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Based on review of records and interview, it was determined that the Governing Body failed to enforce its own policies and procedures in regard to authentication of medical records.

Findings were:

Facility policy entitled "Northwest Texas Hospital South General Rules and Regulations" stated in part under "Physician and Patient records" "All entries in the patient's medical record must be dated, timed, legible and authenticated ...All verbal orders must be dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges, which are consistent with the written orders."

The following medical records had delinquent authentication of verbal orders:

· Patient # 20 had a verbal order dated 5/5/13 that was not authenticated until 5/9/13
· Patient # 20 had a verbal order dated 5/6/13 that was not authenticated until 5/9/13
· Patient # 21 had a verbal order dated 6/4/13 that was not authenticated until 6/11/13
· Patient # 22 had a verbal order dated 4/17/13 that was not authenticated until 4/30/13
· Patient # 22 had a verbal order dated 4/18/13 that was not authenticated until 4/23/13
· Patient # 22 had a verbal order dated 4/24/13 that was not authenticated until 4/30/13
· Patient # 23 had a verbal order dated 5/3/13 that was not authenticated until 6/16/13
· Patient # 40 had a verbal order dated 7/7/13 that was not signed, dated or timed by a physician.
· Patient # 40 had a physician order dated 7/8/13 that was not noted/transcribed by a nurse.
· Patient # 41 had a physician order dated 5/28/13 that was not signed, dated or timed by a physician.
· Patient # 42 had

In an interview with the Director of Quality on 7/10/13, the above delinquent authentication of verbal orders was confirmed. It was also acknowledged that the facility did not follow its own policy in regard to authenticating verbal orders.



28422

Based on a review of documentation, the governing body failed to be responsible for services furnished in the hospital, whether or not they are furnished under contracts.
Findings were:
Facility policy titled Nurse Staffing Committee states, in part, " V. Procedure: A. Under the direction of the Chief Nursing Officer, the facility will establish a Nurse Staffing Committee comprised of at least 50% registered nurses (Texas hospitals 60%) who:
1. Provide direct patient care during at least 50% of their work time; "
A review of documentation listing the Staffing Advisory Committee Members for the calendar years 2012 and 2013 revealed that the committee was comprised of only 50% (not the required 60%) registered nurses who provided direct patient care at least 50% of their work time.

Based on review of facility policies and procedures, staff interview, and review of facility medical records, the hospital failed to ensure the personal privacy of its patients and failed to follow its own policy as there was no documented evidence that patients or their representatives gave consent to or were aware of the patient's being monitored by video.

Findings were:

In 3 of 3 medical records of patients monitored by video (patients #44, 45 and 53) on the Med/Psych Holding Unit, there was no documented evidence available of a consent for electronic monitoring signed by the patient or the patient's representative. In addition, for 3 of these same 3 patients (#44, 45 and 53) there was no documented evidence in the patient record that they or their representatives had been given the Behavioral Health Inpatient Guidelines to review and initial, and thus, no evidence that they had been made aware that they were to be monitored by video camera.

Facility based policy entitled Suicide Precautions, Acute Care stated, in part, "13. Patients in psych hold beds will have written consent for video camera monitoring and signs will be posted in the area for visitor communication."

Facility based policy entitled Care of Pavilion Overflow Patient to Acute Care stated, in part, "1.When it is determined no beds are available in the Pavilion for patients who are medically cleared, a bed assignment will be made in the acute care setting most appropriate to the patient, based on availability ...Sitters will be assigned for constant observation (via camera on the 4 N unit) based on physician order ...
2. Staff will review the Behavioral Inpatient Guidelines with the patient and have them initial and sign in the designated areas. This will be maintained on the medical record."

Facility form Behavioral Health Inpatient Guidelines revealed nine numbered items for a patient to initial, including the following: "1. Patient will remain in a camera monitored room at all times and may only leave the floor for testing."

In an interview on the morning of 07/11/13 with staff member #117, Med/Psych Holding Unit Director, in the unit meeting room, the use of video monitoring with patients on the Med Psych Holding Unit was discussed. The interview confirmed that all patients on the unit are monitored though close circuit video monitoring at a central desk on the unit. This staff member confirmed that there is a unit expectation that every patient sign the Behavioral Inpatient Guidelines, initialing consent for video monitoring upon admission to the unit.

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff the afternoon of 7/11/13 in the facility conference room.

Based on a review of clinical records, facility documentation and an interview with staff, the facility failed to enforce the patient's right to receive care in a safe setting.

Findings were:

Facility policy and procedure #NS-034 titled Sexual Acting Out states, in part,
· POLICY STATEMENT: ...Patients shall not have sexual contact with one another.
· CHILDREN AND ADOLESENTS; ...9. Minors will be placed in rooms with children their own age. No teenagers will be roomed with anyone younger than 13.

In an interview with staff #55 on 7-8-13 at 1:00 pm, she was asked to give the Pavilion's definition of "teenager" in reference to facility policy #NS-034. She stated that a "teenager" was a child between the ages of 13-17 years of age.

During a review of clinical records for patients #18 & #19, it was revealed that patient #18 was 12 years of age and patient #19 was 13 years of age. The two patients were roomed together.

The above was confirmed in an interview with the facility Chief Executive Officer on the afternoon of 7-9-11.




32870

Based on review of facility policies and procedures, staff interview, and review of facility medical records, the hospital failed to ensure the protection of patients in the Med/Psych Holding Unit [also known as the Pavilion Overflow Unit] by failing to implement clear, non-conflicting hospital policies and procedures regarding patient observation levels, and by failing to follow policies in place regarding adequate observation of patients on suicide precautions.

Findings were:

A review of patient records (patients #44, 45 and 53) on the Med/Psych Holding Unit revealed 3 of 3 had an order written upon admission for one-to-one observation.

A hospital policy defining one-to-one observation level was not available upon request.

In an interview with staff member #117, Unit Director for the Med/Psych Holding Unit, on the morning of 7/11/13, she confirmed that there was no one-to-one observation policy for the unit; rather, constant observation was the usual observation level for the patients there. She also stated the patients admitted to the unit were not violent, but more likely suicidal patients.

Facility based policy entitled Care of Pavilion Overflow Patient to Acute Care stated, in part, "1. When it is determined no beds are available in the Pavilion for patients who are medically cleared, a bed assignment will be made in the acute care setting most appropriate to the patient, based on availability ...Sitters will be assigned for constant observation (via camera on the 4 N unit) based on physician order ..."

