HospitalInspections.org

Based on review of credential files and staff interview, the Hospital failed to ensure that 6 (#1, #2, #3, #4, #5, #6) of 6 Physicians and 1 certified registered Nurse Practitioner (CRNP#1) credential files reviewed specified the privileges that the Providers were approved to perform.

Findings include:

1. For Physicians #1, #4, #5, and #6, (all Psychiatrists) review of credential files on 11/20/14, indicated that only the category of "Psychiatry" was documented. The credential files lacked documentation of the specific privileges the Psychiatrists were approved to perform.

2. For Physician #2, a Podiatrist (specialized in foot care and surgery), review of Physician #2's credential file on 11/20/14, indicated that only the category of "Podiatry" was documented. The credential file lacked documentation of the specific privileges the Podiatrist was approved to perform.

3. For Physician #3, a Physician who specialized in medicine, review of Physician #3's credential file on 11/20/14, indicated that only the category of "General Medicine" was documented. The credential file lacked documentation of the specific privileges Physician #3 was approved to perform.

During interview at 9:45 A.M. on 11/20/14, the Medical Director said he was aware specific privileges needed to be identified.

4. CRNP #1 was employed in the Hospital's Medical Clinic. Review of the credential file of NP #1, on 11/20/14, indicated that the credential file lacked a scope of practice and delineation of privileges. Only the category, "General Medicine," was documented. There were no specific privileges documented under this category to identify exactly what procedures CRNP #1 was allowed to perform or what CRNP #1's scope of practice included.

Additionally, the approval for "General Medicine" was not signed by CRNP #1, her Supervising Physician, or Nursing Administration, as required. Also, CRNP #1's credential file lacked documentation of her current certification. The certificate located in the file was expired.

Based on document review and interview, the Hospital's Governing Body (GB) failed to ensure services furnished under contract were evaluated for quality through the Quality Assessment Performance Improvement (QAPI) Program.
Findings included:
The meeting minutes of the Hospital's Governing Body were reviewed for meetings held on July 28, 2014 and September 22, 2014. No agenda item for the Governing Body to evaluate, and/or assess, the quality of contracted services was noted.
The meeting minutes of the Hospital Performance Improvement Committee (QAPI) meeting of 10/22/14 were reviewed. There was no agenda item or discussion of the Hospital's contracted services.
The Director of Quality Management was interviewed on 11/20/14 at 11:00 A.M., regarding the Hospital's process for evaluating through QAPI, services provided to the Hospital by contract. The Director of Quality Management said that prior to two months ago contracted services were not evaluated through the Hospital QAPI program. The Director of Quality Management said that the Hospital had only recently begun to evaluate pharmacy, laboratory, and radiology services through its QAPI process. He/She said that evaluation of contracted services by the QAPI program were a work in progress.
The Chief Operating Officer (COO) was interviewed on 11/21/14 at 11:45 A.M. regarding the Governing Body's role in the QAPI process for evaluating the quality of all contracted services. The COO said that the Governing Body did not evaluate each contracted service for quality at the present time.

The condition for Patient rights is not met as the hospital failed to ensure the patients' right to receive care in a safe setting was upheld.

Please see 0144 which provides evidence of an ongoing unsafe environment which included patient access to objects used to inflict self injury.

Based on observation, review of medical records, Hospital policy and staff interviews, it was determined that the Hospital failed to ensure staff provided supervision and care in a consistent manner to ensure safe patient care for 3 patients who access objects used to self injure (#3, #1 and #17) of a total sample of 32 patients; and the Hospital failed to manage and supervise patients who access lighting materials to smoke on and off the nursing units thereby not ensuring a safe environment.

Findings include:

1. Review of the Hospital's admission policy indicated that they provide care that meet the psychiatric, medical and recovery needs of patients from age 18 and above. The Hospital identifies that they are a recovery oriented hospital and encourages patients to participate in treatment. The Hospital policy indicates the patient should always feel safe.

The Hospital's policies indicates that although patients can have some personal items on the units, that all items are subject to search upon admission and at the time the patient receives new items.

The Hospital's policy clearly indicated that matches. lighters, sharp or other dangerous objects (any object that is sharp, may be sharp, and/or that may be used to injure self or others) are not permitted on the units.

The policy indicated it was when a Patient engages in assaultive or self injurious behavior, that the Hospital staff assess the Patient for safety and at times can be placed on sharps restriction.

The policy indicated that extension cords, power strips are prohibited, as well as personal belongings that can create a fire hazard.

During an initial tour of the Cain 4 West Unit on 11/18/14 at 10:30 A.M., patient environmental safety concerns were observed, by the Surveyor, in areas that had been allocated for treatment of patients. The observed environmental safety concerns included: a three-foot faucet hose (an instrument that could be used for strangulation) in the unit tub room; all patient bed frames were a wire mesh base with springs that could be removed and used as a sharp. During the tour it was also observed that in all rooms on the Cain 4 West unit, amongst the patient belongings which were strewn across the rooms. Clothing that included neck ties and belts. Pens, pencils, writing and/or art supplies and electronics and CD discs and cases were observed in patient rooms, bathrooms and in multi-purposes areas of the unit. The lack of proper storage of these items posed a potential risk for these items to be accessed for self injurious behavior such as strangulation and self cutting.

