these findings at the time of the observation.


Item #4 - Damaged Door and Walls

Based on observation and interview, the hospital failed to maintain the physical facility of the hospital to ensure patient safety.

Failure to maintain the physical facilities of the hospital puts patients at risk from injury due to environmental hazards.

Findings included:

1. On 05/08/17 between 2:00 and 2:20 PM in the Habilitative Mental Health Unit, Surveyor #4 observed peeling paint on the walls in a patient room on Ward W1N and on the walls in a patient room on Ward W1S. At the time of the observations, the day shift manager (Staff Member #RM5) acknowledged the findings.

2. On 05/10/17 at 10:40 AM, on Ward S7 of the Psychiatric Treatment and Recovery Center (PTRC), Surveyor #4 observed sharp edges from the strike plate on the door to Patient Room #222 posed risk of injury. A corner of the strike plate was not flush with the edge of the door. The S7 Ward Administrator (Staff Member #RM11) confirmed the finding and the staff completed repairs during the course of the survey.

3. On 05/10/17 at 9:50 AM, on Ward S7 of the Psychiatric Treatment and Recovery Center (PTRC), Surveyor #4 observed peeling paint in the corridor near a restroom (Room #236) and in the TV Room (room #247). At the time of the observations, the S7 Ward Administrator (Staff Member #RM11) acknowledged the findings.

4. On 05/11/17 at 10:45 AM, on Ward S9 of the PTRC, Surveyor #4 observed peeling paint around the interior door frame of patient room #463. At the time of the observation, the S9 Ward Administrator (Staff Member #RM1) acknowledged the finding.


Item #5 - Emergency Equipment Maintenance

Based on observation, document review, and interview, the hospital failed to ensure that emergency equipment was inventoried and checked according to hospital policy.

Failure to ensure emergency equipment is operational and available places patients at risk of inadequate care in emergency situations.

Findings included:

1. The hospital policy titled "Nursing Services Standard Manual: Medical Emergency Equipment. Procedure 245" (Rev. 11/2015) states in part, "Steps: B. Check and record ward emergency equipment daily by completing the emergency equipment checklist to verify availability, proper location, and operating function."

2. On 05/08/17 at 3:45 PM, Surveyor #2 toured the treatment mall for the C wards. The surveyor inspected the emergency equipment cart in the exam room. The surveyor noted that the checklist had not been documented daily as had been observed in other units.

3. At the time of the observation, the surveyor interviewed the therapy supervisor (Staff Member #TH7) regarding checking the emergency equipment. The supervisor stated the equipment is to be checked once per week.

4. After reviewing the hospital policy, the surveyor returned to the treatment mall on 05/15/17 at 11:07 AM to obtain a copy of a document titled, "Emergency Equipment Checklist". According to the document, the emergency equipment was not checked on 7 of 10 days the treatment mall was open between 05/01/17 and 05/12/17.
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Based on observation and interview, the hospital failed to maintain air pressure relationships consistent with industry standards for ventilation in healthcare facilities.

Failure to maintain air pressure relationships according to industry standards puts patients, visitors, and staff at risk of exposure to communicable diseases.

References:

TSI Healthcare Guidelines and Standards, Table 7-1 Design Parameters from ANSI/ASHRE/ASHE, Standard 170-2008.

Centers for Disease Control and Prevention: Guidelines for Environmental Infection Control in Health-Care Facilities (2003), Pg. 212-214, "Table B.2. Ventilation requirements for areas affecting patient care in hospitals and outpatient facilities."

Findings included:

1. On 05/08/17 at 10:53 AM, Surveyor #2 tested the ventilation pressure relationship for clean utility room C3-352. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #TH6).

2. On 05/08/17 at 1:30 PM, Surveyor #2 tested the ventilation pressure relationship for clean utility room C2-252. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #TH8).

3. On 05/09/17 at 1:25 PM, Surveyor #2 tested the ventilation pressure relationship for clean linen room 151 on Ward E7. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #TH9).

4. On 05/09/17 at 2:00 PM, Surveyor #2 tested the ventilation pressure relationship for the clean linen room on Ward E8. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #TH10).

5. On 05/09/17 at 3:45 PM, Surveyor #4 tested the ventilation pressure relationship in a Clean Utility room on Ward S8 of the Psychiatric Treatment and Recovery Center (PTRC). The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #RM14).

