Pennsylvania Department of Health
NORRISTOWN STATE HOSPITAL
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORRISTOWN STATE HOSPITAL
Inspection Results For:

There are  9 surveys for this facility. Please select a date to view the survey results.

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NORRISTOWN STATE HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a full Medicare recertification survey conducted on December 4, 5, 6, and 7, 2023 at Norristown State Hospital. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.






 Plan of Correction:


482.23(b)(5) STANDARD PATIENT CARE ASSIGNMENTS:Not Assigned
A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

Observations:
Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure registered nurses assigned the care of each patient to other nursing staff in accordance with the patient's needs and qualification of the staff for 3 of 3 nursing units. (51A2, 51C2 and 10D1).

Findings include:

Review on December 6, 2023, of nursing policy "Assignment of Nursing Care" approved November 20, 2023 revealed "... Registered Nurses assigns the care of each patient to a Registered Nurse, Licensed Practical Nurse, Forensic Security Employee (FSEII) or Psychiatric Aide based on their currently clinical competency of that staff member to provide patient care needs ..."

1.Review on December 6, 2023, of facility document "Day Shift Daily Shift Assignment Sheet" not dated for nursing unit 51A2 revealed unit staff were assigned to patient care and special assignments.

Interview on December 6, 2023 at approximately 11:00 AM with EMP1 confirmed FSEII complete the daily assignment sheet for patient care.

2.Review on December 6, 2023, of facility document "Daily Shift Assignment" dated December 6, 2023, for nursing unit 51C2 revealed unit staff were assigned to patient care and special assignments.

Interview on December 6, 2023 at approximately 11:40 AM with EMP3 confirmed FSEII complete the daily assignment sheet for patient care.

3.Review on December 7, 2023, of facility document "Daily Shift Assignment" not dated for nursing unit 10D1 revealed unit staff were assigned to patient care and special assignments.

Interview on December 7, 2023 at approximately 10:45 AM with EMP5 confirmed FSEII complete the daily assignment sheet for patient care.




 Plan of Correction - To be completed: 01/03/2024

Effective 1/1/2024, revised nursing assignment sheets were sent to all unit nurses with instructions indicating that the unit RNs are responsible for completing assignment sheets. Nursing Policy A-6 "Assignment of Patient Care" has also been revised to reflect this change (and to remove the FSE2 from the assignment responsibilities). The updated policy will be sent to nursing staff by 1/5/2024.
482.24(c)(2) STANDARD CONTENT OF RECORD: ORDERS DATED & SIGNED:Not Assigned
All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.
Observations:
Based on review of facility policy, medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure verbal orders were dated, timed and authenticated promptly by the ordering practioner in four of four medical records reviewed. (MR15, MR21, MR28 and MR30)


Findings include:

Review on December 6, 2023, of facility policy "Policy for Verbal Orders" not dated, revealed no provisions verbal orders are dated, timed and authenticated promptly by the ordering practioner.


1.Review on December 6, 2023, of MR15 physician documentation "Physician Orders" dated October 27, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician's that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner.


Review on December 6, 2023, of MR21 physician documentation "Physician Orders" dated October 27, 2023 and November 28, 2023, revealed verbal orders were obtained for patient care and the order was signed by a signature identified as the physician's that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner.


Interview with EMP2 on December 6, 2023, at approximately 12:00 PM confirmed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner.



2.Review on December 7, 2023, of MR28 physician documentation "Physician Orders" dated November 18, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician's that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner.



Review on December 7, 2023, of MR30 physician documentation "Physician Orders" dated November 18, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician's that issued the order. Further review revealed verbal orders were not dated, timed and authenticated promptly by the ordering practioner.


Interview on December 7, 2023, with EMP5 at approximately 10:45AM confirmed verbal orders were not dated, timed and authenticated promptly by the ordering practioner.





