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Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Governing Body as evidenced by failure to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner, permitted by the State to admit patients to a hospital. This deficient practice was evidenced by non physician and non-licensed independent practitioner intake staff evaluating and admitting patients to the hospital without contacting the practitioner to accept or decline the patient for admission to the hospital. (See findings at A-065)

Based on record review and interview, the governing body failed to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner permitted by the State to admit patients to a hospital. This deficient practice was evidenced by non-physician and non-licensed independent practitioner intake staff evaluating and admitting patients to the hospital without contacting the practitioner to accept or decline the patient for admission to the hospital.

Findings:

Review of the Rules and Regulations of the Medical Staff, November 2018, provided by S21HRQA as current, revealed , "4. Admission to Hospital, 4.1 Patients may be admitted to the Hospital only by order of an Admitting Practitioner....4.4 Admission orders are to include provisional diagnoses...4.8 ...Admission orders will be given for the appropriate level of observation. Only a Practitioner can lower the level of observation...6.1 The Attending Physician has the ultimate responsibility for providing a diagnostic impression of each patient as required hereunder and for supervising the care of the patient in the hospital. ..7.8 Orders...Only Practitioners may write orders for the following: * Admission to a program and transfers between programs and program levels;*Laboratory examinations..."

Review of hospital policy #IN-002 titled "Intake Admissions Exclusion Criteria", provided by S21HRQA as current, revealed in part, under Procedure, "A... The attending psychiatrist or qualified designee will make the final decision for admission or denial of patients to Covington Behavioral Health..."

Review of the medical record for Patient #R7 revealed she was admitted 12/12/18 at 1:35 a.m. Review of her intake Assessment dated and timed 12/12/18 at 12:30 a.m. revealed the following documentation: Physician Contacted: S3NP 12/12/19 at 12:20 a.m. and a Diagnosis per Physician as "MDD, Substance Abuse" Review of her Psychiatric Evaluation 12/12/18 at 8:55 a.m. revealed admitting diagnoses that included SAD-Depressed and Amphetamine Use Disorder-Severe. Review of Patient #R7's History and Physical dated and timed 12/12/18 at 10:00 a.m. revealed she had medical diagnoses that included Hypertension, mouth pain, Hepatitis C, Amphetamine use Disorder, and Abnormal Urinalysis.

In an interview 5/15/19 at 3:45 p.m., S3NP reported, he takes call for psychiatric services. S3NP reported that patients are often admitted to the hospital without a physician or practitioner being notified and accepting the patient. He reported, staff does not always call him for a patient admission when he's on call, but reported, they were supposed to. S3NP reported, the intake staff uses the Tier system which is 3 tiers or levels of criteria for patients to meet admission criteria or be excluded if they need care that can not be provided by this hospital. The provider reported, staff will document that they called him but they don't actually call. He reported that because he has objections to documenting he was called when he was not, that staff will often document they called the medical director even though it was him on call. He advised that often patients were admitted on the unit at night and when he arrived the next morning, he didn't even know the patient was there. S3NP reviewed the record of Patient #R7 and verified he did not receive notification from Intake that Patient #R7 was accepted and admitted to the hospital. S3NP reported not only was he not contacted to accept Patient #R7, but that he did not give staff the medical diagnoses of MDD and Substance Abuse at the time of admission.

In an interview on 5/15/19 at 1:06 p.m. with S9Intake, she said she scans through packets on patients for reason, labs, medical history, and complications, and if they are medically cleared. Using the tier system, they (intake staff) determine if patients can be accepted for admission. S9Intake reported, if the patients fall within Tier 1 they accept patients and admit them without calling the provider. Depending of the reason they are in Tier 2, the intake staff may have to call the doctor to admit. For example, if psychosis and brain injury, they will run it by the doctor. She said, Tier 3 they cannot take the patient. She said, they have 60 inpatient beds. She said if they know a patient is leaving in the morning, they can accept the patient if they know someone is being discharged but the (sending) hospital will hold them until the discharging patient leaves. If the patient does arrive before the discharged patient leaves somebody will sit with the patient.

In an interview on 5/15/19 at 1:31 p.m. S4Intake said, she had been director since December and Manager since May 2018. She said, the patient's packet comes through the E-fax and has the face sheet, PEC and CEC. She said, they look for acuity, etc. If patient falls into Tier 2, they have to call the doctor. Tier 3 exclusionary, so they don't have to call the physician. S4Intake said, if a patient is Tier 1 they accept without calling the physician. S4Intake verified this is the practice of all Intake Staff.

