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Based on interview and record review, the hospital's governing body failed to:

1. Ensure an organized nursing service that implemented adequate and standardized nursing care. (Refer to A0144, A0385, A0396, A0397, A0405, and A0407).

2. Ensure that a physician responsible for the care of a patient who died during the first quarter of 2017 observed and responded to the hospital's process to address patient safety issues. (Refer to A0340)

3. Ensure the provision of adequate supervision and staffing of the Nutrition and Dietary Department to meet the nutritional needs of all patients. (Refer to A0618, A0619, A0620, A0621, A0622, and A0629)

4. Ensure that the newly designated qualified infection control officer had adequate orientation to implement the hospital's infection control program. (Refer to A0747, A0748 and A0749)


The cumulative effect of these systemic problems, placed the patients at risk for increased potential harm to patient safety and well-being.

Based on observation, interview and record review, the hospital failed to observe patients rights when the following occurred:

1.) Failure to keep Patient 5 with known active suicidal thoughts and gestures, safe from attempting to strangle herself three times while in the hospital. (Refer to A0144 & A0396)

2.) Failure to obtain the written medication consent of Patient 5's conservator. (Refer to A0117 & A0396)

3.) Failure to maintain the dignity of the adolescent patients during dining. The hospital inappropriately provided only plastic spoons that resulted to the patients' use of their bare hands while eating. (Refer to A0144)

These cumulative failures resulted in the hospital's inability to protect and promote patients' rights required by the Patient's Rights Condition of Participation.

Based on interview and record review, for one (Patient 5) of 29 sampled patients, the hospital failed to obtain written or verbal consent for medication administration from Patient 5's conservator.

Findings:

Review of the "High Risk Screening Tool" showed the hospital admitted Patient 5 on 7/3/17 involuntarily for being a danger to herself after making suicidal statements and cutting on her wrists. The admission record showed that Patient 5 was on a LPS Conservatorship (The legal term used in California which gives an adult conservator the responsibility of overseeing the comprehensive medical and mental treatment for another adult). There was no copy of the legal conservatorship document in the medical record.

Further record review revealed an "Initial Medication Consent" form dated 7/3/17 which listed two medications: Lorazepam (an antianxiety medication) and Zyprexa (an antipsychotic medication). Under the space "Client on Conservatorship, Conservator Signature", there was no signature.

In a record review on 7/12/17 at 4:20 p.m., a "Medication Consent Form," dated 7/3/17 showed Patient 5 signed the consent for the administration of the following medications: Lorazepam, Buspar (an antianxiety medication), Effexor (an antidepressant medication), Seroquel (an antipsychotic medication) and Depakote (a mood stabilizing medication). There was no signature of the conservator on the designated space for "Client on Conservatorship, Conservator Signature".

In an interview on 7/13/17 at 9:15 a.m. Staff 3 stated that a nursing progress note showed a Unit Nursing Manager attempted to contact and inform the conservator on 7/5/17 at 11:35 a.m. about Patient 5's suicidal attempt on 7/4/17. The nursing progress note did not document to obtain the conservator's consent for Patient 5's medication administration.

The nursing progress note dated 7/7/17 at 11:40 a.m. showed, "writer received call from conservator and requested him to sign med consent once writer faxed over...conservator most likely can re-fax consent with signature today". A fax cover sheet dated 7/7/17 at 11:42 a.m. was in the medical records; Patient 5's medication consent remained unsigned by the conservator as of 7/13/2017.

Based on observation, interview and record review:

1. For one (Patient 5) of 29 sampled patients, the hospital failed to prevent Patient 5 who was admitted for cutting on her wrists, from attempted self-strangulation three times within six days of admission. Patient 5 had known active suicidal thoughts and gestures.

2. The hospital failed to provide supervision on handwashing before meals and appropriate eating utensils on the adolescent unit during lunch on 7/12/2017. This failure had to potential to result in infection due to lack of hand washing, accidental choking and lack of dignified dining experience.

Findings:

1. Patient 5's medical record was reviewed. The "High Risk Screening Tool" showed the hospital admitted Patient 5 to the hospital on 7/3/17 involuntarily for being a danger to herself after making suicidal statements and cutting on her wrists.

The admission record showed Patient 5 was on a LPS Conservatorship (the legal term used in California which gives an adult conservator the responsibility for overseeing the comprehensive medical of an adult)

The "Inpatient MD Admission Orders, Certification and Preliminary Treatment Plan" showed an order for every 15 minutes observation to monitor patient safety.

The nursing progress dated 7/4/17 showed the MHT (Mental Health Technician) found Patient 5 sitting in the bathroom with a sports bra wrapped around her neck. The nursing progress showed Patient 5 stated, "the voices is [are] telling me to do it", and "per MD patient has denial of rights for under garment and will be put on 1:1 RTC (Round The Clock) (an order to have a dedicated staff observe and monitor a patient at all times) for increased monitoring".

The physician's orders dated on 7/4/17 at 9:00 p.m., showed that Patient 5 was placed on a 1:1 RTC and a denial of Patient 5's rights to have an under garment.

The admission care plan Patient 5's admission care plan dated 7/3/17 did not have an update to address the attempted suicide on /4/17.

The physician's orders dated 7/5/17 from 1:00 a.m. through 7/6/17 at 12:15 p.m., showed that Patient 5 was on a 1:1 RTC. On 7/6/17 at 12:15 p.m. the physician wrote an order, "DC (Discontinue) 1:1, and COR (Close Observation Rounds) every 5 minutes while awake."

The nursing progress dated 7/6/17 at 7:00 p.m. (less than 7 hours later) showed, "Patient is anxious, barricading herself in her bedroom, patient is alert, breathing even and unlabored, no shortness of breath, no distress noted, no complaints of pain or discomfort noted; Patient was put on a 1:1 RTC after hurting self with mesh underwear. Patient tried to strangle self with mesh underwear. No noticeable injury noted".

Review of a nursing progress dated on 7/6/17 at 7:00 p.m. showed, "Writer called MD to inform of patient incident, no response from physician. Writer called MD three times still no response. Writer deemed that patient should be on 1:1 RTC for safety till MD re-evaluates patient again".

The physician note on 7/7/17 at 4:35 p.m., showed 1:1 RTC observations were again discontinued and placed back on COR without a specified frequency of observations. A physician's order showed that the COR was renewed on 7/8/17 at 4:35 p.m. only to be discontinued 10 minutes later at 4:45 p.m.

A nursing progress dated 9/17 at 9:30 p.m., showed that during safety rounds, MHT found Patient 5 sitting on the shower floor, choking, with a pair of hospital scrub pants around her neck. The staff initiated the every 5 minute safety checks ordered by the physician.

A review of the "Master Treatment Plan" initiated on 7/6/17 did not include interventions to address Patient 5's command auditory hallucinations/psychosis which told her to harm herself. The 1:1 RTC status was not reordered after the second the third observed suicide attempts during Patient 5's remaining hospital stay.

In an interview on 7/12/17 at 3:20 p.m. Staff 26 confirmed that there were no interventions that addressed Patient 5's auditory hallucinations which told her to harm herself. Staff 26 stayed silent and did not respond to the following: where Patient 5 obtained the mesh undergarment that the doctor ordered to be denied and and the pair of hospital scrub pants. These conditions allowed Patient 5 to find opportunities to obtain the items for the suicide attempts that could have potentially resulted in suicidal death.







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2. According to the lunch menu on July 12, 2017, the following items were served: Chicken Chow mein (noodles), Oriental Vegetable blend (broccoli, carrots,) , apricot halves and diet lemonade. During observation of the lunch meal on July 12, 2017 at 12:46 pm, there were eleven adolescent patients eating in the multi- purpose room on the unit. Each was served their food in a white covered Styrofoam container and was provided plastic spoons to eat.

One unsampled patient stated "I never thought I will get to see the day that I will have to eat noodles with a spoon". Two other patients were observed picking up the noodles and broccoli with their hands. Another unsampled patient said to the other patients "Let me show you how" He was then observed inverting the spoon, holding the bowl or open part (which would normally be put in the mouth) and twirling the noodle with the spoon handle. He also demonstrated picking up some of the vegetable pieces by spiking the broccoli and chicken with the spoon handle. He was not successful during all of the attempts.

General dining and social etiquette requires the use of proper dining utensils. The spoon is not the proper utensil for eating noodles or broccoli. There were no hand sinks in the room. None of the patients were observed to wash hands or request hand towels to clean hand prior to eating with their hands. Lack of hand washing prior to eating could result in gastro intestinal distress due to contamination of the food with dirty hands.

Some of the patients were observed putting the pieces of chicken and apricots halves in their mouth whole. This could pose a choking hazard.

In the interview conducted on July 13, 2017 at 11:15 am with Staff 43, he stated he did not know the origin of the use of the plastic spoons but that it has always been the hospital's policy. He further stated he believed it was for patient safety reasons. He acknowledged there could be other ways of ensuring patient safety while providing appropriate eating utensils.

In an interview with the DFS on July 13, 2017 about the use of the plastic spoons for all meals regardless of kind of meal, she indicated it has just been the policy she had been trained on. There was no written policy on the use of utensils for all patients.

Based on staff interview and record review, the hospital failed to include a significant adverse event related to the conduct of one of the hospital's medical Staff; Staff 35, in his physician's focused performance evaluation. This failure to ensure the accuracy of the reappraisal process for Medical Staff, had the potential to negatively impact patient safety and quality of care.

Findings:

During a review of Medical Staff credentials on 7/12/17 at 10:00 a.m., the file for hospital Staff 35 was reviewed. On the performance evaluation form, in the section for reported adverse events for the first quarter of 2017; no adverse events were reported in conjunction with Staff 35. Staff 35 was directly involved with an adverse event which resulted in a complaint validation survey during that time span. When asked about the omission, the Credentialing Staff 34 and Regional Staff 38, could not say why the number of reported adverse events was zero, despite Staff 35's status being under heightened scrutiny and in a focused performance review.

In an interview on 7/12/17 at 3:50 p.m. Staff 3 and Staff 38 were informed that Staff 35 had not responded on the evening of 7/6/17 after several attempts were made by nursing staff to inform him of a patient attempting to strangle herself. Staffs 3 and 38 stated that they were unaware as was Staffs 1, 2, and 5 regarding Staff 35's unresponsiveness to nursing regarding an urgent patient safety need and that appropriate steps would be taken regarding Staff 35's physician contractual position.

Based on observation, interview, and record review, the hospital failed to assess, develop, deliver, and implement adequate and standardized nursing care for four (Patients 5, 6, 7, and 23) of 29 sampled patients.


1. For Patient 23, Diabetic Management was not correctly monitored and administered. (Refer to A0405)

2. For Patient 5, who had three suicide attempts during her hospitalization, nursing staff failed to escalate to nursing management and/or hospital administration when a physician was non-responsive to phone contact (Refer to A0144).

3. For Patient 5, there was no nursing care plan addressing the command type auditory hallucinations she was experiencing telling her to harm herself and no updated interventions when Patient 5 kept attempting to harm herself (Refer to A0396).

4. There was no Policy and Procedure for the management of patient constipation (Refer to A0396).

5. For Patient 7, there was no adequate assessments of bowel movements or update of nursing interventions on her nursing care plan (refer to A0395 & A0396).

6. Nursing staff assignments are done without assessing the complexity and needs of the patients (Refer to A0397).

7. There were multiple verbal/telephone orders as a practice (Refer to A0407).

8. For Patient 6, a nursing care plan was not developed or initiated until three days after admission to address the unstable blood sugar levels related to Diabetes Mellitus (Refer to A0396).

9. For Patient 6, there was inadequate monitoring of dietary accuracy in order to appropriately document concerns to the physician for insulin sliding scale needs (Refer to A0405).

10. There was no hand hygiene during medication administration between three different patients, a collection of dirty hospital issued patient clothing items sitting on top of a washer, there was a dirty seclusion room that had not been cleaned for more than a six hour period. (Refer to A0747 & A0749).

These cumulative failures resulted in the hospital's inability to deliver patient care in accordance with the Nursing Services Condition of Participation.

Based on interview and record review, the hospital failed to ensure that the registered nurses assessed and evaluated the interventions for the chronic constipation of one (Patient 7) of 29 sampled patients. This failure potentially placed Patient 7 at risk for harm related to constipation.

Findings:

Review of the record showed the hospital admitted Patient 7, an elderly female, on 6/14/17 for being suicidal and aggressive behavior. Patient 7 had a history of non-compliance to medication and chronic constipation.

On 6/16/17, the care plan included a self-reported constipation. The interventions for constipation included, "Nursing will complete assessments of bowel elimination patterns, identify factors causing constipation, notify MD for unrelieved constipation, blood in the stool or severe pain during bowel movements for further intervention, administration of Colace (a stool softener) 100 mg daily and would educate patient on hydration, fiber intake. Nursing will identify causes of constipation such as poor fluid intake. Nursing will continue reassessment as needed."

The nursing progress note dated 6/23/17 showed Patient 7 had approximately four episodes of nausea and vomiting. Patient 7 received two doses of Zofran to relieve nausea and vomiting. Patient 7's Daily Nursing Assessment dated 6/23/17 showed an assessment of the gastrointestinal system as "normal gastrointestinal (GI) output with her last bowel movement on 6/23/17. There was no documented intervention to determine the possible reasons for the nausea and vomiting. There was no nursing reassessment of Patient 7's fluid and diet to ensure enough fiber was provided. On 6/27/17, Patient 7 complained of constipation and told the staff, "she need the powder medication for bowel movement." The doctor ordered on 6/27/17 to start Miralax ( a fiber supplement) in 8 ounces of water daily. There was no reassessment following the administration of Miralax.

Review of the Nursing Charting to Treatment Plan and Interventions dated 7/4/2017 showed Patient 7 complained of constipation. The Physician Order dated 7/4/17 at 5:40 p.m. had an order for Dulcolax. Patient 7 received Dulcolax as ordered at 10 p.m. By the end of the evening shift, Patient 7 did not have a bowel movement in response to Dulcolax.

On 7/5/2017 at 2 p.m., Patient 7 had a bowel movement. There was no documented assessment of the stool's consistency such as a normal stool, diarrhea or constipated.

Review of Form #1192 Routine - B to document the activities of daily routine dated 7/6/2017 to 7/11/2017 showed Patient 7 was constipated on 7/10/2017 and 7/11/2017 during the morning shift. There was no intervention documented.

