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Based on hospital contract review and Quality Assessment and Performance Improvement data provided, the hospital's governing body had not evaluated the performance of the contract for 1 of 1 dietary services contract.

Findings included:

Review on 07/11/2023 of the hospital contracts revealed a contract between the Hospital A and Agency B for nutrition and food services provided for hospital patients signed on 07/07/2023.

Review on 07/12/2023 of the Quality and Assessment and Performance Improvement data revealed there have been no evaluations of the contract since the signed date of 07/07/2023 (4 days prior to team arrival). Review revealed there have been concerns with meals that have been provided since the contract was signed such as missing side salads. Interview on 07/11/2023 at 1252 with Exec Dir #3 revealed examples of the concerns with meals were the labels fell off the trays and trays missing items.

Interview on 07/12/2023 at 1413 with Exec Dir #3 revealed he will start the review of the new dietary contract August 2023. Staff are still being trained on the new process with delivery of food trays and what to do if there is a problem with a meal. Interview revealed the original goal on the plan of correction was to have 100% education completed by 7/10/2023. As of 07/12/2023 only 93% of staff have been trained on the new process not including a nurse that is currently working.

Based on hospital policy review, medical record review and staff interview, the hospital staff failed to complete a face-to-face assessment within one hour after a seclusion restraint intervention for 1 of 1 patient restraint records reviewed (Patient #1).

The findings include:

Review of the hospital policy on 07/12/2023 titled "Restraint and Seclusion" with reviewed/revised date of 03/2023 revealed "Procedure: ...7. One-hour face-to-face assessment: The physician, LIP, or a registered nurse or nurse practitioner/physician assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint ...."

Review of an open medical record on 07/11/2023 for Patient #1 revealed a 61-year-old female admitted on 06/28/2023 on an involuntary basis to the inpatient psychiatric unit after transfer from local hospital. Review of the physician's order dated 07/03/2023 at 0500 revealed a verbal order obtained by RN #1 for "Seclusion Order for maximum of 4 hours" for violent self-destructive behavior to others with start time: 07/03/2023 at 0400 and end time at 0555, 1 hour and 55 minutes. Review of the medical record revealed no available documentation of a face-to-face assessment completed after the restrictive intervention order on 07/03/2023 at 0500.

Interview with RN #1 was requested. RN #1 was not available for interview.

Interview on 07/12/2023 at 1840 with Nurse Manager #2 revealed there was no available documentation of the face-to-face for Patient #1 for the seclusion ordered and applied on 07/03/2023.

Based on review of the hospital policy, observations, review of personnel records, and staff interviews, the hospital staff failed to provide a safe environment by failing to don personal protective equipment and perform hand hygiene during distribution of meal trays in 1 of 4 observations.

The findings include:

Review of the hospital policy titled "Dietary Services" with review date of 06/23 revealed "Serving and Sanitation: 1. All meals served at (named facility) will be served by staff who have received facility training on ensuring diet and meal tray accuracy. 2. All staff serving will don a hairnet when distributing meals. All meals will be served with gloves."

Observation on 07/11/2023 at 1700 of the distribution of the evening meal revealed MHT #4 pushing a cart into the kitchen area with a large blue insulated bag on top of cart. MHT #4 was observed washing hands at the sink then applying hair net. Observation revealed the hair net covered MHT #4's hair from the forehead to the neck area, leaving the long strands uncovered and exposed without the hair net. Observation at 1800 revealed MHT #4 accepting a used cup from a patient requesting a refill. MHT #4 placed the used cup on the utility cart used for meals.

Review of personnel records on 07/12/2023 revealed MHT #4 was hired on 07/05/2021 with education on dietary process on 06/07/2023.

Interview on 07/11/2023 at 1805 with MHT #4 revealed the hair net should be put on first then wash hands. MHT #4 stated the cup should not have been accepted from the patient. MHT #4 stated a new cup should have been given to the patient with the refill instead of taking the used cup into the kitchen.

Interview on 07/12/2023 at 1225 with senior MHT #5 revealed MHT #4 has been instructed on proper handwashing and hair nets.
Interview on 07/12/2023 at 1100 with ICP (Infection Control Preventionist) #6 revealed hair nets should be worn in the van during pick up of the meals. The interview revealed hair nets should cover all of the hair of the staff member. Interview revealed the MHT should perform hand washing after the hair net has been placed on the staff member's hair. The interview revealed no used beverage cups should be accepted back in the kitchen due to cross contamination.