Interview with Nurse #3, on 11/18/14 at 11:00 A.M. stated that the patients did have access to these items that included objects that could harm themselves and others in their rooms and he/she did not respond to concerns regarding the 3 foot cord in tub. The Surveyor inquired about safety as she had indicated there were many patients who displayed self injurious behaviors and assaultive behavior and she said the issues were addressed when an incident occurred.

2. Review of Patient #3's medical record on 11/18/14 indicated the Patient had a significant history of self injurious behaviors and suicidal ideation. The Patient was admitted to the Hospital under a civil commitment, which indicates the Patient is committed to the Hospital up to 6 months and then up to an additional year. Patient #3's diagnosis included bipolar disorder and post traumatic stress disorder from sexual abuse.

Patient #3 resided on the Cain West Unit in one of the 4 bed rooms referenced above. Observation of the Patient's room throughout the survey (11/18/14 at 10:30 A.M.. 11/19/14 at 11:13 A.M. and 11/20/14 at 10:10 A.M.) indicated that personal belongings for all patients in the room were accessible to all patients on the unit. The belongings included scarves, bras, extra bed sheets pencils, artistic supplies, electronics, cords, CDs, and multiple other items that patients could harm themselves and others with. The belongings were not locked or stored securely. In addition, Patient #3 was observed in multiple areas on the Unit, which also contained objects that were sharp, may be sharpened, and/or may be used to injure self and others. These items included art supplies, game pieces, electronic equipment, CDs and cords.

Review of Patient #3's record indicated the Patient has and continues to display self injurious behaviors towards self and assaults towards others since his/her admission in May 2014. From 5/2014 through 10/2014, the Patient has displayed self injurious behaviors of cutting self with plastic from a CD case, picking and digging at lacerations on arms from cutting self, hitting walls with fists, ideation's of strangulation of self with a sheet, burning self with a lighter (twice), intrusive, stealing items from other patients' rooms, selling electronics and medication for money to patients and multiple assaults towards others. The medical record indicates Patient #3 is attention seeking and has little insight into the seriousness of his/her behaviors. The Hospital staff would attempt to limit set the Patient's behavior by placing him/her on restrictions that include a room search, sharps restrictions and 1 to 1 for safety, however staff failed to prevent access to such self-injurious objects as observations evidenced.

During interview on 11/21/14 at approximately 10:30 A.M., Social Worker's #1, #2 and #3 said that it was difficult to control Patients who displayed self injurious or assaultive behaviors towards others. Social Worker #3 said that Patient #3 was treated during the crisis, and that the environment did lend the Patient access to harmful objects and behaviors. and did not know why other options were not implemented, for example, limiting Patient's #3 access to CDs, as this is a consistent object the Patient uses to cut him/herself. The Social Workers said that it was difficult to implement certain precautions to protect against harmful behaviors in the setting that provided Patients with access to multiple objects as observed in patient rooms and multi purpose areas in light of Patient #3's significant risks of self injurious behavior.

Review of the incident reports from 5/2014 through 10/2014 revealed that Patient #3 was able to obtain sharp objects to cut his/her arms 1-2 times per month. While the Resident's room was stripped, and plastic cases for CD's as well as CD's themselves were removed from the Patient's room, he/she was able to access other sharp objects left out in the open. A majority of the incidences documented occurred while the Patient was in the bathroom. For at least one incident of self injurious behavior, metal pieces from a pen were used to inflict scratches to his/her forearms. Progress notes indicated that the level of supervision was increased until the facility felt the Patient was stable, however, continued episodes of cutting his/her arms continued as access to these objects was not effectively managed in part.

3. Upon entrance to the Hospital's grounds a large sign indicates the Hospital was a tobacco free campus. The Hospital's smoking policy states that the facility and grounds are non-smoking and that the Hospital staff are responsible for monitoring and implementing a smoke free environment. The Hospital policy indicates that lighters and cigarettes are not allowed on the Hospital units.

a. Review of Patient' #1 medical record on 11/20/14 indicated the Patient was admitted to the Hospital under a civil commitment for a minimum of 6 months; with an additional year. Patient's #1 diagnoses included schizophrenia and poly substance abuse. Per record review the Patient was observed multiple times smoking on the Unit in May 2014, October 2014 and November 2014. During the incidents the Patient's room was searched and the contraband confiscated (which included lighting materials). There was no indication the Hospital offered the Patient smoking cessation and identified interventions to prevent the Patient from accessing smoking materials. The campus wide smoke free policy was not being implemented thereby access to lighting materials provided an unsafe environment.

b. Patient #17 was admitted to Hospital in December 1999, diagnoses included schizophrenia, poly substance abuse and sexually problematic behaviors. Record review on 11/20/14 identified the Patient smokes cigarettes on the Unit, and it is known that he/she smokes on the grounds of the Hospital campus. Record review failed to indicate the Hospital was monitoring and implementing ongoing interventions to manage patients' access to smoking materials.

