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Based on observation and staff interview, it was determined the hospital failed to ensure personal privacy was provided for patients residing in 10 of 11 rooms (Rooms 101-110) on the "Generations" nursing unit. This resulted in the inability of patients to toilet and shower with reasonable assurance that they would not be observed during these activities. Findings include:

The "Generations" nursing unit was a 21 bed psychiatric unit. It served older patients and patients with medical conditions that required nursing care. The unit was observed on 4/09/12 at 9:55 AM with the CNO. The census was 3 patients, ranging in age from 26 to 70. Rooms 101-110 were double occupancy rooms. A single bed "Observation Room" was located at the rear of the nursing station.

Rooms 101-110 each contained a bathroom with a toilet and a shower. The doors to each of these rooms was angled at the top from a height of approximately 75 inches to 66 inches (5 feet 6 inches) at the bottom. The surveyor, who was 6 feet 1 inch tall, walked by the door in room 108, which was empty at the time. The door was closed. The surveyor was able to see into the bathroom and observe the toilet and the area in front of the shower without any special effort, such as standing on tip toes or a step stool.

The DON was interviewed at the time of the observation. He conceded tall persons could easily see into the bathroom when patients were toileting or toweling off after a shower.

The hospital did not provide rooms where patients could toilet and shower without being observed.

Based on review of clinical records and staff interviews, it was determined the hospital failed to ensure an RN supervised and evaluated the nursing care for 3 of 35 in-patients (#22, #35 and #36) whose records were reviewed. The failure of a RN to evaluate the care of patients had the potential for medication errors and deterioration in patients' medical conditions. Findings include:

1. Patient #22 was a 33 year old female admitted 4/01/12 at 4:00 PM. The admission assessment documented Patient #22 was a diabetic with a diagnosis of bipolar disorder, who had recently attempted suicide. The "NURSING ASSESSMENT," dated 4/01/12 was a seven page document that had printed instructions on the first page that included "(to be completed by an RN)." The last page of the assessment had an area for the RN completing the assessment, as well as, for the LPN collecting the data to sign and date/time the document. The form was signed, dated and timed by an LPN. There was no documentation an RN had reviewed or completed the form.

During an interview on 4/09/12 at 10:15 AM, the Adult Unit Charge Nurse, an RN, reviewed the record and confirmed the assessment had not been completed or signed by an RN. She stated she did not know why the form had not been signed by an RN. The Charge Nurse stated assessments are frequently initiated by an LPN, but the Charge Nurse is responsible for the completion of the form, as well as initiating the Plan of Care.

An RN did not complete and oversee the admission assessment for Patient #22.




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2. Patient #36's medical record documented a 19 year old male who was admitted to the hospital on 3/11/12 and discharged on 3/27/12. His diagnosis was bipolar disorder.

A nursing narrative note, dated 3/16/12 at 11:00 PM, stated Patient #19's pulse had risen to 164 beats per minute. (The National Institutes for Health, queried on 4/13/12, defined a normal pulse rate for adults as 60-100.) The note stated the physician was called and Patient #19 was transferred to a local emergency department for evaluation. He returned to the hospital at 1:30 AM on 3/17/12. A physician order, dated 3/17/12 at 12:40 PM, stated Patient #19's vital signs were to be taken twice a day for 3 days. Patient #36's vital signs, including pulse, were documented 4 times on 3/17/12, at 1:48 AM, 6:00 AM, 11:05 AM, and 6:24 PM. His vital signs were documented at least twice on 3/18/12 through 3/26/12. After 1:48 AM on 3/17/12, the vital signs were all documented by psychiatric technicians. No documentation of the quality of Patient #36's pulse, such as whether or not it was regular, was documented following his return from the emergency department. No specific documentation of an assessment of Patient #36's cardiovascular status was documented following his return from the emergency department through his discharge on 3/27/12. At 6:24 PM on 3/17/12, Patient #36's pulse was documented as 119 beats per minute. No assessment by an RN was documented at this time.

The RN Program Manager reviewed the medical record on 4/09/12 beginning at 2:55 PM. He confirmed no documentation of a specific assessment of Patient #36's cardiac status was documented following his return from the emergency department.

An RN did not monitor Patient #36's cardiovascular status.

3. Patient #35's medical record documented a 41 year old male who was admitted to the hospital on 3/30/12 and discharged on 4/02/12. His diagnosis was schizoaffective disorder.

