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ST JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 May 1, 2013
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on observation, record review, and interview the facility failed to ensure needed environment maintenance problems on the Psychiatry Units were dealt with in a timely manner to ensure safe and sanitary work and patient care environment.

Findings:

Review of complaint narrative revealed information that the Psychiatric units two and three were in deplorable condition and had been that way for years.

Observation on 4/30/2013 at 9:15 am on Unit two revealed the entire unit was carpeted except for the bath rooms and patient activity areas. The carpet was very badly stained and had a black build up of dirt ingrained in the material. There were frayed areas on the carpet and several raised (lumpy) areas that had the potential for individuals tripping on the carpet.

Random observation on 4/30/2013 between 9:15 am and 10:05 am in rooms 2017,2019,2020, 2014,2012 and 2015 on Unit Two (2) revealed the bathrooms had missing or loose and badly stained tiles on the floors. The shower stalls were dirty with no seal, resulting in a buildup of soap scum leaving a rust like appearance.

Random observation on 4/30/2012 between 10:15 am and 11:30 am in rooms 3030, 3020,3028,3017,3018 and 3014 on Unit Three (3) revealed base boards near the commode in three bath rooms were completely missing leaving holes with unidentified debris.


There were missing base boards and peeling wall paint in some areas including the hallway. The bathrooms were in similar condition to those on Unit Two.

There were two rooms on Unit two where the patient call lights were not working. One of the rooms was a private room with the patient's bed placed on the opposite wall out of reach of the call lights. The bathroom call lights were not working either.

Observation on unit three revealed none of the call lights in the twenty (20) rooms including the bathrooms were working.

The shower faucets on both units in patient bath rooms had no identification for hot and cold water.

During an interview on 4/30/2013 at 11:10 am with Staff (#5)Nurse Manager for Unit two she stated the lumps in the carpet were a result of frequent shampooing in an effort to keep the carpet clean, also from water from over flowing toilets and spills from shower stall due to poorly fitted shower heads.

During an interview on 5/1/2013 at 7:45 am on Unit Two with Staff (# 22) Charge Nurse she stated there were a few near miss incidents when patients trip and almost fell on the lumpy carpets.

During an interview on 4/30/2013 at 2:15 pm with Staff (#14) Plant Director he stated the facility was aware of the problems and there were proposals submitted and awaiting approval.
Review of a proposal submitted by the Plant Director revealed the date was June 13, 2012 almost a year.

During an interview on 5/1/2012 at 10:15 am with the Chief Executive Officer he stated the plans to complete renovations on Units three and two is now a priority and will be expedited.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to supervise and evaluate the nursing care for each patient. Nursing failed to document or follow-up on the injury to the eye for 1 of 20 patients ' sample (ID# 9).

Patient developed a bruise around his right eye during his admission; nursing documentation did not show an assessment of the injury or referral for physician ' s evaluation.

Findings:

Review of patient ID# 9 medical records with staff ID# 2 revealed the following:

Patient was admitted on [DATE] for depressive disorder and episodic mood disorder.

Patient was placed on 1:1 observation because he required total assistance with activities.

Nursing assessment and physician ' s physical assessment on admission showed multiple abrasions on the extremities but none to the head. Interview with staff ID# 25, physician and staff ID# 26, admitting nurse, they stated that patient had no redness, swelling or abrasions on his head when he was assessed on admission. Staff ID# 25 also stated that he was not informed of the bruise to the eye.

On 3/3/13 at 11:00pm, it was recorded that patient slide out of his wheelchair and was assisted to the floor by the 1:1 staff ID# 24. Interview with staff ID# 24, he explained that on 3/3/13 patient attempted to stand and he was about to fall but he helped the patient to the floor. Staff also said that patient did not hit his head nor come in contact with hard object during this incident.