4. Review of the incident reports from 5/2014 to 10/2014 indicated that 3-5 patients were repeatedly found smoking in the men's bathroom on the unit. Patients were noted to also walk out of the bathroom with a lit cigarette and walked to their room, before extinguishing on at least 2 occasions (5/12/14 and 6/6/14). While room searches and use of metal detecting wands were used to detect metal objects in clothing, these Patients were able to continue to obtain both lighters and cigarettes. Patients were noted in incident reports to come out of the men's bathroom, smelling of smoke and simply denied smoking in the bathroom.

During interview on 11/21/14 at approximately 12:45 P.M. with the Medical Director, Psychologist #1 and the Director of Quality Management, they said the Hospital's program was a recovery program and that the patient's are allowed personal items. The Surveyor inquired about patient safety and the documented incidents of patient's injuring self and/or others and their ongoing access to lighting materials by which to smoke on the units and on the campus. The Surveyor shared that not only was there evidence that Patients were smoking on the Units, there was also multiple observations of Patients smoking in the gazebo in front of the building observed by the Surveyors.

The Medical Director said he was aware of the problem, but that the Hospital had limited ability to control the situations. He said that the Hospital knew which Patients smoked and which patients had contraband that was not allowed on the units, but that the Hospital staff were not successful in preventing and implementing interventions to protect potential harmful behaviors. The Medical Director said each time a Patient displayed a harmful behavior, the Hospital staff would address the behavior at that time. However, he said that it was difficult to enforce the non smoking policy because the Patients obtained contraband from multiple sources and either hid the contraband on the Hospital grounds or in their rooms. The Medical Director said the Hospital had not been successful in enforcing a smoke free campus and preventing the Patients' access to unwanted contraband. He said that they wanted to implement safeguards and develop protocols and procedures to address the problem of contraband that included cigarettes, lighters and sharp objects but had not.

Following the Survey exit (review of survey findings) with the Hospital's staff on 11/21/14 at approximately 3:10 P.M., Hospital staff and others were observed exiting the building and lighting cigarettes a few feet from the exit door and in the gazebo.

Based on review of Governing Body meeting minutes, Hospital QAPI (Quality Assurance Performance Improvement) meeting minutes, and interview with staff, the Hospital failed to ensure that its QAPI program reflected the complexity of its organization and services, including those services furnished under contract or arrangement.

Findings include:

The Director of Quality Assurance was interviewed on 11/20/14 at 11:00 A.M. regarding the Hospital-wide QAPI program. The Director said that the Hospital had only recently included the laboratory, pharmacy, and radiology contracted services, into the hospital QAPI program. The Director of Quality Assurance also said that the Hospital had not yet included all of the Hospital's contracted services into their QAPI program. The Director of Quality Assurance said she was hired by the Hospital in May 2014. Prior to his/her appointment as the Director of Quality Assurance, there was no QAPI process for any of the Hospital's contracted services. He/She said that it was a work in progress.


The meeting minutes of the Hospital's Governing Body were reviewed for meetings held on July 28, 2014 and September 22, 2014. There was no agenda item for the Governing Body to evaluate, and/or assess the quality of contracted services noted.

The meeting minutes of the Hospital Performance Improvement Committee (QAPI) meeting of 10/22/14 were reviewed. There was no agenda item or discussion of the Hospital's contracted services.

The Chief Operating Officer (COO) was interviewed on 11/21/14 at 11:45 A.M. regarding the Hospital Governing Body's role in the QAPI process for evaluating the quality of all contracted services. The COO said that the Governing Body did not evaluate each contracted service of the Hospital for quality at the present time.

Based on record review and staff interview, the Hospital failed to ensure that its policy for the administration of PRN (as needed) medications, with parameters for when to administer each for agitation/anxiety, was followed for 4 (#10, #18, #26 and #17) of a total sample of 32 patients.

Findings included:

1. Patient #10 was admitted on 9/26/14, with diagnoses that included Schizoaffective disorder, Bipolar Disorder and polysubstance dependence.

Review of the patient's clinical record revealed physician orders that included:
Fluphenazine (antipsychotic) 5 mg orally every 12 hours as needed (prn) for agitation and anxiety and Clonazepam (benzodiazepine) 0.5 mg orally daily as needed (prn) for anxiety and agitation

Review of the Medication Administration Record for the month of November 2014 through the date of record review on 11/17/14 revealed that the patient received Clonazepam 6 times on 11/7/14, 11/11/14, 11/14/14, 11/15/14, 11/16/14 and 11/17/14. The patient received no doses of Fluphenazine during the month.

Review of the nursing documentation on the Medication Administration Record and in the nursing notes in the patient's record revealed no information about how to determine which drug to administer for which specific behaviors. There was no description of the specific behavior that the patient exhibited to require administration of the drug, other than "agitated/agitation" or "anxious/anxiety."