Facility based policy entitled Constant Observation Policy stated, in part, "1. A physician's order is required for all sitter situations."

On a tour of the Med/Psych Holding Unit [Pavilion Overflow Unit] on the afternoon of 7/8/13 at approximately 3:10 p.m., 3 of the 3 patients discussed above (patients #44, 45 and 53) were observed by surveyors being constantly monitored via video camera by a "sitter;" yet, 3 of the 3 patient charts did not contain physician orders for constant observation.

Further review of the previous patient records (patients #44, 45 and 53) revealed the "Assessments and Treatments" section showed the observation level for each of the 3 patients above as: "Observation Level: Routine (q 15 minutes)".

The "Assessments and Treatments" section also showed 3 of the 3 patients discussed above (patients #44, 45 and 53) were on Suicide Precautions.

Facility based policy entitled, Suicide Precautions, Acute Care stated, "'1. Suicide precautions' may be implemented by a RN based upon assessment findings or physician order ...
12. One staff member may be responsible to observe more than one patient only when patients may actually be visualized simultaneously."

On a tour of the Med/Psych Holding Unit [Pavilion Overflow Unit] on the afternoon of 7/8/13 at approximately 3:10 p.m., surveyors observed one staff person watching a video monitoring station which contained 6-8 various camera views of the unit, including hallways and stairwells. Three of the views were of the rooms containing patients. One monitor showed a male patient apparently alone in one patient room. Two monitors showed different angles of one patient room which apparently contained two female patients. These were the 3 patients discussed above (patients #44, 45 and 53) who were all on Suicide Precautions.

The above findings regarding conflicting policies and procedures and inadequate observation procedures for the Med/Psych Holding Unit were confirmed in an interview with the Chief Executive Officer and other administrative staff the afternoon of 7/11/13 in the facility conference room.

Based on review of observation and interview, the facility failed to ensure that the right of patients to the confidentiality of information from their clinical record was maintained.

Findings were:

Facility policy entitled "Confidentiality of Patient Health Information", stated in part, "The information contained in the medical record belongs to the patient; and the patient is entitled to the protected right of information. All patient care information shall be regarded as confidential and available only to authorized users...All information contained in the medical record is confidential and the release of information will be closely controlled... All medical records shall be stored in physically secure areas...When in use within the hospital, medical records shall be kept in secure areas at all times. Medical records should not be left unattended in areas accessible to unauthorized individuals."

Facility policy entitled "NWTHS Statement of Patient Rights/Responsibilities", stated in part, ""NWTHS respects your rights as a patient including the right:...To privacy..."

During a tour of the facility on 07/07/13 the following breaches of confidentiality were observed.

· On 5 South, a rolling cart containing 5 unsecured patient charts was observed unattended in a patient hallway.
· This surveyor was able to look through 2 patient charts before facility staff came back into the hallway to retrieve another chart from the cart.
· The 2 patient charts reviewed contained information such as patient face sheet, diagnosis, physician orders, history and physical, medications, and physician progress notes.

This observation of unsecured patient information in the facility was discussed with staff member #119. The staff member acknowledged that this posed a risk of protected information being accessed by unauthorized individuals.
· 5 South was toured a second time on 07/09/13. Another rolling cart containing 7 unsecured patient charts was observed unattended in a patient hallway.
· This surveyor was able to look through 2 patient charts before facility staff came back into the hallway to retrieve another chart from the cart. The patient charts contained information such as patient face sheet, diagnosis, physician orders, history and physical, medications, and physician progress notes.
· On top of this cart, uncovered, was a "Patient Clinical Snapshot" form listing 6 patients. This form included the following patient information: medical record number, attending physician, diagnosis, code status, allergies, age, weight, problem list, and medications.

In an interview on 07/11/12 staff member # 118 confirmed that the presence of unsecured patient charts in the hallways was a known issue on the unit. This staff member indicated that a new group of residents had started rotations on July 1st. Staff member # 118 stated that 5 South staff would be counseled on the need to secure charts and protect patient information on the unit.

Based on observation and interview, the facility failed to ensure patients maintained that the right to safe implementation of restraint or seclusion by trained staff.

Findings were:

Facility policy entitled "Restraint and Seclusion", stated in part, "Competencies requirements apply to all staff designated by the hospital as direct patient care providers, including agency, contract personnel, and security guards or others if they participate with restraints and seclusion. Training is provided by a trainer who is qualified by education, training and experience to address patient behaviors, at the appropriate level and the content is adjusted based on the patient care role of the staff member...
Competency of the staff in application and use of restraints is assessed upon initial orientation, before participating in the use of restraints and annually through either competency skills assessment and/or observation in the work arena by supervising personnel or their designee...
The training must enable staff to show competency in the following areas:
a. The application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion;
b. techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion;
c. The use of nonphysical intervention skills;
d. Choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition;
e. the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia);
f. Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary;
g. Certification in the use of cardiopulmonary resuscitation;
h. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy."

In an interview on 07/11/12 staff member # 117 discussed the status of restraint training on 4 North for the Medical/Psychiatric Holding Unit. This unit provides care for up to 6 mental health patients when no beds are available at the Pavilion or when medical clearance of the patient is needed prior to transfer.
· Staff member #117 confirmed that only 2 staff members that work on that unit have received competency training in restraints, the facility based 2 day program "Handle with Care".
· Often staff members from other units that have not received the "Handle with Care" training provide direct patient care to the population on the Medical/Psychiatric Holding Unit.
· On the two days (07/08/13 and 07/09/13) the Medical/Psychiatric Hold Unit was toured by surveyor, no staff assigned to patient care had received the "Handle with Care" training.
· Staff member # 117 stated that the current job descriptions that will be signed within the next few months included the requirement for all staff working 4 North to complete the "Handle with Care" training.

Staff member # 117 confirmed the need for all staff providing care on the Medical/Psychiatric Hold Unit to receive the "Handle with Care" training which includes in depth restraint training, due to the population of mental health clients on this unit.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to make outdated, mislabeled or otherwise unusable drugs not available for patient use as opened, undated multi-dose vials were found in patient care areas available for patient use in 2 of 27 patient care areas surveyed. This was in violation of facility policy and potentially could have resulted in patients receiving unsafe medications.