 Plan of Correction - To be completed: 01/05/2024

A "Physician Telephone Orders Monitoring" form was created for each doctor to complete/monitor their own telephone orders to ensure their accountability for signing, dating and authenticating orders promptly. The reports will be shared weekly with the CMO and his administrative assistant, as well as reviewed monthly in doctors' meetings. The form and the process/expectations were reviewed with all doctors in the medical/psychiatric staff meeting on 1/4/2024, with a begin date of 1/8/2024.
482.25(b)(3) STANDARD UNUSABLE DRUGS NOT USED:Not Assigned
§482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and
biologicals must not be available for patient use
Observations:


Based on observation and interview with staff (EMP), it was determined the facility failed to ensure outdated medications were removed from service.

Findings include:

Tour conducted on December 6, 2023, at 11:00 AM of building 1, Unit C1 Medication Room had the following expired medications:
Dozolamide HCL and Timolol Maleate Ophthalmic Solution with an expiration date of 10/2022
Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5mg &3 mg /3 ml with expiration date March 2020.
Tour conducted on December 6, 2023, at 12:20 PM of building 1, Unit C1 Medication Room had the following expired medications:
A tube of triple antibiotic ointment that was open and had no cap on the tube and an expiration date of 8/2023.
Artificial tears with an expiration date of 11/ 2022.
Interview conducted on December 6, 2023, at 12:30 PM with EMP11 confirmed that the medications were expired and above findings.











 Plan of Correction - To be completed: 01/05/2024

The Nursing Policy, A-6 "Assignment of Patient Care" was revised to include a section for the night shift nurses to identify and immediately remove/discard any expired, damaged, and discolored creams, inhalers, and medications from the unit. This revised policy will be distributed to staff by 1/10/2024.

Pharmacy Policy "Ward/Medical Clinic Inspections" which involves monthly inspections of all medication rooms and the podiatry and dental clinics, will be re-reviewed with the Chief Pharmacist and one of his designated pharmacists by 1/12/2024.
482.28(a)(1) STANDARD DIRECTOR OF DIETARY SERVICES:Not Assigned
The hospital must have a full-time employee who-

(i) Serves as director of the food and dietetic services;

(ii) Is responsible for daily management of the dietary services; and

(iii) Is qualified by experience or training.

Observations:


Based on observations, review of facility policy and procedures and interviews with staff (EMP), it was determined the facility failed to adhere to established facility policies regarding the safe handling of patient food.
Observation tour of dietary department on December 4, 2023, at 12:25 PM in the walk in refrigerator off of main food preparation area revealed, eight vacuum sealed bags of what appeared to be beef loins with one tray labeled only with the date "December 10, 2023" on the label.
Review on December 5, 2023, of facility policy, "Food Handling Practices" , dated July 15, 2023, revealed, "...4 ...All items must be stored off the floor, and must be properly covered, labeled, and dated ..."
Interview on December 4, 2023, at approximately 1:00PM with EMP9 confirmed the beef was only labeled with the date December 10, 2023.
Interview on December 5, 2023, at 1:34 PM with EMP8 confirmed the labels on the beef did not follow facility policy regarding food handling practices.
______________________________________________________________________
Based on observations, review of facility policy and procedures and interviews with staff (EMP), it was determined the facility failed to adhere to established facility policies regarding the safe handling of patient food.
Observation tour of dietary department on December 4, 2023, at 1:34 PM in the patient snack preparation area, inside the stand alone refrigerator revealed, single serve clear containers with lids marked with the contents of the cups. Further observation revealed: four (4) egg salad cups with no date label, seven (7) chicken salad cups with no date label, one (1) ham salad cup with no date label, and five (5) tuna cups with no date label.
Review on December 5, 2023, of facility policy, "Food Handling Practices", dated July 15, 2023, revealed, "...4 ...All items must be stored off the floor, and must be properly covered, labeled, and dated ..."
Interview on December 4, 2023, at approximately 1:37 PM with EMP9 confirmed the single serve containers were not labeled with a date.
Interview on December 5, 2023, at 1:41 PM with EMP8 confirmed the labels on the single serve cups did not follow facility policy regarding food handling practices.







 Plan of Correction - To be completed: 01/03/2024

Dietary's Food Handling Practices Policy states: "All items must be stored off the floor, and must be properly covered labeled, and dated. Two instances were observed during the CMS tour where food items were not properly dated. Immediately following the tour, staff members involved were interviewed and stated they missed dating the food items. Both staff members were counseled for the infraction and reminded of the policy that all food items must be properly covered, labeled, and dated. On January 3, 2024, all department staff were in-serviced on the Food Handling Practices Policy.
482.41(d)(2) STANDARD FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE:Not Assigned
Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
Observations:

Based on observation of patient care areas, and interview with staff (EMP), it was determined that the facility failed to ensure supplies were not outdated.

