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Based observation, interview, and record review, the facility's Governing Body failed to:

1. Assure patients receive care in a safe setting. Including assuring the facility had routine daily documented contraband check of Patient rooms and common patient care areas. The Governing body failed to assure all Patients rooms were ligature risk free including patient door handles, patient beds and patient faucets. The Governing Body failed to assure Patient room ceiling motion sensors worked in all patient rooms. The Governing Body failed to assure Patient room window curtains were breakaway, if pressure was applied. (A - 144)

2. The Governing Body failed to assure Medical Staff had current clinical privilege lists at time of reappointment. (A - 341)

3. The Governing Body failed to assure there was a Chief Nursing Officer assigned to oversee and coordinate nursing services for the Hospital. The Governing Body failed to assure a Nurse Supervisor was available during night Shift. (A - 386)

4. The Governing Body failed to coordinate and oversee a hospital wide infection control program. The Governing Body failed to Implement an infection control program that assured patient rooms provided a sanitary and safe environment, medical staff had documented Hepatitis B (HepB) vaccination, declination of Hepatitis B immunization. That medical staff had documentation of Flu vaccination or declination of Flu vaccination, prior to start of Flu season. Assure Pharmacy services were carried out in safe and sanitary manner. Assure dietary services are provided in a safe and sanitary manner. Assure corrugated cardboard boxes were not used for Storage of Patient supplies in Material receiving Area of the Hospital. (A - 749)

The cumulative effects of these systemic problems resulted in the Facility's inability to ensure the provision of quality health care in a safe and sanitary environment.

Based on interview and record review, the hospital failed follow up on patients who could not sign admission agreement on admission to ensure patients or patient representatives had acknowledged the patient's rights and related documents (Patient 3). The facility failed to ensure nursing staff made a second (2nd) attempt for patients to sign their admission, agreements, and patient rights forms, and failed to have two nurses signatures, for three of ten sampled patients (Patients 1, 8, and 9)

These deficient practices had the potential for patient not to be aware of their rights, and other conditions to their admission to the hospital.

Findings:

Review of Patient 3's admission record indicated the patient was admitted on 10/8/2019. The admission agreement packet included Consent to Admission, Physicians as Independent Contractors disclosure, Notice of Privacy Practices, "An Important Message from Medicare", and rights of mental health patients acknowledgement. On these forms, the area for patient or patient representative's signature indicated the Patient 3 refused to sign on 10/9/2019 at 12:30 AM. These forms also indicated if patient refuses to sign, "Make two more attempts to have patient sign form".

On 1/9/2020 at 12:15 PM, during an interview and concurrent review of Patient 3's admission agreement packet, the clinical supervisor confirmed that there was lack of evidence that the nurses made two attempts to have Patient 3 sign to acknowledge the aforementioned forms.

During an interview, on 1/7/2020 at 11:13 AM, the director of social services (DSS) stated when a patient cannot sign the admission documents and consents, another registered nurse witnesses and signs the forms, then a second attempt is made for the patient to sign the forms when the patient is less agitated.

A review of Patient 1's "Admission Agreement," dated 12/30/19 at 4 PM, indicated that Patient 1 refused to sign the agreement. The agreement indicated if the patient was unwilling or unable to sign the form upon admission, please make a 2nd attempt to have the patient sign when the patient is more cooperative or condition has improved. Make an attempt to have the patient legal representative sign the form. There was no documented evidence that a 2nd attempt was attempted to have the patient sign the form.

A review of Patient 1's "Notice of Privacy Practices," dated 12/30/19 at 4 PM, indicated Patient 1 was unable to sign the form on the first attempt. The form indicated that if the patient is unwilling or unable to sign the form upon admission, please make a 2nd attempt to have the patient sign when the patient is more cooperative or condition has improved. Make an attempt to have the patient legal representative sign the form. There was no documented evidence that a 2nd attempt was attempted to have the patient sign the form.

A review of Patient 1's "Notification of Patient Admission and Subsequent Events," dated 12/30/19 at 4 PM, indicated the patient refused or was unable to provide information or sign the form. The document indicated to make one more attempt to have patient sign form and provide name (s) when patient is more stable/cooperative. There was no documented evidence that a 2nd attempt was attempted to have the patient sign the form.

A review of Patient 1's "Hospital and Mental Health Patient Rights and Responsibilities," dated 12/30/19 at 4 PM, indicated the patient was unable to sign the form. The form indicated that if the patient is unwilling or unable to sign the form upon admission, please make a 2nd attempt to have the patient sign when the patient is more cooperative or condition has improved. Make an attempt to have the patient legal representative sign the form. There was no documented evidence that a 2nd attempt was attempted to have the patient sign the form.

A review of Patient 8's face sheet, dated December 3, 2019, indicated Patient 8 was admitted to the facility on December 3, 2019.

On January 7, 2020 at 10:46 a.m., during concurrent record review of Patient 8's Hospital and Mental Health Patient Rights and Responsibility, dated December 3, 2019, and interview with Director of Social Services (DSS), DSS stated there was no patient signature, no date and no time indicated on admission and no documentation of a second attempt to have Patient 8 or patient's representative sign, date and time for the Patient Rights and Responsibility document.

Concurrently, on Patient 8's Patient Handbook, dated December 3, 2019, DSS stated there was no patient signature, date and time indicated on admission and no documentation of a second attempt to have Patient 8 or patient's representative sign, date and time of the same document.

A review of Patient 9's face sheet, dated January 6, 2020, indicated Patient 9 was admitted to the facility on January 6, 2020.

On January 8, 2020 at 12:28 p.m., during concurrent record review of Patient 9's Patient Rights documents, dated January 6, 2020, Director of Social Services (DSS), DSS stated Patient 9 refused to sign the Physicians as Independent Contractors, Notice of Privacy Practices and Patient Handbook, so there were two Registered Nurses' (RN) signatures indicated. DSS stated, for the 2nd attempt for patient to sign the same documents, dated January 8, 2020, Patient 9 refused to sign documents and there was only one RN signature indicated.

A review of Informed Consent policy, dated August 2019, indicated it is the intent of the facility to protect the patient's right to an informed consent prior to any medical or behavioral health treatment. If a patient refuses to sign the written consent, it is to be noted by two nurses with signatures.


36206




38310

Based on observation, interview, and record review, the facility failed to provide a safe environment:

1. Nursing staff failed to track and/or monitor for contraband (any articles or medications which could be considered dangerous) in the facility daily.

2. Motion sensors in some patient rooms were not functioning.

3. Faucets and door knobs in all patient restrooms were not ligature resistant.

4. A curtain in one of the rooms fell out when pulled down.

5. Screws in toilet bases were exposed and protruding.

This deficient practices had the potential for self-harm by patients.

Findings:

1. During the initial tour, on 1/6/2020 at 9:46 AM, two scissors were observed in a drawer of the medication room.

Concurrently, the registered nurse (RN 1) stated there were two scissors in the unit. RN 1 stated they did not count the scissors or track them daily. RN 1 was asked if a scissor was accidentally left in a patient's room, how would the nursing staff know a scissor was missing, RN 1 stated they needed to start counting the scissors.

On 1/7/2020, at 10:18 AM, RN 1 stated they did not check the rooms daily for contraband. Patients were checked for contraband upon admission, and family members were checked for contraband when they visited.

The facility's policy and procedure titled, "Contraband and Permitted Items for Patient/Visitor Information," dated 8/2019, indicated that upon admission to out inpatient unit, patient's will have their belongings inventoried. Potentially dangerous items will be sent home if possible or stored in an individual labeled storage container until discharge. Items that may not be kept in the possession of patients include razor blades, nail files, clippers, and scissors.

2. On January 6, 2020 at 9:00 to 9:33 a.m., during initial tour of the facility with Registered Nurse (RN) 1, ten of ten patient bedrooms were observed with door handles on both sides of the bathroom doors and faucets that were not ligature safe.

Concurrently, RN 1 stated the door handles to the bathrooms and the faucets to the patient's sinks were not ligature resistant and can be found throughout the hospital in all ten bedrooms.

3. On January 6, 2020 from 9:00 a.m. to 9:33 a.m., during the initial tour of the facility with Registered Nurse (RN) 1 and the Director of Facility Management (DFM) , rooms 10, 9, 8, 6, 5, 4, and 1 were observed with motion sensor alarms that did not alarm both, when the window curtains were opened and shut abruptly by RN 1, and when the DFM waved his hands above his head in the rooms.

4. On January 6, 2020 at 9:00 to 9:33 a.m., during initial tour of the facility with Registered Nurse (RN) 1, rooms 10, 9, 8, 7, 6, 5, 4, 3, 2, 1's curtains were opened and shut abruptly by RN 1, room 6's curtains were observed breaking away from the railings and falling down on the floor.

5. On January 8, 2020 at 10:06 a.m., during tour of the facility with Registered Nurse (RN) 1, room 9's bathroom had a screw observed protruding above the base of the toilet commode. Concurrently, on the other side, one screw had a white cap that can be easily removed, and when removed, another screw was observed protruding above the base of the same toilet commode. Concurrently, RN 1 stated the exposed screw without the white cap should have been covered with the cap secured for safety.

A review of Suicide Risk Assessment and Ligature Risk policy, dated October 2019, indicated all patients and their belongings are checked for contraband on admission, to decrease ligature risk. Ligature risk includes anything that could be used to attach a cord, rope or other material for purposes of hanging or strangulation. Ligature point is a fixed point which a ligature can be tied to, wedged around or behind or held in place by any means which enables the ligature to bear weight of the patient either wholly or partially. A shift assessment of moderate to risk patient for contraband and ligature risk in the environment is conducted by the person performing the 1:1 observation and the Registered Nurse (RN) and is documented on the Contraband/Ligature Risk Rounds Checklist.