In a concurrent interview and record review on 7/13/17 at 4:45 p.m. Staffs 5 and 15 stated the hospital had no policy and procedure to monitor a patient for chronic constipation. As reviewed with Staffs 5 and 15, Routine-B documented "R" (regular bowel movement) on the morning and evening shifts for Patient 7. It was unclear if the documentation "R" meant Patient 7 had two bowel movements twice a day. There was no documentation of the last bowel movement on the Daily Nursing Assessment each shift. On and the narrative charting, there was no reassessment of the patient stools or information from the patient about the quality, consistency and frequency of the bowel movement. Both Staffs 5 and 15 stated the documented "R" was insufficient. The reassessment and description of the bowel movement should be done in order to determine if Patient 7 had a bowel obstruction.

Based on observation, interview and record review, the hospital failed to develop and provide updates to the nursing care plans for three (Patients 5, 6, and 7) of 29 sampled patients.

1. For Patient 5, there was no nursing care plan addressing the command type auditory hallucinations she was experiencing telling her to harm herself, and no updated interventions when Patient 5 Attempted suicide twice while at the facility.

2. For Patient 7, there was no update of nursing interventions on her nursing care plan regarding her ongoing medical issue of constipation.

3. For Patient 6, a nursing care plan was not developed or initiated until three days after her admission to address interventions related to her Diabetes Mellitus.

These cumulative failures by nursing to develop, and update nursing care plans for Patient 5, 7, and 9 contributed to their health care needs not being fully addressed.

Findings:

Review of the "High Risk Screening Tool" showed that Patient 5 was admitted to the hospital on 7/3/17 involuntarily for being a danger to herself after making suicidal statements and cutting on her wrists.

A review of patient 5's medical record showed that she attempted suicide while at the facility on three occasions. Once, by strangling herself in the bathroom with her bra, another time with her underwear, and again by attempting to strangle herself with her pants. (See tag A0144)

A review of the "Initial Nursing Care Plan" dated for 7/3/17 showed there would be, "removal of personal items to prevent self-injurious behavior". However, there were no interventions updated on the nursing care plan regarding which personal items if any were taken away and there was no belongings form to show what the patient had when she was admitted to the facility. The initial nursing care plan did not reflect that Patient 5 was having auditory hallucinations it showed under, "Alteration in Thinking", that the box for "none" was checked. There was no nursing progress note or update to the nursing care plan that showed interventions for addressing Patient 5's command auditory hallucinations which was the bases of patient 5 hurting herself as documented in the Nursing Progress notes on 7/4/17 "the voices is telling me to do it."

2. Review of the record showed that Patient 7 was 67 years old and was admitted to Unit E on 6/14/17 for suicidality, aggressive behavior, history of non-compliance with her medication, and a urinary tract infection. Patient 7 also had a history of chronic constipation.
On 6/16/17 a constipation care plan was created by nursing for self-reported constipation.

A review of the daily nursing assessment (6/23/17) Physician's Orders (7/4/17 and 6/27/17), the Medication administration Record (form 6/14/17 to 7/11/17) showed that Patient 7 informed the nurses of her constipation but did not receive medications for it till 11 days later. Also the records showed that despite the patient begins constipated the nursing staff were documenting that she had regular bowel movements by marking "R" without describing the characteristic. (See tag A0395)


In a concurrent interview and record review on 7/13/17 at 4:45 p.m. Staffs 5 and 15 stated that the hospital had no policy and procedure or a standardized nursing process for monitoring a patient for chronic constipation. When asked why there was an 11 day delay form the date of reported constipation to the date of the first Miralax, no answer was given by staff 5 and 15. When asked how the constipation care plan and the MAR documentation of "R" daily with no nursing notes addressing constipation or bowel movements could be reconciled, Staff 5 and 15 stated that it was expected that nursing staff would document the consistency, quality, and frequent, of patient 7's bowel movements. Both Staffs 5 and 15 stated that this should be done in order to determine if Patient 7 had a bowel obstruction and marking "R" was insufficient.

3. Review of the medical record showed that Patient 6 was a 14 year old, admitted to the hospital on 7/8/17 on an involuntary 72 hour hold for being a danger to self (suicidal). The "High Risk Screening Tool" showed that Patient 6 was obese, with Diabetes Mellitus Type 1, and was listed as being insulin dependent.
Review of the "History and Physical" showed that Patient 6 was obese, with Diabetes Mellitus Type 2 and was to be started on Novolog insulin sliding scale for additional insulin coverage. Patient 6 was not to have any concentrated sweets in her diet.

Further review of a "Blood Glucose Flowsheet; Adolescent and Latency" showed that Patient 6 had finger stick blood sugar levels that beginning on her 7/8/17 admission through 7/13/17 ranged from 126 to 508 (normal range for a diabetic person is 80-130).

Review of "Intake and Output (I & O)" records showed that records were kept from7/11/17 onwards (2 out of 4 days stay)
7/11/17 at 8:40 a.m. - "1 Potato, Sausage and egg bake, 2 tortillas and 1 pork link and 1 ounce (oz) of water".
7/11/17 at 12:30 p.m. - "1 Chicken, 1 veggies, 2 tortillas and 4 ounces of apple juice".
7/11/17 at dinner (no designated time) - "1 Burger, 1 chuckwagon corn (canned), and 1 brownie". No beverages listed.

7/12/17 at 8:30 a.m. - " 2 Biscuits with gravy, 2 sausages, 125 milliliters (ml) of apple juice, 125 ml of orange juice, and 236 ml of milk".
7/12/17 at 10:50 a.m. - "1 yogurt and 125 milliliters of apple juice".
7/12/17 at 12:30 p.m. - "1 Chow Mien, 1 fruit, 1 veggies".
7/12/17 at 4:00 p.m. - "1 Crackers".
7/12/17 at 4:35 p.m. - "1 Chex Mix".
7/12/17 at 6:15 p.m. - "1 Beef Stew, 1 Rice, 1 Vegetables, 8 oz of Lemonade, and 1 Ice Cream".
7/12/17 at 7:00 p.m. - "16 oz of water".

In a concurrent interview and record review on 7/13/17 at 2:00 p.m., Staff 5 confirmed that Patient 6's dietary intake was not documented prior to 7/11/17. Staff 5 stated it was nursing practice to record dietary intake for patients who were started on sliding scale insulin in order to keep track of the sugar intake and to be able to adjust the diet to aid in blood sugar control.
A review of the nursing care plan titled, "Diabetes Type 1" dated on 7/11/17 (, showed that nursing staff would educate on Consistent Carbohydrate Diet, carbohydrate counting, and document food and fluid consumption". Staff 5 also confirmed that dietary intake had to be recorded accurately in order for the practitioner to be able to order appropriate medications. No updates were made to Patient 6's nursing care plan.

Based on observation, interview and record review of staffing assignments, two of six units in the hospital failed to assigned nurses based on the complexity of patient care needs.
Failure to provide sufficient staff to care for patients as determined by the patient care needs increased the risk that patient's care and needs would not be met.

Findings:

In a concurrent observation and interview of unit E. on 7/10/17 at 10:04 a.m., Staff 18 stated that The total unit census for that day was 16 patients.

In concurrent interview and record review of the nursing assignment sheet for 7/ 10/17 showed that Staff 18 had 16 patients assigned to her. Staff 18 stated that from the list of patients on the unit, one patient was on every 5 minutes safety checks and the rest of the patients were on every 15 minutes safety checks. Staff 18 further stated that her assignments also included :
a. Code green (emergency responder to a patient safety concern)
b. Discharge nurse (for patient evaluation and discharge instructions to patient).
c. Admission nurse; an assignment which also take her out of attending to patients care needs.
d. "Desk work"; such as responding to telephone calls, calling doctors for laboratory results and follow up, checking physician orders and filing reports.
e. Assist the medication nurse in blood sugar testing, administration of patient medication while medication nurse was on break.
Staff 18 further stated that there was no unit clerk that would file and flag physicians' orders and file loose papers in patient's records.

In an observation on 7/10/17 form 10:04 a.m. to 10:12am, Staff 18 did not do every 5 minute safety checks on any of the patients assigned to her care. Staff 18 was at the nurses' station, answering phone calls and while on telephone hold she was reviewing charts and checking for physician's orders.

In a follow-up interview on 7/11/17 at 10 am. , Staff 18 stated there was no criteria used in doing patient assignments on the unit. The practice was, that one registered nurse will be assigned to all the patients. If there are two RNs (registered nurses) the patient assignment would be "split in the middle and divided equally" between two registered nurses. One RN would be the lead nurse and the second RN the medication nurse.

On 7/11/17 at 9:34 a.m. Staff 19 was interviewed regarding staffing assignment criteria of unit A. Staff 19 stated that there was no staffing assignment criteria. Practice was patients census was divided into however many nurses available that day. For example, patient census was 19 on 7/10/17, first RN took 10 and the other RN took 9 patients. And each RN was responsible in checking their patient's charts for new physician's orders.

During the interview a monitor located above the nursing station was observed
Staff 19 stated that, "No one really" looks and checks that monitor which is used to look into the blind spots of the unit.

In a separate interview with Staff 15 and Staff 5 on 7/12/17 between 9:34 and 10:18 am, both stated that hospital had an acuity system that they used for staffing. Staff 15 described the acuity system as "based on patient needs, ADL's (activity of daily living), the need for safety observations, and high fall risks"

During the continued interview and record review, Staff 15 provided a sample of "Acuity Evaluation Form" and "Nursing Needs Assessment". The forms reflected number of patients that needed care for bathing, dressing changes, range of motion, and special treatments. Staff 5 and Staff 15 both confirmed that this complexity of care for each patient was not accounted for on the "nursing assignment sheets" used on the units.

Based on observation, interview, and record review, the hospital failed to ensure the safe administration of medications as evidenced by:

1. The hospital failed to ensure a nurse performed hand hygiene (hand cleaning) between patients. The nurse administered medications to three patients (Patients 12-14). The nurse did not perform hand hygiene between each patient. These failures resulted in the potential for patients to be exposed to preventable infections

2. The hospital failed to ensure documentation of pain scores (level of pain, 0=no pain) of 6-10 for the administration of Percocet (combination of oxycodone (narcotic) and acetaminophen for pain relief). A physician ordered Percocet to be administered to Patient 31 for a pain score of 6-10. For two, out of seven doses of Percocet administered, a pain score of 6-10 was not documented in the medical record. These failures resulted in the potential for patients to be exposed to preventable medication errors.

3. The hospital failed to ensure dietary intake (amount of food eaten) was documented for Patient 6. On 7/8/17 the hospital started the patient of sliding scale (dose based on blood sugar measurement at regular intervals) insulin (medication for the control of blood sugar). The patient's dietary intake was first documented on 7/11/17. This failure resulted in the potential for patients to be exposed to a delay in achieving control of blood sugar (70-100 milligram/deciliter).

4. Staff failed to follow the physician's order to hold (not give) glipzide ( medication to control high blood sugar ) for Patient 23.

Findings:

1. During a concurrent observation and record review, on 7/12/17 at 8:45 am, at nursing unit 3A, Staff 29 identified the medications to be administered to Patient 12, Patient 14 and Patient 13. In the hall, at the medication cart, Staff 29 administered 4 medications to Patient 12, 3 medications to Patient 14, and 1 medication to Patient 13. Staff 29's medication administration process did not include hand hygiene between Patient 12 and Patient 14, and Patient 14 and Patient 13. Inspection of the top of the medication cart showed it contained a bottle of hand sanitizer (alcohol hand rub for performing hand hygiene).

During a group interview, on 7/12/17 at 9:30 am, Staff 6 was asked to describe Staff 29's medication administration to the three patients. Staff 6 stated that Staff 29 did not perform hand hygiene between the three patients. Staff 31 stated not performing hand hygiene between patients did not meet the hospital's expectation.

An administrative record review of the hospital's policy and procedure for Hand Hygiene, Prevention and Control of Infection (Policy Number: 1600.16, Date Reviewed: 3/17) showed, Procedure:, 1. Employees are required to wash hands thoroughly:, 1.5 "Before and after medication preparation/ administration."

2. During a concurrent interview and record review, on 7/13/17 at 10:55 am, Staff 32 identified Patient 31's medical record. Review of the record showed Patient 31 was admitted to the hospital on 7/8/17. Further review showed a physician's order, dated 7/9/17 at 1400, for Percocet 10/325 (10 milligrams (mg) oxycodone and 325 mg acetaminophen) 1 tablet orally twice a day for pain 6-10 for 5 days. Continued review showed a medication administration record (MAR, record of medication administration). Review of the MAR showed the hospital administered, from 7/9-7/13/17, seven doses of Percocet. Review of the medical record for the Percocet administered on 7/11/17 at 0800 did not document a pain score was 6-10. Review of the medical record for the Percocet administered on 7/13/17 at 0900 did not document a pain score was 6-10. Staff 32 reviewed the medical record and acknowledged it did not document Patient 31's pain was 6-10 for the Percocet administered on 7/11/17 at 0800 and 7/13/17 at 0900.

3. During a concurrent interview and record review, on 7/13/17 at 12:35, Staff 33 identified Patient 6's medical record. Review of the record showed Patient 6 was admitted to the hospital on 7/8/17. Further review showed a physician's order, dated 7/8/17 at 1520, for low dose NovoLog Insulin Sliding Scale Protocol. Continued review showed blood glucose and insulin doses were documented on the Blood Glucose Flowsheet from 7/8/17 1800 through 7/13/17 0800. Review of the Blood Glucose Flowsheet showed blood glucose of 508 on 7/10/17 at 2100. Further review showed the dietary intake for breakfast, lunch, dinner, and snacks, were documented on 7/11/17 and 7/12/17. Staff 33 reviewed the medical record and acknowledged it did not document the amounts eaten prior to 7/11/17.

During an interview, on 7/13/17 at 2 pm, Staff 5 acknowledged Patient 6's dietary intake was not documented prior to 7/11/17. Staff 5 stated it was nursing practice to record dietary intake for patients started on sliding scale insulin.

An administrative record review, of the hospital's policy and procedure for Nutritional Status Monitoring (Policy Number: PC #233, Date Revised: 3/17) showed, Procedure, 1. "Every Inpatient is to be monitored for meal intake during each shift: breakfast, lunch, and dinner. The percentage of meals and snack consumed is documented on the Nursing Flow Sheet."



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4. Review of Patient 23's clinical record on 7/13/17 at 9:00 a.m. indicated that patient was admitted on 6/15/2017.
Patient 23 had multiple medical diagnoses that included diabetes (blood sugar disease). On 6/18/17 the physician order was to give Patient 23 Glipzide 5 mg ( milligram) po ( by mouth) q ( every) am( morning) ac ( before meal) , hold if FSBG ( fasting blood glucose)< ( less) 110.

