HospitalInspections.org

Based on staff interviews, review of personnel files, tour and observation of the facility, review of pertinent hospital wide policies and procedures, and review of medical records, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with:
42 CFR 482.28 Food and Dietetic Services
42 CFR 482.41 Physical Environment
42 CFR 482.42 Infection Control

Based on staff interview, medical record review and review of facility documents, it was determined that the facility failed to to follow their Policy and Procedures to take reasonable steps to ensure that the patient or the patients representative is given information needed to make "informed" decisions regarding his/her care.

Findings Include:

Reference: Admissions Procedures policy states, "... PATIENT RIGHTS AND RESPONSIBILITIES: ... Involuntary patients and voluntary patients who, for any reason, cannot complete the registration process will be approached to do so as soon as appropriate after admission by a designated Registrar. Admissions staff will fill out the Incomplete Registration Form, send the original to the unit with the other paperwork to be included in the patient's chart ... The Registrar will make 3 attempts to meet with the patient within 7 days of admission, with the first attempt to be made on the next day following admission. Attempts will be coordinated with the inpatient unit to determine patient's appropriateness and availability to participate in the process. On the 7th day following admission, the unsigned Patient Consent and Hospital Regulation Checklist (Form 957) and the relevant form are to be placed in the miscellaneous section of the patient's chart. At that time, the Registrar will contact the Primary Therapist assigned to the patient to inform that 3 attempts have been made. The Primary Therapist will continue to make attempts and document in the chart on the progress note. All attempts and their outcomes will be documented on the Incomplete Registration Form in the patient's chart. ..."

1. A tour of the General Adult Unit (GAU) on 9/19/16 was conducted with Staff #2, #4, and #14 and revealed the following:

a. Patient #5 was admitted on 9/13/16. A Registration Form was initiated and stated that the patient appeared lethargic, disoriented and refused to sign. There were no follow up attempts to complete the Registration Form in accordance with the above referenced policy.

2. The above finding was confirmed with Staff #1.

Based on a review of a facility policy and procedure and review of the medical records of 3 of 5 patients, it was determined that the facility failed to ensure that all patients have the right to formulate an advance directive.

Findings include:

Reference: Facility policy and procedure titled "Advance Directives" stated:
"POLICY:
In accordance with the New Jersey Advance Directives for Health Care Act, the New Jersey Directives for Mental Health Act, the Patient Self Determination Act and The Joint Commission Patient Rights Standards, the Carrier Clinic will:
- Ascertain if admitted patients including emancipated minors have advance directives at the time of admission.
- Offer information on advance directives to those hospitalized patients who wish to initiate them while in residence. This will include all patients who turn eighteen (18) years old during their stay.
.....
DEFINITIONS OF ADVANCE DIRECTIVES:
* There are three kinds of formal advance directives that can provide legally valid evidence of patients' preferences: living wills, mental health directives, and durable powers of attorney for health care, or a combination of the three.
.....
- "Mental Health Advance Directives" or "Psychiatric Advance Directives" are legal documents that instruct providers and families on what the individual's mental health treatment preferences are.
.....
PROCEDURE:
* Procedure for Routine Inquiry at Admissions:
.....
- If the patient does not have a pre-existing advance directive, Access Center staff will inquire whether or not the patient would like to establish an advance directive while in residence at the Carrier Clinic.
- If the patient wishes to establish an advance directive while hospitalized, the Access Center staff will document this and notify the treatment team of this decision.
- If the patient does not have a pre-existing advance directive, and does not wish to have one prepared while hospitalized at the Carrier Clinic [sic] Access Center staff will document this at the time of admission.
....."

There was no documentation in the medical records of Patients #1 and #2 of whether an inquiry was made of the patients as to the existence of an existing advance directive or if the patients wished to formulate one. A PATIENT CONSENT AND HOSPITAL REGULATION ACKNOWLEDGEMENT form in the medical record of Patient #3 indicated that the patient did not have an Advance Directive, but that he/she wished to establish one. There was no further documentation that an Advance Directive was established or why one wasn't.

Based on observation and staff interview, it was determined that the facility failed to ensure that filtered needles are available for safe administration of medication in glass ampules.

Findings Include:

Reference: Institute for Safe Medication Practices (ISMP) Safe Practice Guidelines for Adult IV Push Medication, Appendix A, states: "3.1 Withdrawal IV push medications from glass ampules using a filtered needle or straw, unless otherwise specific drugs preclude their use..."