The findings were:
The facility policy entitled "Safe Medication Dispensing" dated 6/2009 reflected in part "All multi-dose vials must be initialed, dated, and discarded within 28 days of the date the bottle is opened or by the expiration date printed on the bottle, whichever comes first."

During a tour of the facility's Balance Clinic conducted on the afternoon of 7/8/13 in the company of staff # 18, a multi-dose vial of dexamethasone, 4 mg/ml, 30 ml vial, opened and not dated was found in the hand treatment room available for patient use. This finding was confirmed in an interview with staff # 18 during the tour on 7/8/13 at 1:30 pm.

During a tour of the facility's Women's and Children's Southeast Clinic conducted on the morning of 7/9/13 in the company of staff # 22, a multi-dose vial of lidocaine, 10 mg/ml, 10 ml vial, opened and undated was found in the nursing station available for patient use. This finding was confirmed in an interview with staff # 22 during the tour on 7/9/13 at 8:45 am.

Based on observation, review of documents, and staff interviews the facility failed to maintain the hospital environment in such a manner that the safety and well-being of patients was assured.

Findings included:

Facility policy entitled "Equipment and Furniture Repair/Removal" stated, "The objective of this policy is to promote safety of the facility through discourse, assessment, and action to efficiently handle items in need of repair of removal throughout the facility by the appropriate personnel."
Further review of the policy stated, "Upon finding equipment or furniture in need of repair or removal in any department or area of the NWTHS facilities, the noticing staff member is responsible for submitting an online Work Request immediately...Department Responsibilities: 2. Plant Engineering: All non-patient equipment, furniture and facility repairs as well as item removal and storage and department/office moves; 3. Environmental Services: All cleaning requests and patient bed moves."

During a tour of the Rehabilitation Department with staff members #96 the morning of 7/9/13 the following was revealed:

Pedi Gym
8 holes in the walls approximately ½ inch in diameter

Outpatient Wound Care Area
Bay 1 - 1 hole in the wall
Bay 5 - 10 holes in the wall
Patient restroom- 2 holes in the wall
Floor in prep area- broken tiles

Hallway patient restroom
Leak behind the toilet, wallpaper raised, and cracked floor

Main Gym- exercise room
Ceiling vents dusty and dirty

Small Gym
Staff restroom vent dirty and toilet leak
Cracked floor tiles near large supply cabinet

Pool area
Broken soap dispenser in women's locker room
Paint peeling above pool
4 Sky lights above pool area broken
Fire sprinklers covered with dust in the men and women's locker room
Ceiling vents dusty and dirty in the men and women's locker room

Pool Closet
Insulation hanging from ceiling
Insulation on 2 pipes for pool pump cracked and poorly repaired with old tape
Standing water on floor

Review of facility document "Pool Inspection Log" stated, "Procedure: Daily Check chemical balance using strip test, Backwash filter with pressure reads 27 PSI, Vacuum pool X times per month." Review of the Pool Inspection Log revealed there were no chemical checks for 11 days (6/10/13 thru 6/20/13).

Review of facility Policy and Procedure Manual Department of Physical Medicine, Volume 1, Section 15, Page 3 of 4 stated, "Pool Area: 1. The therapy pool area will be cleaned by Environmental Services and pool maintenance performed by Plant Operations; 2. Chlorine levels will be consistent with current Health Department standards, and appropriate logs will be maintained to verify chlorine levels." "Patient Equipment: 1. Patient Equipment will be cleaned on a routine basis as scheduled by supervisory staff."

The findings were confirmed in an interview with staff member #96 the morning of 7/9/13. Staff member #96 stated that the Environmental Services was responsible for cleaning the department and Plant Operations was responsible for maintaining the pool area and repairs.

In an interview with staff member #71 the morning of 7/11/13, staff member #71 stated the procedure for the technicians was stated on the top of the form and it was to check the chemical balance daily. Staff member #71 confirmed the technician failed to document the daily checks on the Pool Inspection Log.

During a tour of the Labor and Delivery and Newborn Nursery Department the morning of 7/10/13 in the company of staff member #122 revealed the following:

Labor and Delivery Department: Large hole under the sink in the Nutrition Room

Newborn Nursery Department: Large hole under the sink in the Soiled Utility Room

The above findings were confirmed in an interview with staff member #122 the morning of 7/10/13.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain supplies to ensure an acceptable level of safety and quality as expired medical supplies and sterile instrument processed were found in the closed position and also in the clamped position available for patient use in 5 of 27 patient care areas surveyed. This was in violation of facility policy and potentially could have caused unsafe or ineffective supplies to be used in patient care.

The findings were:

The facility policy entitled "Expiration Date Monitoring" with a review date of 4/13 was reviewed on 7/10/13 and reflected in part "All expired/expiring items must be removed prior to the expiration date or the end of the month if only a month and year are noted on the product. No outdated supplies should be left on the nursing units."

The facility policy entitled "Pre-Sterilization Processing Parameters" with a revision date of 4/28/13 was reviewed on 7/11/13 and reflected in part "Instrument sets must be sterilized in perforated wire-mesh bottom trays or in specially designed containers, with all instruments held open, unlocked or dissembled to permit steam contact with all surfaces."

During a tour of the facility's Balance Clinic conducted on the afternoon of 7/8/13 in the company of staff # 18, the following expired medical supplies were found in splint room available for patient use.

1. Triple antibiotic ointment packets, 1 expired 8/09; 3 expired 2/12; 1 expired 7/12; 3 expired 9/12; 25 expired 12/12; and 14 expired 3/13.
2. Steri-strips, ½' x 4", 5 expired 10/12.

These findings were confirmed in an interview with staff # 18 during the tour on 7/8/13 at 1:30 pm.

During a tour of the facility's Wound Care Center conducted on the afternoon of 7/8/13 in the company of staff # 19, the following expired medical supplies were found in patient care areas available for patient use.

1. Found in the supply cabinet: 2-0 silk suture, 16 expired 1/13; 2-0 ethilon suture, 7 expired 1/13.
2. Found in exam room # 1: Shur-clens, 20 ml, 1 expired 1/12, and 7 expired 4/13; Aquacel 9 x 15 cm, 1 expired 1/12 and 5 expired 3/13; Aquacel 9 x 10 cm, 4 expired 10/12.

These findings were confirmed in an interview with staff # 19 during the tour on 7/8/13 at 2:15 pm.

