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Based on observation, record reviews and interviews the facility failed to ensure patients were provided care in a safe setting for 62 of 62 patients by allowing:
-non-suicide- resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls;
-shower water control knobs and bathroom door hinges which provided potential looping hazards for all patients on the units;
-lengthy cords on an entertainment center and speakers, and on a C-Pap machine, which provided potential looping hazards for all patients on the units;
-plastic bags accessible to all patients on the units, which provided potential for suffocation;
-and stackable hard plastic milk cartons which provided the potential means for hanging by looping hazard for all patients on the units.

Due to the severity of the situation and the potential for harm to all patients in the facility, this resulted in overall noncompliance with the Condition of Participation: Patient Rights CFR 482.13 and demonstrated an unsafe patient care environment.

The facility admits patients with diagnoses of suicidal ideation, history of suicidal ideations, attempts at self harm, seizure precautions, assault precautions and fall precautions. The facility had a census of 62 at the start of the survey.

Based on observation and interview the facility failed to ensure personal privacy during a treatment procedure for one (Patient #43) of two treatment procedures observed. The facility had a census of 62.
Findings included:
Observation on 01/04/11 at approximately 1:30 PM, showed the following:
Registered Nurse (RN), Staff OO, accompanied Patient #43 to his/her room to provide treatment to patient's buttocks. Observation of patient's room, #46 showed a room with four patient beds. Observation showed no curtains around any of the beds. Staff OO had Patient #43 stand by his/her bed and lower his/her pants and underwear. Staff OO applied Silvadene 1% cream ( a topical antibiotic used to prevent infection to an open area on this patient's skin) to an area between the patient's buttocks and applied a dressing over the affected area. During this time one of the patient's roommates, who was in the bathroom started to exit the bathroom into the room, but a second staff member in the room stopped the roommate from entering the room. While Patient #43 was standing and receiving treatment a third staff member opened the patient room door without knocking. The second staff member in the room stopped the third staff member from entering the room.
During an interview on 01/04/11 at 1:40 PM, charge nurse, Staff C stated the unit had a treatment room and Staff OO could have taken Patient #43 to the treatment room for his/her procedure. Staff C stated the facility does not have any moveable curtains that staff could use to place around any bed to provide privacy during a treatment or personal care. Staff C stated when a patient needed privacy the staff asked other patients to leave the room.

Based on policy review, observation, interview and record review the facility continued to fail to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for 11 of 16 current patients on the Acute Adolescent, 14 of 15 current patients on the Acute Adult and 31 of 32 current patients on the Adult units. The facility had a census of 62.

Findings included:

1. Review of the facility's policy titled, "Precautionary Levels at CenterPointe Hospital", revised 11/30/10, provided the following guidance (in part):
"LOS (Line of Sight) The patient must be in sight of the staff at all times."
"SP 2 (Suicide Precaution, Level 2) This is our most protective level of suicide watch. Patients are observed every 15 minutes. In addition, patients on SP 2 do not leave the unit/program area. Meals are brought to the unit; Activity Therapy projects are brought to the unit."
"SP 1 (Suicide Precaution, Level 1) Patients are observed every 15 minutes. Patients are permitted to go to the dining room for meals, on outdoor breaks, and to the activities area."
"AP 1 (Assault Precautions, Level 1) This precaution is ordered for patients who have verbalized homicidal or aggressive feelings towards others; or have a history of these types of behaviors."
"AP 2 (Assault Precautions, Level 2) This precaution is ordered for patients who have been recently assaultive, i.e., within the past three months, or actually demonstrate aggressive behaviors towards others."

Review of the policy during the current survey revealed staff had not changed the policy since the last survey of 10/06/10.

2. Review of the facility's document titled, "Statement of Patient Rights", revised 06/15/10, provided the following (in part):
"As a patient at CenterPointe Hospital, you are granted the following rights:"
"To protective oversight while a patient at the hospital".
"To the extent that the facilities, equipment, and personnel are available, to psychiatric and medical care and treatment in accordance with the highest standards accepted in medical/psychiatric practice".

Review of the above document during the current survey revealed staff had not changed the intent or wording since the last survey of 10/06/10.

3. Review of the facility's document titled, "Special Precaution Policy", revised 08/17/10, provided during the current survey showed, in part, the following:
-The licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status. ,
-A physician order was required to decrease or discontinue a special precaution level. This order should be accompanied by a progress note by the physician, within 24 hours of the order, with the rationale for decreasing or discontinuing the precaution.

4. Observations on 10/04/10 at 10:26 AM, (the previous survey) on the Children's Unit revealed staff stored a television and audio visual equipment with lengthy cords unprotected in a corner of the Major League Day Room. There was no line of sight from the hallway so unwitnessed access to the electrical cords was possible.
Observation during the current survey on 01/06/11 at 9:30 AM, in the Acute Adolescent Unit-#1 in the group activities room showed long, exposed cords. Four long-black cords were plugged into a power strip with a five foot long cord attached to it. Two of the black cords were approximately 29 and a half inches long, one of the black cords was approximately four feet nine inches long, and the last black cord measured approximately three feet-three inches long. The measurements were the length of the exposed areas of the cords. There were also four exposed speaker wires that were approximately 26 and a half inchjes long.
During an interview on 01/06/11 at 9:30 AM, RN, Staff M and Nurse Manager of Acute Adolescent Unit, Staff L stated the cords were exposed and accessible and Nurse Manager, Staff L confirmed the approximate lengths of each of the cords.
Observation on 01/06/11 at 10:00 AM, in room #14 on the Acute Adolescent Unit, in the group activities room where patients watch television or listen to music on their own, showed three exposed cords from electronic equipment housed in an entertainment center. There was an exposed cord approximately two feet and three and a half inches from the end of the cord to the entertainment center that was plugged into a socket, a looped cord that was three foot long from the looped end to the entertainment center, and one more cord that was approximately three feet from the end to where it went behind the entertainment center
During an interview on 01/06/11 at 10:00 AM, Nurse Manager of the Adolescent Unit, Staff L confirmed the cords were exposed and accessible and verified the approximate lengths of each of the cords.
During an interview on 01/06/11 at 10:09 AM, Nurse Manager of the Adolescent Unit, Staff L and Charge Nurse, Staff P stated the facility failed to develop a policy or procedure for staff who are monitoring children and adolescents who use the dayroom by themselves.
5.. Record review of current Patient #40's Admission Psychiatric Evaluation dated 12/21/10 revealed the psychiatrist assessed the patient with thoughts of self harm, and past admission for depression and suicidal ideation.
Current observation on 01/03/11 at 1:50 PM, on the Adult Unit 6 showed the following:
-A C-Pap machine (A continuous positive airway pressure machine for the treatment of sleep apnea) with a five and a half foot electrical cord next to the patient's bed.
-The C-Pap machine was on top of two stacked milk crate cartons (of heavy, durable, hard, plastic construction).
-Patient #40's bathroom door had 3 hinges (created gaps between the door and the jamb allowing space to for ligature attachment points).