In a phone interview 5/17/19 at 2:30 p.m., S13MD verified she was a staff physician at Covington Behavioral Health. She reported that she was familiar with the "tier" system the hospital was using for determining if patients met criteria for admission. She reported that staff was supposed to call the admitting physician (or provider on call) with any patient meeting Level 1 or Level 2 criteria for orders to admit the patient, but not level 3 which was exclusionary, such as patients requiring dialysis or IV fluids. S13MD reported the tier system should work better than it is working. She reported the staff was supposed to call the provider and if the patients were accepted, the provider would then give orders. She reported this was done to cut down on some of the calls to the doctors (providers) when the patients were assessed as a Level 3. She stated, "Actually intake[staff] are making more of those decisions than they should be making." S13MD advised that only the providers should accept a patient for admission and give a medical diagnosis for the patient.

Based on record review, observations, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) failure to ensure the director of nursing services was qualified in accordance with state licensure requirements. (See findings in A-0386);

2) failure to maintain ordered observation levels for 2 (#R1, #R2) of 3 patients ordered to be observed every 5 minutes (See findings in A-0395) ; and

3) failure to ensure all admission orders were obtained from a licensed practitioner, not just medications, with the nurses choosing the remainder of the orders such as diet, level of observation. (A-0395)

Based on record review and interview, the hospital failed to ensure the director of nursing services was qualified in accordance with state licensure requirements.

Findings:

Review of requirements of LAC 48: I, Chapter 93: Licensing Standards for Hospitals, Section 9501 revealed the following requirements for the director of psychiatric services:

1. A master's degree in psychiatric or mental health nursing; or

2. a master's degree in a related field such as psychology or nursing education and five years of nursing experience and three years providing nursing care to the mentally ill; or

3. a bachelor's, associate degree or diploma in nursing with documented evidence of educational programs focused on treating psychiatric patients, which has occurred at intervals sufficient enough to keep th nurse current on psychiatric nursing techniques. In addition, the nurse shall have at least five years of nursing experience, three years of which were providing nursing care to the mentally ill, or receive regular documented supervision/consultation from a master's prepared psychiatric nurse.

Review of S2DON's personnel record revealed she was a RN with bachelors degree and she did not have three years experience of providing care to the mentally ill. Further review revealed she had been employed at Covington Behavioral Health since 11/08/17. Review revealed S2DON had only three days documented communication with a master's prepared psychiatric nurse with two of those being written by herself.

In an interview on 5/16/19 at 2:30 p.m. with S2DON, she verified she did not have 3 years experience on a psychiatric unit. She said she was a nursing supervisor over 8 inpatient units and an emergency department plus the psychiatric unit at another hospital. She verified she did not have her Master's degree and did not have consistently scheduled supervision/consultation from a Master's prepared psychiatric nurse.

In an interview on 5/16/19 at 2:41 p.m. with S1CEO, he said the fact that S2DON was not qualified was told to them in January by the Joint Commission accrediting organization. S1CEO verified S2DON did not currently meet qualifications.

Based on observation, record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1) failure to maintain ordered observation levels for 2 (#R1, #R2) of 3 patients ordered to be observed every 5 minutes ; and

2) failure to ensure all admission orders were obtained from a licensed practitioner, not just medications, with the nurses choosing the remainder of the orders such as diet, level of observation.

Findings:

1) Failure to maintain ordered observation levels for patients ordered to be observed every 5 minutes.

Review of the hospital's policy titled Levels of Observation revealed in part:

Level 2 - 5 Minute Checks:

1. Definition: Level 2 means staff visually observe assigned patients every 5 minutes.

3. Used for: Patients who are quite volatile, who give specific evidence that a suicide attempt is suspected, showing minimal impulse control, or those who are experiencing a high level of mood swings.

Review of Observation Logs on 5/15/19 at 8:52 a.m. for Patient #R1 and #R2 revealed both patients were on suicide precautions and were a Level 2 observation status. Further review revealed the last entries for 5 minute observations were at 8:15 a.m. (6 entries not documented).

In an observation from 8:35 a.m. until 8:52 a.m., S5MHT was outside of unit C with 11 patients in the smoking area. S5MHT had her back to the window where the unit was visible from the outside area. Patient #R1 and #R2 were on the unit and not being observed by the RN and LPN in the unit.