38310

Based interview and record review, the nursing staff failed to monitor one (1) of ten sampled patients, (Patient 5), for one hour after receiving a chemical restraint, in accordance with the facilities policies and procedures.

This deficient practice had the potential for any negative effects of receiving a chemical restraint to go unnoticed by nursing staff.

Findings:

During a concurrent interview and review of Patient 5's medical record, the registered nurse (RN 1) stated patients should be monitored for one hour after a chemical restraint is given and should monitoring should be documented in the medical record. RN 1 verified Patient 5 had no documented evidence that he had been monitored for one hour.

A review of Patient 5's medical record indicated Patient 5 was admitted to the facility on 3/28/19. Patient 5 was placed on a 5150 (72 - hour) hold for being a danger to self (DTS) and a danger to others (DTO). Patient 5's diagnoses included major depression (persistent feelings of sadness and hopelessness), hypertension (high blood pressure) and history of a myocardial infarction (heart attack).

A review of a document titled, "AGPU Behavior Management: Restraint Use Orders," dated 3/28/19 at 10:15 PM, indicated to give a chemical restraint of Ativan (lorazepam, a sedative) 0.5 milligrams (mg, a unit of weight equal to one thousandth of a gram) intramuscularly (IM) times one, now, for disoriented and irrational behavior.

A review of Patient 5's medication record indicated Patient 5 received Ativan 0.5 mg IM at 10:45 PM.

A review of a document titled, "AGPU Behavior Management: Restraint Monitoring Flow Sheet," dated 3/28/19, indicated that monitoring for Patient 5's safety & well being, and neurological checks started at 10:45 PM, and continued 15 minutes, then 30 minutes later. Patient 5 was not monitored 45 minutes or 1 hour later, after receiving the chemical restraint. The document indicated that there was to be no less then one hour of monitoring for patients who received a chemical restraint.

The facility's policy and procedure titled, "Emergency Psychiatric Medications: Chemical Restraint," dated 7/2019, indicated whenever a patient is administered an emergency dose of psychiatric medication(s) the patient shall be continuously monitored by a registered nurse (RN) during the immediate period following the administration of the medication. The RN must remain with the patient during the first 15 minutes post medication administration and then reassess the patient every 15 minutes and document on the "Behavior Management Restraint Sheet" and "Neuro/VS Flow Sheet" assessment findings. Monitoring by the RN shall continue every 15 minutes until the patient has sufficiently recovered from the side effects of the medication and can resume previous baseline activity. In no case shall the monitoring period be less then one hour.

Based on interview, and record review, the nursing staff failed to monitor patients' response to a chemical restraints and rational and documentation for continue or discontinued use, for one (1) of ten sampled patients (Patient 1).

This deficient practice had the potential for negative response to chemical restraints to go unnoticed.

Findings:

During a concurrent interview and record review, on 1/8/2020 at 11:18 AM, the registered nurse (RN 1) stated that after a patient receives a chemical restraint the nurse must document the overall response and whether to continue or discontinue the chemical restraint in the form "AGPU Behavior Management: RN One Hour Face to Face Assessment". RN 1 verified Patient 1's form was incomplete.

A review of Patient 1's medical record indicated Patient 1 was admitted to the facility on 12/30/19. Patient 1's diagnosis included advanced dementia (a progressive loss of brain function affecting memory, thinking, and behavior). Patient 1 had become irritable, fell, then became agitated when the husband tried to help her. Patient 1 was taken to an outside emergency room, where she became combative, striking out at staff. Patient 1 was medically cleared and placed on a 5150 (72 hour) hold for grave disability and admitted to the facility.

A review of a document titled, "AGPU Behavior Management: Restraint Use Orders," dated 12/31/19 at 1:15 PM, indicated to give a chemical restraint of Haldol (haloperidol, an antipsychotic medication) 2 mg (a unit of weight equal to one thousandth of a gram), intramuscularly (IM, in the muscle) and Benadryl (dephenhydramine, aids in falling asleep) 25 mg IM for aggressive, violent, disoriented, and irrational behavior.

A review of Patient 1's medication record, indicated Patient 1 received Haldol 2 mg and Benadryl 25 mg IM at 1:25 PM for agitation.

A review of a document titled, "AGPU Behavior Management: RN One Hour Face to Face Assessment," dated 12/31/19 at 1:25 PM, indicated the document was incomplete. It did not indicate Patient 1's overall reaction to the restraints, nor was there documentation as to whether to continue or discontinue the restraints.

The facility's policy and procedure titled, "Emergency Psychiatric Medications: Chemical Restraint," dated 7/2019, indicated whenever a patient is administered an emergency dose of psychiatric medication(s) the patient shall be continuously monitored by a registered nurse (RN) during the immediate period following the administration of the medication. The original restraint order is only good for one hour when the nurse must complete a "RN One Hour Face to Face Evaluation Form" post medication administration.

Based on interview and record one (1) of 10 employees (Employee 6) credential files did not have a current Restraint Training validation present.

This deficient practice resulted in facility not adhering to their policy, state and federal guidelines.

Findings:

On 1/8/2020 during the Personnel File Review, a visual validation of Employee 6 training for Restraint competency showed that it expired. According to the Annual Competencies review Employee 6 last completed Restraint Training on 8/13/2018. Employee 6 did not receive Restraint Training/competency for the 2019.

During an interview on 1/8/2020 at 2:38 PM, the Vice President of Human Resources 1 stated Employee 6 had been out of work for most of 2019. However, upon further record review the Vice President of Human Resources 1 stated Employee 6 returned to work 9/2019 and that his 2019 restraint competency was not done.

A record review of the facility's policy titled "Orientation/Competency Plan for Staff", dated 7/2019, indicated each nursing staff will complete unit specific competencies on an annual basis. Validation of unit specific competencies may be provided through observation, written exams, chart review, skills lab and policy and procedure review. Restraints and Seclusions are listed on competencies assessed on an annual basis.

Based on interview and record review, the hospital's ongoing Quality Assurance and Performance Improvement (QAPI) program failed to, as evidenced by the lack of documented actions, and/or mechanisms, develope or implement any improvement plan or mechanisms derived from analyzing the data collected.

This deficient practice had the potential fo the facility to not recognize and address and or correct practices that could negatively impact patient safety.

Findings:

A review of the minutes of the hospital's pharmacy and therapeutics (P&T) committee meetings held in 2019 indicated the pharmacy reported medication errors as quality assurance data. There were four meetings held in 2019. Each of the meetings minute documented the quantity of errors collected and a brief discussion of some of the cases. However, these minutes did not provide information whether actions plan had been developed and implemented based on the data collected; the areas listed as "Actions/Resolution" and "Follow-up" were blank.

A review of the minutes of the hospital's QAPI council meetings held in 2019 indicated the Director of Pharmacy (DOP) reported on data of six (6) quality indicators; 4 of those 6 were medication error types: data entry errors, filing errors, "external errors reaching the floor", and "external error dispensing through administration".

A review of the hospital policy and procedure "Medication Error Reduction Program (MERP)", last reviewed in 8/2019, indicated the elements of medication errors included but are not limited to prescribing/ordering, communication, date entry, order review process, packaging, compounding, dispensing, distributing, administration, and the use and monitoring of medications.

On 1/8/2020 at approxamately 3:30 PM, during an interview and concurrent review of the aforementioned documents, with the Director of Quality (DOQ) and the DOP, both DOQ and DOP acknowledged the "medication errors" quality indicators reported in the P&T and QAPI meeting minutes were not inline with those elements identified in the hospital's MERP policy. The DOQ and DOP also acknowledged that the collected data was not further analyzed. The DOQ indicated there was no documentation of any action plans, or focused in-services, had been developed, and/or implemented, as the result of their trending analysis.

Based on Interview and record review The facility failed to assure that four (4) out of 10 Medical Staff had current Clinical privilege lists at time of reappointment.

This deficient practice resulted in the facility 's failure to ensure the provision of quality health care in a safe environment.

Findings:

During a review of ten randomly selected Medical Staff Credential files, four (4) of 10 Medical Doctors, (MD 2, 3, 7, 8), did not have a current privilege list approved at time of reappointment.
MD 2 was reappointed on 8/7/2019, the most current privilege list was dated 8/9/2017.
MD 3 was reappointed on 11/6/2019, the most current privilege list was dated 11/8/2017.
MD 7 was Reappointed on 8/7/2019, the most current privilege list was dated 8/9/2017.
MD 8 was reappointed on 10/24/2018, the most current privilege list was dated 10/26/2018.

During a concurrent interview with the Medical Staff Director (MSD), and the Chief Medical Officer (CMO) on 1/7/2020 at 12:30 pm, the CMO stated the facility had stopped doing privileges every 2 years if there was no change. When asked how clinical privileges were evaluated at time of reappointment, the CMO indicated the facility needed to update privilege lists if there was a change to the privilege request during reappointment. The MSD indicated not all randomly selected credential files reviewed had current privilege list at time of review. The CMO indicated Medical Staff performance evaluations are completed 3 times during the time between reappointments.

A review of the facility Document titled, "Medical Staff Bylaws", approved 8/7/2019, indicated, under "Article V: Exercise of Clinical Privileges, Section 2 Delineation of Privileges," "Every application to Medical Staff appointment and Reappointment must contain a request for the specific clinical privileges desired by the applicant." The facility Medical Staff credentialing failed to follow Medical Staff bylaws.

Based on interview and record review the facility failed to staff or appoint a Chief Nursing Officer (CNO) to oversee operation of the nursing services.

This deficient practice resulted in the facility not complying with state and federal laws.

Findings:

During an interview on 1/7/2020 at 12:48 p.m., the Clinical Supervisor 1 stated that the facility was in the process of hiring a chief nursing officer or director of nursing.

During an interview on 1/8/2020 at 11:35 a.m., the Vice President of Human Resources 1 stated, the Clinical Supervisor 1 was interim CNO. However, she later stated "I have not been told, I don't know", when asked who the CNO was.

