HospitalInspections.org

Based on interview, record review and policy review, the facility failed to ensure that Medicare beneficiaries who were inpatients, received the Important Message from Medicare (IM, information about a patient's right to appeal discharge) for two patients (#48 and #52) of five patient records reviewed for the signed IM. This had the potential to affect all patients who were Medicare beneficiaries, by preventing those patients from knowing their discharge rights. The facility census was 41.

Findings included:

1. Record review of the facility's undated policy titled, "Medicare Important Message, Medicare Beneficiary Notification of Discharge Appeal," showed that the hospital must notify Medicare beneficiaries who are hospital inpatients and use the IM to explain the beneficiary's rights as a hospital patient including discharge appeal rights. The hospital's Registration Department will issue the IM upon the time of admission to the patient, but not later than two calendar days of admission, and a copy of the signed notice will be placed in the patient's medical record.

2. Record review on 09/18/14 of Patient #48's medical record, showed that the patient was admitted on 09/12/14, but did not contain a signed IM.

3. Record review on 09/18/14 of Patient #52's medical record, showed that the patient was admitted on 09/02/14, but did not contain a signed IM.

4. During an interview on 09/18/14 at 1:44 PM, Staff EE, Psychiatric Unit Utilization Review (UR) Nurse and Staff Nurse, stated that she did not know who was responsible for ensuring patients received the IM form and information. Staff EE stated that it may have been her responsibility but was not sure because she was new to her UR position. Staff EE added that the night shift staff audited the patient records and if the IM was not found in the record, they were responsible for obtaining the signed IM at that time.

During an interview and concurrent record review on 09/18/14 at 1:55 PM, Staff E, Psychiatric Nurse Manager, stated that the admitting nurse was responsible for ensuring that patients received and signed the IM, and that the night shift staff audited patient records every night to ensure the IM was signed and in the patient record. During review of Patient #48 and #52's medical records, Staff E stated that she was not sure why the IM was not signed and in the records, or why the night shift audits did not ensure the patients received the IM. Staff E stated that staff may have been too busy to complete the audits.

Based on interview, record review and policy review, the facility failed to ensure that the Governing Body or Grievance Committee was responsible for the grievance process when the Governing Body delegated the responsibility of the grievance process to a Grievance Committee that did not exist. The facility also failed to ensure the effective operation of the grievance process for two patient grievances (#30 and #55) of two patient grievances reviewed. This had the potential to affect all patients or patient representatives who filed a grievance against the facility by failing to ensure that patient grievances were resolved. The facility did not maintain a log of grievances. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "Grievance (Complaint) Process for Patient Subject," revised 11/13, showed that when a patient or patient representative filed a grievance:
- The immediate supervisor will visit the patient or their representative to receive and document the nature of the complaint on the Patient Grievance Report.
- If appropriate and within the scope and role of the immediate supervisor, further investigation and implementation of the necessary steps to resolve the grievance will be conducted and completed as soon as possible.
- If the nature of the grievance requires investigation and resolution beyond the scope of the immediate supervisor, the grievance will be submitted to the Director of Nursing and Clinical Services, or designee, for the appropriate distribution, investigation, resolution and follow-up.
- This process may include submission of the grievances to the appropriate Grievance Committee.
- The Administrator, Director of Nursing and Clinical Services, or designee will follow up in writing and verbally with the patient or their representative. Contents of the response will contain the name of the hospital contact person, the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process and the date of completion.
- The Grievance Committee is approved by the hospital Governing Board (Board of Trustees) to oversee the grievance process. The Grievance Committee is utilized as a resource for appropriate review and resolution of grievances.
- The Director of Nursing and/or designee will receive all grievances pertaining to acute nursing care and will maintain a log by classification of type of grievance.
- A summary of all reported grievances and the results of the investigation will be submitted to the Chief Executive Officer (CEO) on a monthly basis.
- The results of the findings of the investigation will be reported to the Board of Trustees on a monthly basis as part of the Quality Improvement (QI) process.

2. During an interview on 09/17/14 at 1:47 PM, Staff C, Chief Nursing Officer (CNO) stated the following about patient complaints and grievances:
- He received all patient complaints and grievances;
- There was no difference between a complaint and grievance;
- He managed complaints and grievances in the same manner;
- He documented his complaint and grievance follow-up sometimes, but not all of the time;
- He had never sent a written response to a complaint or grievance;
- There were no patient or patient representative complaints or grievances in the previous six months;
- He was not aware of a Grievance Committee structure or members. "I am sure I would be part of that committee" if there was one.

During an interview on 09/18/14 at 9:50 AM, Staff TT, Intensive Care Unit (ICU) Nurse Manager, stated that she had recently documented a patient complaint related to care provided by Staff EE, Registered Nurse (RN). Staff TT stated that the complaint was forwarded to Staff C and added that Staff EE was counseled because of the complaint and the complaint was placed in Staff EE's employee file.

3. Record review of the employee file for Staff EE, RN, showed a discipline record with an attached documentation of a grievance filed by Patient #30's representative (family member) on 08/17/14. The grievance was not documented on a Patient Grievance Report. The grievance showed that the patient's representative complained of the following:
- The patient laid in poop two separate times during the day, one time for over an hour;
- Staff EE, who provided care for the patient, had an attitude;
- Staff EE hung (transfused) blood on the patient, left the room, and didn't monitor the patient's vital signs while the blood infused;
- Staff EE tried to get the patient's representative to leave the room while the patient's dressing was changed, which made the representative mad;
- Staff EE failed to ambulate the patient when the patient was to be ambulated four times per day;
- The patient had been up to the bedside commode (portable toilet) only one time throughout the day and was left there;
- Patient #30 was not given a call light because it was broken, so the patient would tap on the bedside with a spoon to get Staff EE's attention, but Staff EE didn't want the patient to tap the spoon on the bed; and
-No one checked on the patient to see if she needed anything.

4. During an interview on 09/18/14 at 11:15 AM, Staff B, Chief Operating Officer (COO) and Staff C verified that the facility did not have a Grievance Committee. Staff C stated that Patient #30's complaint was considered a nursing issue and not a complaint or grievance, and that a written follow-up was not sent to the patient or the patient's representative. Staff B stated that the hospital did receive complaints after patients were discharged, and added that another patient, Patient #55 came back to the hospital administration offices after she was discharged and complained about care she received while she was a patient. Staff C stated that he spoke with Patient #55 when she returned to the hospital and complained, but did not document the complaint, and did not follow-up with the patient in writing.

5. During an interview on 09/18/14 at 2:06 PM, Staff TTT, Governing Body (GB) Chairman, stated that Staff C did not share grievance information with the GB, because Staff C was "focusing on other fires". Staff TTT added that he did not know if there had been any grievances made to the hospital or if there was a Grievance Committee. "I know that we talked about forming a committee, but I don't know if it ever happened".




31891

Based on interview and record review the facility failed to ensure the Food and Nutrition Services (FNS) contractor established and maintained Quality Assessment/Performance Improvement (QAPI) projects to assess the quality of food and nutrition services provided to patients. This deficient practice had the potential to allow unsafe food sanitation practices and inadequate nutritional care to be provided to patients. The facility census was 41.

Findings included:

1. During an interview on 09/16/14 at 10:58 AM, Staff L, Director of FNS, stated that:
- FNS provided patient food service through a contract agreement with the facility;
- He had not developed any QAPI projects for the department to review, assess and improve the work of the department;
- He was not involved with any facility wide QAPI projects.

2. Record review of the facility's current QAPI projects showed the FNS had not submitted any QAPI projects into the facility wide QAPI program for the fiscal year.

During a telephone interview on 09/22/14 at 1:10 PM, Staff VV, QAPI Coordinator confirmed the following:
- Staff L had not submitted any QAPI projects for the FNS;
- Staff L had submitted random data (in 05/14 and 06/14).
- The data submitted in 05/14 and 06/14 was not related to any formalized QAPI projects in an effort to measure any aspects of quality of the food service.
- Staff VV has had a few unsuccessful meetings with Staff L to provide education regarding the QAPI process; how to formalize studies that may be done; how to document and collect meaningful data that was needed for a project or study and how to determine measures needed to study the quality of patient food and nutrition service.
- After those meetings, Staff L had not developed any QAPI projects to review the quality of care provided by the FNS contractor.

Based on interview and record review the facility failed to ensure the Medical Staff conducted periodic appraisals of five of 10 current members per review of their credentialing files (Staff LL, KKK, LLL, MMM, and NNN). This deficient practice had the potential to permit physicians to provide patient care outside acceptable professional guidelines as determined by the Medical Staff membership. The facility census was 41.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," reviewed 07/14, showed the following definitions and direction for the Medical Staff:
- A practitioner is an appropriately licensed individual under the laws of the state;
- Clinical Privileges is the permission granted to a practitioner to render specific diagnostic, therapeutic, medical or surgical services;
- A purpose of the Medical Staff is to provide a mechanism for accountability for the appropriateness of patient care services, and professional and ethical conduct of each practitioner holding membership.
- A responsibility of the Medical Staff is to participate in assessing and improving the effectiveness of medical care provided including evaluating practitioner performance using measurement systems based on objective, clinically sound criteria; monitoring critical aspects of care; evaluating practitioner's credentials for continued membership and assuring that medical care services are appropriately used to meet patient's needs consistent with sound health care utilization practices.

2. Record review of Staff LL's, Staff KKK's, Staff LLL's, Staff MMM's, and Staff NNN's credentialing files (files used in the process of requesting clinical privileges) showed none of the five had documented periodic Medical Staff appraisal of the patient care each had provided.

3. During an interview on 09/18/14 at 11:20 AM, Staff P, Executive Secretary confirmed the following:
-That she was the staff person who held and managed all of the credentialing files for all Medical Staff members;
- That the facility did not have policies and procedures directing the credentialing process (process used to request and grant clinical privileges);
- The credentialing process followed the steps described in the current Medical Staff Bylaws;
- None of the current members of the Medical Staff had documented, periodic appraisals of the patient care each had provided.

Based on interview and record review the facility failed to ensure members of the Medical Staff maintained continuing medical education (CME) hours to support their credentials and continued membership on staff in five of 10 credentialing files reviewed (Staff LL, KKK, LLL, MMM, and NNN). This deficient practice had the potential to permit physicians without up to date education and training to provide patient care that the Medical Staff may find out of date. The facility census was 41.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," reviewed 07/14, showed the following definitions for the Medical Staff:
- A practitioner is an appropriately licensed individual under the laws of the state;
- Clinical Privileges is the permission granted to a practitioner to render specific diagnostic, therapeutic, medical or surgical services;
- A purpose of the Medical Staff is to provide a mechanism for accountability for the appropriateness of patient care services, and professional and ethical conduct of each practitioner holding membership.

Record review of the facility's "Medical Staff Bylaws, Article III: Medical Staff Membership," reviewed 07/14 showed the following direction:
- General Qualifications: Every practitioner who seeks and obtains medical staff privileges must, at time of appointment and continuously thereafter, demonstrate to the satisfaction of the medical staff the following qualifications:
- Professional education, training, experience and clinical results, documenting a continuing ability to provide optimally achievable patient care services.
- Basic Obligations of Individual Staff Membership: Satisfy the continuing education requirements established by state law for continuing education.

2. Record review of Staff LL's, Staff KKK's, Staff LLL's, Staff MMM's, and Staff NNN's credentialing files (personnel files used in the credentialing process) showed none of the five had documentation of any CMEs.

During an interview on 09/18/14 at 11:20 AM, Staff P, Executive Secretary, confirmed the following:
- That she was the staff person who held and managed all of the credentialing files for all Medical Staff members;
- That the facility did not have policies and procedures directing the credentialing process and that would direct physicians to provide their current CMEs;
- The credentialing process followed the steps as described in the current Medical Staff Bylaws;
- None of the files reviewed of current members of the Medical Staff had CMEs documented in each of their credentialing files.

Based on interview and record review the facility failed to ensure hospital-wide nursing services were organized and under the direction of one Registered Nurse (RN). The failure to provide a well-organized nursing service with a plan of administrative authority by one RN had the potential to affect the quality of nursing care provided to all patients who received care in all areas of the facility. The facility census was 41.

Findings included:

1. Record review of the facility's current organizational chart showed Staff C, RN Chief Nursing Officer (CNO), did not have administrative authority for nursing services in the following areas of the facility:
- Infection Control (IC);
- Surgery Services; and
- Nursing Staff Education.

The IC department reported directly to the facility's Long Term Care Unit (LTCU) Administrator.

2. During an interview on 09/18/14 at 10:10 AM, Staff YYY, LTCU Administrator, stated that she had nursing oversight and management of nursing staff education, case management and utilization review and the IC program.

During an interview on 09/17/14 at 10:00 AM, Staff C, CNO, stated that he did not have administrative authority over nursing services in the Infection Control Program, Surgical Services, Case Management and Utilization Review Services. Staff C stated that the facility did not have an organizational chart specific to nursing services which showed the lines of authority for the different departments and units within the facility.

During an interview on 09/17/14 at 10:30 AM, Staff QQQ, Director of Surgical Services, stated that her departments reported directly to the Chief Executive Officer (CEO) and that she was responsible for all of the nurses in the surgical areas.
During an interview on 09/18/14 at 2:00 PM, Staff B, COO, confirmed that the the surgical areas reported directly to the CEO and any nursing issues were responded to by the Director of Surgical Services.



29511

Based on interview, record review, and policy review the facility failed to ensure a qualified Registered Nurse (RN) was immediately available to supervise patient care on all nursing units of the facility twenty four hours a day seven days a week. Three of fifteen day shifts (7:00 AM - 7:00 PM) did not have a qualified RN assigned to supervise patient care. The failure to ensure an RN who was responsible, prepared, oriented and had sufficient experience to perform independent nursing duties, had the potential to affect all nursing care under their supervision. The facility census was 41.

Findings included:

1. Record review of the facility's undated,"Staffing Guide for Hospital," showed direction for facility staff to schedule no less than one qualified RN at all times for all nursing units.

2. Record review of the facility nurse staffing schedule dated 09/05/14 showed no RN assigned to 2A (a medical surgical unit) on the day shift.

Record review of facility nurse staffing schedules dated 09/01/14 through 09/15/14 (15 days) showed Staff VVV, RN, assigned to 2A on the day shift for the dates 09/01/14 and 09/02/14. Staff VVV, was on orientation, and the only RN assigned for the day shifts on 09/01/14 and 09/02/14. [Staff VVV was not available for interview.]

3. During an interview on 09/16/14 at 8:55 AM, Staff C, CNO, stated that the 2A medical surgical unit nurse manager had been absent from her position for months and staff had been working out the schedule amongst themselves and calling him only when needed.

4. Record review of the facility's policy titled, "Orientation Program," dated 11/13, showed staff were required to receive a formalized orientation program that covered all the needs of their position prior to independent assignment and responsibility.

5. During an interview on 09/17/14 at 12:05 PM, Staff RR, RN, stated that orientation to her position began 06/29/14 following the completion of the RN licensure nursing examination 06/26/14. Staff RR stated that she was the only RN assigned to the unit on more than one day shift during her six weeks of orientation and she did not feel comfortable with the amount of responsibility and supervision that came with Licensed Practical Nurses (LPN's) due to her limited experience as an RN. She stated administration of medications to the LPNs patients without knowing them had been a problem.

6. During an interview on 09/17/14 at 10:15 AM, Staff C, CNO, stated that the facility had problems hiring RN's in the past and he was not aware of the requirement of an RN assignment available to respond to the patients bedside to every unit at all times.

Based on interview, record review, and policy review the facility failed to ensure verification of nursing staff licensure for five staff (J, C, T, ZZ and BBB) of five personnel records reviewed for verification and valid nursing licensure. The failure to ensure valid licensure of nursing staff had the potential to expose all patients to staff deemed incompetent or unauthorized to perform patient care. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "Nursing Personnel Licensure," revised 11/13, showed direction for staff to provide a current copy of their license to the Department of Nursing.

2. During an interview on 09/16/14 at 9:20 AM, Staff S, Licensed Practical Nurse (LPN), stated that the facility had not asked her to provide a copy of her nursing license.

3. During an interview on 09/17/14 at approximately 10:25 AM, Staff C, Chief Nursing Officer (CNO), stated that he had gone to a website and verified some nurses' licenses. However, he stated that there was not a mechanism in place to ensure verification for all nursing staff.

4. Record review of Staff J, T, ZZ and BBB's personnel files showed Human Resources (HR) staff failed to maintain verification of nursing licensure and did not keep a personnel file for Staff C.
During an interview on 09/18/14 at 12:52 PM, Staff SS, HR Manager stated that the personnel files for facility nursing directors were kept by Staff P, Executive Secretary, and not by the HR department.

During an interview on 09/18/14 at approximately 12:55 PM, Staff P, Executive Secretary, stated she kept the personnel files for the department directors who were nurses however, those files did not contain proof of current nurse licensure. She indicated the Electronic Medical Records (EMR) Co-coordinator (who was the past Chief Nursing Officer) may keep the current nurse licenses for department directors who were nurses.

During an interview on 09/18/14 at approximately 2:00 PM, Staff O, EMR Co-coordinator stated she did not keep the current nurse licenses for anyone and those licenses were possibly in each of the departments where those staff served as department directors.














16215

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that a nurse provided supervision of staff to complete every 15-minute safety checks (patient safety rounds to ensure patients were observed during each 15-minute timeframe) for 12 patients (#1, #11, #12, #13, #19, #20, #21, #22, #23, #24, #25, and #26) of 17 patient records reviewed in the Behavioral Health Unit (BHU.) This had the potential to affect all BHU patients by failing to ensure that the patient's safety needs were met.
- Ensure completion of nursing assessments for five current patients (#1, #11, #12, #13, and #14) and one discharged patient (#29) of six behavior health unit patients whose medical records were reviewed for nursing assessments. This had the potential to affect all behavioral health unit patients by failing to assess and recognize potential changes in the patients' physical health.
- Ensure a Registered Nurse (RN) evaluated the care for one patient (#56) of one patient reviewed who was at high risk for skin breakdown and developed a pressure sore. The failure to provide daily physical assessments per the facility policy, had the potential to contribute to the deterioration of health conditions for all patients, especially patients who were identified at high risk for skin breakdown and pressure sore development.
- Ensure patients were assessed for safety risks before medications were administered for one patient (#45) of six patients reviewed for safe medication administration. This failure to assess for medication safety had the potential to cause an unrecognized, deterioration in patients health conditions.
The behavioral health units census was 23. The facility census was 41.

Findings included:

1. Record review of the undated facility policy titled, "Resolutions (BHU) Staff Monitoring," showed:
- Staff monitoring was instituted to prevent patients from harming themselves or others.
- Physicians orders included the level of monitoring.
- A staff member was assigned the responsibility to complete 24-hour observation logs (forms to record observation of a patient's safety checks at 15-minute intervals throughout a 24-hour period).