A nursing narrative note, dated 4/01/12 at 5:00 AM, stated Patient #35 had developed a fever and respiratory symptoms in the night. The physician was notified and Patient #35 was sent to a local emergency room for evaluation. He was diagnosed with pneumonia. He returned to the hospital on 4/01/12 at 4:30 AM. A specific assessment of Patient #35's respiratory status by an RN was not documented following his return to the hospital. No documentation was present that an RN had listened to Patient #35's lungs or examined him. A nursing narrative note, dated 4/02/12 at 5:10 AM, stated Patient #35 was "...observed by nursing staff sitting on edge of bed @ approximately 0315. [Patient complained of shortness of breath] at this time." A nebulizer treatment was administered at this time with "..significant improvement" but no assessment of Patient #35's lung sounds was documented. The "Adult Vital Signs Flow Sheet" documented Patient #35's temperature was 97.7 on 4/01/12 at 4:30 AM and 97.3 on 4/01/12 at 3:35 PM. Vital signs were documented at 6:00 AM and 3:30 PM on 4/02/12, however, temperatures were not included.

The RN Program Manager reviewed the medical record on 4/09/12 beginning at 2:55 PM. He confirmed no documentation of a specific assessment of Patient #35's respiratory status was documented following his return from the emergency department.

An RN did not monitor Patient #35's respiratory status.

The facility did not ensure nursing care was supervised by a registered nurse.

Based on review of clinical records and interviews with staff and patients, it was determined the hospital failed to ensure that nursing staff developed and/or kept current nursing care plans for 4 of 35 in-patients (#13, #16, #39 and #44) whose records were reviewed. This resulted in 1) the failure to assist a patient through the grief process; 2) incomplete care planning for patients with wound care, diabetes and hepatitis. Findings include:

1. Patient #39 was a 20 year old male, admitted 4/03/12 with a diagnosis of suicidal ideation, severe bipolar disorder and mild mental retardation.

Three days after admission, Patient #39 was informed of his father's unexpected hospitalization and death. The nursing note, dated 4/06/12, included the following: "Patient was attending a group when his mother called to tell him his father passed away this morning. He was tearful and stated he was sad and shocked about his fathers (incomplete sentence, or unfinished note)."

The "MASTER TREATMENT PLAN," also referred to as the POC, contained diagnoses of "Depressed Affect," "Chronic Medical Condition, Asthma," and "Mood Instability," initiated from 4/04/12 to 4/06/12. The POC did not address the death of Patient #39's father.

A "PROGRESS NOTE," dictated by the psychiatrist and dated 4/06/12, indicated Patient #39 was having anxiety and psychotic symptoms after the death of his father.

As of 4/10/12, the medical record did not contain any further documentation by the nursing staff of acknowledgement of the loss and interventions to assist with the grief process for Patient #39.

Nursing documentation on the forms "IMH NURSING FLOW SHEET," dated 4/07/12 and 4/08/12, and 4/09/12 did not mention the death of Patient #39's father, or of his increased anxiety as noted by the psychiatrist.

During an interview on 4/09/12 at 10:00 AM, Patient #30 stated he was dealing with his father's death, and when asked if the nursing staff was helping with ways to help his anxiety, he stated he really had not talked with anyone about it.

An interview on 4/10/12 at 11:15 AM, the Director of Social Services stated she had talked with Patient #30 shortly after his father passed away. She was unaware the POC had not been updated to include grieving.

The facility did not develop or update the POC related to anxiety and anticipated grief related to the death of an immediate family member.

2. Patient #13 was a 40 year old female, admitted to New Start, a chemical dependency unit, on 4/05/12 for care related to alcohol detoxification. In addition, Patient #13 had diagnoses which included Hepatitis B and Hepatitis C.

Nursing documentation on the forms "IMH NURSING FLOW SHEET," dated 4/05/12 at 11:23 PM, indicated Patient #13 had diarrhea and required medication. There was no POC, and the education sheet had not been initiated.

During a tour with the Manager of New Start on 4/06/12 at 3:45 PM, it was discovered that Patient #13 had a room mate. There was an unmarked toothbrush on the sink in their bathroom, and the Manager of New Start was unable to determine who it belonged to.

During an interview on 4/06/12 at 4:00 PM, the Charge Nurse for New Start reviewed Patient #13's record and confirmed the POC had not been initiated, and there was no documentation to address the diarrhea, Hepatitis B and C, and education on hygiene measures to reduce the possibility of cross infection with any potential room mates. The Charge Nurse indicated the toothbrush in Patient #13's bathroom would be discarded.