1. On 9/19/16, the General Adult Unit (GAU) medication room was toured in the presence of Staff #2, Staff #4, and Staff #14, the Unit Manager and the following was noted:

a. The medications Thorazine, Benzitropine and Chlorpromazine injectables in glass ampules were found in the medication room. When questioned, the Unit Manager (Staff #14) confirmed that filter needles were not available for use.

b. The facility failed to follow the ISMP guidelines.

2. On 9/19/16, the Older Adult Unit (OAU) medication room was toured in the presence of Staff #2 and Staff #7, the Unit Manager and the following was noted:

a. The medication Thorazine injectable in glass ampules were found in the medication room. When questioned, the Unit Manager (Staff #7) confirmed that filter needles were not available for use.

b. The facility failed to follow the ISMP guidelines.

3. The above findings were reviewed with Staff #1 and Staff #2.

Based on observations, staff interview, document review, and review of facility policy and procedure, it was determined that the facility failed to ensure that organized dietary services are directed and staffed by adequate qualified personnel.

Findings include:

1. The facility failed to ensure the Director of Food & Nutrition provides effective daily management of the Food Service Department. (Refer to Tag A 620)

Based on document review, staff interview and observation on 9/19/16, it was determined that the facility failed to ensure that the director of food services provides effective daily management of the Nutritional Services Department in accordance with the facility's "Position Title: GM 3, Food" job description.


Findings include:

Reference #1: The job requirement specifications for the Position Title: GM 3, Food states, "... Responsibilities: Directs daily food service operations in order to provide quality products, Maintains and implements sanitary and food safety conditions and training to adhere to auditing procedures and statutory regulations, ....Directs daily food service operations including: menu evaluation and planning, purchasing, inventory, receiving, food preparation and storage, Maintains kitchen and storage facilities to meet/exceed sanitary conditions; monitoring internal quality assurance and food safety audit process (including HACCP record keeping) ..."

Reference #2: The facility policy titled, IC-606 FOOD SAFETY (HACCP) states, "... The Food and Nutrition Services Department has a comprehensive food safety and self inspection system that includes equipment monitoring to ensure the effectiveness and quality of the food safety program for all our food service customers. ..."

Reference #3: The facility policy titled, Operational Standard IC-611 DISPENSING ICE STATES, "... 4. ICE SCOOPS are stored outside the machine and sanitized daily. Ice is served using ice scoop only and notice is posted to that effect. Management discourages use of glasses or hands by customers to select or serve ice. ..."

Reference #4: The facility policy titled, Food Storage, states, "... Food Items Dry and staple foods- Store on shelving at least 6" off floor in clean, well-vented room. ...Perishable foods- Refrigerate promptly upon receiving. Keep refrigerated as listed below until prepared or served: Fresh fruits/vegetables (40 F or below) Fish and shellfish (35-38F) Dairy products (38 - 40F) Frozen foods (-10 -0F) Meat and poultry (35 - 38F)...5. A daily temperature log will be maintained for all refrigeration and freezer units....7. Corrective action is required when temperatures fail to meet standards documented. ..."

Reference #5: N.J.A.C. 8:24-4.7(a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7(b) states, "Utensils and food-contact surfaces of equipment shall be sanitized before use and after cleaning."

Reference #6: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #7: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #8: N.J.A.C 8:24-6.2(n) states, "Requirements for the protection of outer openings shall include the following: 1. Except as specified in (n)2 and 3 below, outer openings of a retail food establishment shall be protected against the entry of insects and rodents by: (i) Filling or closing holes and other gaps along floors, walls and ceilings; (ii) Closed, tight-fitting windows; and iii. Solid self-closing, tight-fitting doors."

Reference #9: N.J.A.C 8:24-6.2(c) 2. states, " The floors in retail food establishments in which water flush claiming methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be covered and sealed."

1. On 9/19/16, in the presence of Staff #5, the following observations were made:

a. The ice dispensing machine located in the main kitchen failed to have a scoop for dispensing ice. The outside surface of the ice machine had debris and brown stains on it. There was no signage indicating use of the ice scoop to obtain ice from the machine.

(i) Upon request, Staff #5 was unable to provide a cleaning schedule for the ice machine.

b. The ware washing area had approximately 3-5 inches of free standing water on the floor and did not have adequate safety mats.