2. Record review of physician orders for patients (#1, #11, #12, #13, #19, #20, #21, #22, #23, #24, #25, and #26) showed admission orders that included 15-minute safety checks.

3. Record review on 09/16/14 at 9:40 AM, showed nine patient 24-hour observation log forms on a clipboard with Staff H, Certified Nurse Assistant (CNA). Eight of the nine records showed no documentation of safety checks from 6:45 AM to 9:40 AM for 09/16/14.

During an interview on 09/16/14 at approximately 9:40 AM, Staff H, CNA, stated that she was not not able to observe eight patients during that time frame due to assigned duties on another behavioral health unit.

4. Record review on 09/16/14 at 9:50 AM, showed eight, 24-hour patient observation log forms on a clipboard with Staff I, CNA. Four of the eight observation forms showed no documentation of safety checks from 8:00 AM to 9:50 AM on 09/16/14.

During an interview on 9/16/14 at 9:50 AM, Staff I, CNA, stated that she was not able to conduct four patient's 15-minute safety checks during that timeframe due to other assigned duties.

5. During an interview on 09/18/14 at 11:20 AM, Staff E, Nurse Manager, stated that she was not aware that Staff H and Staff I had not completed 15-minute safety checks and that 15-minute safety checks were required for all BHU patients.

During an interview on 09/18/14 at 1:40 PM, Staff III, CNA, Geriatric Unit, stated that during crises it was difficult to complete 15-minute safety checks on patients.

6. Record review of the undated facility policy titled, "Resolutions, Nursing Assessment," directed staff to complete a nursing assessment to include an assessment of the patient's physical, mental, and emotional factors.

Record review of the facility's policy titled, "Standards of Patient Care," dated 11/2013, showed the following direction for nursing staff:
- All patients received care from nurses who were competent, performed within the scope of their practice and who were responsible for their care.
- Patients received care based on well documented physical assessments every shift.
- Patient assessments included but were not limited to identified patient care needs and nursing standards of practice.
- Skin assessments included inspection of elbows, buttocks and other areas of the skin that were at high risk for increased pressure and skin breakdown.

7. Record review of Patient #1's medical record showed:
-A psychiatric evaluation dated 09/07/14 that showed the patient was admitted to the BHU on 09/06/14 and had a medical diagnosis of pneumonia.
-A physician's order dated 09/06/14 for Levaquin 500 mg (an antibiotic used to treat infections), one time by mouth daily and an Albuterol inhaler (a bronchodialator, medication used to relax muscles in the airways and increase airflow to the lungs), two puffs every four hours for shortness of breath.
-There was no nursing assessment, shift assessment or care plan that recognized pneumonia as a problem or supervised the provision of nursing care.

8. Record review of Patient #11's medical record showed:
-A History and Physical (H&P) dated 09/11/14 that showed the patient had a medical diagnosis of cellulitis to the abdomen.
-An admitting physician order dated 09/11/14 for Bactroban ointment (used for treatment of bacterial infections), apply to the area on the abdomen three times a day for seven days.
-No nursing assessment, shift assessment or care plan that recognized cellulitis as a problem and supervised the provision of nursing care.

9. Record review of Patient #12's H&P dated 09/12/14 showed the patient had a medical diagnosis of chronic obstructive lung disease (COPD, a chronic lung disease that blocks the airflow and makes breathing difficult) with signs of anoxia (low oxygen).
There was no nursing assessment, shift assessment or care plan that recognized COPD as a problem or supervised the provision of nursing care.

10. Record review of Patient #13's medical record showed:
-A psychiatric evaluation dated 09/14/14 showed the patient had high blood pressure and a heart disease with a recent defibrillator (a device that activates a shock to the heart when indicated) implant (surgically placed).
-A physician order dated 09/12/14 for Coreg 25mg (a medication used treat heart and circulation disorders) twice daily and Lisinoprel 12.5 mg (a medication used to treat high blood pressure and heart conditions), by mouth two times daily.
-There was no nursing assessment, shift assessment or care plan that recognized high blood pressure or heart disease as a problem and supervised the provision of nursing care.

11. Record review of Patient #14's medical record showed:
-An H&P dated 09/12/14 showed the patient was admitted on 09/12/14 and had medical diagnoses of Insulin Dependent Diabetes Mellitus (IDDM, a disease characterized by high blood sugar levels that can potentially lead to life threatening conditions if untreated) and hypertension (high blood pressure).
-A physician order dated 09/12/14 for Lantus (a medication used to treat IDDM) by injection at bedtime and Lisinoprel 20 mg by mouth twice daily.
-There was no nursing assessment, shift assessment or care plan that recognized IDDM or hypertension as a problem and supervised the provision of nursing care.

During an interview on 09/16/14 at approximately 11:20 AM, Staff E, RN, Nurse Manager, stated that upon admission and every 12 hours thereafter a nurse conducts a nursing assessment for each patient.

12. Record review of Patient #29's medical record showed:
- A Behavioral Health Unit Admission Assessment dated 08/23/14 at 2:43 PM, did not include a head to toe assessment (complete assessment of all patient body systems, including heart, lung, skin, vital signs, etc) of the patient.
- A Nurse Practitioner's order dated 08/23/14 at 9:35 PM for staff to document bruises to the patient's body thoroughly.
- Nursing assessments between 08/23/14 and 08/30/14, did not include documentation of the patients bruises and did not include head to toe assessments or vital signs of the patient, which could have indicated a change or decline in the patient's health.
- On 08/30/14, the patient was transferred from the Behavioral Health Unit to the Emergency Department, after she became less responsive. The patient was diagnosed with hypotension (low blood pressure) and dehydration (low body fluid volume), and was admitted to the hospital's Intensive Care Unit (ICU).

During an interview on 09/18/14 at 11:25 AM, Staff RRR, Nurse Practitioner, stated that upon admission to the BHU Patient #29 was covered in bruises to her body, mainly to her legs and arms, and the bruises were in various stages of healing. Staff RRR stated that she wrote an order for documentation of the patient's bruises because she wanted to ensure the bruises were documented in the patient's medical record.

During an interview on 09/17/14 at 1:00 PM, Staff CCC, Licensed Practical Nurse (LPN), stated that she signed off (acknowledged) the Nurse Practitioner orders to document Patient #29's bruises, but failed to document the bruises because it was very busy the night the patient was admitted and because there was no place to document the bruises in the electronic medical record (EMR).

13. During an interview on 09/17/14 at 8:30 AM, Staff C, Chief Nursing Officer (CNO), stated that he reviewed Patient #29's medical record and expected to find an admission assessment of the patient's heart sounds, lungs sounds and skin when the patient was admitted on 08/23/14, but there was no documentation of these body systems found.

During an interview on 09/17/14 at 8:50 AM, Staff E, Nurse Manager stated that on admission, the nurse was required to document a psychiatric assessment, skin assessment and mental status examination. Staff E stated that nursing staff should document a mental status examination and vital signs every 12 hours, but were not required to document head to toe assessments on the patient. Staff E stated that nurses previously completed head to toe assessments on BHU patients every 12 hours when the assessments were documented on paper, but since the facility moved to electronic documentation, the head to toe assessment was not completed.

During an interview on 09/17/14 at 9:05 AM, Staff CC, LPN, stated that there was no place to document a patient's skin assessment, heart sounds, lung sounds, etc., since the facility moved from paper documentation to an EMR.

During an interview on 09/18/14 at 9:05 AM, Staff O, EMR Director, stated that the BHU staff had the ability to access and document head to toe assessments. Staff O stated that she was aware staff were not documenting head to toe assessments of the BHU patients and that she had brought this to the attention of the previous CNO.

14. Observation on 09/17/14 at 3:05 PM on 2A (medical surgical patient care area) showed Patient #56 had a Stage II pressure ulcer (a skin blister caused by too much pressure against the skin that opened and created a sore) on his buttocks. The pressure ulcer was circular and was approximately one inch in diameter, was red and had dark red skin extending about four inches to the right and left of the sore. The left elbow had discoloration of dark red skin that extended approximately five inches to the right and left side. Staff T, RN, and Staff NN, LPN, were present at the time of observation.

15. Record review of Patient #56's nursing assessments dated 09/12/14 - 09/17/14, showed one skin assessment performed on admission, dated 09/12/14. The assessment documentation showed redness on the buttocks (not measured or otherwise described).

16. Record review of Patient #56's Braden Scale (an assessment tool for predicting the risk for pressure sores) completed on 09/16/14 at 8:00 AM showed a score of 12 (12, predicted a high risk for pressure sore development).

17. Record review of a facility provided list of patients who had wounds, pressure ulcers, urinary catheters and/or other special nursing care needs did not show Patient #56 with a Stage II pressure ulcer.

18. Record review of the staffing schedule and patient assignments for 2A on 09/17/14 showed Staff NN and Staff T were assigned care for Patient #56 during the day shift (7:00 AM to 7:00 PM.)

19. During an interview on 09/17/14 at 2:55 PM, Staff NN, LPN, stated that Patient #56 did not have any skin problems and she did not perform a skin assessment because he did not have any risks for breakdown (pressure sore development).

During an interview on 09/17/14 at 3:25 PM, Staff T, RN, stated that she was responsible for assessing care provided for Patient #56 and she was not aware of Patient #56's Stage II pressure sore, the skin discoloration of the elbow or that his Braden Score was 12. She stated that the facility failed the patient.

20. During an interview on 09/17/14 at 3:05 PM, Patient #56 stated that he knew he had a sore on his buttocks and it hurt and he had not received treatment that promoted healing or pain relief.

21. Record review of Patient #45's Medication Administration Record (MAR) on 09/18/14 showed medications Zosyn and Teflaro (both are medications used to treat infections) administered to Patient #45 on the dates of 09/14/14 to 09/18/14. The alert screen (standard method to ensure medication administration safety) on the MAR warned that infusion of both medications (Zosyn and Teflaro) had severe adverse effects for the development of Thrombophlebitis (inflammation in the vein) and/or acute venous embolism (a blood clot in the vein) and thrombosis (blood clot formation in a deep vein in a extremity) based on the ingredients of the medicines.

During an interview on 09/18/14 at 12:30 PM, Staff RR, RN, who was assigned care of Patient #45 stated that she had not assessed the patient for the risks associated with thrombosis or medications. She stated that she was not aware of the side effects of the current medications for Patient #45.



17863




29047

Based on observation, interview, record review, and policy review the facility failed to develop nursing care plans for eight patients (#1, #11, #12, #13, #14, #18, #45 and #56) of 12 patients reviewed for care plan completion. This had the potential to affect all psychiatric and medical patients by failing to ensure that the patients' physical safety and medical needs were met. The Behavioral Health Unit (BHU) census was 23. The facility census was 41.

Findings included:

1. Review of an undated facility policy titled, "Resolutions (BHU) Nursing Assessment," showed direction for nurses to complete a nursing assessment within eight hours of admission and the nursing assessment was instrumental in developing the patient's treatment plan.

Review of an undated facility policy titled, "Resolutions Treatment Plan Overview," showed the following direction for staff:
-Upon admission the admitting/assigned nurse consults with the admitting physician and other staff involved and develops a nursing care plan.
-The initial process addresses the most immediate and obvious needs of the patient on admission.
-Both medical and psychiatric needs should be discussed.

2. Record review of Patient #1's medical record showed the following:
- The Nursing Admission Assessment dated 09/06/14 showed he was admitted to the adult BHU on 09/06/14 with suicidal ideations (thoughts) and a potential for self-harm.
- The Psychiatric Evaluation dated 09/10/14 showed he was admitted with major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), suicidal ideations, and pneumonia (an infection in the lungs).
- The Treatment Plan dated 09/06/14 showed no nursing goals or interventions for suicidal ideations or pneumonia as assessed.

3. Record review of Patient #11's medical record showed the following:
- The Nursing Admission Assessment dated 09/10/14 showed she was admitted to the adult BHU on 09/10/14 with suicidal ideations, a potential for self-harm, and Hepatitis C (an infectious disease that primarily affects the liver).
- The Psychiatric Evaluation dated 09/11/14 showed she was admitted to the adult behavioral health unit on 09/10/14 with schizoaffective disorder (a condition that causes a loss of contact with reality and mood problems), suicidal ideations, and gastro-esophageal reflux disease (GERD, a chronic digestive disease, also known as acid reflux disease).
- The History and Physical dated 09/11/14 showed medical diagnoses of GERD and cellulitis (a bacterial infection of the skin) with physician orders for treatment.
- The Treatment Plan dated 09/10/14 showed no nursing goals or interventions for suicidal ideation, GERD, Hepatitis C, or cellulitis as assessed.

4. Record review of Patient #12's medical record showed the following:
- The Nursing Admission Assessment dated 09/15/14 showed he had suicidal ideation and a potential for self-harm.
- The Psychiatric Evaluation dated 09/15/14 showed that he was admitted to the adult behavioral health unit on 09/15/14 with a severe major depressive disorder and suicidal ideations.
- The History and Physical dated 09/15/14 showed a medical diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease that blocks airflow and makes breathing difficult) with signs of anoxia (low oxygen.)
- The Treatment Plan dated 09/15/14 showed no nursing goals or interventions for suicidal ideations or COPD as assessed.

5. Record review of Patient #13's medical record showed the following:
- The Nursing Admission Assessment dated 09/14/14 showed he was admitted to the adult BHU on 09/14/14 with suicidal ideations and an internal defibrillator (a device that activates a shock to the heart when indicated) implant (surgically placed) for an irregular heartbeat on 08/14/14.
- The Psychiatric Evaluation dated 09/14/14 showed he was admitted with major depressive disorder, suicidal ideations, and heart disease with a recent defibrillator implant.
- The Treatment Plan dated 09/14/14 showed no nursing goals or interventions for suicidal ideations or heart disease as assessed.

6. Record review of Patient #14's medical record showed the following:
- The Nursing Admission Assessment dated 09/12/14 showed he was admitted to the adult BHU on 09/12/14 with suicidal ideations, a potential for self-harm, diabetes, and hypertension (high blood pressure).
- The Psychiatric Evaluation dated 09/12/14 showed he was admitted with major depressive disorder and suicidal ideations.
-The History and Physical dated 09/12/14 showed he had a medical diagnoses of insulin dependent diabetes (a disease characterized by high blood sugar levels that can potentially lead to life threatening conditions if untreated), GERD, and hypertension.
- The Treatment Plan dated 09/12/14 showed no nursing goals or interventions for suicidal ideations, diabetes, GERD, or hypertension as assessed.

7. During an interview on 09/16/14 at approximately 11:20 AM, Staff E, Behavioral Health Unit Nurse Manager, stated that patient treatment plans included no nursing care plans for medical problems or nursing interventions for suicidal ideation.

8. Observation on 09/16/14 at 9:45 AM on 2A (a medical surgical unit), showed Patient #18 had a urinary catheter (a tube placed in the body to drain and collect urine from the bladder) attached to a drainage collection bag.

Record review of Patient #18's care plan dated 09/17/14, showed no planned nursing care, goals of care or planned interventions for the care of the urinary catheter.

9. Observation on 09/18/14 at 12:05 PM on 2A, showed Patient #45 with a large abdominal wound covered by a bandage and a intravenous (IV, in the vein) catheter (small tube) placed in her hand which had been used for IV medication and fluid administration.

Record review of Patient #45's Medication Administration Record (MAR) on 09/18/14 showed medications Zosyn and Teflaro (both are medications used to treat infections) administered to Patient #45 on the dates of 09/14/14 to 09/18/14. The alert screen (standard method to ensure medication administration safety) on the MAR warned that infusion of both medications (Zosyn and Teflaro) had severe adverse effects for the development of Thrombophlebitis (inflammation in the vein) and/or acute venous embolism (a blood clot in the vein) and thrombosis (blood clot formation in a deep vein in a extremity) based on the ingredients of the medicines.

During an interview on 09/18/14 at 12:30 PM, Staff RR, RN, who was assigned care of Patient #45 stated that she had not assessed the patient for the risks associated with thrombosis or medications and she did not have a care plan for the medications or thrombosis.

Record review of Patient #45's nursing care plan showed no planned nursing care, goals of care or planned interventions for the care of the large abdominal wound or thrombosis.

10. Observation on 09/17/14 at 3:05 PM on 2A, showed Patient #56 with a Stage II pressure sore (a skin blister caused by too much pressure against the skin that opened and created a sore) on his buttocks.

Record review of Patient #56's nursing care plan showed no planned nursing care, goals of care or planned interventions for the care of the pressure sore on the buttocks.

11. During an interview on 09/18/14 at 1:10 PM, Staff T, RN, stated that patients on 2A did not have care plans until the day before (09/17/14) and staff were new to the process and had a lot to learn about care plans.




17863

Based on observation, interview, record review and policy review, the facility failed to ensure staff administered medications safely to six patients (#15, #17, #18, #45, #46 and #56) of eight patients reviewed for safe medication administration practices.
Failures included:
- Staff administered intravenous (IV, in the vein) medications through tubes that were unlabeled or expired (past the date of safe use) to Four patients (#17, #18, #45 and #46) of eight patients were administered observed with IV tubing.
- Staff administered medication without notifying the physician when alerted by the medication scanning system of potential patient harm if administered to one patient (#45) of one patient observed with a medication alert.
- Staff who were Licensed Practical Nurses (LPN's) and not authorized to administer medications by the route of intravenous push (IVP, to manually administer a dose of medication through a tube into a vein), prepared and documented patient administration of IVP medications to two patients (#15, #56) of two records reviewed for IVP medication administration.
The failure to meet safe medication administration practices and established facility policy had the potential to cause serious infections, decline in patient health and avoidable adverse patient outcomes for all patients admitted to the facility who received medications. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "IV Tubing Changes," revised on 11/13, showed direction for facility staff that a sterile environment had to be maintained in the tubing of IV solutions to prevent infection. Staff was to abide by the following guidelines:
- Change (remove and replace) peripheral IV (PIV, small tube inserted through the skin into a vein/blood stream for the administration of medication/fluids usually in a hand) every 72 hours and labeled with the date the PIV was inserted.
- Change IV tubing connected to medications every 48 hours.
- Change IV tubing connected to IV medications/fluids if given intermittently (not continuous) every 24 hours.
- Label all tubing with the date, time hung and nurses initials.

2. Observation on 09/16/14 at 9:25 AM, showed Patient #17 with an undated PIV in her hand. One IV infusion pump had two different IV fluids with two separate unlabeled lines of tubing attached to the medications and connected to the pump.

During an interview on 09/16/14 at 9:30 AM, Staff Q, Licensed Practical Nurse (LPN), stated that Patient #17's PIV and the IV tubing was not labeled, dated and changed appropriately and she did not know why.

