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A. Based on observations made during a tour of the Cornerstone East Unit, conducted at approximately 11:15 AM on 5/15/12 it was determined that the facility failed to ensure a safe setting for all patients.

Findings include:

1. The showers in the private patient rooms on the Cornerstone East Unit had the following issues:

a. The shower control knobs were a type that could support a person's weight in a suicide attempt.

b. The soap dish bars were a type that could support a person's weight in a suicide attempt.

2. The community shower rooms on the Cornerstone East Unit were of the following type:

a. The shower control knobs were a type that could support a person's weight in a suicide attempt.

b. The soap dish bars were a type that could support a person's weight in a suicide attempt.


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2. During a tour of the Psychiatric Unit on 5/14/12, in the presence of Staff # 1, it was determined that the facility failed to comply with suicide prevention based on the following:

a. In the Cornerstone East Unit seclusion room, the HVAC vents and screws of the door handle were not of the tamper resistant type.

b. In the Cornerstone West Unit seclusion room, the screws of the door plates were not of the tamper resistant type.

c. In the Cornerstone West Unit seclusion toilet room, the screws of the electrical switch and the HVAC grill were not of the tamper resistant type.

A. Based on staff interview, document review and lunch meal observation, it was determined that the Director of the Food Service Department failed to ensure that daily supervision of the the Food Service Department was provided.

Findings include:

Reference #1: The Director of Food Service Department job description states, "Plans, organizes, and directs the activities of a dietary department and food service operations of an institution, develops policies and procedures, fiscal resources, coordinates and manages food service operations with those of other units.

Reference #2: The Menu Substitutions policy #184-008 states, "Substitute menu items of equal nutritional value shall be available and offered to all residents/patients/clients... The residents/patients may also select from the "Substitutions Available at Lunch & Dinner" list.

Reference #3: The "Substitutions Available At Lunch & Dinner For Cornerstone Units" list states, "The following food items are available to you when filling out your menu. You may write in these items instead of what is offered at lunch or dinner. Cold Substitutions items: Turkey Sandwich, Peanut Butter & Jelly Sandwich, Egg Salad Sandwich, Cottage Cheese Fruit Plate, Tuna Sandwich. Hot Substitutions Items: Baked Chicken, Baked Fish."

1. On 5/14/2012 at 12:15 PM, during lunch meal observations with Staff #4 and Staff #11,the Cornerstone East patients complained that they did not have a choice of menu and that substitute food items were limited to one choice per day.

a. On 5/14/2012 at 12:25 PM, during lunch meal observations with Staff #4 and Staff #11, Cornerstone East Staff #16 provided for review, a copy of the menu for the week of 5/13/12 - 5/19/12. The menu contained one sandwich and one vegetable choice as the alternate for Breakfast, Lunch & Dinner. The Sandwich of the Day for Monday 5/14/12 was written as Egg Salad, and the vegetable of the day was written as Spinach. The menu did not include alternate choices as stated on the "Substitutions Available At Lunch & Dinner For Cornerstone Units" list. (Reference #3) Staff #16 stated that the patients used to have choices, but not anymore.

b. Staff #11 stated that the Food Service Department provides a non-select menu and no longer provides the alternate choices as stated in the "Menu Substitutions" policy; Reference #2 and Reference #3.

B. Based on record review and staff interviews, it was determined that the facility failed to ensure that the Food Service Department reports to the Performance Improvement (PI) Council to identify problems and recommend, implement and monitor corrective actions.

1. On 5/15/12 at 9:45 AM, Staff #11 and Staff #4 were asked to provide for review, the Food Service Department Quality Plan and reports for 2011 and 2012, including the specific action plans developed for implementation and further evaluation of services.

a. On 5/15/12 at 1:15 PM, Staff #11 and Staff #4 stated that the Food Services Department last reported to the PI Council on July 25, 2011.

b. Staff #11 stated that the Food Services Department collects data, but the data is not analyzed to identify problems and recommend, implement and monitor corrective actions based on this data, as stated in the Continuous Quality Improvement policy; Reference #4.

c. On 5/15/12 at 1:15 PM, Staff #11 and Staff #4 stated that the Food Service Department has not reported to the PI Council for more than 10 months (three quarters).

d. On 5/15/12 at 2:00 PM, Staff #11 and Staff #4 confirmed all of the above.

