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Based on observation, record review and interview, the hospital failed to identify and/or prevent the development of pressure ulcers for 1 of 10 patients (Patient #1) while inpatient. The hospital failed to evaluate and/or accurately document and/or provide treatment for (Patient #1). (Patient #1) was discharged on 10/21/13 to home. The home health nurse assessed (Patient #1) on 10/22/13 and found a total of four Stage II Pressure Ulcers. One pressure ulcer to the left heel, top of coccyx, buttock and lower back not identified by the hospital and, 2) Although (Patient #10) was noted to have blister on his toes and changes to the vision in his left eye on admission, no interventions were initiated until 38 hours into his inpatient hospital stay.

Findings Included:

1) (Patient #1's) initial skin assessment dated 10/12/13 timed at 1900 reflected, "Brain Stimulatory to the right upper chest with a bruise, scratch to the left upper back, scar to the right (outer ankle) and multiple bruises to the right and left (anterior) legs..."

The PES (Psychiatric Emergency Services) unit physician note dated 10/13/13 timed at 0845 reflected, "Female arrives with...police believes someone is trying to sedate her...delusional...thinks husband and son are trying to harm her..."

The 10/20/13 nurse note timed at 1210 reflected, "Patient moved to wheelchair...taken to room...some redness was noted to her bottom...doctor on unit events reported and did see patient..."

The 10/20/13 nurse reassessment note timed at 2250 reflected, "Integumentary Assessment...WDP (within defined parameters) Y (yes)...at 1023 discharged home..." No documentation was found which addressed (Patient #1's) altered skin integrity.

(Patient #1's) medical record from (Outside Agency A #26) reflected the following:

The 10/22/13 Oasis Resumption of Care Assessment reflected, "Inpatient discharge from hospital...10/21/13...pressure ulcer onset 10/21/13, low back, heel, buttocks...Stage II...functional limitations bowel and bladder incontinence..."

The 10/22/13 skin record reflected, "Left Heel Stage II 0.5 cm (centimeters) x 0.5 cm...top of coccyx 0.2 cm x 02 cm Stage II...wound three, buttock 1.8 cm x 1.8 cm Stage II and lower back 1.3 cm x 3.1 cm Stage II...no wound care ordered at this time..."

On 07/17/14 at 1640 Agency A Staff #27 was interviewed. Agency A Staff #27 stated (Patient #1) had no skin issues prior to being admitted to Hospital A. Agency A Staff #27 stated the RN (registered nurse) at Agency A assessed (Patient #1) the day after she was discharged from Hospital A. Agency A Staff #27 stated (Patient #1) acquired multiple pressure ulcers while inpatient at Hospital A.

On 07/24/14 at approximately 1045 Personnel #3 was interviewed. Personnel #3 reviewed (Patient #1's) Agency A's resumption of care assessment dated 10/22/13. Personnel #3 acknowledged (Patient #1) had pressure ulcers.

On 07/24/14 at 1100 Personnel #10 was interviewed. Personnel #10 stated he did not remember anyone contacting and/or notifying him (Patient #1) had any skin problems.

2) (Patient #10) was observed on 07/18/14 at 1219 on the hospital's Adult Unit II requesting help from the surveyor for his left toe. He stated he had received care for the blister on his left toe. He also complained of his left eye being blurry. Upon surveyor notification of nursing staff, (Patient #10) removed his sock and showed Personnel #8 his left toe with a blister.

On 07/18/14 at 1219 Personnel #8 reviewed the chart and denied that (Patient #10) had medical intervention for his toe.

The Triage documents dated 07/16/14 timed at 2154 note (Patient #10) had asthma, blisters on his toes, and changes to the vision in his left eye. Initial diagnoses noted a medical (Axis III) diagnosis of asthma only.

The PES (Psychiatric Emergency Services) Medication Orders dated 07/17/14 timed at 0500 noted (Patient #10) was to"...program on the inpatient unit..." There were no orders for the patient's blisters or vision changes and no nursing interventions to address (Patient #10's) medical conditions of blisters and/or vision changes.

The physician orders dated 07/18/14 timed at 0555 and 1021 did not reflect orders for (Patient #10's) medical conditions.

The policy and procedure entitled, "Organization-Wide Patient Assessment" with a review date of 03/2012 reflected, "Each patient is reassessed as necessary based on his/her plan of care or changes in his/her condition...the patient, family and/or significant other and all clinical disciplines collaborate in the process of planning care including discharge planning...the systems/focused physical assessment of patient...patients are reassessed as needed for significant changes in diagnosis, condition, circumstances..."