Blood glucose flowsheet was reviewed it showed that the blood glucose testing result was less than 110 on 6/26/17 was 107 , 6/27/17 was 102 and on 7/8/17 was 107.

Medication administration record indicated that on those dates that the blood glucose results were below 110, Glipzide 5 mg orally was administered.

Staff 28, and Staff 29 nurses that administered the Glipzide were identified by Staff 15 both of which were unavailable for interview.

In an interview on 7/13/17 at 9 am, Staff 15 confirmed that Glipzide was administered on those days that the blood glucose testing was below 110.

In an interview on 7/14/17 at 3pm, Staff 5 stated diabetic teaching for all the hospital staffs , was done on 2/10/17 through 2/15/17 .

Diabetic education for the staffs were reviewed specific insulin administration it did not include the oral diabetic medication administration for example "Glipzide".

Based on interview and record review of 5 out of 5 patients (Patients 26, 27, 28, 29, 30) medical records, verbal orders were used frequently as common practice rather than infrequently. This practice had the potential for miscommunication that could contribute to a medication or other error that could result in an adverse event that could cause injury or death.

Findings:

During an interview on 7/11/2017 at 11:15 a.m., Staff 27 acknowledged that telephone orders were given when practitioners were not in the hospital. Staff 27 stated that a telephone order was not the same as a verbal order and should not be subject to the restrictions placed on verbal orders.

During a review of the Medical Orders on 7/14/17, 5 out of 5 patients had physician or other provider orders containing total of 60 verbal orders noted on these five patients' medical records.

The facility policy and procedure titled "Transcribing Orders" last reviewed on 5/24/17, indicated a differentiation between telephone orders and verbal orders. The policy dictated that "Telephone orders will only be accepted for admissions, unplanned or AMA discharges, STAT and emergency medications or treatments, denial of rights or in response to an emergent situation or significant change in the patient's condition." Verbal orders were described as: "VERBAL ORDERS SHOULD BE DISCOURAGED EXCEPT IN THE CASE OF EMERGENCY."

Based on interview and record review, the facility failed to maintain complete medical records noted with sufficient information as to identify a patient on 28 medical documents in a review of three patients records, (Patients 8, 28, and 29). This failure had the potential to wrongly attribute or misfile medical information, physician orders, treatment plans, and records to the detriment of the patient.

During a review of clinical patient files over 7/11/17 and 7/12/17, 28 individual documents did not have identifying information on them. These medical records were in the charts of patients 8, 28, and 29. The documents were physician order sheets, social service discharge sheets, vital sign records, patient valuable records, history and physical forms, care plans, progress notes, and seclusion and restraint policy acknowledgements.

During an interview on 7/14/17 at 11:00 a.m., Staff 30 stated that the Health Information Management department was responsible for checking the charts after the patient was dischaged and put patient identifying stickers on the pages of the chart that did not have them. She stated that sometimes she would get group notes of loose papers and she would have to send them to the director of nursing to try to identify. Staff 30 said it was, "Just a guessing game as to the identities."

Based on observation, interview, and record review, the hospital failed to ensure the development and implementation of a process to account for all scheduled medications. Triazolam (scheduled medication used for sleep) was stored in a locked cabinet on a nursing unit. The hospital did not perform a June 2017 count of the medication. This failure resulted in the potential for diversion of controlled medications.

Findings:

During a concurrent tour, interview, and record review, on 7/11/17 at 1:40 pm, in the 3rd floor medication room, Staff 6 identified a narcotic lock box. Inspection of the lock box showed it contained a labeled baggie of triazolam 0.25 milligram. Inspection of the label showed it was dispensed for Patient 11. Inspection of the triazolam inventory sheet showed the last entry was a beginning count of 2 on 5/29/17. Staff 6 inspected the inventory sheet and acknowledged the last entry was on 5/29/17.

During an interview, on 7/12/17 at 11:56 am, Staff 6 stated Patient 11's triazolam should have been counted by pharmacy once a month.

An administrative record review, of the hospital's policy and procedure for Controlled Substances (Policy Number: MM #303, Date Approved: 6/9/2017) did not show a process for the pharmacy to count controlled substances in the nursing unit's lock boxes.

Based on observation, interview, and record review, the hospital failed to ensure used (dirty) injectable medications were not stored in the pharmacy medication refrigerator. A patient's used injectable medication container (pen-injector, device to administer medication through the skin) was stored in the pharmacy medication refrigerator. The refrigerator was used to store clean medications for dispensing to patients. This failure resulted in the potential for patients to be exposed to preventable infections from contaminated medications.

Findings:

During a concurrent tour, interview, and record review, on 7/11/17 at 10:49 am, in the pharmacy, Staff 6 identified the medication refrigerator. Inspection of the refrigerator showed it contained medications that have not been dispensed to patients. Further inspection showed a lirglutide (medication for blood sugar control) pen-injector inside a labeled baggie. Inspection of the label showed the medication was dispensed on 4/28/17 to Patient 10. Continued inspection showed the words "Do not use" in red letters handwritten on the label. Staff 12 was asked to describe what happened to the medication after it was dispensed by the pharmacy. Staff 12's description included it was used to administer doses of medication by injection to Patient 10. Staff 12 further stated the used injector was returned to the pharmacy and placed in the medication refrigerator. Staff 6 was asked if the storage of a used lirglutide pen-injector in the pharmacy medication refrigerator met the hospital's expectation. Staff 6 stated a used lirglutide injector should not have been placed in the pharmacy medication refrigerator.

During an interview on 7/11/17 at 4:17 pm, Staff 20 was asked to describe her role in the hospital. Staff 20's description included that she was the hospital's infection control professional. Staff 20 was asked if she was aware of the used lirglutide injector that was in the pharmacy medication refrigerator. Staff 20 stated she was familiar with the facts as outlined above. Staff 20 stated that it was not her expectation for a used lirglutide injector to have been stored in the pharmacy medication refrigerator.

Based on observation, review of hospital documents, staff and patient interviews, the hospital failed to ensure the food and nutrition department was directed and staffed in a manner appropriate to the scope and complexity of food service operation to ensure that the nutritional needs of all patients were met.

Findings:

1. Based on observation, review of hospital document and staff interviews, the hospital failed to ensure that the director of the food services was able to manage the service appropriate to the scope and complexity of food service operations. (cross reference A0620)

2. Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure the registered dietitian had adequate provisions to ensure the nutritional needs of all patients were met. This deficient practice resulted in needs of three sampled patients (Patients 5, 6, and 7), several unsampled patients including those on NCS (No Concentrated Sweets) diet and others on therapeutic diets were met. (Cross reference A0621)

3. Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that food service staff was competent in food service duties when a food service work failed to correctly test the concentration of the quaternary ammonia sanitizer. Another foodservice work failed to respond appropriately and timely to low food temperatures on the trayline. These failures had the potential to cause food borne illness, unpalatable food resulting in decreased food intake. (cross reference A0622)

4. Based on review of hospital menu, diet order sheet, diet manual and clinical record reviews and staff interviews, the hospital failed to ensure that the nutritional needs of its patients were in compliance with recognized dietary practices. The hospital provided patients with an outdated diet for the treatment of diabetes. In addition, they failed to ensure that patients on the outdated diet (no concentrated sweets) received food according to the guidelines stipulated. Other patients on therapeutic diets with the pink wrist bands were provided diets without a system that would ensure compliance with the orders of their physicians. These failures resulted in one sampled patient (Patient 6) with abnormally high blood sugar levels with insulin injections as many as four times daily, Patient 7 receiving food that could have been a choking hazard, other patients receiving diets that was above their calculated dietary needs. ( Cross reference A0629)

5. Based on observation, patient and staff interviews and review of hospital documents the hospital failed to ensure that there was an effective system for identifying and preventing growth of microorganisms that could cause food borne illness and other infections in the hospital. Food service staff was incompetent in testing the chemical sanitizer. There was improper storage of refrigerated food, poor maintenance of food service equipment (chopping board, ice machine and open refrigerated unit), lack of hand washing procedure for patients allowed to eat with their hands. These deficient practices had the potential to affect all admitted patients and staff.

6. Based on observation, patient and staff interviews and review of hospital documents the hospital failed to ensure that there was an effective system for identifying and preventing growth of microorganisms that could cause food borne illness and other infections in the hospital. Food service staff was incompetent in testing the chemical sanitizer. There was improper storage of refrigerated food, poor maintenance of food service equipment (chopping board, ice machine and open refrigerated unit), lack of hand washing procedure for patients allowed to eat with their hands. These deficient practices had the potential to affect all admitted patients and staff. (refer to A0749)

7. Based on observation, staff and patient interviews, the hospital failed to ensure that patients in the adolescent unit were provided care in a safe setting and dignified manner when it provided plastic spoons for the consumption of food items for which the use of spoons was not appropriate, resulting in many of the patients using their hands to eat. This had to potential to result in infection due to lack of hand washing, a choking hazard when large food pieces are consumed due to the inability to cut into bite sized pieces and humiliation of the patients.

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients' were met in accordance with practitioners' orders and acceptable standards of practice.

Based on observation, review of hospital document and staff interviews, the hospital failed to ensure that the director of the food services was able to manage the food and nutrition service appropriate to the scope and complexity of food service operations.

Finding:

During the survey of the kitchen, nutrition care evaluation from July 10-13, 2017, several deficient practices were identified. These deficient practices included food storage, food preparation and distribution, equipment maintenance. There was also use of outdated diets, lack of an effective system to ensure therapeutic diets were offered as planned, lack of nutrition assessments and care plan utilizing available information.

Food Service
1. During meal observation on July 10, 2017 at 5:20 pm, FSW 1 was observing dishing out pieces of pork roast as part of evening meal into Styrofoam containers. According to the menu, the portion size for the pork roast is 3 ounces. The portions being served looked larger than the 3 ounces listed.

A check of one of the portion served on a scale showed it was 4 ¾ ounces. This approximately one a half times the portion planned by the registered dietitian. This of significance because it could result in excess calories and weight gain in some patients in which weight gain might not be desirable.

2. Food temperatures taken during trayline observation on July 11, 2017 at 11:53 am indicated the chicken entrée was 119 .2 degrees Fahrenheit (F). Food service worker (FSW) 1 who was actively dishing out the entrée and other food items was informed of the temperature of the chicken. The recommended minimum holding food temperature of hot items is 135 degrees F. FSW 1 continued to serve the patients and was not observed to recheck the temperature or take any actions to ensure that the food was being held at the appropriate temperature.

The Dietary Manager (DM) was present during the interview stated that FSW 1 should have reheated the entrée to ensure that the food was at the appropriate temperature. FSW 1 stated at 12:10 pm, she was aware of the policy and that she should rechecked the temperature and reheated it if was below the recommended.

3. According to the menu on July 11, 2017, fish tacos, key Biscayne vegetables, Diet fruit salad, flour tortilla and diet lemonade were items for lunch for patients on the regular diet. However, observation during trayline revealed other entrée items such as tofu and chicken.

Review of the food temperature log on July 11, 2017 at 11:58 am showed the temperature of the only entrée written was the fish dish. FSW 2 who prepared the dish was interviewed about the documentation of food temperatures. At 12:00 pm on July 11, 2017, FSW 2 stated the chicken was 175 degrees F. When she was asked why it was not written down, she asked with a bewildered look "I did not write it down?"

Closer look of the log revealed that there was space for only one entrée. The hospital had not been documenting the temperature of the alternate entrees including the vegetarian dishes. An interview was conducted with the DM at 12:30 pm about the lack of documentation of all prepared foods. The DM provided no explanation.

4. On July 12, 2017 at 10:42 am, FSW 2 was asked to test the concentration of the quaternary (quat.) sanitizer. FSW 2 immersed the test strip into the bucket containing the sanitizer held it for approximately 4 seconds, removed it and read it against the color chart on the test strip holder. She stated "150" (parts per million). FSW 2 was asked how long the test strip should have been left in the sanitizing solution for testing. She stated "about 4 seconds".
She was asked to retest the sanitizer after referring her to the manufacturer's instructions, which indicated 10 seconds. On retesting with the proper immersion time, the test strip was between 200 and 300 ppm.
The Food Service Director (FSD) and DM who were present during the observation indicated during an interview at 10: 45 am, FSW was trained at a monthly meeting or in service on testing the sanitizer.

Sanitizers are important to eliminate the risks of food-borne illness. Ensuring adequate concentration is important for sanitizing. Without proper sanitation of kitchen surfaces and equipment, microorganisms can be transferred from one food or surface to another leading to food-borne illness.

5. During meal observations on July 10 and July 12, 2017, food service staff was observed working hurriedly to assemble meals for both the patients who stay on the unit to eat and those who come to the cafeteria. Throughout all the observations from July 10 - 13, 2107, all food service workers, cooks and dietary aides included were working conscientiously. However, the meals were not produced timely. On July 11, 2017, there was concurrent assembly of patient food for the unit and service of food to patient in the cafeteria.

On July 12, 2017, the food cart arrived at the Adolescent Unit about 18 minutes late. No explanation was provided for why the meal was delivered late.

In an interview on July 13, 2017 at 4:15 pm, the DM was interviewed on the adequacy of staff to ensure that food was prepared timely. She explained all the staff was working hard.

Nutrition Care
6. During food preparation observation on July 10, 2017 at 4:00 pm, FSW 3 was observed cutting up several trays of apple pie. FSW 3 in a concurrent interview, stated the apple pie was dessert for patients on regular diet and that she would be preparing other items such as fruit and diet pudding for other patients such those on the no concentrated sweets diet because they cannot have apple pie.

A review of the diet sheet for the dinner meal for July 10 to July 12, 2017 indicated that there were between six to nine patients on a "No Concentrated Sweets Diet" (NCS). A review of the hospital diet manual revealed there was no diet titled NCS diet. The RD in an interview on July 11, 2017 at 10:50 am stated the NCS diet is served to patients with diabetes.

In 2002, the American Diabetes Association (ADA) in a Position Statement made recommendations to Acute Health care Facilities that "meal plans such as No concentrated sweets, no sugar added, low sugar and liberal diabetic diets are no longer appropriate.

The Consistent Carbohydrate (CCHO) Diet was the recommended diet by the ADA until December 2016. The FSD and DM who are both registered dietitians indicated in the concurrent interview, they were not aware of the recommendations.

Review of the hospital diet ordering system as part of the electronic medical record was reviewed on July 13, 2017. Under the Patient Dietary Needs tab, it showed that the NCS diet was one of the diet options for health care professionals to order. The CCHO diet was not listed.

