Pennsylvania Department of Health CLARION PSYCHIATRIC CENTER Health Inspection Results Information about Acute and Ambulatory Care Inspections CLARION PSYCHIATRIC CENTER Health Inspection Results For: There are 8 surveys for this facility. Please select a date to view the survey results. 05/20/2013 Print Current Report Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey. View Previous Reports Initial Comments: This report is the result of an unannounced onsite complaint investigation (CEN13C216A) completed on May 16, 2013, at Clarion Psychiatric Center, with additional information requested May 17, 2013 and May 20, 2013. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482 Conditions of Participation for Hospitals 482.13(b)(1) STANDARD PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING The patient has the right to participate in the development and implementation of his or her plan of care. http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 1/9
Based on review of facility documents and medical records (MR), observation and staff interview (EMP), it was determined the facility failed to ensure the patient right to participate in his or her plan of care for a low stimulation environment for one of one medical records (MR2). Review of "Clarion Psychiatric Center Rights and Responsibilities of Patients," revised December 2010, no policy number provided, revealed, "... I. Patient's Rights... F. Information You have the right to obtain, from the doctor responsible for coordinating your care, complete and current information concerning diagnosis (to the degree known), treatment, and any other known prognosis to include both the positive and if any negative outcomes of care as documented in the medical record. This information should be communicated in terms you can reasonably be expected to understand.... H. Individual Treatment Plan You have the right to an individualized plan appropriate to your needs, setting for the objectives, goals, activities, experiences, and therapies designed to promote recovery. You have the right to participate to the extent feasible in the development of your treatment plan...." 1. Tour of the Adult Unit on May 16, 2013, at 10:50 AM revealed a patient name (PT6) located outside a seclusion room door. Review of MR2 (PT6) revealed PT6 had slept in the seclusion room on May 14 and May 15, 2013. EMP4, confirmed the patient's sleeping location, stating, "Yes. He/she slept in the safe room May 14 and 15. The door was not locked. It was voluntary for low stimulation, not for behavior." Further review of MR2 revealed no documentation for the altered sleeping arrangement. On May 16, 2013, at 10:52 AM, when asked if there was documentation on MR2 that sleeping in the seclusion room, not the assigned bedroom, was reflected on the patient's care plan, EMP4 stated, "No. It was not added (to the plan of care)." PLAN OF CORRECTION (A 0130) 482.13(b)(1) PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING 1. Education provided to Unit Directors and Social Work staff members on 06/04/2013 that the use of the Quiet Room as a sleeping room must be included on the plan of care. The treatment plan for PT6 was updated with the patient to include the option of using the Quiet Room as a sleeping room should the patient desire. http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 2/9
All current treatment plans were checked to ensure that use of Quiet Room as a sleeping room, or any other infrequently utilized intervention, was included in the plan of care. The individual currently monitoring treatment plans as part of an internal Performance Improvement Committee has been alerted and will audit a sample of charts regularly for the inclusion of any infrequently utilized intervention on the treatment plan. 482.13(c)(1) STANDARD PATIENT RIGHTS: PERSONAL PRIVACY The patient has the right to personal privacy. Based on review of facility documents and medical record (MR), observation and staff interviews (EMP), it was determined the facility failed to ensure the patient's right to privacy for receiving medical treatment and in living environment for two of two patients (PT5 and PT6). Review of "Clarion Psychiatric Center Rights and Responsibilities of Patients," revised December 2010, no policy number provided, revealed, "... I. Patient's Rights... C. Privacy and Confidentiality Your privacy and confidentiality of information is assured through the following:... 3. Audio, visual, personal privacy during examinations or treatment.... 4. Knowing that discussion involving your care is conducted in a discreet manner; individuals not involved in care will not be present, without your consent...." 1. Tour of the Adult Unit on May 16, 2013, at 10:30 AM, revealed patients waiting in line for a smoke break, adjacent to the nursing station. PT5 was sitting among those waiting in the common area with a breathing treatment being administered. EMP1, present for the tour, confirmed the patient being treated in the common area. When asked if there was a treatment room on the unit, EMP4 stated, "No. There is not." On May 16, 2013, at 11:20 AM, when asked if there was a treatment room on the adult unit to allow privacy for patient treatments, EMP1 stated, "No. We don't have a specific treatment room." 2. Tour of the Adult Unit on May 16, 2013 at 10:50 AM, revealed a patient name (PT6) located outside a seclusion room door. Review of MR2 revealed PT6 had slept in the seclusion room on May 14 and May 15, 2013. EMP4, confirmed the patient's sleeping location, stating, "Yes. He slept in the safe room May 14 and 15. The door was not locked. It was voluntary for low stimulation, not for behavior." On May 16, 2013, at 10:54 AM, when asked if there was documentation that the http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 3/9