During interview on 11/21/14 at 12:35 P.M., the Medical Director said that each "prn" drug order should have parameters identifying specific behaviors that warrant the administration of the drug. The Medical Director said that the reason for administration for each drug should be specific only for that drug, and that nurses should not have to choose which drug to give.

2. Patient #26 was admitted 3/25/05 with a long history of atypical psychotic disorder. Review of the nurses' notes revealed that the patient was frequently in a "dissociative state." During these periods, the patient refused to eat or drink, and was often described by staff as holding his/her hands in a praying position and mumbling or talking nonsensically. Other notes described the patient as having "psychotic agitation" and refusing medications.

Review of the patient's clinical record revealed physician orders that included:
Fluphenazine 5 mg every 4 hours orally as needed (prn) for dissociation/psychosis
Fluphenazine 2.5 mg per ml injection, 5 mg intramuscular (IM) every 4 hours as needed (prn) for refusal of oral Ativan 0.5 mg twice daily orally as needed (prn) for agitation

Review of the Medication Administration Record for 10/2014 revealed that the patient had received:

Fluphenazine, orally, on two days - on 10/11/14 at 5:30 A.M. and 10/13/14 at 4:45 A.M.
Fluphenazine, IM, on 5 days - 10/12/14 at 4:45 A.M., 10/13/14 at 4:45 A.M., 10/16/14 at 6:45 A.M., 10/20/14 at 2:00 A.M., 10/22/14 at 6:00 A.M.
Ativan on 10/12/14 at 5:30 A.M., and 10/13/14 at 4:45 A.M.
Review of the nurses' notes did not provide any additional information related to the specific behaviors requiring administration of these drugs, in accordance with the physician orders. For example, on 10/12/14, when it was noted on the Medication Administration Record that the patient received Fluphenazine IM at 4:45 A.M. and Ativan at 5:30 A.M. Review of the nurse's note revealed that the nurse wrote that the patient woke at 3:00 A.M. and became dissociative. The nurse wrote that the patient was "given prn" but spit it out and continued to spit out oral medications. The nurse wrote that Ativan and Fluphenazine were both given IM at 5:30 A.M. No additional documentation was found related to the patient's behavior or need for both of these medications.

During interview on 11/21/14 at 12:35 P.M., the Medical Director said that each "prn" drug order should identify specific behaviors that warrant the administration of the drug. The Medical Director said that the reason for administration for each drug should be specific only for that drug, and that nurses should not have to choose which drug to give.



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3. Patient #18 was admitted to the Hospital in 11/2013 with diagnoses which included Schizoaffective disorder, Impulsive disorder, and Intellectual deficit.

Record review on 11/18/14, revealed that the patient had orders for multiple different medications to be administered PRN (as needed) to treat agitation/anxiety. The PRN medications included:

-Haloperidol 5 mg (milligrams) orally every 6 hours/PRN for agitation
-Hydroxyzine 75 mg po (orally) every HS (hour of sleep) PRN for anxiety.
-Lorazepam 1 mg po every 8 hours PRN for agitation.
-Quetiapine 200 mg po one tablet as needed for agitation, not to exceed 2 doses in 24 hours.

The physicians' orders for each of the different PRN medications failed to include parameters for nursing to follow when deciding on which medication to administer for agitation.

Review of the nursing documentation on the October 2014/November 2014 MAR (Medication Administration Record) and the nursing notes in the patient's record revealed no information about how to determine which drug to administer for which specific behaviors. There was no description of the specific behavior that the patient exhibited to require administration of the drug other than agitation and anxiety. The medical record indicated that nurses had exercised their own discretion when administering a particular PRN medication for agitation as there was no parameter to guide them. The patient received the following medications with no clinical criteria to use for determining when to use one PRN medication over another:

1. Haloperidol 5 mg p.o. was administered for agitation five times by four different nurses (twice by the same nurse).

2. Hydroxyzine 75 mg p.o. was administered once for anxiety.

3. Lorazepam 1 mg p.o. was administered nine separate times by multiple nurses for agitation.

4. Haloperidol 5 mg p.o., Hydroxyzine 75 mg p.o., and Lorazepam 1 mg p.o. were administered at the same time by one nurse on 10/31/14 at 7:00 P.M. for agitation.

5. Quetiapine 200 mg p.o. was administered eight times by multiple nurses for agitation.

Physician #1, the ordering physician, was interviewed on 11/21/14 at 11:15 A.M. Physician #1 said that he/she should have given specific parameters for nurses to follow when administering a particular PRN medication for agitation/anxiety. Physician #1 acknowledged that without specific parameters for rating the patient's agitation/anxiety level, nurses would have no clinical criteria to use for determining when to use one PRN medication over another.

The Medical Director was interviewed on 11/21/14 at 12:35 P.M. and said that the failure of Physician #1 to list specific criteria for when to administer different PRN medications for agitation/anxiety, leaves the decision making for administration solely in the hands of the nurse who is administering it. The Medical Director said it is not Hospital policy to leave administration of multiple different PRN medications for treating agitation/anxiety to the discretion of the nurse without specific parameters.