During an interview on 1/8/2020 at 2:36 p.m., the Clinical Supervisor 1, the prior CNO had vacated the position on 11/2019 and the facility did not have a Registered Nurse responsible for the operation of the nursing service. The Clinical Supervisor stated, "I am the clinical supervisor, I cover the staff, I do assignments, I am not the program manager".

A record review of Clinical Supervisor 1's employee file indicated she had just recently obtained the role of Clinical Supervisor on 10/2019.

A review of the facility's Job Description for 'Acute Psychiatric Program Director', indicated the purpose of the job role is to plan, organize, implement, direct and evaluate the direct nursing care provided to patients and supervision of day to day nursing activities. The Acute Psychiatric Program Director is responsible for knowing and following current federal, state and local standards and compliance with standards.

A review of the facility's policy titled Patient Acuity/Classification System/Staffing Plan Matrix dated 8/2019 indicated AGPU Program Director will not serve as a charge nurse or have direct patient care responsibility on a regular basis.

Based on interview and record review the facility failed to staff appropriately by not providing supervisory personnel (a registered nurse) for the nursing unit to organize and coordinate safe delivery of nursing care and services.

This deficient practice resulted in the facility not complying with their Job Description for the Acute Psychiatric Registered Nurse (Charge Nurse) and failing to comply with State and Federal regulatory guidelines.


Findings:

During a review of the Staffing Assignments dated 1/6/2020 through 1/9/2020 (day shift and night shift), inconsistencies were noted. The documentation was not legible and clear, some space indicated for charge nurse information were blank and other areas indicated for the charge nurse showed two nurses, with the nurses having assigned patients. The night shift staffing assignments did not have an assigned supervisor or charge nurse who was a Registered Nurse (RN) present on the unit to assume the administrative role and responsibility of performing the duties of the charge nurse or supervisor RN.

During an interview on 1/8/2020 at 2:36 p.m., the Clinical Supervisor 1, regarding day-shift charge nurse coverage, stated she covered the day-shift day to day activities; but the night shift did not have an assigned supervisor/charge nurse. The Clinical Supervisor 1 stated there were two nurses present at night but both nurses are assigned patients. The Clinical Supervisor 1 was asked in the event of an emergency and both nurses are needed to restrain/or respond to a patient in urgent need of medical attention, how would the facility monitor all other patients on the unit? The Clinical Supervisor 1 was unable to answer how facility would manage and assist the delivery of nursing care and services to the remaining patients on the unit when both nurses staffed are engaged in a crisis.

A record review of Clinical Supervisor 1 employee file indicated she obtained the role of Clinical Supervisor on 10/2019.

A review of the facility's 'Job Description for Acute Psychiatric Registered Nurse (Charge Nurse)', indicated the primary purpose of the charge nurse duty is to organize, supervise, coordinate, evaluate and assist in the delivery of nursing care and services by assuming administrative authority, assist by supervising staff to complete duty assignments, complete shift rounds, ensure medications, treatments and therapy services are administered as ordered; ensure accurate and timely documentation, receive report from prior charge nurse concerning all changes of condition, place calls to doctors and handle incoming calls from doctors, audit and monitor all intravenous patients, initiate treatments plan and care plan to assure plan reflect patient needs and goals.

Based observation, interview, and record review, the facility failed to ensure nursing care plans were developed and kept current based on individualized assessments and the specific needs of the patients, for six (6) of ten sampled patients (1, 4, 6, 7, 8, and 9)

This deficient practice had the potential for patients needs to not be met and potential complications to go unrecognized, for interventions not being evaluated for effectiveness in order to meet the patients' individualized goals for discharge

Findings:

A review of Patient 1's medical record indicated Patient 1 was admitted to the facility on 12/30/19. Patient 1's diagnosis included advanced dementia (a progressive loss of brain function affecting memory, thinking, and behavior). Patient 1 had become irritable, fell, then became agitated when the husband tried to help her. Patient 1 was taken to an outside emergency room, where she became combative, striking out at staff. Patient 1 was medically cleared and placed on a 5150 (72 hour) hold for grave disability and admitted to the facility.

A review of Patient 1's "Alteration In Medical Condition Treatment Plan, initiated on 1/2/2020, indicated Patient 1 had a problem with a urinary tract infection (UTI). The short term goals included for Patient 1 to remain infection free and to be compliant with medication administration of an antibiotic 100 percent (%) of the time. No interventions or person (s)responsible were documented in the treatment plan.

On 1/8/2020, at 4:02 PM, during a concurrent observation and interview, Patient 4 was observed in bed. Patient 4 had small healing wound with steristrips to the back of the head. The registered nurse (RN 1) stated that on 12/23/19 at approximately 3:45 PM, Patient 4 was seated in the day room, other patients and two certified nurse assistants (CNAs) were also present in the room. RN 1 stated Patient 4 was wearing a boot to the left foot due to a healing pressure ulcer. RN 1 stated Patient 4 got up from the chair, to throw something in the trash, and somehow his foot got stuck in his walker and he fell and hit his head. RN 1 stated that the physician was notified, Patient 4 was taken to the emergency department and returned to the facility. RN 1 stated that Patient 4 had a 3 cm (a metric unit of length equal to one hundredth of a meter) laceration to the back of the head, now with steristrips. RN 1 stated a care plan addressing risk for injury due to status post fall was initiated after the fall.

A review of Patient 4's medical record indicated Patient 4 was admitted to the facility on 7/7/19. Patient 4 was placed on a hold by the police after walking around the neighborhood with a gun, and was taken to an outside emergency room, then transferred and admitted to the facility. Patient 4's diagnoses included dementia (a progressive loss of brain function affecting memory, thinking, and behavior), hypertension (high blood pressure), and diabetes (high blood sugar).

A review of Patient 4's "AGPU Interdisciplinary Treatment Plan, initiated upon admission on 7/7/19, indicated that a plan of care addressing the risk for injury had not been developed since Patient 4's admission.

A review of Patient 4's fall risk assessments indicated that Patient 4 scored a 6 on the fall risk assessment from 12/1/19 to 12/22/19. The document indicated that a score over 5 indicated the patient was at high risk for falls.

A review of Patient 4's "Internal Medicine Progress Note," dated 12/23/19 at 4:56 PM, indicated Patient 4 was ambulating in his room and tripped likely over his own feet, fell, hit his head, and had a laceration the back of his head. Patient 4 would be sent over to the emergency room for evaluation and suture placement.

A review of Patient 4's "AGPU Interdisciplinary Treatment Plan Additional Problems Identified," indicated that a plan of care addressing risk for injury, status post fall, was initiated 12/23/19, after Patient 4's fall.

A review of face sheet, dated June 18, 2019, indicated Patient 6 was admitted to the facility on June 18, 2019.

A review of Patient 6's Care Plan: Co-Existing Medical Issues, dated June 18, 2019, indicated Patient 6 had a history which included a history of falls. Patient 6 did not have a care plan for falls until Patient 6 had a fall accident on July 9, 2019.

A review of Patient 6's care plan: "Pain", dated June 18, 2019, indicated interventions not individualized for pain, did not indicate Patient 6's perscribed pain medications, and did not indicate what interventions to perform prior to administration of medications for pain.

A review of Patient 6's care plan: "Risk for Injury Related to a Fall", dated July 9, 2019, had an intervention to implement fall risk strategies and precautions, but did not indicate what specific individualized strategies and precautions were to be implemented that were measurable.

A review of face sheet, dated December 3, 2018, indicated Patient 7 was admitted to the facility on December 3, 2018.

A review of Patient 7's care plan: "Co-Existing Medical Issues", dated December 3, 2019 to October 7, 2019, indicated interventions that were not individualized and measurable for Patient 7.

A review of Patient 7's care plan: "Impaired Cognitive Functioning, Ineffective Coping, and Altered Thought Processes", dated October 18, 2019, did not indicate individualized interventions which included specific medications ordered for Patient 7, and interventions that were measurable.

A review of Patient 8's face sheet, dated December 3, 2019, indicated Patient 8 was admitted to the facility on December 3, 2019.

A review of Patient 8's care plan: "Impaired Cognitive Functioning", dated December 3, 2019, indicated interventions that were not individualized for Patient 8. One intervention, to 'administer appropriate medication and to document response' did not indicate the medication ordered for Patient 8 and did not indicate what patient responses to document.

A review of Patient 8's care plan: "Infection", dated December 3, 2019, did not indicate individualized and measurable interventions for Patient 8's urinary tract infection (bladder infection), and did not specify what antibiotic therapy was ordered to be administered to the patient and for how long.

A review of Patient 8's care plan: "Harm", dated December 11, 2019, did not indicate any interventions for Patient 8.

A review of Patient 9's face sheet, dated January 6, 2020, indicated Patient 9 was admitted to the facility on January 6, 2020.

A review of Patient 9's Admission Assessment, dated January 6, 2020, indicated Patient 9 had a Foley catheter (indwelling urinary catheter - a thin sterile tube inserted into the bladder to drain urine) in place.

A review of Patient 9's care plans, dated January 6 to 9, 2020, indicated interventions were not individualized for Patient 9, who had an indwelling urinary catheter on admission, and there was no documentation in the care plans that Patient 9 had an indwelling urinary catheter.

The facility's policy and procedure titled, "Treatment Planning Process, Interdisciplinary Team (IDT), dated 7/2019, indicated if at any time during the patient's hospitalization, a problem is identified that needs to be added to the treatment plan, the appropriate numbered treatment plan is opened with the date initiated and the initials of the person making the entry. If at any time, changes (additions, deletions, etc) to the original treatment plan need to be made, indicate the date and initials next to the item to be altered.