In an interview on 5/15/19 at 9:55 a.m., S6RN she said usually on the units there was an RN, LPN, and two MHTs. She verified she was functioning as a MHT on unit C this morning. She said S5MHT was assigned to observe Patient #R1 and #R2 at a level 2 (every 5 minutes). She verified when she and S5MHT were outside at the smoking area with other patients and neither of them were observing Patient #R1 and #R2. She also verified they did not assign the LPN or the RN on the unit to observe Patient #R1 and #R2 while they were outside.

In an interview on 5/15/19 at 8:54 a.m. with S5MHT, she said she was assigned to observe Patient #R1 and Patient #R2 on Level 2. S5MHT verified she was outside with the smoking patients and Patient #R1 and #R2 were in the unit. She also verified she did not document on the 2 patients since 8:15 a.m. S5MHT said, "To be honest, I was outside with the smokers and did not observe them."


2) Failure to ensure all admission orders were obtained from a licensed practitioner.

Review of the preprinted document titled Admission Order revealed check boxes to select orders such as labs, medication levels, observation levels, special precautions, consultations and diets.

Patient #R3
Review of Patient #R3's Admission Orders revealed he had been admitted on 5/15/19 at 11:30 a.m. for Opioid Use Disorder, severe. Further review revealed orders included Patient #R3 to be on level 1 observations (every 15 minutes), withdrawal precautions, seizure precautions and a regular diet. The orders were documented as having been taken by a telephone order from S20NP.

In an interview on 5/15/19 at 2:43 p.m. with S11RN, he said he was a charge nurse. He said there were preprinted admission orders with selections for various orders. He said if the patient came from a hospital the staff would fill out some of the selections from the patients' discharge paperwork. S11RN said he would select precautions based on the patient's risk score and interview. He said when completing the admission orders he only went over medications with the doctors on the telephone unless the patients were psychotic or something. S11RN also said he chose the patients' precautions based on the patients' histories. S11RN presented an admission order sheet he had completed on Patient #R3 earlier in the day. In reviewing the order, he said he selected Patient #R3's observation level, special precautions and diet based on discharge on the patient's paperwork from the sending hospital and interviews with the patient. S11RN verified although he documented verbal/telephone order read back and verified by S20NP, he had selected the patient's observation level, special precautions and diet and did not obtain those orders from the nurse practitioner.


In an interview 5/15/19 at 9:55 a.m. S6RN reported the hospital used a pre-printed order sheet and that the nurses would check some of those orders depending on what their assessments were. The nurse reported if the patient comes with a diet, we mark those. S6RN confirmed it was not the nurses' practice to go over the whole list of orders with the physicians. She reported the nurses went over information about the patient related to their (psychiatric) admission and their medications. The RN reported the nurses selected diet, observation level were chosen by the patient's assessment, like if they score high on suicide risk assessment, they need a higher level of observation.

In an interview 5/15/19 at 2:17 p.m.. S10RN reported she does not go over the entire set of admission orders with the physician [or NP]. She reports the nurses will go over medications and ask for orders for precautions such as suicide, aggression, etc. She reported that all patients get the same orders for labs, depending on what was already collected at the sending ED. She reported she completes the orders as she "just knows what the providers want; it has been the same since she started at the hospital." She reported she chooses the patient's diet based on the information received on their "paperwork." She reported that she does not ask the physician (provider) for orders for observation levels. The Nurse reported the level of observation was chosen based on their scores (intake assessments done by nurses and paramedics in the intake department). S10RN reported the RNs check off the admission orders.


In an interview 5/15/19 at 3:45 p.m. S3NP verified that staff sometimes document that they contacted him and received telephone or verbal orders from him, when he was not contacted at that time and did not give the admitting orders.

In a phone interview 5/17/19 at 2:30 p.m. S13MD reported she was not aware that staff nurses were making decisions on some of the orders. She reported she did not give orders such as diets and labs. She reported she thought the medical providers were giving those orders. She advised that all orders should come from a provider.

Based upon record review and interview, the hospital failed to ensure all entries entered into the medical record were timed and dated by the person responsible for providing or evaluating the service provided. This deficient practice was evidenced by the documentation by intake staff being altered by S4Intake, at a later time than when the entry was first made by other staff for 2 of 2 (#1, #4) records reviewed for alterations in medical records of a total sample of 5.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed the following documentation:

Patient #1's face sheet had an admission date and time of 4/30/19 at 11:55 p.m.