(i) The ware washing area walls were not maintained clean. The walls had visible dried brown/orange food splatter residue on them.

(ii) The racks of the ware washing machine were soiled with brown build.

c. A deep fryer in the cooking area had cooking oil that was cloudy and thick. During interview, Staff #6 stated that the there is no specific schedule to change the frying oil.

d. The double exit doors from the kitchen to the loading dock had visible sweep gaps. Fruit flies were observed throughout the kitchen.

e. The snack preparation area refrigerators contained the following food items:

(i) Six (6) fruit cups, dated 9/15/16.

(ii) Five (5) pans of unlabeled snacks on the bottom shelf of the refrigerator.

(iii) Plastic cups filled with a substance that appeared to be applesauce, but were not labeled.

(iv) The snack preparation area table had several pieces of fruit that appeared brown, rotted and surrounded by fruit flies. Staff #5 discarded the fruit upon discovery.

f. The general storage area door was propped open with many cardboard boxes on the floor. Fruit flies were observed around the storage area.

g. The juice cooler in the back of the kitchen had 2-3 inches of free standing water on the floor, which was brown in color.

(i) The cooler had visible debris and a brown substance on the surface. During interview, Staff #5 stated that there had been a leak in the cooler.

h. Five (5) unwrapped loaves of bread were found in the main kitchen freezer.

i. A milk holding refrigerator placed outside the kitchen on the loading dock, filled with approximately 30 crates of 8 ounce milk boxes, failed to have a working thermometer.

j. A hot food holding unit contained food that was being held for the lunch meal.

(i) The thermometer for the hot food holding unit was not working and the door handle was broken, which prevented completed closure of the unit.

2. The contracted pest control and sanitation reports were reviewed in the presence of Staff #5. The reports recommended the following:

a. The contracted pest control report dated 9/16/16, stated, "... Inspected main kitchen. Recommend thoroughly cleaning full kitchen, with emphasis on scrubbing buildup out of floor, drains and filling with fresh water to push buildup out of drains. Also, sanitize all trash cans. In East mountain kitchen need to sanitize all trash cans in building since other areas are complaining about flies. ..."

(i) The floors through out the kitchen were sticky and had visible debris.

(ii) The drains through out the kitchen were clogged with visible grey/black debris.

3. All of the above findings were confirmed with Staff #5.

These findings resulted in an immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 9/20/2016 upon receipt of an acceptable plan of correction.






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4. A tour of the Pantry on the MICA (Mentally Ill / Chemically Addicted) unit on 9/21/16 revealed:

a. There were raised stains, a plastic fork, grit, dust, paper scraps, and other refuse beneath and behind the refrigerator.

b. Inside of the refrigerator were 32 slices of individually wrapped bread with expiration dates ranging between 9/8/16 and 9/17/16. A container of salad in the refrigerator had an expiration date of 9/16/16. The salad was slimy at the bottom of the container. The bottom of a plastic bin in the refrigerator had food particles and a whitish particulate in it.

c. The drip tray on the Nestle Vitality juice dispenser had a cloudy fluid in it.

d. The counter beneath a plastic condiment tray had dried, yellow, raised stains and a tan fluid on it. Nine small plastic bins atop the condiment tray contained spilt sugar substitute, white granular particulate, and other types of spillage.

e. The middle cabinet beneath the counter holding the drink machines had spillage on the bottom of the cabinet.

Based on observation, and staff interview between 9/19/16 and 9/21/16, it was determined that the facility failed to maintain a safe environment for the patients, staff, and public.

Findings include:

1. The facility failed to comply with the National Fire Protection Association's 2000 edition of the Life Safety Code. (Refer to Tag A 709)

2. The facility failed to maintain adequate facilities for the services it provides. (Refer to Tag A 722)

3. The facility failed to develop and implement policies and procedures to ensure the facilities, supplies, and equipment are maintained to an acceptable level of safety and quality. (Refer to Tag A 724)

4. The facility failed to ensure ensure proper ventilation is provided. (Refer to Tag A 726)

Based on observation and policy review, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety and well-being of the patients, staff, and public.

Findings include:

Reference #1: The facility policy and procedure titled, "Food Storage", states, "... Storage Perishable foods... Refrigerator promptly upon receiving .... Keep refrigerated as listed below until prepared or served: Fresh Fruits/vegetables (40 F or below) ... Dairy products (38-40 F) ..."