During a tour of the facility's Wyatt Community Health Center conducted on the afternoon of 7/9/13 in the company of staff # 62, a Chloraprep One-Step Prep Kit, expired 9/12 was found in the medication room available for patient use. This finding was confirmed in an interview with staff # 62 during the tour on 7/8/13 at 2:30 pm.

During a tour of the cardiac cath lab on the morning of 7/10/13 in the company of staff # 67, the following expired supplies and a hemostat sterilized in the clamped position were found in patient care areas available for patient use.

1. Found in cath lab # 1, Hemochron Jr. test kits, 3 expired 6/13.
2. Found in the EP lab, Hemochron Jr. test kits, 4 expired 6/13; one sterile package containing hemostats that had been processed in the clamped position.

These findings were confirmed in an interview with staff # 67 during the tour on 7/10/13 at 11:30 am.

During a tour of the Rehabilitation Department in the company of staff member #96 the morning of 7/9/13 the following supplies were found expired and available for patient use

1. 4- Scotch cast plaster 3x1 expired 6/13
2. 7- 0.9% NACL IV flush syringe 10ml expired 6/13
3. 1-Suction catheter expired 8/12
4. 1-Glucose gel 37.5 grams expired 6/13
5. 1-TENS pin connector electrodes expired 12/07.

During the same tour of the Rehabilitation Department, 8 of 8 sterile instruments were found in the closed position available for patient use.

The findings were confirmed in an interview with staff member #96 the morning of 7/9/13.

Based on a review of facility policies, tour of facilities, review of facility documents and policies, and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patient.

Findings were:

Tour of the facility on July 08, 09 , and 10 of 2013 found the following infection control deficiencies.

Radiology and Nuclear Medicine
· Inspection of room # 3 the Radiology Department conducted on 07/08/2013 found dust collected on horizontal surfaces of machine used for radiological diagnostics.

Emergency Room
· Inspection of the Emergency Room in the morning of 07/09/2012 revealed that two Trauma rooms had dusty horizontal surfaces of shelves and light fixtures located just above the exam/procedure tables. Containers used to store sterile supplies had dust and debris inside.
· A bag with several expired (2012) blue top Vacutainers was found in a drawer at the nurse's station.

These deficiencies were confirmed by staff #122.

Physical Plant tour:
During a tour of the facility on 07/10/2013, the surveyor inspected the facility's clean linen storage room and noticed that the outside surfaces of the carts carrying the clean linen were soiled. These carts were full of clean linen and were stored against shelves containing clean patient gowns and bed linen. The carts' soiled surfaces were observed to be touching the shelves clean linen. The surveyor also observed boxes with surgical towels being stored on the cement floor. Furthermore, the surveyor observed that boxes containing clean and/or sterile supplies which were stored on shelves had substantial amounts of dust collected on their horizontal surfaces.

Review of Facility policy # V-C.14 revealed under attachment 1 that Carts would have regularly scheduled cleaning performed by Environmental Services. The policy states: "Routine, external wipe down weekly. Interior, scheduled cleaning by whomever stocks".
Furthermore, policy # EVS.1006 states the following on page six and item 5.1: ..."Any trolley sused to transport the linen on an inpatient/residential area must be clean and free of dust and dirt."

These deficiencies were confirmed during the tour of the facility by staff # 72.