The facility did not develop a nursing care plan for Patient #13.

3. Patient #16 was a 49 year old female, admitted 3/25/12 for alcohol detoxification and history of seizures.

Patient #16 had a wound on her right knee with wound care orders written on 3/26/12 at 6:00 PM that included Bactroban ointment, telfa dressing and kerlix wrap. In addition, there was an order on 3/28/12 at 1:00 PM to evaluate healing. The "MASTER TREATMENT PLAN" for Patient #16 dated 3/25/12, also referred to as the POC, did not include wound care or interventions to assist in the healing process for Patient #16's wound.

In an interview on 4/10/12 at 8:20 AM, the Charge Nurse on the Adult Unit reviewed Patient #16's record and confirmed there was no POC that included wound care for the right knee wound.

The facility did not develop a nursing care plan that included wound care for Patient #16.

4. Patient #44 was a 25 year old female, admitted 4/09/12 for alcohol detoxification, suicidal ideation, and diabetes.

Patient #44 had a wound on her left arm upon admission, and the wound care orders written 4/09/12 at 8:20 PM included triple antibiotic ointment and dressing changes twice daily for five days. The "MASTER TREATMENT PLAN" for Patient #44 dated 4/09/12, also referred to as the POC, did not include wound care or interventions to assist in the healing process for Patient #44's wound.

In an interview on 4/10/12 at 8:15 AM, the Charge Nurse on the Adult Unit reviewed Patient #44's record and confirmed there was no POC that included wound care for the left arm wound.

The facility did not develop a nursing care plan that included wound care for Patient #44.

The facility did not develop or modify POC's to include pertinent problems that could affect patient recovery.

Based on observations and staff interview and review of policy and procedures, it was determined the hospital failed to ensure the director of dietary services 1) ensured hospital kitchen staff stored food properly in the facility's dietary department, and 2) ensured infection control measures were enforced. This had the potential to compromise patient health and food safety. Findings include:

1. A policy titled "Food Products/Storage," dated 3/00, regarding food storage, included foods must always be properly dated, labeled, and wrapped. The policy did not include instructions for opened foods and expiration date parameters for meats, dairy products, and prepared foods.

During a tour of the hospital's kitchen, on 4/05/12 starting at 10:30 AM and ending at 11:30 AM, the following foods in the walk-in refrigerator were found to be outdated before 4/05/12:

-Cherry pie filling,
-a container of chicken base,
-garlic,
-pesto,
-tofu,
-whipped topping,
-cheese.

The Dietary Manager was present during the tour and confirmed the foods were outdated and immediately discarded them.

The hospital did not ensure kitchen staff had discarded expired foods.

2. During a tour of the hospital kitchen, the following areas of concern with sanitation were found:

a. A red bucket in the dishwashing area was identified by a kitchen worker to contain a cleaning solution. Upon request, the kitchen worker tested the solution. The quaternary ammonia sanitizer was measured at +500 ppm (parts per million).

The kitchen worker stated the sanitizing solution was too concentrated. He said he would have expected 200 ppm, and he would change the solution and recheck the concentration level. According to the FDA (Food and Drug Administration) 2009 food safety standards, the quaternary ammonia sanitizer solution is to be 200 ppm.

According to the tolerance exemptions in the Code of Federal Regulations, (40 CFR 180.940) large concentrations of sanitizer can be considered toxic or poisonous because residues of the materials remain.

b. A red bucket, identified as a sanitizing solution, was on the counter filled with presoak solution for dishes and utensils. The Dietary Manager stated the presoak solution should not be in that kind of bucket, that the container for the presoak was a large grey shallow plastic container, and requested a worker to change the container. The use of buckets of incorrect color may result in misuse of the solution in the bucket.

c. A personal drink container was observed in the dry storage area on a metal rack that held patient food items.

d. Filters above the cooking area were noted to have dust and grease accumulation. The Dietary Manager stated the filters were cleaned once weekly, but could not provide a schedule or documentation of when they had last been cleaned.

The Dietary Manager did not ensure that kitchen staff practiced and enforced infection control interventions to prevent the possible spread of infections.