1. In the presence of Staff #5, during a tour of the Older Adult Unit (OAU), the following observations were made:

a. The floor in the patient nourishment area had visible dirt and debris. The sewage drains had visible residue build up.

b. The patient nourishment fridge thermometer read 46 degrees Fahrenheit internal temperature. Food items of milk and juices were not maintained at at the required temperature as per the facility policy.


2. In the presence of Staff #5, during a tour of the Adolescent Unit, the following observations were made:

a. The free standing drains on the patient nourishment room floor had visible dirt and debris/residue build up.

b. The patient nourishment fridge thermometer read 50 degrees Fahrenheit internal temperature. Food items stored were not maintained at the required temperature as per the facility policy.

c. During interview, Staff #33 stated that there was no specific schedule to clean the free standing drains in the patient nourishment rooms.




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3. A tour of the Adolescent Unit conducted on 9/19/16, in the presence of Staff #26 revealed:

a. The Restraint Cabinet contained:

(i) Multiple arm and leg restraints entangled.

(ii) One (1) blue wrist restraint an accumulation of hair stuck to the Velcro and a stain on the interior of the cuff.

(iii) One (1) blue wrist restraint frayed and torn on the interior of the cuff.

(iv) One (1) red leg restraint with a stain on the interior of the cuff.

b. The Nurses Station:

(i) The bottom drawer of a cabinet had a heavy accumulation of dust, grit, and paper chads.

(ii) The far left, top drawer as one looks out the window into the hallway contained grit, dust, spilt salt and pepper, and other refuse. The second drawer down contained grit, spilt salt and pepper, and other refuse. The bottom drawer contained a heavy accumulation of spilt ground coffee at the back of the drawer.

(iii) There were clumps of dust, grit, paper clips, food particles, and other refuse behind and beneath a Shred-it box. There was exposed particle board, a non-cleanable surface, at the opening to the box.

(iv) A cabinet drawer on the right side of a door leading out of the Nurses Station had an accumulation of hair, dust, grit, and pieces of plastic at the back of the drawer.

(v) There was a heavy accumulation of dust and grit behind a cubby hole cabinet on a countertop near the back door. There was heavy dust in the individual cubby holes.

c. The Medication Room:

(i) A red plastic bin next to the sink had grit and dust on the exterior and in the interior. The bin contained medications being returned to the pharmacy.

(ii) A plastic medication bin had dust, grit, and torn paper labels attached to it.

(iii) A wall cabinet above a computer contained two lazy Susan's with an accumulation of white particulate on them.

4. The South Wing Lounge:

a. There was a heavy accumulation of dust, grit, a broken pencil, and other refuse beneath a metal cabinet. There was heavy dust and grit at the bottom of the bottom cabinet drawer.

b. There were stains on the walls.

c. A tall metal cabinet had an accumulation of dust atop it.

d. There was heavy dust, grit, Goldfish Crackers, nuts, cracker pieces, a small white pill, cellophane candy wrappers, and other between the cushion of a couch and the arm rest.

5. In the South wing Medication Room, was a heavily frosted air conditioner unit.

6. In the South Wing Restraint Room, was a dead insect on the floor next to the bed.

7. A Minor Treatment Cart in the South Wing Exam Room had a stained particle board counter top. There was also heavy tape residue on the cart.

8. A drawer under the counter in the South Wing Nurses Station contained a bin with individual laundry detergent packets. Some of the packets were broken open with the contents accumulated at the bottom of the bin.

9. The Medication Room in the MICA Unit contained a step stool with raw wood, an uncleanable surface.

Based on observation, it was determined that the facility failed to ensure compliance with the 2000 edition of the National Fire Protections Association's Life Safety Code.

Findings include:

1. On 9/19/16 at 11:45 AM, in the presence of Staff #3, an unsecured helium tank was located in the storage room on the Older Adult Unit.

2. On 9/19/16 at 12:00 PM, in the presence of Staff #3, the Smoke barrier door was equipped with a double key dead bolt on the Older Adult Unit.

3. On 9/19/16 at 12:05 PM, in the presence of Staff #3, all cubical curtains within the Older Adult Unit were of 1/4 inch diameter mesh which interferes with the effectiveness of fire sprinklers.

