HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure nutritional supplement intake was documented for one (#17) of two (#13 and #17) patients for which nutrition supplements were ordered. Failure to document supplement intake did not ensure staff was aware as to whether the patient was getting adequate nutrients and had the likelihood to affect any patient for whom nutritional supplements were ordered. Findings follow.

A. Review of clinical records for Patient #17 showed the following:
1) An order for Ensure Enlive on 01/07/19 at 5:04 PM (no frequency was specified).
2) Review of flowsheets from 01/07/19 at 5:04 PM until the patient discharged on 01/09/19 showed no evidence Patient #17 ever received and/or consumed the Ensure Enlive.
B. Findings were confirmed by the Director of Critical Care on 01/10/19 at 1:26 PM.

Based on observation and interview, it was determined the Infection Control Preventionist failed to ensure a clean and sanitary environment was provided to the patients housed in the Psychiatric Unit located on the 8th floor. Failure to ensure the environment was clean and sanitary had the potential for transmission and cross contamination of bacteria and viruses to patients, staff, and visitors. The failed practice affected 17 inpatients on 01/09/18. Findings follow:

A. Observation of the 8th floor Psychiatric Unit from 9:25 AM to 10:10 AM on 01/09/18 showed coffee stirrers, crackers, cracker crumbs, pieces of cellophane, paper, red tabs, and tissues in the day room under tables, chairs, couches and in the floor. Multiple stains in different colors ranging from red to brown to black, in sizes ranging from dime size to half dollar size and larger, were noted in the day room, the halls and patient rooms. The above observations were verified at the time of observation by the Director of Behavioral Health.

B. Observation of every shower (801-806, 808 - 810) in the 8th floor Psychiatric Unit from 9:25 AM to 10:10 AM on 01/09/19 showed varying amounts of a black substance in the showers. Examples included Patient Room 810 the black substance was observed in every corner, all along the interior wall the shower entry was located on, and sporadically on the grout lines of the shower walls. In patient Room 806 the black substance was observed in every corner, and all along the interior wall the shower entry was located on. The above observations were verified at the time of observation by the Director of Environmental Services.

C. Observation of the air conditioning/heating units in Patient Rooms 801 at 9:52 AM on 01/09/19 and 810 at 9:59 AM on 01/09/19 showed a large accumulation of lint under the units. The above observations were verified at the time of observation by the Director of Environmental Services.

D. Observation in the day room at 10:03 AM on 01/09/19 showed a brown paper sack sitting on top of another brown paper sack. The brown paper sack was moved and brown stains were noted under the sacks. During an interview with the Director of Behavioral Health at 10:03 AM on 01/09/19 he was asked if the stains were chocolate milk. The Director of Behavioral Health donned a glove and felt of the stains. The Director of Behavioral Health stated no, it was not stains, it was pieces of brown paper bag stuck to the floor.