During an interview on 01/03/11 at 1:50 PM, Psychiatric Technician, Staff JJ, who was present in Patient #40's room at time of the above observation stated the C-Pap machine, with lengthy electrical cords should be removed and locked in a cabinet after the patient gets up for the day. The facility failed to identify the electrical cord on the C-Pap machine provided a looping and hanging hazard at all times of the day or night.

6. Record review of Patient #44's Admission Psychiatric Evaluation dated 12/24/10 showed the psychiatrist assessed the patient with symptoms of depression.
Review of Patient #44's admission orders dated 12/24/10 at 2:45 AM, showed: the physician admitted the patient with diagnosis of depression.
Observation on 01/03/11 at 1:00 PM, showed the facility used a staff controlled, electronically locked front door system.
Review of Patient #44's Clinical Progress Notes dated 01/03/11 at 1:35 PM, showed the patient, undetected by staff, eloped out the front door with another group of patients and staff from another unit. Further review of the patient's progress notes revealed a patient reported the elopement to Nursing Supervisor, Staff L, who then requested staff find the patient #44. Patient #44 was returned and placed on elopement precautions.
During an interview on 01/03/11 at 2:15 PM, Patient #44 stated he/she left the facility after lunch, and had decided during lunch to leave with the other group of patients. Facility staff who routinely escorted the other group of patients out to a smoking area failed to notice Patient #44 was mixed in among the exiting group of patients.
Review of the facility's internal investigation regarding Patient #44's elopement of 01/03/11 showed staff assessed:
-Factors contributing to the patient's elopement were the new hallway construction and removal of hall doors that could be closed after entering the Administration Hallway/Lobby area;
-The staff escorting the group of patients was unaware of additional patients walking with the group.
-Patient #44 was manipulative and had a premeditated plan to elope.

On 01/04/11, Staff HH, Chief Operations Office/Chief Nursing Executive, provided a written plan to prevent future elopements, but did not provide evidence the plan had been implemented.

7. Observation on 01/03/11 at 1:55 PM, showed patient rooms #66, #67, #68, and #69, on the Adult Unit #6, had room entry doors with four hinges, (the hinge hardware created gaps between the door and the door jamb which were potential ligature attachment points).

Review of the facility's Adult Census for Unit #6 dated 01/03/11 showed 15 of 16 patients were assessed by staff as requiring suicide precautions.


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8. Observation on 01/03/11 at 2:05 PM, on the Adult Unit #5 showed Patient #12 had ear buds (small, headphones that contain a pair of tiny speakers that rest inside the ears) attached to an approximately 4 foot long cord (most ear bud cords are constructed of polycarbonate, a substance known for strength and durability when if tightly wrapped several times could pose a potential for choking, respiratory arrest or possible hanging). Patient #12 had another set of ear buds resting on the window ledge that the patient reported did not work. The second set of ear buds also had a 4 foot long cord. The cords provided a potential for harm to self and/or others. The Adult Unit 5 Census report showed Patient #12 had been assessed as an SP 1 suicide precaution level.

During an interview on 01/03/11 at 2:08 PM, Registered Nurse (RN), Staff F stated, "it's OK, the patient was a research patient". (Implication was the patient could be unmedicated for his/her psychiatric illness.) .

Observation on 01/03/11 at 2:10 PM, in room #59 of the Adult Unit #5 showed Patient
#12's door had four hinges (creating a gap between the door and the jamb where potential ligature points could be attached for hanging purposes).

9. Observation on 01/03/11 at 2:15 PM, on the Adult Unit #5 in room #59 showed Patient #13 resting on his/her bed watching a portable television approximately one foot square. The television had two cords, each approximately five feet long. The portable television sat in the middle of the Patient's bed with both cords plugged into the television. One of the cords reached from the middle of the bed into an electrical plug-in on the wall behind and above the night stand. The second cord reached from the middle of the bed to the window sill that attached to a small (approximately 3 inch) portable antenna. The Adult Unit 5 Census report showed Patient #13 had been assessed as an SP 1 suicide precaution level.

During an interview on 01/03/11 at 2:20 PM RN, Staff F stated Patient #13 was a research patient (Implication was that the patient could be unmedicated for his/her psychiatric illness).

Observation on 01/03/11 at 2:25 PM,on the Adult Unit #5 showed Patient
#13's in room #57 with a door with had four hinges (created a gap between the door and the jamb where ligature could be attached for hanging purposes).

Observation on 01/03/11 at 2:30 PM, in rooms #56 and #58 of the Adult Unit #5 occupied by Patients #12 and #13 showed doors with four hinges (creating a gap between the door and the jamb where ligature could be attached for hanging purposes).

Record review of the facility's Adult Census for Unit #5 dated 01/03/11 through 01/06/11 showed 16 of 16 patients on suicide precautions.

10. Observation on 01/04/11 at 11:10 AM, on the Adult Unit #5 showed Patient #8 sat in a chair in the hallway next to room #52 with ear buds on with a cord approximately four feet long and a charger connected to the wall, also with a cord approximately four feet long. Patient #8 was a research patient (possibly unmedicated for his/her psychiatric illness) assessed as an SP 1 suicide precaution level.

Review of the Adult Unit 5 Census report showed Patient #8 and the roommate were assessed as suicidal precautions: SP 2, the most protective level of suicide watch, on fifteen minutes checks and who do not leave the unit for meals or activities.

During an interview on 01/04/11 at 11:25 AM, Safety Risk Management Coordinator, Staff GG confirmed there were no physician orders for the use of equipment with cords for Patient #8, #12 or #13.

Record review of the facility's policy titled, "Hospital Involvement in Research", revised 03/22/07, showed in part, " The Research Investigator and Study Sponsor were expected to maintain a high level of ethical, scientific, technical, and regulatory quality in all aspects of the study.".

Record review of the Research Protocol within the patient #8's, #12's, and #13's medical records did not address use of equipment with cords.

11. During an interview on 01/04/11 from 1:53 PM to 3:15 PM, with Staff Q, Registered Pharmacist, Director of Pharmacy, stated research patients were no different than regular patients when it came to using equipment with cords because research patients had a psychiatric diagnosis and may be receiving a placebo rather than a medication to control or treat their disorder.


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12. Observations during previous survey on 10/04/10 at 10:26 AM, on the Children's Unit revealed the following:
-Staff lined two large (approximately four foot tall) enclosed trash bins with plastic can liners. -Plastic liner was accessible by inserting a hand through the opening to discard trash.