The facility's policy and procedure titled, "Nursing Responsibilities/Standards of Care," dated 7/2019, indicated planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation, and as circumstances require, patient advocacy. Nursing shall assure that the environment is free of hazards and implement measures to prevent patient falls and other injuries.

A review of Care Planning policy, Treatment Planning Process, dated July 2019, indicated all patient will have a preliminary treatment plan completed by the Registered Nurse (RN) within 24 hours of admission for shorter term treatment and long-range treatment goals. Treatment goals are related to the problems identified and written as observable and measurable behaviors or interventions. The appropriate treatment plan is dated and initialed by the person initiating the plan. And if there are any changes to the original treatment plan, the date and initials of the person updating the plan will be documented.

A review of Suicide Risk Assessment and Ligature Risk policy, dated October 2019, indicated the treatment plan (care plan) is activated to address the patient's suicidality and reflects goals and interventions, including those interventions ordered by the psychiatrist or the treatment team.




38310

Based on interview and record review, the nursing staff failed to administer a medication as ordered by the physician for one (1) of ten sampled patients (Patient 1).

This deficient practice had the potential for adverse side effects.

Findings:

On 1/8/2020, at 2:02 PM, during a concurrent interview and review of Patient 1's medical record, the registered nurse (RN 1) stated that the blood pressure should have been taken and documented prior to administering Ativan (lorazepam, a sedative).

A review of Patient 1's medical record indicated Patient 1 was admitted to the facility on 12/30/19. Patient 1's diagnoses included advanced dementia (a progressive loss of brain function affecting memory, thinking, and behavior). Patient 1 had become irritable, fell, then became agitated when the husband tried to help her. Patient 1 was taken to an outside emergency room, where she became combative, striking out at staff. Patient 1 was medically cleared and placed on a 5150 (72 - hour) hold for grave disability and admitted to the facility.

A review of Patient 1's physician's order, dated 12/31/19 at 12:50 PM, indicated to give Ativan 2 milligrams (mg, a unit of weigh equal to one thousandth of a gram)/milliliter (ml, a unit of length equal to one thousandth of a meter), 0.5 ml by mouth twice a day, as needed for agitation, if the blood pressure is above 100/60.

A review of Patient 1's "Medication Record," indicated that Patient 1 received Ativan 1 mg by mouth on 1/4/2020 and 1/5/2020 at 6:45 AM. There was no documentation in the medication record of Patient 1's blood pressure, prior to the administration of the medication.

Based on interview and record review, the hospital failed to ensure the after-hours access to the night locker for medication was documented completely. Also, there was a lack of documentation that when the nurses accessed the night locker, they had called the on-call pharmacist for removal of medications. There was no documentation that the access log had been reconciled or reviewed by a pharmacist in a timely manner.

These deficient practices had the potentials for medication errors and/or drug pilferage.

Findings:

On 1/7/2020 at approxmately 11:55 AM, during an interview, the director of pharmacy (DOP) stated the hospital pharmacy hours were typically 9 AM to 5 PM, with an on-call pharmacist that covered after-hours pharmaceutical service needs. The DOP indicated there was a night locker (a secured storage of limited supply medications for orders received after the pharmacy hours).

On 1/7/2020 at approxmately 4:15 PM, during an inspection of the medication room located in the nursing station, with the DOP and a registered nurse (RN 3), the night locker was housed inside a locked cabinet. During a concurrent interview, RN 3 stated that after pharmacy hours, if a patient had medication needs not already in the cassette (an exchangeable cassette in a medication cart that usually prefilled by the pharmacist with 24 hours supply of medications in unit dose), or new medication orders, they would check if that particular medication (med) was available in the night locker. If the med was available, then they (nurses) would retrieve the med and document on the night locker access log. If the med was not available in the night locker, then nurses would call the on-call pharmacist. During a concurrent interview, the DOP stated the pharmacy department will review the after-hours new orders that had been sent to the pharmacy, retrospectively, when the pharmacy opened.

A review of the first three (3) pages of the Night Locker Access Log indicated there were 30 entries dated from 12/16/2019 through 1/5/2020. Under the title of the log, there were instructions printed indicating that, "Must Have 2 RN's Sign" the log. However, two (2) of 29 entries did not have the second RN's signature. Under the column "Date/Time", eight (8) of 29 entries did not record the time the Night Locker was accessed.

On 1/8/2020 at 10:15 AM, during an interview, the DOP indicated the nurses that accessed the night locker did not input the time of access on 12/26/2019, 12/27/2019, 1/3/2020, 1/4/2020, and 1/5/2020. The time of access could be used to verify the appropriateness and frequency of administration of the medication. The DOP also stated a designated pharmacy technician would review the log.

A concurrent review of the 3 pages of logs dated from 12/16/2019 to 1/5/2020, under the column, "RX/DATE/TIME Pharmacy Use Only", four (4) out of 29 total entries, were dated 12/18/2019, with a signature in the "RX/DATE/TIME" column. The DOP indicated that column would document the date the technician reviewed the log. A further review indicated there were 17 of 29 entries dated and signed on 12/31/2019 by the technician, and the remaining eight (8) of 29 entries did not have a review date nor signature.

On 1/8/2020 at 11:40 AM, during an interview and a concurrent review of night locker access log and medication record with the registered nurse (RN1), RN 1 confirmed that there were at least two (2) removal entries in which the doses removed were larger than the order. During a concurrent interview, the DOP and RN 1 stated nurses did not record the wastages of the excess removed; larger doses were removed due to the limited availability of the medications in the night locker.

A review of the hospital's policy and procedure, "After Hours Access to Medications", reviewed in 8/2019, indicated "Back-up Pharmacy service will be available from 5:30 P - 8:30 A, during the week days and on weekends 24/7. All phone calls and fax orders will be forwarded to the On-call Pharmacist ... After Pharmacy Services is closed, the on-call pharmacist shall be called for any and all new orders and any refills needed ... Two nurses must sign the Night Locker Log for retrieval of medications ... The Pharmacist will review all after-hours orders when Pharmacy Services reopens."

Based on observation, interviews and record reviews, the hospital failed to ensure staff were competent in safe and effective food handling practices. Two cooks and one assistant cook were not competent in safe cooling of cooked Time and Temperature Control for Safety (TCS) foods. TCS foods are foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely.

These failures in competency had the potential to result in unsafe food handling practices and suboptimal food quality practices that affected the food served to patients, staff and visitors in the hospital (A - 749)

Findings:

During a tour of the kitchen on January 6, 2020 at 12:27 PM, a large plastic container of tuna salad with preparation date of 1/6/2020 and a medium container of egg salad with preparation date of 1/6/2020 were stored in the reach in refrigerator. The temperature of the tuna salad taken with facility thermometer registered at 55 degrees Fahrenheit (F), and the temperature of the egg salad taken with facility thermometer registered at 47 degrees (F).

During an interview with assistant cook (AC) on January 6, 2020 at 12:40 PM, the AC stated that she had prepared the tuna salad at 9:30 AM and the egg salad at 9:00 AM. The AC stated that she hardboiled eggs mashed them and mixed the eggs with mayonnaise and seasonings. The AC stated she drained the can of tuna she got from the dry storage area then mixed it with the mayonnaise and seasonings and placed both salads in the refrigerator. The AC did not monitor the temperatures of the salad. The AC was not able to verbalize the ambient cool down process or methods for proper cool down, the AC was not able to verbalize the time period when the salads should reach safe temperatures. The AC also stated that she does not monitor cool down for protein salads such as egg, tuna or chicken that she makes. The AC stated that she doesn't use the log to record temperatures of salads that she cooks and prepares. The AC agreed that she should have stored the salads in shallow containers to facilitate cool down.

During a follow up visit to the kitchen on January 6, 2020 at 1:45 PM, the temperature of the tuna salad and the eggs salad inside the refrigerator was checked. The temperature of the tuna salad using the facility thermometer register at 50.8 degrees (F) and the temperature of the eggs salad was at 44.7 degrees (F).

According to the 2017 U.S. Food and Drug Administration Food Code, Time and Temperature control for safety food shall be cooled within 4 hours to 41 degrees Fahrenheit or less if prepared from ingredients at ambient temperature, Such as reconstituted foods and canned tuna.

During an observation in the kitchen on January 6, 2020 at 1:00 PM, there were two large pots of chicken broth stored in the walk-in refrigerator. The pots were filled to the top with chicken broth with hardened fat from the chicken on top of the broth. The temperature of the chicken broth in the first pot checked was 48 degrees Fahrenheit (F) and in the second pot was 49 degrees (F).

During an interview with cook 1 on 1/6/2020 at 1:05 PM, Cook 1 stated he had made the chicken soup the day before.

During a concurrent interview with Cook 2, Cook 2 stated the chicken broth had finished cooking around 7:30 AM on 1/5/2020. Cook 1 stated he boiled chicken with bones and seasonings to make the broth. Cook 1 stated he separated the cooked chicken from the bones and stored it in the walk in refrigerator to add it to the soup. The broth was cooked in the large kettle then transferred to the large deep pots and placed in the walk in refrigerator. The chicken broth will be served for lunch on 1/7/2020. Cook 1 and cook 2 did not check the temperature of the broth before storing it in the refrigerator and did not monitor the broth for cool down. Cook 1 stated that he did not check the temperature of the chicken broth today either. Both Cook 1 and Cook 2 did not know the cool down process. Cook 1 and Cook 2 did not use the cool down log to monitor the soup while cooling. Cook 1 and Cook 2 were not able to provide examples and methods to allow food to cool down fast and in this case hot soup to cool down within 6 hours to 41 degrees Fahrenheit or less. Cook 1 stated, "we don't monitor temperature of broth only large roast beef or turkey". Cook 1 stated the soup is for tomorrow and it should be at the right temperature. Cook 1 later stated temperatures for food in the refrigerator should be 41 degrees (F) or below. Cook 1 and Cook 2 agreed that one way to facilitate the cool down of the chicken broth was to store it in shallow pans instead of deep pots that were used.

