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Based on document review and interview, two of ten patients reviewed failed to have diet orders upon admission.

Findings included:

1. Review of patient medical records indicated the following:
a. Patient #26 was admitted on 9-12-2018 at 2:20 AM and discharged on 9-17-2018 at 10:16 AM. A "Diet Requisition and Cancellation" document dated "09/17/2018" read "Diet Request Type: Cancellation." The document did not indicate the type of diet ordered for the patient. There was no other diet order for the patient during their admission.
b. Patient #28 was admitted on 10-12-2018 at 3:24 PM and discharged on 10-16-2018 at 9:30 AM. A "Diet Requisition and Cancellation" document dated "10/15/2018" read "Diet Request Type: New Order." The document did not indicate the type of diet ordered for the patient. There was no other diet order for the patient during their admission.

2. On 2-27-2018 at 1:30 PM, SP8, Supervisor of Medical Records, acknowledged Patient #26 did not have a diet order. On the same date at 2:18 PM, SP8 further acknowledged Patient #28 did not have a diet order.

Based on record review, observation and interview; the facility failed to ensure all fire alarm system initiating devices were tested in accordance with the schedules for testing frequency in NFPA 72. LSC Section 19.3.4.1 states a manual fire alarm system shall be provided in accordance with Section 9.6. LSC Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 2010 Edition, Table 14.3.1 states that certain fire alarm system components need to be visually inspected semiannually:
a. Control unit trouble signals - verify that they are readily visible
b. Remote annunciators - verify that they are in proper operating condition and free of damage
c. Initiating devices - verify that they are in place, unobstructed and free of damage.
d. Notification appliances - verify that they are unobstructed and free of damage
e. Magnetic hold-open devices - verify that they are free of damage and function properly
This deficient practice could affect all building occupants.

Findings include:

During record review with the General Services Supervisor on 02/26/19 at 11:59 a.m. no documentation could be provided indicating the fire alarm system was visually inspected semi-annually in the most recent twelve month period. Based on interview at the time of record review, the General Services Supervisor agreed that the fire alarm system was not visually inspected semi-annually.

Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all residents, staff, and visitors.

Findings include:

During record review for the most recent twelve month period with the General Services Supervisor during record review on 02/25/19 at 11:49 a.m. weekly dry sprinkler system gauge inspection documentation for 48 weeks of the most recent 52 week period was not available for review. Monthly wet sprinkler system gauge inspection documentation for 8 months of the most recent 12 month period was also not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 8 months of the most recent 12 month period was not available for review. Based on interview at the time of record review, the General Services Supervisor acknowledged sprinkler system gauge and control valves were only inspected when the sprinkler vendor came to the facility on a quarterly basis and that inspection documentation for the aforementioned weekly and monthly periods was not available for review.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5. 8.5.6.3 states that where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5. 8.3.5.1 states that penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The fire stop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all building occupants.

Findings include:

During a facility tour with the General Services Supervisor and the Director of Facilities on 02/26/19 at 11:33 a.m. a 1 inch by 1 inch penetration was found in the smoke barrier wall above ceiling tile near Door 13B. Based on interview at the time of observation, the General Services Supervisor and the Director of Facilities acknowledged the penetrations in the smoke barrier and agreed to the measurement.

Based on document review, observation, and interview, the infection control officer failed to: 1)ensure dietary personnel followed proper hand washing procedures for three of four dietary technicians observed; 2) Ensure the correct strength of the sanitizer used for food contact surfaces for one of one sanitizer buckets observed; and 3) failed to ensure one of one contracted dietician was evaluated for immunization status and screened for tuberculosis.