Observation during a previous survey on 10/05/10 at 1:30 PM, on the Acute Adult unit with Director of Nursing, Staff Q, showed the following:
-Activity Room contained two large trash cans positioned around the corner of the room and was not within line of sight from the hallway.
-Both trash cans held a large plastic trash bag.
-The presence of plastic bags created choking and suffocation hazards for patients at risk for suicide.

Observation during current survey on 01/06/11 at 9:12 AM, of the dining room on unit #4, the Acute Adult Unit showed three patients sitting in the dining room with no staff present in the room. Located in the room were two large (approximately four foot tall) enclosed trash bins with large clear plastic can liners. The plastic liners were accessible and could be removed from the trash bin by inserting a hand through the trash bin opening. Both trash bins were located to the right of the entrance door and could not be seen from the nurses' station.

Review of the facility's Acute Adult Census dated 01/03/11 showed 13 of 14 patients assessed as requiring suicide precautions.

Observation on 01/06/11 at 9:27 AM, on the Acute Adolescent Unit, unit #1 showed one large (approximately four foot tall) enclosed trash bin directly across from the nurse's station. The trash bin had a large clear plastic can liner. The plastic liner was accessible and could be removed from the trash bin by inserting a hand through the trash bin opening.

Review of the facility's Acute Adolescent Census dated 01/03/11 showed 11 of 16 patients assessed as requiring suicide precautions.

Observation on 01/06/11 at 9:29 AM, on Adult Unit 6 showed a large plastic trash bag, (approximately 30 gallon trash bag), inside the large trash container in the Day Room. Further observation showed the plastic liner was accessible by inserting a hand through the opening to discard trash.

Review of the facility's Adult Unit #6 Census dated 01/03/11 showed 15 out of 16 patients assessed as requiring suicide precautions.

The presence of plastic bags on the units created choking/suffocation hazards for patients at risk for suicide/self harm.

These current findings were the same issues with plastic trash can liners found in the previous survey of 10/06/10. These have not been corrected by the facility.


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13. Observations during the previous survey on 10/05/10 at 01:25 PM, showed all bathrooms except one on the Child/Adolescent Unit had separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathrooms also included commodes with exposed plumbing pipes and a lever flush mechanisms at least two feet off the ground.

The configuration of these water control handles, exposed plumbing and lever flush mechanisms created a looping hazard for all patients.

Observation during previous survey on 10/05/10 at 1:30 PM, on the Acute Adult unit with Director of Nursing, Staff Q, showed patient room #43's bathroom, patient room #45's bathroom, shared patient room #47 and #49 bathroom, patient room #48's bathroom and the Day Room bathroom all with commodes with exposed pipes (plumbing) approximately two feet off the ground and shower water control knobs and shower heads that created looping hazard for patients at risk for suicide/self harm.

Observation during previous survey on 10/05/10 at approximately 2:30 PM, on the Adult unit with Nursing Supervisor, Staff R, showed patient room #66 and #68 shared bathroom, patient room #67 and #69 shared bathroom, patient room #63 and #65 shared bathroom all with exposed plumbing, shower water controls and shower heads which could be used as ligature attachment points.

Further observation during the previous survey on 10/06/10 at 9:55 AM, on the Adult unit with Nursing Supervisor, Staff R, showed patient room #57 and #59 shared bathroom, patient room #53 and #55 shared bathroom, patient room #52 and #54 shared bathroom all with the same exposed plumbing, shower water controls and shower heads which could be potential ligature attachment points.

Observation during current survey on 01/03/11 through 01/04/11, in bathrooms adjacent to patient rooms showed the facility had plumbing fixtures and exposed pipes connecting the toilets to bathroom walls, shower water control knobs and bathroom door hinges which provided potential ligature attachment points in units 1,3,4,5, and 6.
Record review of a current list provided by the facility during the 01/06/11 survey showed the following fixtures in patient bathrooms:
-A total of nineteen toilets with exposed pipe plumbing.
-The exposed plumbing pipes extended approximately twenty-six inches above the floor with approximately seven inches of open space behind the commode and the bathroom wall.
-The facility list included room numbers on Unit one- (11,13),12,16,(17,19),18, Unit three- (32,34),(33,35),(36,38),(37,39), Unit four- 43,44,46,(47,49),48, and Unit six- (63,65),(62,64),(67,69),(66 and 68). Note: Parentheses indicate rooms which share one bathroom/toilet between two adjoining patient rooms.
-A total of 10 showers with two control knobs (hot and cold water) which protrude approximately five inches from the shower wall providing potential ligature attachment points.
-The facility list included room numbers on Unit one- 12, 18, 31, Unit three- (33,35),(36,38),(37,39), Unit five- (56,58),(57,59), and Unit six- (67,69),(66 and 68). Note: Parentheses indicate rooms which share one shower between two adjoining patient rooms.
-The list indicated a total of twenty-five bathroom doors with three hinges attaching the door jamb creating open space between the door and the jamb providing potential ligature attachment points.
-The facility list included room numbers on Unit one- 11, 13, 12, 15, 16, 17, 19, 18, Unit three- 31, 32, 34, 33, 35, 36, 38, 37, 39, Unit four- 44, Unit five- 56, 58, 57, 59, and Unit six- 67, 69, 66 and 68. An actual total of 26 rooms specified as having three hinges on the doors.

Based on review of the Quality Assessment and Performance Improvement program plan and interview with Performance Improvement staff, the facility failed to effectively assess for unsafe patient environment concerns as identified on recent past surveys to avert potential adverse patient events. The census was 62.

Findings Included:

1. Review of the Performance Improvement Program plan for years 2010 and 2011 showed staff failed to document remedial actions incorporating regulatory violations for patient safety and unsafe environment found on recent past survey including articles in patient possession that could be used for self harm; strangulation by electrical cords, hanging by ligature on plumbing fixtures, suffocation with plastic trash bags.

2. During an interview with Staff Y on 01/05/11 at 9:35 AM, the Director of Performance Improvement (PI), Staff Y stated the regulatory violations cited on the most recent survey were not incorporated into the Performance Improvement Program plan. The Director of PI, Staff Y stated the Performance Improvement Plan for 2011 remained unchanged from the Performance Improvement Plan for 2010 and without amendments.

Based on interview and review of the hospital Performance Improvement Program Plan for years 2010 and 2011 facility staff failed to document evidence of actions taken to correct deficient practices identified on recent past survey. The census was 62.

