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Based on review of documentation, observation and interview, it was determined that the Governing Body failed to enforce the facility ' s policies and procedures.

Findings were:

Facility policy "Use of Restraint" stated, "All nursing staff shall receive training in management of aggressive behavior and age appropriate application of restraints upon hire and annually thereafter..." The policy did not reflect any information pertaining to physician training and/or competency for restraint an/or seclusion.

? Staff #5's training records revealed no competency for identifying facility-approved restraints, recognizing how age, weight, level of development or functioning, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which an individual reacts to physical contact, using behavioral criteria for the discontinuation of restraint or seclusion and assisting individuals in meeting these criteria and identifying medical and psychological contraindications including physical abuse, sexual abuse, and substance abuse. There was no current documentation for date of training, name of instructor, completed competencies, date assessed and/or the person who assessed the competency.

On 03/08/12, Staff #30 stated if physician competency and/or training for restraint/seclusion was not in the individual files then it was not done.

Facility policy entitled " Dietary Department, Infection Control " stated in part, "Plastic gloves are to be worn when handling individual portions of food on serving line, when mixing food by hand...when scraping dishes...gloves are to be disposed of after use and hand shall be washed...all refrigerated food items are stored promptly upon receipt...frozen foods are defrosted under refrigeration...all food supplies whether refrigerated, frozen or int he storeroom, will be clearly labeled for easy identification. Non-food supplies will be stored in an area separate from food supplies...work surfaces-it is the responsibility of dietary personnel to keep work surfaces clean and uncluttered. Surfaces are cleaned daily using non-toxic sanitizing/disinfection agent...special care will be maintained for all foods in which bacteria grow easily including: mayonnaise, salad dressing, salad or sandwich mixtures, meats (especially chopped or sliced), meat products, gravies, milk cream, eggs, puddings...refrigerator, freezer...food temperatures are checked and recorded daily...dishes and silverware will be allowed to air dry...a routine cleaning schedule is posted for daily cleaning. Specific cleaning procedures for all equipment and areas are written and personnel are trained on those procedures...ice scoop is used to dispense ice...scoops are stored in a dry container outside of the ice machine and never left on the ice bed...they are sanitized a minimum of once daily in the dishwashing machine..."

? On 03/06/12 at approximately 12:10 PM to 12:25 PM the kitchen and service line was toured with Staff #13 and Staff #14. The following observations were made:

? A multiple shelf rack for storage of clean dishes had 14 trays, 4 muffin tins and 2 large bowls stacked wet on top of each other.

? The top shelf above the sink was soiled and greasy. Two of the three coffee urns were assembled wet and available for use. A large yellow sheet cake and a chocolate sheet cake were sitting on the sink ledge uncovered next to the soiled sink. The wall behind the cake was dirty with grime buildup.

? The center metal work station ' s bottom shelf contained 24 (clean) pans stacked wet on top of each other. Several of the pans were soiled/dirty with loose pieces of yellow food matter. The bottom shelf had multiple pans stacked one of top of each other. The shelf was dirty and dusty.

? A second work station had a large container with food items stored inside. One box of gluten free cookies, 1 box of sun dried raisins which expired 02/08/10, 1 large baggie filled with a brown powder substance, 1 bag of potato curls, 2 bags of gravy mix and 1 bag of scallop potato mix were opened and not labeled. The brown powder substance did not have the name of the food item labeled on the exterior surface of the bag.

? The refrigerator had 15 slices of lemon cake and 30 individual salads which were not labeled when prepared.

? The freezer had a twin Popsicle laying on the floor and the freezer temperature log was not completed for 03/06/12.

? The shelf under the grill was rusted, stained and dirty. Clean cloths were stored on the shelf and available for use.

? Next to the grill (shelf unit) the bottom shelf contained multiple cans of cooking spray and butter spray. A metal saucepan had a large amount of a yellow substance sitting at (room temperature) inside the sauce pan with utensil sticking out of the yellow substance. The metal pan was approximately six inches from the floor. Staff #9 stated she did not know who placed the butter in the saucepan.

? The deep fryer ' s two baskets were sitting in old grease. A collection of food debris/residue was collected in the bottom of the fryer. The ledge in front of the grease holding tank was covered with grease and food debris.

? The ice machine was inspected. The metal scoop was inside the ice machine sitting in the ice. A holding container for the scoop was observed on the outside of the machine and not in use.

? The serving line equipment was inspected. The water dispenser had peeling paint which exposed the underlying surface. The water dispenser surfaces could not be adequately sanitized.

? The meal temperature logs from 02/27/12 to 03/06/12 reflected the following: The 03/02/12 evening meal had no food temperatures documented. The 03/04/12 breakfast and lunch meal had no food temperatures documented. The 03/05/12 breakfast and lunch meal had no food temperatures documented. The 03/06/12 breakfast and lunch meal had no food temperatures documented.

? The 03/07/12 at approximately 8:30 AM Staff #11 was observed fixing 5 trays to go on the adult unit. Staff #11 wore no gloves and was asked by the surveyor if she was supposed to wear gloves. Staff #11 stated " yes " but offered no explanation as to why. Staff #11 was asked to show the surveyor how she did food temperatures. Staff #11 took a laser/digital thermometer and pointed it at the metal pan not the food item. The surveyors asked Staff #11 if this was the proper way to do food temperatures. Staff #11 did not offer an explanation.

? A metal work station had 4 large containers of barbecue beef sitting in a container of water in the sink thawing out. Staff #9 stated the water should be left running over the food items. To the right of the sink a box of barbecue beef and two additional containers were sitting on top of the work station thawing out at room temperature. Staff #9 acknowledged the containers should not be sitting out at room temperature.

? The Dietary Cleaning Schedule Daily and Weekend Cleaning Schedule dated 02/26/12 to 03/06/12 reflected the following: The deep fryer was documented as cleaned on 02/26/12 and 03/03/12. The table/counter tops, underneath the counter tops and freezer were documented as cleaned 03/03/12.

? On 03/07/12 at 01:35 PM Staff #23 was interviewed. Staff #23 stated she comes to the hospital twice weekly and checks the freezer and makes sure everything is addressed in the dietary department. Staff #23 stated she was at the hospital on 03/05/12 and everything was fine in the dietary department. Staff #23 was asked if she was aware food items were being stored with non-food items in central supply. Staff #23 stated she was unaware. Staff #23 stated she checks the temperature logs, checks for cleanliness and completes a log on the kitchens condition. Staff #23 stated she was unaware of the above items the survey team found while touring the kitchen.