Findings included:

1. Review of policies and procedures indicated the following:
a. A policy/procedure titled: "Infection Control-Hand Hygiene Procedures, Version #3," approved "12/21/2015" read: Routine Hand Washing Procedure: a) Turn water on to a comfortable temperature; b) Wet hands and wrists and apply a thumbnail-sized amount of soap. c) Vigorously work soap into a rich lather and work the lather around the backs of hands and between fingers. d) Use the palms of hands to work soap onto fingertips and under fingernails. e) Wash hands for at (sic) 20 seconds f) Rinse, avoid splashing g) Keep hands down so that run of will go into the sink and not down the arm. h) Dry hands with a paper towel i) Turn off water using a dry paper towel so that germs on the faucet handles do not re-contaminate hands. j) Discard the towels into the garbage can."
b. A policy/procedure titled: "Dietary Service Sanitation Procedure, Version #3," approved on "03/22/2018" read: "Hands should be washed in hot water 100°F for a minimum of 20 seconds."
c. A policy/procedure titled: "Kitchen/Food Preparation/Kitchen Equipment Sanitation Procedure, Version #2, approved on "10/13/2014" read: "Food Preparation Table Area (USDA Food Guidelines)...A chlorine test strip will also be used to assure proper mixture of bleach/water (200ppm)."
d. A policy/procedure titled: "Hiring Temporary Staff, Unpaid Students and Volunteers - Supervisors Instructions, Version #3" approved "06/21/2018" read: "Temporary agency staff are required to undergo pre-placement drug testing, and may be required to have a TB test (pre-placement and/or annual), if such tests are required for employees in the same department (unless they can provide documentation of having had a negative TB test in the last 6 months)." The policy/procedure did not require the agency staff to be evaluated for immunization status.
e. A policy/procedure titled: "Hiring/Employee Relations - Supervisors Instructions, Version #9" approved on "03/13/2018" read: "Currently the following staff are required to prove immunity to Measles, Mumps and Rubella (MMR) and Chicken Pox (Varicella): Strawhun building: Dietary and Inpatient Staff..." and "Note that individuals are not to begin working until the results of the drug screen, all pertinent documentation regarding TB, MMR, Varicella, and Tdap (including TB test results, documentation of previous illness related to MMR and/or Varicella, titer results, and vaccine administration if needed for MMR and Varicella, and Tdap documentation of previous or current immunization) have been received."

2. Manufacturer's instructions for the "Array Germicidal Bleach and Disinfectant" read: "To sanitize nonporus food contact surfaces such as dishes, glasses, eating utensils, sinks and refrigerators...Prepare the sanitizing solution by thoroughly mixing 1/2 ounce of bleach with 1 gallon of water to provide approximately 200 ppm available chlorine by weight."

3. On 2-25-2019 at 10:30 AM, while on a tour of the kitchen, accompanied by SP4, Dietary Supervisor, the following was observed:
a. SP9, Dietary Technician, was observed wetting their hands, placing soap on their hands, then lathering the soap on their hands for approximately three seconds before rinsing the soap off and drying hands with a paper towel. SP9 was observed a second time wetting their hands, placing soap on their hands, then lathering the soap on their hands for approximately eleven seconds before rinsing the soap off and drying hands with a paper towel.
b. SP10, Dietary Technician, was observed wetting their hands, placing soap on their hands, then lathering the soap on their hands for approximately three seconds before rinsing the soap off and drying hands with a paper towel.
c. SP11, Dietary Technician, was observed wetting their hands, placing soap on their hands, then lathered the soap under the running water for approximately 15 seconds before drying hands with a paper towel.
d. The water temperature at the hand washing sink was observed, using a thermometer couple, to be 83 degrees Fahrenheit.
e. A sanitizer bucket located on a food preparation table contained a bleach sanitizer. When tested, the sanitizer concentration was observed to be 100 parts per million (ppm).

4. Review of "Hand Hygiene Observation Form," dated "3/15/18" indicated SP4 observed the hand washing procedure performed by SP10. However, the document did not indicate if SP10 performed the hand washing procedure properly.

5. Review of "Contract for Services Rendered," signed on 5-7-2013 indicated SP12, Registered Dietician, was a contracted Dietician who provided "On Site" visits "as needed upon request."