7. The hospital failed to ensure that one patient on the NCS diet received the diet as described in the House Diet document and hospital menu. Patient 6 was admitted to hospital (adolescent unit) with psychiatric and medical diagnoses including obesity and diabetes.

Her admission weight was 257 pounds and 5 feet 4 inches tall. Her BMI was over the 99th percentile for age. Her medications included oral diabetes medication and a sliding scale insulin protocol three times a day before meals. Patient 6 was ordered to receive insulin whenever her blood sugar was over 121 mg/dl with insulin amounts increasing with increasing blood sugar levels.

Review of clinical record showed her physician ordered diet was a "diabetic diet". According to the hospital diet there was no diabetic diet. There was no evidence that the diet was clarified by either nursing or food and nutrition staff that the diet approved by the hospital medical staff was ordered. Review of the diet list from the food and nutrition department showed Patient 6 was served a NCS diet.

Laboratory test completed on 7/10/17 at 8:21 am showed Patient 6's glucose was high at 219 mg/dl (normal 65 -99). The Hgb A1C was 8.2 (normal 4-8 - 6.4) with >6.4 as an indication of diabetes. HGB A1C or glycated hemoglobin test is an important blood test that provides an average of a person's blood sugar control over a two to three month period. (webmd.com). There is a correlation between Hgb A1C and average blood sugar. Higher amounts of glycated hemoglobin, indicates poorer control of blood glucose levels. A Hgb A1C of 8 correlates with average blood sugar of 183 (147-217) mg/dl. (webmd.com)

The lack of adequate monitoring of the Patient 6's diet is evidenced by the recorded blood sugars. The Blood sugars recorded for Patient 6 four times a day on the hospital form titled "Blood Glucose Flowsheet" starting July 8 through July 12, 2017 showed her blood glucose was consistently higher than the normal level despite receiving an oral diabetes medication and insulin. Her blood sugars have ranged from 133 -338 mg/dl from July 10 -12, 2017. There was no single test in the time period reviewed that showed Patient 6's blood sugar test in the normal range. On July 10, 2017 at 8:30 pm, Patient 6's blood sugar was 508. She stated according to the interdisciplinary notes "I just ate cookies". She received a total of 14 units of insulin in two hours according to physician's order, to get her blood sugar levels to a level that was acceptable to the physician.

The Intake and Output form from July 10 - 12, 2017 showed Patient 6 received food items that were contraindicated on the hospital's NCS diet. For example, on 7/11/17 she received a brownie. She should have received diet vanilla pudding. On July 12, 2017, the patients on the NCS diet were to receive diet chocolate pudding and those on the regular diet received ice cream for dinner. Patient 6 received ice cream and not the diet pudding as was stated on the menu for patients receiving the NCS diet. In addition, she received 8 ounces of apple and/or orange juices as snacks on July 12, 2017 and July 13, 2017.

In an interview with the charge nurse (Staff 43) on July 13, 2017 at 11:08 am, Staff 43 was asked what a diabetic diet was since that was documented on the admission orders for Patient 6. He stated there was no diabetic diet and that Patient 6 should be a NCS. This interview revealed that the hospital staff (nursing and food and nutrition) could all identify the diabetic diet or diet for patients with diabetes.

Patient 6 stated in an interview on July 13, 2017 at 12:05 pm when asked about food being provided by other patients, stated that none of the patients provided her the extra food, she gets it herself.

In addition, the care plan of Patient 6 was not updated using results of the laboratory test. The RD completed an updated nutritional assessment after the laboratory value was available in the clinical record. Patient 6's Hgb A1C level 8.2 (Normal 4.6 - 6.4) showed poor blood sugar control and possibly compliance with diet and medication. These concerns were not addressed. The RD stated she did not see the laboratory values.

8. During meal service observation in the cafeteria on July 10, 2017 at 5:30 pm, some patients were observed wearing bright pink wrist bands. A Mental Health Technician (Staff 45) explained in an interview at 5:45 pm, the pink wrist bands were for patients on therapeutic diets.

Continued observation did not show any of the patients with the pink wrist band receiving food items in portions or consistencies different from those of other patients on the regular diet. Nursing staff present were not observed using a list to identify the patients and provide food service staff information on what diet the patient was ordered to receive.

RD stated in an interview on July 11, 2017, stated that patients have been educated and therefore allowed to make choices.

9. Patient 5 was admitted to the hospital with psychiatric and medical diagnoses including hypothyroidism, asthma, high blood pressure and GERD. In addition, food allergies noted in the clinical record included fish, shellfish and "lactose intolerance".

Her admission weight was 255. 2 pounds and was 5 feet 1 inch tall. This is calculated as a BMI of 46. A BMI of 46 is classified as morbidly obese. A referral was sent to the registered dietitian (RD) on July 4, 2017 based on her weight, lactose intolerance and allergies to fish and shellfish.

Prior to the RD assessment, the nursing staff had developed a care plan related to Patient 5's weight and blood pressure. Review of the nursing notes revealed documentation that Patient 5 was served and ate ice cream on July 5, 2017. Ice cream contains lactose that had been documented the patient was intolerant to. In addition, Patient 5 was served excessive quantities of snack items and liquids. For example, on July 6, 2017, nursing notes revealed she ate 2 Nutrigrain bars at 8 pm.

On July 7, 2017 at 8:00 am, nursing notes indicated Patient 5 consumed 16 ounces of orange juice with breakfast. Two hours later, it was documented she "ate 2 cereal (boxes) with milk 100%. An hour later at 11:00 am she ate 100% of yogurt. Lunch was a hour later at 12:00 pm. These food items are in addition to the regular diet provided in the hospital. There were several notes that Patient 5 usually consumed 100% of her meals. Although as part of her care plan for GERD, small frequent meals was recommended, there was no indication these small meals were planned to be part of the total caloric intake for one day.

According to the hospital diet manual, the regular diet provides approximately 2352 calories. These additional items would add additional calories to the regular diet that Patient 5 receives resulting in weight gain.
On July 7, 2017, the RD completed a nutrition assessment and her nutritional diagnosis included obesity and high blood pressure. Her adjusted body weight was 140 lbs. (pounds) and her calculated estimated caloric need was 1920 - 2240 calories per day. The RD recommendations were a NAS (No Added Salt) diet with the goal to maintain weight and follow therapeutic meal plan.

There was no system in place to ensure that nutritional needs of patients were met.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure the registered dietitian had adequate provisions to ensure the nutritional needs of all patients were met. This deficient practice resulted in needs of three sampled patients (Patients 5, 6 & 7), several unsampled patients including those on NCS (No Concentrated Sweets) diet and others on therapeutic diets were met.
Finding
According to interview of July 10, 2017 at 3:10 pm, the hospital Food Service Director (FSD) explained her job responsibilities included clinical nutrition in addition to managing the department.
1. Observation during meal preparation revealed the hospital provided to patients with diabetes, an outdated diet called NCS diet. A review of the diet sheet for the dinner meal for July 10 to July 12, 2017 indicated that there were between six to nine patients on a "No Concentrated Sweets Diet" (NCS). A review of the hospital diet manual revealed there was no diet titled NCS diet. The FSD in an interview on July 11, 2017 at 10:50 am stated the NCS diet is served to patients with diabetes.
In 2002, the American Diabetes Association (ADA) in a Position Statement made recommendations to Acute Health care Facilities that "meal plans such as No concentrated sweets, no sugar added, low sugar and liberal diabetic diets are no longer appropriate.

The Consistent Carbohydrate (CCHO) Diet was the recommended diet by the ADA until December 2016. The FSD and DM who are both registered dietitians indicated in the concurrent interview, they were not aware of the recommendations.

Review of the hospital diet ordering system as part of the electronic medical record was reviewed on July 13, 2017. Under the Patient Dietary Needs tab, it showed that the NCS diet was one of the diet options for health care professionals to order. The CCHO diet was not listed.

2. The hospital serves three distinct population of patient, adolescent (12-17years), adults (18 -64 years) and geriatric (> 65 years). The hospital menu does not identify the unique needs of each of these groups of patients. All receive the same kind of food in the same quantity. Review of the hospital's diet manual revealed the differences in nutritional needs between the different age groups.

For example, the adolescent diet is described as a regular diet with increased portions of milk and high calcium foods and additional calories to meet rapid growth requirements. The sample meal plan was 2780 calories and 146 grams protein with 3 cups of fat-free milk. This diet also states to limit 100% juice to 4 to 6 ounces of juice daily. Review of the hospital's regular diet shows it to contain 2 cups of milk and diet lemonade and about 2352 calories.

The geriatric patients receive the same diet as those of adult patients. According to the (Dietary Reference Intake (DRI)s for the 70 year old is approximately between 1873 -2000 calories. The hospital has failed to tailor the nutritional needs of its patients.

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that food service staff was competent in food service duties when a food service work failed to correctly test the concentration of the quaternary ammonia sanitizer. Another foodservice work failed to respond appropriately and timely to low food temperatures on the trayline. These failures had the potential to cause food borne illness, unpalatable food resulting in decreased food intake.

Findings:

1. During meal observation on July 10, 2017 at 5:20 pm, FSW 1 was observing dishing out pieces of pork roast as part of evening meal into Styrofoam containers. According to the menu, the portion size for the pork roast is 3 ounces. The portions being served looked larger than the 3 ounces listed.

A check of one of te portion served on a scale showed it was 4 ¾ ounces. This approximately one a half times the portion planned by the registered dietitian. This of significance because it could result in excess calories and weight gain in some patients in which weight gain might not be desirable.

2. Food temperatures taken during trayline observation on July 11, 2017 at 11:53 am indicated the chicken entrée was 119 .2 degrees Fahrenheit (F). Food service worker (FSW) 1 who was actively dishing out the entrée and other food items was informed of the temperature of the chicken. The recommended minimum holding food temperature of hot items is 135 degrees F. FSW 1 continued to serve the patients and was not observed to recheck the temperature or take any actions to ensure that the food was being held at the appropriate temperature.

Due to the lack of response regarding the low holding temperature for the chicken observed, at 12: 06 pm on July 11, 2017, FSW 1 was interviewed about the hospital's policy on holding food temperatures and lack of action to ensure that the food temperature was appropriate. In the concurrent interview, FSW stated she had stirred the chicken dish. When she was asked what the temperature was after stirring she stated she had not rechecked the temperature after stirring.

The Dietary Manager (DM) was present during the interview stated that FSW should have reheated the entrée to ensure that the food was at the appropriate temperature. FSW 1 stated at 12:10 pm, she was aware of the policy and that she should rechecked the temperature and reheated it if was below the recommended.

Review of the hospital policy titled "Food temperature Checklist" reviewed March 2017 indicated "If the temperature noted is below recommended, it will need to be reheated until the recommended temperature is attained before serving"

3. According to the menu on July 11, 2017, fish tacos, key Biscayne vegetables, Diet fruit salad, flour tortilla and diet lemonade were items for lunch for patients on the regular diet. However, observation during trayline revealed other entrée items such as tofu and chicken.

Review of the food temperature log on July 11, 2017 at 11:58 am showed the temperature of the only entrée written was the fish dish. FSW 2 who prepared the dish was interviewed about the documentation of food temperatures. At 12:00 pm on July 11, 2017, FSW 2 stated the chicken was 175 degrees F. When she was asked why it was not written down, she asked with a bewildered look "I did not write it down?"

Closer look of the log revealed that there was space for only one entrée. The hospital had not been documenting the temperature of the alternate entrees including the vegetarian dishes. An interview was conducted with the DM at 12:30 pm about the lack of documentation of all prepared foods. The DM provided no explanation.

4. On July 12, 2017 at 10:42 am, FSW 2 was asked to test the concentration of the quaternary (quat) sanitizer. FSW 2 immersed the test strip into the bucket containing the sanitizer held it for approximately 4 seconds, removed it and read it against the color chart on the test strip holder. She stated "150" (parts per million). FSW 2 was asked how long the test strip should have been left in the sanitizing solution for testing. She stated "about 4 seconds".
She was asked to retest the sanitizer after referring her to the manufacturer's instructions, which indicated 10 seconds. On retesting with the proper immersion time, the test strip was between 200 and 300 ppm.
The Food Service Director (FSD) and DM who were present during the observation indicated during an interview at 10: 45 am, FSW was trained at a monthly meeting or inservice on testing the sanitizer.

Sanitizers are important to eliminate the risks of food-borne illness. Ensuring adequate concentration is important for sanitizing. Without proper sanitation of kitchen surfaces and equipment, microorganisms can be transferred from one food or surface to another leading to food-borne illness.

Based on review of hospital menu, diet order sheet, diet manual and clinical record reviews and staff interviews, the hospital failed to ensure that the nutritional needs of its patients were in compliance with recognized dietary practices. The hospital provided patients with an outdated diet for the treatment of diabetes. In addition, they failed to ensure that patients on the outdated diet (no concentrated sweets) received food according to the guidelines stipulated. Other patients on therapeutic diets with the pink wrist bands were provided diets without a system that would ensure compliance with the orders of their physicians. These failures resulted in one sampled patient (Patient 6) with abnormally high blood sugar levels with insulin injections as many as four times daily, Patient 7 receiving food that could have been a choking hazard, other patients receiving diets that was above their calculated dietary needs.

Finding

1. During food preparation observation on July 10, 2017 at 4:00 pm, FSW 3 was observed cutting up several trays of apple pie. FSW 3 in a concurrent interview, stated the apple pie was dessert for patients on regular diet and that she would be preparing other items such as fruit and diet pudding for other patients such those on the no concentrated sweets diet because they cannot have apple pie.

A review of the diet sheet for the dinner meal for July 10 to July 12, 2017 indicated that there were between six to nine patients on a "No Concentrated Sweets Diet" (NCS). A review of the hospital diet manual revealed there was no diet titled NCS diet. The Director of Food services (DFS) in an interview on July 11, 2017 at 10:50 am stated the NCS diet is served to patients with diabetes. The NCS diet according to the hospital document titled "House Diets" describes the diet as the "house diabetic diet or calorie controlled diet". It has 4-5 carbohydrate choices per meal, 60 - 75 grams of carbohydrate per meal. The description of the diet includes that "no concentrated sweets will be given unless indicated on diet census sheet. Sugar free options will be given if/when available. Patients on this diet will be restricted on fruits packed in syrup or high sugar substitute, and will be provided fresh fruit or fruits packed in juice, sugar free pudding or fruit.