4. On 9/19/16 at 12:40 PM, in the presence of Staff #3, trash cans in the cafeteria were larger than 32 gallons.

5. On 9/19/16 at 1:40 PM, in the presence of Staff #3, no exit sign was found over the emergency exit from the Solarium.

6. On 9/21/16 at 10:40 AM, in the presence of Staff #3, trash cans in the ACU East Unit were larger than 32 gallons.

7. On 9/21/16 at 10:45 AM, in the presence of Staff #3, cigarette receptacles were not constructed of noncombustible material with self-closing covers.

Based on observation and staff interview, it was determined that the facility failed to ensure adequate facilities are maintained for the services it provides.

Findings include:

1. On 9/19/16 at 12:40 PM, in the presence of Staff #3, the Interview Room on the Older Adult Unit was also being used as a Storage Room.

a. Nine (9) boxes of supplies were located on the floor.

b. During interview, Staff #3 confirmed the Interview Room was also used for storage.

(i) The sign on the door read, "Interview/Storage Room."

2. On 9/20/16 at 10:45 AM, in the presence of Staff #3 and Staff #13, one (1) patient was placed in Room #905A. This room is the ante room to the Seclusion Room.

a. Room #905A had no window to the outside.

b. All the patients personal belongings, including clothes and footwear were in bags in Room #905, next to the bed.

c. The patient was not provided storage for his/her belongings.

d. The toilet room for the Seclusion Room was full of this patients personal hygiene products.

e. The seclusion Room was not available for other patients.

f. Staff #3 and Staff #13 stated that the patient who was in Room #905A was actually assigned to Room #906 but during the survey, a tour of Room #906, provided no evidence that Room #906 was currently occupied.

(i) Room #906 was empty.

(ii) The room was clean with the beds made.

(iii) No patient belongings were found in the room.

(iv) No personal hygiene products were located in the toilet room.

(v) Staff #3 and Staff #13 could not provide evidence that any patients were regularly using Room #906.

A. Based on observation, review of facility policy and procedure, and interviews with administrative staff, it was determined that the facility failed to ensure facilities, supplies, and equipment are maintained to an acceptable level of safety and quality.

Findings include:

Reference #1: The PROCEDURE section of policy titled "Storage of Medications" stated:
"Preparations for external use are segregated from medications for external use.
....."

Reference #2: The "Procedure" section of policy titled "Floor Stock Medication" stated: ".....
* Floor Stock medications must be kept neat and orderly with external and internal medications being stored separately. .....
* Floor stock medications will be inspected monthly to ensure medications [sic] kept neat [sic] orderly and are in date."

Reference #3: The PROCEDURE section of policy titled "Control of Medications" stated:
"* All medications must be kept in a locked medication room on the respective unit. Medications to be administered via routes other than oral and injectable are not to be kept in the same closet, i.e. externals.
* Medications for specific patients are to be kept in separate drawers labeled with the respective patient's name.
.....
* All medications must be returned to pharmacy if no longer in use due to discontinuation or discharge. [Sic] Shall be returned to the pharmacy. This is done by placing the drug to be returned into the red container for return to the pharmacy.
....."


1. On 9/19/16 at 11:45 AM, in the presence of Staff #3, the handrail in the corridor outside Room #810 on the Older Adult Unit was loose.

2. On 9/19/16 at 12:05 PM, in the presence of Staff #3, a mattress pad was stored on the floor in the bathroom of Room #816 B on the Older Adult Unit.

3. On 9/19/16 at 12:10 PM, in the presence of Staff #3, an electrical outlet was unsecured to the wall in the Woman's Shower Room on the Older Adult Unit.

4. On 9/19/16 at 12:20 PM, in the presence of Staff #3, seven (7) boxes of adult diapers were stored on the floor in the Woman's Shower Room on the Older Adult Unit.

5. On 9/19/16 at 12:25 PM, in the corridor outside Room #802, an isolation cart was found to have a clear liquid pooled on the top level of the cart.

a. Staff #3 confirmed this finding.

6. On 9/19/16 at 1:30 PM, in the presence of Staff #3, an ice machine (Model B 400, Serial Number #110702032) located in the Kitchen had black spots located on the inside of the machine and around the edges of the hopper.

7. On 9/19/16 at 1:35 AM, in the presence of Staff #3, the light in the Men's Patient Toilet across from Room #118 on the General Adult Unit, was not functioning.

