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Based on record review and interview, nursing staff failed to document the reason for restraint use in 1 of 3 patients placed in restraints (Patient #1) in a total of 30 medical records reviewed.

Findings include:

Record review of policy "Restraint/Seclusion" #02-055-09 effective date 3/01/2011 under Restraint/Seclusion Justification Form revealed "Must contain assessment of behaviors warranting r/s" (restraints and seclusion).

Patient #1's medical record was reviewed 8/14/2023 at 2:06 PM and revealed patient #1 was a 37-year- old admitted involuntarily on 8/04/2023 with a diagnosis of bipolar disorder, manic, with psychotic features. Patient #1 was placed in restraints on 8/09/2023 at 4:30 AM. There was no Restraint/Seclusion Justification Form or documentation of patient #1's behaviors warranting restraints or seclusion documented.

On 8/14/2023 at 2:38 PM during interview with Business Office Manager W, when asked the reason for use of the restraints, Manager W stated "I don't see anything."

On 8/15/2023 at 8:25 AM during interview with Advanced Practice Nurse Prescriber (APNP) H, APNP H confirmed the behaviors indicating the need for restraint and seclusion are documented on the "Restraint/Seclusion Justification" form and stated "the form is missing."

Based on record review and interview, the facility failed to document least restrictive interventions taken to avoid restraint/seclusion in 1 of 4 patient restraint incidents reviewed (Patient #1) in a total of 30 medical records reviewed.

Findings include:

Record review of policy "Restraint/Seclusion" #02-055-09 effective date 3/01/2011 under Restraint/Seclusion Justification Form revealed "Must include documentation of interventions taken to avoid r/s" (restraints/seclusion).

Patient #1's medical record was reviewed 8/14/2023 at 2:06 PM and revealed patient #1 was a 37-year- old admitted involuntarily on 8/04/2023 with a diagnosis of bipolar disorder, manic, with psychotic features. Patient #1 was placed in restraints on 8/09/2023 at 4:30 AM. There was no Restraint/Seclusion Justification Form or documentation of interventions taken prior to initiation of the restraints.

On 8/14/2023 at 2:38 PM during interview with Business Office Manager W, when asked what least restrictive measures were tried before placing patient #1 in restraints, Manager W stated "I don't see anything."

On 8/15/2023 at 8:25 AM during interview with Advanced Practice Nurse Prescriber (APNP) H, APNP H confirmed there was no documentation of less restrictive measures tried, as "the form is missing."

Based on record review and interview, the nursing staff failed to discontinue restraints at the earliest possible time in 2 of 4 patient restraint incidents reviewed (Patient #1 & Patient #2) in a total of 30 medical records reviewed and the facility failed to address the categories of staff authorized to discontinue restraints in 1 of 1 restraint policy.

Findings include:

Record review of policy "Restraint/Seclusion" #02-055-09 effective date 3/01/2011 under Restraint/Seclusion Flow Sheet revealed "Documentation must reflect need for continued restraint and/or seclusion for this intervention to continue." There was no clarification of which staff were authorized to discontinue restraints in the policy.

Record review of "RN Restraint and Seclusion Training" not dated, under Care Requirements revealed "Documentation is very important especially in justifying continued R&S [restraint and seclusion] when Q [every] 15 minute documentation refers to the patient as lying quietly or sleeping."

Patient #1's medical record was reviewed on 8/14/2023 at 2:06 PM and revealed Patient #1 was admitted involuntarily 8/04/2023 with manic bipolar disorder with psychotic features. On 8/09/2023 at 4:35 AM patient #1 was placed in restraints for "extreme mood/agitation" (sic). Restraint/Seclusion flow sheet documented patient #1 was asleep and quiet from 6:45 AM until 7:30 AM. Clinical progress note by certified nursing assistant S on 8/09/2023 at 6:28 AM revealed "Patient appears to have slept 3 hours while on close observation per MD [medical doctor] order." Inpatient nursing note by Registered Nurse U on 8/09/2023 at 10:09 AM revealed "Upon assessment at 7:30 AM patient was sleeping. Writer attempted to wake patient. She was arousable (sic) but quite lethargic. 4 point restraints were removed and the seclusion was ended." Patient #1 was in restraints for a total of 3 hours.