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4. For Patient #17, a) it was determined the Hospital administer an antipsychotic medication that was not in accordance with the Court specified treatment plan and b) the Hospital failed to document explanations why the Patient was not administered the physician ordered bowel medications on multiple occasions.

a) Record review indicated Patient #17's guardianship included a Court approved antipsychotic treatment plan. The antipsychotic treatment plan, dated 3/13/14, indicated the following antipsychotic medications could be administered; Risperidone, Abilfy, Seroquel XR (extended release) and Risperdal Consta.

Review of the medication administration record (MAR) for September 2014 indicated Patient #17 was administered 5 milligrams (mg) of the antipsychotic medication Haldol at 10:30 A.M. on 9/10/14. A review of Patient's #17 physician orders indicated on 9/10/14, the Physician ordered one dose of the Haldol for anger and agitation.

Nurse #2 was interviewed on 11/21/14 at 10:00 A.M. and said she thought that it was "ok" that the medication was not in accordance with the Court's treatment plan because the Patient was agitated. During an interview with the Medical Director on 11/21/14 at approximately 12:45 P.M., he said the antipsychotic treatment plan should have been followed.

b). For Patient's #17 there was no documentation explaining why the physician ordered bowel medications had not been administered as ordered and that the plan of care was not being followed.

Review of the October 2014 and November 2014 MARs and the physician orders indicated the Patient's bowel regimen included the following laxatives: bisacodyl 12 mg, by mouth every morning, bisacodyl 6 mg every evening and Senna 8.6 mg, 2 tablets daily.

Review of the October 2014 MAR indicated Patient #17 did not receive the Senna 28 times and the bisacodyl 46 times. For November 2014, the MAR indicated Patient #17 did not receive the Senna 12 times and the bisacodyl 25 times. The nurses documented by circling their initials on the MAR that these medications were not administered.

Nurse #2 was interviewed on 11/21/14 at approximately 10:00 A.M., she said that Patient #17 frequently refused his/her bowel medications. Nurse #2 said that according to Hospital policy staff are suppose to circle their initials when a medication is not administered and then document, per policy, on the back of the MAR the reason. She said that the nurses were to notify the physician if medications were missed. Nurse #2 said that Patient #17 was on the bowel medications because of constipating side effects due to many of his/her medications. Further review of the MARs and medical record failed to indicate that the nursing staff documented the reason why the medication was not administered.

Based on observations, staff interviews, and review of Hospital documents and protocols, the Hospital failed to ensure the following:

1. Infection control (IC) protocols for hand washing and cleaning the glucometer when obtaining blood sugar results were implemented for 1 Patient (#25) from a total sample of 30 Inpatients;

2. An IC policy was developed for the requirement for an infection control risk assessment (ICRA) related to hospital renovations and construction; and IC protocols for the monitoring of chemical sanitizer for the facility dish machine.

Findings include:

1. For Patient #25, observations of a finger stick for a blood sugar test in the Patient's room, on 11/20/14 at 7:15 A.M., indicated the following:

a. Registered Nurse (RN) #4 obtained all necessary equipment (glucometer, box containing finger stick tools, sponges and alcohol wipes), and brought to Patient #25's room;

b. RN #4 then placed the box containing all supplies and the glucometer directly on Patient #25's bureau, providing a risk of cross-contamination from the bureau to the glucometer case and the box of supplies;

c. RN #4 performed hand hygiene (HH) and donned clean gloves;

d. RN #4 then cleansed Patient #25's index finger with alcohol, pricked the finger to obtain the blood sample. The finger-stick was unsuccessful;

e. RN #4 then and brought the glucometer, still in its case, to the Patient's bed, touching the case on the Patient's blankets, cleansed Patient #25's index finger with alcohol, pricked the finger to obtain the blood sample. The second finger-stick was also unsuccessful to obtain a blood sample;

f. RN #4 then returned the contaminated glucometer case, with the glucometer to Patient #25's bureau. The RN failed to remove his gloves and perform HH before attempting to perform a third finger-stick, although required by Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene;

g. RN #4 removed the glucometer from its case, brought the glucometer to Patient #25's bed and pricked Patient #25's finger a third time, this time he obtained a blood sample for a blood sugar level.

h. RN #4 then brought the glucometer, glucometer case, and box of supplies to the nurses' station and placed the above equipment on the counter.

i. RN #4 removed his gloves, failed to perform HH after glove removal, and disinfected the glucometer per manufacturer's directions for use (MDFU) with contaminated hands.

j. RN #4 then placed the glucometer in the now-contaminated glucometer case and placed the contaminated case and box of supplies back in the medication room without first disinfecting the glucometer case and supply box. RN #1 also failed to disinfect the counter of the nurses' station, where he had placed the contaminated glucometer case, glucometer and box of supplies.

k. Interview on 11/20/14 at 11:30 A.M., the Infection Control Nurse (ICN) said that RN #4 failed to follow Hospital infection control policy.