Patient #1's Formal Voluntary Admission was not signed until 1:00 a.m.

Patient #1's High Risk Notification Form was originally dated and signed at 5/1/19 at 1:20 a.m. by the intake staff and a RN. A line was drawn through the date and time and the word omit was written. A new date and time of 4/30/19 at 11:55 p.m. was written on the document.

Review of Patient #1's Nursing Assessment revealed the time of arrival on the unit was 1:20 a.m.

Review of Patient #1's Admission Orders revealed the admission date and time was 5/1/19 at 1:20 a.m.


In an interview on 5/15/19 at 1:31 p.m. S4Intake said she had been director since December and Manager since May 2018. She said the patient's packet comes through the E-fax and has the face sheet, PEC and CEC. She said they look for acuity, etc. If the patient falls into Tier 2 they (intake staff) have to call the doctor. Tier 3 is exclusionary, so they don't have to call the physician. If the patient's physical assessment, history, and/or mental complaints and symptoms fall under Tier 1 the intake staff accept the patient for admission without calling the physician. With regards to times and dates altered in a medical record, S4Intake reported a couple of weeks ago on the night shift, one of the coordinators called and reported the patient got there around 10:00 p.m. She said they had a bed situation, due to them thinking it was a male and the patient was a female so they did not have a female bed for her. The night intake manager S23Intake called her and said they did not have a bed for her. The RN on unit C was refusing to accept the patient because they had so many admissions. Since the patient was at the hospital before midnight, she (S4Intake) changed the time on the high risk notification form. She thought S23Intake said she was supposed to change the time on the high risk form notification to 11:55 p.m. instead of 1:20 a.m. which was on the intake form. She said S23Intake called her the next day and told her to fix the times. S4Intake advised she changed the high risk notification, the notification of high suicide risk assessment and the accepting time. The FVA is usually in the front of the chart, and she saw it was not signed until 1:00 a.m. She said this was an isolated incident and she knows it was wrong.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital 12/10/18 at 10:05 p.m. with admitting diagnoses of Paranoid Schizophrenia, Impulse Control Disorder, Intermittent Explosive Disorder, and Rule Out: MDD, Bipolar, SAD per his Psychiatric Evaluation dated 12/11/18. Further review of his Intake assessment revealed it had documentation with two different pen/ink patterns and handwriting. Some documentation was documented in a lighter gray and thin inked handwriting, as in a fine point ink pen, and was noted on the majority of the 8 pages of intake assessment and the High Risk Notification Form. The second noted penmanship was in a thicker darker black ink and of a different handwriting style. The intake form was signed by S24Intake, dated and timed at 12/10/18 at 9:45 p.m. and the Suicide Risk Assessment was signed 12/10/18 at 10:05 p.m. by S24Intake. Further review of these documents revealed numerous markings with a darker and thicker ink of a different handwriting style with some entries marked through, omit written, and entries made to change a score and/or document handwritten notes. The Suicide Risk Assessment total score of "2", written in the lighter ink, was marked through and "8" written next to the word, "omit". On the same document boxes for Known Medical Problems and Other had an X placed in them with the documentation of "Schizophrenia, Bipolar" and "med non-compliant" documented in the darker ink. No date, time, or author identification was noted in the darker ink at the entries.

In an interview 5/15/19 at 3: 45 p.m. S3NP reported he had witnessed S4Intake making changes in the medical record of patients. He reported he witnessed her writing on an intake form for Patient #4 12/11/18, the day after the patient was admitted. He reported he witnessed S4Intake complete the Alcohol Use Screen on Page 7 without talking to the patient, documented an "x" for patient denies on the section of Alcohol and Drug Use History and History of Blackouts, without talking to the patient. He further reported he watched her change the Suicide Risk Assessment Score, add "med non-compliant" on the "other" blank line at the bottom of the assessment and add "Schizophrenia, Bipolar" to the known Medical problems. The NP reported the Intake staff are documenting that they call the provider to notify them of the admission, but this is not always actually done. The medical diagnosis documented as the "Diagnosis per Physician" is not given by the physician or NP at the time of admission.