Findings include:

Tour conducted on December 6, 2023, at 11:00 AM of building 1, Unit A1 in the medication room had the following expired supplies:
Non-Adhesive foam dressing 8 x 8 in with expiration date of 2020 -04 -01
Viral Transport for Viruses, Chlamydia, Mycoplasmas, and Urea plasmas with expiration date of 2021/04.
Tour conducted on December 6, 2023, at 11:20 AM if building 1, Unit A1 at the Nursing Station had the following expired supplies:
14 F suction catheter with an expiration date of March 2020
Sterile alcohol prep pads with expiration date of 2021 /05
Nebulizer Kit with 7-inch (2.1 ml) oxygen level with expiration date of 2018/01.
2 Combine dressing with expiration date of 2008/03. G x 1 inch with expiration date of 2022-01-28.
5 packet of 3-0 silk suture with expiration date of 1/09.
1 Vanish Point syringe 3 ml 22G x 1 inch with expiration date of 2022-01-28.
A suction container with "NSS" written on it. The container had no date or time.
Suction Catheter with yellow packaging with a 2 inch dark stain on the package.
The policy for expired for supplies was requested. The facility was unable to provide the requested document.
The policy for beyond use date of supplies was requested. The facility was unable to provide the requested document.
Interview conducted during the tour of the areas, with EMP11 confirmed that the supplies were expired and still available for patient use.
Tour conducted on December 7, 2023, at 11:20 AM if building 1, Unit A 2 at the Supply Room had the following expired supplies:
6 containers of multipurpose wipes with an expiration date 3/10/22.
40 bottles of hand sanitizer with expiration dates of 5/23 or 7/22.
One bottle of Perineal & Skin Cleanser with expiration date of Sept 2023.
5 Suture Removal Kits with an expiration dates of 2021 -11
Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit A 2 at the Medication Room had the following expired supplies:
Four bottles of Hand sanitizer foam with an expiration date of 11/2023.
Two bottle of Perineal & Skin Cleanser with an expiration date of Sept 2023.
Bacti Swabs:
Five with expiration dates of 2022 -04-27.
12 with expiration dates of 2022-10-19.
12 with expiration dates of 2022-04-27.
Five with expiration dates of 2023-11-29.
Glutose 15 (oral glucose gel) with expiration dates of 11-20-15 and 10-31-2023.
Glucose controls with do not use after 2-28-23 written on sticker by staff.
Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit C2 at the Supply Room had the following expired supplies:
50 bottles of Hand sanitizer with expiration date of 7/22.
20 bottles of Perineal & Skin Cleanser with expiration date of July 2020.
The policy for expired for supplies was requested. The facility was unable to provide the requested document.
The policy for beyond use date of supplies was requested. The facility was unable to provide the requested document.
Interview conducted during the tour of the areas, with EMP12 confirmed that the supplies were expired and still available for patient use.
Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit C2, environmental room revealed a hopper sink with gray couldy fluid in the sink. Staff was not able to flush the sink.
Interview conducted during the tour of the areas, with EMP12 confirmed the sink would not flush.
_____________

Based on observation and interview with staff (EMP) it was determined the facility failed to ensure outdated supplies were not available for use on patient care unit 51A2.

A request was made on December 6, 2023, to EMP2 for policy regarding the use of outdated supplies. None provided.

Review on December 6, 2023 of the manufacturer's instruction for the use of glucose testing control solution revealed "...Check expiration dates on the control solution bottle ... discard control solution if either the Expiration date printed on the bottle or 3 months after opening ..."
Observation on December 6, 2023, at approximately 10:30 AM of 51A2 medication area revealed the control solution containers for quality testing for the glucose meter were opened and not dated 3 months after opening. Further observation revealed the manufacturer's printed expiration date on the bottle for level 1 control testing expired 12/31/20 and the manufacturer's printed expiration date on the bottle for level 2 testing expired 5/31/21.