? The most recent RD/LD (Registered Dietician/Licensed Dietician) consultant dietary report provided to the surveyor dated 02/24/12 reflected, "Temperature monitoring, food quality and sanitation all checked as done..."

In an interview with the Registered Dietician and the Consultant Dietician on 3/7/12, the above dietary concerns were acknowledged. It was also confirmed that the facility ' s policies and procedures had not been followed according to approved process in the kitchen.

Facility policy entitled " Laundry Facilities " stated in part " Washing machines will be sanitized at least daily by housekeeping staff. "

Facility policy entitled " Washing of Patient Clothing " stated in part " Clean lint trap after you remove the clothes. Wipe drier out with germicidal cleaner. "

Tour of the patient laundry area on 3/5/12 revealed the following:

? 2 of 2 dryers were found with dirty and full lint filters.
? The agitator in 1 of 2 washing machines was full of odiferous mold and what appeared to be wet lint.
? The water boxes in back of the washing machines were rusted and had chipped paint.

When asked the policy for disinfecting the washing machines between use, the Director of Maintenance stated, " The Mental Health Techs do it. " When asked the same question, the Infection Control Nurse stated, " Maintenance is responsible for doing that. " Neither Maintenance nor Nursing Services could produce a log sheet that documented disinfection of the washing machines.

Facility policy entitled " Dress Code " stated in part " Fingernails: Direct Care and Dietary Staff must not wear artificial fingernails or extenders while at work. "

? When asked about the facility policy on fingernails, the Infection Control Nurse told the survey team that there was no policy. This nurse was observed to have artificial nails that extended approximately 1/3 of an inch past her fingertips.

Facility cleaning policy entitled " General Policing " stated in part, " Daily: Dust sills, ledges and other horizontal building and furniture surfaces to remove obvious soil ...Damp mop non carpeted floors. Use a well wrung mop and germicidal detergent solution. Spray buff floors coated with finish to remove scuffs, marks, to replace worn finish and to restore a uniform gloss to the floor. Dust mop after spray buffing. "

Tour of the Central Supply area on 3/5/12 revealed the following:

? The floor was dirty with debris collected in corners and under shelving units.
? A plastic pitcher was stored on the shelving which contained dried food debris.
? 2 soiled towels were found thrown atop stored water bottles.
? An open, soiled (with brown, splattered material) container of 1cc allergy syringes was found stored on a shelf.
? An open (exposed to air) bag of 1000 count cotton balls was found on a shelf. These cotton balls are not considered " clean " and should not be available for patient use.

A Janitor Closet was opened and inspected on 3/5/12 that revealed the following:

? Dirty dust mop heads were found piled atop clean mop heads.
? A pile of " clean " towels was noted on the floor of the closet. Next to the pile of towels was a canister with an attached hose that sprayed pesticide. The pile of towels was contaminated by the proximity of the pesticide container and the floor.

Tour of the Patient Gym on 3/5/12 revealed the following:

? The floor throughout the gym was soiled with dirt and scuff marks. The floor behind and next to the trash can had a build up of dried liquids and dirt.

In interviews with the Assistant Director of Nurses, the Dietician, the Risk Manager and the Chief Executive Officer on 3/6 and 3/7/12, the above infection control concerns were acknowledged. It was also confirmed that the facility did not always follow its own policies and procedure in regard to the cleaning of the hospital.

Facility policy entitled " Emergency Drug Box " stated in part " A mini-drug box, containing drugs and equipment as approved by the Medical Staff will be available on each of the nursing units in the medication room ... The 24 Hour Nightly Audit will be performed every night by the designated nursing staff. If, during the audit, it is discovered that the mini-emergency drug box has an expired medication or has been opened and the contents used, the nursing staff must notify the pharmacy before the end of their shift ....The pharmacy will be responsible for refilling the contents of the mini-emergency drug box and for charging the appropriate patient for the items used. "

Tour of the Patient Units 1-2 and 4 on 3/7/12 revealed the following expired emergency medications:

? Patient Units 1-2 had an Emergency Kit that had the following expired medications: Epipen, Normal Saline and two bottles of eye wash, 2 empty O2 tanks
? Patient Unit 4 had an Emergency Kit that had the following expired medications: Ammonia Ampoules (expired 11/11), Normal Saline (expired 6/11), 1 empty O2 tank

In an interview with the Charge Nurse on 3/07/12, the above expired medications and emergency supplies were acknowledged.

Facility policy entitled " Master Staffing Plan " stated in part " Staffing is based on normal staff mix ratios of the following:
? RN House Supervisor on each shift (mayor may not be assigned to a unit).
? At least 1 RN for every 12 clients
? LVN will be added for high acuity or increased census to give medications
? MHT (Mental Health Technician) for each program if census and acuity warrant or according to unit need and patient observation levels
? Adult Services ratio will be maintained at 1:4 for the day and evening shift. A 1:6 ratio will be maintained for the night shift. This number will vary according to acuity needs and number of high risk clients as determined by the Charge Nurse and House Supervisor. "

The following dates and shifts did not meet patient to staff ratios according to facility policy:

? 2/22/12, 3-11 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/22/12, 3-11 shift, Unit 5 had 18 patients and 1 RN, 1 LVN and 2 MHTs (1:4.5 ratio)
? 2/22/12, 11-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/23/12, 7-3 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 7-3 shift, Unit 4 had 10 patients and 1 RN and 1 MHT (1:5 ratio)
? 2/23/12, 3-11 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 3-11 shift, Unit 4 had 9 patients (1:4.5 ratio)
? 2/23/12, 11-7 shift, Unit 5 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/24/12, 7-3 shift, Unit 1 had 18 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN, and 3 MHTs (1:4.5 ratio)
? 2/24/12, 7-3 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/24/12, 3-11 shift, Unit 1 had 17 patients, 1 RN and 1 LVN and 2 MHTs (1:4.25 ratio)
? 2/24/12, 3-11 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 1 had 22 patients and 1 RN and 1 LVN and 2 MHTs (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.3 ratio)
? 2/25/12, 7-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/26/12, 7-7 shift, Unit 1 had 27 patients and 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/26/12, 7-7 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/27/12, 7-3 shift, Unit 1 had 27 patients, 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/27/12, 7-3 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 1 had 25 patients and 1 RN and 1 LVN and 2 MHTs (1:6.25 ratio)
? 2/27/12, 3-11 shift Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 2/28/12, 7-3 shift, Unit 1 had 27 patients and 2 RNs and 2 MHTs (1:6.75 ratio)
? 2/28/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 2/28/12, 3-11 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/29/12, 7-3 shift, Unit 1 had 25 patients and 2 RNs and 2 MHTs (1:6.25 ratio)
? 2/29/12, 3-11 shift, Unit 1 had 23 patients and 2 RNs and 2 MHTs (1:5.75 ratio)
? 3/1/12, 7-3 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/1/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/2/12, 7-3 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 7-3 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 7-3 shift, Unit 5 had 14 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/2/12, 3-11 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 3-11 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 3-11 shift, Unit 5 had 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 day shift, Unit 1 had 26 patients and 2 RNs and 2 MHTs (1:6.5 ratio)
? 3/4/12, 7-7 day shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/4/12, 7-7 day shift, Unit 4 had 14 patients and 1 RN and MHT (1:7 ratio)
? 3/4/12, 7-7 day shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 night shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 3 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 2 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 3/5/12, 3-11 shift, Unit 1 had 27 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.75 ratio)
? 3/5/12, 3-11 shift, Unit 3 had 13 patients with 1 RN and 1 LVN and 1 MHT (1:4.3 ratio)
? 3/5/12, 3-11 shift, Unit 4 had 14 patients with 1 RN and 1 MHT (1:7 ratio)
? 3/5/12, 11-7 shift, Unit 1 had 26 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.5 ratio)

