Name   Andy Atkinson, Quality Improvement Officer   [CPN]
E-mail    andrew.atkinson@dmh.mo.gov
Facility Name  Fulton State Hospital (FSH)
Facility COO:   Marty Martin
Facility Address:  600 E. 5th St., Fulton MO 65251-1798

Jt Com Org ID#    850

# Beds - Adult (Civil only)    401
# Beds - Child & Adol (Civil only) 
# Beds - Forensic    67
# Beds - Geriatric 
# Beds - MR/DD
# Beds - Sex Offender  
# Beds - Sub Abuse 
# Beds - Total (all Civil & For)   468
# Beds - CMS Distinct   24
# Units - Total    21
# Staff - Total    1363

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    6/29/09-7/2/09
Survey Days (e.g., Mon - Weds)    Mon - Thurs
Number of Surveyors   4
Priority Focus Areas   
Last Survey Ending Date   4/10-14/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   George W. (Bill) Race M.D.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Kathleen T. Townsend, MBA, RN/Nurse/Nurse Surveyor
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   John E. Eiland, MSN, RN / Nurse/Integrated Nurse/Likes to talk about research and data. Talks a lot about previous experiences in military and as an OR nurse. Likes having thoughtful discussion and does well at putting staff at ease during interview. Seems to take pride in feeling like he's providing consultation and helping staff and leadership understand standards and rationale for RFIs. Very thorough.  Solicits feedback, but doesn't always listen. Seems to know a little about everything, including Life Safety Code, food preparation requirements, etc. Really focused on the assessment of safety risks throughout the survey.
Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks) Roger L. Cagle, CHFM / Engineer/Life Safety Code Specialist/
 

# of Non-Compliant Standards    18 (HAP: 6 Direct/ 12 Indirect) {BHC: Direct/ Indirect} [Clarified]

APR/NPSG Cites 

• NPSG.02.02.01/ EP4 /During tracer activities, observations were made that a” do not use” abbreviation QD was used in a preprinted order form  /Direct/Srvyr#2
• NPSG.02.03.01/EP1 /During Data System tracer,  it was observed that the critical test process had not been defined or monitored. /Indirect/Srvyr#1,3
  
• NPSG.03.03.01/EP3 /During tracer activities, it was observed that four different types of insulin were stored together in the night medication closet.  /Indirect/Srvyr#3
  
• NPSG.07.03.01/EP2 /During Infection Control tracer, it was observed that the draft implementation plan did not include all required information.  /Indirect/Srvyr#2
  
• NPSG.16.01.01/EP2 /During tracer activities, observations were made that staff were unaware of specific criteria for identification and response to changes in a patient condition. Policy written, but not fully implemented.  /Direct/Srvyr#1

MM/PC  Cites

• MM.04.01.01/EP13  During tracer activities, it was observed that one set of physician orders not timed, one set of physician orders for medication without defining time component, two sets of physician orders used abbreviations that had not been approved and were not clarified by the nurse. /Indirect/Srvyr#2.
  
• PC.02.02.03/EP6,11 During building tour, it was observed that there were several days when refrigerator, freezer, and dishwasher temperatures were not recorded and there was inconsistent documentation of corrective actions when failed to meet minimum temperatures. Additional housekeeping was needed in the main kitchen, including window and door screens. Penetrations on floors and walls were identified. Exhaust fans were observed as not being enclosed, exposing areas of the kitchen to the outdoors. Unused floor drains not sealed or periodically flushed. /Direct/Srvyr#3
• PC.03.03.23/EP2 /  During tracer activities, it was observed that the 15 minute restraint monitoring flow sheet did not document required components of assessment as completed. /Indirect/Srvyr#2
• 
  

RC/RI  Cites

• RC.01.04.01/EP1/  During record review, the author of two documents and three sets of physician orders could not be determined due to legibility.  /Indirect/Srvyr#2
• RC.02.03.07/EP4/  During tracer activities, it was observed that authentication of five different telephone orders were either missing dates and times or had been signed after the 48 hour requirement.  /Indirect/Srvyr#2,3
• 
  

IC/WT Cites

HR/LD Cites

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01/EP3/ - During building tour, multiple ligature points were identified as potential hanging risks, including exposed plumbing, grab bars, shower heads and dials, sprinkler heads, and door knobs. Findings noted FSH's proactive risk assessment of environment of care safety risks, a request to state legislature for correcting them, and steps taken to mitigate risks. During tracer activity, audible security alarms were found in certain wards, but not others and there was no risk assessment to explain why. During tracer activity, some phones were identified as having shortened, non-removable cords and handsets and some had long and removable cords and handsets and there was no risk assessment to explain why.  /Direct/Srvyr#3
  
• EC.02.03.01/EP1/ - During building tour, four different electrical junction boxes were found without covers, exposing high voltage wiring.  /Direct/Srvyr#4
  
• EC.02.03.03/EP2/ During document review, there was no documentation that there had been any fire drills conducted in the seven free standing business occupancy buildings.  /Indirect/Srvyr#4
  
• EC.02.03.05/EP15/ During tracer activity, access to three different fire extinguishers was blocked by furniture and/or equipment.  /Indirect/Srvyr#3
• EC.02.05.07/EP4, 5, 6, 7 - During document review, documentation for eight emergency generators did not support that they ran under load based on missing or inconsistent amp readings. Could not identify if generators were meeting 30% of nameplate rating and annual load bank testing had not been done. No documentation that any of the automatic transfer switches had been tested twelve times a year, at intervals of not less than 20 days and not more than 40 days. No documentation showing that each generator was tested for a minimum of 4 continuous hours at least once every 36 months. /Direct/Srvyr#4
  
• EC.02.06.01/EP20/  During building tour, air conditioning vents were dirty in bathrooms and hallway.  /Indirect/Srvyr#1
  
• LS.02.01.10/EP3/  During building tour, penetrations in two hour fire rated walls were identified in four different locations. /Indirect/Srvyr#4
  
• LS.02.01.35/EP4/ During building tour, the automatic sprinkler piping system was found to be supporting conduit, cables, and ceiling grid.  /Indirect/Srvyr#4
  

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.06.01.07/EP8/ During credentialing tracer, three physicians were found to be credentialed over the two year limit. /Indirect/Srvyr#1

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

Preliminary Survey Result    Some Requirements for Improvement

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc

EP Related to Direct Impact Findings:
1- NPSG.02.02.01/ EP4
2- NPSG.16.01.01/EP2
3- PC.02.02.03/EP6,11
4- EC.02.01.01/EP3/
5- EC.02.03.01/EP1
6- EC.02.05.07/EP4, 5, 6,

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01/EP1, 3
2- NPSG.07.03.01/EP2
3- MM.04.01.01/EP13
4- PC.03.03.23/EP2
5- RC.01.04.01/EP1
6- RC.02.03.07/EP4-
7- EC.02.03.03/EP2
8- EC.02.03.05/EP15
9- EC.02.06.01/EP20/
10- LS.02.01.10/EP3/
11- LS.02.01.35/EP4/
12- MS.06.01.07/EP8
 
 

Andy Atkinson