28043



During a tour of the facility the morning of 7/8/13 accompanied by Staff #13, Associate Administrator and Staff #14, Director of Food and Dietetic Services, the following was observed:
· The plate warmer in the tray line area was in need of cleaning, as the hinges for the top were dirty with a greasy substance and there were crumbs and debris inside the food warmer where clean plates were stored, available for patient use, creating a risk for cross contamination.
· The microwave oven in the tray line area was in need of cleaning, as there were food particles and drips in the interior, including old dried food particles in the grooves of the interior.
· The floors in the tray line area under and behind all equipment was observed to have a large accumulation of grease and debris, including dried food particles in the corners of the room. Despite having wheels on many of the large kitchen equipment, ovens, grills, there was an accumulation of dirt and grease around the wheels of the equipment indicating the equipment had not been moved for cleaning.
· The vent hood over the griddle had a layer of a black greasy substance. In an interview with the Director, he stated the vent hoods are cleaned weekly. The ceiling vent in the food storage area was covered in dirt. The vent hood above the deep fryer had black grease, which easily rubbed off onto the surveyor's finger.
· There was rust around the light fixtures and 2 out of 3 light fixtures were cracked over the food prep area.
· There were cracks and gouges in the tile around the floor drain. The cracks and gouges were dirty and could not be properly cleaned or disinfected.
· 6 of 6 "new mother baskets" wrapped in shrink wrap containing apples, oranges, and other food items were not labeled with a date prepared or expiration date.
· The shelves holding dry goods were dirty, and the food storage trays containing formula and food supplements were dirty and dusty.
· Clean towels and supplies were stored in the broken ovens that were in need of cleaning and repair.
· The food warmer had a film of grease and dirt on top.
· The teapot was dripping onto the counter and floor leaving a 2 x 3 foot area of pooled liquid, creating a safety hazard and risk for cross contamination.
· There was a peeling plastic sticky residue on top of the refrigerators in the food prep area.
· There was a torn rug in front of the coolers creating a trip hazard.
· The interior of the refrigerators 1, 2, 3, and 4 and the "reach-in freezer" which were in use and contained food in the tray line area were dirty, with old food and debris in the base of the refrigerators; the door seals/gaskets were dirty with were disintegrated, torn and dirty with a black appearance which appeared to be mildew, and had dirt and dried food particles adhered to the inside; the torn door seals could allow the possible entry of dirt particles or insects, and would not ensure that the correct temperature range was maintained for food storage. There were dried food and drips which were adhered to the interior floor of the refrigerators and freezer. There was ice formed from condensation on the interior ceiling of the freezer.
· There was a plastic sheet protector taped to the front of the refrigerator which was dirty as there was peeled back tape with dirt adhered to the sticky tape residue, and there was dirt in the bottom of the sheet protector; the paper inside the sheet protector was torn and stained with a black substance which appeared to be mildew.
· There was raised greasy dust and debris on the floor behind the refrigerators and reach-in freezer.
· There was dust and lint on the vent over the food prep area.
· There was a hole in a section of ceramic brick wall, approximately 30 inches x 24 inches, which had been covered with a clear plastic and duct tape encompassing an area approximately 4 feet x 4 feet. The duct tape was only partially adhered to the wall in some areas, and had dust and debris adhered to the duct tape. The 4 x 4 foot area was dirty, which drips and dried food debris on the plastic and the wall. The plastic wrap did not fully seal the broken wall, leaving an entry for dust, insects, and other environmental contaminants to the food preparation area.In the passage way behind the food prep area, the wall seam had separated from the wall and was not attached, leaving a 1 inch strip from the ceiling to the floor, which was covered in dust and allow the possible entry of dirt particles, insects, and other environmental contaminants.
· Ceiling tiles around the exhaust vent were covered in dust in the dishwashing area.
· There was rust, and chipped and peeling paint on the tray drying racks in the dishwashing area; rust, chipped and peeling paint cannot be disinfected.
There were cup lids and the floor and step ladder were covered with crumbs in the dishwashing area.
· There was a pair of used yellow rubber gloves which had been placed on top of the wire shelving unit above clean dishware, creating a risk for cross contamination.
· In the catering area, there were 6 out of 10 " clean " pans which had dried food adhered to the interior of the pans; 1 pan lid had rusted screws where the handle was attached in the interior of the pan; 1 sterno unit pan was observed with water drops in the stack of clean pans.
· In a bin containing kitchenware, there were 7 large spoons stored with the bowls up; 3 spoons with dried food adhered to the surface, and one large scoop with a layer of grease on the inside and the outside of the scoop.
· On the wire rack unit, there were 3 out of 6 "clean" pans available for patient food preparation, observed with dried food residue adhered to the surface, and 10 out of 21 large trays with dried food residue adhered to the trays.
· The clean tray and pan wire rack shelving units were rusted and therefore could not be properly cleaned or disinfected.
· In the dishwashing area, there were 2 mops standing in a mop bucket with dirty water, creating a risk for cross contamination.
· There was a broken area in the ceiling above the dishwasher.
There was a rusted and dirty vent in the clean dishwashing area.
· A large manual can opener mounted on a prep table was dirty with a dried black substance.
· A second large manual can opener mounted on a prep table was dirty with a black sticky substance and what appeared to be a metal shaving adhered to the blade. This presents a risk for cross contamination and a risk for metal shavings to be introduced into food products.
· There were 5 ounce bottles containing Mrs. Dean seasoning mixture, thyme, and basil that were sticky and dirty. The bottles were not labeled to indicate the date opened.
· There were 3 "clean" large kitchen knives with a food-like substance adhered and the blade was incorrectly sharpened on the knives, leaving raised metal areas and creating a risk for metal shavings/pieces to flake off into food;
· In the paper product storage area, there was a corrugated cardboard box of Chinet Bowls, available for use which were stored on the floor, creating a risk for cross contamination. There was dirt and debris on the floor in the storage area. There were mixed internal boxes and external shipping boxes, which also creates a risk for cross contamination. "It is necessary to remove external shipping containers before items are transported to processing areas because the containers have been exposed to unknown and potentially high microbial contamination. In addition, shipping cartons, especially those made of corrugated material, serve as generators of and reservoirs for dust" (AAMI ST46 - section 5.2 Receiving items).
· In the receiving and dry storage area, there was rust on the meat freezer, and the door gaskets were torn and deteriorated. The floor in the meat freezer was dirty, especially around the threshold of the door.

In the receiving and dry storage area, the following was observed:
· The lid to the bulk flour storage container was broken, as was the lid to the bulk rice container, presenting a risk for contamination.
· There was a cabinet that Staff #16 (Production Manager) stated was "not used." When the door of the cabinet was opened by the surveyor, the following was observed in the cabinet: a 16 ounce Styrofoam cup without a lid containing liquid coffee without a lid; a 20 ounce Styrofoam cup containing a liquid with ice with a lid; a bin of folded cleaning cloths. There were 2 pieces of dirty wood furring strips which appeared to have been used as home-made door stops on top of the folded cloths contaminating the cloths; a used cleaning brush; a sleeve of Styrofoam food container lids; and notebooks and other personal items. This presents a risk for cross contamination in the patient food storage area.
· There was dust, dirt and debris above the food prep sink where uncooked chicken was being prepared, creating a risk for contamination. There was a dirty vent and the plastic covering on the fluorescent light above the food prep sink was broken.
· There was raised dust adhered to the greasy walls in the dry storage area, and there were food-like drips and splashes on the walls in the charity food area.
· There was a plastic bag containing corn meal which was open and unsealed on the shelf, creating a risk for cross contamination.
· There were unused, folded corrugated boxes stored on the floor next to the shelving units, which creates a risk for contamination during floor cleaning.
· On a wire shelving unit the following was observed:
· A 1 gallon ziplock bag which was approximately 1/8 full containing a brown powder which was not labeled with the contents or expiration date.
· a 7.6 ounce packet of dry Italian dressing mix which was opened and not labeled
· a 7.6 ounce packet of dry Italian dressing mix which was unopened, but was stained and dirty
· 3 small styrofoam containers labeled "Cajun", "Ranch", and "BBQ" which contained a powdered substance without an expiration date.
· A 12 ounce container of Coriander with had a raised dried substance which appeared to be food adhered to the lid
· 3 opened 24 ounce boxes of baking soda which were grease stained and had dust on the top.
· A package which had been opened and was wrapped in plastic wrap without a date containing couscous.
· There was a pan on the shelf which was covered with plastic wrap containing an oily liquid and dried spices and herbs which was unlabeled and undated.
· A 1.32 gallon bottle of balsamic vinegar which had multiple drips, was greasy and dusty on the outside of the bottle.
· A foil package approximately 8 x 4 x 4 inches wrapped in plastic wrap which was unlabeled and undated. The staff were unable to state what was in the package and when opened by the staff, it was determined that the package contained almonds.
· A container which appeared to contain cinnamon and sugar was dirty on the outside and had no lid, label or date.
· There was a ziplock bag which contained a powdered substance that staff stated was barbecue seasoning, but the bag was undated and unlabeled.