6. On 05/10/17 at 10:20 AM, Surveyor #4 tested the ventilation pressure relationship in a clean linen closet on Ward S7 of the PTRC. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #RM11).

7. On 05/10/17 at 1:55 PM, Surveyor #4 tested the ventilation pressure relationship in a Clean Utility room on Ward S3 of the PTRC. The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #RM12) and the ward RN3 (Staff Member #RM13).

8. On 05/10/17 at 2:10 PM, Surveyor #4 tested the ventilation pressure relationship in the Ward S3 Treatment Room (used to store sterile supplies). The room was under negative air pressure instead of positive pressure with respect to the corridor. This finding was confirmed by the Ward Administrator (Staff Member #RM12) and the ward RN3 (Staff Member #RM13).
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Item #1 - N95 Respirator Fit Testing Program

Based on interview and review of hospital policies and procedures, the hospital failed to implement its N95 respirator fit testing program.

Failure to test for proper fit of N95 respirators risks transmission of airborne diseases to patient care staff members.

Reference: 29 CFR 1910.134 - "Occupational Health and Safety Standards - Personal Protective Equipment - Respiratory Protection."

Findings included:

1. The hospital's policy and procedure titled "Employee N95 Respirator Fit Testing" (Policy No. 2.4.16; Effective 11/15/15) under "Policy", read: "In the event of potential exposure to airborne pathogenic particles, the Medical Nurse Consultants will don the N95 respirator and ensure the appropriate precautions are applied to the potential host (patient with respiratory communicable disease). If there is concern for potential exposure to staff while implementing precautions, the Medical Nurse Consultant will fit test all necessary staff while implementing precautions using the N95 respirator." Under "Procedure", the policy read : "The Industrial Hygienist will oversee a Train the Trainer (TTT) program to enable the hospital to have the capability to fit test employees with an N95 respirator".

2. On 05/10/17 at 4:00 PM, Surveyor #6 interviewed the hospital's infection preventionist (Staff Member #M3), regarding the hospital's respiratory protection program. During the interview, the staff member stated that not all the Medical Nurse Consultants (MCN) had been fit tested for N95 masks. There was no method for ensuring that an MCN who had been fit tested for an N95 mask was on duty at all times. The staff member also stated that the hospital did not have an industrial hygienist on staff to oversee the TTT program as stated in the policy and procedure.


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Item # 2 - Hand Hygiene

Based on observation and document review, the hospital failed to ensure that staff members complied with the hospital's hand hygiene policy.

Failure to perform appropriate hand hygiene puts patients, staff and visitors at risk of infections.

Findings included:

1. The hospital policy titled "Hand Hygiene Guidelines" (Approved 11/15) stated in part, "Policy: If hands are not visibly soiled, use a hospital approved alcohol-based hand rub for routinely decontaminating hands in the following situations: After removing gloves. If there has been any contact with the patient or patient's environment, hands should be decontaminated when leaving the patient's bedside or room."

2. On 05/08/17 between 11:25 and 11:46 AM, Surveyor #9 observed a Licensed Practical Nurse (Staff Member #KM4) prepare and administer oral medications to six patients (Patient #KM6, Patient #KM7, Patient #KM8, Patient #KM9, Patient #KM10, and Patient #KM11). On 6 of 6 occasions the nurse failed to perform hand hygiene prior to donning gloves and administering medication.

3. On 05/09/17 from 9:00 to 9:45 AM, Surveyor #2 observed a housekeeping procedure on Ward C2. The housekeeper (Staff Member #TH1) did not conduct hand hygiene following glove changes on five separate occasions.

4. On 05/09/17 from 11:00 to 11:40 AM, Surveyor #2 observed a housekeeping procedure on the treatment mall of the C wards. The housekeeper (Staff Member #TH2) cleaned 4 bathrooms and the high touch surfaces of approximately 20 rooms without changing gloves or performing hand hygiene. The housekeeper did not change gloves following cleaning of bathrooms before moving to cleaning the high touch surfaces of classrooms.

5. On 05/09/17 at 2:00 PM, Surveyor #2 observed cleaning procedures on E8. The housekeeper (Staff Member #TH3) did not perform hand hygiene during glove changes.