8. On 9/19/16 at 1:40 PM, in the presence of Staff #3, the ceiling was peeling and cracking in Shower #1 and Shower #2 on the General Adult Unit.

a. Both Shower #1 and Shower #2 had a black substance in the corners and at the seams where the floor meets the walls. A black substance was also observed in the grout between the tiles on the shower floors.

9. On 9/19/16 at 1:45 PM, a green, orange and black substance was found along the wall near the heater in the Luggage Room on the General Adult Unit.

a. Staff #3 confirmed this finding.

10. On 9/20/16 at 11:00 AM, in the presence of Staff #3, black stains were found on the ceiling around all air vents throughout the Kitchen.



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11. The following observation was made in the Main Kitchen on 9/19/16 at 11:15 AM in the presence of Staff #3 and Staff #5:

a. The Hobart Baxter Dishwasher (identified with property #784, model #CRS66A), failed to wash at the required 160 degrees Fahrenheit and rinse at the required 180 degrees Fahrenheit. The gauge on the Dishwasher read 140 degrees Fahrenheit during the dishwashing cycle.

(i) A permanently affixed label identified the correct operating temperature of 160-180 degrees Fahrenheit.

b. During interview, Staff #5 stated, "a few trays must be run though the washer to bring the temperature of the water up."

c. Staff #5 confirmed the washer was already washing pans and trays when the surveyors arrived at the dish washing area. Staff #3 sent seven (7) trays though the dishwasher in the presence of the surveyors with no change in the temperature of the water. The gauge on the Dishwasher continued to read 140 degrees Fahrenheit during the dishwashing cycle.

d. The above findings were confirmed with Staff #5.




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12. A tour of the Adolescent Unit conducted on 9/19/16, in the presence of Staff #26 revealed:

Medication Room:

a. There was heavy dust inside the handle of the medication refrigerator and atop the refrigerator. There was heavy dust, grit, paper scraps, medication vial caps, and other refuse beneath and behind the refrigerator. The shelves inside of the refrigerator had a coat of dust on them.

b. A drawer contained an individually packaged 2mg. Loperamide HCl (Hydrochloride)tablet with an expiration date of "1/16" (January 31, 2016).

c. A glucometer supply case had dust and grit on the interior and heavily soiled surgical tape on the broken latch.

d. A metal medication holder on the counter had paper stickers and sticker residue on it. There was dust atop it and stains, raised stains, and dust beneath and behind it.

e. A shelf in a wall cabinet above the computer contained an opened container of Menthol Gel Pain Reliever, an unopened bottle of Aloe Vera, and one (1) individually packaged tablet of 325mg Tylenol with an expiration date of "6/2016" (June 30, 2016).

(i) Topical medications were stored with oral medications.

(ii) The Tylenol tablet was expired.

South Wing Medication Room:

a. A cabinet contained:

(i) One (1) individually packaged tablet of 325mg Tylenol with an expiration date of "6/2016" (June 30, 2016).

(ii) One Epi Pen with the name of Patient #17 on a sticker attached to it. The South Wing of the Unit had no patient census at the time of the tour. The Epi Pen should have followed the patient when he/she was transferred to another unit or to the pharmacy if discharged.

b. The medication cart contained a bottle of nail polish remover in the same drawer as Milk of Magnesia, a sleeve of 5-ounce plastic cups, paper souffle cups, and an opened bottle of hydrogen peroxide. The topical medications should not have been stored with the oral medication. Additionally, the nail polish remover and hydrogen peroxide should not have been stored in the same drawer as the cups used for drinking and administering medications.

13. An Emergency Kit in the Copy Room did not have a breakaway lock on it. The "Emergency Response Bag with lock intact (enter last 2 digits of lock number)" section of an "11-7 RN Duties Checklist" for the Unit included the entry "Open." There was no documentation that nursing staff reported the opened lock.

14. A tour of the MICA Unit conducted on 9/21/16 revealed:

Medication Room:

a. A metal cabinet above the counter contained:

(i) A glucometer supply case had dust and grit beneath the blood glucose control solution bottles. There were particles of food including a piece of a snack chip beneath the single-use lancets.

(ii) A medication bottle containing "Vitamin D (Ergocalciferol Capsules, USP)." The expiration date sticker on the bottle stated: "AUG 16" (August 31, 2017).

(iii) One (1) "Curad Xerofoam Petroleum Dressing" with an expiration date of "2015-07" (July 31, 2015).

(iv) One (1) "Curad Xerofoam Petroleum Dressing" with an expiration date of "2015-09" (September 30, 2015).

