Name   Anne Ecker, PI/RM Assistant Director   [CPN]
E-mail    anne.eckert@dmh.mo.gov
Facility Name  Hawthorn Children's Psychiatric Hospital (HCPH)
Facility COO: Marcia Perry 
Facility Address: 1901 Pennsylvania Avenue, Saint Louis, MO 63133

Jt Com Org ID#    725 !

# Beds - Adult    ??????
# Beds - Child & Adol    ??????
# Beds - Sub Abuse    ??????
# Beds - Forensic ??????
# Beds - MR/DD    ??????
# Beds - TotaL    ????
# Beds - CMS Distinct Part    ??????

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 10-13, 2009
Survey Days (e.g., Mon - Weds)    Tue - Fri
Number of Surveyors    2
Priority Focus Areas   
Last Survey Ending Date   1/31-2/3/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   George W. (Bill) Race M.D./Psychiatrist/Team Leader/Focused on  NPSG, Medical Staff Credentialing and Privileging, Leadership, Waived Testing, Medication Management /Dr. Race did not “trace” the way we expected a tracer to occur per TJC definitions of tracers.  Surveyor used his experience and practice in his own hospital as a baseline for investigating practices at our facility. His first impressions of people at our facility carried a lot of weight.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)   David K. Samples, LSC - Life Safety  Life Safety / Mr. Samples had been in a hospital fire at one time in his career so was quite focused on safe escape in case of fire.  He looked at all exits from every angle and monitored hallways to make sure there weren’t any fall hazards in case of smoke/fire.  Mr. Samples was helpful in that he educated staff, not only on standards compliance, but on other steps we could take to make the environment safer.

# of Non-Compliant Standards    21 (HAP: 8 Direct/ 13 Indirect) {BHC: Direct/ Indirect}

APR/NPSG Cites 

• BHC & HAP NPSG.03.03.01 EP 3  The organization takes action to prevent errors involving the interchange of the medications on the list of look-alike/sound-alike medications.- Observed in Cottage B at Hawthorn Children's Psychiatric Hospital site. There is an inconsistency related to the policies and procedures regarding high risk/high alert medications and LASA medications. The organization has implemented a pharmacy intervention to label LASA medications. However, two unit nurses that dispense medications, did not have an awareness of the facility LASA drug safe administration processes. Their understanding was limited to knowing that some medications are labeled LASA. The facility action to address LASA safety information and safety actions had not penetrated the level of nursing concerning this goal. / Direct / Srvyr#1
• BHC NPSG.15.01.01 EP3. The organization provides information such as a crisis hotline to individuals at risk for suicide and their family members. - A patient with suicidal history was discharged on 3/10/09. She, nor her family, received information such as a crisis hotline number to call for help in addressing this risk. Discussion with unit and facility staff leaders noted no current policy , or routine action , exists to address this NPSG element of performance. Observed in Cottage E at Hawthorn Children's Psychiatric Hospital site. A patient with suicidal history was discharged a second time on 10/09/08. She, nor her family, received information such as a crisis hotline number to call for help in addressing this risk. Discussion with unit and facility staff leaders noted no current policy , or routine action , exists to address this NPSG element of performance. / Direct / Srvyr#1
• BHC & HAP NPSG.02.03.01 EP1, 5, 6, 7:  We did not specify critical values for EEG, EKG and x-ray, therefore we could not collect data on timeliness, assess data on timeliness or improve timeliness of reporting.  Indirect / Srvyr# 1

MM/PC  Cites

• MM.03.01.01 EP 7  A multi-use Tylenol liquid medication container was observed stored without labeling its opening date per policy. Observed in Adolescent unit at Hawthorn Children's Psychiatric Hospital site. An opened multi-use Kaopectate bottle was observed stored without labeling it per opening date per policy. (Note - we did not have a policy requiring open date...)  / Direct / Srvyr#1
• BHC  Standard  MM.2.20 EP 9. A Lantis Insulin vial was seen opened and not labelled as to opening date per policy and manufacturers recommendation / Indirect / Srvyr# 1
• BHC PC.16.50 EP5. For instrument-based waived testing, quality control procedures are performed at least once each day on each instrument used that day for client testing.- Observed in Cottage B at Hawthorn Children's Psychiatric Hospital site. A glucometer in use was not checked for quality control on multiple dates when providing care for a patient receiving insulin on a sliding scale that required three blood glucose daily checks during this hospitalization period. / Direct / Srvyr#1
• HAP PC.02.02.03 & BHC  PC.7.10  EP2. Food and nutrition products are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. - Patient food was found stored with staff food in the unit refrigerator with no separation or consistent clear labeling as to ownership. This is not in accord with facility policies. Observed in Cottage C at Hawthorn Children's Psychiatric Hospital site. Patient food such as salad dressings, jelly and food in plastic bins was stored in the unit refrigerator with no labeling as to when these were opened. This situation presents a risk to patients with spoilage. / Direct / Srvyr#1
• BHC PC.8.10 EP 4 Found several instances where client received Tylenol without documentation of reassessment of pain.