6. On 05/10/17 at 8:50 AM, Surveyor #4 observed a housekeeper (Staff Member #RM9) as he performed a daily room cleaning of Patient Room #275 on Ward S7 of the Psychiatric Treatment and Recovery Center (PTRC). Staff Member #RM9 changed gloves two times without performing hand hygiene as required by policy.

7. On 05/10/17 from 8:52 AM to 9:52 AM, Surveyor #2 observed the cleaning procedure for five patient rooms on C2. The housekeepers (Staff Member #TH1 and #TH4) did not perform hand hygiene during glove changes as required by policy. Hand sanitizer was not present on the cleaning cart.


Item # 3 - Medical Instruments

Based on observation and document review, the hospital failed to ensure that staff members complied with the hospital policy on handling of procedure instruments in the examination rooms

Failure to promptly clean procedural instruments after use, risks inadequate disinfection and sterilization.

Findings included:

1. The hospital policy titled "Treatment of Used Medical Instruments on the Wards at WSH" (Effective 07/11/16) stated in part, "Take the instrument return bucket with dirty instruments in it to its location assigned to your ward for sharps collection. Place the instrument return bucket into the secondary sharps collection totes found on the pallets in the sharps collection room. Call Central Service at 756-2508 to request a pickup of used instrument for reprocessing. Instruments should be sent to Central Service during the same shift if at all possible to avoid drying of debris on instrumentation."

2. On 05/08/17 at 9:45 AM, Surveyor #3 interviewed a patient safety nurse (Staff Member #LM2) about the process for ensuring prompt removal of bioburden on medical instruments used in the F2 exam room, after observing instruments left in their biohazard container. The nurse indicated that providers are responsible for pre-treating the instruments and putting them in their biohazard container. The nurse indicated that the staff removed the items from the room "every day to a day and a half".

3. On 05/08/17 at 1:45 PM, Surveyor #4 observed contaminated items (bandage scissors and suture scissors) in a covered, plastic container located in the Treatment Room of Ward W1N in the Habilitative Mental Health Unit (HMH). The surveyor asked the ward Day Shift Manager (Staff Member #RM5) about the process for transport of the contaminated items. Staff Member #RM5 said he did not know the process or whether there was a policy.

4. On 05/11/17 at 11:50 AM, Surveyor #4 observed contaminated items (suture scissors and bandage scissors) in a covered, plastic container located in the Dirty Utility room of Ward S9.


Item #4 - Environmental Cleaning

Based on observation, and review of hospital policy and procedures, the hospital failed to ensure that staff members followed the hospital's policy for cleaning in the patient's environment.

Failure to properly clean the patient's living environment places patients at risk of illness or infection.

Findings included:

1. Review of hospital policies and procedures showed the following:

a. The hospital's policy and procedure titled, "Environmental Services Standard Operating Procedures" read on page 10, step 9, "Damp dust front and back of door, door knobs, hinges, tops of doors with cleaning cloth dipped in germicidal detergent solution."

b. A hospital document titled, Behavioral Health Administration Inter-Hospital Policy, Policy No. 1.7 (Effective Date: 01/30/17), under "Step C. Prepare the seclusion/restraint room, Key Points", read: "On a regular basis (and after use), seclusion/restraint room and mattress are checked and cleaned when room is unattended."

c. The hospital's policy titled, "Chapter 8, Nursing Units - Infection Control Policy" (Approved by the Infection Control Committee 03/21/17), under "IV. Procedure, J. Cleanliness and Sanitation, 2. Routine and Terminal Cleaning", read: " ...Thorough cleaning of each patient's room (incl. [including] mattress and pillow) ..."

2. On 05/09/17 at 9:00 AM, Surveyor #1 observed a daily cleaning of patient room #112 on unit E5. During the process, the housekeeper (Staff Member #A6) cleaned the patient's restroom, but did not disinfect the patient's restroom door or doorknob.

3. On 05/09/17 at 10:25 AM, Surveyor #4 observed a used menstrual pad in the wastebasket of Room #537, the Seclusion Room (#537) on Ward S10 of the Psychiatric Treatment and Recovery Center (PTRC). The surveyor asked the Ward S10 RN3 (Staff Member #RM15) and Staff Member #RM16 about the procedure for cleaning the Seclusion Room between uses. Staff Member #RM15 stated the room was checked before a new patient was admitted. Staff Member #RM16 said the restroom was cleaned daily on a rotation with the ward restrooms.