In an interview with the Director of Nurses on 3/6/12, it was acknowledged that the facility did not always meet staffing needs according to company policy.

In an interview on 3/8/12 with the Chief Executive Officer, the Corporate Director of Clinical Services, the Director of Financial Services, the Assistant Director of Nurses/Infection Control Nurse, the Director of Nurses, the Director of Clinical Services and the Dietician, it was acknowledged that the facility did not always comply with it ' s own policies and procedures.

Based on review of facility contracts with outside resources, it was revealed that the facility did have a contract with an Organ Procurement Organization (OPO) as required, signed in August of 2011, and in effect at the time of the survey. The protion of the contract regarding notification of a patient's demise or pending demise stated that the facility Director of Nursing would be responsible for contacting the Organ Procurement Organization at the appropriate time.

Review of facility policies revealed that there were no associated policies written regarding notification of the OPO. There were no policies found regarding facility involvement with any Organ Procurement Organization.

The Director of Nursing was interviewed in the conference room off the administrative area of the facility on 3/7/2012. During the interview, the Director was asked what her involvement in contacting an Organ Procurement Organization would be in the event of a patient death. She stated that she was not aware of any policies that dealt with that. She was shown the contract with the OPO which delineated her role, and she admitted that she had niot been aware of this fact.

Based on observation, interview and record review the hospital Governing Body failed to ensure 1 of 1 contracted services (Dietician Services) provided a safe and sanitary environment for 1 of 1 Dietary Department. This failure placed patients at risk for acquiring infections.

Findings included:

On 03/06/12 at approximately 12:00 noon, the central supply storage room was toured with Staff #13. The following observations were made:

The storage shelves and floor of the room were soiled with debris, dirt and grime.

Multiple cans of pudding and pasta were stored on the shelf. The shelf and the items were dusty.

Multiple drinking pitchers were observed on the same shelf. The pitchers were dirty and dusty. Plastic ware such as plates and bowls were stacked on top of each other and stored uncovered on the same dusty shelf.

The central supply room contained multiple boxes of wound supplies, enemas and syringes to name a few.

On 03/06/12 at approximately 12:10 PM to 12:25 PM the kitchen and service line was toured with Staff #13 and Staff #14. The following observations were made:

A multiple shelf rack for storage of clean dishes had 14 trays, 4 muffin tins and 2 large bowls stacked wet on top of each other.

The top shelf above the sink was soiled and greasy. Two of the three coffee urns were assembled wet and available for use. A large yellow sheet cake and a chocolate sheet cake were sitting on the sink ledge uncovered next to the soiled sink. The wall behind the cake was dirty with grime buildup.

The center metal work station ' s bottom shelf contained 24 (clean) pans stacked wet on top of each other. Several of the pans were soiled/dirty with loose pieces of yellow food matter. The bottom shelf had multiple pans stacked one of top of each other. The shelf was dirty and dusty.

A second work station had a large container with food items stored inside. One box of gluten free cookies, 1 box of sun dried raisins which expired 02/08/10, 1 large baggie filled with a brown powder substance, 1 bag of potato curls, 2 bags of gravy mix and 1 bag of scallop potato mix were opened and not labeled. The brown powder substance did not have the name of the food item labeled on the exterior surface of the bag.

The refrigerator had 15 slices of lemon cake and 30 individual salads which were not labeled when prepared.

The freezer had a twin popsicle laying on the floor and the freezer temperature log was not completed for 03/06/12.

The shelf under the grill was rusted, stained and dirty. Clean cloths were stored on the shelf and available for use.

Next to the grill (shelf unit) the bottom shelf contained multiple cans of cooking spray and butter spray. A metal saucepan had a large amount of a yellow substance sitting at (room temperature) inside the sauce pan with utensil sticking out of the yellow substance. The metal pan was approximately six inches from the floor. Staff #9 stated she did not know who placed the butter in the saucepan.

The deep fryer ' s two baskets were sitting in old grease. A collection of food debris/residue was collected in the bottom of the fryer. The ledge in front of the grease holding tank was covered with grease and food debris.

The ice machine was inspected. The metal scoop was inside the ice machine sitting in the ice. A holding container for the scoop was observed on the outside of the machine and not in use.

The serving line equipment was inspected. The water dispenser had peeling paint which exposed the underlying surface. The water dispenser surfaces could not be adequately sanitized.

The meal temperature logs from 02/27/12 to 03/06/12 reflected the following:

The 03/02/12 evening meal had no food temperatures documented.
The 03/04/12 breakfast and lunch meal had no food temperatures documented.
The 03/05/12 breakfast and lunch meal had no food temperatures documented.
The 03/06/12 breakfast and lunch meal had no food temperatures documented.

The 03/07/12 at approximately 8:30 AM Staff #11 was observed fixing 5 trays to go on the adult unit. Staff #11 wore no gloves and was asked by the surveyor if she was supposed to wear gloves. Staff #11 stated " yes " but offered no explanation as to why. Staff #11 was asked to show the surveyor how she did food temperatures. Staff #11 took a laser/digital thermometer and pointed it at the metal pan not the food item. The surveyors asked Staff #11 if this was the proper way to do food temperatures. Staff #11 did not offer an explanation.