In 2002, the American Diabetes Association (ADA) in a Position Statement made recommendations to Acute Health care Facilities that "meal plans such as No concentrated sweets, no sugar added, low sugar and liberal diabetic diets are no longer appropriate. These diets do not reflect the diabetes nutrition recommendations and unnecessarily restrict sucrose. Such meal plans may perpetuate the false notion that simply restricting sucrose -sweetened foods will improve blood glucose control." (Diabetes Care Vol 25, Supplement 1, January 2002)

The Consistent Carbohydrate (CCHO) Diet was the recommended diet by the ADA until December 2016. The DFS and DM who are both registered dietitians indicated in the concurrent interview, they were not aware of the recommendations. Neither was unable to provide an explanation on why the NCS diet was provided instead of the CCHO diet that was in the hospital diet manual.
Review of the hospital diet ordering system as part of the electronic medical record was reviewed on July 13, 2017. Under the Patient Dietary Needs tab, it showed that the NCS diet was one of the diet options for health care professionals to order. The CCHO diet was not listed.

2. The hospital failed to ensure that one patient on the NCS diet received the diet as described in the House Diet document and hospital menu. Patient 6 was 14 years old and was admitted to hospital with psychiatric and medical diagnoses including obesity and diabetes.
Her admission weight was 257 pounds and 5 feet 4 inches tall. Her medications included oral diabetes medication and a sliding scale insulin protocol three times a day before meals. Patient 6 was ordered to receive insulin whenever her blood sugar was over 121 mg/dl with insulin amounts increasing with increasing blood sugar levels.
Review of clinical record showed her physician ordered diet was a "diabetic diet". According to the hospital diet there was no diabetic diet. There was no evidence that the diet was clarified by either nursing or food and nutrition staff that the diet approved by the hospital medical staff was ordered. Review of the diet list from the food and nutrition department showed Patient 6 was served a NCS diet.

Laboratory test completed on 7/10/17 at 8:21 am showed Patient 6's glucose was high at 219 mg/dl (normal 65 -99). The Hgb A1C was 8.2 (normal 4-8 - 6.4) with >6.4 as an indication of diabetes. HGB A1C or glycated hemoglobin test is an important blood test that provides an average of a person's blood sugar control over a two to three month period. (webmd.com). There is a correlation between Hgb A1C and average blood sugar. Higher amounts of glycated hemoglobin, indicates poorer control of blood glucose levels. A Hgb A1C of 8 correlates with average blood sugar of 183 (147-217) mg/dl. (webmd.com)

The lack of adequate monitoring of the Patient 6's diet is evidenced by the recorded blood sugars. The Blood sugars recorded for Patient 6 four times a day on the hospital form titled "Blood Glucose Flowsheet" starting July 8 through July 12, 2017 showed her blood glucose was consistently higher than the normal level despite receiving an oral diabetes medication and insulin. Her blood sugars have ranged from 133 -338 mg/dl from July 10 -12, 2017. There was no single test in the time period reviewed that showed Patient 6's blood sugar test in the normal range. On July 10, 2017 at 8:30 pm, Patient 6's blood sugar was 508. She stated according to the interdisciplinary notes "I just ate cookies". She received a total of 14 units of insulin in two hours according to physician's order, to get her blood sugar levels to a level that was acceptable to the physician.

The Intake and Output form from July 10 - 12, 2017 showed Patient 6 received food items that were contraindicated on the hospital's NCS diet. For example, on 7/11/17 she received a brownie. She should have received diet vanilla pudding. On July 12, 2017, the patients on the NCS diet were to receive diet chocolate pudding and those on the regular diet received ice cream for dinner. Patient 6 received ice cream and not the diet pudding as was stated on the menu for patients receiving the NCS diet. In addition, she received 8 ounces of apple and/or orange juices as snacks on July 12, 2017 and July 13, 2017.

In an interview with the charge nurse, (Staff 43), on July 13, 2017 at 11:08 am, Staff 43 was asked what a diabetic diet was since that was documented on the admission orders for Patient 6. He stated there was no diabetic diet and that Patient 6 should be a NCS. This interview revealed that the hospital staff (nursing and food and nutrition) all identify the diabetic diet or diet for patients with diabetes.

Staff 43 was also asked about Patient 6's high blood sugars despite taking oral diabetic medication and insulin and the observation that food items served to her were not generally on her NCS diet. Staff 43 stated there are a variety of snacks brought to the unit and the type of snack varies by day and time. Snacks provided could be chips, cookies, fruit, cereal, string cheese. Staff 43 stated on July 13 at 10:50 am, a large bowl of mixed fruit was brought to the unit including bananas, apples, oranges, peaches, pears and string cheese.

An interview was conducted on July 13, 2017 at 11: 30 am with a Mental Health Technician (Staff 44). Staff 44 identified Diabetic snacks as items "low sugar and high protein such as string cheese, yogurt, granola bars, sugar-free jello. Staff 44 stated Patient 6 was served on July 13, 2017 one juice box but she got two additional juices boxes from others. Staff 44 was asked what the hospital staff was doing to ensure the appropriate items was served to prevent high blood sugars as was observed on July 10, 2017. Staff 44 stated Patient 6 has been counseled and had been told she may have to sit privately and not sit with other patients if she continued to receive food from others.

In an interview on July 13, 2017 at 12:05 p.m., Patient 6 stated when asked about food being provided by other patients, that none of the patients provided her the extra food, she gets it herself.

3. During meal service observation in the cafeteria on July 10, 2017 at 5:30 pm, some patients were observed wearing bright pink wrist bands. A Mental Health Technician (Staff 45) explained in an interview at 5:45 pm, that the pink wrist bands were for patients on therapeutic diets.

Continued observation did not show any of the patients with the pink wrist band receiving food items in portions or consistencies different from those of other patients on the regular diet. Nursing staff present were not observed using a list to identify the patients and provide food service staff information on what diet the patient was ordered to receive.

Patient 7 was one of those patients who had on a pink wrist band. During a random interview with Patient 7 on July 10, 2017 regarding the food in the hospital, it revealed she had missing teeth on her lower jaw. She had received the same entrée as other patients in the dining area.

4. Patient 7 was admitted to the hospital with both psychiatric and medical diagnoses including hypertension (high blood pressure), constipation, hyperparathyroidism, urinary tract infection. She was borderline underweight weighing 120 pounds (lbs.) and 5 feet and 6 inches. Ideal body weight range 117 - 143 lbs. and a BMI of 19 (Normal 18-25) Body Mass Index (BMI) is a measurement of degree of fatness.

Clinical record review conducted on July 13, 2017 showed that the physician ordered diet Patient 7 was a NAS diet. Review of the diet list posted in the nursing station revealed a discrepancy between what the physician ordered on June 24, 2017. The posted list indicated she was also on mechanical soft ground texture in addition to the NAS diet.

Review of clinical record showed that Patient 7's diet was changed several times since she had been admitted. On June 14, 2017 she was on a regular diet and later changed to Mechanical soft NAS diet. On June 19, 2017 her diet was downgraded further to a ground texture on the recommendation of the registered dietitian (RD). On June 23, 2017, Patient 7's diet was changed to a full liquid diet for dinner due to complaint of nausea. The full liquid diet was discontinued and upgraded to a BRAT diet later that day. The BRAT (bananas, rice, apples and toast) diet, is an outdated diet used for the treatment of nausea. On June 24, 2017, her diet was changed to NAS with the order "resume NAS diet". There was no modifier on the texture. There was no documentation in the clinical record that nursing staff clarified the order to include the texture modifications. Patient 7 is currently receiving a NAS, mechanical soft, ground diet.

In an interview with the unit manager (Staff 15) at 1:40 pm on July 13, 2017, Staff 15 indicated that when diet orders are reordered after being previously discontinued, any texture modifications are automatically added to the diet as it was before without physician clarification or instructions. In an interview with the DFS on July 13, 2017 at 4:20 pm, she indicated that the ground consistency may no longer have been necessary since Patient 7 currently has upper dentures which were not available when the initial recommendation was made to modify the texture.

On June 14, 2017, The RD recommended Patient 7 receive Ensure Plus, a high calorie nutritional supplement, due to poor appetite, no teeth (edentulous) and low weight. On June 16, 2017, an order was written for the nutritional supplement twice a day with snacks.
During interview with Patient 7 on July 13, 2017 at 12:51 pm, she indicated she had lunch but could not taste her food because the medications which she understands she needs to take have altered her taste. Patient 7 indicated she had mentioned to the staff but that they cannot do anything about it.

Staff 15 was interviewed about the taste alterations that Patient 7 had mentioned in the interview. Staff 15 stated in the interview at 12:57 pm, that he was not aware of her taste alteration concerns. Further clinical record review did not indicate whether or much of the nutritional supplement Patient 7 was consuming. There was indication Patient 7 had compliant of nausea and was given medication for nausea on June 23, 2017.

Staff 15 was interviewed on whether Patient 7 was consuming the supplement with the concern of nausea. Staff 15 was asked how the tolerance and efficacy of the medical nutrition therapy will be correctly evaluated if the information was not collected to help the RD in care planning. Staff 15 indicated in the concurrent interview the nursing staff did not document intake of nutritional supplements.

Further review of the clinical record of Patient 7's showed that the RD had recommended discontinuation of the nutritional supplement. In a follow up note, the RD requested the discontinuation of the supplements but as of July 13, 2017, Patient 7 was listed as receiving the nutritional supplement twice a day.

In an interview with the RD on July 13, 2017 at 4:25 pm, she stated Patient 7 had expressed not liking the Ensure Plus because of nausea. The RD further stated Patient 7 did not have dentures when she was first admitted but family brought in the "uppers" and so she was eating better. The RD stated she agreed to discontinue the supplement because there had been improvements in weight gain due to improvement in intake.

The hospital lacked a system to evaluate effectiveness of the nutritional supplement an integral of medical nutrition therapy for Patient 7. In addition, the recommendations of the registered dietitian were not communicated with the physician timely to ensure appropriate resolution.

3. Patient 5 was admitted to the hospital with psychiatric and medical diagnoses including hypothyroidism, asthma, high blood pressure and GERD. In addition, food allergies noted in the clinical record included fish, shellfish and "lactose intolerance".
Her admission weight was 255. 2 pounds and was 5 feet 1 inch tall. This is calculated as a BMI of 46. A BMI of 46 is classified as morbidly obese. A referral was sent to the registered dietitian (RD) on July 4, 2017 based on her weight, lactose intolerance and allergies to fish and shellfish.

Prior to the RD assessment, the nursing staff had developed a care plan related to Patient 5's weight and blood pressure. Review of the nursing notes revealed documentation that Patient 5 was served and ate ice cream on July 5, 2017. Ice cream contains lactose that had been documented the patient was intolerant to. In addition, Patient 5 was served excessive quantities of snack items and liquids. For example, on July 6, 2017, nursing notes revealed she ate 2 Nutrigrain bars at 8 pm. On July 7, 2017 at 8:00 am, nursing notes indicated Patient 5 consumed 16 ounces of orange juice with breakfast. Two hours later, it was documented she "ate 2 cereal (boxes) with milk 100%. An hour later at 11:00 am she ate 100% of yogurt. Lunch was a hour later at 12:00 pm. These food items are in addition to the regular diet provided in the hospital. There were several notes that Patient 5 usually consumed 100% of her meals. Although as part of her care plan for GERD, small frequent meals was recommended, there was no indication these small meals were planned to be part of the total caloric intake for one day.

According to the hospital diet manual, the regular diet provides approximately 2352 calories. These additional items would add additional calories to the regular diet that Patient 5 receives resulting in weight gain.

On July 7, 2017, the RD completed a nutrition assessment and her nutritional diagnosis included obesity and high blood pressure. Her adjusted body weight was 140 lbs. (pounds) and her calculated estimated needs was 1920 - 2240 calories per day. The RD recommendations were a NAS (No Added Salt) diet with the goal to maintain weight and follow therapeutic meal plan.

Based on observation, interview and record review the hospital failed to assure patients were protected from potenital hospital acquired infections and failed to provide a sanitary environment.

1. A medication nurse did not perform hand hygiene during medication administration between patients (Refer to A0405).

2. The used and wet hospital issued swimming trunks were kept exposed on top of a washer on Unit G (refer to A0749).

3. The seclusion room on Unit G has not been cleaned of trash, discarded food items and containers on the floor and blood stained mattress box. (Refer to A0749).

4. An adolescent gained access and barricaded himself into a janitor's closet with overflowing trash receptacle that contained dirty and used feminine sanitary pads. (Refer to A0749).

5. The housekeepers responsible for terminal cleaning of patient rooms after discharge were not available to perform the task. (Refer to A0749).

6. Several adolescent patients ate lunch without hand hygiene before meals. (Refer to A0749)

7. The newly designated Infection Control Officer of 3 months and under the mentorship of the corporate Infection Control Office has not provided any infection technical support and education for the facility staff. (Refer to A0748).

8. There was improper storage of refrigerated food, poor maintenance of food service equipment (chopping board, ice machine and open refrigerated unit). (Refer to A0749).


These deficiencies resulted in potential harm such as hospital acquired infections during the hospital stay.

Based on interview and record review, the hospital failed to assure that the newly designated infection control nurse has developed a system to monitor staff practices in the prevention and transmission of hospital acquired infections. This failure resulted in potential continued deficient staff practices to prevent and control hospital acquired infections.

Findings:

In an interview on 7/13/17 at 3:15 p.m., Staff 20 said, she has worked with the hospital since February 2017 as an Admissions and Intake nurse and was designated as the Infection Control Officer since April of 2017.

Staff 20 said, the hospital has provided 24 hours of training by an Infection Preventionist at a sister corporation hospital. According to Staff 20, her infection control experience included only implementation of the infection control program as a charge nurse in a nursing unit and as a wound nurse of another hospital. Staff 20 said the hospital administration recently gave approval for her to attend a certification class on infection control and epidemiology in Fall of 2017.

The hospital did not present any other staff development plan for Staff 20 to learn the hospital's overall infection control program and enable Staff 20 to develop a system to monitor staff practices in the prevention and control of hospital acquired infections.

Based on observation, interview and record review the hospital failed to ensure that the newly designated infection control officer had a system to ensure that the staff and/or patients implement hand hygiene and maintain a sanitary environment to prevent potential hospital acquired infections.