In an interview 5/16/19 at 4:05 p.m. S4Intake, after reviewing the medical record of Patient #4, confirmed she was the author of the darker documentation and changes to the patient's intake assessment. She confirmed that she did make changes to intake assessments done by other intake staff after the patients' admissions. The intake director confirmed she did not sign, date, time, or make any other notation to show she made the changes to other staff member's documentation, or added notes in their documentation. S4Intake confirmed intake staff documented a notification is made to the provider with a date and time when they do not actually notify the provider for Tier I patients admitted. S4Intake further confirmed the diagnosis documented under "Diagnosis per Physician" is not obtained from the provider when the intake assessment is completed. She reported sometimes it can be obtained from the ED records, from the patient's symptoms, or their history.

Based on record review, observation, and interview, the hospital failed to meet the Condition of Participation for Food and Dietetic Services as evidenced by :

1) Failure to ensure that food and dietetic services organization requirements were met as evidenced by the Food and Dietetic Services not being under the supervision of a registered dietitian, as required by Louisiana Hospital Licensing rules.(See Findings in A-0619)

2) Failure to ensure menus met the needs of patients as evidenced by an observation of a patient not receiving a diabetic diet, as ordered and staff interviews. (See Findings in A-0629), and

3) Failure to ensure all patient diets, including therapeutic diets were ordered by a practitioner responsible for the care of the patients or by a qualified dietitian. (See Findings in A-0630).

Based on record review and interview the hospital failed to ensure that food and dietetic services organization requirements were met.as evidenced by the Food and Dietetic Services not being under the supervision of a registered dietitian, as required by Louisiana Hospital Licensing standards.
Findings:

Review of the Louisiana Hospital Licensing standards (LAC 48:I, Chapter 93: Licensing Standards for Hospitals, section 9379) revealed, in part, "Food and dietetic services shall be under the supervision of a registered dietitian, licensed to practice in Louisiana..."

Review of the hospital organizational chart revealed the Dietary Manager was S8DM.

Review of the personnel file for S8DM revealed no documentation of education, registration, certification, or licensing related to being a dietician.

Review of the personnel files for S18RD and S19RD revealed they were both Registered Dieticians and Licensed Dietitian Nutritionists. Further review of documents provided by administration revealed each dieticians was contracted, separately (S18RD since September 26, 2018 and S19RD since October 1, 2018), in an agreement titled , "Registered Consultant Dietitian Contract." Further review revealed no signed job description for either RD.

In an interview 5/16/19 at 3:41 p.m. S8DM reported that his direct supervisor was S1CEO. He advised that if he had a question regarding a diet he could call S19RD or S18RD, but they did not supervise the dietary department.

In an interview 5/16/19 at 3:45 p.m. S1CEO reported S8DM reported directed to him (S1CEO) concerning financials only. He reported the hospital had 2 dietitians that supervised the hospital dietary services. When asked which one was designated at the director of dietary services, he reported he was not aware that one had to be designated. He reported he was not aware of the state hospital licensing rules that required a dietitian be over the dietary services.

In a phone interview 5/16/19 at 2:40 p.m. S18RD verified she was a consulting dietitian for the hospital, through an agreement and advised she did not oversee or supervise the dietary department or personnel .

In a phone interview 5/16/19 at 3:55 p.m. S19RD reported she provided dietary consults to the patients at Covington Behavioral Health. She reported she was not the Director of the Dietary Services. She confirmed she did not supervise or oversee the operations and staff of the dietary department.

Based on record review, observation and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This deficient practice was evidenced by patients not receiving a diabetic diets with double portions for 1(#R4) of 4(#'s R2, R4, R5, R6) observed patients with therapeutic diets ordered.

Findings:

Review of hospital policy # NU 416 titled "Diet Orders", (last revision date 5/21/17) provided by S21HRQA as current, revealed it was the policy of Covington Behavioral Health that to ensure that all patients receive their proper diet as ordered by their physician. The policy stated it was the dual responsibility of the nursing staff and the dietary staff to see that the patients receive their proper diets. "The procedure steps were documented, in part, as ...2) each patient coming into the hospital must have a written order for a diet by his/her physician. 3) If a patient is on a modified diet or in the case of a diet change, the nursing personnel receiving the physician's order will complete a Diet Order Requisition for a modified diet or diet change; the senior dietary person will complete a "special diet card' for this patient. This card will then be placed in an index type file and kept on the cafeteria line during serving times..."

Review of documents containing patient information from Units A, B and C for 05/15/19 revealed Patients #R2, R4, and R5 were ordered to have an ADA diet. Patient #R4 was to have an ADA diet with double portions of Protein and vegetables, but no double portions of carbohydrates. Patient # R6 was ordered to have a Lactose Free diet with double portions.