3. Observation on 09/16/14 at 9:45 AM, showed Patient #18 with an unlabeled PIV in her left hand. An infusion pump next to Patient #18's bed had two IV medication bags connected with unlabeled IV tubing.

During an interview on 09/016/14 at 9:50 AM, Staff Q, stated that Patient #18's PIV should have had a date documented on the bandage that identified when it was inserted and that the tubing on the IV medication tubing should have been labeled.

4. Observation on 09/18/14 at 11:35 AM showed Patient #46 with an undated PIV in her right hand. An IV infusion pump next to the bed had one empty IV medication bag with unlabeled tubing connected to the infusion pump.

During an interview on 09/18/14 at 11:35 AM, Staff NN, LPN, stated that the PIV and IV tubing for Patient #46's should have been labeled and dated.

5. Observation on 09/18/14 at 12:15 PM during medication administration to Patient #45 showed:
- Patient #45 had a PIV in her right hand not connected to continuous IV medication/fluid administration. The PIV was dated 09/11/14 [per facility policy staff should have changed the PIV no later than 09/15/14.]
- An infusion pump (machine used for controlling the rate of medication/fluids administered to patients) was next to the bed.
- One empty (had been administered) 50 milliliters (ml, a measurement of liquid) labeled with the medication, Teflaro (used to treat infections) 600 milligrams (mg, a unit of measure) administered 09/18/14 at 8:00 AM hung from the infusion pump with unlabeled tubing attached to the bag and connected to the pump.
- One empty 50 ml bag labeled with the medication Zosyn (medication used to treat infections) 2.25 grams (gm, a unit of measure) administered 09/18/14 at 6:00 AM hung from the pump with unlabeled tubing attached to the bag and connected to the pump.

During an interview on 09/18/14 at approximately 12:30 PM, Patient #45 stated that the PIV had been in her hand since her admission and nurses checked it only when the tape came off. She stated that it hurt when the medicines went in her veins.

6. Further observation of the medication administration to Patient #45 showed:
- Staff RR, Registered Nurse (RN), performed an electronic bar code scan (standard method to ensure medication administration safety) to the medication package of Zosyn 2.25 gm prior to preparation and administration to Patient #45.
- A bar code scan alert message appeared on the medication administration screen after the Zosyn was scanned which stated, "Duplicate therapy, Teflaro and Zosyn. When both medications are included in medication intravenous therapy... 'Side Effects - Severe', Zosyn intravenous solution may cause Thrombophlebitis (inflammation in the vein) and/or acute venous embolism (a blood clot in the vein) and thrombosis (blood clot formation in a vein) based on ingredients found in the medications.
- Staff RR overrode the alert, and selected "Override Reason: Clinical decision support".
- Staff RR prepared the medication, connected the medication to the unlabeled IV tubing that was present in the infusion pump, then connected the IV tubing to Patient #45's right hand PIV after she confirmed the date of 09/11/14 written on the PIV and administered the medication to Patient #45.

During an interview on 09/18/14 at approximately 12:30 PM, Staff RR stated that:
-She had given the medication and selected the override many times for Patient #45's medication alerts. She stated that all the nurses did overrides when the alerts came up in the computer and she did not call the physicians to clarify or verify the safety of the orders.
- She would change the PIV later after she administered the medications.
- She was not aware of the side effects of the current medications for Patient #45.
- She would change and label IV tubing the next time she administered medications.
- She would look into the override problem in the computer.

During an interview on 09/18/14 at approximately 2:30 PM, Staff XX, Director of Pharmacy, stated that:
- Nursing staff should not override the medication alerts when they appeared when medications were scanned.
- The system's alert was set for pharmacy and physician alerts, not nursing alerts.
- The pharmacy does not use the same system as the nurses on the floor.
- Overrides and clinical decisions should only be made by a Pharmacist in consultation with the treating physician because of their scope of knowledge and expertise.
- He was familiar with the medication regimen for Patient #45 and side effects of the therapy.
- He was not aware nursing staff did not consider medication adverse effects when planning and delivering nursing care.
- He does not document his rational or review of medications in the clinical record or communicate the information to nursing staff or physicians in a consistent manner and knew this was an area he should improve.
- He could not recall when medication overrides by nursing staff had become a problem and the issue had first been discovered and discussed.
- He would immediately put a stop to the nurses ability to override the alerts.

7. Record review of the facility's policy titled, "Intravenous Therapy," revised on 11/13, showed the RN was responsible for intravenous fluid administration. Further review provided staff specific direction that LPN's were not authorized, regardless of certification, to administer drugs via manual IV push (IVP).

8. Record review on 09/16/14 at approximately 1:45 PM, of Patient #15's medication administration record (MAR) showed Staff Z, LPN, documented medication administration per IVP of Lasix (medication to cause fluid loss) 20 mg on 09/16/14 at 8:36 AM.

During an interview on 9/16/14 at approximately 1:50 PM, Staff Z, stated that she never administered IVP medications to patients. She stated that she prepared, documented and gave the medications to an RN to administer to patients assigned to her care. She stated that she worked in all units of the facility and it was done the same in all areas.

During an interview on 9/16/14 at approximately 1:55 PM, Staff AA, RN, stated that when RNs worked with LPNs, the LPNs routinely prepared and documented the medications were given by them however, the RNs administered the IVP's to patients. She stated that she never believed it was the right thing to do.

9. Record review of Patient #56's MAR dated 09/17/14, showed Protonix (medication to reduce acids in stomach) 40 mg administered by IVP at 9:01 AM to Patient #56 by Staff NN, LPN.

During an interview on 09/18/14 at approximately 11:35 AM, Staff NN, stated that she did not administer the Protonix 40 mg IVP on 09/17/14 at 9:01 AM to Patient #56. She stated that she prepared the medication and documented that she gave the medicine but actually handed the medication to an RN to administer. She thought Staff T administered the medication to Patient #56.

During an interview on 09/18/14 at approximately 12:30 PM, Staff T, RN, stated that she routinely gave IVP medications to patients for the LPNs. She stated that it was routine in the facility for the LPNs to prepare the medications, document that they were given by them and then hand them to the RN's to administer to their patients. She stated that she does not believe it is the right process to follow, however, it is what is expected in the facility. She could not recall if she gave Patient #56 medication on 09/17/14.

Based on interview, record review and policy review, the facility failed to ensure that controlled substance (drugs or medications that are high risk for personal consumption or abuse) losses were investigated and reported to the proper agencies when one drug (Lorazepam, used to treat anxiety) was found missing on two separate occasions. This had the potential to affect all patients, through misappropriation of patient medications and the potential for impaired patient care staff. The pharmacy dispenses an average of 5,660 controlled substances per month. The facility census was 41.

Findings included:

1. Record review of the facility undated policy titled, "Controlled Drug Distribution," showed that when an error occurred in the inventory count which cannot be explained on investigation, the error is to be reported using the Hospital's Variance Reporting (similar to an event report) system. These reports will be reviewed by the Director of Pharmacy and the Director of Nursing, and that all unauthorized losses shall be reported to the appropriate State and Federal authorities.

2. Record review of a pharmacy discrepancy report showed a missing Lorazepam, 0.5 milligrams (mg, unit of measure) tablet on 07/18/14 at 6:37 AM, and again on 08/01/14 at 9:07 AM. Documentation further showed that Staff EE, Registered Nurse (RN), was the last staff member who accessed the medications prior to the discovery of the discrepancy on both 07/18/14 and 08/01/14.

3. Record review of Medication Variances Reports for March through August, 2014, showed no variance reports for the missing Lorazepam on 07/18/14 and 08/01/14.

During an interview on 09/18/14 at 12:00 PM, Staff XX, Director of Pharmacy, stated that the facility did not complete variances reports for incidental losses, and therefore, there were no variances reports completed for the missing Lorazepam on 07/16/14 and 08/01/14.

4. Record review of Staff EE's employee file showed no documentation or investigation or follow-up to the missing Lorazepam.

During an interview on 09/17/14 at 11:20 AM, Staff EE stated that she did not know anything about the missing Lorazepam on 07/16/14 and 08/01/14, and that she had never been questioned about the missing Lorazepam.

5. During an interview on 09/16/14 at approximately 9:00 AM, Staff XX stated the discrepancies for the Lorazepam were not reported to any Federal or State Agencies because it was considered insignificant day to day loss of controlled substances.

Based on observation, interview and record review the facility Food and Nutrition Services (FNS) failed to ensure the following:
- The Director was qualified by maintaining continuing education hours to keep certification as a dietary manager (refer to A 620);
- The Director established and maintained new employee orientation and routine periodic in-service training for employees including basic safe food storage, basic food sanitation and food handling (refer to A 620);
- The Director established, implemented and maintained policies for cleaning and sanitizing equipment, food contact and non food contact surfaces and for use of appropriate hand hygiene (refer to A 620);
- The Director established and maintained FNS specific QAPI studies and contributed those to the facility wide QAPI program (refer to A 620);
- The Director and the Registered Dietitian (RD) established and maintained policies, and procedures for the nutritional care of tube fed patients including distribution of tube feeding products (refer to A 621);
- The RD supervised and directed patient nutritional care by overseeing nutritional screening and performing nutritional assessment according to consistent criteria documented in facility policy (refer to A 621);
- The RD collaborated with Nursing Services to establish and maintain consistent nutrition screening policies and procedures to identify patients at nutritional risk on admission (refer to A 621);
- The RD maintained patient care data to ensure adequate follow up care was provided to patients identified at nutritional risk (refer to A 621);
- The Director and the RD developed facility menus to meet the nutritional needs of the patients especially the younger Psychiatry patients (refer to A 628).
- The Director and the RD established and maintained current and accurate policy describing the availability of an approved facility diet manual (A 631).

These deficient practices placed all patients at risk for unsanitary food service, cross contamination of food and possible food poisoning and placed all patients at risk for inadequate nutritional care.

These systemic failures contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Food and Dietetic Services.
The facility census was 41.

Based on observation, interview and record review the facility failed to ensure that the Director of Food and Nutrition Services (FNS) was qualified with documented, current education and training. The lack of current education and training had negative impact on the department as demonstrated by his failure to implement appropriate food service orientation and training for staff; his failure to implement and enforce basic food sanitation policies and procedures including appropriate food storage, cleaning of equipment and food contact surfaces, and hand hygiene; and his failure to establish and maintain an appropriate quality assessment and performance improvement program for the department.

These deficient practices allowed the contracted staff person, without current training and education, to ineffectively manage the department and negatively impact all aspects of the patient food and nutrition services. The facility census was 41.

Findings included:

1. Review of the Association of Nutrition and Food Service Professionals (ANFP) website showed a Certified Dietary Manager was required to earn 45 continuing education credit hours (CEUs) every three years in order to maintain the certification. Five of the CEUs were required to be in sanitation and food safety. Since CEUs were only awarded to education programs related to the industry, the requirement guaranteed access to updated knowledge used to develop professional skills. Methods of earning CEUs included readily available sources such as reviewing ANFP approved articles online; reading approved resource books; completing ANFP online courses and webinars and attending ANFP state, regional and national meetings.

2. During an interview on 09/16/14 at 9:30 AM, Staff L, Director of Food and Nutrition Services (FNS) stated the following:
- He obtained certification as a dietary manager on 03/31/12.
- He had not maintained the required continuing education requirements since that time.
- He had not undertaken any CEU course work or attended any of the approved meetings in the last two and a half years.

During an interview on 09/16/14 at 10:15 AM, Staff L stated the following:
- He had not developed structured and documented orientation to the FNS and if he had a new staff person he just told them what to do.
- The newest staff person was a cook/supervisor hired two weeks ago.
- Staff L had not documented any verbal instruction he had given the new cook/supervisor and had not watched the new person to check comprehension of instructions.
- He had no documentation any special diet preparation training provided to the new cook/supervisor (special diets were served to patients).
- Staff L did not have a planned annual training schedule for all FNS staff and stated, "I should have one."
- Staff L felt he provided training through daily "huddles" during which undocumented topics were briefly discussed without follow-up or monitoring for comprehension of the information he had verbally presented.

3. Record review of the FNS policies and procedures manual showed the policies were last approved on 12/19/12 and directed that the next annual review was scheduled for 11/13.

During an interview on 09/16/14 at 10:42 AM, Staff L confirmed the FNS policies and procedures were last approved on 12/19/12 and he had failed to review the policies in 11/13 as directed by the department policy. He also confirmed that he was responsible to ensure the policies were up to date and followed by staff.

4. Record review of the facility's policy titled, "Food Handling Guidelines," revised 03/12 directed FNS to clean and sanitize specific areas including floors and specific pieces of equipment in the department.

5. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the FNS showed examples of the lack of basic food sanitation to clean equipment and floors and the lack of ongoing monitoring by Staff L:
- A heavily soiled table mounted can opener in the cook's table, with a streak of congealed reddish colored food adhering to the blade and gears behind the blade.
- A heavily soiled floor in the chemical storeroom with cove base missing and loosened off the walls.
- Soiled floor in the refrigerator with a debris lined perimeter of spilled food, unknown debris and torn paper.
- A soiled floor in the walk-in meat freezer with unknown debris around the perimeter.
- A dessert walk-in refrigerator with soiled floor, spilled foods and paper debris lining the perimeter and under shelving.

During interviews done concurrently with the observations on 09/16/14 from 10:55 AM through 11:30 AM, Staff L confirmed the can opener was soiled and should be cleaned; and the floors in the chemical store room and in the refrigeration units were soiled and needed to be cleaned.

6. Record review of the facility's policy titled, "Food and Supply Storage Procedures," revised 03/12 directed staff to store foods in appropriate refrigeration; to store food in clean areas; to store food in clean containers and to store food off the floor.

7. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the FNS department showed examples of poor food storage and lack of ongoing monitoring by Staff L including:
- Ceiling tiles in the dry food storeroom broken out and damaged with browned and blackened circles over an area where dust and debris covered soft drink dispensing equipment and where cases of soft drink concentrate were stored;
- An opened, partial 48 ounce container of chocolate syrup with a manufacturer's label directing "refrigerate after opening" unrefrigerated out on a shelf in the dry food storeroom;
- Two heavily soiled canned goods racks (with nine shelves each) covered with dust, unknown debris and ceiling tile particles in the dry food storeroom with the rims of the cans in the heavily soiled tracks.
- A thirty three pound case of raw chicken stored on the soiled floor of a walk-in refrigerator.
- An opened to air case of lettuce stored on wire shelving under a case of unwashed potatoes.
- Two cases of milk stored on the floor of a walk-in refrigerator that had dripped milk which pooled around the cartons in the bottom of the cases (one carton was opened).
- A heavily soiled bulk container of cornmeal without external label stored under the cook's preparation table.
- An opened, partial 20 ounce container of caramel sauce labeled by the manufacturer to "refrigerate after opening," stored on the shelf next to the cook's preparation table.

8. During an interview on 09/16/14 at 10:54 AM, Staff L stated he could not recall if the facility had a personal hygiene policy (that included hand hygiene) for FNS staff to follow.

9. Observation on 09/17/14 of poor hand hygiene by FNS staff in the kitchen and on the patient unit showed Staff L failed to perform ongoing training and monitoring of the training:
- At 11:25 AM, Staff FF, Diet Aide, handled foods for patient meal service and gloved without hand hygiene;
- At 11:30 AM. Staff OO, Cook, with gloved hands, pushed a soiled cart into place near the tray line, then without removing soiled gloves, using hand hygiene and re-gloving, portioned food onto patient trays using her soiled gloved hands;
- At 11:45 AM, Staff OO assembled foods on patient meal trays, reached over the steam table which allowed the edge of her uniform sleeve to touch foods on plates while she assembled;
- At 12:05 PM, Staff L gloved without hand hygiene and handled pureed foods for patient meal service;
- From 12:11 PM through 12:22 PM, Staff GG, Diet Aide, delivered trays to multiple patients. He entered each room with food trays; touched patient over bed tables; moved objects on over bed tables and exited each room without hand hygiene performed before the next tray in the food cart was handled.

During interview on 09/17/14 at 12:26 PM, Staff GG confirmed that he had not used hand hygiene between each patient tray delivery and he knew he should have done so.

10. During an interview on 09/16/14 at 10:58 AM, Staff L stated he had not developed and maintained any formalized Quality Assessment/Performance Improvement (QAPI) studies or projects for the FNS. He stated that he had met with the facility QAPI staff person however, had not developed any QAPI.

Based on observation, interview and record review the facility failed to ensure the Registered Dietitian (RD):
- Adequately supervised and directed patient nutritional care by oversight of nutritional screening and performing nutritional assessment using consistent criteria as documented in facility policy;
- Collaborated with Nursing Services to develop nutritional screening criteria used in nurse admission assessments;
- Adequately supervised the nutritional care of tube fed (nutrition received via tube into the body) patients;
- Maintained pertinent patient data to ensure follow up nutritional care, consistent with each patient's need.

These deficient practices had the potential to prevent or delay adequate nutritional care to patients who were at nutrition risk. The facility census was 41.

Findings included:

1. Record review of the facility's Food and Nutrition Services policy titled, "Initial Assessment," revised 03/12 showed direction for nursing staff to perform an initial nutritional screening based on (a lengthy list of) pre-determined criteria including:
- Tube feeding;
- Skin breakdowns, wounds;
- Albumin less than 2.8 and prealbumin of less than 16 (both are blood proteins, which are indicators of nutritional status);
- Consult the RD if the patient was found to be at potentially increased nutritional risk (met four or more of any of the criteria).
- The Diet Technician evaluated information from sources including Pharmacy, Medical Services, and Admitting.

2. During an interview on 09/17/14 at 2:50 PM, Staff M, Registered Dietitian (RD), stated the following:
- She had not collaborated with any Nursing Services staff to develop the lengthy list of criteria that she expected nurses to gather when a patient was admitted;
- She did not know who wrote the criteria (she did not) so, did not know why some criteria were on the list;
- Felt the criteria should include "all laboratory values" but, did not have a specific nutritional reason for wanting to add "all laboratory values" to the list;
- Felt the Braden scale (multi-factor rating scale to assess pressure ulcer risk) was not used by nursing staff to assess wounds (later retracted when reviewing a patient medical record showed nursing staff had used Braden scoring);
- Felt that sometimes nursing staff failed to screen all patients so she had to screen some patients.
- Did not know how many times (because she did not maintain records) the nutritional screening resulted in a consult for her to review nutritional status;
- Since she did not maintain records on patients who were screened at nutritional risk, she could not determine which patients needed follow up nutrition care;
- She documented all of her work in the facility's patient electronic medical records (EMR);
- Stated the facility never had a staff person called "Diet Technician" as indicated in the policy.