Patient #2's medical record was reviewed on 8/16/2023 at 7:50 AM and revealed Patient #2 was admitted involuntarily 3/20/2023 at 10:00 PM with a diagnosis of schizophrenia with bipolar disorder and put into restraints 3/20/2023 during admission for physically aggressive behavior and threatening to kill staff. Restraint/Seclusion flow sheet documented patient #2 was asleep and quiet from 4:45 AM until 6:30 AM with a line through initials at 6:15 AM, a line through column timed 6:30 AM and "error" hand-written in. Inpatient nursing note by Nurse Tech T on 3/21/2023 at 5:42 AM revealed "Patient has slept for 3.4 hours under stict (sic) observation as ordered by the MD." Inpatient nursing note by Registered Nurse V on 3/21/2023 at 7:25 AM revealed "Patient taken out of restraint and seclusion at 6:00 AM." Patient #2 was in restraints for a total of 8 hours.

On 8/16/2023 at 8:58 AM during an interview with Advanced Practice Nurse Prescriber (APNP) H, when asked why restraints were continued on patient #1 and patient #2 if they were asleep, APNP H stated "that would have been at change of shift" and stated they were removed during the nurses' first assessment.

On 8/16/2023 at 2:22 PM during an interview with APNP H, when asked where it stated who was authorized to discontinue restraints APNP H stated "the nurse." APNP H confirmed it was "not in the policy," who was authorized to discontinue restraints or the need to discontinue restraints or seclusion at the earliest possible time.

Based on record review and interview, the facility failed to provide criteria for identifying the requirements to ensure reporting of deaths associated with restraint/seclusion incidents in 1 of 1 restraint/seclusion policy in the facility's death reporting procedures.

Findings include:

Record review of policy "Restraint/Seclusion" #02-055-09, effective date 3/01/2011, did not include criteria for reporting deaths associated with restraints and/or seclusions.

On 8/16/2023 at 3:40 PM during interview with Deputy Program Director D, Deputy D stated "there is no" death reporting policy and confirmed, their "Restraint/Seclusion" policy did not include criteria on when to report deaths associated with the use of restraints or seclusion.

Based on record review, observation, and interview, the facility staff failed to ensure safe medication administration practices by confirming the right patient for medication administration for 7 of 7 patients receiving medication (Patient #12, 13, 14, 15, 16, 27, 34) out of a total universe of 10 patients on the inpatient unit.

Findings Include:

A review of the facility's policy #02-066-01 titled, "Medication Administration" last updated on 01/27/2022 revealed, "... Patients must be identified before administering medication...Medication prescribed for one patient shall not be administered to any other patient... The medication name, dosage, route and interval shall be read from the medication administration record... Compare individual patient's labeled drugs with Medication and Treatment Record."


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During a tour and observation of the inpatient unit on 08/16/2023 starting at 7:30 AM, Licensed Practical Nurse (LPN) P was observed administering medications to 7 patients on the inpatient unit. The following was observed:

On 08/16/2023 at 7:40 AM LPN P did not confirm Patient #14's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:43 AM LPN P did not confirm Patient #13's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:47 AM LPN P did not confirm Patient #34's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:50 AM LPN P did not confirm Patient #15's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:53 AM LPN P did not confirm Patient #16's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:57 AM LPN P did not confirm Patient #12's full name and date of birth for identity for medication administration.

On 08/16/2023 at 7:59 AM LPN P did not confirm Patient #27's full name and date of birth for identity for medication administration.

During an interview on 08/16/2023 at 8:01 AM with LPN P, when asked about medication administration and confirming the right patient, s/he stated, "I have worked here for 30 years and have never asked patients for their full name or birthday. I know who all of the patients are by looking at them."

During an interview on 08/16/2023 at 3:16 PM with Acute Unit Supervisor A when asked about medication administration and verifying the right patient s/he stated, "I feel like we should be verifying. Verification is always a good thing. I would recommend asking a first and last name. If the patient is not comfortable providing a full last name, an initial would be good as well."

Based on record review, observation, and interview, facility staff failed to discard medications that were ordered for 2 of 2 discharged patients (Patients #31, 32) in 1 of 1 medication room.

