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Based on review of the medical record, policies and procedures, and staff interviews, the hospital failed to provide the standardized notice, " An Important Message from Medicare, " (IM) to beneficiaries within 2 days of admission as evidenced by:

In 4 of 52 record reviews the patients did not receive the IM. In 2 of 52 records reviewed (patient #30 and #31) the IM forms were found blank in the front of the patient's medical record. In 2 of 52 records reviewed (patient #40 and #41), no IM form could be found in the medical record.
For those patients on admission who were unable to sign the IM, the hospital had staff from admissions come to the units and inform the patients of their rights and have them sign and date the form. When due to the patient's condition, he/she are unable to sign the form, the unit level social worker becomes responsible for follow-up. The geriatric psychiatric social worker, in an interview conducted June 21, 2011, confirmed that the Important Message from Medicare comes up from the Admitting Office with other paper work for new patients. The social worker said that she focuses on getting the financial information signed and does not do anything with the Important Message. In all four cases the patients did not receive their rights as evidenced by no form or blank forms in the medical record.

Based on observation, policies and procedures, and staff interviews the hospital failed to ensure the patient's right to personal privacy.

The Sheppard Pratt Towson/Ellicott City campuses have semi-private bedrooms with two person occupancy. On the Ellicott City campus the beds bolted to the floor in the restraint/seclusion rooms were removed. Although no patients were in restraint/seclusion during the survey, an interview with the Ellicott City Program manager and unit manager for Adult Inpatient Unit revealed that there are times when a patient may be restrained in their bedroom, which they share with a roommate. The roommate may be allowed to remain in the room or offered use of the quiet room. For the restrained patient, their privacy is already limited since they must be continuously observed. With the presence of the roommate, the restrained patient's right to personal privacy to discuss their behavior, feelings, concerns, and general care needs such as personal hygiene have been violated, since persons not involved in the care of the patient should not be present without his/her consent. The hospital is exploring the use of portable beds that can be quickly transported to the quiet room for restraint purposes.

Based on review of the medical records, policies and procedures the hospital failed to ensure the medical records were complete, accurate, and legible as required by the Federal regulations as evidenced by:

In 1 of 52 records reviewed (patient #11) face to face was incomplete.

In 1 of 52 records reviewed (patient #13) the voluntary form could not be found in the medical record.

In 1 of 52 records reviewed (patient #15) has signed the voluntary form on admission but as of 6/21/11 the form was not endorsed by the physician.

In 1 of 52 records reviewed (patient #42) was admitted on 3/10/11 and discharged on 4/21/11. The patient's discharge summary was not completed until 5/23/11.

Based on review of the medical record and hospital policies and procedures the hospital failed to ensure that the verbal orders were authenticated based on Federal and State law. Per the hospital policy telephone and verbal orders shall be authenticated within 48 hours after they are given.

A review of 52 open records revealed 2 of 52 records with telephone orders that were not authenticated in a timely manner.

Patient #2 was a 22 year old admitted on 6/2/11. The patient had a telephone order written on 6/6/11 for Nicotrol inhalation, the order was not authenticated until 14 days later on 6/20/11. The patient had a restraint order written 6/15/11 also authenticated 5 days later on 6/20/11.

Patient #8 was admitted 6/15/11 with diagnosis of Bipolar Disorder. The following telephone orders were signed late.
? Order for Acetaminophen written 6/16/11 but not signed until 6/21/11.
? Order for Ibuprofen written 6/16/11 but not signed until 6/21/11.
? Order for Maalox written 6/16/11 but not signed until 6/21/11.
? Order for Haldol written 6/16/11 but not signed until 6/21/11.
After review of the hospital board committee minutes, which referenced the continued problem with authentication of verbal/telephone orders, the Vice President of Medical Affairs was interviewed on 6/23/11 regarding the failure for medical staff to authenticate telephone/verbal orders. The hospital acknowledged that there is a problem, which they continue to track. They have addressed the problem by increasing the resident staff numbers, reminders to the attending over the weekends and holidays to sign their orders and in-service for the attending physicians on how to sign their orders via computer.