Interview with nurse manager staff ID# 2 on 4/30/13, she stated that she noted patient had redness around his eye when she assessed him the morning of 3/4/13. She added that she did not document her assessment because she assumed it was already recorded. Staff acknowledged that change in skin condition should have been documented and the patient referred for further evaluation.

On 3/5/13 at 7:00pm, oncoming1:1 staff ID# 11 recorded a right black eye and a scratch on his right forehead. Interview with staff on 5/1/13 over the phone, he stated that when he asked the outgoing staff about the black eye, he was informed that he (outgoing staff) received the patient with the black eye and the nurses were aware of it. Staff added that patient was difficult to manage, always wanted to do things for himself even though he cannot. Patient exhibited self-injurious behavior and often tried to roll out of wheelchair/bed.

Interview with staff ID# 18 on 5/1/13 in the conference room, he stated that when he saw the patient on 3/4/13, the patient had a bruise around one of his eyes; it was purple/yellow in color. Staff added " when i asked the 1:1 staff, he stated that he did not know how the patient got it but also said that the patient has spasms which caused him to fall frequently. "

Review of nurses ' notes did not reflect the ecchymosis to the right eye or referral for assessment of injury to patient ' s eye by the physician.
Review of Incident Log revealed only two documented fall incidents: the assisted fall on 3/3/13 and a fall on 3/7/13 in telemetry during his readmission. No injuries were recorded for both falls.

Facility ' s internal investigation of the complaint did not identify the cause of the injury to the eye. Investigation analysis did not address nursing failure of proper assessment after the bruise was discovered and referral for further evaluation by the physician.

Review of facility ' s policy and procedure titled " Provision of Care, Treatment, and Services Guidelines: Assessment of Patients " read under Nursing " Assessment content and time frames are based on clinical setting and need, and does not exceed 24 hours. "
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, interview, and record review the facility failed to maintain floors, shower stalls, walls and emergency call lights in patient care areas to ensure a safe environment for staff and patients. This failed practice had the potential to adversely affect the safety and well- being of patients and staff. Citing two (2) of four (4) Psychiatric Units #s 2 and 3.

Findings:

Review of complaint narrative revealed information that Psychiatric units two and three at the facility were in deplorable condition and had been that way for years.

Observation on 4/30/2013 at 9:15 am on Unit two revealed the entire unit was carpeted except for the bath rooms and patient activity areas. The carpet was very badly stained and had a black build up of dirt ingrained in the material. There were frayed areas on the carpet and several raised (lumpy) areas that had the potential for individuals tripping on the carpet.

Random observation on 4/30/2013 between 9:15 am and 10:05 am in rooms 2017,2019,2020, 2014,2012 and 2015 on Unit Two (2) revealed the bathrooms had missing or loose and badly stained tiles on the floors. The shower stalls were dirty with no seal, resulting in a buildup of soap scum leaving a rust like appearance.

Random observation on 4/30/2012 between 10:15 am and 11:30 am in rooms 3030, 3020,3028,3017,3018 and 3014 on Unit Three (3) revealed base boards near the commode in three bath rooms were completely missing leaving holes with unidentified debris.


There were missing base boards and peeling wall paint in some areas including the hallway. The bathrooms were in similar condition to those on Unit Two.

There were two rooms on Unit two where the patient call lights were not working. One of the rooms was a private room with the patient's bed placed on the opposite wall out of reach of the call lights. The bathroom call lights were not working either.

Observation on unit three revealed none of the call lights in the twenty (20) rooms including the bathrooms were working.

The shower faucets on both units in patient bath rooms had no identification for hot and cold water.

During an interview on 4/30/2013 at 11:10 am with Staff (#5)Nurse Manager for Unit two she stated the lumps in the carpet were a result of frequent shampooing in an effort to keep the carpet clean, also from water from over flowing toilets and spills from shower stall due to poorly fitted shower heads.

During an interview on 5/1/2013 at 7:45 am on Unit Two with Staff (# 22) Charge Nurse she stated there were a few near miss incidents when patients trip and almost fell on the lumpy carpets.