The cooling logs for these foods was requested. A review of the log did not include the chicken broth and the log was incomplete for many days and not accurate for some items listed.

During a concurrent interview with the Food Service Director (FSD), the FSD stated the cool down log had not been utilized accurately and she will in-service all staff and kitchen supervisors to monitor logs and cool down process. The FSD also stated the chicken broth in the pots was not cooled down safely and will be discarded.

A review of the job description for the cook indicated, "The primary purpose of the job is to assist in preparation of food in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policy and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times." It also indicated a competency requirement that the cook "must maintain the care and use of supplies, equipment, the appearance of work areas, and perform regular inspections of food service areas for sanitation, order, safety and proper performance of assigned duties."

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, cooked Time and Temperature Control for Safety (TCS) foods shall be cooled within two hours from 135 °F (degrees Fahrenheit) to 70 °F, and within a total of six hours from 135 °F to 41 °F. It further states that if TSC foods are not cooled according to this code, harmful bacteria may grow to sufficient numbers to cause food borne illness. The initial two-hour cool is a critical element of this cooling process.

In addition, according to the 2017 USDA Food Code, Time/temperature control for safety food includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consists of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes ...

Based on observation, interview and document review, the hospital failed to maintain a ligature resistant physical environment in the AGPU, an Inpatient Geriatric Psychiatric Unit (GPU).

The deficiency had the potential for ligature risk points that could be used to create a sustainable attachment point where a bed sheet or other material could be looped or tied to fashion a point of attachment that may lead to self-harm.

Findings:

During the Hospital Validation survey tour of the GPU on 1/7/20 at 9:40 a.m., the evaluator observed that there were potential ligature risk points throughout the GPU's patient rooms and common areas that included the following:

1. There was a T bar drop down ceiling system in the patient rooms.
2. There were ceiling mounted air vents / grilles that were not ligature-resistant in the patient rooms
3. There were window curtains in the patient rooms.
4. There were shower mixing valves that were not ligature-resistant in the patient room bathrooms.
5. There were wall mounted shower chairs that were not ligature-resistant in the patient room bathrooms.
6. There were sink faucet spouts that were not ligature-resistant in the patient room bathrooms.
7. There were paper towel dispensers that were not ligature-resistant in the patient room bathrooms.
8. There were soap dispensers that were not ligature-resistant in the patient room bathrooms.
9. There were door handles that were not ligature-resistant in the patient room.
There were door hinges that were not ligature-resistant in the patient room.
10. There was an unsecured television in the activity room.
11. There were cabinet handles and hinges that were not ligature-resistant in the activity room.
12. There were two wall mounted drinking water fountains that were not ligature-resistant in the common area between the activity room and the nurses station.
13. There was a wall mounted fire extinguisher cabinet with a door handle that was not ligature-resistant in the common area corridor.

During an interview on 1/7/20 at 12:40 a.m., the Director of Quality stated that the hospital was aware of the ligature risk points in the GPU, and that the hospital had hired a hospital safety contractor to assess the GPU for ligature risk and suicide prevention.

During document review on 1/8/20, review of the Ligature Risk and Suicide Assessment dated 8/29/18 indicated that a ligature risk and suicide assessment was conducted of the GPU. The assessment report had findings with recommendations.

The potential ligature risk points observed during the tour of the GPU on 1/7/20 at 9:40 a.m., were also some of the findings listed in the Ligature Risk and Suicide Assessment dated 8/29/18.

A review of the Professional Services Proposal dated 2/6/19, from an architectural and engineering service, included a scope of work for upgrading the GPU for anti-ligature / suicide risk based on the findings defined in the Ligature Risk and Suicide Assessment dated 8/29/18. The scope of service provided would address the items in the assessment that require Office of Statewide Health Planning and Development (OSHPD) approval and contractor installation. The proposal was signed as accepted on 3/12/19.

Review of an OSHPD Project Assessment data document dated 12/30/19, indicated that the project had been filed with OSHPD on 7/29/19.

On 1/8/20 at 10:00 a.m., during a second tour of the GPU, the evaluator observed that some of the findings detailed in the Ligature Risk and Suicide Assessment dated 8/29/18, had been resolved. Easily moved bedroom furniture in the patient rooms was replaced with ligature-resistant weighted furniture, the removal of cubicle curtains, and the removal of wall mounted picture frames.

Based on observation, interview, and record review, the facility failed to ensure medical equipment was inspected and maintained, in accordance with the facility's policy and procedures.

This deficient practice had the potential for malfunctioning equipment to be used on patients.

Findings:

During the initial tour of the facility, on 1/6/2020 at 9:32 AM, a vital signs (VS) machine, and two manual blood pressure machines were observed in the supply room. The VS machine had a preventative maintenance sticker indicating that machine was due for inspection on 10/27/2019. Two manual blood pressure machines had preventative maintenance stickers indicating that the machines were due for inspection on 10/12/2019

Concurrently, the registered nurse (RN 1) stated the machines were overdue for inspection.

During an interview, the Director of Purchasing, stated preventative maintenance was performed on medical equipment annually.

The facility's policy and procedure titled, "Medical Equipment," dated 7/2019, indicated each piece of equipment will be complete inspected for general appearance, condition, cleanliness, proper function, and safety. Once Central Supply has inspected equipment it will be tagged with a Medical Equipment Inspection Tag and the inspection date will be written on the tag. All medical equipment will be inspected annually for overall safety. A new inspection tag will be placed on the piece of equipment each year.

36206





38310


Based on observation, interview and record review, the facility failed to ensure their infection prevention and control program adequately monitored their practices in preventing and controlling the transmission of infections with (1) corrugated boxes in the facility, (2) soiled curtains in rooms designated to admit new patients, (3) incomplete physician health files, and (4) the hospital failed to develop a system to identify, report, investigate and control unsafe food sanitation practices in the Food and Nutrition Service Department and one nursing station nourishment refrigerator including the following deficient practices:

a. The cooling of previously cooked foods and previously prepared salads that were time and temperature Controlled for safety (TCS) foods were not monitored to ensure these foods were safe for consumption. TCS foods are foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely. Additionally, methods for safe cooling including final cooking temperature and cooling logs were not being utilized to monitor and document safe cooling of TCS foods to ensure those foods were safe for consumption by the patients, staff and visitors.

b. A refrigerator in one nursing station nourishment room did not maintain safe food storage temperatures for TCS foods stored in the refrigerator.

c. Expired milk was stored in the patient refrigerator in nursing station nourishment room. One large tray of pureed food exceeding storage period was stored in the reach in refrigerator in the kitchen.

d. Three Dietary staff did not practice personal hygiene when they did not wear facial hair restraints (beard covers) in the kitchen. Hair can be a source of food contamination.

e. The can opener blade was worn and nicked with the potential to harbor harmful bacteria that were not easily cleanable.

f. The hospitals infection control committee did not identify, report, investigate or control these deficient practices in the food and nutrition services, nursing unit nourishment room. unsanitary practices in the kitchen.

These deficient practices had the potential to spread infections to vulnerable patients.

Findings:

1. a. On January 6, 2020 at 9:51 a.m., during initial tour of the facility with the Director of Purchasing (DOP), there were multiple carts covered in blue cart covers with medical supplies stored in corrugated cardboard boxes, boxes on the floor, and corrugated boxes with shipping labels outside the boxes. Concurrently, the DOP stated he was not aware that medical supplies should not be stored in corrugated boxes.

1. b. On 1/8/2020 around 10:30 AM during a tour of the pharmacy in the presence of the director of pharmacy (DOP) and the infection preventionist (IP), the pharmacy had an open floor plan with shelving units and desks against the walls, and filling stations in the middle of the room. There was also a segregated compounding area by way of a demarcation line on the floor with a germ free compounding hood located at the far end of the pharmacy. On a couple of the shelving units, there were numerous corrugated boxes containing intravenous fluids.

During a concurrent interview, the IP stated corrugated boxes should not be used for storage in the pharmacy. IP further indicated the contents of the boxes should be unloaded upon received and remove the boxes from the pharmacy area.

A review of Infection Control Policy for Central Supply Area, dated July 2019, indicated the central supply shall be maintained in a clean manner and no boxes shall be kept on the floor.

2. On 1/7/2020 at 10:30 AM, a red colored stain was observed on a curtain in room 10. There were no patients in the room.

Concurrently, the registered nurse (RN 3) stated the room was empty and was ready to admit a patient. RN 3 observed the stained curtain and stated it looked like something had splashed on it and needed to be changed. RN 3 stated that curtains do not get changed in between patients, only if something happens to the curtain.

3. During a review of Medical Staff Credential Files with Medical Staff Director(MSD) and the Chief Medical Officer(CMO), ten of 10 medical doctors randomly reviewed did not have documentation of Hepatitis B immunization status, or waiver of not receiving Hepatitis B vaccines. During a concurrent interview with the MSD and CMO on 1/7/2020 at 12:30 PM, the MSD indicated the facility did not have a policy for Hep B immunization status or declination for Medical Staff.

During an interview with the Director of Infection Control on 1/9/20 at 1:45 PM, teh Director of Infection Control stated the Facility followed CDC guidelines for infection control. The Governing Body failed to Assure Medical Staff had Hepatitis B Status or Declination on file. The Governing body failed to assure Medical care was provided in a Sanitary environment.

4 a. During a tour of the kitchen on January 6, 2020 at 12:27 PM, a large size deep plastic container of tuna salad with preparation date of 1/6/2020, and a medium size deep container of egg salad with preparation date of 1/6/2020, were stored in the reach in refrigerator. The temperature of the tuna salad, taken with facility thermometer, registered at 55 degrees Fahrenheit (F), and the temperature of the egg salad, taken with facility thermometer, registered at 47 degrees F.