Findings Included:

1. Review of the Performance Improvement Program Plan revealed in part, the following:
-Staff failed to documented actions taken to address recent regulatory violations cited on survey dated 10/06/10.
-Staff failed to incorporate activities into the Performance Improvement Program Plan specifically related to:
-any processes for providing patient care in a safe setting through monitoring for unsafe environmental conditions such as the presence of lengthy electrical cords which present potential hanging devices,
-presence of anti-ligature plumbing fixtures
-presence of large plastic trash bags accessible to suicidal patients.
-Staff failed to incorporate activities to monitor the required completion of patient discharge summaries by physicians.
-Staff failed to incorporate activities to monitor and ensure patient medical records were completed within thirty days of discharge.
-Staff failed to incorporate activities to ensure timely completion of psychiatric evaluations.
-Staff failed to incorporate activities to ensure sustained processes to address physicians orders were dated, timed and signed as required.

2. During an interview on 01/05/11 at 9:35 AM, the Director of Performance Improvement, Staff Y stated citations for regulatory violations dated 10/06/10 were not incorporated into the Performance Improvement Program Plan. Staff Y further stated the Performance Improvement Plan (for 2011) remained unchanged from the current Performance Improvement Plan for 2010. Staff Y also stated there were no amendments to the Performance Improvement Plan for 2010.

Based on clinical record review, policy review and interview, the facility Registered Nurses (RNs) failed to supervise and evaluate clinical outcome of nursing care for patients who were administered PRN (abbreviated term for as needed) medications for 4 of 6 (Patients #29, #30, #32 and #34) Adult Unit #6 patients reviewed for evaluation of clinical outcome after medication administration. The facility census was 62.

Findings Included:

1. Review of facility policy Medication Ordering, Storing, Dispensing, Administering, Monitoring, #MMM.001, revised 09/29/10, Administration of Medication section, Item #5; included in part: Each dose of a PRN medication administered must be properly recorded on the patient's Medication Administration Record (MAR) to include the time of day the medication was administered and a notation of the patient's response to the dose of PRN medication given on the back of the PRN MAR.

2. During an interview on 01/04/11 at 9:47AM, RN, Staff SS stated, PRN medications were recorded on the front and back of the MAR. The documentation on the back side of the MAR should include what medication was given, reason the PRN medication was given and the patient's response to the medication.

3. Review of Patient #29's MAR showed:
-Maalox 30 ml (milliliters) was documented as administered PO (by mouth) on 01/03/11 at 2230 (10:30 PM).
-Maalox 30 ml was documented as administered PO on 01/02/11 at 1500 (3 PM).
-Maalox 30 ml was documented as administered PO on 01/01/11 at 1330 (1:30 PM).
-The PRN medications were documented as administered, but staff failed to document evaluation of the effectiveness of the medication.

4. Review of Patient #30's MAR showed:
-Maalox 30 ml was documented as administered PO on 12/30/10 at 13:30 (1:30 PM) for complaints of vomiting.
-The PRN medication was documented as administered, but staff failed to document evaluation of the effectiveness of the medication.

5. Review of Patient #32's MAR showed:
-PRN medication Ambien 10 mg was documented as administered at 2100 (9:00 PM) on 01/03/11; and
-PRN medication Ambien 10 mg was documented as administered at 2105 (9:05 PM) on 01/04/11.
-The PRN medications were documented as administered, but staff failed to document evaluation of the effectiveness of the medications.

6. Review of Patient #34's MAR showed:
-PRN medication ProAir HFA Albuterol Inhaler was documented as administered on 12/28/10 at 2235 (10:35 PM)
-PRN medication Robitussin-DM was documented as administered on 12/28/10 at 2235 (10:35 PM);
-PRN medication Robitussin-DM was documented as administered on 12/29/10 at 2120 (9:20 PM);
-PRN medication Maalox was documented as administered on 12/30/10 at 2155 (9:55 PM); and
-PRN medication Maalox was documented as administered on 12/31/10 at 2200 (10 PM).
-The PRN medications were documented as administered, but staff failed to document evaluation of the effectiveness of the medications.

Based on observation, review of patient Medication Administration Records (MAR), policy review and interview, facility nursing staff failed to administer medications within thirty minutes of administration times as indicated on the MAR and failed to accurately document medication administration times for 4 of 6 patients on Adult Unit #6 (Patient #30, #31,#32 and #34) and eight of sixteen patients on Adult Unit #5. The facility census was 62.

Findings Included:

1. Review of policy titled Medication Ordering, Storing, Dispensing, Administering, Monitoring,# MMM.001, approved 09/21/10, included, in part, each dose of medication administered must be properly recorded on the patient's Medication Administration Record (MAR). The MAR will become part of the patient's medical record. Further review of the policy showed staff failed to include acceptable administration times related to when the medication was due. The policy failed to require accurate documentation of the time when the medication was actually administered.

2. Observation during medication pass on 01/04/10 at 9:40 AM, on Unit #6 showed Registered Nurse (RN), Staff SS administered Lithium, Clonazepam, Geodon and Fluoxetine to Patient #31.

Review of Patient #31's MAR dated 01/04/11 showed Staff SS inaccurately recorded the medications were administered at 9:00 AM (not 9:40 AM).

3. Observation during medication pass on 01/04/11 at 9:47 AM, showed Staff SS administered Buspar,Cyclobenzaprine, Propranolol, Lexapro, Clonidine, Meloxicam, Lorazepam and Saprhris to Patient #30.

Review of Patient #30's MAR dated 01/04/11 showed Staff SS inaccurately recorded the medications were administered at 9:00 AM (not 9:47 AM).

4. Observation during medication pass of 01/04/11 at 9:48 AM, showed Staff SS administered Abilify and Hydrochlorothiazide to Patient #32.

Review of Patient #32's MAR dated 01/04/11 showed Staff SS inaccurately recorded the medications were administered at 9:00 AM (not 9:48 AM).

5. Observation during medication pass on 01/04/11 at 9:55 AM, showed Staff SS administered two puffs of Albuterol, Advair Diskus, Aspirin, Buspar, Lisinopril, Robutussin and Topiramate to Patient #34.

Review of Patient #34's MAR dated 01/04/11 showed Staff SS inaccurately recorded the medications were administered at 9:00 AM (not 9:55 AM).

6. During an interview on 01/06/11 at 9:54 AM, Staff SS stated the following:
-He/she had to wait in line to obtain patient medications.
-The medication room was small and only one nurse could obtain medications at a time.
-The delay in obtaining the medications caused medication administration to be late.
-In the past he/she came to work earlier than scheduled to obtain patient medications so the medication administration would not be late.
-He/she had not come in earlier than scheduled recently.
-Acceptable patient medication pass times were 30 minutes before and after the medications are due.


