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Based on record review and interview the facility failed to ensure the completion and documentation of nursing assessments in the Psychiatric Crisis Services (PCS) center per facility policies in 2 of 20 (Patient #'s 32 & 38) PCS medical records reviewed in a total universe of 50 medical records reviewed.

Findings include:

The facility document titled "Psychiatric Crisis Service Policy & Procedure" #10246945 last revised 8/17/2021 was reviewed. This document revealed "B. Triage Procedure: 1. These patients need immediate assessment by the RN (Registered Nurse), and immediate referral to a PCS psychiatrist for evaluation and/or treatment; patients with urgent or emergent medical needs will be sent to the appropriate Emergency Department via paramedics or ambulance when clinically indicated...2. While assessing the patient, the RN will assign and implement an initial priority level based on the urgency and severity of the patient's needs...D. Registered Nurse Intake Assessment: The registered nurse initiates the Crisis Nursing Assessment...5. Obtain and document demographic data, vital signs, intoximeter reading for alcohol level, urine to complete urine drug screen, and pregnancy test. 6. Assess and document information regarding presenting emotional and physical status; reasons for seeking service; current medications (prescribed, over the counter, and/or herbal remedies); medical problems; TB (tuberculosis) status; recent exposure to life threatening event, physical abuse, sexual abuse or domestic violence; pregnancy status; allergies; recent alcohol/drug use/abuse; potential for dangerousness; and presence of psychotic symptoms. Transfer/discharge papers from another hospital/clinic, legal documents, and other referral information will also be reviewed...6. The RN, using initial assessment data, direct observation, and interactions with the patient will evaluate changes in the patient's medical, mental, or behavioral status. Through the PCS process, the RN will monitor and document patient observation and treatment regularly as clinically indicated."

The facility document titled "Suicide Risk Assessment and Risk Reduction; Psychiatric Crisis Service" #8346661 last revised 10/7/2020 was reviewed. This document revealed "A. Upon entry to PCS, each individual receives a triage screening and a full Crisis Service Nursing Assessment. 1. A Registered Nurse conducts a triage screening, which includes a standardized Suicide Screening utilizing the Columbia Suicide Severity Rating Scale. 2. A Registered Nurse also completes the Crisis Service Nursing Assessment, which includes additional questions pertaining to risk of suicide."

A record review was conducted on 10/5/2021 at 12:40 PM on Patient #32's closed clinical record accompanied by PCS Medical Director O, PCS Manager P and Nurse Educator R who confirmed the following findings: Patient #32 was seen in the PCS department on 9/20/2021 was brought there by local police on a Chapter 51/legal hold for suicidal and homicidal ideations. The "Crisis Nursing Assessment" completed did not have any entries for Assessment Risk Factors: Suicide Risk Factors, Violence Risk Factors, Elopement Risk Factors & Pain and Physical Assessment. When asked about the expectations of the "Crisis Nursing Assessment" being completed PCS Manager P stated "Yeah those areas are blank and they should be filled in or say 'unable to obtain' and the reason why they couldn't obtain the information and that isn't there."

A record review was conducted on 10/5/2021 at 2:25 PM on Patient #38's closed clinical record accompanied by PCS Medical Director O, PCS Manager P and Nurse Educator R who confirmed the following findings: Patient #38 was seen in the PCS department on 10/1/2021 was brought there by local police on a Chapter 51/legal hold for violence toward his father and was admitted to the on site child and adolescent unit. There was no documented "Crisis Nursing Assessment" completed on 10/1/2021. When asked about the expectations of the "Crisis Nursing Assessment" being done Nurse Educator R stated "I can not find that one was completed for this visit and it should be done every time someone comes in."

Based on observation, staff interview and review of maintenance records on 10/05-10/07/2021, the Milwaukee County Behavioral Health Division failed to construct, install, and maintain the building systems to ensure safety of patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K222 - Egress Doors
2. K271 - Discharge from Exits
3. K291 - Emergency Lighting
4. K321 - Hazardous Areas - Enclosure
5. K345 - Fire Alarm System Testing and Maintenance
6. K362 - Corridor - Construction of Walls

7. K363 - Corridor - Doors
8. K372 - Subdivision of Building Spaces - Smoke Barrier Construction
9. K374 - Subdivision of Building Spaces - Smoke Barrier Doors
10. K911 - Electrical Systems - Others
11. K918 - Electrical Systems - Essential Electric System Maintenance and Testing
12. K920 - Electrical Equipment - Power Cords and Extension Cords
13. A701 - Maintenance of Physical Plant
14. A709 - Life Safety from Fire

As a result of these deficiencies, 42 CFR Subpart CFR 482.41 Condition of Participation: Physical environment was NOT MET.

See K-tags, A701, and A709 for details of the specific findings.