3. Observation of Staff M and concurrent record review on 09/17/14 at 2:50 PM, showed Staff M accessed the EMR of several patients and could not identify any criteria in the EMR that were used to perform nutritional screening.

During an interview on 09/17/14 at 2:50 PM, Staff M confirmed:
- She could not find the EMR criteria for nutritional screening used to identify patients at nutritional risk;
- She did not know why and did not know who she needed to collaborate with to obtain information regarding the EMR computer system;
- The inconsistencies between the policy and the EMR entries could cause delay; failure to identify patients at nutritional risk; or error in identification of patients at nutritional risk.

4. During an interview on 09/16/14 at 10:07 AM, Staff M stated that:
- The facility did not have a policy and procedure directing staff on how to handle physician's orders for tube fed patients.
- She worked with the Food and Nutrition Services (FNS) contractor;
- FNS was not involved (did not handle tube feeding orders);
- Thought that the physician's tube feeding orders were transmitted to Materials Management or Pharmacy;
- Was not sure but felt the tube feeding products came from the Supply department across the street from the facility;
- Did not know who was responsible for checking and confirming the accuracy of the type and amount of tube feeding provided to those patients.

5. Record review of an undated job description for the facility RD, (provided by Staff SS, Human Resources Manager) showed one of the responsibilities of the RD was evaluation of nutritional care of all tube fed patients.

Based on interview and record review the facility failed to ensure the facility menus, served to all patients, met the nutritional needs of each individual patient. This failure especially affected younger Behavioral Health Unit (BHU) patients as evidenced by two (#1 and #13) of 17 patients interviewed. This deficient practice had the potential to under feed some younger patients and/or allow poorly accepted foods to be served to patients. The facility census was 41 with 23 of those on the behavioral health units.

Findings included:

1. During an interview on 09/16/14 at 9:50 AM, Staff M, Registered Dietitian stated that the facility used menus written by the company that sold groceries and food service supplies to the facility.

During an interview on 09/17/14 at approximately 11:30 AM, Staff L, Director of Food and Nutrition Services (FNS) stated that the facility menus were served as written (no changes for quantity or portion sizes) to all patients in the facility (BHU patients received the same types and amounts of foods as the medical/surgical unit patients who were ordered to have the same diet).

2. Record review of the "Menu Guide," dated 2012, provided by the grocery company showed the following:
- The overview of the menus provided showed the menus were written to meet the nutritional status of older adults residing in health care communities.
- The menus were provided only as a guide and that the grocery company expected each facility to review the menus and ensure the menus met the needs of the facility's population.
- The "Menu Planning" section of the overview described that the menus were written for Long Term Care (Nursing Homes.)
- The menus were written for a 51 to 70 year old female (the most prevalent age and gender of Nursing Home patients.)

During a telephone interview on 09/23/14 at 11:35 AM, Staff GGG, Licensed Practical Nurse (LPN) confirmed the following:
- The Adult BHU patients ranged in age from 18 to 55 years;
- The Geriatric (older) BHU patients were above 55 years of age;
- The BHU always had more adult patients than Gero-BHU patients.

3. During an interview on 09/16/14 at 10:45 AM, Patient #1 stated that food portions were too small, they can't always get seconds, and "I'm a grown man, look at my size." He also stated that sometimes the eggs come up cold and it was not appetizing.

During an interview on 09/18/14 at 12:50 PM, Staff EE, Registered Nurse (RN), stated that the most common patient complaint was about the food.

4. During an interview on 09/18/14 at 1:55 PM, Patient #13, stated that patients had complained that they wanted larger portions of food.

During an interview on 09/18/14 at 2:00 PM, Staff E, Nurse Manager, stated that patients complained a lot about the food and they did not like the food.

During an interview on 09/18/14 at 2:20 PM, Staff JJ, Certified Nurse Assistant (CNA), stated that patients had complained about the portions of food not being enough.



31891

Based on observation, interview and record review facility staff failed to ensure an approved, current diet manual was available to all staff for use as a diet reference. This deficient practice had the potential to permit patients to be served unapproved diets. The facility census was 41 with 18 of those on special diets.

Findings included:

1. Record review of the facility's policy titled, "Review and Approval of Diet Manual," revised 03/12, showed the following direction:
- The facility's diet manual was maintained online and purchased from the American Dietetic Association (ADA).
- The manual from the ADA was designated as the approved diet manual for nutrition therapy in the facility.
- A hard copy of the Texas Dietetic Association (TDA) diet manual (not the ADA diet manual) would be maintained in the FNS (Food and Nutrition Services) diet office for use when the staff could not use the online ADA diet manual.
- The annual approval documentation for both diet manuals (TDA and the ADA) was maintained in the front of the TDA diet manual.

2. During an interview on 09/16/14 at 10:10 AM, Staff M, Registered Dietitian (RD) stated that:
- She had no knowledge of the TDA diet manual;
- She did not know the TDA diet manual was mentioned in the facility policy;
- She felt the facility did not have a copy of the TDA manual;
- The diet office did not have a copy of the TDA manual;
- She did not have any documentation that the online ADA diet manual was approved for use in the facility.

During an interview on 09/17/14 at 12:30 PM, Staff KK, Registered Nurse (RN) stated that she did not know where the facility diet manual was located but felt it may be on a book shelf in the medication room.

3. Observation on 09/17/14 at 12:30 PM showed Staff KK searched a book shelf in the medication room on the acute unit.

During an interview on 09/17/14 at 12:31 PM, Staff C, Chief Nursing Officer stated that he thought the diet manual was kept in the medication room on a book shelf.

During an interview on 09/17/14 at 12:32 PM, Staff PP, Licensed Practical Nurse (LPN) stated that she did not know where the diet manual was kept.

Based on observation, record review, and interview, the facility failed to:
- Make necessary repairs to walls, ceilings, floors, doors and trim to reduce hazards and enhance housekeeping to ensure that the condition of the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. (Refer to A701)
- Conduct at least one facility-wide annual disaster drill. (Refer to A701)
- Meet the requirements of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2000 (existing) Life Safety Code of the National Fire Protection Association (NFPA) to provide a safe environment for all patients, staff and visitors. (Refer to A710)
- Maintain an effective preventative maintenance (PM) program for patient care equipment in the Behavioral Health Units (BHU), radiology, emergency department, and in the food service department. (Refer to A724)
- The facility also failed to ensure an acceptable level of safety and quality by storing foods in a safe, sanitary manner. (Refer to A724)

Due to the widespread and cumulative effect of these deficient practices, which presented multiple hazards that directly affect the safety and well-being all patients, staff and visitors, it was determined that 42 CFR 482.41 Condition of Participation: Physical Environment was out of compliance. The facility census was 41.

Based on observation, record review, and interview, the facility failed to make necessary repairs to walls, ceilings, floors, doors and trim to reduce hazards and enhance housekeeping to ensure that the condition of the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. The facility also failed to conduct at least one facility-wide annual disaster drill.

Without a routine and scheduled maintenance program to make necessary repairs to the physical environment the 101 bed facility cannot ensure a healthy environment for patient care. Without rehearsed and tested disaster drills, the facility cannot assure the safety of patients and staff during a disaster situation. These deficient practices affect all staff, visitors and patients. The facility census was 41.

Findings included:

1. Record review of a housekeeping procedure titled, "Housekeeping Services To Be Performed", dated 06/09/14 showed that housekeepers were assigned to clean patient rooms and common areas daily, seven days a week. The procedure showed staff was to wet mop the floors and wet wipe all furniture with germicidal solution. The procedure directed housekeepers to clean and disinfect patient's washrooms, bathrooms and furnishings with germicidal solution. The procedure directed housekeepers to daily clean the non-occupied patient areas such as utility rooms, nourishment stations, treatment rooms and diet kitchens.

2. Observation on 09/16/14 at 9:30 AM of a common shower in the hospital critical care unit showed an eight by four inch area of missing floor tile on the crest of the ridge that keeps shower water from flowing on to the bathroom floor. The shower also had dark brown and pink stains that looked like mold in the corners and grout around the perimeter of the tiled shower, and soiled dark stained grout at the threshold of the door entering the bathroom, especially darkest at the corner base of the door frame.

During an interview on the same date and time as above, Staff DD, Director of Maintenance agreed with the finding and stated that there was no work order submitted for the missing floor tiles.

3. Observation on 09/16/14 at 10:15 AM of the outpatient rooms showed peeling paint and scuffed, chipped plaster corners and entrance doors in 16 of 16 patient rooms (110, 111, 112, 113, 114, 115, 119, 121, 122, 123,124, 125, 126, 127, 128, and 129.)

4. Observation on 09/16/14 at 1:30 PM of the second floor Medical-Surgical inpatient rooms showed peeling paint and scuffed, chipped plaster corners and entrance doors in 16 of 16 patient rooms (210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 229.)

5. Observation on 09/16/14 at 3:15 PM and 09/17/14 at 1:30 PM in the Resolutions (BHU) wing showed the following:
- Group dining/activity room: Missing tiles in a six foot by two foot area in the center of the room exposed the barren concrete floor with bits of adhesive. A large area (approximately 15 feet by 12 feet) of the vinyl tiled floor in the room was lined with numerous hairline cracks and crevices and buckled and sunken tiles. The cracked tile surfaces extended into the corridor that served the room. Corners of the room and areas of the edge along the cove base were soiled and darkened with soil accumulations not removed when the floor was cleaned. There were gaps between the four-foot pieces of cove base and the wall, and a corner piece was missing from the southwest corner of the room. Six of six white painted window sills were dusty, scratched and marked up from heavy use. The wall along the north side of the room was marked up and had holes in several places, the largest area of broken plaster measured about 12 X 12 inches.

6. Observation on 09/16/14 at 3:30 PM and 09/17/14 at 1:30 PM in the BHU of 17 of 17 patient rooms (252, 253, 254, 255, 256, 257, 258, 259, 260, 264, 269, 271, 273, 277, 278, 283, and 284) showed:
- Black lines of soiled grout and caulk around the base of toilets and accumulated unidentified soil and hair in corners, behind toilets and around the edge of each toilet room.
- Black lines of soil, which measured approximately one quarter inch in width ringed the edge of each room at the bottom of the cove base and expanded into corners and under the sinks.
- Cove strips throughout the unit (most were in four foot sections) applied to the had gaps up to one quarter inch wide between them and peeled away from the wall at the corners, which provided multiple areas where dust and dirt had accumulated.

Observation on 09/16/14 at 3:30 PM and 09/17/14 at 1:30 PM in other areas of the BHU showed:
- Yellowed floor with accumulated dust and dirt behind open bi-fold doors in a smoke wall that divided the unit.
- A common shower room near Room 259 had missing cove base at the entrance to an alcove for the washer and dryer, and the flexible hose that attached to the vent pipe was torn off, (which left no external exit point for the dryer exhaust).
- A common shower room on the west hall had pieces of cove base missing from the end base of the partial wall that enclosed the shower stall.- A common shower stall on the east hall had black colored residue that looked like mold inside the floor drain tray and around the edge up to 12 inches above the shower floor. Rivulets of the black substance had grown up the grout and tiled sides of the lower portion of the shower wall.

Observation on 09/16/14 at 3:20 PM showed the toilet in room 255 had been moved or knocked askew, which exposed areas of black stains and unidentifiable debris where the base of the toilet had been. There was also a strong urine smell in toilet rooms 256 and 257.

7. Observation on 09/16/14 at 2:10 PM showed a collapsed ceiling in room 305, part of the obstetrics/newborn unit (OB) that recently closed. Several ceiling tiles had collapsed when wet and fallen out of the metal suspension grid, and pieces lay piled on the floor.

8. Numerous observations throughout the facility showed multiple ceiling tiles (Dietary, patient rooms, food storage area, group rooms and medical records room) with dark stains and ringlets (evidence of past and present leaks.)

9. Observation on 09/16/14 at 9:00 AM showed a brown spot about the size of a dinner plate on a ceiling tile in the conference room off the corridor near the reception desk. An unidentified maintenance repairman brought in another ceiling tile and replaced the stained one. The next morning on 09/17/14 at 8:30 AM, the replacement ceiling tile had a wet spot on it that continued to widen and was still present on 09/17/4 at 1:00 PM.

During an interview on 09/16/14 at 2:10 PM and at 3:30 PM, Staff DD, Director of Maintenance stated that the roof was in constant need of repair. He stated that it was an old roof, he did not know how old, but based on the frequency of repairs needed, he felt like the roof should be replaced if the facility could afford it. He stated that maintenance generally tried to patch and repair any leaks as soon as they were reported or observed. He stated that there have been many leaks in the BHU, kitchen, and OB unit. He stated that those areas had no floors above them and leaks could show up quickly and without prior warning.

Staff DD agreed with the finding on maintenance problems in patient rooms and common areas. He stated that Maintenance use to do quarterly rounds for preventive maintenance, however since the facility was short on money and with staffing cuts in maintenance, housekeeping and other departments, he had neither the extra personnel or enough time to address preventive maintenance. He stated that he and the two staff assigned to maintenance could not keep up. He stated that the scuffed and scratched window sills along the BHU north wall were damaged because patients liked to put their feet up on the window sills and look out the large windows.

10. Observation on 09/16/14 at approximately 9:20 AM in the Health Information Management (HIM) main office area showed:
- Approximately 38 feet of damaged interior wall (a wall with multiple windows that overlook the roof of an adjacent section of the building);
- The wall damage showed sections of the wall covering loosened and partially detached from the wall surface by as much as one to two inches and ceiling tiles sagged from the metal suspension grid.
- Approximately six to seven random ceiling tiles each showed various sized circles of brown and black colored stains;
- Approximately 38 feet of 12" by 12" floor tile showed brown stained sections with gouged and marred corners.

During an interview on 09/16/14 at 9:20 AM, Staff K, Director of HIM, stated that:
- The walls had been damaged by rain water and the wall covering had come off the walls.
- The ceiling tiles were damaged after a rain storm and had remained stained.
- The floor tiles along the water damaged wall were also buckled and damaged by rain water.

11. Observation in the Emergency Department (ED) on 09/16/14 at 9:15 AM showed five large areas (at least 24 inches by 24 inches) where the paint had peeled away from the wall. These areas were in the patient treatment rooms as well as the common hall areas.

Observation in the ED Nurses station on 09/16/14 at 9:20 AM showed two large areas (at least 10 inches by 12 inches) where the floor tile had been completely worn away down to the concrete subfloor.

During an interview on 09/16/14 at 9:25 AM, Staff J, ED Nurse Manager, stated that after the walls were painted, for some reason, large areas peeled off. Maintenance had not repaired it yet. Staff J stated that the tile had just worn away over the years and it hadn't been fixed.

12. Record review of the US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code directed the following:
- Chapter 4-601.11(C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
- Chapter 4-602.13 Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
- Chapter 6.201.11 Floors, floor coverings, walls, wall coverings and ceilings shall be designed constructed and installed so they are smooth and easily cleanable.

13. Observation on 09/16/14 at 1:05 PM showed 13 ceiling tiles in a dry goods storage area of the kitchen (used to store paper plates, plastic utensils and ceramic dishes.) Ten of the 13 ceiling tiles had dark ringlet stains on them, several of the spots were black colored with residue that looked like mold, two were broken, and one of the two by four tiles was missing entirely, which exposed wiring, air duct and plumbing systems.

Observation on 09/16/14 at 1:10 PM, of a large dry food storage room in the kitchen showed the following:
- Nine missing ceiling tiles, each two feet wide by four feet long, exposed wiring, air vents and plumbing and did not present a safe and clean environment for food storage.
- Ten places on ceiling tiles had brown stains from past or present water leaks.
- Floor tiles along the east wall were buckled and broken from a past water leak.
- Eighteen floor tiles on the west wall were buckled from water damage and had turned up edges, which exposed adhesive which could collect dirt and fuzz.
- The floor was soiled with dust, pieces of onion skins, as well as bits of paper and plastic packaging, and had multiple cracks and rust spots from the wire shelf racks sitting on it.
- Multiple nicks and scratches on all four walls of the food storage room exposed open plaster and failed to present an easily cleanable surface.

Observation on 09/16/14 at 1:20 PM of the kitchen showed:
- The fresh air return vent along the front lip of a hood had accumulated dust and lint fuzz embedded in a grease-laden film.
- The drywall above the air conditioning unit was pulled away from the wall at the ceiling and formed a gap of unknown width between the surface and the framework of the wall.
- The lower part of a wall behind the cook line was caved in, which exposed drywall chalk dust and the inner framework of the wall and was not an easily cleanable surface. The damaged area measured 15 inches wide by four inches high and was right above the cove base.

During an interview on 09/16/14 at 1:00 PM, Staff L, Director of Food Services, stated that he was a contracted employee and he did not know of a policy or written schedule for housekeeping to clean the kitchen. He stated that kitchen staff generally cleaned up after themselves between meals, and mopped the floors in the evening. He stated that it was his understanding that housekeeping was supposed to be coming in to clean the floor and to do some kind of deep cleaning (strip, clean, apply new wax and buff) monthly, but he had not seen evidence of it. He stated it had been an unknown length of time since he had seen any deep cleaning in the kitchen by housekeepers. He stated that kitchen staff had never cleaned the fresh air return vents at the front of the hood. He stated he did not have a policy or procedure that included that. He stated that it had been difficult to get maintenance in to fix anything with the hours the kitchen kept. He said they have had some wall repairs and several ceiling tiles replaced, but his work orders submitted in June and July to have some mold cleaned and ceiling tiles replaced had not been resolved.

14. During an interview on 09/17/14 at 11:55 AM Staff OOO, Director of Housekeeping stated that if there was a structural or maintenance related problem that prevented housekeepers from doing their daily routine, he created a work order as soon as possible and tried to get maintenance on it. He stated that he did not have a policy to provide specific guidance for housekeepers to report a maintenance problem. He stated that staffing cuts had hurt his productivity. He stated that if he had an extra housekeeper, he could keep the BHU shining. Due to the [staffing] cuts, he had no one to work on BHU to strip and wax the floors on a full time basis like they should be. He stated that is was the same case for the kitchen. His 3:00 PM-11:00 PM shift was assigned to clean the kitchen, but they had been getting pulled to help out in other areas due to call-ins and staff shortages. He stated that he's been with the facility for 36 years and this is the "worst it has ever been" (shortage of staff and over burdened with responsibilities). He stated that the infection control nurse is supposed to review housekeeping policies, procedures and services annually to give him feedback on what could be done better. He stated that he does random inspections in patient areas for quality and to make sure his employees are doing their jobs; however he had only been eyeballing the BHU, and was not reporting on any performance initiatives to Quality Assurance (QA, a system for ensuring a level of quality in service/performance) for that unit.

15. Review of the facility's, undated disaster plan titled, "Emergency Operations Plan", showed the facility had an organized plan for several types of disasters, however there was no documentation that the plan had been reviewed and approved by the medical staff, and no directive in the plan for staff to conduct at least one disaster drill with written critique every 12 months.