Findings:

1. During random observations, record reviews and staff interviews from 7/10/2017 to 7/14/2017, the survey team noted the following:

a). During an observation on 7/12/17 at 8:45 a.m., Staff 29, the medication nurse on Unit 3A, did not perform hand hygiene during medication administration between Patients 12, 14, & 13. While in the hallway and by the medication cart, Staff 29 administered 4 medications to Patient 12, followed by 3 medications to Patient 14 and 1 medication to Patient 13 without hand hygiene in between patients. There was a bottle of alcohol based hand sanitizer on top of the medication cart accessible to Staff 29.

b). On 7/10/17 at 11:35 a.m., the seclusion room on Unit G was dirty with discarded food items on a tray in the alcove, discarded food container and styrofoam cups in the bathroom. The bed was not made. Staff 46 was present during the observation and stated a patient was admitted earlier that day at 4:00 a.m.. Staff 46 said, sometimes, the night staff would initially place a newly admitted patient. Staff 46 said, the staff probably forgot to call housekeeping to clean the room.

c). On 7/10/17 at 11:40 a.m. while in the presence of Staffs 3 and 46, a collection of dirty hospital issued swimming trunks sat exposed on top of a washer on Unit G. Staff 46 said, the patients used swimming trunks at the hospital pool. The swimming trunks were on top of the washer waiting for the washer to be available.

d). On 7/11/17 at 11:47 a.m., there was a trash receptacle on the floor with overflowing trash receptacle in the janitor's closet on Unit 2C. The overflowing trash included used feminine sanitarty tampons. Staff 47 said, an adolescent patient had just barricaded himself in the janitor's closet and knocked down the trash receptacle. Staff 47 stated, overflowing trash was no surprise. Staff 27 said, she had not seen a housekeeping personnel for 2 - 3 hours that morning. According to Staff 27, the Mental Health Technicians (MHTs) had been performing terminal cleaning of the rooms when discharges occur because they couldn't get in touch with a housekeeper to clean the patient rooms. Staff 47 continued to say, Unit 2C had a patient in 204 - B who was bedwetting and had nose bleeding. The bed was not cleaned properly. Staff 47 showed the bed to the surveyor. As observed, the bed box had a long notcieable dried dark reddish brown stain on one side.

e). On 7/11/17 at 10:49 a.m., a used dirty pen-injector ( injectable medication container device to administer medication through the skin) was stored in the pharmacy medication refrigerator. During an interview with the pharmacist, the refrigerator was to store only clean medication for patients.


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2. On July 10, 2017 at 3:46 pm, six cutting boards that had been stored away as clean were examined. The three green, one red and one blue, cutting board had varying amounts on dark brown substance on them. There was this dark brown substance in the groove of the cut marks of the blue cutting board. The Director of Food Service (DFS) who was present during the observation stated the boards are cleaned after use by running them through the dish machine. Hospital policy titled "Cutting Board" approved March 22, 2017, states the cutting boards " may be periodically sprayed with sanitizer to reduce the amount of bacteria" it was unclear when this procedure was last applied to the boards

3. There was a large mixing bowl stored away as clean that had food debris. There was a white silvery colored substance. The shaft of the mixer had white dried on substance around it. DFS stated in the concurrent interview, the mixer is only used for mixing mashed potatoes.

4. On July 12, 2017 at 10:30 am, the ice machine located in the kitchen had a dark brown, orange and pink colored slimy residue in the ice dispensing area when it was wiped with a paper towel. The Dietary Manager who was present during the observation stated the ice machine bin is cleaned monthly by the food and nutrition staff while the other areas are cleaned by an outside contractor.
According to the hospital policy titled "Care of the Storeroom" approved March 22, 2017, the ice machine is cleaned "1 time per month, or as needed".
Review of the cold equipment maintenance checklist provided by the contractor dated 5/22/17 showed tasks completed. The columns completed included cleaning coils, harvest ice, leak checks, motor and electrical, etc. there was no indication that the interior components were cleaned and sanitized. Sanitizing with the appropriate chemical will prevent the growth of the water borne bacteria that causes the pink, orange, brown colored residue.

5. The open refrigerated holding unit used for salad display was also observed to have the same dark brown colored substance around the rim and crevices. There was visible condensation and ice frost build up in some of the corners which indicates some warming and therefore may not as as cold is recommended for cold holding which is below 41 degrees Fahrenheit.
Slime also known as yeast, mold, biofilm, organic growth and biological pollution. The precursors are naturally occurring in the air and contaminate ice machine as air is drawn in as part of its normal operation. The temperature, moisture, and environment in the kitchen make it an ideal environment for the growth of the yeast and/or bacteria. "Most times slime will take on a pinkish tone, if left untreated will turn to red, green, brown or even black." (Houston Department of Health and Human Services article on houstontx.gov).
If left untreated, the slime results in machine efficiency problems and contamination of ice production. There have been several published reports of infection outbreaks in hospitals traced back to contaminated ice machines. Infections include legionella pneumophila, the bacteria which causes Legionnaire's disease; mycobacterium fortuitum, nontuberculous mycobacteria, which is a major cause of infections in immunocompromised patients. ( BioZone Scientific International: Slime in Ice machine article)

6. Inside the refrigerator on July 10, 2017 at 3:26 pm, a metallic silver colored pouch was observed in the walk -in refrigerator labeled "7/6/17" Chicken broth. The DFS who was present during the observation explained it was a broth concentrate used for soups for patient on liquid diets. The product did not have a use by date or expiration date and the DFS indicated she was unsure but the product was shelf stable for three years. She was unsure how long to keep the product after it was open. The product had been opened.
On July 12, the DFS stated she had called the manufacturer and was told was broth was good for one year. Based on the science of food, moist products with protein do not routinely last a year and the information seemed unreliable. According to the company website, each pouch is stamped with a "best -by date and instructions" According to the United States Department of Department of Agriculture Food Safety and Inspection Service "Best if Used By/Before" indicates when a product will be of best flavor or quality. It is not a purchase or safety date. According to the USDA the pouch also called retort packaging is shelf stable at room temperature but with poultry products in retort pouches it is good for 3 to 4 days in the refrigerator after opening.

7. During observation of the lunch meal on July 12, 2017 at 12:46 pm, there were eleven adolescent patients eating in the multi- purpose room on the unit. Each was served their food in a white covered Styrofoam container and was provided plastic spoons to eat.
One unsampled patient stated "I never thought I will get to see the day that I will have to eat noodles with a spoon". Two other patients were observed picking up the noodles and broccoli with their hands. Another unsampled patient said to the other patients "Let me show you how" He was then observed inverting the spoon, holding the bowl or open part (which would normally be put in the mouth) and twirling the noodle with the spoon handle. He also demonstrated picking up some of the vegetable pieces by spiking the broccoli and chicken with the spoon handle. He was not successful during all of the attempts.
General dining and social etiquette requires the use of proper dining utensils. The spoon is not the proper utensil for eating noodles or broccoli. There were no hand sinks in the room. None of the patients were observed to wash hands or request hand towels to clean hand prior to eating with their hands. Lack of hand washing prior to eating could result in gastro intestinal distress due to contamination of the food with dirty hands.

Based on interview, observations and document review the facility failed to:

I. Revise treatment plans for two (2) of 10 active sample patients (A6 and B5) in a timely manner. This failure jeopardizes a timely, coordinated, responsive treatment process. (Refer to B118)

II. Develop treatment plans that clearly delineated interventions to address the specific treatment needs of 10 of 10 active sample patients (A6, A14, B5, B6, C7, C10, E5, E13, F14 and G19). Instead, treatment plans included interventions that were routine, generic discipline functions, or staff goals. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment. (Refer to B122)

III. Ensure that active individualized psychiatric care was provided for two (2) of 10 active sample patients (A6 and B5) Even though these patients failed to attend the majority of groups/activities on the unit, alternative treatment based on their individual treatment needs was not provided. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning. (Refer to B125, Section I)

IV. Ensure that structured groups/activities to meet the needs of the patient population were provided. All patients were expected to attend the same groups/activities on five (5) of five (5) adult units (A, B, E, F and G) even though this programming did not meet their individual needs. This failure hindered patient's participation in active treatment and resulted in patients roaming the halls and sleeping in bed. (Refer to B125, Section II)

Based on record reviews and staff interviews, the facility failed to develop and include patient specific conclusions and recommendations by the social worker staff in the Biopsychosocial Assessment of 10 of10 sample patients' records (A6, A14, E5, E13, F14, B5, B7, C7, C10, G19). Specifically Case Manager's roles and interventions for preliminary discharge planning were generic functions of social work staff. The Assessments lacked the following:

1. Anticipated necessary steps for discharge to occur.

2. Specific patient and family psychosocial issues requiring early treatment planning and immediate interventions.

3. Specific community resources/support systems for utilization in discharge planning.

Such failure impedes treatment team's ability to formulate an appropriate and timely discharge, resulting in prolonged hospitalization.

Findings Include:

A. Record Review:

1. For Patient A6 Admitted on 6/22/17, Biopsychosocial Assessment dated 6/24/17 listed the following in Case Manager's (CM) role in preliminary discharge planning: "CM will collaborate with pt. and supports to est(ablish) a safe d/c [discharge] plan that will include psychiatric aftercare upon d/c."

2. For Patient A14 admitted on 6/19/17, Biopsychosocial Assessment listed 6/20/17 listed the following in Case Manager's role in preliminary discharge planning: "Case Manager will collaborate with Pt., MD and outpatient provider to coordinate a safe discharge plan for patient. Case manager will arrange aftercare appointment as appropriate ...."

3. For Patient E5 admitted on 7/4/17, Biopsychosocial Assessment dated 7/4/17 listed the following in Case Manager's role in preliminary discharge planning: "Social services will collaborate with patient, patient's family and service providers to arrange a safe discharge plan with after care appointments."

4. For Patient E13 admitted on 7/7/17, Biopsychosocial Assessment dated on 7/9/17 listed the following in Case Manager's role in preliminary discharge planning: "CM will work with patient, treatment team and family to ensure a safe environment and discharge is in place prior to patient leaving FH. CM will arrange follow up appointments and necessary aftercare services to decrease rehospitalization [sic]."

5. For Patient F14 admitted on 5/24/17, Biopsychosocial Assessment dated 5/27/17 listed the following in case manager's role in preliminary discharge planning: "CM will collaborate with patient and supports to develop safe discharge plan including appropriate follow up care."

6. For Patient B5 admitted on 6/15/17, Biopsychosocial Assessment dated on 6/16/17 listed the following in Case Manager's role in preliminary discharge planning: "SS will work with patient and social support to make appropriate discharge plan with safety plan and appropriate follow up care to address paranoia."

7. For Patient B7 admitted on 7/3/17, Biopsychosocial Assessment dated 7/4/17 listed the following in case manager's role in preliminary discharge planning: "Case Manager will collaborate with patient, treatment providers to ensure patient has follow up psychiatric care."

8. For Patient C7 admitted on 7/8/17, Biopsychosocial Assessment dated 7/9/17 listed the following in Case Manager's role in preliminary discharge planning: "CM will work with patient, family and community providers to set up psychiatric care and safe discharge plan...."

9. For Patient C10 admitted on 6/28/17, Biopsychosocial Assessment dated 7/1/17 listed the following in Case Manager's role in preliminary discharge planning: "SS will collaborate with patient, patient's family and other service providers to provide safe discharge plan with aftercare appointment."

10. For Patient G19 admitted on 6/30/17, Biopsychosocial Assessment dated 7/6/17 listed the following in Case Manager's role in preliminary discharge planning. "SS will collaborate with patient and family to establish discharge and follow up psychiatric care to prevent rehospitalization and maintain stability in [his/her] community."

B. Staff Interview:

In an interview with the surveyors on 7/12/17 around 11:30 AM, the Director of Social Work acknowledged that the preliminary discharge planning in Biopsychosocial Assessments of all the sample patients was generic functions of the social work discipline.

Based on interview and document review, treatment plans for two (2) of 10 active sample patients (A6 and B5) had not been revised in a timely manner. This failure jeopardizes a timely, coordinated, responsive treatment process.

Findings include:

A. Patient A6 was admitted on 6/22/17.

1.According to the psychiatric evaluation (6/23/17), Patient A6 was admitted after being paranoid, delusional and threatening to hurt self and others.

2.Review of Patient A6's treatment plan (6/25/17) revealed that an intervention titled "milieu therapy" stated "[Patient] will process triggers of psychotic symptoms in group. [S/he] will learn 2 positive activities such as deep breathing and 5 senses to ground [himself/herself] in reality"

3.Review of the "Inpatient Group Therapy Notes" for Patient A6 from 7/3/17 to 7/10/17 revealed that this patient had attended only 4 of 28 available groups/activities. From 7/7/17 to 7/10/17, patient A6 did not attend a single group. Group leader notes indicated interaction duration of 1-2 minutes. Most common reason for non-attendance was "patient sleeping".

4. Patient A6 had not attended most groups (24 out of 28), yet Master Treatment Plan update (7/9/17) for this patient noted following behaviors: "Talk to self [sic]. some group attendance". Changes/Interventions noted were "continue with current plan" with revised target date of 7/16/17.

5. During interview about Patient A6's treatment on 7/12/17 at 11:30 a.m., the Director of Social Services reported that additional documentation of alternative treatment might be in the patient's progress notes. No proof of alternative treatment was provided to the surveyors.

6. Even though this patient failed to attend assigned groups/activities, as of 7/11/17, Patient A6's treatment plan was not revised to include alternative treatment based on his/her individual needs.

B. Patient B5 was admitted on 6/15/17.

1.According to the psychiatric evaluation (6/16/17), upon admission Patient B5 stated that "the phones were tapped at Grant House ...had other bizarre delusions ...a delusion of being poisoned & (and) resulting in [his/her] right arm coming out of the socket."

2. Review of Patient B5's treatment plan (6/18/17) revealed that an intervention titled "milieu therapy" stated "[Patient] will process triggers that lead to paranoi [sic] in group. [S/he] will learn 2 positive activities such as deep breathing and 5 senses (sic) to ground [himself/herself] in reality."

3. Review of the "Inpatient Group Therapy Notes" for Patient B5 from 7/3/17 to 7/10/17 revealed that this patient had attended only eight (8) of 28 available groups/activities.

4. During interview on 7/12/17 at 8:30 a.m., RN8 stated that Patient B5 has a "hard time" sitting still (for group attendance). S/he reported that although a weekly "update" of the patient's plan has been conducted, the patient's treatment plan has not been revised although the patient does not participate in his/her treatment.

5. Even though this patient failed to attend assigned groups/activities, as of 7/11/17, Patient B5's treatment plan was not revised to include alternative treatment based on his/her individual needs.

C. Interview:

During interview with the Medical Director on 7/12/17 around 10:45 AM, he acknowledged that the sample patients A6 and B5 did not have active alternative treatment when they refused to attend groups. On failure to revise treatment plans for these two sample patients he commented, "That's a problem. That's the issue we need to work on."