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7. Observation on 01/04/11 at 9:00 AM, showed medication administration was performed by RN, Staff I, to four Patients on Unit #5 of the Adult unit. Medication administration began at 9:10 AM and was completed at 9:32 AM.

8. Record review of the MAR dated 01/04/11 showed Staff I inaccurately initialed all medications scheduled for 9:00 AM as being administered at 9:00 AM, however the medications were administered between 9:10 AM and 9:32 AM. The MAR was inaccurate as to the times medications were administered.

9. Observation on 01/04/11 at 12:55 PM, showed RN, Staff J, administered medications to four patients. The medication administration began at 1:14 PM and ended at 1:34 PM. The MAR was inaccurate as to the times medications were administered.

10. During an interview on 01/04/11 at 1:45 PM, Staff J stated he/she had one hour to administer the medications, " I try to give meds from 1:00 PM to 1:30 PM but as long as it isn't past 2:00 PM, it's OK" .

11. Record review of the MAR dated 01/04/11 at 1:00 PM, showed Staff J inaccurately initialed 1:00 PM medications as being administered at 1:00 PM, however the medications were administered beginning at 1:14 PM and ended at 1:34 PM. The MAR was inaccurate as to the times medications were administered.

12. During an interview on 01/04/11 from 1:53 PM through 3:15 PM, Director of Pharmacy, Registered Pharmacist, Staff Q, stated medications should be administered 30 minutes before to 30 minutes after the scheduled physician's ordered time. Staff Q also stated he/she was unaware nurses were inaccurately documenting time of medication administration on the patient MAR. Staff Q further stated he/she would include the appropriate time frame (thirty minutes before and thirty minutes after) into the facility policy and procedures for medication administration.

Based on interview and record review facility staff failed to ensure physician's orders were authenticated and/or dated and/or timed within twenty-four hours in four of sixteen (Patients #9, #10, 11, and #13) medical records reviewed on the Adult unit #5, and three of fourteen (Patients #14, #16 and #17) medical records reviewed on the Acute Adolescent unit #1, and one (Patient #2) of three medical records reviewed on the Acute Adult unit #4. The facility census was 62.

Findings included:

1. Record review of the facility Amended and Restated Rules and Regulations of the Medical Staff reviewed and revised 10/15/09 directed, in part, the following:
-Section 7.4. 1 Orders must be written clearly and legibly and must be dated, timed and authenticated promptly by the ordering practitioner and include justification for the order.
-Section 7.4.1 {further directed} An order shall be considered to be written if dictated in person to a licensed nurse and authenticated by the ordering practitioner, attending physician, or another responsible physician, such as covering, rounding, or co-attending within 24 {twenty four} hours (or such shorter time period as may be required by a Hospital program, policy, or law).

2. Record review of the facility policy numbered MMM .001 titled Medication Ordering, Storing, Dispensing, Administering, Monitoring revised 09/29/10 stated, in part, the following:
ORDERING MEDICATION
1. . . . The order for medications must be written by the physician in his/her handwriting or must be transmitted to the nursing unit or pharmacist as a telephone or in an emergent situation a verbal order; read back to the physician, and reduced to writing by the nurse receiving the order, and countersigned within 24 hours by the physician originating the order, or those physicians identified as designee(s).
2. The order must contain:
a. The date and time of order

3. Review of current Patient #13's physician's orders showed the physician failed to date and time orders including:
-May see for the physician for UTI (urinary tract infection).
-Azithromycin (an antibiotic) a large dose orally then a lesser dose for four days.
-Clonopin (an anti-seizure drug) orally for five days.
-Start HBG A 1 (blood sugar testing).
-Diabetic diet per dietitian

4. Review of current Patient #11's physician's orders showed the physician failed to sign, date and time orders including:
-Lithium Carbonate (a drug for depression) orally twice a day.
-Prozac (anti-depressant) orally daily.
-Lab testing for lithium blood level in the morning 12/31/10.

Further review of current Patient #11's physician's orders showed the physician failed to date and time orders including:
-Discontinue propanolol (blood pressure drug).
-Check ECT (electroconvulsive therapy) benefits.
-ECT clearance to the physician.
-Cancel Lithium (a drug for depression) levels;
-Increase Cymbalta (anti-depressant drug) twice a day after meals.
-Increase Seroquel XR (an anti-psychotic drug with extended release) orally at 7:00 PM daily.

5. Review of current Patient #10's physician's orders showed the physician failed to date and time orders including:
-Lamidol (anti-fungal) twice a day.
-(unreadable) XR (illegibly written extended release medication at 9:00 AM and 9:00 PM.
-Symbyou (unreadable) orally at 9:00 AM and 9:00 PM.
-Topomore (may be misspelled, unreadable) at 9:00 AM and 9:00 PM.

6. Review of current Patient #9's physician's orders showed the physician failed to date and time an order to continue Librium (anti-anxiety drug) every four hours as needed.

Further review of current Patient #9's physician's orders showed the physician failed to sign, date and time orders including the following:
-Increase Seroquel XR to 150 mg.
-Tegretol level (Lab test for blood level of anti-seizure drug) in AM.
-Repeat urine drug screening with a specific lab and send results to the Post Hospital Program.
-Benzodiazepine (anti-anxiety drug) detox protocol.
-Discontinue Abilify (brand name anti-psychotic).
-Seroquel XR specific does at 7 PM daily
-Take vital signs every 24 hours X 24 hours.
-Opiate (narcotic pain relieving drug) detox protocol except clonidine and Restoril.
-Clonidine (blood pressure medication) twice a day hold if blood pressures were measured at a specific level.

7. During an interview on 01/04/11 at 10:15 AM, Nursing Supervisor/Nurse Educator, Staff K, confirmed the physician orders reviewed were not signed and/or dated and/or timed as required by facility policy and procedure.


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8. Review of current Patient #2's physician's orders showed the following:
-An order written by a Physician Assistant dated 12/27/10 - R (right) hand x-ray /indication: pain and swelling S/P (status post, after) injury - fist to concrete - intentional injury
-The Physician Assistant did not time the order.

-An order written by the physician dated 12/28/10 - Suicide precautions and unit restriction, lower Zyprexa (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) to 10 mg (milligrams) P.O. (by mouth) at HS (bedtime), D/C (discontinue) AM (morning) dose
-The physician did not time the order.

-An order written by the physician dated 12/30/10 - Lower Prozac (used to treat depression, obsessive-compulsive disorder, which are bothersome thoughts that won't go away and the need to perform certain actions over and over, some eating disorders, and panic attacks, which are sudden, unexpected attacks of extreme fear and worry about these attacks) 40 mg P.O. q (orally every) AM.
-The physician did not time the order.