4. On 05/10/17 at 8:00 AM on Ward S7, Surveyor #4 observed a housekeeper (Staff Member #RM9) as he sprayed disinfectant cleaner onto the top surface of a patient mattress and used a cloth to wipe the top and bottom surfaces of the mattress. The staff member wiped none of the side surfaces with disinfectant. Staff Member #RM9 then used his gloved hand to remove gross debris from the flat surface of the molded-plastic bed. No part of the bed was wiped with disinfectant. The S7 Ward Administrator (Staff Member #RM11) acknowledged the observations.

5. On 05/11/17 at 11:10 AM, Surveyor #4 observed waste wrappers from an adhesive bandage and alcohol swab in the seat of the restraint chair in the Seclusion Room on Ward S9 of the PTRC. The S9 Ward Administrator (Staff Member #RM1) and the S9 Ward Clerk (Staff Member #RM2) acknowledged the observation.


Item #5 - Disinfectant Use

Based on observation and interview, the hospital failed to ensure that housekeepers knew the contact time for disinfectants.

Failure to know the contact time for disinfectants prevents staff members from properly using disinfectants and risks infection of patients and staff.

Findings included:

1. The manufacturer's instructions for use for Ecolab Disinfectant 2.0 read: "Contact Time: Use a 10-minute contact time for disinfection against all other viruses, fungi, and bacteria claimed."

2. On 05/09/17 from 9:00 to 9:45 AM, Surveyor #2 observed a housekeeper (Staff Member #TH1) clean a common area on ward C2. The surveyor asked the housekeeper for the contact time (the time required to kill microorganisms) of the disinfectant (Ecolab Disinfectant 2.0). The housekeeper stated that the product did not have a contact time.

3. On 05/10/17 at 8:00 AM, Surveyor #4 observed a housekeeper (Staff Member #RM9) on Ward S7 during a daily room cleaning of Patient Room #275. The surveyor observed that the surface of the mattress appeared dry when Staff Member #RM9 exited the room. The housekeeper did not monitor disinfectant cleaner to ensure the surface of the patient mattress remained wet for 10 minutes as directed by the manufacturer instructions for use.


Item #6 - Sharps Containers

Based on observation, interview and document review, the hospital failed to ensure that staff members followed the hospital's policy for handling sharps containers (receptacles for needles and other "sharp" items contaminated with potentially infectious materials).

Failure to maintain sharps containers in a safe manner puts staff and patients at risk of exposure to infectious organisms.

Findings included:

1. The hospital document titled, "Chapter 8, Nursing Units - Infection Control Policy" (approved by the Infection Control Committee 3/21/2017), under IV. Procedure: A. Standard Precautions: 4. "Sharps" Handling, stated in part, " ...Full sharps containers must be sealed and returned to Central Service within 7 days."

2. On 05/11/17, at 11:30 AM, during a tour of Ward S9 of the Psychiatric Treatment and Recovery Center (PTRC) with the Ward Administrator (Staff Member #RM1) and the Ward Clerk (Staff Member #RM2), Surveyor #4 observed a full sharps container on a shelf in the Medication Room.

3. At the time of the observation, Staff Member #RM1 stated the room was not currently being used by staff due to an in-progress HVAC project. The surveyor asked the Ward Administrator and the Ward Clerk about the process for transport of the contaminated items and the sharps container. They stated that they were not sure how long the contaminated items or the sharps container had been awaiting transport. Staff Member #RM2 stated that normally an RN takes a full sharps container immediately to the waste collection point. She did not know its location.
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Based on policy and procedure review and interview the hospital failed to ensure that the organization and staffing of physical therapy services was appropriate to the scope of services offered.

Failure to adequately organize the scope of services for the physical therapy department and staff it accordingly places patients at risk for inadequate care or delays in receiving necessary treatments.

Findings included:

1. On 05/11/17 at 10:25 AM, Surveyors #2 and #6 interviewed the physical therapy manager (Staff Member #TH20) regarding the overall physical therapy structure. The manager stated that the physical therapy department consisted of two physical therapists and one ambulation technician for the 842 bed facility. The department was in the process of hiring a physical therapy assistant. The department offered restorative and preventative therapy services but was only recently able to add skilled therapy with the addition of the second physical therapist (Staff Member #TH22). The manager stated that the department had also been able to increase the treatment frequency for patients with the addition of the new physical therapist.