During a concurrent observation and interview with the Food Service Director (FSD), the FSD stated the tuna and egg salad were made this morning. The FSD also stated that cool down is only monitored for large meat items such as roast beef and turkey roast.

During an interview with Assistant Cook (AC) on January 6, 2020 at 12:40 PM, the AC stated that she had prepared the tuna salad at 9:30 AM and the egg salad at 9:00 AM. The AC stated that she hardboiled eggs mashed them and mixed with mayonnaise and seasonings. The AC also stated she drained the can of tuna she got from the dry storage area then mixed it with the mayonnaise and seasonings and placed both salads in the refrigerator. The AC did not monitor the temperatures of the salad. The AC was not able to verbalize ambient cool down process or methods for proper cool down. The AC further stated that she does not monitor cool down for protein salads such as egg, tuna or chicken that she makes.

During a follow up visit to the kitchen on January 6, 2020 at 1:45 PM, the temperature of the tuna salad and the eggs salad inside the refrigerator was checked. The temperature of the tuna salad using the facility thermometer register at 50.8 degrees F and the temperature of the eggs salad was at 44.7 degrees F.

During a concurrent observation and interview with the FSD, the FSD stated that food should be held at 41 degrees F or lower and these salads will be discarded. The FSD stated that she will in-service staff to monitor temperatures of the protein salads.

During an observation in the kitchen on January 6, 2020 at 1:00 PM, there were two very large and deep pots of chicken broth stored in the walk-in refrigerator. The pots were filled to the top with chicken broth with hardened fat from the chicken on top of the broth. The temperature of the chicken broth in the first pot checked was 48 degrees F and in the second pot was 49 degrees F.

During an interview with cook 1 on 1/6/2020 at 1:05 PM, Cook 1 stated he had made the chicken soup the day before.

During a concurrent interview with Cook 2 he stated the chicken broth had finished cooking around 7:30 AM on 1/5/2020. Cook 1 stated he boiled chicken with bones and seasonings to make the broth. Cook 1 stated he separated the cooked chicken from the bones and stored it in the walk in refrigerator to add it to the soup. The broth was cooked in the large kettle then transferred to the large deep pots and placed in the walk in refrigerator. The chicken broth will be served for lunch on 1/7/2020. Cook 1 and Cook 2 did not check the temperature of the broth before storing it in the refrigerator and did not monitor the broth for cool down. Cook 1 stated that he did not check the temperature of the chicken broth today either. Cook 1 stated temperature for food in the refrigerator should be 41 degrees F or below.

A review of the cooling log did not include the chicken broth and the log was incomplete for many days and not accurate for some items listed.

During a concurrent interview, the FSD stated they are not utilizing the cool down logs per policy and staff do not know how to use it. The FSD stated she will provide in-service on monitoring temperatures for safe cooling of food. The FSD stated that they were not monitoring soups for cool down and they were only monitoring large meat roasts. The FSD also stated that the broth will be discarded.

A review of the hospital policy titled, "Cooling Process", policy No 7-8 (revised 7/2019) indicated, "Foods that need time and temperature control for safety should be cooled from 140 F to 41 F or lower within six hours. Complete cooling log using the following guidelines: First cool food from 140 F to 70 F within two (2) hours, then cool it from 70 F to 41 F or lower in the next four hours. If the food hasn't reached 70 F within two hours, it must be reheated and then cooled again. IF you can cool the food from 140 F to 70 F in less than two hours, you can use the remaining time to cool it to 41 F or lower. However, the total cooling time cannot be longer than six hours."

A review of the hospital policy titled, "Specific Food Handling Practices", Policy No.7-2 (revised 7/19) indicated, "Protein salads and sandwiches: chill all ingredients thoroughly before mixing. This will aid in slowing bacterial growth. Upon mixing, store in 4 inch or less depth container, cover, date and refrigerate until service.

A review of the hospital log titled, "Final Cooking Temperature and Cooling Log", indicated, "cooling Procedures: Food is cooled quickly and safely from 140 F to 70 F within 2 hours and then to 40 F or below in additional 4 hours (total cooling time is 6 hours), always separate food into small quantities and place them into shallow pans, the food should be no deeper than 4 inches, food that is cooked, cooled and reheated for hot holding is reheated rapidly within 2 hours to 165 F."

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated, cooked Time and Temperature Control for Safety (TCS) foods shall be cooled within two hours from 135 °F (degrees Fahrenheit) to 70 °F, and within a total of six hours from 135 °F to 41 °F. It further states that if TSC foods are not cooled according to this code, harmful bacteria may grow to sufficient numbers to cause food borne illness. The initial two-hour cool is a critical element of this cooling process. In addition, time and temperature control for safety food shall be cooled within 4 hours to 41 degrees Fahrenheit or less if prepared from ingredients at ambient temperature, Such as reconstituted foods and canned tuna.

4 b. During an observation of the nourishment room in the psychiatric unit on January 7, 2020, at 10:27 AM, the temperature of the patient refrigerator was 43 degrees F (Fahrenheit). Inside the refrigerator were juices, milk and fruits for patients. A temperature check of the milk carton indicated it was 42.6 degrees F.

During a concurrent interview with Food Service Director (FSD) and Kitchen Supervisor (KS), they stated the dietary staff do not check the temperature for the nourishment refrigerator. FSD further stated the nursing staff checks the temperatures.

A review of the hospital policy titled "storing refrigerated/Frozen Foods" Policy No.6-3 (revised7/2019), indicated that Refrigerated and frozen foods will be stored in a safe and sanitary manner, every refrigerator and freezer will be equipped with an inside, accurate thermometer, which will be used to read the temperature of each unit and the refrigerators will be maintained at 41 degrees F or below.

A review of the hospital policy titled "Nursing Responsibilities/standards of care" (revised 9/2016), indicated nursing staff shall be responsible for monitoring the temperatures of medication refrigerators on the nursing units. Patient food refrigerators are monitored daily by Dietary.

A review of the 2017 U.S. Food and Drug Administration Food Code, Time/Temperature control for safety food shall be maintained 135 degrees F or above or at 41 degrees F or less.

4 c. During an observation of the reach in refrigerator on January 6, 2020, at 12:40 PM, there was a large container of pureed food with a preparation date of 1/3/2020.

During a concurrent interview, the FSD did not know what the pureed food was, the FSD stated there is no name on the pureed food. During the same observation and interview Cook 1 was not sure if the item was bread or another pureed food. Cook 1 stated its probably left over pureed bread. The FSD stated hospital policy is to use food within 72 hours and this pureed food has been prepared for longer than 72 hours. The FSD further stated the pureed food will be discarded.

During an observation of the nourishment room in the psychiatric unit on January 7, 2020, at 10:27 AM, there were three expired milk cartons and three bowl of prunes stored in the patient refrigerator.

During a concurrent observation and interview, the FSD and Kitchen Staff (KS) stated the dietary staff is responsible to stock the patient nourishment refrigerator. The KS stated the dietary staff come around 10:30 AM and will remove expired items. The FSD discarded the expired milk and fruits from the patient refrigerators.

A review of the hospital policy titled "Storing refrigerated/Frozen foods" Policy No.6-3 (revised 7/2019) indicated to store dairy products away from foods with strong odors and maintain internal temperature of dairy products at or below 40 degrees Fahrenheit. It also indicated, leftovers will be stored in the refrigerator and will be tightly covered, labeled and dated using label or marker. Leftovers will be used within 72 hours or discarded.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded.

According to FDA Food Code, a date marking that meet criteria include: marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.

4 d. During an observation in the kitchen on January 6, 2020, at 12:50 PM Cook 2 was not wearing a facial hair cover. Cook 2 was observed in the meat production area preparing food. Cook 2 had a thick mustache and was not wearing a cover.

During an observation in the kitchen on January 6, 2020, at 1:13 PM, Dietary Aid 1(DA 1) walked through the kitchen during food production to deliver carts and dirty trays. DA 1 had full facial hair and was not wearing a facial hair restraint.

During a concurrent interview with DA 1, DA 1 stated he forgot to wear facial hair cover and that he should.

During an observation in the kitchen on January 6, 2020, at 1:30 PM, DA 2 was observed delivering products and organizing the kitchen supplies. DA 2 had long facial hair and was not wearing facial hair covers.

During an interview with DA 2, DA 2 stated if facial hair is neatly trimmed then facial hair covers are not needed. DA 2 stated his beard was neatly trimmed.

During a concurrent observation and interview with the Food Service Director (FSD), the FDS stated hospital policy is to wear facial hair cover only for long facial hair. The FSD verified that Cook 2, DA 1 and DA 2's facial hair was long and not neatly trimmed and required facial hair covers.

A review of hospital policy titled "hair restraints/Jewelry/nail Polish" Policy No. 5-3 (revised 7/2019), indicated, beards and mustaches, which are not closely cropped and neatly trimmed shall be covered."

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restrain keeps dislodged hair from ending up in the food and may deter employees from touching their hair. Employees shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens and unwrapped single service and single use articles.

4 e. During a tour of the kitchen on January 6, 2020, at 1:13 PM, the can opener blade near the meat production area was nicked and had dents. The blade was not smooth to touch due to the nicks on the surface of the blade.

During a concurrent interview with the FSD, the FSD verified that the blade was not smooth and stated she will change the blade right away.

A review of the 2017 U.S. Food and Drug Administration Food Code, cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. It also states food-contact surfaces of equipment shall be smooth, free of breaks, open seams, cracks chips, inclusions, pits, and similar imperfections. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms (a thin, slimy film of bacteria that adheres to a surface). Once established, these biofilms can release pathogens (disease causing organisms) to food. Biofilms are highly resistant to cleaning and sanitizing efforts.