camera located in the seclusion room was turned off while the patient was occupying the room, and not considered to be in seclusion, EMP4 stated, "There is no documentation like that." PLAN OF CORRECTION (A 0143) 482.13(c)(1) PATIENT RIGHTS: PERSONAL PRIVACY 1. A room has been identified on each unit as a Treatment Room. The room is to be used exclusively as a Treatment Room and is available so that treatments need not occur in a common area. Necessary medical treatments will occur in the Treatment Room unless the patient prefers, as appropriate and applicable, that the treament occur in an alternate location. 2. On 06/06/2013, Nursing staff members were educated regarding changes forthcoming to the camera system in the quiet rooms. At this time, the cameras are on only by exception. There will be documention to show any times the cameras were turned on and the duration for which they remained on. A form will be created so that this information is available going forward. Applicable, policy revisions will be completed to reflect this procedure. The Director of Nursing will maintain a record of when the camera was in use. This will periodically be checked for accuracy by reviewing the camera system. 482.13(d)(1) STANDARD PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS The patient has the right to the confidentiality of his or her clinical records. Based on review of facility documents, observation and staff interviews (EMP), it was determined that the facility failed to ensure the confidentiality of medical record information in clinical areas. Review of "Clarion Psychiatric Center Rights and Responsibilities of Patients," http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 4/9
revised December 2010, no policy number provided, revealed, "... I. Patient's Rights... C. Privacy and Confidentiality Your privacy and confidentiality of information is assured through the following:... 3. Audio, visual, personal privacy during examinations or treatment.... 4. Knowing that discussion involving your care is conducted in a discreet manner; individuals not involved in care will not be present, without your consent. 5. Having your medical record read only by individuals directly in treatment or the monitoring of its quality, and by other individuals directly only on written authorization or your legallyauthorized representative.... 6. Assuring that all communications and other records pertaining to your care, including the source of payment for treatment, be treated as confidential...." Review of the Clarion Psychiatric Center Policy, "Medical Records," revised September 2007 revealed, "I. POLICY... The records will be maintained in a manner compatible with the current standards of... all internal policies of the hospital, all local, state and federal regulations. II. PRINCIPLE To ensure the records are kept in a fashion that meets the regulatory requirement and maintains the privacy of the individual. III. PROCEDURE... 7.... a. Use of the Medical Records: 1.) Only authorized persons shall be allowed access to the patient records." 1. Tour of the Adolescent Unit on May 16, 2013, at 10:10 AM revealed an unattended nursing station. A housekeeper was cleaning the floor in the adjacent hall at the time. A medical record, multiple patient laboratory sheets, two medication administration records and a patient photo with discharge information were unattended at the station. 2. On May 16, 2013, at 10:15 AM, when asked if the patient medical information should be unattended, EMP4 stated, "I understand. That shouldn't happen." EMP1, also present for the tour, added, "You are right. That shouldn't happen." PLAN OF CORRECTION (A 0147) 482.13(d)(1) PATIENT RIGHTS: CONFIDENTIALITY Staff members involved in described incident, wherein PHI was left on nurse's station desk, were identified and educated related to the need to maintain control over all PHI thoughout the discharge process, as well as, the importance of adherence to rules and regulations designed to ensure patient privacy. All staff are being re educated that it is forbidden to unnecessarily access any information related to a patient's treatment, including that in the chart. All staff are being reeducated that it is necessary to immediately alert a charge nurse if they should http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 5/9