A metal work station had 4 large containers of barbecue beef sitting in a container of water in the sink thawing out. Staff #9 stated the water should be left running over the food items. To the right of the sink a box of barbecue beef and two additional containers were sitting on top of the work station thawing out at room temperature. Staff #9 acknowledged the containers should not be sitting out at room temperature.

The Dietary Cleaning Schedule Daily and Weekend Cleaning Schedule dated 02/26/12 to 03/06/12 reflected the following:

The deep fryer was documented as cleaned on 02/26/12 and 03/03/12.
The table/counter tops, underneath the counter tops and freezer were documented as cleaned 03/03/12.

On 03/07/12 at 01:35 PM Staff #23 was interviewed. Staff #23 stated she comes to the hospital twice weekly and checks the freezer and makes sure everything is addressed in the dietary department. Staff #23 stated she was at the hospital on 03/05/12 and everything was fine in the dietary department. Staff #23 was asked if she was aware food items were being stored with non-food items in central supply. Staff #23 stated she was unaware. Staff #23 stated she checks the temperature logs, checks for cleanliness and completes a log on the kitchens condition. Staff #23 stated she was unaware of the above items the survey team found while touring the kitchen.

The most recent RD/LD (Registered Dietician/Licensed Dietician) consultant dietary report provided to the surveyor dated 02/24/12 reflected, "Temperature monitoring, food quality and sanitation all checked as done..."

The policy entitled, Dietary Department, Infection Control with a review date of 10/11 reflected, "Plastic gloves are to be worn when handling individual portions of food on serving line, when mixing food by hand...when scraping dishes...gloves are to be disposed of after use and hand shall be washed...all refrigerated food items are stored promptly upon receipt...frozen foods are defrosted under refrigeration...all food supplies whether refrigerated, frozen or int he storeroom, will be clearly labeled for easy identification. Non-food supplies will be stored in an area separate from food supplies...work surfaces-it is the responsibility of dietary personnel to keep work surfaces clean and uncluttered. Surfaces are cleaned daily using non-toxic sanitizing/disinfection agent...special care will be maintained for all foods in which bacteria grow easily including: mayonnaise, salad dressing, salad or sandwich mixtures, meats (especially chopped or sliced), meat products, gravies, milk cream, eggs, puddings...refrigerator, freezer...food temperatures are checked and recorded daily...dishes and silverware will be allowed to air dry...a routine cleaning schedule is posted for daily cleaning. Specific cleaning procedures for all equipment and areas are written and personnel are trained on those procedures...ice scoop is used to dispense ice...scoops are stored in a dry container outside of the ice machine and never left on the ice bed...they are sanitized a minimum of once daily in the dishwashing machine..."

The Nutrition Therapist Consultant Agreement dated 08/19/11 reflected, "To communicate efficiently with Client's Administrator, Director of Dietary Services...other personnel in the facility for the purpose of coordinating effective food service and total care with the general management of Client...Dietary Consultant and Client will maintain the relationship of independent contractor, not as employer and employee..."

Based on interview and record review the hospital failed to ensure 2 of 2 Staff (Staff #16 and #18's) training records for demonstrated ongoing competency in the application of restraints and/or seclusion was current.

Findings included:

1) Staff #16's training record was reviewed. Staff #16's restraint/seclusion competency revealed the last competency completed was on 02/03/11. No current annual competency was found.

2) Staff #18's training record was reviewed. Staff #18's restraint/seclusion competency revealed the last competency completed was on 02/03/11. No current annual competency was found.

On 03/08/12 at 12:20 PM Staff #2 was interviewed. Staff #2 stated restraint/seclusion competency was to be done annually. Staff #2 stated the individual who was keeping up with the training due dates no longer worked at the hospital. Staff #2 stated the nursing supervisors were supposed to be training the nursing staff.

The policy and procedure entitled, "Use of Restraint" with a revised date of 06/08 reflected, "All nursing staff shall receive training in management of aggressive behavior and age appropriate application of restraints upon hire and annually thereafter..."

Based on review of documentation, observation and interview, it was determined that the facility failed to provide adequate and safe nursing services to its patients, as evidenced by the fact that there were expired medications found in an emergency kit, empty oxygen tanks found on units, and inadequate staffing levels for the provision of safe and effective care.

Cross refer to:
the findings under A505 which address the issues with medications and oxygen tanks; and
A0392 which addresses the adequacy of nurse staffing.

In addition to the cross references noted above, an incident occurred on March 7th, 2012 in the early afternoon when a "Code blue" was called, indicating a possible cardiac emergency. The survey team also went to the code site to observe. It was noted that a Registered nurse from a neighboring unit responded to the code, as did the house supervisor, the director of nursing, and other staff. During the time of the code and its immediate aftermath, the nurse from the neighboring unit remained on the unit with the code, leaving the neighboring unit uncovered for the immediate availability of an RN to the patients on that (neighboring) unit.


In an interview with the Director of Nurses, the Assistant Director of Nurses and the Chief Executive Officer on 3/8/2012, the above concerns in regard to nursing services were acknowledged.

Based on review of documentation, observation and interview, it was determined that the facility failed to provide adequate nursing staff to ensure the safety of the facility ' s patients and staff.

Findings were:

Facility policy entitled " Master Staffing Plan " stated in part " Staffing is based on normal staff mix ratios of the following:
? RN House Supervisor on each shift (mayor may not be assigned to a unit).
? At least 1 RN for every 12 clients
? LVN will be added for high acuity or increased census to give medications
? MHT (Mental Health Technician) for each program if census and acuity warrant or according to unit need and patient observation levels
? Adult Services ratio will be maintained at 1:4 for the day and evening shift. A 1:6 ratio will be maintained for the night shift. This number will vary according to acuity needs and number of high risk clients as determined by the Charge Nurse and House Supervisor. "

Meeting Minutes from the Nursing Staffing Committee dated July 2011 stated in part, " Round Robin Issues With Staff:

? DS--Expressed concern about not having a 2nd nurse on A5 children ' s unit when there are more than 14 patients. The ADON stated when there is no nurse available the supervisor will staff with an extra MHT to support the RN. Ultimately there will and should be 2 RNs and 2 MHTs. Also, she had concerns about the lack of flexibility of the grid to provide adequate staffing when aquity changes from unit to unit. "
? CB-Concerned about the visitation policy. Not enough staff to accommodate visitation every day especially now since there needs to be an RN on the unit at all times. "

Meeting Minutes from the Nursing Staffing Committee dated January 2012 stated in part, " Round Robin Issues With Staff:

