I. PSYCHIATRIC TREATMENT
Provision for Treatment
Article IV - Right to a Humane Physical and Psychological Environment
(a) Treated humanely
(b) Positive self-image
(1) own clothing
(2) providing clothing
(3)(4) provision for personal hygiene items
(c) Living facilities
(d) Diet
(e) Sanitary facilities
(f) Activities/Recreation
Adequate treatment includes such accommodations as diet, heat, light, sanitary facilities, clothing, recreation, education and medical care as necessary to maintain a decent, safe and healthful living conditions
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Observations:
Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to maintain a safe and sanitary environment on the Adolescent, Adult and Geriatric Behavioral Health.
Findings include:
Review on February 6, 2024, of the facility's "Environmental Services Policies and Procedures Manual", last revised October 1, 2022, revealed "Purpose: To ensure the complete, safe and systematic cleaning and disinfection of the Psychiatric Unit adhering to the "contain, assist & disinfect" protocols ...Procedure: ...6 ...Using the bowl mop and germicide, clean under the rim of the toilet and all around the inside of the toilet in a circular motion. Dip the cloth and clean the top and bottom of the toilet seat, then the outside of the toilet. Flush toilet ...Tips: Housekeeping Cart and Chemicals to be monitored at all times secure in appropriate closet when not in use & never left unattended..."
Review on February 6, 2024, of the facility's "Environmental Tours Program - Environment of Care" policy, last approved March 1, 2022, revealed "...I. Policy: LVHN routinely performs environmental tours to identify and correct environmental hazards and unsafe practices that may adversely affect the safety and health of patients, employees, and/or visitors. These rounds also serve to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate Environment of Care risks. Environmental Tours are performed routinely in patient care areas and in non-patient care areas..."
1. Observation tour of the Adolescent BHU on February 6, 2024, revealed the following findings:
In the seclusion room there was an accumulation of dust on the inside window and on the window ledge measuring approximately a dime size when gathered and there was dust and debris in the grooves of the bed. This seclusion room was considered ready for patient use.
Interview with EMP1 and EMP2 at the time of the observations confirmed the above findings.
Patient room 655 there was a screw protruding approximately one-half inch from ceiling light over the bed.
Interview with EMP1 and EMP2 at the time of the observation confirmed the adolescent patient could stand on the bed and easily access and manipulate this screw.
Patient room 659 the edge of the radiator cover was bent and had a sharp edge that a patient could cut themselves on; there was a screw missing from the ceiling light fixture over the commode; the floor mounted commode had uncapped screws on each side and the tips of these screws were sharp and posed a cutting hazard for a patient.
Patient room 658 had a brown substance on the bottom of the shower.
Interview with EMP2 confirmed the above finding and revealed this brown substance was mold.
2. Observation tour of the Adult BHU on February 6, 2024, revealed the following findings:
In the seclusion room with the bed there were two boards secured to the wall with caulk, one board measured approximately three and one-half feet high by two and one-half wide and the second board measured approximately one and one-half feet high by one and one-half wide. Both boards had sharp edges on all four sides where the caulk was missing.
The interior door of the seclusion room without the bed had rust and sharp edges along the bottom of the door window.
The seclusion shower wall had chipped and peeling paint and spackle.
Patient room 550 had drywall separating from between the wall and the radiator and there was a wall vent above the bathroom sink which had separated from the wall approximately one-quarter inch.
Patient room 556 had a stand measuring approximately three feet high by two feet wide and was secured to the wall; there was a ceiling vent directly above this stand measuring approximately six inches by six inches and the entire vent was separating from the ceiling by approximately one-quarter inch; the shower had missing caulk; the plexi glass window covering had a sharp edge and the bottom window frame had a sharp edge.
The dining room had plaster separating from between the wall and the radiator leaving an approximate one-half inch gap.
The television room had an accumulation of dust and food crumbs in the area between the window and the radiator.
Interview with EMP1 and EMP2 at the time of the observations confirmed these findings.
3. Observation tour of the Adult BHU on February 6, 2024, revealed the following findings:
The seclusion room commode had blue water in the bowl.
Interview with EMP1 and EMP2 revealed this blue water was toilet bowl cleaner.
Interview with EMP1 and EMP2 revealed the commode is to be flushed after cleaning and it is not appropriate to leave unflushed toilet bowl cleaner in the commode as it poses a risk to patients who may be tempted to drink it.
Patient room 305 there were two screws missing from the ceiling panel directly over the patient bed.
Interview with EMP1 and EMP2 at the time of the observations confirmed these findings.
Observation of EMP5 on February 6, 2024, at approximately 1500 revealed this employee parked the Environmental Service (EVS) cart in front of the EVS room, turned their back toward the cart leaving it unattended, to unlock the EVS door. This surveyor approached the cart along with EMP1 and EMP4. This surveyor opened the top storage area of the cart revealing five rolls of plastic garbage can liners, a box of gloves and a bottle of hand sanitizer.
Interview with EMP1 at the time of the observation revealed the EVS carts are to be locked when the cart is not in direct observation of EVS personnel.
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Based on review of medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure a patient on the Adolescent Behavioral Health Unit (BHU) completed assigned schoolwork for one of five applicable medical records reviewed (MR1).