2. During implementation of the Centers for Medicare and Medicaid Services (CMS) approved Infection Control Worksheet, it was determined that the Hospital lacked protocol for mitigation of construction related nosocomial infections.

On 11/19/14 and 11/2014, this Surveyor requested a copy of the Hospital's policy and procedure that was relevant to construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project is started, as required by the Association of Professionals in Infection Control (APIC) Standards of Practice. The Infection Control Nurse (ICN) did not provide the requested policy. During interview on 11/20/14 at 11:00 A.M., the ICN said that the Hospital had not developed and implemented the above policy and procedure, although required by IC Standards of Practice.



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3. During the observation of the dish machine procedure on 11/19/14 at 8:00 A.M., it was identified that the dietary staff failed to monitor the concentration of the chemical sanitizer for the facility dish machine prior to each use.

Interview with the Food Service Director on 11/19/14 at 8:00 A.M. said that there was no Policy and Procedure available to staff identifying the proper procedure on how to check the concentration of the chemical sanitizer to ensure that all dishware, pots and pans were adequately sanitized to prevent the spread of food borne pathogens. The surveyor asked to observe one of the FSW test the concentration of the chemical sanitizer in the dish machine. The Food Service Director said that they do not have the correct test stripes in the facility to check the concentration of the chemical sanitizer in the dish machine. The Food Service Director said that the dietary staff had not been checking, nor documenting, the concentration of the chemical sanitizer since he arrive at the facility over a year ago.

Based on observation, review of Hospital Policies, and staff interview, the Hospital failed to ensure:

1. Staff adhered to manufacturer's directions for use (MDFU) for disinfection of equipment, and separation of clean and dirty;
2. Staff maintained a sanitary environment and ensured the separation of clean and dirty; and
4. Ensuring that all staff were tested annually for tuberculosis and offered the Influenza (flu) vaccine for 6 of 6 physician files reviewed per facility policy; and
4. Dietary staff checked the concentration of the chemical sanitizer in the dish machine prior to each use, and record the results, to prevent the spread of food borne pathogens.

Findings include:

1. Interview with Facility Services Worker (FSW) #2, on 11/18/14 at 9:45 A.M., on the 3 West Unit, indicated that FSW #2 cleaned patients' bedrooms and bathrooms, unit bathrooms, floors, walls and discharge units, daily. The FSW #2 said she used the Disinfectant Virex and a new clean cloth for each area. FSW #2 said she allowed the disinfectant to dry for one full minute.

During Interview on 11/19/14 at 9:40 A.M., the Director of Housekeeping and Laundry, said the dry time for Virex was one minute. However, review of MDFU indicated that the dry (kill) time for the disinfectant Virex was 10 minutes. The Director of Housekeeping and Laundry said she was not aware of the MDFU dry time and the staff had not been letting the Virex dry for 10 minutes.

2a. Observation of the Soiled Workroom on the 3 West Unit on 11/18/14 at 10:05 A.M., revealed the following clean items stored in the Soiled Workroom: privacy screen, an over the toilet commode, one plastic chair (outdoor quality), a fan, and an over the bed table.

Also observed in the Soiled Workroom was a large blue container with dirty laundry, a soiled linen hamper with dirty cleaning rags, a clinical flushing sink to dispose of urine and other body and dirty waste, and a trash hamper.

The above clean items were stored near the dirty items.

Interview with FSW #2, during the observation indicated that she cleaned the items after they were used with patients, and returned them to the Soiled Workroom for storage.

Interview with the Director of Quality on 11/20/14 at 1:50 P.M., indicated that clean items were not to be stored in the Soiled Workroom and that separation of clean and dirty needed to be maintained.

2b. Observations in the Clean Laundry Room at 9:40 A.M. on 11/19/14, indicated the following:

-Two ceiling vents were dirty with built-up layers of dirt, dust and lint;

-The rear window was broken and taped with tape to seal the broken pane. Also, a fan was in the window wrapped with silver insulation strips and a sheet to keep out the cold;
(The Director of the Laundry said the window had been that way since at least 1/2013);

-The rear of the room was very cluttered with four metal trash cans; an old broken washing machine; a floor cleaning bucket; a new, never used compressor; four mattresses; six large wall protector pads; two old, rusted step ladders; one old ripped laundry hamper; rusted wall shelving; and two, 4x8 foot room dividers.

The Director of the Laundry said the above items were stored in the Clean Laundry Room for many years.


3. Review of Physician credential files on 11/20/14, indicated that 6 (#1, #2, #3, 34, #5, #6)of 6 files lacked documenation that the physicians had been offered the Flu vaccine and tested for TB annually, although required by Hospital policy.

During interview on 11/19/14 at 11:00 A.M., the ICN said that Hospital policy required all staff to be offered the Flu vaccine and tested for TB annually.

Review of the policy titled "TB Control Program," indicated that the policy covered "all healthcare workers, patients, volunteers, visitors, and other persons."