Surveyor #2 asked the manager to describe how ambulation therapy functions in the hospital. The manager stated that this service was conducted on the unit by the nursing department. The physical therapy department has an ambulation technician located in the department to perform restorative therapy, but the department does not provide on-unit therapy, such as range of motion or ambulation exercises. The manager stated that physical therapy staff is not allowed to conduct therapy on the unit and must rely on the medical escort service to coordinate patient care in the department. The surveyor asked the manager if any training with the nursing staff on physical therapy procedures had been conducted to ensure continuity of care. The manager stated that the last training had occurred at least four years ago.

2. On 05/16/17 from 10:35 AM to 10:55 AM, Surveyor #2 conducted another interview with the physical therapy manager (Staff Member #TH20) regarding patient assessments and staffing. The manager stated that five additional physical therapists had been contracted to conduct patient assessments on 05/15/17. He stated that this staff was necessary to complete 19 additional assessments that had been submitted as a result of survey findings and continue with the standard case load. He stated that he was happy that the facility was utilizing its therapy staffing contract because the department was able to receive the help they needed and departmental staff were able to provide better quality of care.

3. On 05/24/17 at 11:30 AM, Surveyor #2 requested a scope of services policy for the physical therapy department to ensure that staffing was adequate to handle the scope of practice being conducted at the facility. No scope of practice document could be provided. The manager provided a document titled "Rehabilitative Services - Inpatient Evaluation - Physical Therapy (WSH 23-170)" (Rev. 12/2012) as the closest example of a document describing what physical therapy staff assesses that might dictate subsequent services. The Quality Director (Staff Member #TH13) coordinated the request for the scope of practice document and confirmed that the only documentation was the policy described above.
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Based on interview and document review, the hospital failed to ensure that an individual directed the overall operations of occupational therapy services.

Failure to have a director of occupational therapy with oversight of the entire services places patients at risk of inadequate care.

Findings included:

1. On 05/23/17 from 10:30 AM to 11:00 AM, Surveyor #2 interviewed an occupational therapist (Staff Member #TH17) regarding the hospital's occupational therapy services. The surveyor asked the therapist how the service was organized and if there was a director that provided oversight over the entire service. The therapist stated that occupational therapy is managed on the unit with oversight from the therapy supervisors for each ward. She stated that there was no single director over the entire service and there has never been one in the past.

2. On 05/23/17 from 11:00 AM to 11:20 AM, Surveyor #2 interviewed the therapy supervisor (Staff Member #TH18) for the E wards. The surveyor asked the supervisor how occupational therapy was supervised. The supervisor stated that occupational therapy is managed by therapy supervisors on each ward. The supervisor confirmed that the hospital did not have director for occupational therapy services and stated that the position had been posted on 05/01/17.

3. Review of a job bulletin for the position "DSHS Occupational Therapy Services Manager" showed the position was posted on 05/01/17 with a closing date of 05/15/17.
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Based on medical record review, policy and procedure review, and interview, the hospital failed to ensure that orders for physical therapy were written prior to scheduling treatment for 1 of 2 patients reviewed (Patient #TH1).

Failure to ensure that orders are written by a credentialed physician prior to performing therapeutic services risks patients receiving medical treatment that may not be necessary or in the best interests of their health.

Findings included:

1. The hospital's policy titled, "Medical Records Procedures. 6.3. Rehabilitative Services Consultant Referral (WSH 23-59)" (Revised 01/2016) read: "4. Treatment recommendations shall only be implemented upon approval and signature of the attending physician (Inpatient Treatment Plan Addendum WSH 23-172)."

2. The hospital's policy and procedure titled, "Management of the patient at risk for falls" (Revised March 2017) read: "Area of Responsibility D. Physical Therapy Referral if needed, "4. Refer for PT eval if: a. High Fall Risk (Tinetti score 0-19). B. Pt is non-ambulatory upon admit or with change of condition affecting ambulation". Under the heading "F. Interdisciplinary Management Interventions", the policy read: "9. Consult with physical and occupational therapy to plan a program to increase patient's endurance and strength."