Findings include:

A review of the facility's policy #02-066-02 titled "Medication Disposal and Destruction," effective date 03/11/2020 revealed, " ...Upon discharge or discontinuance, all unused portions of any prescription drug is disposed of... 6. All patient specific medication will be disposed of once discontinued or upon discharge from the unit ..."

During a tour and observation of the medication room behind the nurse's station with Acute Unit Supervisor A on 08/14/2023 at 1:04 PM, observed the following items located on the top of the medication cart:

One (1) 120 milliliter (mL) bottle of Fluphenazine Hydrochloride oral liquid labeled with Patient #31's information. During a concurrent interview, Acute Unit Supervisor A confirmed Patient #31 was not a current inpatient. A review of Patient #31's admission history revealed Patient #31 had been discharged from the facility on 02/14/2023 (6 months ago).

One (1) 120 mL bottle of Haloperidol oral liquid labeled with Patient #32's information. During a concurrent interview, Acute Unit Supervisor A confirmed Patient #32 was not a current inpatient. A review of Patient #32's admission history revealed Patient #32 had been discharged from the facility on 08/05/2022 (over 12 months ago).

During an interview with Acute Unit Supervisor A on 08/14/2023 at 1:12 PM, Supervisor A stated patient specific medications should be disposed of when patients are discharged from the facility.

Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination on 1 of 1 nursing units (inpatient psychiatric unit) in a total of 5 departments observed.

Findings include:

A review of the facility's policy #02-065-16 titled, "Cleaning Schedules," updated 03/11/2020 revealed, "Policy: The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. Protocols for cleaning and disinfecting patient care equipment and furniture have been established ...Patient refrigerator ...cleaned by Acute unit staff on the night shift or as arranged per established schedule. Food or beverages should be labeled and dated to monitor for food safety: All food and beverage items are to be covered and dated. Any opened food or beverage item without a date will be discarded immediately. Food or beverages in the original containers marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage. Food or beverages that have passed the manufacturer's expiration date are to be discarded ...Food or beverage items without a manufacturer's expiration date should be dated upon arrival and discarded as per the recommendation of Foodsafety.gov ...Food or beverage items in unmarked or unlabeled containers should be marked with the current date which the food item was stored and discarded as per the recommendation of Foodsafety.gov ...Any suspicious, obviously contaminated, or spoiled food or beverages are to be discarded immediately ...Cleaning requires wiping surfaces with a cloth dampened with water and mild detergent ..."

Patient Refrigerator/Freezer:

During a tour and observation with Acute Unit Supervisor A on 08/14/2023 at 12:26 PM, the Acute Care Unit refrigerator and freezer were unlocked by Supervisor A and the following was observed: The freezer was noted to contain: A 1 gallon bucket of vanilla ice cream, less than ¼ full, not dated; a 1 quart container of chocolate ice cream, approximately ¾ full, not dated; 4 one pound packages of margarine, no manufacturer's expiration date and not labeled; and 5 packs of lunch meat with an expiration date of 06/24/2023.

The refrigerator was noted to contain: A tupperware container containing a noodle or rice salad, not labeled, not dated; a 4 ounce container of vanilla shake, no manufacturer's expiration date and not labeled; one Ziploc bag containing what appeared to be small pieces of yellow cheese, dated 07/20/2023; 3 one pound packages of margarine, no manufacturer's expiration date and not labeled; 2 packs of opened lunch meat with a manufacturer's expiration date of 06/24/2023; 1 gallon of chocolate milk, approximately 3/4 full, not dated; 1 gallon of white milk, approximately 1/4 full, not dated; 3/4 of a loaf of bread, not dated; 1- 5 pound container of cottage cheese, approximately 3/4 full, not dated; and 1- 10 ounce container of marschino cherries, approximately 3/4 full, not dated.

During a concurrent interview on 08/14/2023 at 12:26 PM, Acute Unit Supervisor A stated all items in the refrigerator and freezer without a manufacturer's expiration date should be labeled with the date received, any opened items should be labeled with the date opened, and expired or unlabeled or undated items should be disposed of. When asked about the Ziploc bag containing the cheese, Supervisor A was unable to confirm whether the date written on the bag indicated the received date or the "best by" date. Supervisor A stated, "The night shift CNAs [Certified Nursing Assistants] are responsible" for checking and ensuring the food items are labeled appropriately and discarding unlabeled or expired food.