An observation of the lunch meal service for Units B and C was conducted 5/16/19 from 12:05 P.M. TO 12:40 P.M. revealed the following: The patients came into the lunch room and through the serving line. S8DM checked the patient's diet card with their ID sticker and a type diet on it, as well as their ID Bracelet against the list of patients and their diets. He would then tell S7Cook what diet to serve the patient. The menu for lunch was shrimp Alfredo over pasta, steamed mixed vegetables (broccoli, cauliflower, carrots), herbed biscuits, and for dessert cake or fruit cup. When serving Patient #R4, who had a ADA diet, double portions she was served 2 regular scoops/helpings of pasta (shrimp Alfredo) as well as 2 servings of veggies and 2 biscuits, along with a fruit cup. Patient #R6 had a Lactose free diet/double portions diet ordered and S8DM stopped S7Cook from serving the regular Shrimp Alfredo, and told him he had to get the special pasta and chicken. After being told Patient #R6 would get the other pasta and chicken, the patient was served 2 smaller portions (smaller scoop for measuring ADA portions) of buttered pasta over a single chicken patty, veggies (double portion) , 1 biscuit and a fruit cup. In an interview at the end of the observation, S7Cook was asked how he knew what portions to serve on a diabetic diet, he reported he used the smaller scoop. When asked about Patient #R4 getting regular sized double portions of the Shrimp Alfredo over pasta, and 2 biscuits, S7Cook reported he thought just the biscuits were the carbohydrate and wasn't aware that the pasta, too, was a carbohydrate. S8DM, present for the interview stated, "We failed on that one."

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In an interview 5/15/19 at 2:17 p.m. S10RN reported she worked days and when Diabetic Patients are admitted they are given the same food as all other patients with the exception of desserts. She gave an example of fried catfish and French Fries, and mashed potatoes. S10RN stated, "I guess we could be more focused and patient specific. I call the dietary department and tell them I need a dietary tray. S10RN reported the staff do not document what the patients are fed, or how much they eat.

In an interview 5/15/19 at 2:43 p.m. S11RN reported he didn't know how the diabetic or therapeutic diets were because he didn't go to the cafeteria (where patient's take their meals). The RN reported he had a lot of patients come back to the unit and say they were not getting a diabetic diet. He advised that patients will sometimes give their snacks to other patients. S11RN reported that the MHTs go with the patients to the cafeteria for meals, but they are not trained regarding what is an appropriate diet. He reported both nurses on the unit stay on the unit while patients go to meals because they are either catching up on charting and/or pulling medications.

In a phone interview 5/16/19 at 2:40 p.m. S18RD reported she was a consulting dietitian for the hospital through an agreement. She reported she provided dietary consults for patients when ordered by the physicians. She confirmed she did not oversee or supervise the dietary department or the personnel or approved the menus or the dietary manual.

5/16/19 at 3:55 p.m. In a phone interview S19RD reported she provided dietary consults to the patients at the hospital. She reported she was not the Director of the Dietary Services. She reported she had received a call from S8DM yesterday requesting a special menu for today since surveyors were onsite. She confirmed she did not supervise or oversee the operations and staff of the dietary department. She reported she was not aware that therapeutic diets were not always being served as ordered.

Based on record review, observation, and interview the hospital failed to ensure all patient diets, including therapeutic diets were ordered by a practitioner responsible for the care of the patients or by a qualified dietitian.
Findings:

Review of a Nursing Policy titled, "Diet Orders" (#NU416), provided by S21HRQA as current, revealed in part that it was the policy of Covingtion Behavioral Health that each patient would receive a diet as ordered by their physician or registered dietitian. Further review revealed it would be the "dual responsibility of the nursing staff and the dietary staff to see that the patients receive their proper diets." Under procedure, each patient coming into the hospital must have a written order for a diet by his/her physician. Modified diets would be ordered by a physician or registered dietitian.


In an interview on 5/15/19 at 2:43 p.m. S11RN, said he was a charge nurse. He said there were preprinted admission orders with selections for various orders. He said if the patient came from another hospital the staff would fill out some of the selections from the patients' discharge paperwork. He said when completing the admission orders he only went over medications with the doctors on the telephone unless the patients were psychotic or something. S11RN presented an admission order sheet he had completed on Patient #R3 earlier in the day. In reviewing the order, he said he selected Patient #R3's observation level, special precautions and diet based on discharge on the patient's paperwork from the sending hospital and interviews with the patient. S11RN verified although he documented verbal/telephone order read back and verified by S20NP, he had selected the patient's observation level, special precautions and diet and did not obtain those orders from the nurse practitioner. Review of the orders for Patient #R3 revealed he had a regular diet ordered.