? " We currently do not have an acuity tool. We are at this time staffing based on numbers. At times the acuity on the units make it necessary to increase tech support. Supervisors consider reviewing the acuity of the patients on each unit from shift to shift and make appropriate adjustments. Current issues have been on Adult 1 where 1 nurse and 1 tech are not safely able to meet the needs of the patients. Reconsider adding a second tech to unit 1 when patient numbers are 9 or more. "

The following dates and shifts did not meet patient to staff ratios according to facility policy:

? 2/22/12, 3-11 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/22/12, 3-11 shift, Unit 5 had 18 patients and 1 RN, 1 LVN and 2 MHTs (1:4.5 ratio)
? 2/22/12, 11-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/23/12, 7-3 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 7-3 shift, Unit 4 had 10 patients and 1 RN and 1 MHT (1:5 ratio)
? 2/23/12, 3-11 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 3-11 shift, Unit 4 had 9 patients (1:4.5 ratio)
? 2/23/12, 11-7 shift, Unit 5 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/24/12, 7-3 shift, Unit 1 had 18 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN, and 3 MHTs (1:4.5 ratio)
? 2/24/12, 7-3 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/24/12, 3-11 shift, Unit 1 had 17 patients, 1 RN and 1 LVN and 2 MHTs (1:4.25 ratio)
? 2/24/12, 3-11 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 1 had 22 patients and 1 RN and 1 LVN and 2 MHTs (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.3 ratio)
? 2/25/12, 7-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/26/12, 7-7 shift, Unit 1 had 27 patients and 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/26/12, 7-7 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/27/12, 7-3 shift, Unit 1 had 27 patients, 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/27/12, 7-3 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 1 had 25 patients and 1 RN and 1 LVN and 2 MHTs (1:6.25 ratio)
? 2/27/12, 3-11 shift Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 2/28/12, 7-3 shift, Unit 1 had 27 patients and 2 RNs and 2 MHTs (1:6.75 ratio)
? 2/28/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 2/28/12, 3-11 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/29/12, 7-3 shift, Unit 1 had 25 patients and 2 RNs and 2 MHTs (1:6.25 ratio)
? 2/29/12, 3-11 shift, Unit 1 had 23 patients and 2 RNs and 2 MHTs (1:5.75 ratio)
? 3/1/12, 7-3 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/1/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/2/12, 7-3 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 7-3 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 7-3 shift, Unit 5 had 14 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/2/12, 3-11 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 3-11 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 3-11 shift, Unit 5 had 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 day shift, Unit 1 had 26 patients and 2 RNs and 2 MHTs (1:6.5 ratio)
? 3/4/12, 7-7 day shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/4/12, 7-7 day shift, Unit 4 had 14 patients and 1 RN and MHT (1:7 ratio)
? 3/4/12, 7-7 day shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 night shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 3 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 2 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 3/5/12, 3-11 shift, Unit 1 had 27 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.75 ratio)
? 3/5/12, 3-11 shift, Unit 3 had 13 patients with 1 RN and 1 LVN and 1 MHT (1:4.3 ratio)
? 3/5/12, 3-11 shift, Unit 4 had 14 patients with 1 RN and 1 MHT (1:7 ratio)
? 3/5/12, 11-7 shift, Unit 1 had 26 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.5 ratio)

In an interview with the Director of Nurses on 3/6/12, it was acknowledged that the facility did not always meet staffing needs according to company policy.

Based on observation and interview, it was determined that the facility ensured that outdated medications were not available for patient use.

Findings were:

Facility policy entitled " Emergency Drug Box " stated in part " A mini-drug box, containing drugs and equipment as approved by the Medical Staff will be available on each of the nursing units in the medication room ... The 24 Hour Nightly Audit will be performed every night by the designated nursing staff. If, during the audit, it is discovered that the mini-emergency drug box has an expired medication or has been opened and the contents used, the nursing staff must notify the pharmacy before the end of their shift ....The pharmacy will be responsible for refilling the contents of the mini-emergency drug box and for charging the appropriate patient for the items used. "

Tour of the facility on 3/7/12 revealed the following:

? Patient Units 1-2 had an Emergency Kit that had the following expired medications: Epipen, Normal Saline and two bottles of eye wash, 2 empty O2 tanks
? Patient Unit 4 had an Emergency Kit that had the following expired medications: Ammonia Ampoules (expired 11/11), Normal Saline (expired 6/11), 1 empty O2 tank

In an interview with the House Supervisor/Charge Nurse on 3/07/12, it was revealed that the 24 hour nightly audit consists of checking to see that the "key seal" has not been broken- the plastic tag that is attached to the latch of the box indicating that the box has not been opened. The House Supervisor indicated that there were no medications to be found in the "red bag"- the emergency kit on the facility's unit housing older adults; even after it was revealed that the surveyors had found medications in the "red bag" as well as an empty "shorty" oxygen tank.The above expired medications and emergency supplies were acknowledged in interview.

Based on observation, interview and record review the hospital failed to ensure the Dietary Department was managed and/or maintained in a sanitary condition in the following manner:

1) Food items such as canned pudding and pasta were stored with non dietary items such as syringes, wound supplies and enemas. Frozen food was being thawed at room temperture, uncovered cakes were placed next to the dirty sink. Butter was left out at room temperature and left in a saucepan approxiametly 6 inches from the floor. Food items in the kitchen were not labeled.

2) Clean pans were stored and stacked wet on top of each other, work stations were soiled and dirty. Dietary personnel at the serving line did not wear gloves for food handling.

Refer to A0620

Based on observation, interview and record review the hospital failed to ensure the Dietary Director managed the dietary department in a responsible manner. The dietary department was not maintained in a sanitary condition. Food items such as canned pudding and pasta were stored with non dietary items such as syringes, wound supplies and enemas. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings included:

On 03/06/12 at approximately 12:00 noon, the central supply storage room was toured with Staff #13. The following observations were made:

The storage shelves and floor of the room were soiled with debris, dirt and grime.

Multiple cans of pudding and pasta were stored on the shelf. The shelf and the items were dusty.

Multiple drinking pitchers were observed on the same shelf. The pitchers were dirty and dusty. Plastic ware such as plates and bowls were stacked on top of each other and stored uncovered on the same dusty shelf.

The central supply room contained multiple boxes of wound supplies, enemas and syringes to name a few.

On 03/06/12 at approximately 12:10 PM to 12:25 PM the kitchen and service line was toured with Staff #13 and Staff #14. The following observations were made:

A multiple shelf rack for storage of clean dishes had 14 trays, 4 muffin tins and 2 large bowls stacked wet on top of each other.