RC/RI  Cites

IC/WT Cites

• IC.02.01.01 EP 1 The nursing station had a Lice comb in a box that noted it was last cleaned in 5/24/2005. The nurse noted a facility policy requiring cleaning it before and after use, but he was unsure as to its use in patient care since 2005. A policy or procedure to examine these devices on a regular interval was unknown to the nurse. Observed in Pharmacy night medication locker at Hawthorn Children's Psychiatric Hospital site. A medication for external use was found to be stored under the pharmacy night locker sink. The facility infection control professional affirmed this was not an acceptable infection control practice to reduce infection risks due to potential humidity or microbial contamination issues of patient use medications stored in such locations.
  

HR/LD Cites

• HR.01.02.05 EP 1  Nurses currently licensed, certified, or registered to practice have verified credentials with the primary source. However the hospital dietitian and 4 contract pharmacists did not have documented primary source verification. This was corrected on site and all professionals are currently licensed. Indirect / Srvyr# 1
• LD.04.01.07 EP 2  The leadership has awareness of many safety goals and has an active performance improvement process. However implementing change addressing nursing unit LASA and High Alert/Risk medications practices had not penetrated to the front line staff. Numerous nurses across the campus were unaware of their roles in these safety initiatives. Indirect / Srvyr# 1
  
  

IM/PI Cites

• IM.03.01.01 EP 1 The nursing access to knowledge-based information resources 24 hours a day, 7 days a week on the unit is limited to dated materials of 2002 PDR, a 1984 Mosby Medical manual, a 1994 Handbook of Medical Surgical Nursing , and a 1984 Handbook on nursing by Clayton. The nurse reported the central nursing office had more up to date or current information materials. However to access these information sources, he would have to leave the unit. This situation presents a clinical and process difficulty for nursing staff with 'on unit' patient care responsibilities.

EC/EM//LS Cites 

• EM.02.02.13 EP 5 The medical staff policy does not require a 'valid government issued photo ID' in addition to all other approved verifying documents or sources verifying LIP identity or competency. Direct/ Dr.Race
  
• EC.01.01.01 EP 3 The facility does not have a written comprehensive plan describing managing the 'environmental safety of everyone who enters the hospital facilities'. EP 4 The hospital has some written policies concerning security, but does not have a comprehensive written plan for managing the 'the security of everyone who enters the hospital facilities.' EP 5  The hospital has some specific hazmat policies on chemicals and infectious waste, but has no comprehensive written plan for describing the overall facility management of 'hazardous materials and waste'. EP 6 The hospital has a certain policy for addressing fire safety, but has no comprehensive written facility wide plan for managing 'fire safety'. Indirect / Srvyr# 1
  
• EC.02.03.05 EP 15  Several fire extinguishers had no checks documenting integrity as required . The fire extinguisher records indicated that the monthly inspections had only been completed for 8 of the last 12 months.Indirect / Srvyr# 1
  
• EC.04.01.01 EP 15  The hospital assesses activities for EOC activities for safety each year, but does not evaluate all environment of care management plans annually, to include a review of each plan’s objectives, scope, performance, and effectiveness. Indirect / Srvyr# 1
  
• LS.02.01.20 EP 27 Observed in the building tour at Hawthorn Children's Psychiatric Hospital site. There was a doorway in the middle of the exit corridor of the adolescent unit that was missing a required exit sign. Observed in the building tour at Hawthorn Children's Psychiatric Hospital site. There was not an exit sign for 152 feet outside the gymnasium corridor intersection. Indirect / Srvyr# 2

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.   

MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)

• MS.06.01.13 EP 6 Observed in Medical staff tracer review of Bylaws at Hawthorn Children's Psychiatric Hospital site. The Medical Staff Bylaws allow granting 90 days temporary medical staff privileges, and can grant a second 90 day extension of these privileges before requiring the full medical staff privileging process. / Indirect / Srvyr# 1
   

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)

• Surveyor
  

Preliminary Survey Result    JC: Accreditted, No RFI

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc
Note: We were surveyed under HAP and BHC standards so several citations are duplicated.

EP Related to Direct Impact Findings:
1- NPSG.03.03.01 EP 3 
2- NPSG.03.03.01 EP 3
3- NPSG.15.01.01 EP3
4- MM.03.01.01 EP 7
5- PC.16.50 EP5.
6- PC.02.02.03
7- PC.7.10  EP2
8- PC.8.10 EP 4

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01 EP1, 5, 6, 7 & NPSG.02.03.01 EP1, 5, 6, 7
2- MM.2.20 EP 9
3- PC.8.10 EP 4
4- IC.02.01.01 EP 1
5- HR.01.02.05 EP 1
6- LD.04.01.07 EP 2
7- IM.03.01.01 EP 1
8- EM.02.02.13 EP 5
9- EC.01.01.01 EP 3, EP 4, EP 5, EP 6
10- EC.02.03.05 EP 15
11- EC.04.01.01 EP 15
12- LS.02.01.20 EP 27
13- MS.06.01.13 EP 6

Anne Eckert