In an interview 5/15/19 at 9:55 a.m. S6RN reported the hospital used a pre-printed order sheet and that the nurses would check some of those orders depending on what their assessments were. The nurse reported if the patient comes with a diet, we mark those. S6RN confirmed it was not the nurses' practice to go over the whole list of orders with the physicians. She reported the nurses went over information about the patient related to their (psychiatric) admission and their medications. The RN reported the nurses selected diet.

In an interview 5/15/19 at 2:17 p.m.. S 10 RN reported she does not go over the entire set of admission orders with the physician[or NP]. She reports the nurses will go over medications and ask for orders for precautions such as suicide, aggression, etc. She reported she chooses the patient's diet based on the information received on their "paperwork." S10RN reported the RNs check off the admission orders.


In a phone interview 5/17/19 at 2:30 p.m. S13MD reported she was not aware that staff nurses were making decisions on some of the orders. She reported she did not give orders such as diets and labs. She reported she thought the medical providers were giving those orders. She advised that all orders should come from a provider.

30420


Based on observation, record review and interviews, the infection control officer failed to develop and implement a system for identifying and controlling infections in the kitchen. This deficient practice is evidenced by staff failing to ensure the third sink in the 3 compartment sink used for sanitizing cookware contained the manufacturer's recommended amount of quaternary solution or was at the recommended temperature.

Findings:

Review of the Quaternary Solution test strips revealed a color coded chart to compare the test strips to for indicating the amount of quaternary solution mixed with water. The directions from the manufacturer indicated to immerse the strip for 10 seconds in the water with the quaternary solution and then compare to the chart while wet. Further instructions indicated the solution should have been between 65-75 degrees F.

Review on 5/15/19 at 9:04 a.m. in the kitchen of a document titled 3 Compartment Sink Sanitation Log for 5/15/19. Under the heading titled lunch, the Quaternary solution in the 3rd sink was documented as being 400 parts per million by S7Cook. The water in the 3rd sink was only a third of the way to a sign indicating where the fill line of the water should have been.

In an interview on 5/15/19 at 9:00 a.m. with S7Cook, he said he did not take temperatures on the water with the quaternary solution. When asked the process for ensuring the 3rd sink had enough quaternary solution to be effective, he said the test strip should have been submerged into the water in the 3rd sink with the quaternary solution for 15-30 seconds and then compared to the colored chart. He said he had tested the water in the sink for lunch and it was 400 ppm. He said the acceptable amount of solution was between 300 ppm and 400 ppm. When asked to test the water, he submerged a test strip for 23 seconds. When he removed the strip from the water, the strip was observed to be yellow which was less than the lowest amount (100ppm) on the color chart. When asked how full of water the sink should have been, S7Cook said to the fill line. When asked why it was a third of the way full, he said he was going to add water to it later.

In an interview on 5/15/19 at 9:10 a.m. with S8DM, he said the 3rd compartment sink for washing dishes should have contained between 300 ppm - 400 ppm of quaternary solution. S8DM also verified the sink should have been filled with water to the fill line indicated on the sink but it was not. When asked to test the quaternary, he emptied the sink and filled it with the quaternary solution and water. When he tested the water it was 100 ppm. He said he did not know what was wrong with the equipment. When asked to see the log for temperatures of the water, S8DM said they did not keep a log for the temperatures.

An observation 5/16/19 at 12:10 a.m. revealed S7Cook test the Quatenary solution in the 3rd sink by submerging the test strip in the solution for 30 seconds. The test strip did not turn colors with the exception of some green discoloration at the very edges of the strip. A repeat test revealed the same results. A review of the 3 Compartment Sink Sanitation Log for 5/16/19 revealed the results under breakfast as 400 ppm and at lunch 380 ppm. S7Cook reported he had tested the sink just before the kitchen started serving lunch. When asked how he evaluated the results at 380 (the lunch reading), since the readings were comparison of colors for 100 ppm, 200 ppm, 300 ppm and 400 ppm, he reported that it was between the colors so he called it 380. He also reported that the temperature was still not being tested. S8DM, present for the observation, reported the temperature was not being taken yet, as they were waiting for an updated log.