Based on review of the medical record and policies and procedures, the hospital failed to ensure the medical history and physical examinations were completed and documented within 24 hours of admission as evidenced by:

Patient #3 was admitted on 6/3/11 with rule-out Mood Disorder. Review of the medical record revealed the history and physical was completed and signed on 6/13/11, ten days after admission.

Patient #42 was admitted 3/10/11 with Major Depression had a history and physical that was not signed until 3/30/11.

On June 22 and 23, 2011, the dietary service areas for both the Towson and Ellicott City campuses of the Sheppard Pratt Hospital were inspected. Based on interview of key staff and/or of observations made during these inspections, it was determined that staff failed to assure the sanitization of of essential food service equipment and/or they failed to assure that food was received and stored in a sanitary manner.

The findings included:

On June 23, 2011, an inspection of the dietary service area and lower level dry goods and refrigerated storage areas was conducted at the Towson campus of the Sheppard Pratt Hospital.

Upon inspecting the three compartment manual washing and sanitizing sink and work station, it was revealed that there was no detectable level of chemical sanitizer within the sanitizing sink.

Upon inspecting the lower level dry goods and refrigerated storage area on the lower level of the hospital, it was revealed that a large quantity of perishable and frozen perishable items has been received on this date. Interview of the food service manager and of a dietary worker (assigned to put the new food items into storage), it was determined that the perishable and frozen perishable items had been out of refrigerated storage for up to 90 minutes. Interview of the food service manager revealed that he was aware of the need to have such food items promptly placed into refrigerator or freezers; however, he had stock to be put away in both this area as well as in the main kitchen and the two staff assigned to the task had not been able to get the items into refrigerated storage as quickly as was desired.

All hospitals shall provide competent staff as required to provide for safe and sanitary food service. Based on the observations and interviews conducted at the two different campuses of the Sheppard Pratt Hospital on June 22 and 23, 2011, such staff was not retained with adequate knowledge and/or in sufficient numbers as was needed.

Based on a dinner meal observation, interviews with food service staff and the dietitian, it was determined that the facility staff failed to: have a nutritional analysis and written menu plan to identify the food items and portion sizes for the mechanical soft and pureed diets served in the facility, nor provide bread or a bread substitute for patients receiving a mechanical soft and pureed diet.

1. Interview with the dietitian and review of the production sheet for 6/22/11 revealed that the facility provides 2 patients a pureed diet and 10 patients a mechanical soft diet. A pureed diet is blended to the consistency of applesauce and used for patients with chewing and/or swallowing problems. A mechanical soft diet is used for patients with difficulty chewing regular food. Certain foods must be chopped or ground depending on the texture of the food and individual needs. On 6/22/11 at 5:00 p.m. the surveyor observed the dinner meal service. The food service worker served the following on the mechanical soft meal tray: 3 ounces Sloppy Joe, 3 ounces peas, #6 scoop (5 ounces) mashed potatoes, 8 ounces milk and ? cup of sherbet. Interview with the CNM (Clinical Nutrition Manager) at 5:10 p.m. revealed that the facility failed to have a nutritional analysis and written menu plan to identify the food items and portion sizes for the mechanical soft diet. Review of the Week at a Glance Menu for the regular diet and interview with the CNM confirmed that the correct portion sizes should have been 2 ounces of Sloppy Joe, #8 scoop (4 ounces) mashed potatoes and 4 ounces of peas.
At 5:30 p.m. on 6/22/11, the surveyor observed the food service worker served the following on the pureed diet: 3 ounces of pureed Sloppy Joe, 3 ounces pureed peas, #6 scoop (5 ounces) mashed potatoes, 4 ounces apple juice and ? cup of apple sauce. Interview with the CNM at 5:40 p.m. revealed that the facility failed to have a nutritional analysis and written menu plan to identify the food items and portion sizes for the pureed diet. Review of the Week at a Glance Menu for the regular diet and interview with the CNM confirmed that the correct portion sizes should have been 2 ounces of Sloppy Joe, #8 scoop (4 ounces) mashed potatoes and 4 ounces of peas.
The facility staff failed to provide bread or a bread substitute for patients receiving a mechanical soft and pureed diet. On 6/22/11, the surveyor reviewed the regular diet plan on the week at a glance and noted that the regular diet receives the Sloppy Joe on a bun. Interview with the CNM on the same day revealed that that the facility does not provide bread or bread substitute for the patients receiving a mechanical soft and pureed diets. This concern was discussed with the CNM and the food service manager (FSM) and they stated they would address the issue.