4 f. During an interview with the hospitals Infection Preventionist (IP) on January 7, 2020, at 4:00 PM, the IP stated that once a month the infection prevention department conducts audits in the kitchen. The IP stated she looks at general cleanliness of the kitchen, the dish machine operation and cleanliness of the dishes and utensils. The IP stated she does not look at the temperature of the refrigerators or food temperatures. The infection prevention department had not identified the above deficient practices in the kitchen and nursing nourishment room. The IP stated that although surveillance and audit was conducted related to safe food handling, these deficient practices were not identified.

A review of the hospital's last kitchen audit checklist titled 'JEKMC Kitchen Manager Rounds', dated 11/1/2019, indicated cool down of foods was not an item investigated during audits. Auditing stored food and food storage temperatures were not items investigated by Infection preventionists. Another item on the list to investigate was staff personal hygiene including hair restraints. This was not identified as an issue even though the dietary staff had not been consistent with wearing facial hair restraints.


38740

Based on interview and record review the facility failed to initiate a designated requestor and maintain a current contract for organ or tissue donation.

This deficient practice resulted in the facility not complying with their policy, state and federal laws.

Findings:

On 1/8/2020 during a record review of the contractual services listed between this facility and OneLegacy (a transplant donor network), the last addendum to the contract was written in 2/11/2011. The contract had not been updated.

During an interview on 1/9/2020 at 11:52 a.m.,the Contract Supervisor 1 stated, "I just deal with contracts, I don't coordinate with family". The Facility was unable to provide name of a designated requestor.

A review of the facility's policy titled 'Organ/Tissue/Eye Donation' indicated the AGPU Program Director is designated as the donation liaison to OneLegacy.The Facility did not have a Program Director or interim representative for organ procurement as needed.

Based on interview and record review three (3) of 10 employees (Employee 2, 6 and 9) did not have a current and complete Evaluation of Performance and/or Satisfactory Performance Evaluation present in their files. The Intravenous competency was not offered to staff. One out of 10 employees (Employee 9) whose credential file was reviewed did not have a record of status for Hepatitis B screening present.

This deficient practice resulted in facility not following their policy and had the potential to result in employee decline competency which could result in negative patient outcome issues.

Findings:

On 1/8/2020 during the Personnel File Review, Employees 2, 6 and 7 files did not contain documentation that training, and demonstration of competencies were successfully completed in their employee files. During the review some components of the unit specific annual competencies were missing, incomplete, and topics were written in acronyms (subject not clear) and not standardized for all staff according to facility policy and regulatory guidelines. In addition, there were no intravenous competencies provided to nurses in 2019; and documentation of competencies done were written and maintained in employee file in pencil.

During an interview on 1/8/2020 the Vice President of Human Resources 1 confirmed the incomplete and missing employee evaluations. Furthermore, the Vice President of Human Resources 1 stated the competencies were lacking, pencils should not be used and that no intravenous training/competency was implemented for the year 2019 to any staff. The Vice President of Human Resources 1 stated, "it was not done we are working on it".

A record review of the facility's policy titled "Orientation/Competency Plan for Staff", dated 7/2019, indicated professional development is ongoing and formally evaluated annually. Competency promotes consistency and standardization in professional practice, validation of competency is unit specific and documentation of competencies shall be maintained in the employee files.

A record review of the facility's policy titled "Documentation Principles", dated 7/2019, indicated records shall be permanent or legibly written in ink. All required records shall be maintained in legible form and readily available upon request of person authorized by law to make such request. According to this policy, permanent ink (black preferred) shall be used in recording any entry. Pencils are not to be used.

A record review of the facility's policy dated 7/2019 and titled "Performance Evaluations" indicated supervisors are to complete evaluations annually. Supervisors evaluate employees and prepare written evaluation of each employee's job performance based on their job description. In addition, employees and supervisor should sign and date evaluation and place in employee files.

On 1/8/2020 during the Personnel File Review, there was no evidence of Employee 9's status related to Hepatitis B vaccination series, titer level (to test for antibody). There was no statement of declination present in Employee 9's employee file.

During an interview on 1/8/2020 at 11:03 AM, the Vice President of Human Resources 1 stated all employees who decline the hepatitis B immunization series are required to sign a declination statement. The Vice President of Human Resources 1 stated she needed additional time to search and validate Employee 9's Hepatitis B status.

During an interview on 1/9/2020 at 12:10 PM, the Vice President of Human Resources 1 stated the facility did not have a record of whether Employee 9 received the Hepatitis B vaccination or not. The Vice President of Human Resources 1 stated "we don't have a hep B declination form for Employee 9".

Based on record review, document review, observation and interview, the facility failed to ensure that:

l. Active treatment measures, such as group and/or individual treatment, were provided for two (2) of five (5) sample patient (A2 and A4). Specifically, Patients A2 and A4 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on medical records review, policy review, and interview the facility failed to provide Master Treatment Plans (MTPs), referred to by the facility as "Interdisciplinary Treatment Plans," that identified patient-related, short-term (STG) and long-term goals (LTG) stated in observable, measurable, behavioral terms and/or STGs related to the patients' problems for five of five active sampled patients (A1, A2, A3, A4, and A5). This failure results in a document that does not identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure individual progress in care. In addition, this failure may prevent the team from modifying plans in response to patient needs and could extend the length of hospitalization.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 07/07/19. The MTP, dated 07/08/19, listed for the problem, "Impaired Cognitive Functioning with Behavioral Changes as manifested by Memory Failure, Paranoid thinking," the unrelated, non-measurable short-term goal (STG), "Patient will be able to offer assistance to other pts [patients] when interacting in table activities."

2. Patient A2 was admitted on 12/30/19. The MTP, dated 01/02/2020, listed for the problem, "Impaired Cognitive Functioning with Behavioral Changes," the non-measurable STG, "Decrease in hallucinations as evidenced by: able to accept reality orientation."

3. Patient A3 was admitted on 12/03/18. The MTP, updated 12/06/19, listed for the Problem, "Impaired Cognitive Functioning with Behavioral Changes as manifested by Memory Failure, Paranoid thinking, and Anxiety," the unrelated, non-measurable (STGs), "Patient will be able to discuss finances without getting angry/irritable," and "Decrease in paranoia other Delusions as evidence by Pt [Patient] able to listen to staff reality orientation and support at least 2x/day x5 mins [minutes]."

This patient's Long Term Goal (LTG), beginning 12/13/18, was "Conservatorship/Placement," and according to MD1, during interview on 01/07/2020 at 2:00 p.m., this LTG remains current.

4. Patient A4 was admitted on 12/03/19. The MTP, dated 12/05/19, listed for the Problem, "Impaired Cognitive Functioning with behavioral changes the non- measurable STGs, "Decrease in Paranoia or other Delusions as evidenced by med compliance and cooperation c [with] care," and "follow verbal cues 80% of the time."

5. Patient A5 was admitted on 03/28/19. The MTP, dated 04/01/19, listed for the Problem, "Self/Other-Harm Thoughts or Impulses," the non-measurable STGs, "Pt verbalizes need for support/contact appropriately prn [as needed] and frequency [sic] when feeling depressed with people," and "avoids isolating in room during waking hours for more than 1 hour at a time."

The LTG listed for this patient, beginning 6/10/19, was, "Pt is waiting for conservatorship/placement," and according to MD1, during interview on 01/07/2020 at 2:00 p.m., this goal remains current.

B. Policy Review

Review of the facility policy, "Treatment Planning Process, Interdisciplinary Team," revised 2/2019, stated, " ... goals/outcomes are developed that are measurable and interventions defined."

C. Interviews

1. In an interview on 01/07/2020 at 9:30 a.m., the Director of Social Work concurred with the findings regarding the lack of observable, measurable behavioral STG's on the reviewed MTPs.

2. In an interview on 01/07/2020 at 11:30 a.m., the Clinical Supervisor and the Unit Activity Therapist agreed with the findings regarding the lack of measurable, observable STG's on the reviewed MTP's.

3. In an interview on 01/07/2020 at 1:15 p.m., the facility Nurse Consultant concurred with findings regarding the lack of observable, measurable STG's.

4. In an interview on 01/07/2020 at 2:00 p.m., MD1 agreed with the findings of the lack of observable, measurable STG's on the reviewed MTP's.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for five of five sample patients (A1, A2, A3, A4, and A5) included physician and nursing treatment modalities (interventions) that were individualized based on patient needs. Physician interventions were not always listed for specific goals, and modalities were generic job description functions regardless of the identified patient need and goals. This failure results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings Include:

A. Medical Record

1. Patient A1 was admitted on 07/07/19. The MTP, dated 07/08/19, listed the short-term goals (STGs), "No harm to self and/or others during hospitalization," and "Takes medications as ordered." The interventions for these goals included the non-individualized, generic interventions, "Administer meds/PRNs [as needed] and document responses [RN]," and "Titrate medications to reduce symptoms [Physician]."

2. Patient A2 was admitted on 12/30/19. The MTP, dated 01/02/2020, listed the STG, "Decrease in hallucinations as evidenced by: able to accept reality orientation." The generic, non-individualized nursing interventions were, "Administer appropriate meds/PRNs and document response," and "Assist with ADL [Activities of Daily Living] as needed while encouraging independence." There were no physician interventions listed for this goal.

3. Patient A3 was admitted on 12/03/18. The MTP, updated 12/06/19, listed the STGs, "Patient will be able to discuss finances without getting angry/irritable," and "Decrease in paranoia other Delusions as evidence by Pt [Patient] able to listen to staff reality orientation and support at least 2x/day x5 mins [minutes]." The interventions for these goals included the non-individualized, generic interventions, "Assess behavior q [each] shift [RN]," and "Titrate medications to reduce symptoms [Physician]."

4. Patient A4 was admitted on 12/03/19. The MTP, dated 12/5/19, listed the STGs, "Decrease in Paranoia or other Delusions as evidenced by med compliance and cooperation c [with] care," and "follow verbal cues 80% of the time." The interventions for these goals included the non-individualized, generic nursing interventions, "Assess behavior q [each] shift," and "Provide a safe non stimulating environment." There were no physician interventions listed for these goals.

