Brylin Hosp

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 25545 Based on observation and interview, the facility does not ensure all exits are unobstructed. Findings include: Observation on 01/28/25 at 11:00 AM in Stairwell #1 revealed a plastic raceway (a device that encloses, conceals, and protects electrical wiring) that contained low voltage wires for the card access scanner for the door, that was hanging from the outlet box. The wires and raceway were obstructing the door and the length of the stairwell. Interview on 01/28/25 at 11:00 AM with Staff (I), Facilities, verified this finding.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 32261 Based on document review, policy review, and interview, in three of three credential files, the facility does not require physicians to participate in an education and training program that protects the patient’s right to the safe implementation of restraint or seclusion (Staff M, Staff O, and Staff R). Findings include: Review of the “Medical Staff Rules & Regulations,” dated 2016, revealed the primary medical provider must conduct an in-person patient assessment and write/sign the order for restraint or seclusion. The policy does not include training/education requirements for physicians for the utilization of safe restraint and seclusion implementation. Review on 01/29/25 of credential files for Staff (M), Medical Director, Staff (O), Psychiatrist, and Staff (R), Physician, revealed no evidence of education/training for the utilization of safe restraint and seclusion implementation. Interview on 01/30/25 at 10:00 AM with Staff (A), Vice President Patient Care Services, revealed physicians do not receive restraint and seclusion training. Interview on 01/30/25 at 10:00 AM with Staff (A), Vice President Patient Care Services, verified the above findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49420 Based on policy review, document review, and interview, in four of four personnel files, the hospital failed to ensure clinical staff are evaluated every year (Staff D, Staff H, Staff K, and Staff L). Findings include: Review of the policy “Performance Appraisals,” last revised June 2012, indicated staff development needs are assessed organizationally, departmentally, and individually. These appraisals are conducted annually and include the following components: review of objective criteria on job descriptions and performance standards, review of in-service education record and other staff development initiatives, review of process improvement initiatives or performance improvement plans, and individual staff feedback on their performance for the period. Review on 01/29/25 of the personnel files for Staff (D), Registered Nurse, hired on 04/30/20 and Staff (L), Registered Nurse, hired on 10/01/24 revealed that they have not been evaluated during their employment at the hospital. Review on 01/29/25 of the personnel file for Staff (H), Licensed Practical Nurse, revealed that their last evaluation was in 2021. Review of the personnel file for Staff (K), Registered Nurse, revealed that their last evaluation was in 2019. Interview on 01/29/25 at 11:00 AM, Staff (A), Vice President of Patient Care Services, revealed that staff evaluations are not being completed yearly per policy.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 25545 Based on observation and interview, the facility does not maintain mattress upholstery to be free from tears. Findings include. Observation on 01/28/25 at 10:15 AM in the electroconvulsive therapy room, revealed the mattress on the exam table had two large tears, and many small tears exposing the foam mattress pad. One large tear had duct tape running from side to side. The duct tape had pulled away from the material and mattress pad was exposed. In the laboratory technician room, the exam table in was missing vinyl material from both corners at the foot of the table. The mattress padding was exposed. Interview on 01/28/25 at 10:15 AM with Staff (I), Facilities, verified these findings.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 32261 Based on document review and interview, the facility did not review and update their emergency preparedness plan annually and did not conduct a risk assessment using an all-hazard approach. Findings include: Review on 01/29/25 of the facility “Emergency Preparedness Plan,” dated 2016, revealed no evidence of an annual review and/or evidence of a risk assessment using an all-hazards approach. Interview on 01/29/25 at 09:00 AM with Staff (I), Facilities, revealed that the facility has not completed a risk assessment annually. Interview on 01/30/25 at 10:00AM with Staff (A), Vice President Patient Care Services, verified the above findings.”