The top shelf above the sink was soiled and greasy. Two of the three coffee urns were assembled wet and available for use. A large yellow sheet cake and a chocolate sheet cake were sitting on the sink ledge uncovered next to the soiled sink. The wall behind the cake was dirty with grime buildup.

The center metal work station 's bottom shelf contained 24 (clean) pans stacked wet on top of each other. Several of the pans were soiled/dirty with loose pieces of yellow food matter. The bottom shelf had multiple pans stacked one of top of each other. The shelf was dirty and dusty.

The stove top had 6 electric burners which were turned on the "high" position on the stove top. No food was being prepared at the time of this observation. This practice placed anyone passing by the stove top to sustain a burn. Staff #11said some of the burners on the stove were not working so in the morning the staff turns them all on to see which ones are working for the day. Staff #11 said she reported the problem to maintenance but the problem had not been fixed.


A second work station had a large container with food items stored inside. One box of gluten free cookies, 1 box of sun dried raisins which expired 02/08/10, 1 large baggie filled with a brown powder substance, 1 bag of potato curls, 2 bags of gravy mix and 1 bag of scallop potato mix were opened and not labeled. The brown powder substance did not have the name of the food item labeled on the exterior surface of the bag.

The refrigerator had 15 slices of lemon cake and 30 individual salads which were not labeled when prepared.

The freezer had a twin popsicle laying on the floor and the freezer temperature log was not completed for 03/06/12.

The shelf under the grill was rusted, stained and dirty. Clean cloths were stored on the shelf and available for use.

Next to the grill (shelf unit) the bottom shelf contained multiple cans of cooking spray and butter spray. A metal saucepan had a large amount of a yellow substance sitting at (room temperature) inside the sauce pan with utensil sticking out of the yellow substance. The metal pan was approximately six inches from the floor. Staff #9 stated she did not know who placed the butter in the saucepan.

The deep fryer ' s two baskets were sitting in old grease. A collection of food debris/residue was collected in the bottom of the fryer. The ledge in front of the grease holding tank was covered with grease and food debris.

The ice machine was inspected. The metal scoop was inside the ice machine sitting in the ice. A holding container for the scoop was observed on the outside of the machine and not in use.

The serving line equipment was inspected. The water dispenser had peeling paint which exposed the underlying surface. The water dispenser surfaces could not be adequately sanitized.

The meal temperature logs from 02/27/12 to 03/06/12 reflected the following:

The 03/02/12 evening meal had no food temperatures documented.
The 03/04/12 breakfast and lunch meal had no food temperatures documented.
The 03/05/12 breakfast and lunch meal had no food temperatures documented.
The 03/06/12 breakfast and lunch meal had no food temperatures documented.

The 03/07/12 at approximately 8:30 AM Staff #11 was observed fixing 5 trays to go on the adult unit. Staff #11 wore no gloves and was asked by the surveyor if she was supposed to wear gloves. Staff #11 stated " yes " but offered no explanation as to why. Staff #11 was asked to show the surveyor how she did food temperatures. Staff #11 took a laser/digital thermometer and pointed it at the metal pan not the food item. The surveyors asked Staff #11 if this was the proper way to do food temperatures. Staff #11 did not offer an explanation.

A metal work station had 4 large containers of barbecue beef sitting in a container of water in the sink thawing out. Staff #9 stated the water should be left running over the food items. To the right of the sink a box of barbecue beef and two additional containers were sitting on top of the work station thawing out at room temperature. Staff #9 acknowledged the containers should not be sitting out at room temperature.

The Dietary Cleaning Schedule Daily and Weekend Cleaning Schedule dated 02/26/12 to 03/06/12 reflected the following:

The deep fryer was documented as cleaned on 02/26/12 and 03/03/12.
The table/counter tops, underneath the counter tops and freezer were documented as cleaned 03/03/12.

On 03/06/12 at 3:30 PM Staff #15 was interviewed. Staff #15 stated she makes rounds in the dietary department and reports her findings via e-mail to the department director. Staff #15 provided the surveyor and in-service conducted 12/16/11 form 11:00 AM to 12:00 noon. Staff #15 said she has discussed labeling, cleanliness and food storage with the dietary staff.

On 03/07/12 at 01:35 PM Staff #23 was interviewed. Staff #23 stated she comes to the hospital twice weekly and checks the freezer and makes sure everything is addressed in the dietary department. Staff #23 stated she was at the hospital on 03/05/12 and everything was fine in the dietary department. Staff #23 was asked if she was aware food items were being stored with non-food items in central supply. Staff #23 stated she was unaware. Staff #23 stated she checks the temperature logs, checks for cleanliness and completes a log on the kitchens condition. Staff #23 stated she was unaware of the above items the survey team found while touring the kitchen.

The most recent RD/LD (Registered Dietician/Licensed Dietician) consultant dietary report provided to the surveyor dated 02/24/12 reflected, "Temperature monitoring, food quality and sanitation all checked as done..."

The policy entitled, Dietary Department, Infection Control with a review date of 10/11 reflected, "Plastic gloves are to be worn when handling individual portions of food on serving line, when mixing food by hand...when scraping dishes...gloves are to be disposed of after use and hand shall be washed...all refrigerated food items are stored promptly upon receipt...frozen foods are defrosted under refrigeration...all food supplies whether refrigerated, frozen or int he storeroom, will be clearly labeled for easy identification. Non-food supplies will be stored in an area separate from food supplies...work surfaces-it is the responsibility of dietary personnel to keep work surfaces clean and uncluttered. Surfaces are cleaned daily using non-toxic sanitizing/disinfection agent...special care will be maintained for all foods in which bacteria grow easily including: mayonnaise, salad dressing, salad or sandwich mixtures, meats (especially chopped or sliced), meat products, gravies, milk cream, eggs, puddings...refrigerator, freezer...food temperatures are checked and recorded daily...dishes and silverware will be allowed to air dry...a routine cleaning schedule is posted for daily cleaning. Specific cleaning procedures for all equipment and areas are written and personnel are trained on those procedures...ice scoop is used to dispense ice...scoops are stored in a dry container outside of the ice machine and never left on the ice bed...they are sanitized a minimum of once daily in the dishwashing machine..."

Based on observation and interview, it was determined that the facility failed to ensure that outdated or damaged supplies were not available for patient use.