3. On 05/16/17 at 3:00 PM, Surveyor #5 reviewed the medical record for Patient #TH1. The patient had a Tinetti score of 16, which indicated the patient had a high risk for falls and should receive a physical therapy evaluation. The attending physician ordered a physical therapy consult on 03/01/17. Staff were unable to locate the consult in the patient's medical record. The physical therapy department faxed a record of the consult to staff at the time of the record review. The consult was completed on 03/09/217 and recommended physical therapy. No physician order was signed for physical therapy services. The patient was scheduled to have physical therapy services on 03/15/17, 03/17/17, 03/21/17, and 03/24/17, but the patient refused.

4. A registered nurse (Staff Member #TH19) confirmed the findings above.
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Based on record review, policy and procedure review, and interview, the hospital failed to ensure that rehabilitative services were documented in the medical record for 2 of 2 patients reviewed (Patients #TH1, #TH2).

Failure to document rehabilitative services in the patient medical record limits the ability of patient care staff to have a complete picture of the patient's medical history and develop appropriate treatment plans.

Findings included:

1. The hospital policy titled, "Medical Records Procedures. 6.3. Rehabilitative Services Consultant Referral (WSH 23-59)" (Rev. 01/2016) read: "3. The credentialed therapist receiving the referral form will complete the appropriate evaluations within seven (7) calendar days of the date received. A complete record of the evaluation(s) will be provided on the appropriate Rehabilitative Services Database form and placed in the Rehab section of the patient's medical record."

2. Surveyor #5 conducted a chart review for Patient #TH2. The attending physician ordered a physical therapy consult on 12/30/2016. Physical therapy staff completed the consult on 1/3/2017, but staff did not place the results of the evaluation in the medical record. Staff assisting with the medical record review confirmed the finding.

3. On 05/16/17 at 3:00 PM, Surveyor #5 reviewed the medical record for Patient #TH1. The patient had a Tinetti score of 16, which indicates they are at high risk for falls and should receive a physical therapy evaluation. The attending physician ordered a physical therapy consult on 03/01/17. During an interview at the time of the record review, a registered nurse (Staff Member #TH19) was unable to locate the results of the consult in the patient's medical record. The physical therapy department faxed a record of the consult to staff at the time of the record review. The consult was completed on 3/9/2017, and the physical therapist had recommended physical therapy for the patient. No physical therapy had been ordered.
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Based on interview, document review, and policies and procedures, the hospital failed to ensure that alterations to durable medical equipment were completed according to physical therapy recommendations and the patient's treatment plan, as demonstrated by Patient #TH3

Failure to alter durable medical equipment per physical therapy recommendations places patients at risk of having improperly functioning assist devices that could lead to injury or delay in rehabilitation.

Findings included:

1. The hospital's procedure titled "Medical Records Procedures - Procedure: Rehabilitative Services Consult Referral (WSH 23-59)" (Rev. 1/2016) read: " ....5. Possible Criteria for Referral: ...E. Physical Therapy deficit in: i. Range of Motion; ii. Muscle Strength; iii. Mobility (Transfers/Ambulation); iv. Neuromuscular or Musculoskeletal conditions." The policy did not contain information regarding wheelchair assessments.

2. On 05/11/17 at 10:25 AM, Surveyors #2 and #6 interviewed the Physical Therapy Manager (Staff Member #TH20) about the physical therapy department's scope of service. The manager stated that the physical therapy department oversees patient wheelchair assessments. The manager stated that the hospital's Equipment Manager (Staff Member #M10) provided and maintained pre-fabricated wheelchairs, attachments, and equipment on behalf of the physical therapy department.

3. Surveyor #5 and #10 reviewed documents regarding a wheelchair strap in need of repair for Patient #TH3. The patient was referred to physical therapy for a wheelchair assessment on 05/12/17. Physical therapy conducted the assessment on 05/13/17. The assessment identified a loose strap and recommended that it be fixed. The patient's treatment plan was updated on 05/18/17 to indicate that the patient's wheelchair strap needed repair. A note on 05/24/17 stated that the patient still needed follow up for the strap repair. No information was documented that the Equipment Manager was notified about the strap or that any follow up on the unit occurred.

4. On 05/24/17 at 10:00 AM, Surveyor #5 interviewed the E8 ward administrator (Staff Member #TH10) and reviewed the referral tracking sheet on ward E8. The wheelchair assessment for Patient #TH3 was documented on the spreadsheet. The ward administrator confirmed that she had documented the patient assessment on the tracking spreadsheet. She stated that she did not know if the issue had been resolved.
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