Record review showed no evidence that the plan was approved by the medical staff and no records of annual drills with written after-action reports, and no record of a rehearsal or drill conducted in the past 12 months.

Record review showed no current information regarding contact or planning meetings with the state, county or local first responders.

During an interview on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance, confirmed that no disaster drills had been conducted during the past year. He stated that he didn't remember when the last drill was conducted, whether it was last year (2013) or the year before last (2012). He stated that no one was currently in charge of developing and implementing drills. He stated that the person who was in charge of the disaster preparedness program was in the the Emergency Medical Services (EMS) staff, and they were released in the spring (March) of 2014 due to shortage of funds. He stated that the security staff, who were also designated in the Emergency Operations Plan, were released for the same reason. He stated that the hospital did not have any special equipment such as protective suits and tents.







16215




29511

Based on observation, interview, policy review, and review of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2000 (existing) Life Safety Code of the National Fire Protection Association (NFPA) the facility failed to provide a safe environment. The facility must be in compliance with all applicable codes referenced in the Life Safety Code. The facility failed to ensure:
- Doors to two (122 and 123) of 19 patient room doors closed and latched securely to resist the passage of smoke into corridors or patient rooms. This deficient practice had the potential to prevent staff from being able to isolate a fire to a limited area and prevent the spread of smoke and, could affect all patients, staff and visitors on the first floor medical-surgical wing.
- Annual inspection, testing and maintenance of the facility fire alarm system by qualified and experienced personnel. This failure could potentially jeopardize the life safety of all patients, staff and visitors.
- Required safety measures for designated smoking areas were implemented and enforced in one of one designated smoking area for Behavioral Health Unit (BHU) patients. This deficient practice could potentially result in a fire from unsecured cigarette ash residue that was not emptied into proper receptacles.
-The kitchen range hood received biannual (twice yearly) inspection, testing and maintenance. Failure to ensure the fire suppression system was ready for use endangered the kitchen staff, and increased the chances of a grease fire getting out of control in an unsprinklered area of the building.
- Self-closing doors to an unsprinklered (not protected by a sprinkler system) soiled linen chute, which extended over three floors were maintained in good working order. This deficient practice had the potential to spread fire quickly to other floors in the building, affecting all patients, staff and visitors.
- Flammable liquids were stored in an approved container suitable for storage of flammable and combustible liquids. This deficient practice could potentially affect the safety of all staff and patients.
- Appropriate, readable precautionary signs were posted on the door to a corridor room where flammable compressed gases were stored for use by Respiratory Therapy. Warning signs are mandated for listing hazards to protect fire-fighters and first responders who respond to a fire and failure to provide signage endangers all patients, staff and visitors.
- They load tested the diesel fueled generator during the past 12 months to ensure reliability of the facility's single source of emergency power. All hospitals are expected to have life support capability and to have a minimum of two separate electrical systems backed up by one or more power plants (generators), which support the emergency (Life Safety) branch and the critical branch. The emergency branch system is limited to circuits essential to life safety and patient care. The critical branch is for remaining essential systems; HVAC (heating, ventilating and air conditioning), pumps, utility support equipment, etc.
- Annual safety inspections for three of three elevators, which were in frequent use daily. Should a catastrophic equipment failure occur, this deficient practice could potentially result in serious injury or death for patients, staff or visitors.
The facility census was 41.

Findings included:

1. Observation on 09/16/14 at 11:15 AM showed the entrance door to patient rooms 122 and 123 failed to close into the door jamb (the vertical portion of the frame onto which a door is secured) due to misalignment and binding. The doors required a hard pull with considerable force to close into the jamb and latch.

During an interview at the same date and time, Staff DD, Director of Maintenance, agreed with the finding and stated that due to his staff being cut, maintenance personnel had not enough time to perform regularly scheduled preventive maintenance rounds to ensure a high quality environment of care. He stated that there was no policy and procedure to govern preventive maintenance rounds. He stated that he used to make quarterly rounds but being short of staff, they were all busy trying to keep up with repairs.

2. Record review of invoices from an outside vendor for fire alarm inspections on 09/17/14 at 10:15 AM showed the last annual inspection, testing and maintenance (checking backup batteries or replacing faulty pull stations) of the facility fire alarm was performed on 02/14/13. Staff DD, the Director of Maintenance, showed two requisitions dated 06/05/14 and 08/28/14, that he had submitted to Administration to have the alarm company come and perform the scheduled annual inspection, test and maintenance.

During an interview on 09/17/14 at 10:30 AM, Staff DD stated that he had submitted the requests twice but the facility had been short of funds so he was not sure if either requisition had gone through. He stated that generally vendors contact the facility ahead of time so the inspection and tests can be arranged, but some vendors received late payments or had not been paid in full for their past services.

3. Record review of an undated smoking policy for the BHU showed that patients shall smoke only in an area designated specifically for smoking. It does not specify the provision for using ashtrays of safe design and a covered container of metal or other suitable fire-resistant (non-flammable) material.

Observation on 09/16/14 at 4:20 PM showed a smoking room located on the BHU. Three containers of ashes, each filled with numerous cigarette butts, were sitting on the floor and one was balanced on the arm of a chair. One of the containers was a 10 inch square cake pan with a narrow rolled rim that was not suitable for resting a cigarette. The second container was the clamshell top of a nearby pedestal ash tray. Although the clamshell top had suitable resting places around the rim, the doors were easily opened and without the bottom half of the container to catch the hot ash, a patient could accidentally trip the doors and have a lap full of hot ashes. The third container was the bottom of the clamshell pedestal ash tray which was not a suitable safe design as it lacked any place around the narrow rim for a cigarette to balance or to be at rest unattended. Without ashtrays of safe design, patients are at risk for being burned or catching their clothing on fire, even in a supervised area.

NFPA requires metal or non-flammable containers with self-closing cover devices into which ashtrays can be emptied to be readily available in all areas where smoking is permitted.

Observation showed that the room lacked an appropriate receptacle for disposal of hot ashes and spent cigarette butts.

During an interview on 09/15/14, Staff UUU, BHU staff, stated that the ash trays were emptied daily into the regular trash.

4. Record review on 09/17/14 at 10:15 AM showed the last two inspections for the kitchen range hood were on 06/10/14 and 04/24/13. Review of past inspections showed the biannual inspection of the kitchen range hood's fire suppression system would have been due in October 2013 (the sixth month), and there was no documentation to indicate a biannual inspection had been performed.

During an interview on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he agreed with the finding.

5. Observation on 09/16/14 at 1:30 PM showed a metal linen chute door in a small soiled linen closet on the second floor was jammed partially open and did not close automatically as designed.

During an interview on 09/16/14 at 1:30 PM, Staff DD, Director of Maintenance stated that the soiled linen chute had been there since the hospital was built and was not sprinklered. He acknowledged the finding and stated that the chain was broken again (which kept the door from closing.)

6. Observation on 09/16/14 1:00 PM in the kitchen's dry goods storage room showed a partially used case of Sterno, (flammable gelatin in a can, used for warming casseroles or dutch ovens), a case of butane canisters for a small cooking stove (highly flammable pressurized gas) and a partial case of charcoal lighter fluid. The cases of highly flammable products were all sitting in their original cardboard containers on open shelves in a small unsprinklered room where all of the kitchens' paper products, paper and plastic dinnerware, foam cups and holiday decorations were stored.

During an interview on 09/16/14 at 1:05 PM, Staff L, Director of Food Services, stated that he probably used the fuel once or twice a week. He stated that he had never been advised to get a special cabinet to store them in and he did not have a policy or procedure on storage and use of flammable gas products.

7. Observation on 09/16/14 at 10:12 AM of a storage room used by Respiratory Therapy contained numerous racks of cylinders of compressed oxygen (a flammable gas product that supports combustion). There was no warning sign on the door. At a minimum, the warning sign should read: CAUTION OXIDIZING GASES STORED WITHIN NO SMOKING

During an interview on 09/16/14 at 10:15 AM, Staff DD, Director of Maintenance acknowledged the finding and stated that there had never been a sign on the door.

8. Observation on 09/16/14 at 10:00 AM showed the facility had a large diesel fueled emergency generator.

Record review on 09/17/14 at 10:15 AM of generator performance logs showed the generator had been exercised weekly and load tested monthly under the facility load (part of the maintenance regimen which allows the generator to run for a while to determine if there are any engine or cooling system problems. Diesel engines especially need a periodic load test in order to maintain performance and fuel economy.) Records showed that the last full load bank test (a preventive maintenance practice to ensure a standby generator performs in the event of a power failure. This test checks the generator engine's ability to perform and provide the required horsepower needed in an emergency) on the generator was conducted on 03/14/12 by an outside company.

During interviews on 09/16/14 and 09/17/14, Staff DD, Director of Maintenance acknowledged that the generator was new in 2010. He stated that he thought he remembered the initial load bank test but due to budget cuts and shortage of funds, the facility had not performed a full load test for at least 12 months.

9. Observation during tours on 09/16/14 at 9:30 AM through 09/17/14 at 1:00 PM showed the facility had three of three passenger elevators in operating condition.

Record review on 09/17/14 at 10:15 AM of maintenance logs and inspection certifications showed the elevators were last inspected on 04/01/13 and licensed by the Division of Fire Safety's Elevator Inspection Division.

During interviews on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he had requested the inspection and the inspector told him that he would get back to him with a date for the inspection. He stated that the inspector had not contacted him since. He stated that the facility had been short of funds. He stated that generally vendors contact the facility ahead of time so the inspection and tests can be arranged, but some vendors received late payments or had not been paid in full for their past services.

Based on observation, interview and record review the facility failed to maintain an effective preventative maintenance (PM) program for patient care equipment in the Behavioral Health Units (BHU), radiology, emergency department, and in the food service department. The facility also failed to ensure an acceptable level of safety and quality by storing foods in a safe, sanitary manner.

These deficient practices had the potential to negatively affect patient safety through staff use of poorly maintained equipment and by patients receiving foods that were inappropriately stored or prepared on soiled equipment contributing to the possibility of cross contamination of foods. The facility census was 41.

Findings included:

1. During an interview on 09/18/14 at 2:00 PM, Staff B, Chief Operating Officer (COO), stated that there were no facility policies that dictated how PM should be managed in the facility.

2. Observation and concurrent interview on 09/17/14 at approximately 3:45 PM in the BHU crash cart (a cart that houses equipment and supplies needed for medical emergencies) showed:
-One defibrillator (medical equipment that shocks the heart when activated during medical emergencies) with an outdated inspection sticker dated 06/30/11;
-Two accucheck monitors (medical equipment that tests the sugar level in the blood) without inspection stickers;
-No suction machine available for emergency suctioning;
- Staff E stated that the suction machine was sent to Central Supply for cleaning two weeks ago following a medical emergency but she did not know why it had not been returned.

During an interview on 09/17/14 at 4:05 PM, Staff MM, Central Supply, stated that suction machines were usually replaced when the used equipment was returned to central supply. She stated there was no record of when equipment was delivered or replaced in the central supply department.

Observation and concurrent interview on 09/17/14 at 4:10 PM showed a suction machine was delivered to the BHU and it had no inspection sticker. Staff NN, Licensed Practical Nurse (LPN), stated that she did not know of an inspection sticker on any suction equipment.

3. Observation in the Radiology Department on 09/17/14 at 1:30 PM showed the Ultrasound machine (Radiology equipment that is used to create images of internal organs) had no identification sticker that indicated the last time the equipment received PM.
During an interview on 09/17/14 at 1:35 PM, Staff PPP, Director of Radiology, stated that the equipment (ultrasound) was overdue for an annual check but a mix-up between vendors had delayed the check. Staff PPP stated that she was not exactly sure when the inspection would occur, but was sure it would get checked soon.

4. Observation of the defibrillator in the Emergency Department on 09/16/14 at 9:40 AM, showed no identification sticker that indicated the last time the equipment received PM.
During an interview on 09/16/14 at 9:45 AM, Staff J, ED Nurse Manager, stated that the equipment was tested every day by staff but she was not sure of the last time PM was performed on the equipment.
During an interview on 09/18/14 at 2:00 PM, Staff B, COO stated that all of the defibrillators in the facility were replaced around the end of 2011. Staff B stated that none of them have had PM checks since purchased. Staff B stated that no one in the facility keeps track of equipment or when safety checks are due.
5. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the facility kitchen showed the following examples of poor food storage practices including:
- Ceiling tiles in the dry food storeroom broken out and damaged with browned and blackened circles over an area where dust and debris covered soft drink dispensing equipment and cases of soft drink concentrate were stored.
- An opened partial 48 ounce container of chocolate syrup with a manufacturer's label directing "refrigerate after opening" unrefrigerated out on a shelf in the dry food storeroom.
- Two heavily soiled canned goods racks (with nine shelves each) covered with dust, unknown debris and ceiling tile particles stored in the dry food storeroom with the rims of the cans in the soiled tracks.
- A thirty three pound case of raw chicken stored on the soiled floor of a walk-in refrigerator.
- An opened to air case of lettuce stored on wire shelving under a case of unwashed potatoes.
- Two cases of milk stored on the floor of a walk-in refrigerator which had dripped milk that pooled around the cartons on the bottom of the cases (one carton was opened).
- A heavily soiled bulk container of cornmeal without external label stored under the cook's preparation table.
- An opened, partial 20 ounce container of caramel sauce labeled by the manufacturer to refrigerate after opening, stored on the shelf next to the cook's preparation table.
- A heavily soiled table mounted can opener on the cook's table, with a streak of congealed reddish colored food which adhered to the blade and gears behind the blade.

During interviews on 09/16/14 done from 10:55 AM through 11:30 AM concurrently with each observations, Staff L, Director of Food and Nutrition Services, stated that:
- Damaged ceiling tiles occurred over time and was especially bad when it rained;
- The 48 ounce container of chocolate syrup should have been refrigerated;
- Two heavily soiled canned goods racks were soiled and should have been cleaned;
- A thirty three pound case of raw chicken should not have been on the floor;
- The large bowl of lettuce should have been covered;
- Two cases of milk should not have been on the floor of a walk-in refrigerator;
- A heavily soiled bulk container of cornmeal should be cleaned once a week;
- The 20 ounce container of caramel sauce should have been refrigerated;
- A heavily soiled table mounted can opener should be cleaned daily.

6. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the facility kitchen showed the following examples of poor basic food sanitation in the kitchen especially heavily soiled, damaged and marred floors contributing to an unsanitary environment in which patient meals were prepared and:
- A heavily soiled floor in the chemical storeroom with cove base missing and loosened off the walls;
- Soiled floor in the refrigerator with a debris lined perimeter of spilled food and torn paper;
- A soiled floor in the walk-in meat freezer with unknown debris around the perimeter;
- A dessert walk-in refrigerator with soiled floor, spilled foods and paper debris lining the perimeter and under shelving.

During interviews on 09/16/14 done from 10:55 AM through 11:30 AM concurrently with each observation, Staff L stated that the soiled floor in the chemical storeroom with cove base damage was being damaged by recent heavy rain fall and the soiled floor in the refrigerators and freezer should be swept daily but it did look like staff had missed the perimeters.





16215




29511

Based on observation, interview and policy review, the facility failed to ensure all patient care equipment and areas throughout the facility were monitored for cleanliness and were cleanable.
- Several pieces of patient care equipment stored amongst many (too numerous to count) multiple use patient care items in a large storage room had visible debris located on areas touched by patients.
- One of one medication room on the 2A Medical Surgical Unit was found unclean.
- Six of 11 chairs on the adult Behavioral Health Unit (BHU) had multiple burn holes (open to the absorbent cushion, not sealed and/or cleanable) that created an un-cleanable surface.
The lack of monitoring and surveillance for all risk of infection had the potential to expose all patients, staff and the community to infections and communicable disease. The facility census was 41.

Findings included:

1. Record review of the facility's policies showed no policy for patient care equipment cleaning or medication room cleaning.

2. Observation on 09/16/14 at approximately 10:20 AM, of the 2A clean storage room showed:
- Two intravenous (in the vein) infusion pumps (machines used for controlling the rate of fluids administered to patients) had multiple areas of dried pink liquid on the lateral and vertical surfaces (too numerous to count) machine;
- A mechanical patient lift had multiple (too numerous to count) dried liquid stains on the base of the lift.
- A bedside commode had multiple dried liquid stains on the base of all four legs.
- Multiple folded walkers and patient assistance devices had visible hand-prints on the rails and handgrips.
No equipment was identified as cleaned.

During an interview on 09/16/14 at 10:25 AM, Staff X, Central Supply Technician, stated that housekeeping staff was supposed to clean some of the equipment and nursing cleaned other equipment. Staff X stated that she did not know how to determine if the equipment was clean.

3. Observation on 09/16/14 at approximately 10:30 AM of the 2A medication room showed:
- All four walls had approximately 50% of the surfaces from the ceiling to mid wall with streams of visible dried light brown liquid stains.
- All floor surfaces were visibly dirty.
- Dried liquid stain around the sink created an (audible) tacky surface when walked on.
- All lateral and vertical shelves had stains and debris throughout.
- Handles on cabinets and glass doors of automated medication dispensing machine were visibly dirty with a higher concentration at the handles.
- Plaster on one corner near the entry door was missing from a section approximately five inches by six inches.
- One ceiling tile to the right rear of the room appeared to have had an ongoing moisture leak which resulted in black staining in an area approximately eight inches in diameter. The area was immediately above a cabinet used for medical equipment storage.

During an interview on 09/16/4 at approximately 10:30 AM, Staff C, CNO, stated that the staff nurses and/or charge nurses were responsible for keeping the equipment and medication room clean.

During an interview on 09/18/14 at 1:05 PM, Staff T, 2A RN Charge Nurse, stated she was not sure who was responsible for cleaning the medication room and patient care equipment until notified by Staff C on 09/17/14.

During an interview on 09/17/14 at 2:00 PM, Staff QQ, Infection Control Nurse, stated that she was not aware of any problems with cleanliness of the 2A medication room or patient care equipment in the storage area. She stated that no surveillance was conducted of the two areas and she was not aware of the process or policy for cleaning the equipment or medication room and stated the storage area and equipment was dirty and did not meet an acceptable standard for infection prevention.

4. Observation and concurrent interview on 09/16/14 at approximately 10:00 AM showed six chairs out of 11 chairs with two to nine burn holes each located in the smoking room on the adult BHU. Staff E, Nurse Manager for the behavioral health units, acknowledged that the chair surfaces were not cleanable with burn holes through the material.