Based on interview and record review the hospital failed to provide 1) a full-time director of food and dietetic service in that Personnel #6 served as the hospital's Dietary Manager and EVS (environmental services) Director. 2) failed to ensure the Dietary Director maintained the dietary department in a responsible manner in that: a) Cleanliness issues were observed throughout the kitchen, b) Lack of labeling of food items in the kitchen and/or refrigeration units, c) Perishable food item left thawing in standing water in the kitchen, d) Cold food items at the service line were not held at the appropriate temperature. Such practices placed patients, employees, and visitors at risk for acquiring illnesses and infections.

Findings Included:

1) Personnel #6's Job Description dated 06/30/14 reflected, "Title Director of Nutritional/Environmental Services...this position oversees the overall operations of nutritional/environmental services..."

On 07/18/14 at approximately 1300 Personnel #1 was interviewed. Personnel #1 stated Personnel #6 was responsible for the environmental services department and the dietary department.

2) On 07/18/14 from 1038 to 1155 during observation rounds in the dietary department with Personnel #1 and Personnel #6 the following was observed:

2 a) Kitchen Cleanliness:

The interior surface of the refrigerated unit was soiled with debris and grime on the floor of the unit and the external surface of the unit.

Three white bins on wheels were observed under a metal work station. Bin #1, #2, and #3 were soiled with dirt and debris on both the interior and exterior surface of the bins. The plastic lids covering the bins were soiled with grime and debris on both exterior and interior surface. The bins housed flour, rice and sugar. The bins were moved and large amount of dirt and debris was observed on the floor. A single soiled disposable glove was observed on the floor.

Behind the oven area/grill a box of cellophane wrap was observed sitting on the ledge behind the oven and grill. A box of foil was observed sitting on the floor. A thick coat of grease/grime and debris was observed behind the units.

A large sink was observed filled with water. Floating in the water was a large amount of raw fish. The interior surface of the sink was soiled with a brown substance. Personnel #6 stated the sink was dirty. Personnel #6 stated the sink should be clean before thawing fish out.

A large 4 tier shelf unit was observed. One of the shelves had greater than 20 pans stacked wet on top of each other. One of the four shelves was rusted.

A large metal work station adjacent to the 4 tier shelf unit was observed. The bottom of the work station was soiled with dirt and debris. A pan of uncovered black eyed peas was sitting on the bottom of the shelf.

2 b) Food items in the kitchen and/or refrigeration units were not labeled:

A large metal work station adjacent to the 4 tier shelf unit was observed. A pan of uncovered black eyed peas was sitting on the bottom of the shelf. The pan of peas was not labeled.

The refrigerator unit had a opened package of sliced American cheese. The cheese was not labeled when opened.

Twelve individually sliced pieces of lemon meringue pie were not labeled when prepared.
A container of diced green peppers, ham and chili peppers was not tabled.

3) Perishable food item left thawing in standing water in the kitchen:

A large sink was observed filled with water. A large amount of fish were observed floating in standing water. Personnel #6 stated the fish should not be thawed out floating in the water. Personnel #6 stated the fish was going to be used to feed the patients. Personnel #6 stated the fish must be covering the drain.

4 d) Cold food items at the service line were not held at the appropriate temperature.

The lunch meal service was in progress at 1130. Personnel #7 was asked for the food temperature log. Personnel #7 stated the food temperatures were not taken prior to starting meal service.

The following cold items on the service line were greater than 41 degrees:
Pistachio Salad 44 degrees Fahrenheit.
Mandarin Oranges 45 degrees Fahrenheit.
Macaroni Salad 44 degrees Fahrenheit.
Hard Boiled Eggs 44 degrees Fahrenheit.

On 07/18/14 at approximately 1155 Personnel #6 stated the above observations and/or findings were not how the kitchen is typically managed. Personnel #6 stated she was responsible for the dietary department.

The policy and procedure entitled, "Food and Supply Storage" with a review date of 06/11 reflected, "Food products shall be stored in a safe, sanitary manner...organization and cleaning of the storage areas...all food should be stored in closed containers, clear plastic wrap...all food storage containers must be marked with item name and date...are labeled with tight fitting lids..."

The policy and procedure entitled, "Food Temperature Patient Service Log-Checklist" with a review date of 06/11 reflected, "Temperatures of hot and cold foods need to be logged...correct temperature for cold food items should be 40 degrees Fahrenheit or below..."

The policy and procedure entitled. "Food Preparation and Service" with a review date of 06/11 reflected, "Foods will be prepared and serviced in such a manner as to prevent food borne illness and contamination...equipment is cleaned and sanitized..."