In the bakery area, the following was observed:
· A partially empty opened bag of pecans, which was not sealed or labeled with a date opened.
· 1 shaker containing cinnamon and sugar which was dirty and did not have a lid.
· There was a tackle box on the food prep shelf which had a locked padlock. When the lock was opened on surveyor request, the contents of the box included a cloth icing/pastry bag that was wet, creating a risk for bacterial growth and cross contamination. Also in the box were cooking and baking utensils, including 2 rubber spatulas which were damaged which chunks of rubber missing, a set of measuring spoons which were in need of cleaning, and a wire whisk that had a brown substance adhered to the interior of the wires.
· There were 10 round cake pans that were stacked on the shelving unit which were not stored in a covered or inverted position, which increases the risk for dust or contamination; one of the round cake pans was not clean as there were 2 pieces of a white food-like substance adhered.
· There were 3 loaf pans that were old and pitted in the interior of the pans; the pitted areas of the metal pans were black; kitchen ware and utensils should have a smooth, easily cleanable surface which is resistant to pits, cracks, chips and other imperfections which prevent adequate cleaning.
· There was a pitcher stored on a shelf which had not been dried and was wet inside.
· There were 5 muffin tins with carbon build-up and what appeared to be dried food.
· The lid to the bulk flour was not fitted on top of the bulk container, creating a risk for cross contamination.
· The shelving units containing food supplies and baking ware were dusty, stained, and in need of cleaning.

In the salad prep area, the following was observed:
· There was a metal can containing 5 cooking knives stuck blade down in the can, without knife guards. One of the knife tips was bent at an angle; 2 of the knives had a food-like substance adhered to the surface.
· There were what appeared to be dried shredded carrots in a bin containing plastic soufflé cups, available for patient use.
· There was dried food debris in a plastic bin containing plastic lids.
· The plastic bin containing loaves of bread was in need of cleaning as there was a layer of bread crumbs in the bin. There was old, sticky tape residue on the outside of the plastic bin, creating a risk for cross contamination.
· Underneath the sink, the rubber baseboard was detached from the wall for approximately 2 1/2 feet and laying on the floor; there was a mildew-like substance on the wall where the rubber baseboard had been attached. There were red drips and splashes of dried food on the wall above the detached baseboard.
· The towel dispenser at the handwashing sink was not functional, requiring staff and surveyors to walk approximately 6 feet to a roll of paper hand-drying towels with wet hands after handwashing. The paper towels were placed on a wire shelving unit containing food products. This created a risk for cross contamination and safety as employees reached over food products with wet, dripping hands to obtain paper towels.

In the cold production freezer, there was a bag of pizza dough which was opened and not labeled; there was a bag of cinnamon rolls which was opened and not labeled, creating a risk of cross contamination.
There were 20 unlabeled strawberry shortcakes in the walk in cooler.

In the catering food storage area, there were 5 boxes of food service paper products stored on the floor, creating a risk of cross contamination from dust, insects, and moisture when the area was swept or mopped. There was visible food debris adhered to 6 serving spoons and knives. The serving utensil tray was dirty.

The external doors to the shipping receiving area for food service had no door seals or weather stripping, leaving a 1 inch vertical gap between the doors, and a gap with outside light visible between the doors and underneath the doors. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects, rodents, and other environmental contaminants.

Review of the "Sanitizer Test Procedures" stated, in part, "Verify that the food-grade sanitizer solution is at the proper concentration by following these steps ...Text the concentration of the solution using a QT-40 test strip ...compare the test strip color to the chart on the test paper dispenser to determine the concentration of the sanitizer. When the concentration is outside of the 150-400 ppm range...notify the manager."

During a tour of the kitchen food prep area the morning of 7/8/13, the surveyors reviewed the Sanitizer Dispenser Log, which revealed the concentration had been tested at 6:54 am on 7/8/13, however when one bucket of sanitizer concentration was tested on request of the surveyors, the test strip indicated no change or a result of 0, indicating the sanitizer did not have the proper solution to sanitize or disinfect the food preparation area. This was confirmed during the tour by Staff # 14 and Staff #15, Patient Services Manager in the kitchen.

During a second tour of the kitchen food prep area the morning of 7/11/13, the surveyors requested that the sanitizer solution bucket again be tested for proper concentration. As on 7/8/13, the test strip indicated no change or a result of 0, indicating the sanitizer did not have the proper solution to sanitize of disinfect the food preparation area. This was confirmed during the tour by Staff # 14 and Staff #15, Patient Services Manager in the kitchen.

In the Java City coffee food service area, there was an opened box of wooden stir sticks which were being used to stir coffee that was placed in the cabinet for the trash container. There were drips and an opened trash can next to the box of wooden stir sticks, presenting a risk for cross contamination. The refrigerator door was dirty and sticky with drips inside and outside of the door. There was an employee purse placed on top of the coffee beans in a storage cabinet. The bottom of the cabinet was dirty with a spilled dark substance which had not been cleaned. There was an external shipping container with the address label attached containing coffee cup sleeves which an employee placed on top of the coffee preparation counter while she restocked the cabinets. This presents a risk for contamination for a box that has been exposed to the environment while shipping to be placed on top of the coffee preparation counter. There was a drawer that contained food products, plastic utensils (unwrapped), work gloves, a roll of stickers, a labeling gun, a timer, and various other clean and dirty items. The bottom of the drawer was dirty with coffee grounds and other debris. The drawer under the coffee liquid flavors in the coffee shop had an opened bag of truffle mix and the coffee flavorings had spilled out into the drawer.

The door seals/gaskets were torn in 2 of the pass through refrigerators. The disposable cup dispensers were cracked, broken, and dirty, creating a risk of contamination.

In the serving line, there was a black plastic bin containing black plastic serving utensils. When asked, the staff stated that the bin contained clean, ready for use serving utensils. There was food adhered to 4 of the serving utensils, and the bottom of the bin had various dried food debris and a layer of dust, indicating a lack of cleaning.
The salad bar area did not have a sneeze guard on the serving side, providing a risk for cross contamination of the salad bar foods. There was a knife holder which was dirty and contained a knife, available for use.

In the pizza serving area, there was a handwashing sink which was within 18 inches of the pizza oven. There was an exposed uncooked pizza on the conveyor portion of the pizza oven, next to the handwashing sink, which could easily be splashed with water while an employee was washing their hands. On the other side of the handwashing sink was the food prep table where cooked pizzas were placed to slice. This surface was less than 12 inches from the handwashing sink and the towel dispenser which was mounted over the sink. This presents a risk for cross contamination of uncooked and food in very close proximity to a handwashing sink.

The refrigerator next to the grill was dirty, with food debris and a black substance in the base on the interior. The door seal/gasket was worn, sticky and dirty with food debris.