Dry Food Storage:

During a tour and observation with Acute Unit Supervisor A on 08/14/2023 at 12:44 PM, the Acute Care Unit food storage cabinets and drawers were unlocked by Supervisor A and the following was observed: A full, 1 gallon Ziploc bag containing Cheerios labeled, "Best by 02/01/2023;" one opened, 16 ounce container of Butter-Flavored Popcorn Salt, no manufacturer's expiration date and not labeled; 5 unopened sleeves of graham crackers, no manufacturer's expiration date and not labeled; 45 packages of saltine crackers, no manufacturer's expiration date and not labeled; 1 opened bag of Ruffles potato chips, no manufacturer's expiration date and not labeled; 1 opened bag of Fritos corn chips, no manufacturer's expiration date and not labeled; 1 opened bag of Lay's Classic potato chips, no manufacturer's expiration date and not labeled; 2 opened bags of Tostitos tortilla chips, no manufacturer's expiration date and not labeled; 1 opened bag of pretzels, no manufacturer's expiration date and not labeled; 122 ¾ ounce cups of Jif peanut butter, no manufacturer's expiration date and not labeled; 100 packs of jam and jelly, no manufacturer's expiration date and not labeled; tea bags, salt, and pepper packs, no manufacturer's expiration date and not labeled; 4 bags of expired popcorn; 3 cream of wheat packages, no manufacturer's expiration date and not labeled; and 9 packages of oatmeal, no manufacturer's expiration date and not labeled.

During a concurrent interview on 08/14/2023 at 12:44 PM, Acute Unit Supervisor A stated, "Typically we would see an opened date" on opened food items.

During an interview with Dietary Director K on 08/15/2023 at 12:52 PM, when asked about food items brought to the inpatient psychiatric unit, Director K stated, "Our staff does not go on the unit. We bring things over and ring the bell and the unit staff is responsible from there." When asked how food items are labeled, Director K stated, "The food service staff should be labeling everything with the 'best by' date before bringing it over." When asked about bulk items, such as margarine, graham crackers or peanut butter, that are removed from the original packaging containing the manufacturer's expiration date prior to being sent to the unit, Director K stated, "We bring all those things over in individual plastic containers with the 'best by' date labeled on the container. If they [the unit staff] are taking things out of those and not putting the dates on them, I don't know what to tell you. Like I said, we don't go on the unit."




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Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination on 1 of 1 dietary kitchen in a total of 5 departments observed.

Findings include:

On 8/15/2023 at 1:00 PM during a tour of the dietary kitchen accompanied by Dietician I the "Dishwasher Temperature Checklist" was observed posted on a bulletin board. Review of the checklist revealed missing documentation for the supper wash and rinse for August 6, 7, 8, 11 and 14. Dietician I confirmed the findings.

Record review of the posted "Food Service Cleaning Schedule" revealed a listing of weekly cleaning tasks that are assigned to "FSW (food service worker)" positions. Tasks include, in part, cleaning and sanitizing food service carts, sweep and mop dish room, clean all drawers, clean and sanitize all countertops, take out trash.

In an interview on 8/16/2023 at 11:45 PM with Lead Cook J he/she explained that the positions are assigned each week and the expectation that the cleaning tasks are completed and initialed by the assigned staff member. Lead Cook J stated that Positions 3, 7, and 10 have cleaning tasks that are to be completed on a daily basis.

Review of the cleaning schedules revealed, "Schedule for Position 7, an expectation of daily cleaning, 7/30-8/5/23, documentation only completed on Sun (Sunday), 8/6-8/12/23 no documentation for the week, 8/13-8/19/23 no documentation for the week to date (tour completed on 8/15/2023), Schedule for Position 3, an expectation of daily cleaning, 8/13- 8/19/23 documentation only completed on Sun (Sunday), Position 10 an expectation of daily cleaning documentation only completed on Sun (Sunday).

On 8/15/2023 at 1:10 PM in an interview with Director of Dietary K when asked about documentation on the temperature checklist and cleaning schedule stated, "I would expect staff to document when completed."

Based on observation, staff interviews, and review of maintenance records on 08/14/2023, Fond du Lac County Acute Psych Unit, in Fond Du Lac, WI did not construct, install and maintain the building systems to ensure life safety for patients.