5. Patient A5 was admitted on 03/28/19. The MTP, dated 04/01/19, listed the STG, "Pt verbalizes need for support/ contact appropriately prn [as needed] and (frequency not filled in) when feeling depressed with people." The generic nursing intervention listed for this STG was, "Encourage pt. to report thoughts/impulses to staff immediately." There were no physician interventions listed for this goal.

B. Interviews

1. In an interview on 01/07/2020 at 9:30 a.m., the Director of Social Work concurred with the findings regarding the interventions on MTPs being generic job descriptions.

2. In an interview on 01/07/2020 at 11:30 a.m., the Clinical Supervisor and the Unit Activity Therapist agreed with the findings regarding the lack of individualized treatment interventions on the MTP's.

3. In an interview on 01/07/2020 at 1:15 p.m., the Nurse Consultant concurred with the findings that the nursing interventions were not individualized and instead were generic job descriptions. In addition, she concurred that some of the reviewed goals did not have needed physician interventions.

4. In an interview on 01/07/2020 at 2:00 p.m., MD1 agreed with the findings concerning the lack of individualized treatment interventions for the STG's and the absence of physician interventions for some of the goals in the reviewed MTP's.

Based on record review, observation, and interview the facility failed to ensure that active treatment measures, such as group and/or individual treatment, were provided for two of five sample patient (A2 and A4). Specifically, Patients A2 and A4 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A2

a. Record Review

Patient A2 was admitted on 12/30/19. The "Psychiatry Admission Note," dated 12/31/19, described the patient as having "advanced dementia." S/he reportedly fell at home and was taken to the Emergency Department where s/he became agitated and combative. After admission, the "Nursing Progress Notes" (dated 12/30/19-01/04/2000) documented behavior that continued to be agitated and aggressive. The MTP, dated 01/02/2020, did not include interventions for addressing his/her agitation and aggressive behavior on the unit. The MTP had the short-term goal (STG), "Pt. [patient] will attend 1 group/activity daily for 5-10 minutes." Although Patient A2 did not attend groups, the MTP did not address treatment alternatives.

B. Document Review

Review of the "Patient-Group and Activity Attendance Log," from 12/31/19 to 01/05/2020, revealed that 29 groups were scheduled for Patient A2 to attend. Patient A2 did not attend 26 of those groups and only partially attended three of the groups.

C. Observations

During observations on the unit on 01/06/2020 from 1:15 p.m. - 3:00 p.m., Patient A2 was observed in bed, apparently asleep. There were three groups offered during this time, "Social Skills," "Recreation Activity," and "Wrap Up."

D. Interview

1. In an interview on 01/06/2020 at 1:20 p.m., RN1 stated that Patient A2 did not go to groups first admitted because s/he was disruptive and had not gone in the past few days because s/he was dehydrated, sedated, and sleepy.

2. In an interview on 01/07/2020 at 9:15 a.m., the Clinical Supervisor stated that Patient A2 had been transferred to a local hospital due to a change in his/her condition which included an increase in blood pressure, increase in heart rate and responding only to painful stimuli.

2. Patient A4

a. Record Review

Patient A4 was admitted on 12/03/19. The "Psychiatry Admission Note," dated 12/03/19, indicated that the patient had a history of, "depression, psychosis, and Major Neurocognitive Disorder with behavioral disturbance." Reportedly the patient was becoming more aggressive, irritable, angry, and was throwing food at the facility where s/he was staying. The patient reportedly was exhibiting aggressive behavior toward female staff and s/he could only be managed my male staff. The evaluation further stated that most of the interview was "nonsensical."
The admission Psychosocial Evaluation, dated 12/06/19, stated that the patient had a history of punching a Certified Nursing Assistant (CNA), being combative with staff, and throwing a walker at staff.

b. Document Review

Review of the facility "Patient-Group and Activity Attendance Log" indicated the patient was assigned to 30 activity groups and attended only one from the time period 12/30/19 to 01/05/2020.

c. Observations

1. On 01/06/2020 at 1:30 p.m., Patient A4 was observed sleeping in bed with a 1:1 staff assigned for safety. There was a scheduled Social Skills group being held during this time.

2. On 01/07/2020 at 11:00 a.m., Patient A4 was observed sleeping in bed while an activity group was being held.

3. On 01/07/2020 at approximately 3:00 p.m., Patient A4 was awake and being attended by a male staff. The patient was attempting to kick the staff member. S/he could not coherently respond to the interviewer questions and appeared to be responding to internal stimuli.

4. On 01/08/2020 at approximately 9:30 a.m., CNA1 was observed attempting to assist patient A4 to remain in bed. Patient A4 was continually attempting to kick CNA1. CNA1indicated that it was difficult to communicate with the patient and most of the time Patient A4 talked "nonsense."

d. Interviews

1. In an interview on 01/06/2020 at 1:05 p.m., RN 2 indicated that Patient A4 typically spent a great deal of time asleep in his/her bedroom. RN2 further stated that group attendance was problematic, and that patient A4 could only remain in a group for about 5 to 10 minutes.

2. In an interview on 01/07/2020 at 11:45 a.m., the Unit Activity Therapist concurred with the findings regarding the lack of group attendance for Patient A4 as indicated on the "Patient- Group and Activity Attendance Log." She discussed the difficulty in getting the patient to attend groups and keeping him/her in groups for more than a short period of time.

3. In an interview on 01/07/2020 at 2:00 p.m., MD1 discussed the difficulties in treating Patient A4. S/he stated it was difficult to get the patient's behavior under control because increasing medications created excessive sedation while decreasing dosages allowed for a resurgence of aggressive or violent behavior. MD1 voiced that the patient needed a different placement and thought that palliative care or hospice would be an appropriate option.

Based on record review, observation and interview, the Medical Director failed to:

l. Provide Master Treatment Plans (MTPs), referred to by the facility as "Interdisciplinary Treatment Plans," that identified patient-related, short-term (STG) and long-term goals (LTG) stated in observable, measurable, behavioral terms and/or STGs related to the patients' problems for five of five active sampled patients (A1, A2, A3, A4, and A5). This failure results in a document that does not identify individualized expected treatment outcomes in a manner that can be utilized by the treatment team to measure individual progress in care. In addition, this failure may prevent the team from modifying plans in response to patient needs and could extend the length of hospitalization. (Refer to B121)

ll. Ensure that the Master Treatment Plans (MTPs) for five of five sample patients (A1, A2, A3, A4, and A5) included physician and nursing treatment modalities (interventions) that were individualized based on patient needs. Physician interventions were not always listed for specific goals, and modalities were generic job description functions regardless of the identified patient need and goals. This failure results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

lll. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two of five sample patient (A2 and A4). Specifically, Patients A2 and A4 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Interviews

1. In an interview on 01/07/2020 at 11:45 a.m., the Unit Activity Therapist concurred with the findings regarding the lack of group attendance for Patient A4 as indicated on the "Patient- Group and Activity Attendance Log." She discussed the difficulty in getting the patient to attend groups and keeping him/her in groups for more than a short period of time.

2. In an interview on 01/07/2020 at 2:00 p.m., MD1 agreed with the findings of the lack of observable, measurable STG's on the reviewed MTP's.

3. In an interview on 01/07/2020 at 2:00 p.m., MD1 agreed with the findings concerning the lack of individualized treatment interventions for the STG's and the absence of physician interventions for some of the goals in the reviewed MTP's.

Based on record review and interview, the Director of Nursing failed to ensure that the Master Treatment Plans (MTPs) for five (5) of five (5) active patients (A1, A2, A3, A4, and A5) contained individualized nursing interventions. The interventions were listed as routine discipline functions rather than individualized treatment options. This practice does not allow the nursing staff and other disciplines to know what the nursing staff should be addressing in the way of individual interventions and has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Medical Record

1. Patient A1 was admitted on 07/07/19. The MTP, dated 07/08/19, listed the short-term goal (STG), "Takes medications as ordered." The non-individualized, generic nursing intervention for this goal was, "Administer meds/PRNs [as needed] and document responses."

2. Patient A2 was admitted on 12/30/19. The MTP, dated 01/02/2020, listed the STG, "Decrease in hallucinations as evidenced by: able to accept reality orientation." The generic, non-individualized nursing interventions were, "Administer appropriate meds/PRNs and document response," and "Assist with ADL [Activities of Daily Living] as needed while encouraging independence."

3. Patient A3 was admitted on 12/03/18. The MTP, updated 12/06/19, listed the STGs, "Patient will be able to discuss finances without getting angry/irritable," and "Decrease in paranoia other Delusions as evidence by Pt [Patient] able to listen to staff reality orientation and support at least 2x/day x5 mins [minutes]." The non-individualized, generic nursing intervention for these goals was, "Assess behavior q [each] shift."

4. Patient A4 was admitted on 12/03/19. The MTP, dated 12/5/19, listed the STGs, "Decrease in Paranoia or other Delusions as evidenced by med compliance and cooperation c [with] care," and "follow verbal cues 80% of the time." The non-individualized, generic nursing interventions for these goals were, "Assess behavior q [each] shift," and "Provide a safe non stimulating environment."

5. Patient A5 was admitted on 03/28/19. The MTP, dated 04/01/19, listed the STG, "Pt verbalizes need for support/ contact appropriately prn [as needed] and (frequency not filled in) when feeling depressed with people." The generic nursing intervention listed for this STG was, "Encourage pt. to report thoughts/impulses to staff immediately."

B. Interviews

In an interview on 01/07/2020 at 1:15 p.m., the Nurse Consultant concurred with the findings that the nursing interventions were not individualized and instead were generic job descriptions. In addition, she concurred that some of the reviewed goals did not have needed physician interventions.