While grilling burgers on 7/18/13, Staff #116, a cook, was observed dropping a towel on the floor, picking up the towel and placing it on the counter and not washing his hands after contamination and continuing to grill burgers. In an interview with Staff #116, a cook who was grilling burgers, the surveyor asked if a bin containing cooking utensils in the grilling area was clean. Staff #116 stated he wasn't sure, but thought the utensils were clean. The surveyor pulled the bin out, revealing dirty utensils. Staff #116 again stated that he wasn't sure if the utensils were clean or dirty, but thought they were clean (available for use in cooking). Upon review of the bin of utensils with Staff #16, production manager, he confirmed that the bin containing utensils was not clean, but were dirty. Staff # 116 and Staff #16 both stated that Staff #16 did not work in this area, but was at that time because the kitchen was short-staffed. The bin containing dirty utensils was removed from the grilling area. In an interview with Staff #116 the morning of 7/11/13, he stated again that he had not worked in the area before and had not been told whether the utensils in the bin were dirty or clean. This presents a risk for cross contamination when staff are pulled to an area and not oriented to the area, including which utensils are clean and available for use in food preparation or are dirty and should not be used.

The above was confirmed during the tour with the Food Service Director, the Food Production Manager, and the Associate Administrator on 7/8/13 in the kitchen, food service, and dietary areas.

During a second tour of the kitchen and food service area on 7/11/13, accompanied by Staff #14, Food Service Director, Staff #16, Food Production Manager, and Staff #79, Infection Control Director, the following was observed:
· The plate warmer in the tray line area was in still in need of cleaning, as the hinges for the top were still dirty with a greasy substance and there were crumbs and debris inside the food warmer where clean plates were stored, available for patient use.
· In the dirty utensil storage area, 3 of 3 mop buckets were full of dirty water with mops soaking in the dirty water; the bottom of the bucket was not visible through the cloudy water. 2 brooms that were worn and dirty propped against the wall on the floor.
· During a second tour of the kitchen food prep area the morning of 7/11/13, the surveyors requested that the sanitizer solution bucket in the area tested on 7/8/13 again be tested for proper concentration. As on 7/8/13, the test strip indicated no change or a result of 0, indicating the sanitizer did not have the proper solution to sanitize of disinfect the food preparation area. This was confirmed during the tour by Staff # 14 and Staff #15, Patient Services Manager in the kitchen.

The above was confirmed during the tour with the Food Service Director, the Food Production Manager, and the Infection Control Director on 7/11/13 in the kitchen, food service, and dietary areas.



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Facility policy entitled "Environmental Sanitation-Hard Surface Mopping" stated its purpose as to "Provide instructions for mopping hard floor surfaces daily." The procedure for floor mopping stated in part
· "Using a scouring pad and a putty knife carefully remove any heavy soil or other foreign materials from the floor ...
· Prepare micro fiber mop using germicidal or floor cleaning solution as per manufacturer's recommendations.
· Mop the perimeter of the room or area. Beginning at the door or perimeter of the area, mop all edges and baseboards and around any items you were unable to move.
· Begin at the corner of the room farthest from the door and mop the floor by placing the mop on the floor and pulling it along the floor from left to right in an "S" pattern as you back out of the area. Overlap strokes to ensure total floor cleaning."

Facility policy entitled "Environmental Sanitation-Ceiling and Vents" stated its purpose as "To provide cleaning instructions for all ceilings and vents."

Contracted dietary services contract dated January 1, 2013 stated in part, "ARAMARK shall maintain high standards of sanitation and shall be responsible for routine cleaning and housekeeping in the food preparation and retail service areas (including food service equipment, kitchen and retail area floors, walls, hoods and grease filters) and for the routine cleaning of cafeteria tables and chairs."

Aramark procedure entitled "Walk in Refrigerator/Freezer Cleaning and Sanitizing" described the frequency of cleaning as "As needed." Procedure steps were as follows:

· "Remove all unpacked foods and food packaging from area. Clear floor of all moveable equipment including floor mats.
· Wipe up spills and sweep away any loose soil and debris. Use a scraper or abrasive pad to remove built up deposits
· Apply " Kool-Klene " directly to freezer/refrigerator floor surface, walls and shelving using a mop, sponge or sprayer. Soak for 10-20 minutes depending on the amount of soil and ice present.
· Wipe area with mop to loosen and remove soil. Dry mop or squeegee to remove excess liquid and wipe with a dry cloth if needed to aid drying.
· Allow to air dry."

Aramark procedure entitled "Cleaning Ceramic/Quarry/Terrazzo Tile" described the frequency of cleaning as "daily." Procedure steps were as follows:

· Clear floor of all moveable equipment. Wipe up spills and sweep to remove loose soil and debris.
· Using an Ecolab floor cleaner dispenser, fill mop bucket to desired level with a solution of Oasis floor cleaner and WARM water.
· Apply the solution with a mop. Leave on floor until solution penetrates grease and soil.
· Scrub the solution into the floor with a stiff-bristled deck brush.
· Mop up or squeegee the solution towards the drain. Rinse the mop and clean water. Allow to air dry."

Aramark cleaning manual stated in part under "Floor Care," "In order to clean properly, you must use clean equipment and clean water. Mop water should be checked frequently. As you walk by a housekeeping cart, look at the mop water. If you cannot see the bottom of the bucket, the water is too dirty and needs to be changed immediately.

The temperature of the mop water is also important. Look at the detailed information for each product. Some products require the water temperature to be in a certain range to maximize the efficiency of the product. Using water in the wrong temperature range may compromise the efficiency of the product, causing damage to the flooring, or make the floor more slippery.

Mop heads need to be changed when they become dirty. If the mop is dirty or if it smells, the head should be changed immediately. Mop heads should be changed at least once a day. Mop heads should also be designated for certain areas. For instance, a mop that is used to clean a bathroom should never be used to clean a kitchen."

Aramark procedure entitled "Floor Drains, Cleaning and Sanitizing" described the frequency of cleaning as "daily." Procedure steps were as follows:

· Dispense a solution of Pantastic or other Ecolab manual detergent solution in a mop bucket.
· Apply manual detergent to the drains with the covers on first. Thoroughly clean the drain with a designated floor drain brush and scrub drain lids and area around drain to remove any food debris.
· Remove drain and strainer basket. Using fresh water, thoroughly rinse the drain soil and debris from the drain and surrounding area.
· Scrub drain lid or basket with the designated drain brush and basket. Dispense a solution of Oasis Multi Quat Sanitizer into a clean mop bucket.
· Allow to air dry. Thoroughly clean and sanitize any equipment such as the mop bucket and drain brush to prevent cross-contamination."