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4. On 11/19/14 at 8:00 A.M., the surveyor observed the dish machine procedure, which was being completed by two dietary Food Service Workers II (FSW). The dish machine temperature gage was observed to be registering 150 degrees Fahrenheit for the wash cycle and 170 degrees Fahrenheit for the rinse cycle. One of the FSW approached the surveyor and said that the temperature did not always get up to the right temperature. The Food Service Director then approached the surveyor and said that a chemical sanitizer was used to sanitize all dishware including pots and pans instead of hot water greater than 180 degrees Fahrenheit. The surveyor asked to observe one of the FSW test the concentration of the chemical sanitizer in the dish machine. The Food Service Director said that they do not have the correct test stripes in the facility to check the concentration of the chemical sanitizer in the dish machine. The Food Service Director said that the dietary staff had not been checking, nor documenting, the concentration of the chemical sanitizer since he arrive at the facility over a year ago.

Based on record review and interview the facility failed to provide Social Work Assessments that were timely and included specific treatment recommendations defining the anticipated social worker role in the treatment and discharge for four (4) of eight (8) active sample patients (A1, A3, A5 and A6). This failure results in the Treatment Team not knowing what the specific social worker's role will be in providing goals and interventions for these patients.

Findings include:

A. Record review

1. The facility's "Admission Process with Electronic Documentation" sheet, dated 10/14/14, listed that Psychosocial Assessments are to be completed by "Day 10."

2. Patient A1 (admitted on 8/13/14) had a social services assessment completed 9/17/14. The "Recommendations for Treatment and Discharge" section at the end of the assessment stated: "Her medications will be addressed"..."unclear what her discharge plan will be"..."will need to work on decreasing her psychotic and delusional symptoms." The specific role of the social worker was not identified. The assessment was completed 30 days after it was due.

3. Patient A3 (admitted on 9/4/14) had a social services assessment completed on 9/17/14. The "Recommendations for Treatment and Discharge" included: "could benefit from therapeutic partnership"..."avoiding substance relapse." The specific role of the social worker was not mentioned. The assessment was completed five (5) days after it was due.

4. Patient A5 (admitted 2/25/14) had a social services assessment completed 3/13/14. The "Recommendations for the Treatment and Discharge" stated: "It is my opinion that the patient is currently in need of further inpatient psychiatric hospitalization for evaluation and treatment, as [s/he] would be at risk of harm to self and others without the structure of the inpatient setting. It would be useful to learn more about etiological factors including premorbid functional capacity, details regarding onset of psychosis, determination of whether there was exposure to trauma, clarification of current functional capacity at the point of stabilization, and possible resources to manage [his/her] apparent need for a secure environment while minimizing restrictiveness." The specific role of the social worker was not identified. In addition, the assessment was completed nine (9) days late.

5. Patient A6 (admitted 10/23/14) had a social services assessment completed 11/13/14. The "Recommendations for Treatment and Discharge" stated: "[Name of patient] will continue to work with the team on a discharge plan that [s/he] is happy with. [Name of patient] will apply for DMH [Department of Mental Health], SSI [Social Security Income] and other services as needed. [S/he] will attend groups and gain insight into [his/her] mental illness." The specific role of the social worker was not identified and the assessment completion was 13 days late.

B. Staff Interview:

1. In an interview on 11/18/14 at 10:10 a.m., the lack of the inclusion of the specific role of the social worker in the Psychosocial Assessment for Patient A1 was discussed with SW1. She agreed that the conclusions and recommendations "do not meet the standards."

2. In an interview on 11/19/14 at 1:00 p.m., the absence of specific roles of social workers in the psychosocial of the four (4) active sample patients listed above was discussed with the Director of Social Work. The Director acknowledged the deficiency and stated "I painfully agree" (that the Recommendations for Treatment and Discharge do not meet the standards).

3. In an interview on 11/19/14 at 1:15 p.m., the lack of specific roles of the Social Worker in the Psychosocial Assessment of active sample patient A6 was discussed with SW1. She stated: "This is how I've always written them [meaning the Psychosocials], but I see what you are saying."

Based on record review and staff interview, the facility failed to identify and address medical problems in the "current treatment/recovery plans" identified during the admission evaluation for two (2) (A1 & A3) of eight (8) active sample patients. This failure could result in the failure of the staff to be aware of the medical problems to be addressed and may compromise patient's health, active treatments and discharge planning.

The findings include:

Record review:

1) Patient A1 was hospitalized on 8/13/14. Physical Examination was refused on 8/14/14, was completed on 8/19/14 and the summary indicates "Abdominal mass of uncertain etiology"..."will order abdominal ultrasound for further assessment-Fibroid." The "Current Treatment/Recovery Plan" of 8/21/14 and 10/16/14 lists current diagnosis on Axis III as "None" and as such this finding has not been identified as a problem to be addressed in the Treatment Plan.

2) Patient A3 was hospitalized on 9/4/14. Physical Examination completed on 9/4/14, the summary indicates "A 34 year old obese male with history of sleep apnea not currently using his machine despite gaining weight"..."May need to do random SaO2s during night to see if the patient desaturates." The "Current Treatment/Recovery Plan" of 9/22/14 and 11/5/14 lists current diagnosis on Axis III as "No active medical issues" as such this finding has not been identified as a problem to be addressed in the Treatment plan.