Based on observation, record review and interview, the hospital failed to identify and/or prevent the development of pressure ulcers for 1 of 10 patients (Patient #1) while inpatient. The hospital failed to evaluate and/or accurately document and/or provide treatment for (Patient #1). (Patient #1) was discharged on 10/21/13 to home. The home health nurse assessed (Patient #1) on 10/22/13 and found a total of four Stage II Pressure Ulcers. One pressure ulcer to the left heel, top of coccyx, buttock and lower back not identified by the hospital and, 2) Although (Patient #10) was noted to have blister on his toes and changes to the vision in his left eye on admission, no interventions were initiated until 38 hours into his inpatient hospital stay.

Findings Included:

1) (Patient #1's) initial skin assessment dated 10/12/13 timed at 1900 reflected, "Brain Stimulatory to the right upper chest with a bruise, scratch to the left upper back, scar to the right (outer ankle) and multiple bruises to the right and left (anterior) legs..."

The PES (Psychiatric Emergency Services) unit physician note dated 10/13/13 timed at 0845 reflected, "Female arrives with...police believes someone is trying to sedate her...delusional...thinks husband and son are trying to harm her..."

The 10/20/13 nurse note timed at 1210 reflected, "Patient moved to wheelchair...taken to room...some redness was noted to her bottom...doctor on unit events reported and did see patient..."

The 10/20/13 nurse reassessment note timed at 2250 reflected, "Integumentary Assessment...WDP (within defined parameters) Y (yes)...at 1023 discharged home..." No documentation was found which addressed (Patient #1's) altered skin integrity.

(Patient #1's) medical record from (Outside Agency A #26) reflected the following:

The 10/22/13 Oasis Resumption of Care Assessment reflected, "Inpatient discharge from hospital...10/21/13...pressure ulcer onset 10/21/13, low back, heel, buttocks...Stage II...functional limitations bowel and bladder incontinence..."

The 10/22/13 skin record reflected, "Left Heel Stage II 0.5 cm (centimeters) x 0.5 cm...top of coccyx 0.2 cm x 02 cm Stage II...wound three, buttock 1.8 cm x 1.8 cm Stage II and lower back 1.3 cm x 3.1 cm Stage II...no wound care ordered at this time..."

On 07/17/14 at 1640 Agency A Staff #27 was interviewed. Agency A Staff #27 stated (Patient #1) had no skin issues prior to being admitted to Hospital A. Agency A Staff #27 stated the RN (registered nurse) at Agency A assessed (Patient #1) the day after she was discharged from Hospital A. Agency A Staff #27 stated (Patient #1) acquired multiple pressure ulcers while inpatient at Hospital A.

On 07/24/14 at approximately 1045 Personnel #3 was interviewed. Personnel #3 reviewed (Patient #1's) Agency A's resumption of care assessment dated 10/22/13. Personnel #3 acknowledged (Patient #1) had pressure ulcers.

On 07/24/14 at 1100 Personnel #10 was interviewed. Personnel #10 stated he did not remember anyone contacting and/or notifying him (Patient #1) had any skin problems.

2) (Patient #10) was observed on 07/18/14 at 1219 on the hospital's Adult Unit II requesting help from the surveyor for his left toe. He stated he had received care for the blister on his left toe. He also complained of his left eye being blurry. Upon surveyor notification of nursing staff, (Patient #10) removed his sock and showed Personnel #8 his left toe with a blister.

On 07/18/14 at 1219 Personnel #8 reviewed the chart and denied that (Patient #10) had medical intervention for his toe.

The Triage documents dated 07/16/14 timed at 2154 note (Patient #10) had asthma, blisters on his toes, and changes to the vision in his left eye. Initial diagnoses noted a medical (Axis III) diagnosis of asthma only.

The PES (Psychiatric Emergency Services) Medication Orders dated 07/17/14 timed at 0500 noted (Patient #10) was to"...program on the inpatient unit..." There were no orders for the patient's blisters or vision changes and no nursing interventions to address (Patient #10's) medical conditions of blisters and/or vision changes.

The physician orders dated 07/18/14 timed at 0555 and 1021 did not reflect orders for (Patient #10's) medical conditions.

The policy and procedure entitled, "Organization-Wide Patient Assessment" with a review date of 03/2012 reflected, "Each patient is reassessed as necessary based on his/her plan of care or changes in his/her condition...the patient, family and/or significant other and all clinical disciplines collaborate in the process of planning care including discharge planning...the systems/focused physical assessment of patient...patients are reassessed as needed for significant changes in diagnosis, condition, circumstances..."

