Initial Comments:
This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on March 20, 2024 at The Washington Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.
Plan of Correction:
5100.54 REQUIREMENT
Manual rights for persons in treatment
Name - Component - 00
5100.54 MANUAL OF RIGHTS FOR PERSONS IN TREATMENT
The following is the manual of rights for persons in treatment:
Article I Right to communicate
Article II Right of religious freedom
Article III Right to handle your personal affairs
Article IV Right to a humane physical and psychological environment
Article V Right to Treatment
Article VI Permissible, restricted and prohibited treatment procedures
Article VII Grievance and appeal procedures
Observations:
Based upon observation and staff interview (EMP), it was determined that the facility failed to maintain a clean and safe setting.
Findings include:
On March 20, 2024, from 11:15 AM to 11:35 AM, an accompanied tour of the unit and patient rooms (Rooms 1, 2, 3, 4, 5, 6, 7, and 8) was completed. Tour observations revealed the following:
Desk chairs in rooms 1, 2, 3, 4, 5, 6, 7, and 8 were moldable plastic and unweighted. The desk chairs were able to be lifted from the floor with a single hand; thus, allowing the desk chairs to potentially be used as projectiles.
The stainless steel toilet, serving Rooms 2 and 3, was stained and contained streaks of brown material.
The stainless steel toilet serving Room 5 was stained and the bowl discolored.
The stainless steel toilet serving Room 6 was stained and contained streaks of brown material.
On March 20, 2024, during an accompanied tour of the unit, it was noted that the four weighted chairs contained in the hallway seating alcove were able to be easily pushed and potentially creating a hazard.
On March 20, 2024, during an accompanied tour of the unit shower room, a dark black material was noted at the top lip of the shower wall on three sides. Dark black material was also noted between the top of the wall protection in the shower and the ceiling.
The above findings were confirmed by EMP1, EMP5 and EMP10 on March 20, 2024, at 11:35AM.
Plan of Correction:1. On 3/20/24, the unit clinical director completed an immediate inventory of seating furniture on the unit. In addition to the eight lightweight chairs identified during the on-site survey, three more were identified in the classroom. The three classroom lightweight chairs were replaced immediately with three sand-ballasted weighted chairs. Senior Leadership approved the replacement of the remainder of the lightweight chairs with sand-ballasted chairs. A purchase order was submitted on 4/1/24 with a scheduled delivery in six to eight weeks. A visual inspection will be conducted weekly by the clinical nurse coordinator accompanied by the hospital regulatory analyst to confirm the ongoing use of safe furniture. The weekly inspections will take place for a minimum of 3 months; if 100% compliance is maintained during the initial 3-month period, they will be sustained monthly by the unit nursing staff with validation by the regulatory analyst once per quarter. Any new furnishings ordered for the unit will require notification by the unit director to the regulatory analyst and patient safety officer to evaluate for safe use.
2. On 3/20/24, the unit clinical director arranged for the environmental services staff to immediately reclean the toilets between patient rooms 2&3, and in room 5&6 to ensure no biological residue was left in the toilet bowls or on the surfaces. Further detailed visual inspection with confirmation by the facilities director revealed that toilet bowl "stains" were in fact chemical etching of the stainless-steel surface likely caused by caustic cleaning chemicals. An interdisciplinary group convened on 3/28/24 to determine options to remove the toilet bowel stains. Leadership approval was granted for the purchase of pumice rubbing stone wands and calcium lime and rust remover. On 4/1/24, upon use of the products, the stains were removed from the toilets. A visual inspection of bathrooms, inclusive of toilet bowls, will be conducted weekly by the clinical nurse coordinator accompanied by the hospital regulatory analyst to confirm the ongoing maintenance of a clean and safe environment. The weekly inspections will take place for a minimum of 3 months; if 100% compliance is maintained during the initial 3-month period, they will be sustained monthly by the unit nursing staff with validation by the regulatory analyst once per quarter.
3. On 3/20/24, the unit clinical director submitted a work order for facilities cleaning, repair & replacement of the shower trim inclusive of the area between the top of the shower and the wall, and the top of the wall/ceiling. Kilz mildew-resistant paint coat was applied to the shower ceiling. The work order was signed off as completed by the facilities staff by 3/28/24. The shower room will be included in the visual inspection process conducted weekly by the clinical nurse coordinator accompanied by hospital regulatory analyst to confirm the ongoing maintenance of a clean and safe environment. The weekly inspections will take place for a minimum of 3 months; if 100% compliance is maintained during the initial 3-month period, they will be sustained monthly by the unit nursing staff with validation by the regulatory analyst once per quarter.
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