Based on observation and interview, the heating, ventilating and air conditioning system (HVAC) ductwork was not maintained clean. This deficient practice had a potential to affect all patients who receive care using oxygen in the facility.

Findings include

1. On 10/07/2021 at 10:00 am, observation revealed that two supply grilles in the Medical Gas Oxygen Cylinder storage room were dirty. The storage room was located adjacent to the Loading Dock in Building 5 2nd Level Area E.

2. Observation on 10/07/21 at 10:25 am revealed that the metal astragal at the meeting edge of a pair of cross-corridor smoke doors, SD-7, was bent at the bottom end of it with 2 screw fasteners almost completely pulled out from the door. The bent astragal was a safety hazard. The smoke doors were located in the Unit 53A of Building #5 Level 3.

This deficiency was confirmed by interview with Staff M1, Staff M2 and Staff Q at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation, staff interview and review of maintenance records on 10/05-10/07/2021, the Milwaukee County Behavioral Health Division failed to construct, install, and maintain the building systems to ensure safety of patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K222 - Egress Doors
2. K271 - Discharge from Exits
3. K291 - Emergency Lighting
4. K321 - Hazardous Areas - Enclosure
5. K345 - Fire Alarm System Testing and Maintenance
6. K362 - Corridor - Construction of Walls

7. K363 - Corridor - Doors
8. K372 - Subdivision of Building Spaces - Smoke Barrier Construction
9. K374 - Subdivision of Building Spaces - Smoke Barrier Doors
10. K911 - Electrical Systems - Others
11. K918 - Electrical Systems - Essential Electric System Maintenance and Testing
12. K920 - Electrical Equipment - Power Cords and Extension Cords

As a result of these deficiencies, 42 CFR Subpart CFR 482.41(b) Standard: Life safety from fire was NOT MET.

See K-tags for details of the specific findings.

Based on record review and interview, facility staff failed to maintain an environment that was free from potential contamination by failing to document corrective action for, and/or report out of parameter temperatures in 1 of 2 cold storage areas (kitchen freezer) out of 1 of 9 departments observed (dietary).

Findings include:

Review of policy titled "Freezer Temperature Log For Non-24-Hour Operation" #FS-RS-06-FM-03 dated 04/14/15 revealed, "Corrective Actions: 1. If freezer temperature is above 0°F degrees (-18°C), immediately check if the product is frozen solid from front/top, middle, and back/bottom of the freezer and record 'FRZ' in the corrective action box. 2. If the product is frozen solid, re-check the freezer temperature in 1 hour (KEEP THE DOOR CLOSED) and record the temperature in the corrective action box. Go to step 4. 3. If the product is not frozen solid, move the product to a refrigerator and follow the Aramark Thawing Standard. Notify your manager to determine the next step. 4. If the freezer is still above 0°F degrees (-18°C), quickly move the food into a working freezer and notify your manager."

Record review of the form "Freezer Temperature Log For Non-24-Hour Operation," that were kept in a binder in the kitchen, revealed completed daily forms for 2021; there were freezer temperatures above 0°F degrees (-18°C) and no documentation of corrective actions per policy in the following months: March (3/1, 3/8, 3/10, 3/22, 3/23, 3/24, 3/25, 3/26, 3/29 and 3/30), April (4/8, 4/9, 4/13, 4/14, 4/19 and 4/20), May (5/3, 5/7, 5/17, 5/23 and 5/28), June (6/12, 6/27, 6/29 and 6/30), July (7/7, 7/9, 7/11, 7/12, 7/24, 7/26, 7/29 and 7/31), August (8/12, 8/10, 8/16, 8/20, 8/23, 8/24, 8/26, 8/28, and 8/31), September (9/4, 9/5, 9/7, 9/8, 9/10, 9/11, 9/12, 9/13, 9/14, 9/16, 9/17, 9/18, 9/20, 9/21, 9/23, 9/26, 9/27 and 9/30) and October (10/1 and 10/2).

On 10/05/21 at 12:46 PM during interview with Dietary Director G, when asked if there should be corrective actions documented on the freezer temperature log forms if freezer temperatures are above 0°F degrees (-18°C), G stated "Yes, there should be corrective actions documented by staff." When asked if he/she is being notified when freezer temperatures are out of the specified range, G stated "No, I have not been aware." When asked how often daily freezer forms are being reviewed, G stated "I try to look at them weekly."

On 10/05/21 at 1:05 PM during interview with Dietary Manager F, when asked if there should be corrective actions documented on the freezer temperature log forms if freezer temperatures are above 0°F degrees (-18°C), F stated "These forms are given to us from our contracted service 'Aramark' and I now see that there should be corrective actions documented, but I am sure that food is being checked that it is frozen." When asked how often cold food storage logs are being reviewed, F stated "I do safety inspections every 4-6 weeks, any problems I find get reported to the SABHD (Safety Audit Behavioral Health Division) performance for Contract management."