happen to identify a situation wherein an individual could easily gain unathoorized access to PHI. Senior Leadership have begun to do regular unit checks and this is an item they will be monitoring regularly for. 48.41(c) STANDARD FACILITIES The hospital must maintain adequate facilities for its services. Based on observation, staff interviews (EMP) and patient interviews (PT), it was determined the facility failed to ensure living spaces, toilets and sinks were functional and or accessible for seven of 16 rooms on the Adult Behavioral Health Unit. 1. Tour of the Adult Unit on May 16, 2013, at 11:00 AM revealed Room #132, #134, #135, #136, #137, #138 and #140 to be under construction, toilets removed and/or rooms filled with beds, furniture and/or construction supplies. 2. On May 16, 2013, at 11:01 AM, when asked what if PT6 (included in the above rooms) wanted to go to his/her assigned room..., EMP4 stated, "His/her room is out of condition for the day." 3. Review of a room assignment for May 16, 2013, revealed 13 patients were displaced as a result of the construction. 4. On May 16, 2013, at 11:04 AM, when asked to describe the room construction, PT2 stated, "The majority was OK but the bathroom was all torn up last night." 5. On May 16, 2013, at 11:12 AM, when asked to describe the room construction, PT1 stated, "I don't know. I do know I missed my smoke break since I couldn't get into my room." 6. On May 16, 2013, at 11:15 AM, when asked when construction began for Room #132, #134, #135, #136, #137, #138 and #140, OTH2 stated, "We ripped this section up this week. I'd like to be done tonight or tomorrow morning." OTH2 further confirmed Monday, May 13, 2013, as the start date for the aforementioned rooms. 7. On May 16, 2013, at 12:10 PM, when asked if rooms previously remodeled had also displaced patients, EMP1 stated that the process was the same unless the room was unoccupied due to census. 8. On May 16, 2013, at 1:40 PM, when asked to describe the room construction, PT3 stated, "Yeah, I had a toilet last night. Just no access (to his/her room) during http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 6/9
the day." 9. On May 16, 2013, at 1:45 PM, when asked to describe the room construction, PT4 stated, "I had to sleep on the couch during the day. Not allowed in my room. It's (expletive)! May as well tell the (expletive) truth!" 10. On May 16, 2013, at 2:50 PM, EMP4 confirmed, "They (flooring company) started to rip up the unit (Room #132, #134, #135, #136, #137, #138 and #140) on Monday (May 13, 2013) and started to lay floor on Tuesday. The full project started on April 22, and there are 26 rooms done of 36 rooms." PLAN OF CORRECTION (A 0722) 48.41 (c) FACILITIES Patient rooms undergoing major renovation were completed. Going forward, patient rooms in need of major renovation will be decomissioned and managed care organizations will be notified, as per applicable agreements, of reduced bed capacity. Plant Engineer/ Safety Director was educated as related to this change. 482.42(a)(1) STANDARD INFECTION CONTROL OFFICER RESPONSIBILITIES The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to maintain techniques for the maintenance of food sanitation for patient food located on the Adult Behavioral Health Unit. Review of the Clarion Psychiatric Center Policy, "Kitchens & Food Storage on Units," reviewed September 2012 revealed, "IV. PROCEDURE... B. Freshness of food in kitchens and refrigerators shall be maintained by nursing staff and Dietary Department. 1. All perishable foods will be labeled and dated. a. All foods not labeled and dated will be removed by Dietary Department." http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 7/9
Review of the Clarion Psychiatric Center Policy, "Dietary Closing Check List," revised September 2012 revealed, "IV. PROCEDURE... C. Kitchen Area 1. All food covered, dated and stored in proper areas." Review of the Clarion Psychiatric Center Policy, "Food Purchasing," revised October 2012 revealed, "Procedures... Food shall be stored at least 12 inches from the floor and 18 inches from the ceiling." 1. Tour of the medication room on the Adult Unit on May 16, 2013, at 10:40 AM revealed a refrigerator designated for patient food items. Uncovered and covered food was located on top of the refrigerator. The food was not dated. The top of the refrigerator also included plastic food storage containers with food remnants inside. Inside the refrigerator were two unmarked fruit cups, and three open milk containers. One container was dated May 9, 2013. The other two open cartons were not dated. On May 16, 2013, at 10:42 AM, when asked about the food on top of the refrigerator, EMP10 stated, "It's from last night. It's employee food.... Those are not patient containers." When asked how old the unmarked/dated cups and food inside the refrigerator was, EMP10 stated, "I don't know." When asked how long the open milk carton dated May 9, 2013, was good for, EMP10 stated, "Three days." 2. On May 16, 2013, at 10:50 AM, a plastic bin containing food and juice containers was observed on the floor. EMP10 stated, "That is food for the diabetics." PLAN OF CORRECTION (A 0749) 482.42(a)(1) INFECTION CONTROL OFFICER RESPONSIBILITIES 1. Dietary staff and nursing staff re educated regarding proper food labeling and handling. Education provided to all staff members that employee food is not permitted on units. 2. Nursing staff re educated on 06/06/2013, regarding proper food storage as related to physical location of food. A designated location, adhering to policy guidelines, was identified for the Diabetic Emergency Supply Kit. Unit Directors and Infection Control Nurse will check units regularly to ensure that food is stored and labeled, as per requirements, and that food is disposed of immediately that is outside of those parameters. Charge Nurse will be immediately notified of any identified problems so that follow up can occur with any and all staff involved. http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 8/9
http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/qasurvey.asp?facid=06300100&page=1&name=clarion+psychiatric+cent 9/9