31891

Based on interview, record review and policy review, the facility failed to ensure that the Governing Body or Grievance Committee was responsible for the grievance process when the Governing Body delegated the responsibility of the grievance process to a Grievance Committee that did not exist. The facility also failed to ensure the effective operation of the grievance process for two patient grievances (#30 and #55) of two patient grievances reviewed. This had the potential to affect all patients or patient representatives who filed a grievance against the facility by failing to ensure that patient grievances were resolved. The facility did not maintain a log of grievances. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "Grievance (Complaint) Process for Patient Subject," revised 11/13, showed that when a patient or patient representative filed a grievance:
- The immediate supervisor will visit the patient or their representative to receive and document the nature of the complaint on the Patient Grievance Report.
- If appropriate and within the scope and role of the immediate supervisor, further investigation and implementation of the necessary steps to resolve the grievance will be conducted and completed as soon as possible.
- If the nature of the grievance requires investigation and resolution beyond the scope of the immediate supervisor, the grievance will be submitted to the Director of Nursing and Clinical Services, or designee, for the appropriate distribution, investigation, resolution and follow-up.
- This process may include submission of the grievances to the appropriate Grievance Committee.
- The Administrator, Director of Nursing and Clinical Services, or designee will follow up in writing and verbally with the patient or their representative. Contents of the response will contain the name of the hospital contact person, the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process and the date of completion.
- The Grievance Committee is approved by the hospital Governing Board (Board of Trustees) to oversee the grievance process. The Grievance Committee is utilized as a resource for appropriate review and resolution of grievances.
- The Director of Nursing and/or designee will receive all grievances pertaining to acute nursing care and will maintain a log by classification of type of grievance.
- A summary of all reported grievances and the results of the investigation will be submitted to the Chief Executive Officer (CEO) on a monthly basis.
- The results of the findings of the investigation will be reported to the Board of Trustees on a monthly basis as part of the Quality Improvement (QI) process.

2. During an interview on 09/17/14 at 1:47 PM, Staff C, Chief Nursing Officer (CNO) stated the following about patient complaints and grievances:
- He received all patient complaints and grievances;
- There was no difference between a complaint and grievance;
- He managed complaints and grievances in the same manner;
- He documented his complaint and grievance follow-up sometimes, but not all of the time;
- He had never sent a written response to a complaint or grievance;
- There were no patient or patient representative complaints or grievances in the previous six months;
- He was not aware of a Grievance Committee structure or members. "I am sure I would be part of that committee" if there was one.

During an interview on 09/18/14 at 9:50 AM, Staff TT, Intensive Care Unit (ICU) Nurse Manager, stated that she had recently documented a patient complaint related to care provided by Staff EE, Registered Nurse (RN). Staff TT stated that the complaint was forwarded to Staff C and added that Staff EE was counseled because of the complaint and the complaint was placed in Staff EE's employee file.

3. Record review of the employee file for Staff EE, RN, showed a discipline record with an attached documentation of a grievance filed by Patient #30's representative (family member) on 08/17/14. The grievance was not documented on a Patient Grievance Report. The grievance showed that the patient's representative complained of the following:
- The patient laid in poop two separate times during the day, one time for over an hour;
- Staff EE, who provided care for the patient, had an attitude;
- Staff EE hung (transfused) blood on the patient, left the room, and didn't monitor the patient's vital signs while the blood infused;
- Staff EE tried to get the patient's representative to leave the room while the patient's dressing was changed, which made the representative mad;
- Staff EE failed to ambulate the patient when the patient was to be ambulated four times per day;
- The patient had been up to the bedside commode (portable toilet) only one time throughout the day and was left there;
- Patient #30 was not given a call light because it was broken, so the patient would tap on the bedside with a spoon to get Staff EE's attention, but Staff EE didn't want the patient to tap the spoon on the bed; and
-No one checked on the patient to see if she needed anything.

4. During an interview on 09/18/14 at 11:15 AM, Staff B, Chief Operating Officer (COO) and Staff C verified that the facility did not have a Grievance Committee. Staff C stated that Patient #30's complaint was considered a nursing issue and not a complaint or grievance, and that a written follow-up was not sent to the patient or the patient's representative. Staff B stated that the hospital did receive complaints after patients were discharged, and added that another patient, Patient #55 came back to the hospital administration offices after she was discharged and complained about care she received while she was a patient. Staff C stated that he spoke with Patient #55 when she returned to the hospital and complained, but did not document the complaint, and did not follow-up with the patient in writing.

5. During an interview on 09/18/14 at 2:06 PM, Staff TTT, Governing Body (GB) Chairman, stated that Staff C did not share grievance information with the GB, because Staff C was "focusing on other fires". Staff TTT added that he did not know if there had been any grievances made to the hospital or if there was a Grievance Committee. "I know that we talked about forming a committee, but I don't know if it ever happened".




31891

Based on interview and record review the facility failed to ensure hospital-wide nursing services were organized and under the direction of one Registered Nurse (RN). The failure to provide a well-organized nursing service with a plan of administrative authority by one RN had the potential to affect the quality of nursing care provided to all patients who received care in all areas of the facility. The facility census was 41.

Findings included:

1. Record review of the facility's current organizational chart showed Staff C, RN Chief Nursing Officer (CNO), did not have administrative authority for nursing services in the following areas of the facility:
- Infection Control (IC);
- Surgery Services; and
- Nursing Staff Education.

The IC department reported directly to the facility's Long Term Care Unit (LTCU) Administrator.

2. During an interview on 09/18/14 at 10:10 AM, Staff YYY, LTCU Administrator, stated that she had nursing oversight and management of nursing staff education, case management and utilization review and the IC program.

During an interview on 09/17/14 at 10:00 AM, Staff C, CNO, stated that he did not have administrative authority over nursing services in the Infection Control Program, Surgical Services, Case Management and Utilization Review Services. Staff C stated that the facility did not have an organizational chart specific to nursing services which showed the lines of authority for the different departments and units within the facility.

During an interview on 09/17/14 at 10:30 AM, Staff QQQ, Director of Surgical Services, stated that her departments reported directly to the Chief Executive Officer (CEO) and that she was responsible for all of the nurses in the surgical areas.
During an interview on 09/18/14 at 2:00 PM, Staff B, COO, confirmed that the the surgical areas reported directly to the CEO and any nursing issues were responded to by the Director of Surgical Services.



29511

Based on interview, record review, and policy review the facility failed to ensure verification of nursing staff licensure for five staff (J, C, T, ZZ and BBB) of five personnel records reviewed for verification and valid nursing licensure. The failure to ensure valid licensure of nursing staff had the potential to expose all patients to staff deemed incompetent or unauthorized to perform patient care. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "Nursing Personnel Licensure," revised 11/13, showed direction for staff to provide a current copy of their license to the Department of Nursing.

2. During an interview on 09/16/14 at 9:20 AM, Staff S, Licensed Practical Nurse (LPN), stated that the facility had not asked her to provide a copy of her nursing license.

3. During an interview on 09/17/14 at approximately 10:25 AM, Staff C, Chief Nursing Officer (CNO), stated that he had gone to a website and verified some nurses' licenses. However, he stated that there was not a mechanism in place to ensure verification for all nursing staff.

4. Record review of Staff J, T, ZZ and BBB's personnel files showed Human Resources (HR) staff failed to maintain verification of nursing licensure and did not keep a personnel file for Staff C.
During an interview on 09/18/14 at 12:52 PM, Staff SS, HR Manager stated that the personnel files for facility nursing directors were kept by Staff P, Executive Secretary, and not by the HR department.

During an interview on 09/18/14 at approximately 12:55 PM, Staff P, Executive Secretary, stated she kept the personnel files for the department directors who were nurses however, those files did not contain proof of current nurse licensure. She indicated the Electronic Medical Records (EMR) Co-coordinator (who was the past Chief Nursing Officer) may keep the current nurse licenses for department directors who were nurses.

During an interview on 09/18/14 at approximately 2:00 PM, Staff O, EMR Co-coordinator stated she did not keep the current nurse licenses for anyone and those licenses were possibly in each of the departments where those staff served as department directors.














16215

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that a nurse provided supervision of staff to complete every 15-minute safety checks (patient safety rounds to ensure patients were observed during each 15-minute timeframe) for 12 patients (#1, #11, #12, #13, #19, #20, #21, #22, #23, #24, #25, and #26) of 17 patient records reviewed in the Behavioral Health Unit (BHU.) This had the potential to affect all BHU patients by failing to ensure that the patient's safety needs were met.
- Ensure completion of nursing assessments for five current patients (#1, #11, #12, #13, and #14) and one discharged patient (#29) of six behavior health unit patients whose medical records were reviewed for nursing assessments. This had the potential to affect all behavioral health unit patients by failing to assess and recognize potential changes in the patients' physical health.
- Ensure a Registered Nurse (RN) evaluated the care for one patient (#56) of one patient reviewed who was at high risk for skin breakdown and developed a pressure sore. The failure to provide daily physical assessments per the facility policy, had the potential to contribute to the deterioration of health conditions for all patients, especially patients who were identified at high risk for skin breakdown and pressure sore development.
- Ensure patients were assessed for safety risks before medications were administered for one patient (#45) of six patients reviewed for safe medication administration. This failure to assess for medication safety had the potential to cause an unrecognized, deterioration in patients health conditions.
The behavioral health units census was 23. The facility census was 41.

Findings included:

1. Record review of the undated facility policy titled, "Resolutions (BHU) Staff Monitoring," showed:
- Staff monitoring was instituted to prevent patients from harming themselves or others.
- Physicians orders included the level of monitoring.
- A staff member was assigned the responsibility to complete 24-hour observation logs (forms to record observation of a patient's safety checks at 15-minute intervals throughout a 24-hour period).

2. Record review of physician orders for patients (#1, #11, #12, #13, #19, #20, #21, #22, #23, #24, #25, and #26) showed admission orders that included 15-minute safety checks.

3. Record review on 09/16/14 at 9:40 AM, showed nine patient 24-hour observation log forms on a clipboard with Staff H, Certified Nurse Assistant (CNA). Eight of the nine records showed no documentation of safety checks from 6:45 AM to 9:40 AM for 09/16/14.

During an interview on 09/16/14 at approximately 9:40 AM, Staff H, CNA, stated that she was not not able to observe eight patients during that time frame due to assigned duties on another behavioral health unit.

4. Record review on 09/16/14 at 9:50 AM, showed eight, 24-hour patient observation log forms on a clipboard with Staff I, CNA. Four of the eight observation forms showed no documentation of safety checks from 8:00 AM to 9:50 AM on 09/16/14.

During an interview on 9/16/14 at 9:50 AM, Staff I, CNA, stated that she was not able to conduct four patient's 15-minute safety checks during that timeframe due to other assigned duties.

5. During an interview on 09/18/14 at 11:20 AM, Staff E, Nurse Manager, stated that she was not aware that Staff H and Staff I had not completed 15-minute safety checks and that 15-minute safety checks were required for all BHU patients.

During an interview on 09/18/14 at 1:40 PM, Staff III, CNA, Geriatric Unit, stated that during crises it was difficult to complete 15-minute safety checks on patients.

6. Record review of the undated facility policy titled, "Resolutions, Nursing Assessment," directed staff to complete a nursing assessment to include an assessment of the patient's physical, mental, and emotional factors.

Record review of the facility's policy titled, "Standards of Patient Care," dated 11/2013, showed the following direction for nursing staff:
- All patients received care from nurses who were competent, performed within the scope of their practice and who were responsible for their care.
- Patients received care based on well documented physical assessments every shift.
- Patient assessments included but were not limited to identified patient care needs and nursing standards of practice.
- Skin assessments included inspection of elbows, buttocks and other areas of the skin that were at high risk for increased pressure and skin breakdown.

7. Record review of Patient #1's medical record showed:
-A psychiatric evaluation dated 09/07/14 that showed the patient was admitted to the BHU on 09/06/14 and had a medical diagnosis of pneumonia.
-A physician's order dated 09/06/14 for Levaquin 500 mg (an antibiotic used to treat infections), one time by mouth daily and an Albuterol inhaler (a bronchodialator, medication used to relax muscles in the airways and increase airflow to the lungs), two puffs every four hours for shortness of breath.
-There was no nursing assessment, shift assessment or care plan that recognized pneumonia as a problem or supervised the provision of nursing care.

8. Record review of Patient #11's medical record showed:
-A History and Physical (H&P) dated 09/11/14 that showed the patient had a medical diagnosis of cellulitis to the abdomen.
-An admitting physician order dated 09/11/14 for Bactroban ointment (used for treatment of bacterial infections), apply to the area on the abdomen three times a day for seven days.
-No nursing assessment, shift assessment or care plan that recognized cellulitis as a problem and supervised the provision of nursing care.

9. Record review of Patient #12's H&P dated 09/12/14 showed the patient had a medical diagnosis of chronic obstructive lung disease (COPD, a chronic lung disease that blocks the airflow and makes breathing difficult) with signs of anoxia (low oxygen).
There was no nursing assessment, shift assessment or care plan that recognized COPD as a problem or supervised the provision of nursing care.

10. Record review of Patient #13's medical record showed:
-A psychiatric evaluation dated 09/14/14 showed the patient had high blood pressure and a heart disease with a recent defibrillator (a device that activates a shock to the heart when indicated) implant (surgically placed).
-A physician order dated 09/12/14 for Coreg 25mg (a medication used treat heart and circulation disorders) twice daily and Lisinoprel 12.5 mg (a medication used to treat high blood pressure and heart conditions), by mouth two times daily.
-There was no nursing assessment, shift assessment or care plan that recognized high blood pressure or heart disease as a problem and supervised the provision of nursing care.

11. Record review of Patient #14's medical record showed:
-An H&P dated 09/12/14 showed the patient was admitted on 09/12/14 and had medical diagnoses of Insulin Dependent Diabetes Mellitus (IDDM, a disease characterized by high blood sugar levels that can potentially lead to life threatening conditions if untreated) and hypertension (high blood pressure).
-A physician order dated 09/12/14 for Lantus (a medication used to treat IDDM) by injection at bedtime and Lisinoprel 20 mg by mouth twice daily.
-There was no nursing assessment, shift assessment or care plan that recognized IDDM or hypertension as a problem and supervised the provision of nursing care.

During an interview on 09/16/14 at approximately 11:20 AM, Staff E, RN, Nurse Manager, stated that upon admission and every 12 hours thereafter a nurse conducts a nursing assessment for each patient.

12. Record review of Patient #29's medical record showed:
- A Behavioral Health Unit Admission Assessment dated 08/23/14 at 2:43 PM, did not include a head to toe assessment (complete assessment of all patient body systems, including heart, lung, skin, vital signs, etc) of the patient.
- A Nurse Practitioner's order dated 08/23/14 at 9:35 PM for staff to document bruises to the patient's body thoroughly.
- Nursing assessments between 08/23/14 and 08/30/14, did not include documentation of the patients bruises a

Based on observation, interview, record review, and policy review the facility failed to develop nursing care plans for eight patients (#1, #11, #12, #13, #14, #18, #45 and #56) of 12 patients reviewed for care plan completion. This had the potential to affect all psychiatric and medical patients by failing to ensure that the patients' physical safety and medical needs were met. The Behavioral Health Unit (BHU) census was 23. The facility census was 41.

Findings included:

1. Review of an undated facility policy titled, "Resolutions (BHU) Nursing Assessment," showed direction for nurses to complete a nursing assessment within eight hours of admission and the nursing assessment was instrumental in developing the patient's treatment plan.

Review of an undated facility policy titled, "Resolutions Treatment Plan Overview," showed the following direction for staff:
-Upon admission the admitting/assigned nurse consults with the admitting physician and other staff involved and develops a nursing care plan.
-The initial process addresses the most immediate and obvious needs of the patient on admission.
-Both medical and psychiatric needs should be discussed.

2. Record review of Patient #1's medical record showed the following:
- The Nursing Admission Assessment dated 09/06/14 showed he was admitted to the adult BHU on 09/06/14 with suicidal ideations (thoughts) and a potential for self-harm.
- The Psychiatric Evaluation dated 09/10/14 showed he was admitted with major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), suicidal ideations, and pneumonia (an infection in the lungs).
- The Treatment Plan dated 09/06/14 showed no nursing goals or interventions for suicidal ideations or pneumonia as assessed.

3. Record review of Patient #11's medical record showed the following:
- The Nursing Admission Assessment dated 09/10/14 showed she was admitted to the adult BHU on 09/10/14 with suicidal ideations, a potential for self-harm, and Hepatitis C (an infectious disease that primarily affects the liver).
- The Psychiatric Evaluation dated 09/11/14 showed she was admitted to the adult behavioral health unit on 09/10/14 with schizoaffective disorder (a condition that causes a loss of contact with reality and mood problems), suicidal ideations, and gastro-esophageal reflux disease (GERD, a chronic digestive disease, also known as acid reflux disease).
- The History and Physical dated 09/11/14 showed medical diagnoses of GERD and cellulitis (a bacterial infection of the skin) with physician orders for treatment.
- The Treatment Plan dated 09/10/14 showed no nursing goals or interventions for suicidal ideation, GERD, Hepatitis C, or cellulitis as assessed.

4. Record review of Patient #12's medical record showed the following:
- The Nursing Admission Assessment dated 09/15/14 showed he had suicidal ideation and a potential for self-harm.
- The Psychiatric Evaluation dated 09/15/14 showed that he was admitted to the adult behavioral health unit on 09/15/14 with a severe major depressive disorder and suicidal ideations.
- The History and Physical dated 09/15/14 showed a medical diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease that blocks airflow and makes breathing difficult) with signs of anoxia (low oxygen.)
- The Treatment Plan dated 09/15/14 showed no nursing goals or interventions for suicidal ideations or COPD as assessed.

5. Record review of Patient #13's medical record showed the following:
- The Nursing Admission Assessment dated 09/14/14 showed he was admitted to the adult BHU on 09/14/14 with suicidal ideations and an internal defibrillator (a device that activates a shock to the heart when indicated) implant (surgically placed) for an irregular heartbeat on 08/14/14.
- The Psychiatric Evaluation dated 09/14/14 showed he was admitted with major depressive disorder, suicidal ideations, and heart disease with a recent defibrillator implant.
- The Treatment Plan dated 09/14/14 showed no nursing goals or interventions for suicidal ideations or heart disease as assessed.

6. Record review of Patient #14's medical record showed the following:
- The Nursing Admission Assessment dated 09/12/14 showed he was admitted to the adult BHU on 09/12/14 with suicidal ideations, a potential for self-harm, diabetes, and hypertension (high blood pressure).
- The Psychiatric Evaluation dated 09/12/14 showed he was admitted with major depressive disorder and suicidal ideations.
-The History and Physical dated 09/12/14 showed he had a medical diagnoses of insulin dependent diabetes (a disease characterized by high blood sugar levels that can potentially lead to life threatening conditions if untreated), GERD, and hypertension.
- The Treatment Plan dated 09/12/14 showed no nursing goals or interventions for suicidal ideations, diabetes, GERD, or hypertension as assessed.