Staff interview:

In a meeting and review with the Medical Director on 11/19/14 at 2 p.m., the Medical Director agreed these medical problems identified in the Physical Examinations should have been listed and addressed in the Treatment Plans.

The Clinical Director failed to adequately monitor and evaluate the quality of the care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

(A) The Psychosocial Assessments (A1, A3, A5 and A6) are completed in a timely manner and that these Assessments are individualized and address patient specific needs and anticipated Social services role in achieving the identified goals (Refer to B108).

(B) All active therapeutic efforts are addressed (A1 and A3) in the "Current Treatment/Recovery Plan" (Refer to B125).

In an interview with the Clinical Director on 11/19/14 at 2 p.m., the Clinical Director concurred with the above deficiencies.

Based on record review and interview, it was determined that the Director of Nursing [DON] failed to meet the educational and/or on-going training requirements necessary for his administrative position as Director of Nursing within the facility. The DON did not have a master's degree in Psychiatric Mental Health and/or documented evidence of consultation from a nurse with a Master's Degree in Psychiatric/Mental Health nursing.

Findings include:

A. Record Review

A record of the DON's curriculum vitae [CV] revealed that his nursing experience had been primarily in statewide administrative positions in health services in the area of developing policies/procedures and evaluating health-based quality indicators of care to assure the care is provided effectively. He has also had experience as a health services administrator working with forensic patients for whom he has done mental health assessments. A quote from CV in this area was "automated physical exam, mental health assessment and initial medical intake screening to maximize the use of human resources." Evidence of providing direct patient care, staff supervision, and/or ongoing continuing formal education, seminars and workshops on topics that target psychiatric mental health issues was not included in his CV.

B. Interview

1. In an interview with the DON on 11/19/14 at 2:20 p.m., he disagreed with the finding. He felt that he had had a lot of experience working with mentally ill patients in an administrative level especially in the forensic field, but his CV did not support that statement. He was told that the CV did not show any experience working directly in the mental health field. Nor did his formal education reflect any completion of courses in psychiatric mental health. The DON has an Associate Nursing Degree, a Bachelor of Arts, Humanities and Social Services Degree and a Master of Social Community Nursing Option Degree.

2. In an interview on 11/19/14 at 2:45 p.m., The CMS (Centers for Medicare/Medicaid Services} criteria for a Director of Nursing was discussed with the Medical Director, who had interviewed the DON for the position. After reading the standard, he stated: "I didn't know what the requirements were."

Based on record review and interview, it was determined that the Director of Social Services failed to ensure the timely completion of Psychosocial Assessments (within ten (10) days of admission) for four (4) of eight (8) active sample patients (A1, A3, A5, and A6) and that the specific role of the social work staff was included in their "Recommendation for Treatment and Discharge" summary section."

Findings include:

1. Patient A1 (Admitted on 8/13/14) had a social services assessment completed 9/17/14. The " Recommendations for Treatment and Discharge" section at the end of the assessment stated: "Her medications will be addressed"..."unclear what her discharge plan will be"..."will need to work on decreasing her psychotic and delusional symptoms." The specific role of the social worker was not identified. The assessment was completed 30 days after it was due.

2. Patient A3 (Admitted on 9/4/14) had a social services assessment completed on 9/17/14. The "Recommendations for Treatment and Discharge" included: "could benefit from therapeutic partnership"..."avoiding substance relapse." The specific role of the social worker was not mentioned. The assessment was completed five (5) days after it was due.

3. Patient A5 (admitted on 2/25/14) had a social A services assessment completed 3/13/14. The "Recommendations for the Treatment and Discharge" stated: "It is my opinion that the patient is currently in need of further inpatient psychiatric hospitalization for evaluation and treatment, as [s/he] would be at risk of harm to self and others without the structure of the inpatient setting. It would be useful to learn more about etiological factors including premorbid functional capacity, details regarding onset of psychosis, determination of whether there was exposure to trauma, clarification of current functional capacity at the point of stabilization, and possible resources to manage [his/her] apparent need for a secure environment while minimizing restrictiveness." The specific role of the social worker was not identified. In addition, the assessment was completed nine (9) days late.

4. Patient A6 (admitted on 10/23/14) had a social services assessment completed 11/13/14. The "Recommendations for Treatment and Discharge" stated: "[Name of patient] will continue to work with the team on a discharge plan that [s/he] is happy with. [Name of patient] will apply for DMH [Department of Mental Health], SSI [Social Security Income] and other services as needed. [S/he] will attend groups and gain insight into [his/her] mental illness." The specific role of the social worker was not identified and the assessment completion was 14 days late.

Interview

In an interview on 11/19/14 at 1:00 p.m., the absence of specific roles of social workers in the psychosocial of the four (4) active sample patients listed above was discussed with the Director of Social work. The Director acknowledged the deficiency and stated "I painfully agree" (that the "Recommendations for Treatment and Discharge" do not meet the standards).