Findings were:

Tour of the facility on 3/8/12 revealed the following outdated and/or soiled supplies in the Central Supply Room:

? 6530 ECG Tab Electrodes with the expiration date of 6/07
? 25 1cc Syringes were found in an open, soiled (brown splattered unidentified material) tray
? 1 large open (contents exposed to the air) bag of cotton balls (1000 count)

Tour of the kitchen on 3/6/12 revealed the following:

? 3 large carving knives were discovered in the locking knife storage cabinet. 2 knives had broken tips, and 1 knife had 2 gouges on the cutting surface

Tour of the patient treatment areas revealed the following:

? The Emergency Carts on Units 1-2 and Unit 4 had 3 (of 6) empty oxygen tanks

In an interview with the Risk Manager on 3/6/12, the above soiled, broken and expired supplies were acknowledged.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

Facility policy entitled " Laundry Facilities " stated in part " Washing machines will be sanitized at least daily by housekeeping staff. "

Facility policy entitled " Washing of Patient Clothing " stated in part " Clean lint trap after you remove the clothes. Wipe drier out with germicidal cleaner. "

Facility policy entitled " Dress Code " stated in part " Fingernails: Direct Care and Dietary Staff must not wear artificial fingernails or extenders while at work. "

Facility policy entitled " Dietary Department " stated in part " Plastic gloves are to be worn when handling individual portions of food on a serving line, when mixing food by hand, when the worker has a cut or burn on the hand and when scraping dishes. Gloves are to be disposed of after use and hands should be washed ...Only fresh, wholesome food and food products will be used-uncracked eggs, non-wilted produce, unspoiled meats and fish, products with packaging integrity intact, etc. Work surfaces-It is the responsibility of dietary personnel to keep work surfaces clean and uncluttered ...Special care will be maintained for all foods in which bacteria grow easily including: mayonnaise, salad dressing, salad or sandwich mixtures, meats, meat products, gravies, seafood, shellfish, milk, cream, eggs, custards, puddings, cream pies, any filled pastries and poultry dressings ...Dishes and silverware will be allowed to air dry. Pots and pans will be washed using the same dishwashing procedures. A routine cleaning schedule is posted for daily cleaning. Specific cleaning procedures for all equipment and areas are written and personnel are trained on those procedures. An automatic ice machine shall be maintained by the dietary department and an ice scoop is used to dispense ice. Scoops are stored in a dry container outside of the ice machine and never left on the ice bed. "

Facility cleaning policy entitled " General Policing " stated in part, " Daily: Dust sills, ledges and other horizontal building and furniture surfaces to remove obvious soil ...Damp mop non carpeted floors. Use a well wrung mop and germicidal detergent solution. Spray buff floors coated with finish to remove scuffs, marks, to replace worn finish and to restore a uniform gloss to the floor. Dust mop after spray buffing. "

Tour of the facility on 3/6/12 revealed the following:

Central Supply Room:
? The floor was dirty with debris collected in corners and under shelving units. This demonstrated ineffective cleaning of the area.
? A plastic pitcher was stored on the shelving which contained dried food debris. This indicated improper cleaning.
? 2 soiled towels were found thrown atop stored water bottles. A dirty item should not be placed on top of a clean item as this could lead to cross contamination.
? An open, soiled (with brown, splattered material) container of 1cc allergy syringes was found stored on a shelf. These contaminated syringes should not have been available for patient use.
? An open (exposed to air) bag of 1000 count cotton balls was found on a shelf. These cotton balls are not considered " clean " and should not be available for patient use.

Patient Washing Machine Room:

? 2 of 2 dryers were found with dirty and full lint filters. This created a fire hazard
? The agitator in 1 of 2 washing machines was full of odiferous mold and what appeared to be wet lint which demonstrated ineffective cleaning of the machine
? The water boxes in back of the washing machines were rusted and had chipped paint. This makes effective cleaning of the area impossible.
? When asked the policy for disinfecting the washing machines between use, the Director of Maintenance stated, " The Mental Health Techs do it. " When asked the same question, the Infection Control Nurse stated, " Maintenance is responsible for doing that. " Neither Maintenance nor Nursing Services could produce a log sheet that documented disinfection of the washing machines.

Janitor Closet:

? Dirty dust mop heads were found piled atop clean mop heads. Placing a dirty item on a clean item contaminated the clean item.
? A pile of " clean " towels was noted on the floor of the closet. Next to the pile of towels was a canister with an attached hose that sprayed pesticide. The pile of towels was contaminated by the proximity of the pesticide container and the floor.

Patient Gym:

? The floor throughout the gym was soiled with dirt and scuff marks. The floor behind and next to the trash can had a build up of dried liquids and dirt demonstrating ineffective cleaning of the area

Kitchen:

? Shelving was dirty and had notable food crumbs throughout the kitchen demonstrating ineffective cleaning of the area
? There was a large pan of uncovered butter sitting on a shelf under the Vulcan. This practice invited the growth of bacteria.
? Temperatures of the food that was being served were not taken and documented in a consistent manner. This practice could lend to the growth of microorganisms in under heated food.
? 2 knives were found in the locking knife cabinet that were laying flat in the cabinet. The floor of the cabinet was dirty and contaminated the " clean " knives.
? 1 ungloved staff member was observed in the serving line dispensing food to the patients. This practice could lead to cross contamination.
? A Popsicle was discovered on the floor of the walk in freezer which demonstrated ineffective cleaning of the area.
? Refrigerator temperatures were not taken and documented on a consistent basis. On 03/02/12, evening meal had no food temperatures documented. On 03/04/12, breakfast and lunch meal had no food temperatures documented. On 03/05/12, breakfast and lunch meal had no food temperatures documented and on 03/06/12 breakfast and lunch meal had no food temperatures documented. This practice could lead to the growth of bacteria in food not kept at the appropriate temperature.
? Pans were observed to be washed but not allowed to air dry. These wet pans were stacked which allowed the growth of bacteria.
? A large yellow sheet cake and a chocolate sheet cake were sitting on the sink ledge uncovered next to the soiled sink. The wall behind the cake was dirty with grime buildup. Proximity to these dirty areas could contaminate the cake.
? The shelf under the grill was rusted, stained and dirty. Clean cloths were stored on the shelf and available for use. Placing a clean item in a dirty area contaminates the clean item.
? The water dispenser in the serving line had peeling paint which exposed the underlying surface. The water dispenser surfaces could not be adequately sanitized.
? A metal work station had 4 large containers of barbecue beef sitting in a container of water in the sink thawing out. Staff #9 stated the water should be left running over the food items. To the right of the sink a box of barbecue beef and two additional containers were sitting on top of the work station thawing out at room temperature. Staff #9 acknowledged the containers should not be sitting out at room temperature.

Infection Control Nurse:

? When asked about the facility policy on fingernails, the Infection Control Nurse told the survey team that there was no policy. This nurse was observed to have artificial nails that extended approximately 1/3 of an inch past her fingertips.