7. During an interview on 09/16/14 at approximately 11:20 AM, Staff E, Behavioral Health Unit Nurse Manager, stated that patient treatment plans included no nursing care plans for medical problems or nursing interventions for suicidal ideation.

8. Observation on 09/16/14 at 9:45 AM on 2A (a medical surgical unit), showed Patient #18 had a urinary catheter (a tube placed in the body to drain and collect urine from the bladder) attached to a drainage collection bag.

Record review of Patient #18's care plan dated 09/17/14, showed no planned nursing care, goals of care or planned interventions for the care of the urinary catheter.

9. Observation on 09/18/14 at 12:05 PM on 2A, showed Patient #45 with a large abdominal wound covered by a bandage and a intravenous (IV, in the vein) catheter (small tube) placed in her hand which had been used for IV medication and fluid administration.

Record review of Patient #45's Medication Administration Record (MAR) on 09/18/14 showed medications Zosyn and Teflaro (both are medications used to treat infections) administered to Patient #45 on the dates of 09/14/14 to 09/18/14. The alert screen (standard method to ensure medication administration safety) on the MAR warned that infusion of both medications (Zosyn and Teflaro) had severe adverse effects for the development of Thrombophlebitis (inflammation in the vein) and/or acute venous embolism (a blood clot in the vein) and thrombosis (blood clot formation in a deep vein in a extremity) based on the ingredients of the medicines.

During an interview on 09/18/14 at 12:30 PM, Staff RR, RN, who was assigned care of Patient #45 stated that she had not assessed the patient for the risks associated with thrombosis or medications and she did not have a care plan for the medications or thrombosis.

Record review of Patient #45's nursing care plan showed no planned nursing care, goals of care or planned interventions for the care of the large abdominal wound or thrombosis.

10. Observation on 09/17/14 at 3:05 PM on 2A, showed Patient #56 with a Stage II pressure sore (a skin blister caused by too much pressure against the skin that opened and created a sore) on his buttocks.

Record review of Patient #56's nursing care plan showed no planned nursing care, goals of care or planned interventions for the care of the pressure sore on the buttocks.

11. During an interview on 09/18/14 at 1:10 PM, Staff T, RN, stated that patients on 2A did not have care plans until the day before (09/17/14) and staff were new to the process and had a lot to learn about care plans.




17863

Based on observation, interview, record review and policy review, the facility failed to ensure staff administered medications safely to six patients (#15, #17, #18, #45, #46 and #56) of eight patients reviewed for safe medication administration practices.
Failures included:
- Staff administered intravenous (IV, in the vein) medications through tubes that were unlabeled or expired (past the date of safe use) to Four patients (#17, #18, #45 and #46) of eight patients were administered observed with IV tubing.
- Staff administered medication without notifying the physician when alerted by the medication scanning system of potential patient harm if administered to one patient (#45) of one patient observed with a medication alert.
- Staff who were Licensed Practical Nurses (LPN's) and not authorized to administer medications by the route of intravenous push (IVP, to manually administer a dose of medication through a tube into a vein), prepared and documented patient administration of IVP medications to two patients (#15, #56) of two records reviewed for IVP medication administration.
The failure to meet safe medication administration practices and established facility policy had the potential to cause serious infections, decline in patient health and avoidable adverse patient outcomes for all patients admitted to the facility who received medications. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "IV Tubing Changes," revised on 11/13, showed direction for facility staff that a sterile environment had to be maintained in the tubing of IV solutions to prevent infection. Staff was to abide by the following guidelines:
- Change (remove and replace) peripheral IV (PIV, small tube inserted through the skin into a vein/blood stream for the administration of medication/fluids usually in a hand) every 72 hours and labeled with the date the PIV was inserted.
- Change IV tubing connected to medications every 48 hours.
- Change IV tubing connected to IV medications/fluids if given intermittently (not continuous) every 24 hours.
- Label all tubing with the date, time hung and nurses initials.

2. Observation on 09/16/14 at 9:25 AM, showed Patient #17 with an undated PIV in her hand. One IV infusion pump had two different IV fluids with two separate unlabeled lines of tubing attached to the medications and connected to the pump.

During an interview on 09/16/14 at 9:30 AM, Staff Q, Licensed Practical Nurse (LPN), stated that Patient #17's PIV and the IV tubing was not labeled, dated and changed appropriately and she did not know why.

3. Observation on 09/16/14 at 9:45 AM, showed Patient #18 with an unlabeled PIV in her left hand. An infusion pump next to Patient #18's bed had two IV medication bags connected with unlabeled IV tubing.

During an interview on 09/016/14 at 9:50 AM, Staff Q, stated that Patient #18's PIV should have had a date documented on the bandage that identified when it was inserted and that the tubing on the IV medication tubing should have been labeled.

4. Observation on 09/18/14 at 11:35 AM showed Patient #46 with an undated PIV in her right hand. An IV infusion pump next to the bed had one empty IV medication bag with unlabeled tubing connected to the infusion pump.

During an interview on 09/18/14 at 11:35 AM, Staff NN, LPN, stated that the PIV and IV tubing for Patient #46's should have been labeled and dated.

5. Observation on 09/18/14 at 12:15 PM during medication administration to Patient #45 showed:
- Patient #45 had a PIV in her right hand not connected to continuous IV medication/fluid administration. The PIV was dated 09/11/14 [per facility policy staff should have changed the PIV no later than 09/15/14.]
- An infusion pump (machine used for controlling the rate of medication/fluids administered to patients) was next to the bed.
- One empty (had been administered) 50 milliliters (ml, a measurement of liquid) labeled with the medication, Teflaro (used to treat infections) 600 milligrams (mg, a unit of measure) administered 09/18/14 at 8:00 AM hung from the infusion pump with unlabeled tubing attached to the bag and connected to the pump.
- One empty 50 ml bag labeled with the medication Zosyn (medication used to treat infections) 2.25 grams (gm, a unit of measure) administered 09/18/14 at 6:00 AM hung from the pump with unlabeled tubing attached to the bag and connected to the pump.

During an interview on 09/18/14 at approximately 12:30 PM, Patient #45 stated that the PIV had been in her hand since her admission and nurses checked it only when the tape came off. She stated that it hurt when the medicines went in her veins.

6. Further observation of the medication administration to Patient #45 showed:
- Staff RR, Registered Nurse (RN), performed an electronic bar code scan (standard method to ensure medication administration safety) to the medication package of Zosyn 2.25 gm prior to preparation and administration to Patient #45.
- A bar code scan alert message appeared on the medication administration screen after the Zosyn was scanned which stated, "Duplicate therapy, Teflaro and Zosyn. When both medications are included in medication intravenous therapy... 'Side Effects - Severe', Zosyn intravenous solution may cause Thrombophlebitis (inflammation in the vein) and/or acute venous embolism (a blood clot in the vein) and thrombosis (blood clot formation in a vein) based on ingredients found in the medications.
- Staff RR overrode the alert, and selected "Override Reason: Clinical decision support".
- Staff RR prepared the medication, connected the medication to the unlabeled IV tubing that was present in the infusion pump, then connected the IV tubing to Patient #45's right hand PIV after she confirmed the date of 09/11/14 written on the PIV and administered the medication to Patient #45.

During an interview on 09/18/14 at approximately 12:30 PM, Staff RR stated that:
-She had given the medication and selected the override many times for Patient #45's medication alerts. She stated that all the nurses did overrides when the alerts came up in the computer and she did not call the physicians to clarify or verify the safety of the orders.
- She would change the PIV later after she administered the medications.
- She was not aware of the side effects of the current medications for Patient #45.
- She would change and label IV tubing the next time she administered medications.
- She would look into the override problem in the computer.

During an interview on 09/18/14 at approximately 2:30 PM, Staff XX, Director of Pharmacy, stated that:
- Nursing staff should not override the medication alerts when they appeared when medications were scanned.
- The system's alert was set for pharmacy and physician alerts, not nursing alerts.
- The pharmacy does not use the same system as the nurses on the floor.
- Overrides and clinical decisions should only be made by a Pharmacist in consultation with the treating physician because of their scope of knowledge and expertise.
- He was familiar with the medication regimen for Patient #45 and side effects of the therapy.
- He was not aware nursing staff did not consider medication adverse effects when planning and delivering nursing care.
- He does not document his rational or review of medications in the clinical record or communicate the information to nursing staff or physicians in a consistent manner and knew this was an area he should improve.
- He could not recall when medication overrides by nursing staff had become a problem and the issue had first been discovered and discussed.
- He would immediately put a stop to the nurses ability to override the alerts.

7. Record review of the facility's policy titled, "Intravenous Therapy," revised on 11/13, showed the RN was responsible for intravenous fluid administration. Further review provided staff specific direction that LPN's were not authorized, regardless of certification, to administer drugs via manual IV push (IVP).

8. Record review on 09/16/14 at approximately 1:45 PM, of Patient #15's medication administration record (MAR) showed Staff Z, LPN, documented medication a

Based on observation, interview and record review the facility failed to ensure that the Director of Food and Nutrition Services (FNS) was qualified with documented, current education and training. The lack of current education and training had negative impact on the department as demonstrated by his failure to implement appropriate food service orientation and training for staff; his failure to implement and enforce basic food sanitation policies and procedures including appropriate food storage, cleaning of equipment and food contact surfaces, and hand hygiene; and his failure to establish and maintain an appropriate quality assessment and performance improvement program for the department.

These deficient practices allowed the contracted staff person, without current training and education, to ineffectively manage the department and negatively impact all aspects of the patient food and nutrition services. The facility census was 41.

Findings included:

1. Review of the Association of Nutrition and Food Service Professionals (ANFP) website showed a Certified Dietary Manager was required to earn 45 continuing education credit hours (CEUs) every three years in order to maintain the certification. Five of the CEUs were required to be in sanitation and food safety. Since CEUs were only awarded to education programs related to the industry, the requirement guaranteed access to updated knowledge used to develop professional skills. Methods of earning CEUs included readily available sources such as reviewing ANFP approved articles online; reading approved resource books; completing ANFP online courses and webinars and attending ANFP state, regional and national meetings.

2. During an interview on 09/16/14 at 9:30 AM, Staff L, Director of Food and Nutrition Services (FNS) stated the following:
- He obtained certification as a dietary manager on 03/31/12.
- He had not maintained the required continuing education requirements since that time.
- He had not undertaken any CEU course work or attended any of the approved meetings in the last two and a half years.

During an interview on 09/16/14 at 10:15 AM, Staff L stated the following:
- He had not developed structured and documented orientation to the FNS and if he had a new staff person he just told them what to do.
- The newest staff person was a cook/supervisor hired two weeks ago.
- Staff L had not documented any verbal instruction he had given the new cook/supervisor and had not watched the new person to check comprehension of instructions.
- He had no documentation any special diet preparation training provided to the new cook/supervisor (special diets were served to patients).
- Staff L did not have a planned annual training schedule for all FNS staff and stated, "I should have one."
- Staff L felt he provided training through daily "huddles" during which undocumented topics were briefly discussed without follow-up or monitoring for comprehension of the information he had verbally presented.

3. Record review of the FNS policies and procedures manual showed the policies were last approved on 12/19/12 and directed that the next annual review was scheduled for 11/13.

During an interview on 09/16/14 at 10:42 AM, Staff L confirmed the FNS policies and procedures were last approved on 12/19/12 and he had failed to review the policies in 11/13 as directed by the department policy. He also confirmed that he was responsible to ensure the policies were up to date and followed by staff.

4. Record review of the facility's policy titled, "Food Handling Guidelines," revised 03/12 directed FNS to clean and sanitize specific areas including floors and specific pieces of equipment in the department.

5. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the FNS showed examples of the lack of basic food sanitation to clean equipment and floors and the lack of ongoing monitoring by Staff L:
- A heavily soiled table mounted can opener in the cook's table, with a streak of congealed reddish colored food adhering to the blade and gears behind the blade.
- A heavily soiled floor in the chemical storeroom with cove base missing and loosened off the walls.
- Soiled floor in the refrigerator with a debris lined perimeter of spilled food, unknown debris and torn paper.
- A soiled floor in the walk-in meat freezer with unknown debris around the perimeter.
- A dessert walk-in refrigerator with soiled floor, spilled foods and paper debris lining the perimeter and under shelving.

During interviews done concurrently with the observations on 09/16/14 from 10:55 AM through 11:30 AM, Staff L confirmed the can opener was soiled and should be cleaned; and the floors in the chemical store room and in the refrigeration units were soiled and needed to be cleaned.

6. Record review of the facility's policy titled, "Food and Supply Storage Procedures," revised 03/12 directed staff to store foods in appropriate refrigeration; to store food in clean areas; to store food in clean containers and to store food off the floor.

7. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the FNS department showed examples of poor food storage and lack of ongoing monitoring by Staff L including:
- Ceiling tiles in the dry food storeroom broken out and damaged with browned and blackened circles over an area where dust and debris covered soft drink dispensing equipment and where cases of soft drink concentrate were stored;
- An opened, partial 48 ounce container of chocolate syrup with a manufacturer's label directing "refrigerate after opening" unrefrigerated out on a shelf in the dry food storeroom;
- Two heavily soiled canned goods racks (with nine shelves each) covered with dust, unknown debris and ceiling tile particles in the dry food storeroom with the rims of the cans in the heavily soiled tracks.
- A thirty three pound case of raw chicken stored on the soiled floor of a walk-in refrigerator.
- An opened to air case of lettuce stored on wire shelving under a case of unwashed potatoes.
- Two cases of milk stored on the floor of a walk-in refrigerator that had dripped milk which pooled around the cartons in the bottom of the cases (one carton was opened).
- A heavily soiled bulk container of cornmeal without external label stored under the cook's preparation table.
- An opened, partial 20 ounce container of caramel sauce labeled by the manufacturer to "refrigerate after opening," stored on the shelf next to the cook's preparation table.

8. During an interview on 09/16/14 at 10:54 AM, Staff L stated he could not recall if the facility had a personal hygiene policy (that included hand hygiene) for FNS staff to follow.

9. Observation on 09/17/14 of poor hand hygiene by FNS staff in the kitchen and on the patient unit showed Staff L failed to perform ongoing training and monitoring of the training:
- At 11:25 AM, Staff FF, Diet Aide, handled foods for patient meal service and gloved without hand hygiene;
- At 11:30 AM. Staff OO, Cook, with gloved hands, pushed a soiled cart into place near the tray line, then without removing soiled gloves, using hand hygiene and re-gloving, portioned food onto patient trays using her soiled gloved hands;
- At 11:45 AM, Staff OO assembled foods on patient meal trays, reached over the steam table which allowed the edge of her uniform sleeve to touch foods on plates while she assembled;
- At 12:05 PM, Staff L gloved without hand hygiene and handled pureed foods for patient meal service;
- From 12:11 PM through 12:22 PM, Staff GG, Diet Aide, delivered trays to multiple patients. He entered each room with food trays; touched patient over bed tables; moved objects on over bed tables and exited each room without hand hygiene performed before the next tray in the food cart was handled.

During interview on 09/17/14 at 12:26 PM, Staff GG confirmed that he had not used hand hygiene between each patient tray delivery and he knew he should have done so.

10. During an interview on 09/16/14 at 10:58 AM, Staff L stated he had not developed and maintained any formalized Quality Assessment/Performance Improvement (QAPI) studies or projects for the FNS. He stated that he had met with the facility

Based on observation, record review, and interview, the facility failed to make necessary repairs to walls, ceilings, floors, doors and trim to reduce hazards and enhance housekeeping to ensure that the condition of the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. The facility also failed to conduct at least one facility-wide annual disaster drill.

Without a routine and scheduled maintenance program to make necessary repairs to the physical environment the 101 bed facility cannot ensure a healthy environment for patient care. Without rehearsed and tested disaster drills, the facility cannot assure the safety of patients and staff during a disaster situation. These deficient practices affect all staff, visitors and patients. The facility census was 41.

Findings included:

1. Record review of a housekeeping procedure titled, "Housekeeping Services To Be Performed", dated 06/09/14 showed that housekeepers were assigned to clean patient rooms and common areas daily, seven days a week. The procedure showed staff was to wet mop the floors and wet wipe all furniture with germicidal solution. The procedure directed housekeepers to clean and disinfect patient's washrooms, bathrooms and furnishings with germicidal solution. The procedure directed housekeepers to daily clean the non-occupied patient areas such as utility rooms, nourishment stations, treatment rooms and diet kitchens.

2. Observation on 09/16/14 at 9:30 AM of a common shower in the hospital critical care unit showed an eight by four inch area of missing floor tile on the crest of the ridge that keeps shower water from flowing on to the bathroom floor. The shower also had dark brown and pink stains that looked like mold in the corners and grout around the perimeter of the tiled shower, and soiled dark stained grout at the threshold of the door entering the bathroom, especially darkest at the corner base of the door frame.

During an interview on the same date and time as above, Staff DD, Director of Maintenance agreed with the finding and stated that there was no work order submitted for the missing floor tiles.

3. Observation on 09/16/14 at 10:15 AM of the outpatient rooms showed peeling paint and scuffed, chipped plaster corners and entrance doors in 16 of 16 patient rooms (110, 111, 112, 113, 114, 115, 119, 121, 122, 123,124, 125, 126, 127, 128, and 129.)

4. Observation on 09/16/14 at 1:30 PM of the second floor Medical-Surgical inpatient rooms showed peeling paint and scuffed, chipped plaster corners and entrance doors in 16 of 16 patient rooms (210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 229.)

5. Observation on 09/16/14 at 3:15 PM and 09/17/14 at 1:30 PM in the Resolutions (BHU) wing showed the following:
- Group dining/activity room: Missing tiles in a six foot by two foot area in the center of the room exposed the barren concrete floor with bits of adhesive. A large area (approximately 15 feet by 12 feet) of the vinyl tiled floor in the room was lined with numerous hairline cracks and crevices and buckled and sunken tiles. The cracked tile surfaces extended into the corridor that served the room. Corners of the room and areas of the edge along the cove base were soiled and darkened with soil accumulations not removed when the floor was cleaned. There were gaps between the four-foot pieces of cove base and the wall, and a corner piece was missing from the southwest corner of the room. Six of six white painted window sills were dusty, scratched and marked up from heavy use. The wall along the north side of the room was marked up and had holes in several places, the largest area of broken plaster measured about 12 X 12 inches.