The cumulative effect of environment deficiencies are not compliant with 42 CFR 482.41(a) was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies:
K211 Means of Egress - General
K321 Hazardous Area - Enclosure
K372 Subdivision of Building Spaces - Smoke Barrier Construction
K741 Smoking Regulations
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing

Refer to the full description at the cited K tags.

Based on observation, staff interviews, and review of maintenance records on 08/14/2023, Fond du Lac County Acute Psych Unit, in Fond Du Lac, WI did not construct, install and maintain the life safety systems for patients.

The cumulative effect of environment deficiencies with 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies.
K211 Means of Egress - General
K321 Hazardous Area - Enclosure
K372 Subdivision of Building Spaces - Smoke Barrier Construction
K741 Smoking Regulations
K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing

Refer to the full description at the cited K tags.

Based on record review, observation, and interview, the facility staff failed to ensure hospital equipment was maintained on a preventive maintenance schedule to ensure an acceptable level of safety and quality for 1 of 1 electronic scale and 4 of 4 battery-powered recumbent exercise bikes, and failed to ensure that all surfaces were smooth, intact and in good repair in order to be disinfected in 1 of 1 inpatient unit observed.

Findings include:

Equipment Maintenance:

A review of the facility's policy #02-097-09 titled, "Recreational Equipment and Facilities," updated 01/27/2022 revealed, " ...Equipment is checked periodically by the O. T. [Occupational Therapy] staff for maintenance and safety ..."

During an interview with Acute Unit Supervisor A on 08/15/2023 at 2:20 PM, when asked about preventative maintenance policies or calibration checks for the electronic scale, Supervisor A stated, "I called [Maintenance Director C]. There is no current process or policy for calibrating or doing PMs [preventative maintenance] on the scale. That is not something we've historically done."

During an interview with Acute Unit Coordinator H on 08/16/2023 at 3:02 PM Coordinator H stated the Occupational Therapist that was responsible for completing the checks on the exercise bikes was off and unavailable, and therefore Coordinator H was unable to access or provide any information regarding a maintenance schedule or when the checks were last completed.

Integrity of Surfaces:

A review of the facility's policy #02-065-27 titled, "Supply and Equipment Storage," updated 08/01/2014 revealed, "... A sanitary environment shall be maintained throughout the unit and storage areas to avoid sources and transmission of infection..."

During a tour and observation of the inpatient unit with Acute Unit Supervisor A on 08/14/2023 beginning at 11:55 AM, noted the following:

The exterior of the wooden door to room 1 revealed a gouge near the door handle and multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 2 revealed multiple cracks and gouges near the bottom right of the door and the exterior of the wooden door into the bathroom revealed a gouge near the door handle, exposing porous wood underneath.

The exterior of the wooden door into the bathroom from room 4 revealed multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 6 revealed multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 7 revealed a gouge near the door handle, exposing porous wood underneath.

The exterior of the wooden door to room 9 revealed chipping below the door handle and multiple cracks and gouges near the bottom right of door, exposing porous wood underneath.

The exterior of the wooden door to room 10 revealed multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 11 revealed multiple cracks and gouges near the bottom right of the door and the exterior of the wooden door into the bathroom revealed multiple cracks and gouges near the bottom of the door, exposing porous wood underneath.

The exterior of the wooden door to the bathroom in room 12 revealed multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 13 revealed multiple cracks and gouges near the bottom right of the door, exposing porous wood underneath.

The exterior of the wooden door to room 14 (seclusion room) revealed multiple cracks and gouges near the bottom of the door, exposing porous wood underneath.

The exterior of 2 linen closets revealed multiple gouges, exposing porous wood underneath.

During an interview on 08/14/2023 at 2:55 PM, the above findings were reviewed with and confirmed by Acute Unit Supervisor A. Acute Unit Supervisor A stated that s/he noticed the gouges and multiple cracks on the patient room doors and bathroom doors and stated that she will reach out to get them fixed. Acute Unit Supervisor A stated, "It looks like we will be keeping housekeeping busy."

Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination in 2 of 5 departments observed (Inpatient Acute Care Unit and Medical Record Department) in a total of 5 departments observed.