Based on review of clinical records and staff interviews, it was determined the hospital failed to ensure an RN supervised and evaluated the nursing care for 3 of 35 in-patients (#22, #35 and #36) whose records were reviewed. The failure of a RN to evaluate the care of patients had the potential for medication errors and deterioration in patients' medical conditions. Findings include:

1. Patient #22 was a 33 year old female admitted 4/01/12 at 4:00 PM. The admission assessment documented Patient #22 was a diabetic with a diagnosis of bipolar disorder, who had recently attempted suicide. The "NURSING ASSESSMENT," dated 4/01/12 was a seven page document that had printed instructions on the first page that included "(to be completed by an RN)." The last page of the assessment had an area for the RN completing the assessment, as well as, for the LPN collecting the data to sign and date/time the document. The form was signed, dated and timed by an LPN. There was no documentation an RN had reviewed or completed the form.

During an interview on 4/09/12 at 10:15 AM, the Adult Unit Charge Nurse, an RN, reviewed the record and confirmed the assessment had not been completed or signed by an RN. She stated she did not know why the form had not been signed by an RN. The Charge Nurse stated assessments are frequently initiated by an LPN, but the Charge Nurse is responsible for the completion of the form, as well as initiating the Plan of Care.

An RN did not complete and oversee the admission assessment for Patient #22.




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2. Patient #36's medical record documented a 19 year old male who was admitted to the hospital on 3/11/12 and discharged on 3/27/12. His diagnosis was bipolar disorder.

A nursing narrative note, dated 3/16/12 at 11:00 PM, stated Patient #19's pulse had risen to 164 beats per minute. (The National Institutes for Health, queried on 4/13/12, defined a normal pulse rate for adults as 60-100.) The note stated the physician was called and Patient #19 was transferred to a local emergency department for evaluation. He returned to the hospital at 1:30 AM on 3/17/12. A physician order, dated 3/17/12 at 12:40 PM, stated Patient #19's vital signs were to be taken twice a day for 3 days. Patient #36's vital signs, including pulse, were documented 4 times on 3/17/12, at 1:48 AM, 6:00 AM, 11:05 AM, and 6:24 PM. His vital signs were documented at least twice on 3/18/12 through 3/26/12. After 1:48 AM on 3/17/12, the vital signs were all documented by psychiatric technicians. No documentation of the quality of Patient #36's pulse, such as whether or not it was regular, was documented following his return from the emergency department. No specific documentation of an assessment of Patient #36's cardiovascular status was documented following his return from the emergency department through his discharge on 3/27/12. At 6:24 PM on 3/17/12, Patient #36's pulse was documented as 119 beats per minute. No assessment by an RN was documented at this time.

The RN Program Manager reviewed the medical record on 4/09/12 beginning at 2:55 PM. He confirmed no documentation of a specific assessment of Patient #36's cardiac status was documented following his return from the emergency department.

An RN did not monitor Patient #36's cardiovascular status.

3. Patient #35's medical record documented a 41 year old male who was admitted to the hospital on 3/30/12 and discharged on 4/02/12. His diagnosis was schizoaffective disorder.

A nursing narrative note, dated 4/01/12 at 5:00 AM, stated Patient #35 had developed a fever and respiratory symptoms in the night. The physician was notified and Patient #35 was sent to a local emergency room for evaluation. He was diagnosed with pneumonia. He returned to the hospital on 4/01/12 at 4:30 AM. A specific assessment of Patient #35's respiratory status by an RN was not documented following his return to the hospital. No documentation was present that an RN had listened to Patient #35's lungs or examined him. A nursing narrative note, dated 4/02/12 at 5:10 AM, stated Patient #35 was "...observed by nursing staff sitting on edge of bed @ approximately 0315. [Patient complained of shortness of breath] at this time." A nebulizer treatment was administered at this time with "..significant improvement" but no assessment of Patient #35's lung sounds was documented. The "Adult Vital Signs Flow Sheet" documented Patient #35's temperature was 97.7 on 4/01/12 at 4:30 AM and 97.3 on 4/01/12 at 3:35 PM. Vital signs were documented at 6:00 AM and 3:30 PM on 4/02/12, however, temperatures were not included.

The RN Program Manager reviewed the medical record on 4/09/12 beginning at 2:55 PM. He confirmed no documentation of a specific assessment of Patient #35's respiratory status was documented following his return from the emergency department.

An RN did not monitor Patient #35's respiratory status.

The facility did not ensure nursing care was supervised by a registered nurse.