6. Review of personnel records for SP12 indicated the facility did not have documentation of a tuberculosis (TB) test or immunity to Measles, Mumps, Rubella, and Varicella.

7. On On 2-25-2019 at 10:30 PM, SP4 acknowledged SP9, SP10, and SP11 failed to perform hand washing procedures in accordance with approved policies/procedures. SP4 further acknowledged the water in the hand washing sink was typically cold and didn't get warm until the afternoon, when it usually reaches 90°F. SP4 also acknowledged the sanitizer in the sanitizer bucket on the food preparation table was used to sanitize the preparation table and the preparation table was a food contact surface. SP4 indicated the sanitizer was between 50 and 100 ppm.

8. On 2-26-2019 at 1:00 PM, SP7, Human Resources Business Partner, confirmed the facility did not have documentation of a TB test or immunity to Measles, Mumps, Rubella, or Varicella for SP12.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations included an inventory of specific personal patient assets that could be used in treatment planning for two (2) of four (4) active sample patients (1 and 3). The failure to identify patient assets in descriptive, not interpretive fashion can impair the treatment team's ability to develop treatment interventions that utilize the individual strengths of the patient.

Findings include:

A. Record Review

The following 2 Psychiatric Evaluations (dates of the Evaluations in parenthesis) had no mention of patient assets included in the report: Patient1 (1/9/2019) and Patient 3 (2/22/2019).


B. Interview

In an interview with the Medical Director on 2/27/19 at 11:57 a.m., the failure to include patient assets in the Psychiatric Evaluations of these two patients was discussed. He did not dispute the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for four (4) of four (4) active sample patients (1, 2, 3 and 4) that included individualized physician interventions with a specific purpose and focus. The physician interventions were generic discipline functions and/or there was a failure to identify interventions based on the patient's needs. Failure to clearly describe specific modalities on patients' MTPs can hamper the physician's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review

1. Patient 1 (MTP dated 2/19/19). For the problem: "hallucination" as evidenced by: "client responding to internal stimuli by exhibiting inappropriate laughter and talking to self" the psychiatrist intervention was "Medication management."

2. Patient 2 (MTP dated 2/22/19). For the problem of "aggressive and threatening behavior" as evidenced by: "Reported that client was trying to kill family dog, threatening mother and going after mother due to being off meds (medication)", the psychiatrist intervention was "Medication management."

3. Patient 3 (MTP dated 2/22/19). For the problem: "Aggressive and threatening behavior" as evidenced by: "Client was aggressive verbally towards boyfriend and [his/her] mother and [s/he] tore up [his/her] new born baby social security card", the psychiatrist interventions were: "Psychiatric interventions, Frequency: 6 times per week" and "Medication management."

4. Patient 4 (MTP dated 2/23/19). For the problem: "Threatening behavior" as evidenced by: "Stated got mad at another resident and verbally threatening [him/her]", the psychiatrist interventions were: "Psychiatric interventions. Frequency: 6 times per week" and "Medication management."

None of the psychiatrist's interventions listed above included a specific focus of what would be discussed, the medications that would be prescribed, etc. with each patient.


B. Interview

During an interview with the Medical Director on 2/27/19 at 11:57a.m., the generic psychiatrist's intervention on the MTPs was discussed. He agreed with the findings.

Based on record review and interview, the clinical director failed to----

1. Ensure that Psychiatric Evaluations contained an assessment of patient assets in descriptive, not interpretive fashion for four (4) of four (4) active sample patients (1,2,3 and 4). (Refer to B117 for details)

2. Ensure that Master Treatment Plans (MTPs) for four (4) of four (4) active sample patients (1, 2, 3 and 4) included individualized physician interventions with a specific purpose and focus. The physician interventions were generic discipline functions and/or there was a failure to identify interventions based on the patient's needs. Failure to clearly describe specific modalities on patients' MTPs hampers the physician's provision of information related to individual patient needs. (Refer to B122 for details)