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Based on observation of one patient (Patient #26) who had sharp utensils in her possession, one patient (Patient #25) who acted in an unsanitary manner, the physical environment which contained unsafe items, a portable phone used in an unsanitary manner, hot coffee accessible in the dayroom and in the cafeteria, and an altercation with thrown hot coffee on one patient to another ( Patients #28 and #32), the facility failed to ensure the patients were cared for in a safe setting.

Findings include:

1. Patient #26

Patient #26 was a 19 year old admitted on an involuntary psychiatric hold on 10/31/2011 with diagnoses to include psychosis, poly-drug use and drug induced hallucinations.

Observation:

On 11/2/2011 in the morning, Patient #26 was observed walking into her room with a rolled up napkin that contained two sporks (a combination plastic spoon and fork). The patient attempted to conceal the items in her room. A Mental Health Technician (MHT) who was in the hall near the patient's room was asked if Patient #26 should have those items in her possession in her room. The MHT indicated, "no" and removed them from the patient's room.

On 11/2/2011 at approximately 10:00 AM, a Styrofoam box containing six sporks was stored on the table near the dayroom and accessible to patients. The MHT in the hall was asked if the sporks should be stored in that area. The MHT indicated, "No they should not."

On 11/2/2011 at 10:15 AM, several sharpened pencils were observed being stored on the crafts table in the dayroom which were accessible to patients. Several verbal altercations broke out in the dayroom while patients were being administered medications on 11/2/2011. The nurse who administered the medications indicated the pencils should not have been in plain sight and accessible to the patients without supervision.

Policy review:

Policy #: PC.062-Controlled/Contraband Items revised 8/1, documented the following:

"...Eating utensils (sporks) will be provided to patients in the dining room at meals and are visually checked by the staff when they return their trays for disposal. For patients who remain on the unit in order to eat their meal, staff collect all sporks after their meals and dispose of such..."

"...During the inpatient stay, patients will be allowed golf pencils in order to complete therapeutic activities. In the event that these items become a safety issue, the golf pencils will be given to patients to complete the activity and then will be taken away by staff at the end of the activity..."

2. Patient #28

Patient #28 was admitted involuntarily on a psychiatric hold to the facility on 10/28/2011, with diagnoses to include bi-polar with hallucinations.

Patient #32

Patient #32 was involuntarily admitted with a psychiatric hold on 10/31/2011, with diagnoses to include acute psychosis non-specified.

On 11/2/2011 in the morning a cylindrical closed urn containing coffee measured at 128 degrees Fahrenheit was stored on a table which was accessible to the patients in the dayroom.

On 11/3/2011 in the afternoon, a video was observed in the Risk Manager's office which showed Patient #28 throwing a cup of coffee at Patient #32. Patient #32 was sent to the Emergency Room on 11/2/2011 at an acute hospital immediately after the incident. Patient #32 returned with no serious burns the same day.

3. Patient #25

Patient #25 was involuntarily admitted on a psychiatric hold on 11/1/2011 with diagnoses to include chronic alcohol abuse, Post Traumatic Stress Disorder and aggressive behavior.

On 11/2/2011 in the morning, Patient #25 removed a brown rag from the trash bin in the dayroom, smelled it and wiped the dayroom table. He then threw the rag back in the trash. He repeated this procedure several times during the day. Patients were observed sitting at the table eating.

4. Observations made in the south adult care unit on 11/1/2011-through 11/3/2011, noted the portable telephone was used without being disinfected between patient use. The MHTs stored the phones in their pockets between use.



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The facility failed to ensure the following practice of using the common telephones protected the patients from cross contamination of germs:

On 11/3/11 in the late afternoon and on 11/4/11 in the morning, the telephone handsets were observed to be used by several patients in the south Adult Care Unit, with contact of the mouthpiece and the patients' mouths and hands. The handsets were not disinfected between use by the patients.

5. On 11/3/11 during the dinner meal, two patients were observed standing in the cafeteria right in front of the coffee machine dispenser socializing for approximately 10 minutes. The hot coffee, which was measured at 145 degrees Fahrenheit, was available to the patients without direct staff supervision.

-On 11/4/11 in the morning, it was observed with the Administrator and the Kitchen Manager the coffee from the coffee machine dispenser in the cafeteria was measured at 180 degrees Fahrenheit. The hot water from the dispenser was measured at 160 degrees Fahrenheit.

-On 11/4/11 in the morning, the Administrator and the Kitchen Manager verified the coffee was directly available to be dispensed by the patients in the cafeteria. The Administrator further indicated the coffee was too hot for patients and acknowledged the hot coffee could present a scalding hazard. The Administrator indicated there was no written policy regarding hot beverages.

Based on document review and staff interview, the facility failed to make a provision for the reporting of tissue specimen examination results.

Findings include:

On 11/3/11 at 2:00 PM, the Administrator (Employee #1) verified the facility did not make a provision for the reporting of tissue specimen examination results.

There was no written procedure for ensuring that patient tissue specimen examination results were reported and placed in patient charts.

Based on document review and staff interview, the facility failed to ensure the medical staff and the pathologist determined specimen examination requirements.

Findings include:

On 11/3/11 at 2:00 PM, the Administrator (Employee #1) verified the medical staff and the pathologist did not determine specimen examination results.

There was not a list, determined by the medical staff and a pathologist, stating which tissue specimens required a macroscopic examination and which specimens required both macroscopic and microscopic examinations.