Findings include:

A review of the facility's policy #02-065-16 titled, "Cleaning Schedules," updated 03/11/2020 revealed, "Policy: The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. Protocols for cleaning and disinfecting patient care equipment and furniture have been established ...Patient refrigerator ...cleaned by Acute unit staff on the night shift or as arranged per established schedule. Food or beverages should be labeled and dated to monitor for food safety: All food and beverage items are to be covered and dated. Any opened food or beverage item without a date will be discarded immediately. Food or beverages in the original containers marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage. Food or beverages that have passed the manufacturer's expiration date are to be discarded ...Food or beverage items without a manufacturer's expiration date should be dated upon arrival and discarded as per the recommendation of Foodsafety.gov ...Food or beverage items in unmarked or unlabeled containers should be marked with the current date which the food item was stored and discarded as per the recommendation of Foodsafety.gov ...Any suspicious, obviously contaminated, or spoiled food or beverages are to be discarded immediately ...Cleaning requires wiping surfaces with a cloth dampened with water and mild detergent ..."

Cleanliness of Environment:

During a tour and observation of the Acute Care Unit with Acute Unit Supervisor A on 08/14/2023 starting at 11:50 AM, the following was observed:

The interior of the room 9 revealed a cob web near the exterior door.

The exterior of the wooden door to room 11 revealed white, splotchy stains on the bottom half of the door.

The exterior of the wooden door to room 13 revealed brown, splotchy stains on the bottom half of the door.

The shared patient sink in room 4 revealed lime buildup and rust.

The sink near the patient refrigerator and freezer revealed lime buildup and rust.

The paper towel holder near the patient refrigerator and freezer revealed water and rust stains.

In the shower of the shared bathroom between rooms 12 and 13, which were both unoccupied and had been identified as clean and ready for patients, a small plastic medicine cup containing an off-white substance was noted. When asked about the item, Acute Unit Supervisor A stated, "That looks like someone left their shampoo in here."

During an interview on 08/14/2023 at 2:50 PM, the observation findings were reviewed with and confirmed by Acute Unit Supervisor A.



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Housekeeping:

Review of the facility policy titled Housekeeping #02-065006 dated 1/27/2022 revealed, "Policy: The workplace shall be maintained in a clean and sanitary condition. Procedure: 1. Housekeeping shall maintain a written schedule for cleaning and method of decontamination in the Acute Unit utility closet."

On 8/14/2023 at 1:00 PM during a tour of the Acute Care Unit accompanied by Lead Housekeeper G, Housekeeper G unlocked the housekeeping closet on the Acute Care unit and produced the monthly cleaning schedule.

Record review of the log titled, "Acute Unit-Housekeeping Schedule" revealed a monthly calendar with a listing of 34 cleaning tasks and the expected frequency for completion of each task. The schedule revealed, "Initial after task completed." The following tasks and frequencies included: Offices - 3 x (times) week, Treatment Rooms 3 x week, Quiet Room #14 - 3 x week, Room #8 - daily, Visitation Room - daily, Patient Bathrooms and Patient bedrooms - daily, Bubbler - daily. Other tasks indicated weekly and monthly cleaning schedules.

Review of the logs from April 2023 - August 2023 revealed the following: no documentation of any daily or 3 times/week cleaning being done on April: 1st -5th, 8th-10th, 15th-16th, 22nd-23rd, 28th-30th . May 2023 no documentation of any cleaning being done on May 1st, 6th-7th, 13th-14th, 20th-21st, 25th, 27th-29th. June 2023 no documentation of any cleaning being done on June 3rd-4th, 9th-10th, 16th-18th, 22nd, 24th-26th. July 2023 no documentation of any cleaning being done on July 1st-2nd, 7th-9th, 15th, 16th, 18th, 20th, 22nd,24th-31st. August 1st -15th no documentation of any cleaning being done on August 5th-6th, 11th-15th.

During an interview with Housekeeper G on 8/14/2023 at 1:15 PM Housekeeper G stated that he/she is assigned to the Acute Care Unit Monday-Friday and others, including nursing staff, are responsible to complete the cleaning tasks and document on the log when he/she is not working, including weekends. When the incomplete logs were shown to Housekeeper G, he/she stated, "I'm sure cleaning was done but just not documented, I guess. They should be putting their initials on it."