-An order written by the physician dated 12/31/10 - D/C Prozac. [Give] Cymbalta (used to treat depression and generalized anxiety disorder, which is excessive worry and tension that disrupts daily life and lasts for six months or longer) 30 mg P.O. q AM
-The physician did not time the order.

-An order written by the physician dated 01/01/11 - D/C Xanax (used to treat anxiety disorders and panic disorder)
-Ativan (used to relieve anxiety) 2 mg q 6h (every 6 hours) prn (as needed)
-Increase Zyprexa (used for schizophrenia) to 15 mg at HS (bedtime).
-Can be transferred back to adult unit.
-The physician did not time the order.


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9. Review of Patient #17's physician orders showed the following:
-Dated 12/28/10 "Depakote (A medication that is used to control seizures, mania in patients with a bipolar diagnosis, and migraines) 250 mg (milligrams) at HS (hour of sleep) PO (by mouth)" and "Sudafed ( an antihistamine medication) 50 mg at HS PO."
The physician failed to time the order.
-Dated 12/28/10 Xanax (an anti-anxiety medication) 0.5 mg PO stat."(Give medication immediately.). The physician failed to time the order.

10. Review of Patient #17's physician orders showed the following:
-Dated 12/29/10 "Celexa (anti-depressant) 10 mg one," (Unable to interpret the last word due to illegibility). The physician failed to time the order.
-Dated for 01/11/01, signed off by nursing on 01/01/11 at 7:45 PM for the following: "Increase Depakote ER to 750 mg (at) HS add Seroquel(an anti-psychotic medication) 25 mg TID (three times a day)." The rest of the order was illegible. The physician failed to time the order.

11. During an interview on 01/04/10 at 10:50, AM Nurse Manager Child and Adolescent Unit, Staff L reviewed the orders and stated the physicians failed to time the orders.

12. Review of Patient # 16's physician's orders showed an order dated 01/01/11 reduce Prozac (an anti-depressant medication) to 20 mg one am, Depakote ER to 500 mg one HS, (illegible) 0.2mg HS (bedtime), DC (Discontinue) Propanolol (A medication used to decrease tremors, blood pressure, and irregular heart rate.), Increase Abilify (an anti-psychotic medication) to 5 mg BID (two times). The physician failed to time the order.

13. Review of Patient #14's physician's orders showed the following:
-Dated 12/25/10 Abilify 2.5mg BID (8 AM and 6 PM), DC Zyprexa, (and) Abilify 5 mg PO stat." The physician failed to time the orders.
-Dated 12/26/10 Abilify 5 mg PO stat (and) increase Abilify dosage to 5 mg BID." The physician failed to time the orders.
-Dated 12/31/10 Increase Concerta (treatment for attention deficit and hyperactivity disorders) to 36 mg one (in) AM. The physician failed to time the orders.
-Dated 01/01/11 Increase Depakote ER to 500 mg one HS. The physician failed to time the order.

During an interview on 01/04/10 at 2:00 PM, Nurse Manager of the Child and Adolescent Units, Staff L reviewed the orders and stated the physician failed to time Patient #14's orders.

Based on review of the Amended and Restated Rules and Regulations of the Medical Staff and record review the facility failed to ensure verbal and/or telephone orders were signed by the physician within 24 hours for four patients (#14, #15, #16 and #17) of fourteen patient records reviewed, for two patients (#2 and #1) of three verbal/telephone orders reviewed for Unit 5 and 4 of 6 patient records reviewed for Unit 6 (Patients #29, #30, #32, #34). The facility had a census of 62.

Findings included:

1. Review of the Amended and Restated Rules and Regulations of the Medical Staff approved 12/16/10 showed (in part) in section 7.4:
Orders must be written clearly and legibly and must be dated, timed, and authenticated promptly by the ordering practitioner and include justification for the order. An order shall be considered to be written if dictated in person to a licensed nurse and authenticated by the ordering practitioner, attending physician, or another responsible physician, such as covering, rounding, or co-attending within 24 hours.

2. Medical record review for current Patient #2 on 01/03/11 showed the following orders:
A telephone order written 12/29/10 at 1:25 PM, to transfer pt (patient) to Acute Unit today.
The physician did not date or time his/her signature.

A verbal order written 12/31/10 at 10:40 AM, to start Cymbalta (used to treat depression and generalized anxiety disorder, which is excessive worry and tension that disrupts daily life and lasts for six months or longer) 30 mg P.O. on 01/01/11.
The physician did not date or time his/her signature.

A telephone order written 01/02/11 at 10:15 AM, to transfer pt. to Acute now due to thoughts of harming self.
The physician did not date or time his/her signature.

There was no evidence the physician signed the above orders within 48 hours.

3. Medical record review for current Patient #1 on 01/03/11 showed the following admission telephone orders dated 12/31/10 at 3:00 AM:
-Klonopin (used to control certain types of seizures. It is also used to relieve panic attacks, which are sudden, unexpected attacks of extreme fear and worry about these attacks) 0.5 mg P.O. QID (four times a day)
-Narco (used for moderate to severe pain) 10/325 mg 1 P.O. q 6h PRN (as needed) for pain
-Tramadol (used to relieve moderate to moderately severe pain) 50 mg 1 P.O. q 6h PRN for pain
-Flexeril ( a muscle relaxant) 10 mg P.O. TID (three times a day) PRN q 8 hours [for] muscle pain
-Seroquel (used to treat the symptoms of schizophrenia, which is a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) 50 mg P.O. q 6h PRN [for] agitation
-Haldol (used to treat psychotic disorders, which are conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real) 5 mg IM (into the muscle) q 6h PRN [for] agitation

The physician signed the telephone orders on 01/03/11 at 9:30 PM, more than 24 hours after the nurse received the orders from the physician.


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4. Review of Patient #30's physician orders revealed the physician failed to date and time his/her authentication:
-A telephone order received by a nurse on 12/30/10, at 1415 (2:15 PM), for Motrin is undated, untimed and unsigned by the physician.
-An order written by a physician assistant dated 12/30/10, at 9:45 PM, for phazyme and is unsigned, undated, and untimed by the physician.
- A verbal clarification order received by a nurse on 12/31/10, at 0730, (7:30 AM), for Phazyme and Simethicone, and Clonidine is unsigned, undated and untimed by the physician.

5. Review of Patient #32's physician orders revealed the telephone clarification order taken by a nurse on 12/30/10 at 1830 (6:30 PM),
failed to include authentication by the physician with orders undated, untimed and unsigned by the physician.