(v) Two (2) "Duoderm Signal Colostomy" applications with an expiration date of "2015-10" (October 31, 2015).

(vi) Two (2) "Duoderm Signal Colostomy" applications with an expiration date of "2015-7" (July 31, 2015).

(vii) Two (2) "Medihoney Calcium Alginate Dressing with Active Leptospermum Honey" dressings with an expiration date of "2015-07."

(viii) A clear plastic bin containing individually packaged throat lozenges without the original packaging indicating an expiration date. The lozenges had been cut from the original package which had an expiration date on it, but once the lozenges were separated the date was also cut so that each lozenge did not have an expiration date on it.

b. The Syringe Drawer contained:

(i) Three (3) "BD Instyle Autoguard Shielded IV (Intravenous) Catheter" packages with an expiration date of "2010-08" (August 31, 2010).

(ii) Five (5) needles in sterile packaging with a rubber band applied tightly around them.

(iii) One (1) "BD Instyle Autoguard Shielded IV (Intravenous) Catheter" package with an expiration date of "2009-12" (December 31, 2009).

(iv) Thirteen packs of various sized syringes and needles with rubber bands tightly wrapped around them.

c. A Metal Cabinet beneath and to the right of the sink contained (1) "Air-Life Sterile Water" container with an expiration date of "JUL-16" (July 30, 2016).

A. Based on observation and staff interview, it was determined that the facility failed to ensure that proper ventilation is provided.

Findings include:

1. On 9/20/16 at 11:45 AM, in the presence of Staff #3, two (2) portable air conditioning units were being used at the Nurses Station to supplement the main air conditioning system in the Adolescence Unit .

a. Staff #3 confirmed the main building Heating and air conditioning system does not adequately cool the unit.


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B. Based on tour of the Electroconvulsive Therapy (ECT) rooms, it was determined the facility failed to ensure that pharmaceuticals are stored properly.

Findings include:

1. A tour of the ECT post procedure room on 9/20/16 in the presence of Staff #4, #7, and #15 that revealed the following:

a. The Temperature Log Sheet for the medication refrigerator was reviewed. The Safety Zone temperatures were noted as 36 degrees to 46 degrees. The Danger Zone temperatures were noted below 36 degrees and above 46 degrees.

(i) The temperatures were noted below the Safety Zone of 36 degrees on three separate dates for the month of August 2016 and two separate dates in the current month of September 2016. There was no documentation for notification to Maintenance, Action, Temperature Recheck or Notify Pharmacy on the Temperature Log Sheet.

2. The above findings were reviewed with Staff #4 and Staff #7.

Based on staff interviews, and review of facility documents, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings include:

The facility failed to ensure that multi-dose vials accessed in an immediate patient care area were used for one patient and immediately discarded. (Refer to Tag A 749)

A. Based on observation and interview, it was determined that the facility failed to ensure that safe injection practices are implemented in accordance with CDC guidelines.

Findings include:

Reference: CDC guidelines for multidose vials website:
http://www.cdc.gov/HAI/setting/outpatient/checklist/outpatient-care-checklist-observations.html>, titled "Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care" states, "Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g,. operating room, patient room/cubicle) (Note: If multi-dose vials enter the immediate patient treatment area they should be dedicated for single-patient use and discarded immediately after use.)"

1. During a tour of the Electroconvulsive Therapy (ECT) Procedure Room on 9/20/16 in the presence of Staff #4, #7, and #15, the Controlled Substance Administration Record was reviewed for multiple dose vials of Ketamine.

a. Staff #16 confirmed that Ketamine is used for multiple dose patient administration.

b. Staff #16 confirmed that the anesthesiologist medication preparation area is in the patient care area.

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 9/20/16 upon receipt of an acceptable plan of correction.


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B. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings include:

1. On 9/21/16 at 12:30 PM, in the presence of Staff #3 and Staff #23, two (2) Philips Norelco batter operated electric razors were observed in the Examination Room of ACU East.

a. During interview, Staff #23 confirmed the razors are shared by multiple patients and are used every day.

b. Both electric razors had visible hair and debris on the razor head and grip.

c. During a review of the manufactures instructions for use, Page 13 states, "... For hygienic reasons, the shaver should only be used by one person. ... Use this shaver for its intended household use as described in this manual. ..."

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 9/21/16 upon receipt of an acceptable plan of correction.