Interview on December 6, 2023, at approximately 10:30 AM with EMP1 confirmed the control solution were not dated 3 months after the containers were opened and confirmed both containers of control solution were expired based on the manufacturers expiration date printed on the containers.
____________
Based on observations, review of facility policy and procedure and interviews with staff (EMP), it was determined the facility failed to ensure the physical facilities in a patient care area were maintained at an acceptable level of quality.
Review on December 5, 2023, of facility policy and procedure, "Norristown State Hospital Housekeeping Department Policies and Procedures" , revised April 2022, revealed, "...Purpose and Function ...The purpose of the Housekeeping Services Department is to provide a clean, sanitary and attractive environment in a condition that complies with the standards of surveying and accrediting agencies and standards required by the Hospital and the Department of Human Services ..."

1.Observation tour of patient care unit C1 on December 6, 2023, at 12:17 PM in patient care room number 1026 revealed, inside the room's exterior window, between the screen and shutters, there appeared to be two (2) bird nests made of brown straw or grass.

Interview on December 6, 2023, at 12:17 PM with EMP2 confirmed there were two bird nests in the window of room 1026 in patient care unit C1. Further interview with EMP2 confirmed the bird nests should be removed.

2.Observation on December 6, 2023, at approximately 10:30 AM of patient care unit 51A2 revealed the floor in the entrance hallway had an accumulation of a black substance along the corners of the hallway floor and included approximately four inches of the wall. Continued observation revealed room 2434 had an accumulation of dust and unknown small pieces of debris scattered across the floor.

Observation on December 6, 2023, at approximately 10:40 AM of the 51A2 nurses station revealed the flooring had an accumulation of a black substance along the corners of the floor, small peices of debris and dust. Further observation revealed multiple areas of an unknown dried substance on the wall behind the medication cart.

Interview on December 6, 2023, at approximately 10:45 AM with EMP2 confirmed the observations of the hallway floors, room 2434 and nurses station.

3.Observation on December 6, 2023, at approximately 11:30 AM of patient care unit 51C2 revealed the floor in the entrance hallway had an accumulation of a black substance along the corners of the hallway floor and included approximately four inches of the wall. Further observation of the hallway adjacent to the nurses station revealed a thick coating of a gray substance along overhead pipes that were attached to the wall.

Observation on December 6, 2023, at approximately 11:45 AM of the 51C2 nurses station revealed the flooring had an accumulation of a black substance along the corners of the floor, and small pieces of debris and dust. Further observation revealed multiple areas of an unknown dried substance on the wall behind the medication cart.

Observation on December 6, 2023, at approximately 12:15 PM of the stairwell identified with door number 1020 leading from 51C2 to 51C1 revealed an accumulation of heavy dust and small pieces of debris.

Interview on December 6, 2023, at approximately 12:30 PM with EMP2 confirmed the observations of the hallway floors, overhead pipes, nurses station and stairwell.
























 Plan of Correction - To be completed: 01/05/2024

Nursing's Emergency Cart Policy has been revised to include instructions on what to do with expired, damaged, and discolored supplies. Replace and Reorder sections have been added to the emergency cart reviews to be done weekly by the unit nurses and monthly by the nursing supervisors, with a copy of the reorder sheet sent to the nurse managers to confirm completion. This revised policy will be going out to staff by 1/5/2024.

Bird nests are outside of glass and behind the security screens, therefore patients have no access to the nests and birds. The nests found during the CMS visit were removed immediately and the Maintenance Department removes nests throughout the year at all buildings on the campus as they are rebuilt by birds.

NSH's Housekeeping staff will receive retraining over the course of the next few weeks on the proper process to strip old wax, scrape corners, and apply new wax to the floor. Immediately after the training, Housekeeping staff will strip old wax from floors and apply new wax. They will coordinate with the Nursing staff to ensure that patients are not occupying the rooms at the time they are scheduled for routine cleaning as well as the RN in charge of the Medication Room for supervised access to that area, per protocol. Staff training and completion of the work for the cited units will be completed by 2/2/2024.

NSH's Maintenance Department will repair or replace flaking insulation on exposed pipes by 2/2/2024.


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