Based on record review and interview, the facility failed to develop treatment plans that clearly delineated interventions to address the specific treatment needs of 10 of 10 active sample patients (A6, A14, B5, B6, C7, C10, E5, E13, F14 and G19). Instead, treatment plans included interventions that were routine, generic discipline functions, or staff goals. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A Patient Findings:

1.Patient A6-Treatment plan of 6/25/17

For problem, "Psychotic Behavior: [Patient] internally preoccupied, threatened to hurt self or others ...paranoid, delusional and yelling, refused to eat food as was poisoned," a generic nursing intervention was "Educate medication side effects to pt. (patient)." There were no specific nursing interventions to direct staff in the monitoring and care of the patient presenting aggression and irrational behavior in the clinical area other than reporting feelings of self- harm or of hurting others.

A generic social work intervention was "Treatment planning with [Patient] and Medicare/Medical liaison to coordinate proper aftercare plan."

2. Patient A14-Treatment plan dated 6/22/17

For problem, "Taking [his/her] clothes off walking around the hospital naked. Delusions: A robot is inside [his/her] brain and moved to [his/her] abdomen," generic nursing interventions are "Engage in 1:1 with [Patient]" and "Encourage compliance with meds (medications)." There were no specific interventions to direct nursing personnel to address the patient's disrobing on the unit, nor the patient's delusions.

A generic social work intervention is stated as "Writer will collaborate with patient to create a plan for self care when [s/he] discharges from the hospital."

3.Patient B5-Treatment plan date of 6/18/17

For problem, "Psychotic behavior: thinks arm is being ripped out of socket ...believes there is a murder hit on [him/her]," nursing interventions failed to direct nursing personnel in responding to and assisting patient to control psychotic behavior. The only nursing interventions were generic, stated as "Benefits of taking meds (medications), using positive coping skills, benefits of attending groups and benefits of interacting & engagcd in 1:1."

A social work generic intervention was stated as "Tx (Treatment) planning with [Patient], family, conservator [name] to determine best discharge plan for [patient]. Safety planning to ensure safe DC [discharge] upon discharge."

4.Patient B7-Treatment plan of 7/6/17

a. For problem, "Psychotic Behavior: [Patient] was disorganized making bizarre statement [sic], and internally preoccupied," a generic nursing intervention was "orient [Patient] to unit and establish rapport with patient."
There were no nursing interventions to direct nursing personnel in how to respond to psychotic behaviors other than "reorient to reality as needed/redirect."

A generic social work intervention was "Treatment planning with family and out pt. (out- patient) to coordinate appropriate aftercare plan."

b. For problem, "Assaultive/Aggressive Behavior: [Patient] assaulted a nurse and peers at ER (Emergency Room) and went to jail for it," a generic nursing intervention was "Educate [Patient] on unit rules and expectations." An unclear intervention was stated as "Establish clear boundaries with [Patient]." There were no nursing interventions to direct staff regarding specific behavioral monitoring for either patient or how to handle this behavior in the clinical area.

5. Patient C7-Treatment plan date of 7/8/17

For problem, "Psychotic Behavior: [Patient] told teacher [s/he] was hearing voices in [his/her] head and seeing ghosts," in the section for the physician intervention, a
a patient assessment was documented: "Pt. [Patent] still in denial and fixated on discharge. No side effects. Family (sentence unfinished)."

A generic social work intervention was listed as "Treatment planning with [Patient], family and dr. (doctor) to coordinate appropriate after care plan."

6.Patient C10-Treatment plan date of 6/20/17

For problem, "Assaultive/Aggressive Behavior," the only physician intervention was "Assess mental status and titrate medications: Aggression." This was an expected role function.

A generic nursing intervention was stated as "Encourage verbalization of feelings." There were no specific nursing interventions to direct nursing personnel regarding specific behavioral monitoring for this patient.

A generic social work intervention was "Tx (Treatment) planning with [Patient], family and OP (out-patient) providers to identify appropriate aftercare appts. (appointments). Safety planning to review concerns and ensure safe DC (discharge) back to [his/her] community."

7. Patient E5-Treatment plan of 7/7/17

For problem, "Depressed: [Patient] heard neighbors & police officer 'in my basement, who knows what they were looking for down there,'" rather than nursing interventions, patient goals were stated as interventions: "[Patient] will remain free of (unclear word); [Patent] will verbalize suicidal ideation and discuss these with nursing staff; [Patient] will identify a support system outside the hospital; and [Patient] will create a safety plan." A treatment compliance statement was listed as "[Patient] will comply with medication."

Generic social work interventions were "Treatment planning with [Patient], family, treatment team, & Kaiser case manager to coordinate appropriate follow up care" and "Safety planning with [Patient] to establish a safe D/C (discharge) plan."

8. Patient E13-Treatment plan of 7/10/17

For problem, "Psychotic Behavior: Pt. [Patient] refused to take meds (medications) & had been very suspicious that family has been crushing pills to put in [his/her] food. Pt. (Patient) hid in garage with crowbar & threatened them with violence and death," generic nursing interventions were "Encourage pt. (patient) to take [his/her] medications. Encourage patient to attend groups, use of + (positive) coping skills." There were no interventions to address either the patient's suspicious behaviors or the threat of violence towards others.

Generic social work interventions were listed as "Treatment planning with [Patient], family, treatment team to coordinate appropriate follow-up care" and "Safety planning with [Patient] and family to establish a safe D/C (discharge) plan."

9. Patient F14-Treatment plan of 5/26/17

For problem, "Psychotic Behavior: Drinking out of toilet bowl and urinating outside, internally preoccupied ... selectively mute and does not reciprocate when staff is talking," generic nursing interventions listed were "Engage in 1:1 with [Patient]," Encourage medication compliance," and "Encourage verbalizations of feelings with staff." There were no specific nursing interventions to address the patient's 'drinking out of toilet or urinating in inappropriate places'. Also the patient's being selectively mute was not addressed.

A generic social work intervention was stated as "D/C (Discharge) planning to aftercare program that will adequately address pt.'s (patient's) continued recovery from psychotic symptoms."

10. Patent G19-Treatment plan of 7/3/17

For problem, "Psychotic Behavior: [Patient] was rambling and talking about wanting to save the bees," a generic nursing intervention was stated as "Encourage group/activities."
The only nursing intervention to address this patient's psychotic symptoms was "Orient to reality."

A generic social work intervention was "Treatment planning with [Patient and spouse] and Kaiser providers to coordinate an appropriate aftercare plan"

B. Interviews

1.During interview on 7/12/17 at 8:40 a.m., RN8 acknowledged that the nursing interventions for Patient B7 did not specifically address his/her problems.

2. During the interview with the Medical Director on 7/12/17 around 10:45 a.m. he agreed that the social work interventions were generic discipline functions.

3.During interview with review of social work interventions on the treatment plans, on 7/12/17 at 11:30 a.m., the Direct of Social Services stated that these interventions were "similar."

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

I. Ensure that active individualized psychiatric care was provided for two (2) of 10 active sample patients (A6 and B5) Even though these patients failed to attend the majority of groups/activities on the unit, alternative treatment based on their individual treatment needs was not provided. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning.

II. Ensure that structured groups/activities to meet the needs of the patient population were provided. All patients were expected to attend the same groups/activities on five (5) of five (5) adult units (A, B, E, F and G) even though this programming did not meet their individual needs. This failure hindered patient's participation in active treatment and resulted in patients roaming the halls and sleeping in bed.

Specific Findings Include:

I. Failure to provide individualized active treatment:

A. Patient Findings:

1. Patient A6 was admitted on 6/22/17

a. According to the psychiatric evaluation (6/23/17), Patient A6 was admitted after being paranoid, delusional and threatening to hurt self and others.

b. Review of Patient A6's treatment plan (6/25/17) revealed that an intervention titled "milieu therapy" stated "[Patient] will process triggers of psychotic symptoms in group. [S/he] will learn 2 positive activities such as deep breathing and 5 senses to ground [himself/herself] in reality"

c. Review of the "Inpatient Group Therapy Notes" for Patient A6 from 7/3/17 to 7/10/17 revealed that this patient had attended only four (4) of 28 available groups/activities. From 7/7/17 to 7/10/17, patient A6 did not attend a single group. Group leader notes indicated interaction duration of 1-2 minutes. Most common reason for non-attendance was "patient sleeping".

d. Patient A6 had not attended most groups (24 out of 28), yet Master Treatment Plan update (7/9/17) for this patient noted following behaviors. "Talk to self [sic]. some group attendance". Changes/Interventions noted were "continue with current plan" with revised target date of 7/16/17.

e. During interview about Patient A6 's treatment on 7/12/17 at 11:30 a.m., the Director of Social Services reported that additional documentation of alternative treatment might be in the patient's progress notes. No proof of alternative treatment was provided to the surveyors.

f. Even though this patient failed to attend assigned groups/activities, as of 7/11/17, Patient A6's treatment plan was not revised to include alternative treatment based on his/her individual needs.

2. Patient B5 was admitted on 6/15/17.

a. According to the psychiatric evaluation (6/16/17), upon admission Patient B5 stated that "the phones were tapped at Grant House ...had other bizarre delusions ...a delusion of being poisoned & (and) resulting in [his/her] right arm coming out of the socket."

b. Review of Patient B5's treatment plan (6/18/17) revealed that an intervention titled "milieu therapy" stated "[Patient] will process triggers that lead to paranoi [sic] in group. [S/he] will learn 2 positive activities such as deep breathing and 5 senses (sic) to ground [himself/herself] in reality."

c. Review of the "Inpatient Group Therapy Notes" for Patient B5 from 7/3/17 to 7/10/17 revealed that this patient had attended only eight (8) of 28 available groups/activities.

Group leader notes (7/3/17 and 7/4/17) documented, "Pt. (Patient) sleeping. 1:1 given about group." Duration of note of interaction was 1-2 minutes. Another group note on 7/4/17 stated "Pt. (Patient) in/out of group-struggled to sit & engage in group for extended time-anxious & pacing ..."

Additional group notes on 7/4/17- documented that Patient B5 was "in hallway talking to staff members," "sleeping," "walking in hallway," and "talking on the phone." All follow-up interactions were documented as being 1-3 minutes in length.

d. Even though group notes documented that Patient B5 had refused the majority of groups/activities, a note on the "social services update" section of the "Master Treatment Plan Update (7/2/17)" stated "Attending most groups, but some of the groups was [sic] in [his/her] room, agitated." The social services update (7/9/17) stated "attends some groups, but will stay in room internally preoccupied."

e. During interview on 7/12/17 at 8:30 a.m., RN8 stated that Patient B5 has a "hard time" sitting still (for group attendance). S/he reported that the group leader "reaches out to see why the patient did not attend." S/he reported that although a weekly "update" of the patient's plan has been conducted, the patient's treatment plan has not been revised although the patient does not participate in his/her treatment.

f. During interview about Patient B5's treatment on 7/12/17 at 11:30 a.m., the Director of Social Services reported that additional documentation of alternative treatment might be in the patient's progress notes. No proof of alternative treatment was provided to the surveyors.

g. Even though this patient failed to attend assigned groups/activities, as of 7/11/17, Patient B5's treatment plan was not revised to include alternative treatment based on his/her individual needs.

B. Interview:

During interview with the Medical Director on 7/12/17 around 10:45 A.M, he acknowledged that sample patients A6 and B5 did not have active alternative treatment when they refused to attend groups.

II. Failure to ensure the provision of structured groups/ activities to meet the needs of the patient population:

A. Review of the structured programming schedules revealed only one set of groups/activities for all five adult units (A, B, E, F and G) with 16-26 patients on each unit. Groups were scheduled on each day from 10:00 a.m. to 5:00 p.m. with a movie most evenings. On each day (Sunday-Saturday) the groups followed a topic such as "mindfulness," "addiction," "stress management," "depression," etc. All patients on the unit were expected to attend the programming even though it failed to meet the individual needs for all patients on the unit.

B. Patient Observations:

1.Observations during group (Mindfulness) on 7/10/17 at 11:10 a.m. revealed 10-12 of the 20 patients on Unit B attended the group. However, 2-3 patients left and returned several times. Active sample Patient B5 attended the group but was standing or walking about the group room during the majority of the session. In addition, active sample Patient B7 walked out and returned to the group room twice. A total of seven (7) patients remained until the end of the group session.

2. Observations of Unit G on 7/10/17 at 1:10 pm. revealed that 6 of 26 patients attended a group (Coping Skills). The remaining patients on the unit (20) were in their assigned rooms or roaming the halls.

3. Attendance at a group (Stress Management) on Unit G on 7/11/17 at 11:00 a.m. revealed that 12 of the 26 patients on the unit attended. Rounds revealed that the majority of remaining patients were in their assigned rooms or roaming the hallways.

C. Monitoring Sheets Review:

1.Review of the 15 minute monitoring sheets on 7/10/17 for the patients assigned to Unit F revealed that six (6) of 26 patients on this unit remained in their assigned rooms during the majority of the time while groups were on-going.

2. Review of the 15 minute monitoring sheets on 7/10/17 for the patients assigned to Unit G revealed that 17 of 26 patients on this unit remained in their assigned rooms during the majority of the time while groups were on-going.

D. During interview on 7/12/17 at 11:35 a.m., the Director of Social Services and the Program Manager verified the findings in section A. above. They both stated awareness that the programming did not meet the treatment needs of all patients on each of the units. The Director of Social Services acknowledged that 1:1 treatment might be more appropriate for some patients assigned to attend the available programming.