Based on a dinner meal observation, interviews with food service staff and the dietitian, it was determined that the facility staff failed to: Utilize the proper measuring utensils that would ensure the appropriate portion size to meet the nutritional needs of the patients, have the correct portion size for hot cereal posted on the Portion Control Guide in the kitchen, have the correct portion size for a menu item on the Week at a Glance form and provide the correct portion size to patients on the eating disorder unit. In addition, based on medical record review and interview with the Clinical Nutrition Manager (CNM), it was determined that the dietitian failed to accurately document a patients ideal body weight (IBW) on a patients nutritional assessment. This was evident for 1 of 4 medical records reviewed by the dietitian surveyor. The findings include:
As referenced in citation 0628 the facility staff failed to have a nutritional analysis and written menu plan to identify the food items and portion sizes for the mechanical soft and pureed diets served in the facility. In addition, the facility staff failed to have the correct portion size for hot cereal posted on the Portion Control Guide in the kitchen. On 6/22/11, the surveyor reviewed the Portion Control Guide that was hanging on the bulletin board beside the area where the meals are prepared. The form indicated both 4 ounces and 6 ounces should be used to serve hot cereal at breakfast. Interview with the FSM revealed that the correct portion size for hot cereal is 6 ounces and the 4 ounces should be for hash brown potatoes. After surveyor intervention, the guide was corrected.

The facility staff failed to have the correct portion size for a menu item on the Week at a Glance form. On 6/22/11, the surveyor reviewed the facility ' s Week at a Glance Form for Summer Week 4. On Saturday dinner meal, the form stated " Cheese Stuffed Shells 1 Ea(ch). " On 6/22/11 at 5:25 p.m., interview with the Operations Manager revealed that the guide should say 2 each for the Cheese Stuffed Shells. After surveyor intervention, the CNM corrected the Week at a Glance Form.
The facility staff failed to provide the correct portion size to patients on the eating disorder unit. Interview with the CNM on 6/22/11 at 5:45 p.m. revealed that all of the patients in the hospital receive the starch servings based on the diabetic food group. This means that the patients on the eating disorder unit receive the following: penne rigate 3 ounces, French fries 3 ounces, rice 1/3 cup, pasta 3 ounces, tater tots 3 ounces and yellow rice with peas 1/3 cup. On 6/23/11 at 1:30 p.m., interview with the dietitian working on the Eating Disorders unit revealed that the patients are taught and given education materials that include the following " Serving Size of Grain is ? cup pasta, rice or cooked cereal " . The dietitian stated that the patients are taught that 1 serving of grain is ? cup including French Fries, Tater Tots, rice and pasta. The CDM also stated that she was going to change the grain portion sizes in the facility to ? cup for consistency.
The dietitian failed to accurately document a patient's IBW in pounds (lb.) and kilograms (kg) on a patient ' s nutritional assessment. On 6/23/11 at 12:01 p.m., the surveyor reviewed medical record for patient #41 and found that the nutrition assessment dated 6/21/11 included the following: " ideal body weight in lbs. 50 and ideal body weight in kg 22.6 kg. " Interview with the CDM at 12:05 p.m. confirmed that correct IBW in lbs should have been 110 and the correct IBW in kg should have been 50. This causes a potential for a medical professional to incorrectly dose a medication if they use the incorrect dietitian calculations.