A. Based on observations made during a tour of the Cornerstone East Unit, conducted at approximately 11:15 AM on 5/15/12 it was determined that the facility failed to ensure a safe setting for all patients.

Findings include:

1. The showers in the private patient rooms on the Cornerstone East Unit had the following issues:

a. The shower control knobs were a type that could support a person's weight in a suicide attempt.

b. The soap dish bars were a type that could support a person's weight in a suicide attempt.

2. The community shower rooms on the Cornerstone East Unit were of the following type:

a. The shower control knobs were a type that could support a person's weight in a suicide attempt.

b. The soap dish bars were a type that could support a person's weight in a suicide attempt.


15481



2. During a tour of the Psychiatric Unit on 5/14/12, in the presence of Staff # 1, it was determined that the facility failed to comply with suicide prevention based on the following:

a. In the Cornerstone East Unit seclusion room, the HVAC vents and screws of the door handle were not of the tamper resistant type.

b. In the Cornerstone West Unit seclusion room, the screws of the door plates were not of the tamper resistant type.

c. In the Cornerstone West Unit seclusion toilet room, the screws of the electrical switch and the HVAC grill were not of the tamper resistant type.

A. Based on staff interview, document review and lunch meal observation, it was determined that the Director of the Food Service Department failed to ensure that daily supervision of the the Food Service Department was provided.

Findings include:

Reference #1: The Director of Food Service Department job description states, "Plans, organizes, and directs the activities of a dietary department and food service operations of an institution, develops policies and procedures, fiscal resources, coordinates and manages food service operations with those of other units.

Reference #2: The Menu Substitutions policy #184-008 states, "Substitute menu items of equal nutritional value shall be available and offered to all residents/patients/clients... The residents/patients may also select from the "Substitutions Available at Lunch & Dinner" list.

Reference #3: The "Substitutions Available At Lunch & Dinner For Cornerstone Units" list states, "The following food items are available to you when filling out your menu. You may write in these items instead of what is offered at lunch or dinner. Cold Substitutions items: Turkey Sandwich, Peanut Butter & Jelly Sandwich, Egg Salad Sandwich, Cottage Cheese Fruit Plate, Tuna Sandwich. Hot Substitutions Items: Baked Chicken, Baked Fish."

1. On 5/14/2012 at 12:15 PM, during lunch meal observations with Staff #4 and Staff #11,the Cornerstone East patients complained that they did not have a choice of menu and that substitute food items were limited to one choice per day.

a. On 5/14/2012 at 12:25 PM, during lunch meal observations with Staff #4 and Staff #11, Cornerstone East Staff #16 provided for review, a copy of the menu for the week of 5/13/12 - 5/19/12. The menu contained one sandwich and one vegetable choice as the alternate for Breakfast, Lunch & Dinner. The Sandwich of the Day for Monday 5/14/12 was written as Egg Salad, and the vegetable of the day was written as Spinach. The menu did not include alternate choices as stated on the "Substitutions Available At Lunch & Dinner For Cornerstone Units" list. (Reference #3) Staff #16 stated that the patients used to have choices, but not anymore.

b. Staff #11 stated that the Food Service Department provides a non-select menu and no longer provides the alternate choices as stated in the "Menu Substitutions" policy; Reference #2 and Reference #3.

B. Based on record review and staff interviews, it was determined that the facility failed to ensure that the Food Service Department reports to the Performance Improvement (PI) Council to identify problems and recommend, implement and monitor corrective actions.

1. On 5/15/12 at 9:45 AM, Staff #11 and Staff #4 were asked to provide for review, the Food Service Department Quality Plan and reports for 2011 and 2012, including the specific action plans developed for implementation and further evaluation of services.

a. On 5/15/12 at 1:15 PM, Staff #11 and Staff #4 stated that the Food Services Department last reported to the PI Council on July 25, 2011.

b. Staff #11 stated that the Food Services Department collects data, but the data is not analyzed to identify problems and recommend, implement and monitor corrective actions based on this data, as stated in the Continuous Quality Improvement policy; Reference #4.

c. On 5/15/12 at 1:15 PM, Staff #11 and Staff #4 stated that the Food Service Department has not reported to the PI Council for more than 10 months (three quarters).

d. On 5/15/12 at 2:00 PM, Staff #11 and Staff #4 confirmed all of the above.