Based on interview and document review, the facility failed to ensure that a sufficient number of nursing personnel (RNs, LPNs and Mental Health Technicians) were assigned to six (6) of six (6) certified Units (A, B, C, E, F and G) to provide safe care to the patients on all shifts of duty. Due to the acuity of patients and various off ward duties performed by nursing personnel (patient escort, behavioral and medical codes, meal breaks, etc.), many shifts on all 6 units were not sufficiently staffed. In addition, this staffing hindered the presence of at least two nursing personnel on each unit at all times, in order to prevent having to call for assistance if a patient incident occurred. This staffing deficiency hinders quality patient care and results in a safety risk for all patients and staff on these certified units. (Refer to B150)

In addition,

II. The Clinical Director failed to assure treatment plans for two (2) of 10 active sample patients (A6 and B5) were revised in a timely manner; and failed to assure treatment plans were developed that clearly delineated interventions to address the specific treatment needs of 10 of 10 active sample patients (A6, A14, B5, B6, C7, C10, E5, E13, F14 and G19). The Director also failed to ensure that active individualized psychiatric care was provided for two (2) of 10 active sample patients (A6 and B5); and ensure that structured groups/activities to meet the needs of the patient population were provided. (Refer to B144)

III. The Director of Nursing failed to ensure that nursing interventions on the Master Treatment Plans for nine (9) of 10 active sample patients (A6, A14, B5, B6, C10, E5, E13, F14 and G19) were individualized to meet specific patient needs. Most of the nursing interventions were routine, generic discipline functions that would be performed regardless of the different patients' problems and needs. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. (Refer to B148)

Based on interview, observations and document review the Medical Director failed to:

I. Assure treatment plans for two (2) of 10 active sample patients (A6 and B5) were revised in a timely manner. This failure jeopardizes a timely, coordinated, responsive treatment process. (Refer to B118)

II. Asure treatment plans were developed that clearly delineated interventions to address the specific treatment needs of 10 of 10 active sample patients (A6, A14, B5, B6, C7, C10, E5, E13, F14 and G19). Instead, treatment plans included interventions that were routine, generic discipline functions, or were staff goals. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment. (Refer to B122)

III. Ensure that active individualized psychiatric care was provided for two (2) of 10 active sample patients (A6 and B5) Even though these patients failed to attend the majority of groups/activities on the unit, alternative treatment based on their individual treatment needs was not provided. This deficiency resulted in patient inactivity and prevented them from achieving their optimal level of functioning. (Refer to B125, Section I)

IV. Ensure that structured groups/activities to meet the needs of the patient population were provided. All patients were expected to attend the same groups/activities on five (5) of five (5) adult units (A, B, E, F and G) even though this programming did not meet their individual needs. This failure hindered patient's participation in active treatment and resulted in patients roaming the halls and sleeping in bed. (Refer to B125, Section II)

Based on interview and document review, the Director of Nursing failed to:

I. Ensure that nursing interventions on the Master Treatment Plans for nine (9) of 10 active sample patients (A6, A14, B5, B6, C10, E5, E13, F14 and G19) were individualized to meet specific patient needs. Most of the nursing interventions were routine, generic discipline functions that would be performed regardless of the different patients' problems and needs. In addition, there was failure to include interventions to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

Patient Findings:

1.Patient A6-Treatment plan of 6/25/17

For problem, "Psychotic Behavior: [Patient] internally preoccupied, threatened to hurt self or others ...paranoid, delusional and yelling, refused to eat food as was poisoned," a generic nursing intervention was "Educate medication side effects to pt. (patient)." There were no specific nursing interventions to direct staff in the monitoring and care of the patient presenting aggression and irrational behavior in the clinical area other than reporting feelings of self- harm or hurting others.

2. Patient A14-Treatment plan dated 6/22/17

For problem, "Taking [his/her] clothes off walking around the hospital naked. Delusions: A robot is inside [him/her] brain and moved to [his/her] abdomen," generic nursing interventions were "Engage in 1:1 with [Patient]" and "Encourage compliance with meds (medications)." There were no specific interventions to direct nursing personnel to address the patient's disrobing on the unit, nor the patient's delusions.

3.Patient B5-Treatment plan date of 6/18/17

For problem, "Psychotic behavior: thinks arm is being ripped out of socket ...believes there is a murder hit on [him/her]," nursing interventions failed to direct nursing personnel in responding to and assisting patient to control psychotic behavior. The only nursing interventions were generic stated as "Benefits of taking meds (medications), using positive coping skills, benefits of attending groups and benefits of interacting & engaged in 1:1."

4.Patient B7-Treatment plan of 7/6/17

a. For problem, "Psychotic Behavior: [Patient] was disorganized making bizarre statement [sic], and internally preoccupied," a generic nursing intervention was "orient [Patient] to unit and establish rapport with patient." There were no nursing interventions to direct nursing personnel in how to respond to psychotic behaviors other than "reorient to reality as needed/redirect."

b. For problem, "Assaultive/Aggressive Behavior: [Patient] assaulted a nurse and peers at ER (Emergency Room) and went to jail for it," a generic nursing intervention was "Educate [Patient] on unit rules and expectations." An unclear intervention was stated as "Establish clear boundaries with [Patient]." There were no nursing interventions to direct staff regarding specific behavioral monitoring for neither the patient nor how to handle this behavior in the clinical area.

5.Patient C10-Treatment plan date of 6/20/17

For problem, "Assaultive/Aggressive Behavior," a generic nursing intervention was stated as "Encourage verbalization of feelings." There were no specific nursing interventions to direct nursing personnel regarding specific behavioral monitoring for this patient."

6. Patient E5-Treatment plan of 7/7/17

For problem, "Depressed: [Patient heard neighbors & police officer 'in my basement, who knows what, they were looking for down there,'" rather than nursing interventions, patient goals were stated as interventions: "[Patient] will remain free of (unclear word); [Patent] will verbalize suicidal ideation and discuss these with nursing staff; [Patient] will identify a support system outside the hospital; and [Patient] will create a safety plan." A treatment compliance statement was listed as "[Patient] will comply with medication."

7. Patient E13-Treatment plan of 7/10/17

For problem, "Psychotic Behavior: Pt. [Patient] refused to take meds (medications) & had been very suspicious that family has been crushing pills to put in [his/her] food. Pt. (Patient) hid in garage with crowbar & threatened them with violence and death," generic nursing interventions were "Encourage pt. (patient) to take [his/her] medications. Encourage patient to attend groups, use of + (positive) coping skills." There were not interventions to address the patient's suspicious behaviors, nor the threat of violence towards others.

8. Patient F14-Treatment plan of 5/26/17

For problem, "Psychotic Behavior: Drinking out of toilet bowl and urinating outside, internally preoccupied ... selectively mute and does not reciprocate when staff is talking," generic interventions listed were "Engage in 1:1 with [Patient]," "Encourage medication compliance," and "Encourage verbalizations of feelings with staff." There were no specific nursing interventions to address the patient's 'drinking out of toilet or urinating in inappropriate places'. Also the patient's being selectively mute was not addressed.

9. Patent G19-Treatment plan of 7/3/17

For problem, "Psychotic Behavior: [Patient] was rambling and talking about wanting to save the bees," a generic nursing intervention was stated as "Encourage group/activities."

B. Interview

During interview on 7/12/17 at 8:40 a.m., RN8 acknowledged that the nursing interventions for Patient B7
were generic.

II. Ensure that a sufficient number of nursing personnel (RNs, LPNs and Mental Health Technicians) were assigned to six (6) of six (6) certified Units (A, B, C, E, F and G) to provide safe care to the patients on all shifts of duty. Due to the acuity of patients and various off ward duties performed by nursing personnel (patient escort, behavioral and medical codes, meal breaks, etc.), many shifts on all 6 units were not sufficiently staffed. In addition, this staffing hindered the presence of at least two nursing personnel on each unit at all times to prevent having to call for assistance if a patient incident occurred. This staffing deficiency hinders quality patient care and results in a safety risk for all patients and staff on these certified units. (Refer to B150)

Based on interview and document review, the Director of Nursing failed to:

Ensure that a sufficient number of nursing personnel (RNs, LPNs and Mental Health Technicians) were assigned to six (6) of six (6) certified Units (A, B, C, E, F and G) to provide safe care to the patients on all shifts of duty. Due to the acuity of patients and various off ward duties performed by nursing personnel (patient escort, behavioral and medical codes, meal breaks, etc.), many shifts on all 6 units were not sufficiently staffed. In addition, this staffing pattern precluded the presence of at least two nursing personnel on each unit at all times to prevent having to call for assistance if a patient incident occurs. This staffing deficiency hinders quality patient care and results in a safety risk for all patients and staff on these certified units.

Findings include:

I. Unit Descriptions:

A. Unit A is a 20-bed acute adult co-ed unit with a census of 19 on the first day of the survey (7/10/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

B. Unit B is a 20-bed acute adult co-ed unit with a census of 20 on the first day of the survey (7/10/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

C. Unit C is a 20-bed acute adolescent and latency age children co-ed unit with a census of 16 adolescents on the first day of the survey (7/10/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

D. Unit E is a 16-bed adult co-ed unit for patients with co-morbidity illnesses with a census of 16 on the first day of the survey (7/10/17). This unit had patient rooms on one hallway with male and female patients assigned on this same hallway.

E. Units F and G are 26-bed adult co-ed units for less acutely ill patients with a census of 26 on each of the units on the first day of the survey (710/17). These units are designed as an elongated rectangle with patient rooms on 3 of the 4 hallways. Male and female patients are assigned to rooms on all three of the hallways. Due to the design of these 2 units at least 3 nursing personnel are required to monitor patients at all times on the 4 areas. Even though there were camera monitors for the "blind areas" of the unit hallways, these monitors were not always utilized.

II. Staffing Forms:
A. Review of Nursing Staffing Forms completed by a RN for a 7-day period, including the first day of the survey (7/10/17), revealed the following information:

1. Even though the "Direct Nursing Staffing Form"
revealed that the majority of the day and evening shifts of duty for all 6 units appeared to be sufficiently staffed to care for the assigned patient population, this staffing was greatly impacted by assignments/tasks requiring nursing personnel to leave their assigned units. These tasks included covering other units where staff were absent; off unit escort of patients for various reasons including appointments; attending "codes" (behavioral and medical) in other parts of the facility; and going off-ward for meal break. The absence of even one staff member on many shifts of duty hindered staff in ensuring proper monitoring of the patients and providing crisis intervention to prevent escalation of negative patient behaviors.

In addition to providing basic care for the patients, the 2-3 assigned technicians were also responsible for providing 1:1 and every 5-minute checks as well as every 15 minute monitoring checks for all patients on each unit.

2. Units A and F were staffed on all night shifts with a total of only 2 nursing personnel (1 RN and 1 HCT). This staffing did not allow for meal breaks, as there would not be a sufficient number of nursing personnel to provide basic care and required monitoring of patient areas to ensure safety of patients and staff.

3, In addition, the following night shifts of duty were staffed with only 2 nursing personnel (1 RN and 1 HCT):

a. Unit B on 7/4/17, 7/5/17 and 7/6/17.
b. Unit C on 7/4/17 and 7/5/17.
c. Unit E on 7/4/17, 7/6/17, 7/7/17, 7/8/17, 7/9/17 and 7/10/17.
d. Unit G on 7/7/17, 7/8/17, 7/9/17 and 7/10/17.

B. Interviews:

1. During interview on 7/10/17 at 10:55 a.m., RN3 reported that Unit B was staffed that day with one additional RN (assigned to administer medications) (a total of 2 RNs) and 2 HCTs for a census of 20. S/he reported that one of these HCT's was assigned to monitor patients on 1:1, and the other HCT completed the 5-minute safety checks for 2 patients and the 15-minute safety checks for the remaining 17 patients on the unit. S/he added that the RN had to help with these checks due to meal breaks and additional duties performed by HCTs.

2. During interview on 7/10/17 at 1:45 p.m. RN 4 reported that Unit G, with a census of 26, was staffed that day with one additional RN (total of 2 RNs), 1 LPN (assigned to administer medications) and 3 HCTs. S/he reported that 1 of these HCTs was assigned 1:1 supervision of a patient and 1 HCT completed the 5-minute safety checks for 3 patients and the 15-minute safety checks for the remaining 22 patients on the unit. This staffing left only 2-3 staff to care for these acutely ill patients when nursing personnel were off the unit.

3. During interview on 7/10/17 RN 5 reported that Unit C was staffed that day with 1 additional RN (assigned to administer medications) and 2 HCT's. S/he reported that 1 of these HCTs was assigned 1:1 supervision of a patient and 1 HCT completed the 5-minute safety checks for 3 patients and the 15-minute safety checks for the remaining 12 patients on the unit.

4. During interview on 7/11/17 at 10:45 a.m. RN 6 reported that Unit C was staffed with 2 RNs (one giving medications) and 2 HCTs of which one was assigned 1:1 supervision for a patient. S/he added that there was an additional patient on 5-minute safety checks that day. RN 6 stated that if a code blue (behavioral) occurs a HCT is sent to the incident. S/he reported that the HCTs are assigned for 30-minute lunch breaks and s/he takes a break later in the shift when there is more time to be gone from the unit.

5. During interview on 7/11/17 at 11:05 a.m., RN 7 reported that on that day on G Unit there was an additional RN, 2 LPNs and 1 HCT, with 1 Patient on 1:1 when awake and 3 patients on every 5 minute safety checks (one only while sleeping). S/he reported that the nursing manager was available that day if needed. S/he reported that the usual staffing for this unit was 4 nursing personnel for fewer than 20 patients and 5 personnel for 20-26 patients. RN 7 added that staffing is an issue. She stated, "By lunch we lose someone (staff reassigned or on break). It is more of an issue when we get down to 1 RN and 1 HCT on the unit."
S/he added, "During the summer time (when working on Adolescent Unit) we may have fewer than 10 patients. Then we have only 1 RN and 1 HCT. If the HCT has to take some of the kids off the unit, that leaves only 1 RN on the unit."

6. During interview on 7/11/17 at 3:00 p.m., RN 2 reported that at least 3 nursing personnel were required to provide safety monitoring of patients for Units F and G when patients are in their bedrooms with some in the dayroom areas due to the "blind areas" in the hallways. S/he verified that 2 staff members could provide proper monitoring if one was assigned to the hallway junctures if all patients were in their rooms, but that this would not allow for assigned monitoring checks. S/he added that when patients' visitors are on the unit 1 staff member must monitor this area in addition to patient rounds. S/he reported that the RN needs to remain in the nursing station because of tasks to be completed.

7. During interview on 7/11/17 at 2:35 p.m., RN 1 reported that the usual staffing for up to 7 patients is 1 RN and 1 HCT for all units. S/he stated, "When the HCT goes on break the RN may not feel safe." She reported that when a unit calls for additional staff, they are assigned another if possible. We do the best we can." RN 1 reported that s/he has been in situations when a patient has been placed on 1:1 and s/he was not able to get an additional staff member to come in for this assignment. When asked how often nursing personnel were moved from one unit to assiste in another unit, s/he replied, "Frequently and often we have to turn around and move them to another unit (2 moves)."


8. During interview on 7/12/17 at 8:40 a.m. the DON reported that she was not aware that at times only one staff member staffed a unit. She acknowledged that this was against facility policy.

9. During interview on 7/12/17 at 10:15 a.m. when staffing, including number of RNs was discussed, the DON stated, "I believe that all units cannot be staffed based on the same staff: patient ratio (referring to the current staffing rations for this facility). Something drastic needs to change. I keep pressuring for more changes."