Based on observations made during tours of the facility in both Towson and Ellicott City it was determined that the Condition of the Physical Environment was not met as result of deficiencies of the Life Safety Code that included:

? The operation of smoke barrier doors as noted at K027 at both campuses;
? The failure to adequately identify areas that lacked egress as noted at K034 noted at the Towson campus;
? The failure of the sprinkler system to provide coverage to the vestibules outside of the quiet rooms at the Ellicott City campus and the sprinkler in two locations required maintenance at the Towson campus as cited at K062;
? The doors of the fire extinguisher cabinets were not breakable to allow access to the fire extinguishers as noted in K084 at the Ellicott City campus; and
? Observed electrical hazards as noted in K147 at both campuses.

Based on the June 22, 2011 observation of the buildings located that the Ellicott City campus of the Sheppard Pratt Hospital, it was determined that the entire physical plant was not being maintained as needed to assure a safe and sanitary hospital environment.

The findings included:

1. On June 22, 2011, an inspection of the buildings comprising the Ellicott City campus of the Sheppard Pratt Hospital was conducted. During that inspection, several concerns were noted with respect to maintenance of the physical plant. One concern was detailed in another tag of this report with respect to the ice machine (Refer to CMS 2567, tag A0724).

All equipment within a kitchen and any associated dietary service area must be maintained in such a manner that the safety and well-being of the patients are assured.

2. In addition to that concern, it was revealed that the ventilation provided within the laundry rooms at this campus was not adequate. Upon inspection of these laundry rooms, the environment of each was found to be very warm and damp. Examination of the room connections to exhaust ventilation revealed a connection was present in one room but was not provided in another. Upon inspection of the ceiling register for the exhaust system provided in the laundry room just outside of the 70 Unit, no airflow could be detected. Upon inspection of the laundry rooms within the 61 Unit, it was revealed that there was no connection to an exhaust ventilation system.

Ventilation must be provided within all soiled areas, bathrooms, toilet compartments, janitorial closets, and other similar areas. Ventilation rates should be consistent with the recommendations of the American Institute of Architects or a similar standard setting institution.

Several residential dryers on different units in the facility had a buildup of lint behind the dryers as well as debris, laundry, dryer sheets, etc.
The dryer on Terrace F85 had its flexible dryer vent pipe disconnected - this should be temporarily reattached and the flexible plastic exhaust duct should be replaced with a commercial grade, rigid or semi-rigid, metal exhaust duct with metal fittings.
The condition of the physical plant, as well as the overall hospital environment, must be addressed in a written plan for operations and it must be maintained in such a manner that the safety and well-being of patients are assured.

On June 22 and 23, 2011, the dietary service areas for both the Towson and Ellicott City campuses of the Sheppard Pratt Hospital were inspected. Based on interview of key staff and/or of observations made during these inspections, it was determined that staff failed to assure the proper installation and function of essential equipment and/or they failed to assure that food was received and stored in a sanitary manner.

The findings included:

1. On June 22, 2011, an inspection of the dietary service area at the Ellicott City campus of Sheppard Pratt Hospital was conducted. Based upon an examination of the ice machine located in the kitchen proper, it was revealed that the drain lines were not provided with atmospheric venting. In addition, the drain lines were installed such that the ends of the lines were located below the rim level of the floor sink. In addition, a second ice machine that was installed within a storage area outside of the kitchen proper was found to be properly piped but the drain pipe was never provided with brackets to keep the pipe off of the floor. During the inspection of June 22, 2011, it was revealed that the drain line had fell off of a block of wood and it was draining onto the floor instead of into the floor sink.

2. On June 23, 2011, an inspection of the dietary service area and lower level dry goods and refrigerated storage areas was conducted at the Towson campus of the Sheppard Pratt Hospital. Upon inspecting ice machine number 2 within the main kitchen, it was revealed that the two drain lines from this ice machine lacked atmospheric venting as required.

Upon inspecting the three compartment manual washing and sanitizing sink and work station, it was revealed that there was no detectable level of chemical sanitizer within the sanitizing sink.