Laundry:

Review of the facility policy titled, Patient Laundry #02-065-25 effective date 9/1/2014 revealed, "Policy: Patient clothing will be laundered by Acute Unit staff in the soiled linen room washer and dryer ..." Procedure: 9. Following completion of the wash/rinse cycle, set the washer to rinse/spin cycle, push start button on the X-pert pump (a sanitizing system for washing machines) to dispense sanitizer into wash tub and initiate a second rinse/spin cycle."

Review of the "Washing Instructions" posted on the washer revealed, "When the load has gone through its entire wash cycle, set washer to rinse/spin and start it. Push green button on the Ecolab X-Pert panel which will dispense the pre-measured Laundry Bacstat sanitizer into the tub for the rinse cycle..."

During a tour of the soiled utility room on the Acute Care Unit on 8/15/2023 at 10:05 AM accompanied by CNA (certified nursing assistant) F it was observed that the X-Pert pump was on the wall next to the washer and dryer but not connected to the washer or dryer. Solution was observed in the X-Pert container and was observed to be dripping out of the connection hose onto the floor. When CNA F was asked about sanitizing the washer after each load CNA F stated, "Since we got a new washer and dryer we don't use that anymore, after I use it I just wipe the washer out with a rag."

On 8/14/2023 at 11:55 AM in an interview with Administrator B, Administrator B stated that he/she was the supervisor over Housekeeping and Laundry for the facility. When asked about the disconnected X-Pert pump on the Acute Care unit he/she stated, "I'm not sure why it wasn't removed. If it's not being used it should be taken out of there."

On 8/15/2023 at 3:20 PM in an interview with Acute Unit Supervisor A confirmed that the "Patient Laundry Policy #02-065-25 was the most current. When asked about the expectation for sanitizing the washer after use Supervisor A stated, "We need to update that policy and include how staff should be sanitizing the unit. We need to get the old X-Pert pump removed." Supervisor A confirmed that a new washer and dryer was installed in 2021.

Medical Records Department:

On 8/15/2023 at 8:30 AM during a tour of the medical record storage area in the basement accompanied by Director of Medical Records E, 5 cardboard file boxes were observed to be placed directly on the cement flooring. In an interview on 8/15/2023 at 8:30 AM Director E stated, "I know they shouldn't be on the floor, they've only been there a couple of weeks."

Based on record review and interview, the facility staff failed to document a thorough screening neurological examination, including gross testing of all 10 cranial nerves, for 5 of 30 patients (Patients #8, 12, 20, 21, 22) in a total universe of 30 medical records reviewed.

Findings include:

A review of the facility's policy #02-070-01 titled, "Admission History & Physical Format," updated 04/13/2023 revealed, " ...Formats for documentation content have been established and are to be followed for content and detail ...See format exhibit #02-070-01A."

A review of the exhibit #02-070-01A, no date, revealed, "Neurological Examination ...Cranial Nerves ..."

A review of Patient #22's medical record revealed Patient #22 was admitted to the facility from 08/08/2023 to 08/09/2023 for detox with a diagnosis of polysubstance abuse. The "Acute Intake Evaluation" completed on 08/08/2023 at 7:08 AM revealed, " ...Cranial Nerves: Extraocular muscles intact. No nystagmus. Good speech quality." There was no documented evidence found that all 10 cranial nerves were assessed.


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A review of Patient #8's medical record revealed Patient #8 was admitted to the facility from 7/1/2023 - 7/3/2023 for detox with a diagnosis of heroin and fentanyl addiction. The "Acute Intake Evaluation" completed on 7/1/2023 at 10:36 AM revealed, " ...Cranial Nerves: Extraocular muscles intact. No nystagmus. Good speech quality." There was no documented evidence found that all 10 cranial nerves were assessed.

A review of Patient #12's medical record revealed Patient #12 was admitted to the facility on 08/01/2023 to current for homicidal ideation. The "Acute Intake Evaluation" completed on 08/02/2023 at 9:26 AM revealed, "... Cranial Nerves: Extraocular muscles intact. No nystagmus. Good speech quality." There was no documented evidence found that all 10 cranial nerves were assessed.