In interviews with the Assistant Director of Nurses, the Dietician, the Risk Manager and the Chief Executive Officer on 3/6 and 3/7/12, the above infection control concerns were acknowledged.

Based on review of documentation, observation and interview, it was determined that the facility failed to provide adequate nursing staff to ensure the safety of the facility ' s patients and staff.

Findings were:

Facility policy entitled " Master Staffing Plan " stated in part " Staffing is based on normal staff mix ratios of the following:
? RN House Supervisor on each shift (mayor may not be assigned to a unit).
? At least 1 RN for every 12 clients
? LVN will be added for high acuity or increased census to give medications
? MHT (Mental Health Technician) for each program if census and acuity warrant or according to unit need and patient observation levels
? Adult Services ratio will be maintained at 1:4 for the day and evening shift. A 1:6 ratio will be maintained for the night shift. This number will vary according to acuity needs and number of high risk clients as determined by the Charge Nurse and House Supervisor. "

Meeting Minutes from the Nursing Staffing Committee dated July 2011 stated in part, " Round Robin Issues With Staff:

? DS--Expressed concern about not having a 2nd nurse on A5 children ' s unit when there are more than 14 patients. The ADON stated when there is no nurse available the supervisor will staff with an extra MHT to support the RN. Ultimately there will and should be 2 RNs and 2 MHTs. Also, she had concerns about the lack of flexibility of the grid to provide adequate staffing when aquity changes from unit to unit. "
? CB-Concerned about the visitation policy. Not enough staff to accommodate visitation every day especially now since there needs to be an RN on the unit at all times. "

Meeting Minutes from the Nursing Staffing Committee dated January 2012 stated in part, " Round Robin Issues With Staff:

? " We currently do not have an acuity tool. We are at this time staffing based on numbers. At times the acuity on the units make it necessary to increase tech support. Supervisors consider reviewing the acuity of the patients on each unit from shift to shift and make appropriate adjustments. Current issues have been on Adult 1 where 1 nurse and 1 tech are not safely able to meet the needs of the patients. Reconsider adding a second tech to unit 1 when patient numbers are 9 or more. "

The following dates and shifts did not meet patient to staff ratios according to facility policy:

? 2/22/12, 3-11 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/22/12, 3-11 shift, Unit 5 had 18 patients and 1 RN, 1 LVN and 2 MHTs (1:4.5 ratio)
? 2/22/12, 11-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/23/12, 7-3 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 7-3 shift, Unit 4 had 10 patients and 1 RN and 1 MHT (1:5 ratio)
? 2/23/12, 3-11 shift, Unit 1 had 19 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN and 3 MHTs (1:4.75 ratio)
? 2/23/12, 3-11 shift, Unit 4 had 9 patients (1:4.5 ratio)
? 2/23/12, 11-7 shift, Unit 5 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/24/12, 7-3 shift, Unit 1 had 18 patients and 1 1:1 Close Observation. The unit had 1 RN, 1 LVN, and 3 MHTs (1:4.5 ratio)
? 2/24/12, 7-3 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/24/12, 3-11 shift, Unit 1 had 17 patients, 1 RN and 1 LVN and 2 MHTs (1:4.25 ratio)
? 2/24/12, 3-11 shift, Unit 4 had 11 patients and 1 RN and 1 MHT (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 1 had 22 patients and 1 RN and 1 LVN and 2 MHTs (1:5.5 ratio)
? 2/25/12, 7-7 shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.3 ratio)
? 2/25/12, 7-7 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/26/12, 7-7 shift, Unit 1 had 27 patients and 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/26/12, 7-7 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/27/12, 7-3 shift, Unit 1 had 27 patients, 1 RN and 1 LVN and 2 MHTs (1:6.75 ratio)
? 2/27/12, 7-3 shift, Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 1 had 25 patients and 1 RN and 1 LVN and 2 MHTs (1:6.25 ratio)
? 2/27/12, 3-11 shift Unit 4 had 14 patients and 1 RN and 1 MHT (1:7 ratio)
? 2/27/12, 3-11 shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 2/28/12, 7-3 shift, Unit 1 had 27 patients and 2 RNs and 2 MHTs (1:6.75 ratio)
? 2/28/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 2/28/12, 3-11 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 2/29/12, 7-3 shift, Unit 1 had 25 patients and 2 RNs and 2 MHTs (1:6.25 ratio)
? 2/29/12, 3-11 shift, Unit 1 had 23 patients and 2 RNs and 2 MHTs (1:5.75 ratio)
? 3/1/12, 7-3 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/1/12, 3-11 shift, Unit 1 had 24 patients and 2 RNs and 2 MHTs (1:6 ratio)
? 3/2/12, 7-3 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 7-3 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 7-3 shift, Unit 5 had 14 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/2/12, 3-11 shift, Unit 1 had 20 patients and 2 RNs and 2 MHTs (1:5 ratio)
? 3/2/12, 3-11 shift, Unit 4 had 9 patients and 1 RN and 1 MHT (1:4.5 ratio)
? 3/2/12, 3-11 shift, Unit 5 had 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 day shift, Unit 1 had 26 patients and 2 RNs and 2 MHTs (1:6.5 ratio)
? 3/4/12, 7-7 day shift, Unit 3 had 13 patients and 1 RN and 2 MHTs (1:4.6 ratio)
? 3/4/12, 7-7 day shift, Unit 4 had 14 patients and 1 RN and MHT (1:7 ratio)
? 3/4/12, 7-7 day shift, Unit 5 had 15 patients and 1 RN and 2 MHTs (1:5 ratio)
? 3/4/12, 7-7 night shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 3 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 1 had 26 patients with 1 1:1, 2 RNs and 2 MHTs (1:6.25 ratio)
? 3/5/12, 7-3 shift, Unit 4 had 13 patients and 1 RN and 1 MHT (1:6.5 ratio)
? 3/5/12, 3-11 shift, Unit 1 had 27 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.75 ratio)
? 3/5/12, 3-11 shift, Unit 3 had 13 patients with 1 RN and 1 LVN and 1 MHT (1:4.3 ratio)
? 3/5/12, 3-11 shift, Unit 4 had 14 patients with 1 RN and 1 MHT (1:7 ratio)
? 3/5/12, 11-7 shift, Unit 1 had 26 patients with 1 1:1, 1 RN and 1 LVN and 3 MHTs (1:6.5 ratio)

In an interview with the Director of Nurses on 3/6/12, it was acknowledged that the facility did not always meet staffing needs according to company policy.