Aramark "Daily Sanitation Check Sheet" stated in part "Floors throughout" should be "Swept and mopped daily, moving all mobile equipment to get underneath. Use wash and walk floor cleaner, pour down drains after use. Clean mop bucket and rinse mop head."

Aramark procedure entitled "Cleaning Kitchen Walls and Doors" described the frequency of cleaning as "needed." Procedure steps were as follows:

· Spray a 10 X 10 wall area or door with Oasis Orange Force multi surface cleaner.
· Allow surface to remain wet for 1 to 2 minutes. Areas with heavier soil, such as around light switches or walls by cooking areas may require light scrubbing.
· Using hot water in a bucket, rinse thoroughly with a clean towel. Change water and cleaning towel as needed.
· For areas that are hard to reach, use a ladder or wall cleaning system with extendable pole, and a thoroughly dampened cleaning pad. Wipe wall with a clean towel."

Aramark procedure entitled "Cleaning Mop Bucket" described the frequency of cleaning as "needed. " Procedure steps were as follows:

· After cleaning the floors, take the cleaning equipment to the mop sink to clean and rinse thoroughly with water.
· Dump dirty cleaning solution from the mop bucket into the mop sink and rinse with water to remove the soil. Use Pantastic detergent to clean the mop bucket. Use a nylon brush if needed. Allow mop bucket to air dry.
· After using the mop, ring out and rinse under running hot tap water in the mop sink. Allow mop head to air dry."

Aramark cleaning manual stated in part under "Cleaning and Sanitation," "Pathogenic microorganisms and physical and chemical contaminants (including allergens) can be introduced into food and cause food borne illness, injury, or allergic reactions when:

· Food contact surfaces are not properly cleaned and sanitized
· Equipment and utensils are not properly cleaned and sanitized
· Equipment and utensils are contaminated with pathogenic microorganisms or physical and chemical contaminants.
· The correct sanitizing concentrations are not followed
· Wiping cloths are not kept clean

Growth of pathogenic bacteria can occur if:

· Dirty cloths are improperly stored.
· Buckets are not properly cleaned, sanitized, and allowed to air dry.
· Equipment and utensils are not properly cleaned, sanitized, and air-dried (dishes should not be wet stacked after washing and sanitizing).

Wiping Cloths:

· Always use a clean (disposable or washable) cloth
· Maintain dry cloths in a dry state while they are in use.
· Change wet and dry cloths every four hours or sooner if they become soiled.
· Store clean cloths in an area that protects them from contamination
· Store soiled towels and linens in a separate, covered receptacle to eliminate contact with clean surfaces and clean towels to reduce attraction to flies and other pests.

Non-Food Contact Surfaces:

· Keep non-food contact surfaces free of an accumulation of dust, dirt, food residue and other debris.
· Clean up food splashes and spills on non-food contact sur

Based on observation, review of documentation, and interviews with staff the facility failed to follow its own Malignant Hyperthermia (MH) policies and procedures.

Findings included:

Facility policy entitled "Malignant Hyperthermia" stated, "Scope: This policy applies to patient care under conditions of malignant hyperthermia occurring in the operating room including but not limited to surgical services and obstetrical services." "Definition: Malignant Hyperthermia is a life-threatening pharmacogenetic disorder triggered by the administration of commonly used volatile or inhaled anesthics..."

Further review of the policy stated, "E. Supply, Storage, and Access of Dantrolene IV: 5. Hospitals should determine appropriate placement and supply of Dantrolene IV in order to meet the 5 minute availability expectation with staff education and drills to assure timely access."

During a tour of the Labor & Delivery Operating Room with staff members #93 and #122 the morning of 7/10/13, revealed the following;
· At 10:00am the surveyor requested for staff member #93 to unlock the Malignant Hyperthermia cart.
· At 10: 20am the facility staff located the key and unlocked the cart for inspection.

Review of the department "Mock Codes" revealed the last department drill for Malignant Hyperthermia was conducted on 3/13. 3 of the 4 staff members attempting to locate the key were present at the drill on 3/13.

The findings above were confirmed in an interview with staff members #93 and #122 the morning of 7/10/13.

Based on review of facility policies and procedures, staff interview, and review of medical records, the hospital failed to ensure the misappropriation of resident property by failing to follow facility written policies and procedures that ensure the safety of resident property.

Findings were:

A review of 3 patient records on the Med/Psych Holding Unit revealed the following:
· The record of patient #45 contained an incomplete "Patient Valuables Envelope" checklist which contained inventoried personal belongings. The "Patient Valuables Envelope" list shows only one staff signature dated 7/8/13 with no time included. The patient did not sign the form, nor did anyone else, thus belongings were not verified by the patient or patient ' s representative. The record of patient #45 included admission orders completed at 9:30 p.m. on 7/7/13.
· The record of patient #44 contained a "Patient Valuables Envelope" list completed by a staff person on the Med/Psych Holding Unit, not the Emergency Department, on 7/8/13 at 1743. The record of patient #44 included admission orders completed at 11:50 p.m. on 7/7/13.
· The record of patient #53 did not contain a "Patient Valuables Envelope" checklist, and thus no personal belongings inventory.

Facility based policy entitled, Patient Valuables stated, "Patient's personal effects are inventoried and, when indicated, placed in the safe in the Business Office for safekeeping ...
For patients that do not have family members available or for patients who may have become stranded due to a trauma, acute onset illness, MVC, etc., the ED or admitting RN will be responsible for inventorying patient's valuables and completing the Valuable Checklist in its entirety."

In an interview with the staff member #121, Emergency Room Director, on 07/11/13, the Emergency Department's role in documenting patient personal belongings was discussed. While in the Emergency Department if a patient has belongings they are unable to send home, the non-valuable item such as clothing will be documented on a checklist in the electronic medical record. Valuables such as money and cards would be documented on a paper form, signed by the patient, and deposited in the business office. The documentation of patient personal belonging is to be documented prior to transfer from the ED to a unit in the facility.

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff the afternoon of 7/11/13 in the facility conference room.