Fairmount Behavioral Health System was cited during a full Medicare Validation Survey conducted by the Pennsylvania Department of Health (DOH) for deficiencies related to patient rights, facility maintenance/housekeeping, dietary services, and standard content of records. DOH found deficiencies related to two main issues: use of mechanical restraints and facility maintenance/housekeeping.
DOH found that the “facility failed to monitor and assess a patient during the use of physician restraints.” A medical record review revealed a physician order for ankle restraints on June 1, 2013. DOH found that the “restraints were applied at 4:00PM and released at 8:30PM” but there was “no documented evidence that the patient’s Circulation, Hygiene, and Comfort were assessed on June 1, 2013 from 4:00PM to 8:30PM in accordance with facility policy.” The facility’s policy states that “the patient shall be assessed every 10 minutes by a Psych Tech or RN while in a hold/restraint, and every 15 minutes by an RN while in restraint.” Just 7 months prior in December 2012, Fairmount Behavioral was cited for similar violations
for not assessing a patient’s circulation, hygiene, or comfort while s/he was placed in a mechanical restraint.
DOH also found additional deficiencies related to the use of physical restraints and wrote that the “facility failed to use restraints in accordance with physician orders for two of seven restraint medical records reviewed (MR6 and MR8). Review of medical records revealed that two patients had physician orders for physical holds but instead were “placed in mechanical restraints and not a physical hold as ordered by the physician.”
The on-site inspection also revealed deficiencies related to kitchen sanitation due to observations of dirty areas in food preparation and storage areas. Inspectors found:
“Build up of dirt, dust and debris” near the entrance door of the walk in refrigerator, on stop of the oven, a ceiling vent, and a shelving unit that contained pots and pans. The report also noted that “the dry storage room contained a six shelving unit which had a build up of a black, sticky life substance.” Also, the report noted that “the housekeeping closet and the paper product room was observed with several gnats.”
The inspection report also noted facility maintenance/housekeeping deficiencies in patient care areas and utility rooms. Observations revealed the hallway floor of the unit “appeared to be dirty and covered with dark stains” and “garbage debris [was found] on the floors” in five patient rooms. DOH also found “black-like substance which appeared to be mold on the bottom of the shower area” for room numbers 4 and 5. In the Adolescent Building’s Quiet Room, DOH found “various amount of debris on the floor to include food particles, wrappers, chalk, plastic cups” and stained carpet.
Observations in the “Clean Utility Room revealed a dirty linen cart containing dirty linen and two soiled white towels on the floor” and “six large linen bags filled with linen bags on the floor.” Inspectors also found “three large bins [containing] clean linens” in the Soiled Utility Room. The report also noted that there were:
“Large bins of towels and spreads opened to air with plastic wrap draped and lying on the floor. Damage was noted to the drywall, including two areas of approximately three feet by six inches. There was a trash can in the rear of the room containing a soiled utility bag. A dirty utility cart frame with a dirty linen bag was also found in the clean utility room.”
An interview with an employee confirmed “there was no policy to address storage and disposal of linens.”
Inspectors found that “the facility failed to ensure a safe setting for patients” after observations revealed “two video game cords approximately four feet in length, one phone cord approximately six feet in length, and one phone cord approximately 12 feet in length were readily accessible to the patients located in the television sitting area.” The inspectors confirmed during a staff interview that the “unit provides services to suicidal patients.” DOH also cited Fairmount Behavioral for not completing medical records within 30 days of patient discharge for 8 of 13 medical records.
In the plan of correction, the facility agreed to re-educate all medical and nursing staff on physician orders of restraints and mechanical holds by holding staff meetings and releasing a formal memo. The facility also agreed that the Director of Dietary Services would establish and implement a designated cleaning schedule that will be communicated to staff via memo. Lastly, the Director of Plan Operations agreed to perform weekly environmental rounds to ensure the facility is meeting facility maintenance standards.