Findings include:
A request was made of EMP1, EMP2 and EMP3 for the facility policy, procedure, guideline, or protocol facility staff follow regarding ensuring adolescent school class work assignments are completed. None was provided.
Interview with EMP1, EMP2 and EMP3 on February 6, 2024, at approximately 1600 revealed there is no facility policy, procedure, guideline, or protocol facility staff follow regarding ensuring adolescent school class work assignments are completed.
Review of MR1 on February 6, 2024, revealed this adolescent was admitted on January 22, 2024, and on unit classroom school began on January 23, 2024.
Review on February 6, 2024, of the facility provided on unit teacher progress record for MR1 revealed documentation this patient did not attend class due to a medical issue on January 25, 26, 29, 30 and 31, 2024.
There was no documentation MR1 completed the assigned schoolwork for these dates.
Interview with EMP1, EMP2 and EMP3 at the time of review confirmed the above finding.
| | Plan of Correction - To be completed: 04/05/2024
1. The President of Lehigh Valley Hospital – Schuylkill is responsible for the following plan of correction.
2. Environmental services staff were educated on policy "Environmental Services Policies and Procedures Manual" by the Director Environmental Services on February 22, 2024. This policy specifically addresses the observation of an EVS employee leaving their cart unlocked when not in their direct observation. Policy states "Housekeeping Cart and Chemicals are to be monitored at all times, secure in appropriate closet when not in use and never left unattended".
3. Maintenance staff will be educated on policy "Environmental Tours Program -Environment of Care" by the Director Facilities. This education will be completed by March 8, 2024.
4. The Behavioral Health staff will be educated on policies "Environmental Services Policies and Procedures Manual" and "Environmental Services Policies and Procedures Manual" by the Assistant Program Director and the Director Clinical Services Behavioral Health. This education will be completed by March 11, 2024.
5. The following items were corrected on February 6 and 7, 2024 during on site survey:
a. Adolescent Behavioral Health
i. Removal of dust on the inside window and on the window ledge and removal of dust and debris in the grooves of the bed in the seclusion room.
ii. Room 655 had the screw fully inserted in the ceiling light over the bed.
iii. Room 659 had the edge of the radiator cover fixed, the screw was in inserted in the ceiling light fixture over the commode, and the floor mounted commode had caps secured over the screws.
iv. Room 658 had the brown substance at the bottom of the shower removed.
b. Adult Behavioral Health Unit
i. In the seclusion room the boards were recalked, and sharp edges corrected, the door had the rust and sharp edges along the bottom of the door window corrected, the shower wall was repaired and repainted.
ii. Room 550 had drywall repaired and the wall vent above the bathroom sink was fixed.
iii. Room 556 had ceiling vent was re-secured, the shower caulk repaired, the plexi glass window sharp edge corrected, and the bottom window frame sharp edge corrected.
iv. The dining room plaster repaired at the radiator gap.
v. The television room dust and crumbs removed from the area between the window and the radiator.
c. Senior Behavioral Health Unit
i. The blue water was flushed from the commode.
ii. Room 305 had the two screws replaced in the ceiling panel over the bed.
6. Environmental rounds were completed on February 9, 2024, on all three behavioral health units to ensure that all items identified during on site survey were corrected. Rounds also included identifying any new issues that were not identified during survey and work orders completed for the items identified. Any new items identified were added to the rounding form for follow up during the next weeks rounds to ensure completion.
7. Environmental rounds commenced on February 16, 2024. These rounds will be completed weekly on a rotational basis with all three behavioral health units. Rounds include leadership and or staff members from Behavioral Health, Environmental Services, Maintenance, Security, and Quality. An environmental rounds form was updated to address all issues identified during the survey. The form includes a total of 72 individual items, including those identified during survey. The form will be used during the rounds to identify new concerns also address new issues that were identified during survey. Any issues identified will have work orders submitted for corrective actions.
8. Rounds and rounding form include monitoring EVS staff and EVS carts to ensure that all carts are locked and not left unattended.
9. Behavioral health staff will have education reinforced by behavioral health leadership on current work order system in place that staff can utilize at any time to submit any identified environmental issues. This education reinforcement will be completed by March 8, 2024.
10. The results of the weekly rounds will be summarized and reported monthly to the Patient Safety Committee, Director Quality, Director Environmental Services, Facilities Director, and President.
11. Rounds will continue weekly for six months, and then continue monthly on each unit.
12. The contracted teacher was educated by the school superintendent February 23, 2024, to ensure that the teacher is documenting the adolescent either completed or did not complete their assigned work for the school day.
13. The contracted teacher will be educated by the school superintendent by March 11, 2024, to ensure that the teacher is documenting a reason for any student that did not complete their school work.
14. Behavioral health leadership staff will conduct a weekly audit beginning March 4, 2024, of all students to ensure that the teacher documented that the student completed or did not complete their assigned schoolwork for the day and that any student that did not complete their assigned schoolwork for the day has a documented reason why.
15. Audits will continue weekly until the end of the school year.
16. Any area of non-compliance will result in re-education to the teacher by behavioral health leadership staff.
17. The results of the audit will be reported to the Patient Safety Committee beginning with the March 2024 meeting.
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