6. Review of physician orders for Patient #34 revealed the physician failed to date and time his/her authentication:
-The physician assistant order of 12/30/10 (the time when the order was written failed to be documented by the physician assistant) failed to be signed, timed or dated by the physician;
-The verbal order taken by a nurse on 12/31/10 at 7:01 AM, failed to be signed, timed or dated by the physician;
-The telephone order taken by a nurse on 12/31/10 at 8:05 AM, included the physician signature, but failed to include the date and time.

7. Review of Patient #29 physician's orders revealed the physician failed to date and time his/her authentication:
-A clarification telepone order taken by a nurse on 12/30/10 at 1920 (7:20 PM), failed to be signed, timed or dated by the physician;
-Substitution order taken by the pharmacist on 12/30/10 at 2135 (9:35 PM), failed to be signed, timed or dated by the physician.


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8. Review of Patient #17's physician telephone orders showed the physician failed to date and time the authenicated orders:
-An order dated 12/28/10 at 10:10 AM, DC (Discontinue) order for 400 mg (milligrams) Ibuprofen (an anti-inflammatory medication) PO (by mouth) every eight hours prn (as needed) tooth pain, previously ordered by a physician.
-An order dated 12/28/10 at 8:20 PM, Please give Benadryl (an anti-histamine medication) 50 mg PO 1 x (one time) now for anxiety and sleep.
-An order dated 12/29/10 at 10:00 AM, Place pt (patient) on SP 2-(suicidal precautions 2 [a higher level than just suicidal precautions]).
-An order dated 12/29/10 at 9:16 PM, Please give Benadryl 50 mg PO 1 x now for anxiety and sleep.
-An order dated 12/30/10 at 10:00 AM, Give Zyprexa Zydis (an anti psychotic medication) 10 mg PO or Zyprexa 10 mg IM (intramuscularly) now for agitation.
-An order dated 12/31/10 at 6:31 PM, D/C (Discontinue) SP 2/UR (Unit Restrictions).
-An order dated 01/01/11 at 10:00 AM, Zydis 10 mg SL (to put under the tongue) for agitation.

During an interview on 01/04/10 at 10:50 AM, Nurse Manager Child and Adolescent Unit, Staff L reviewed Patient #17 undated, untimed telephone orders and confirmed the physician failed to date and time all seven authenticated orders.

9. Review of Patient #16's admission orders dated 01/01/11 at 10:00 AM, showed in part, an allergy list, a medication list, and a prn list. The physician failed to sign, date and time the orders.

Review of Patient #16's telephone orders showed the following:
-An order dated 01/01/11 at 12:20 PM, Continue Keflex . . . to cover area.
-An order dated 01/02/11 at 4:05 PM, D/C UR.
-The physician failed to date and time both authenticated orders.

During an interview on 01/04/10 at 11:15 AM, Nurse Manager of the Child and Adolescent Units, Staff L, reviewed Patient #16's orders and confirmed the physician failed to date and time the authenticated order.

10. Review of Patient #15's telephone orders dated 01/02/11 at 10:00 AM, showed an undated, untimed order to discontinue UR (Unit Restriction).
The physician failed to date and time the authenticated order.

During an interview on 01/04/10 at 1:25 PM, Nurse Manager of Child and Adolescent Unit, Staff L reviewed Patient #15's telephone order and confirmed the physician failed to date or time the authenticated order.

11. Review of Patient #14's telephone orders showed the physician failed to date and time the authenticated orders which included the following:
-An order dated 12/22/10 at 4:06 PM, D/C UR.
-An order dated 12/23/10 at 10:55 AM,Benadryl 25mg x 1 now for aggression, irritability, and assaultive bx. (illegible abbreviation).
-An order dated 12/23/10 at 9:05 PM, Benadryl 25 mg 1 mx (illegible abbreviation), 1 now for agitation and irritability.
-An order dated 12/28/10 at 2:35 PM, change Ritalin to 1300 (1:00 PM) daily.

During an interview on 01/04/10 at 2:00 PM, Nurse Manager of Child and Adolescent Units, Staff L reviewed Patient #14's orders and confirmed the physician failed to date and time the authenticated order.

Based on close record review facility staff failed to ensure a physician's Discharge Summary was completed within 30 days following the patients' discharge for three of three (Patient #22, #23 and #24). The facility census was 62.

Findings included:

1. Review of Patient #22's discharge summary showed the physician discharged the patient from the facility on 11/22/10. Further review of the discharge summary showed it was signed by the physician on 12/24/10, over 30 days past the patients actual discharge date.

2. Review of Patient #23's discharge summary showed the physician discharged the patient on 11/24/10. Further review of the discharge summary showed a Master of Social Work, (MSW) Staff, signed, dated and completed the discharge summary. The physician failed to time/date or sign the patients discharge summary.

3. Review of Patient #24's discharge summary showed the physician discharged the patient on 11/09/10. Further review of the discharge summary showed the physician failed to sign, date or time the document within 30 days of the patient's discharge.

Based on observation, interview and record review the facility failed to administer a medication as ordered by the physician for 1 (Patient #36) of 16 patients on the Adult unit #5. The census at the time of survey was 62.

Findings included:

1. Observation on 01/03/11 at 12:55 AM, on Adult Unit #5 showed Registered Nurse (RN), Staff J administered meds to Patient #36.

2. During an interview on 01/03/11 at 12:55 AM, RN, Staff J, stated one of the ordered medications for Patient #36 wasn't available and this happens often.

3. Record review of Patient #36's medical record Inpatient & Outpatient Discharge/Aftercare Plan dated 12/23/10, stated Zyprexa Relprevv, (a long-acting atypical antipsychotic for intramuscular injection indicated for the treatment of schizophrenia) 300 mg IM q (every) 2 weeks next dose due 01/03/11, last given 12/21/10.

4. Record review of Patient #36's medical record showed the Admit Orders/Medication Reconciliation dated 12/29/10 and signed by the physician on 12/30/10 for Zyprexa Relprevv 300 mg IM (intramuscular - in the muscle) q (every) 2 weeks antipsychotic.

5. Record review of Patient #36's medical record showed the Medication Administration Records (MAR) dated 01/03/11 with the following:
Miscellaneous injection 1 ea (each) IM every 2 weeks one dose = Zyprexa Relprevv 300 mg IM due 01/04/11. Staff J, circled the 0900 time on the MAR and wrote " med not available " " supervisor aware " then written below " Please clarify with Dr. - no order " and was crossed out and initialed by Staff J.

6. Record review of Patient #36's medical record showed the Physician's orders sheet dated 01/04/11 with an order signed by the Nurse Practitioner as follows:
Give pt (patient) Zyprexa Relprevv 300 mg IM every 2 weeks - start 2 weeks from last injection received. (Given 12/21/10). This entire order was crossed out and re-written on the following Physician's orders page dated 01/04/10 (should have been 01/04/11) as Zyprexa Relprevv IM 300 mg every 2 weeks (dose due today as lst IM given 12/21/10) by the Nurse Practitioner.