A review of Patient #20's medical record revealed Patient #20 was admitted to the facility from 07/06/2023 through 07/10/2023 for severe depression, anger and severe mood swings. The "Acute Intake Evaluation" completed on 07/07/2023 at 2:06 PM revealed, "... Cranial Nerves: Extraocular muscles intact. No nystagmus. Good speech quality." There was no documented evidence found that all 10 cranial nerves were assessed.

A review of Patient #21's medical record revealed Patient #21 was admitted to the facility from 06/23/2023 through 06/24/2023 for severe depression and mood swings. The "Acute Intake Evaluation" completed on 06/23/2023 at 9:04 AM revealed, "... Cranial Nerves: Extraocular muscles intact. No nystagmus. Good speech quality." There was no documented evidence found that all 10 cranial nerves were assessed.

During an interview on 08/16/2023 at 3:30 PM, the medical record review findings were discussed with Acute Unit Coordinator H who stated, "I do not see them documented. Typically, I list all cranial nerves. It is a standard of practice to list all of the cranial nerves. The provider should re-attempt throughout the patient's stay to assess the patient's cranial nerves if they are not obtained upon admission."

Based on record review and interview the facility failed to include an inventory of the patient's strengths and assets that describe personal factors on which to base the treatment plan for 8 of 30 inpatients (Patients #1, 2, 3, 8, 11, 15, 29 & 30) in a total sample of 30 medical records reviewed.

Findings include:

A review of the facility's policy #02-070-01 titled, "Admission History & Physical Format," updated 04/13/2023 revealed, " ...Formats for documentation content have been established and are to be followed for content and detail ...See format exhibit #02-070-01A."

A review of the exhibit #02-070-01A, no date, revealed, "Mental Status Examination ...Strengths ..."

A review of Patient #1's medical record revealed patient #1 was admitted to the facility from 8/04/2020 to 8/09/2023 with the diagnosis of bipolar disorder, manic with psychotic features. The Psychiatric Evaluation dated 8/05/2023 at 9:12 AM under "Strengths" was blank.

A review of Patient #2's medical record revealed patient #2 was admitted to the facility from 3/2023 to 5/12/23 with the diagnosis of schizophrenia and bipolar disease. The Psychiatric Evaluation dated 3/21/2023 at 10:01 AM under "Strengths" revealed "group home."

A review of Patient #3's medical record revealed patient #3 was admitted to the facility from from 4/15/2023 to 4/17/2023 with suicidal ideation's and a diagnosis of bipolar disease. The Psychiatric Evaluation dated 4/15/2023 at 10:05 AM under "Strengths" was blank.



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A review of Patient #8's medical record revealed Patient #8 was admitted to the facility on 7/1/2023 with a diagnosis of heroin and fentanyl addiction. The "Acute Unit Intake Evaluation" completed on 7/1/2023 at 10:36 AM revealed under "Strengths: Vital Signs."

A review of Patient #11's medical record revealed Patient #11 was admitted to the facility from 07/29/2023 through 08/02/2023 for suicidal ideation. The "Acute Unit Intake Evaluation" completed on 07/30/2023 at 11:25 AM revealed no patient assets or strengths documented.

A review of Patient #15's medical record revealed Patient #15 was admitted to the facility on 08/12/2023 for suicidal and homicidal ideations, with a diagnosis of acute exacerbation of Bipolar I disorder. The "Acute Unit Intake Evaluation" completed on 08/13/2023 at 9:24 AM revealed no patient assets or strengths documented.

A review of Patient #29's medical record revealed Patietn #29 was admitted to the facility on 08/05/2023 through 08/11/2023 for suicidal ideation after an overdose. The "Acute Unit Intake Evaluation" completed on 08/06/2023 at 10:52 AM revealed no patient assets or strengths documented.



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A review of Patient #30's medical record revealed patient #30 was admitted to the facility from 7/06/2022 to 8/22/2022 with the diagnosis of chronic undifferentiated schizophrenia. The Psychiatric Evaluation dated 7/06/2023 at 11:52 AM under "Strengths" revealed "None."

During an interview with Acute Unit Supervisor A on 08/16/2023 at 3:15 PM, the medical record review findings were discussed with and confirmed by Supervisor A who stated, "I would expect to see some strengths listed."