6. Observation on 09/16/14 at 3:30 PM and 09/17/14 at 1:30 PM in the BHU of 17 of 17 patient rooms (252, 253, 254, 255, 256, 257, 258, 259, 260, 264, 269, 271, 273, 277, 278, 283, and 284) showed:
- Black lines of soiled grout and caulk around the base of toilets and accumulated unidentified soil and hair in corners, behind toilets and around the edge of each toilet room.
- Black lines of soil, which measured approximately one quarter inch in width ringed the edge of each room at the bottom of the cove base and expanded into corners and under the sinks.
- Cove strips throughout the unit (most were in four foot sections) applied to the had gaps up to one quarter inch wide between them and peeled away from the wall at the corners, which provided multiple areas where dust and dirt had accumulated.

Observation on 09/16/14 at 3:30 PM and 09/17/14 at 1:30 PM in other areas of the BHU showed:
- Yellowed floor with accumulated dust and dirt behind open bi-fold doors in a smoke wall that divided the unit.
- A common shower room near Room 259 had missing cove base at the entrance to an alcove for the washer and dryer, and the flexible hose that attached to the vent pipe was torn off, (which left no external exit point for the dryer exhaust).
- A common shower room on the west hall had pieces of cove base missing from the end base of the partial wall that enclosed the shower stall.- A common shower stall on the east hall had black colored residue that looked like mold inside the floor drain tray and around the edge up to 12 inches above the shower floor. Rivulets of the black substance had grown up the grout and tiled sides of the lower portion of the shower wall.

Observation on 09/16/14 at 3:20 PM showed the toilet in room 255 had been moved or knocked askew, which exposed areas of black stains and unidentifiable debris where the base of the toilet had been. There was also a strong urine smell in toilet rooms 256 and 257.

7. Observation on 09/16/14 at 2:10 PM showed a collapsed ceiling in room 305, part of the obstetrics/newborn unit (OB) that recently closed. Several ceiling tiles had collapsed when wet and fallen out of the metal suspension grid, and pieces lay piled on the floor.

8. Numerous observations throughout the facility showed multiple ceiling tiles (Dietary, patient rooms, food storage area, group rooms and medical records room) with dark stains and ringlets (evidence of past and present leaks.)

9. Observation on 09/16/14 at 9:00 AM showed a brown spot about the size of a dinner plate on a ceiling tile in the conference room off the corridor near the reception desk. An unidentified maintenance repairman brought in another ceiling tile and replaced the stained one. The next morning on 09/17/14 at 8:30 AM, the replacement ceiling tile had a wet spot on it that continued to widen and was still present on 09/17/4 at 1:00 PM.

During an interview on 09/16/14 at 2:10 PM and at 3:30 PM, Staff DD, Director of Maintenance stated that the roof was in constant need of repair. He stated that it was an old roof, he did not know how old, but based on the frequency of repairs needed, he felt like the roof should be replaced if the facility could afford it. He stated that maintenance generally tried to patch and repair any leaks as soon as they were reported or observed. He stated that there have been many leaks in the BHU, kitchen, and OB unit. He stated that those areas had no floors above them and leaks could show up quickly and without prior warning.

Staff DD agreed with the finding on maintenance problems in patient rooms and common areas. He stated that Maintenance use to do quarterly rounds for preventive maintenance, however since the facility was short on money and with staffing cuts in maintenance, housekeeping and other departments, he had neither the extra personnel or enough time to address preventive maintenance. He stated that he and the two staff assigned to maintenance could not keep up. He stated that the scuffed and scratched window sills along the BHU north wall were damaged because patients liked to put their feet up on the window sills and look out the large windows.

10. Observation on 09/16/14 at approximately 9:20 AM in the Health Information Management (HIM) main office area showed:
- Approximately 38 feet of damaged interior wall (a wall with multiple windows that overlook the roof of an adjacent section of the building);
- Th

Based on observation, interview, policy review, and review of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2000 (existing) Life Safety Code of the National Fire Protection Association (NFPA) the facility failed to provide a safe environment. The facility must be in compliance with all applicable codes referenced in the Life Safety Code. The facility failed to ensure:
- Doors to two (122 and 123) of 19 patient room doors closed and latched securely to resist the passage of smoke into corridors or patient rooms. This deficient practice had the potential to prevent staff from being able to isolate a fire to a limited area and prevent the spread of smoke and, could affect all patients, staff and visitors on the first floor medical-surgical wing.
- Annual inspection, testing and maintenance of the facility fire alarm system by qualified and experienced personnel. This failure could potentially jeopardize the life safety of all patients, staff and visitors.
- Required safety measures for designated smoking areas were implemented and enforced in one of one designated smoking area for Behavioral Health Unit (BHU) patients. This deficient practice could potentially result in a fire from unsecured cigarette ash residue that was not emptied into proper receptacles.
-The kitchen range hood received biannual (twice yearly) inspection, testing and maintenance. Failure to ensure the fire suppression system was ready for use endangered the kitchen staff, and increased the chances of a grease fire getting out of control in an unsprinklered area of the building.
- Self-closing doors to an unsprinklered (not protected by a sprinkler system) soiled linen chute, which extended over three floors were maintained in good working order. This deficient practice had the potential to spread fire quickly to other floors in the building, affecting all patients, staff and visitors.
- Flammable liquids were stored in an approved container suitable for storage of flammable and combustible liquids. This deficient practice could potentially affect the safety of all staff and patients.
- Appropriate, readable precautionary signs were posted on the door to a corridor room where flammable compressed gases were stored for use by Respiratory Therapy. Warning signs are mandated for listing hazards to protect fire-fighters and first responders who respond to a fire and failure to provide signage endangers all patients, staff and visitors.
- They load tested the diesel fueled generator during the past 12 months to ensure reliability of the facility's single source of emergency power. All hospitals are expected to have life support capability and to have a minimum of two separate electrical systems backed up by one or more power plants (generators), which support the emergency (Life Safety) branch and the critical branch. The emergency branch system is limited to circuits essential to life safety and patient care. The critical branch is for remaining essential systems; HVAC (heating, ventilating and air conditioning), pumps, utility support equipment, etc.
- Annual safety inspections for three of three elevators, which were in frequent use daily. Should a catastrophic equipment failure occur, this deficient practice could potentially result in serious injury or death for patients, staff or visitors.
The facility census was 41.

Findings included:

1. Observation on 09/16/14 at 11:15 AM showed the entrance door to patient rooms 122 and 123 failed to close into the door jamb (the vertical portion of the frame onto which a door is secured) due to misalignment and binding. The doors required a hard pull with considerable force to close into the jamb and latch.

During an interview at the same date and time, Staff DD, Director of Maintenance, agreed with the finding and stated that due to his staff being cut, maintenance personnel had not enough time to perform regularly scheduled preventive maintenance rounds to ensure a high quality environment of care. He stated that there was no policy and procedure to govern preventive maintenance rounds. He stated that he used to make quarterly rounds but being short of staff, they were all busy trying to keep up with repairs.

2. Record review of invoices from an outside vendor for fire alarm inspections on 09/17/14 at 10:15 AM showed the last annual inspection, testing and maintenance (checking backup batteries or replacing faulty pull stations) of the facility fire alarm was performed on 02/14/13. Staff DD, the Director of Maintenance, showed two requisitions dated 06/05/14 and 08/28/14, that he had submitted to Administration to have the alarm company come and perform the scheduled annual inspection, test and maintenance.

During an interview on 09/17/14 at 10:30 AM, Staff DD stated that he had submitted the requests twice but the facility had been short of funds so he was not sure if either requisition had gone through. He stated that generally vendors contact the facility ahead of time so the inspection and tests can be arranged, but some vendors received late payments or had not been paid in full for their past services.

3. Record review of an undated smoking policy for the BHU showed that patients shall smoke only in an area designated specifically for smoking. It does not specify the provision for using ashtrays of safe design and a covered container of metal or other suitable fire-resistant (non-flammable) material.

Observation on 09/16/14 at 4:20 PM showed a smoking room located on the BHU. Three containers of ashes, each filled with numerous cigarette butts, were sitting on the floor and one was balanced on the arm of a chair. One of the containers was a 10 inch square cake pan with a narrow rolled rim that was not suitable for resting a cigarette. The second container was the clamshell top of a nearby pedestal ash tray. Although the clamshell top had suitable resting places around the rim, the doors were easily opened and without the bottom half of the container to catch the hot ash, a patient could accidentally trip the doors and have a lap full of hot ashes. The third container was the bottom of the clamshell pedestal ash tray which was not a suitable safe design as it lacked any place around the narrow rim for a cigarette to balance or to be at rest unattended. Without ashtrays of safe design, patients are at risk for being burned or catching their clothing on fire, even in a supervised area.

NFPA requires metal or non-flammable containers with self-closing cover devices into which ashtrays can be emptied to be readily available in all areas where smoking is permitted.

Observation showed that the room lacked an appropriate receptacle for disposal of hot ashes and spent cigarette butts.

During an interview on 09/15/14, Staff UUU, BHU staff, stated that the ash trays were emptied daily into the regular trash.

4. Record review on 09/17/14 at 10:15 AM showed the last two inspections for the kitchen range hood were on 06/10/14 and 04/24/13. Review of past inspections showed the biannual inspection of the kitchen range hood's fire suppression system would have been due in October 2013 (the sixth month), and there was no documentation to indicate a biannual inspection had been performed.

During an interview on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he agreed with the finding.

5. Observation on 09/16/14 at 1:30 PM showed a metal linen chute door in a small soiled linen closet on the second floor was jammed partially open and did not close automatically as designed.

During an interview on 09/16/14 at 1:30 PM, Staff DD, Director of Maintenance stated that the soiled linen chute had been there since the hospital was built and was not sprinklered. He acknowledged the finding and stated that the chain was broken again (which kept the door from closing.)

6. Observation on 09/16/14 1:00 PM in the kitchen's dry goods storage room showed a partially used case of Sterno, (flammable gelatin in a can, used for warming casseroles or dutch ovens), a case of butane canisters for a small cooking stove (highly flammable pressurized gas) and a partial case of charco

Based on observation, interview and record review the facility failed to maintain an effective preventative maintenance (PM) program for patient care equipment in the Behavioral Health Units (BHU), radiology, emergency department, and in the food service department. The facility also failed to ensure an acceptable level of safety and quality by storing foods in a safe, sanitary manner.

These deficient practices had the potential to negatively affect patient safety through staff use of poorly maintained equipment and by patients receiving foods that were inappropriately stored or prepared on soiled equipment contributing to the possibility of cross contamination of foods. The facility census was 41.

Findings included:

1. During an interview on 09/18/14 at 2:00 PM, Staff B, Chief Operating Officer (COO), stated that there were no facility policies that dictated how PM should be managed in the facility.

2. Observation and concurrent interview on 09/17/14 at approximately 3:45 PM in the BHU crash cart (a cart that houses equipment and supplies needed for medical emergencies) showed:
-One defibrillator (medical equipment that shocks the heart when activated during medical emergencies) with an outdated inspection sticker dated 06/30/11;
-Two accucheck monitors (medical equipment that tests the sugar level in the blood) without inspection stickers;
-No suction machine available for emergency suctioning;
- Staff E stated that the suction machine was sent to Central Supply for cleaning two weeks ago following a medical emergency but she did not know why it had not been returned.

During an interview on 09/17/14 at 4:05 PM, Staff MM, Central Supply, stated that suction machines were usually replaced when the used equipment was returned to central supply. She stated there was no record of when equipment was delivered or replaced in the central supply department.

Observation and concurrent interview on 09/17/14 at 4:10 PM showed a suction machine was delivered to the BHU and it had no inspection sticker. Staff NN, Licensed Practical Nurse (LPN), stated that she did not know of an inspection sticker on any suction equipment.

3. Observation in the Radiology Department on 09/17/14 at 1:30 PM showed the Ultrasound machine (Radiology equipment that is used to create images of internal organs) had no identification sticker that indicated the last time the equipment received PM.
During an interview on 09/17/14 at 1:35 PM, Staff PPP, Director of Radiology, stated that the equipment (ultrasound) was overdue for an annual check but a mix-up between vendors had delayed the check. Staff PPP stated that she was not exactly sure when the inspection would occur, but was sure it would get checked soon.

4. Observation of the defibrillator in the Emergency Department on 09/16/14 at 9:40 AM, showed no identification sticker that indicated the last time the equipment received PM.
During an interview on 09/16/14 at 9:45 AM, Staff J, ED Nurse Manager, stated that the equipment was tested every day by staff but she was not sure of the last time PM was performed on the equipment.
During an interview on 09/18/14 at 2:00 PM, Staff B, COO stated that all of the defibrillators in the facility were replaced around the end of 2011. Staff B stated that none of them have had PM checks since purchased. Staff B stated that no one in the facility keeps track of equipment or when safety checks are due.
5. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the facility kitchen showed the following examples of poor food storage practices including:
- Ceiling tiles in the dry food storeroom broken out and damaged with browned and blackened circles over an area where dust and debris covered soft drink dispensing equipment and cases of soft drink concentrate were stored.
- An opened partial 48 ounce container of chocolate syrup with a manufacturer's label directing "refrigerate after opening" unrefrigerated out on a shelf in the dry food storeroom.
- Two heavily soiled canned goods racks (with nine shelves each) covered with dust, unknown debris and ceiling tile particles stored in the dry food storeroom with the rims of the cans in the soiled tracks.
- A thirty three pound case of raw chicken stored on the soiled floor of a walk-in refrigerator.
- An opened to air case of lettuce stored on wire shelving under a case of unwashed potatoes.
- Two cases of milk stored on the floor of a walk-in refrigerator which had dripped milk that pooled around the cartons on the bottom of the cases (one carton was opened).
- A heavily soiled bulk container of cornmeal without external label stored under the cook's preparation table.
- An opened, partial 20 ounce container of caramel sauce labeled by the manufacturer to refrigerate after opening, stored on the shelf next to the cook's preparation table.
- A heavily soiled table mounted can opener on the cook's table, with a streak of congealed reddish colored food which adhered to the blade and gears behind the blade.

During interviews on 09/16/14 done from 10:55 AM through 11:30 AM concurrently with each observations, Staff L, Director of Food and Nutrition Services, stated that:
- Damaged ceiling tiles occurred over time and was especially bad when it rained;
- The 48 ounce container of chocolate syrup should have been refrigerated;
- Two heavily soiled canned goods racks were soiled and should have been cleaned;
- A thirty three pound case of raw chicken should not have been on the floor;
- The large bowl of lettuce should have been covered;
- Two cases of milk should not have been on the floor of a walk-in refrigerator;
- A heavily soiled bulk container of cornmeal should be cleaned once a week;
- The 20 ounce container of caramel sauce should have been refrigerated;
- A heavily soiled table mounted can opener should be cleaned daily.

6. Observation on 09/16/14 from 10:55 AM through 11:30 AM in the facility kitchen showed the following examples of poor basic food sanitation in the kitchen especially heavily soiled, damaged and marred floors contributing to an unsanitary environment in which patient meals were prepared and:
- A heavily soiled floor in the chemical storeroom with cove base missing and loosened off the walls;
- Soiled floor in the refrigerator with a debris lined perimeter of spilled food and torn paper;
- A soiled floor in the walk-in meat freezer with unknown debris around the perimeter;
- A dessert walk-in refrigerator with soiled floor, spilled foods and paper debris lining the perimeter and under shelving.

During interviews on 09/16/14 done from 10:55 AM through 11:30 AM concurrently with each observation, Staff L stated that the soiled floor in the chemical storeroom with cove base damage was being damaged by recent heavy rain fall and the soiled floor in the refrigerators and freezer should be swept daily but it did look like staff had missed the perimeters.





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Based on observation, interview and policy review, the facility failed to ensure all patient care equipment and areas throughout the facility were monitored for cleanliness and were cleanable.
- Several pieces of patient care equipment stored amongst many (too numerous to count) multiple use patient care items in a large storage room had visible debris located on areas touched by patients.
- One of one medication room on the 2A Medical Surgical Unit was found unclean.
- Six of 11 chairs on the adult Behavioral Health Unit (BHU) had multiple burn holes (open to the absorbent cushion, not sealed and/or cleanable) that created an un-cleanable surface.
The lack of monitoring and surveillance for all risk of infection had the potential to expose all patients, staff and the community to infections and communicable disease. The facility census was 41.

Findings included:

1. Record review of the facility's policies showed no policy for patient care equipment cleaning or medication room cleaning.

2. Observation on 09/16/14 at approximately 10:20 AM, of the 2A clean storage room showed:
- Two intravenous (in the vein) infusion pumps (machines used for controlling the rate of fluids administered to patients) had multiple areas of dried pink liquid on the lateral and vertical surfaces (too numerous to count) machine;
- A mechanical patient lift had multiple (too numerous to count) dried liquid stains on the base of the lift.
- A bedside commode had multiple dried liquid stains on the base of all four legs.
- Multiple folded walkers and patient assistance devices had visible hand-prints on the rails and handgrips.
No equipment was identified as cleaned.

During an interview on 09/16/14 at 10:25 AM, Staff X, Central Supply Technician, stated that housekeeping staff was supposed to clean some of the equipment and nursing cleaned other equipment. Staff X stated that she did not know how to determine if the equipment was clean.

3. Observation on 09/16/14 at approximately 10:30 AM of the 2A medication room showed:
- All four walls had approximately 50% of the surfaces from the ceiling to mid wall with streams of visible dried light brown liquid stains.
- All floor surfaces were visibly dirty.
- Dried liquid stain around the sink created an (audible) tacky surface when walked on.
- All lateral and vertical shelves had stains and debris throughout.
- Handles on cabinets and glass doors of automated medication dispensing machine were visibly dirty with a higher concentration at the handles.
- Plaster on one corner near the entry door was missing from a section approximately five inches by six inches.
- One ceiling tile to the right rear of the room appeared to have had an ongoing moisture leak which resulted in black staining in an area approximately eight inches in diameter. The area was immediately above a cabinet used for medical equipment storage.

During an interview on 09/16/4 at approximately 10:30 AM, Staff C, CNO, stated that the staff nurses and/or charge nurses were responsible for keeping the equipment and medication room clean.

During an interview on 09/18/14 at 1:05 PM, Staff T, 2A RN Charge Nurse, stated she was not sure who was responsible for cleaning the medication room and patient care equipment until notified by Staff C on 09/17/14.

During an interview on 09/17/14 at 2:00 PM, Staff QQ, Infection Control Nurse, stated that she was not aware of any problems with cleanliness of the 2A medication room or patient care equipment in the storage area. She stated that no surveillance was conducted of the two areas and she was not aware of the process or policy for cleaning the equipment or medication room and stated the storage area and equipment was dirty and did not meet an acceptable standard for infection prevention.

4. Observation and concurrent interview on 09/16/14 at approximately 10:00 AM showed six chairs out of 11 chairs with two to nine burn holes each located in the smoking room on the adult BHU. Staff E, Nurse Manager for the behavioral health units, acknowledged that the chair surfaces were not cleanable with burn holes through the material.






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