7. During an interview on 01/04/11 from 1:53 PM to 3:15 PM, Registered Pharmacist, Director of Pharmacy, Staff Q stated the medication Zyprexa costs $1500.00 per injection so we wait to see if the patient will be discharged so the cost can be deferred to private or public insurance and not paid by the facility.

8. Record review of Policy #39 titled Obtaining Non-Formulary Medications dated October 2010 states, in part the following:

Procedure:
When the nurse receives a medication order, and the medication is not available, the nurse will contact the pharmacist. Then the pharmacist will contact the physician regarding the non-formulary drug, at the soonest possible moment to ascertain if a formulary drug may be substituted. If a formulary drug is not acceptable to the physician, a written request for non-formulary item(s) will then be made by the physician on a Non-Formulary drug Request Form(s) and forwarded to the Medical Director for approval.

9. During an interview on 01/04/11 from 1:53 PM to 3:15 PM, Director of Pharmacy, Staff Q, stated Zyprexa Relprevv was not on the facility formulary and the physician had not been notified the medication was not administered or available to administer to Patient #36.

Based on observation, interview and record review facility dietary staff failed to store foods in a clean, safe manner and failed to clean and maintain equipment and surfaces used in the dietary department. The facility census was 62 patients.

Findings included:

1. Record review of the U. S. Department of Health and Human Services (USDA), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code directed the following:
-Chapter 3-305.11 Food shall be stored to protect against contamination, in a clean, dry location, not exposed to splash, dust or other contaminants, at least six inches off the floor.
-Chapter 3-305.12 Food may not be stored under sources of contamination.
-Chapter 3-305.14 During preparation food shall be protected from environmental sources of contamination.
-Chapter 4-601 Equipment, food contact surfaces, non food contact surfaces and utensils shall be clean to sight and touch.

2. Observation on 01/03/11 at 2:15 PM, showed dietary staff failed to store foods used in patient meal service in a safe, clean manner including:
-Two cases of canned foods on a dry food storeroom floor ladened with unknown debris.
-A dried food specked, debris covered unlabeled twenty-two quart container initially identified by the Lead Cook, Staff B as flour but, when opened showed it contained rice.
-A unknown debris covered unlabeled twenty-two quart container of food, when opened found to contain brown sugar.

Observation on 01/03/11 at 2:20 PM, showed staff failed to clean and maintain dietary department equipment and surfaces including:
- A unknown debris covered condenser fan blade guard in the walk-in refrigerator with tendrils of dust and unknown debris (some as long as one inch) cascading off the fan blade guard.
-The food splashed, debris covered floor with large dried, browned food spills and unknown speckles of debris circling the legs of the equipment and around the oven (where staff sometimes stored unneeded wire oven racks).
-A table mounted can opener caked with dried food debris behind the blade and gears and metal can shavings imbedded in the debris on the base.
-A dust and debris covered nine shelf can rack with the rims of the canned foods resting in the dust and debris.

Observation on 01/03/11 at 2:50 PM, showed staff stored cases of canned foods on the dust and unknown debris covered floor of the emergency supply room.

3. During an interview on 01/03/11 at 2:50 PM the Lead Cook, Staff B stated dietary department equipment was usually cleaned by dietary department staff once a month.

Based on observation, interview and record review facility infection control staff failed to develop a system for identifying and controlling poor food sanitation practices in the dietary department including inappropriate hand washing and gloving techniques during food handling and wearing ineffective hair restraints in the kitchen during food handling. The facility census was 62 patients.

Findings included:

1. Record review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code directed in part the following:
-Chapter 2-301.14 Food handlers should wash hands before donning gloves and after engaging in activities that contaminate the hands.
-Chapter 2-402.11 Food handlers should wear effective hair restraints including beard restraints to keep hair from exposed foods, clean equipment and utensils.
-Chapter 3-304 Food handlers should wear single use gloves for one task and discard when damaged soiled or when interruptions occur in the operation.

Review of the facility policy titled, Food Management, Appendix L of the Infection Control Manual, revised 04/28/05 directed, in part, Preparation and Handling: Disposable plastic gloves or tongs shall be used by employees who directly touch food products.

Review of the facility policy titled Hand Hygiene Program, Appendix A of the Infection Control Manual, revised 02/28/07 directed, in part, Indications: Employees shall wash their hands at least at the following times and whenever the hands were soiled; before putting gloves on and after taking gloves off.

2. Observation on 01/04/11 from 9:25 AM through 10:00 AM, showed the following:
-Cook, Staff E prepared foods for patient noon meal service and failed to wear effective hair restraint over facial hair.
-Diet Aide, Staff CC incompletely covered hair (failed to enclose bangs on the forehead) while shelving a food delivery.

Observation on 01/04/11 in the kitchen showed the following:
-At 11:24 AM, Cook, Staff S served patients lunch meals and failed to wear an effective hair restraint over facial hair.
-At 11:40 AM, Diet Aide, Staff R handled a plastic bag of sandwich rolls and failed to wear an effective hair restraint over facial hair.

Observation on 01/05/11 at 10:40 AM, showed Cook Staff W in the food preparation area, failed to wear an effective hair restraint over facial hair.

3. Observation on 01/04/11 from 9:25 AM through 10:00 AM, showed the following:
-Cook, Staff E handled sheet pans, aluminum foil dispenser, multiple containers of seasoning then, without hand washing gloved and handled raw chicken.
-Diet Aide, Staff CC placed a pen top between his/her teeth, placed his/her hand to the side of the face, failed to wash hands and retrieved paper bags of snacks for Children and Adolescent Unit patients.
-Diet Aide, Staff DD placed a hand to the side of his/her face, then without hand washing assisted with shelving a food delivery.
-Cook, Staff E handled packages of lunch meats then, without hand washing, gloved and assembled sandwiches for patient meal service.

Observation on 01/04/11 in the kitchen showed the following:
-At 11:40 AM, Diet Aide, Staff R dropped a plastic bag of sandwich rolls on the floor, retrieved it and placed it on the cooks prep table. Further observation revealed Cook, Staff E handled the bag then, prepared sandwiches for noon meal service.
-At Noon, Cook, Staff S failed to wash hands prior to gloving then served foods to patients.

4. During an interview on 01/05/11 at 9:25 AM, the Infection Control Consultant, Staff V stated the following:
-He/she does not routinely provide in-service training to facility staff regarding infection control topics.
-However, he/she will be providing a special in-service to dietary department staff next week.
-Staff in the dietary department should be adhering to the facility policy titled Appendix L regarding hand washing and gloving.




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