During an interview on 4/30/2013 at 2:15 pm with Staff (#14) Plant Director he stated the facility was aware of the problems and there were proposals submitted and awaiting approval.
Review of a proposal submitted by the Plant Director revealed the date was June, 2012 almost a year.

During an interview on 5/1/2012 at 10:15 am with the Chief Executive Officer he stated the plans to complete renovations on Units three and two is now a priority and will be expedited.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview and record review the facility failed to enforce their infection control policy to ensure staff demonstrate acceptable infection control practices when handling prepared foods, soiled linen, trash and equipment after use. This failed practice had the potential to adversely affect patients and staff on the units. Citing 4 random observations.

Findings:

Observation on 4/30/2013 at 11:45 am revealed a dietary staff transporting prepared patient meals to Unit two on an covered cart. The Dietary suite is located about a block away from the unit the staff had to travel along lengthy hallways used by other persons to get to the Unit.

Observation on unit two and units three on 5/1/2013 between the hours of 7:35 and 8:35 am revealed the opened carts were on the units with remnants of breakfast.

During an interview on 5/1/2013 at 7:45 with the Nurse Manager on unit three regarding uncovered food cart she stated she had previously voiced her concern regarding the issue to the dietary department but the practice continued.

During an interview on 5/1/2013 at 8:05 am with the Charge Nurse (#22) on Unit Two she stated the patients meals comes to the unit in an uncovered cart and the food is cold and patients are always complaining.

Interview on 5/1/2013 with two Mental Health Technicians (#s 27 and 28) on the two units who pass out the meals to patients, the consensus of the staffs was that the carts came to the units uncovered and patients complain about cold food.

During an interview on 4/30/2013 at 2:05 pm with the Infection Control Manager (#23) he stated he was not aware the patients meals were transported to the units in uncovered carts and that the problem would be resolved as soon as possible.

Observation on 4/30/2013 9:43 am on Unit Two revealed Staff (#27) Mental Health Technician was observed using blood pressure equipment on a patient in his room. The staff came out of the room with gloves on his hands went to the Nursing station, picked up a clip board documented on it then returned the blood pressure equipment to the clean area. The Staff did not clean the equipment after use and did not remove his gloves and wash his hands after completing a task and prior to handling clean items in the nursing station.

Observation on 4/30/2013 at 11:55 am in the patient intake unit of the Psychiatric Department revealed Staff (#19) Mental Health Technician picked up soiled patient linen from the trash bin in the patient bath room with ungloved hands.

Staff (21) Housekeeping was observed on 4/30/2013 at 12:15 pm in the intake unit handling trash at the patient's waiting area and in the patient's bath room with ungloved hands. The staff mopped up drainage from one of the trash bags with a cleaning rag and did not put gloves on. The staff did not wash her hands before moving on to another task.

On 5/1/2013 at 8:45 am Staff (# 2 ) RN was observed picking up used patient linen with ungloved hands from the floor in a patient's room.

Observation on 4/30/2013 in room 2017 revealed a wet adult pampers and disposable chuck in the regular trash bin.

During an interview on 4/30/2013 with the Infection Control Manager he stated staff will be inserviced on the proper infection control protocols.


Review of the facility's infection control policy/procedure submitted during the investigation revealed the following information:

Soiled Linen Collection Procedure dated 1/20/13

"Employee who handle soiled linen shall wear the appropriate personal protective equipment (PPE) at all times while handling/collecting soiled linen. PPE shall consist of disposable latex or vinyl gloves and or reusable latex gloves".

Housekeeping Policy dated 8/2012

" While cleaning spills, personnel will wear all appropriate PPE and apply all Standard Precautions"

Hand Hygiene Policy dated 2/4/2011

"Decontaminate hands after contact with the patient's intact skin(e.g., when taking a pulse or blood pressure lifting a patient)
Remove gloves after caring for a patient and decontaminate hands after removing gloves"