Based on interview and record review the hospital failed to provide 1) a full-time director of food and dietetic service in that Personnel #6 served as the hospital's Dietary Manager and EVS (environmental services) Director. 2) failed to ensure the Dietary Director maintained the dietary department in a responsible manner in that: a) Cleanliness issues were observed throughout the kitchen, b) Lack of labeling of food items in the kitchen and/or refrigeration units, c) Perishable food item left thawing in standing water in the kitchen, d) Cold food items at the service line were not held at the appropriate temperature. Such practices placed patients, employees, and visitors at risk for acquiring illnesses and infections.

Findings Included:

1) Personnel #6's Job Description dated 06/30/14 reflected, "Title Director of Nutritional/Environmental Services...this position oversees the overall operations of nutritional/environmental services..."

On 07/18/14 at approximately 1300 Personnel #1 was interviewed. Personnel #1 stated Personnel #6 was responsible for the environmental services department and the dietary department.

2) On 07/18/14 from 1038 to 1155 during observation rounds in the dietary department with Personnel #1 and Personnel #6 the following was observed:

2 a) Kitchen Cleanliness:

The interior surface of the refrigerated unit was soiled with debris and grime on the floor of the unit and the external surface of the unit.

Three white bins on wheels were observed under a metal work station. Bin #1, #2, and #3 were soiled with dirt and debris on both the interior and exterior surface of the bins. The plastic lids covering the bins were soiled with grime and debris on both exterior and interior surface. The bins housed flour, rice and sugar. The bins were moved and large amount of dirt and debris was observed on the floor. A single soiled disposable glove was observed on the floor.

Behind the oven area/grill a box of cellophane wrap was observed sitting on the ledge behind the oven and grill. A box of foil was observed sitting on the floor. A thick coat of grease/grime and debris was observed behind the units.

A large sink was observed filled with water. Floating in the water was a large amount of raw fish. The interior surface of the sink was soiled with a brown substance. Personnel #6 stated the sink was dirty. Personnel #6 stated the sink should be clean before thawing fish out.

A large 4 tier shelf unit was observed. One of the shelves had greater than 20 pans stacked wet on top of each other. One of the four shelves was rusted.

A large metal work station adjacent to the 4 tier shelf unit was observed. The bottom of the work station was soiled with dirt and debris. A pan of uncovered black eyed peas was sitting on the bottom of the shelf.

2 b) Food items in the kitchen and/or refrigeration units were not labeled:

A large metal work station adjacent to the 4 tier shelf unit was observed. A pan of uncovered black eyed peas was sitting on the bottom of the shelf. The pan of peas was not labeled.

The refrigerator unit had a opened package of sliced American cheese. The cheese was not labeled when opened.

Twelve individually sliced pieces of lemon meringue pie were not labeled when prepared.
A container of diced green peppers, ham and chili peppers was not tabled.

3) Perishable food item left thawing in standing water in the kitchen:

A large sink was observed filled with water. A large amount of fish were observed floating in standing water. Personnel #6 stated the fish should not be thawed out floating in the water. Personnel #6 stated the fish was going to be used to feed the patients. Personnel #6 stated the fish must be covering the drain.

4 d) Cold food items at the service line were not held at the appropriate temperature.

The lunch meal service was in progress at 1130. Personnel #7 was asked for the food temperature log. Personnel #7 stated the food temperatures were not taken prior to starting meal service.

The following cold items on the service line were greater than 41 degrees:
Pistachio Salad 44 degrees Fahrenheit.
Mandarin Oranges 45 degrees Fahrenheit.
Macaroni Salad 44 degrees Fahrenheit.
Hard Boiled Eggs 44 degrees Fahrenheit.

On 07/18/14 at approximately 1155 Personnel #6 stated the above observations and/or findings were not how the kitchen is typically managed. Personnel #6 stated she was responsible for the dietary department.

The policy and procedure entitled, "Food and Supply Storage" with a review date of 06/11 reflected, "Food products shall be stored in a safe, sanitary manner...organization and cleaning of the storage areas...all food should be stored in closed containers, clear plastic wrap...all food storage containers must be marked with item name and date...are labeled with tight fitting lids..."

The policy and procedure entitled, "Food Temperature Patient Service Log-Checklist" with a review date of 06/11 reflected, "Temperatures of hot and cold foods need to be logged...correct temperature for cold food items should be 40 degrees Fahrenheit or below..."

The policy and procedure entitled. "Food Preparation and Service" with a review date of 06/11 reflected, "Foods will be prepared and serviced in such a manner as to prevent food borne illness and contamination...equipment is cleaned and sanitized..."