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Based on observations and interview with staff, it was determined the facility failed to provide a safe and ligature risk free environment for geriatric psychiatric patients admitted to New Day Senior Care. This had the potential to affect all patients admitted to New Day Senior Care.

Findings include:

Please refer to tag A-0144 for findings.

Based on observations in the New Day Senior Care unit, medical record (MR) review, policies and procedures, and interviews with staff, it was determined the facility failed to ensure:

a) A safe and ligature risk free environment for psychiatric patients.

b) Policies and procedures were followed for patients exhibiting dangerous or destructive behaviors in 2 of 2 medical records reviewed.

c) The Director maintained Crisis Intervention Certification and current CPR (Cardiopulmonary Resuscitation) per policy.

d) The Director provided education and in-service to staff, and maintained a yearly plan for in-services and completed necessary documentation, per policy.

e) Supply room, containing oxygenators, wheelchairs, and other supplies, had controlled entry.

This affected 2 of 2 records reviewed on the New Day Senior Care unit, and did affect MR # 13 and MR # 14 and had the potential to affect all patients served by New Day Senior Care unit.

Findings include:

Policy: Management of Agitated Patient or Visitor
Revised Date: 3/31/2015

I. Policy:

It is the policy of the unit to assist the agitated and/or combative patient in minimizing his/her response to internal confusion and prevent injury for patients suffering emotional/ neurological impairment.

II. Supportive Data:

A. The patient in an agitated phase cannot be held accountable for his/her actions...

B. The use of restraints/ medications shall be used only when absolutely necessary, and all other less restrictive measures have failed, to protect the patient from physical harm as they generally serve to increase a patient's agitated response/ internal confusion.

C. (III) Procedure:

A. Upon admission, the Unit Coordinator / Medical Director shall meet with appropriate family member to discuss... the potential need for the use of restraints.

...D. Potential treatment intervention/ strategies may include, but not limited to the following:
1. Decrease stimuli in room... limit pieces of furniture and equipment...
4. If risk of injury is evident, the patient will be under direct observation...
5. Use physical reassurance as much as possible, and where touch does not elicit a negative response.
...8. Inform family members of treatment strategies...

E. Should all other methods fail and seclusion/ restraints be required, the nurse shall obtain a physician's order...

Policy: Dr. Strong
Revised Date: 4/1/15

I. Policy:

A. "Dr. Strong" procedure shall be initiated when the unit staff is in need of additional persons to assist in controlling an emergency situation. Such situation may include but is not limited to the following:

1. A patient exhibits dangerous or destructive behaviors.
2. A patient verbalizes the intent to exhibit behaviors.
3. A patient poses an immediate threat to self or others.

II. Procedure:

A. The staff will attempt all non-intrusive methods for de-escalating the situation...

B. If unsuccessful, the staff will contact the physician for seclusion and/or restraint orders as necessary...

C. If patient is uncooperative or poses a threat and staff feels that additional persons are required to control the situation, staff will initiate "Dr. Strong" procedure....

D. The hospital will identify individuals in the facility (on each shift) who will respond to the "Dr. Strong" announcement. Recommended individuals/ departments may include, but is not limited to:

1. Nursing supervisor
2. Maintenance
3. ER (Emergency Room)

...F. A program staff member having received Crisis Intervention training shall act as the team leader and will organize the team effort by:

1. Doing all the communicating with the patient.
2. Indicating the decision for restrictive interventions...
4. Directing the procedure without becoming involved unless absolutely necessary.
5. Indicating the decision of administration of medications as necessary.
...8. Dismissing the responding personnel.

Job Specifications and Evaluation
Job Title: Nurse Manager/ Clinical Supervisor- Psychiatric Unit

Job Summary

...The Nurse Manager/ Clinical Supervisor promotes patient care consistent with the philosophy and objectives of the facility and accepted standard of practice.

Duties and Responsibilities
A. Essential Job Functions
-...Provides education, in-service...
-Maintains a yearly plan for in-services. Completes necessary documentation.

B. Professional Growth and Development
-Follows policies and procedures of the program.
-Maintains current CPR training, crisis intervention certification...

Community Hospital, Inc.
Position Description
Psychiatric Staff RN
Revised Date: 10/94

...Position Qualifications:

-Certification: ...Non-violent Crisis Intervention training.

A tour of the New Day Senior Care unit was conducted on 4/15/19 at 1:15 PM with Employee Identifier (EI) # 18, Outreach Coordinator. The following was observed:

1. Rooms 201 and 203 are private, and rooms 202, 204, 206, and 208 are semi-private.

Rooms 201 and 203 each contained:
1- Stryker brand patient bed. Bed contained open side rails, removable headboard and footboard. Both headboard and footboard contained 2 open areas for handle grip.
1- overbed table, with opening drawer and flip up plastic mirror.
1- bedside table with drawers, on wheels.
1- light weight chair.
1- light at head of bed mounted on wall. The light had plastic covers and was reachable by surveyor.
1- metal paper towel dispenser with a flat top, mounted on wall.
3- open handicap rails, 1 beside toilet and 2 in tub area.
1- plastic/ vinyl shower curtain.
1- sink with exposed plumbing, 2 lever handles, and arching spout.
1- portable shower chair/ raised toilet seat, sitting over toilet, with open hand rails.
2- flat topped closet doors with 3 regular hinges on each door and open handle on each door.
Bathroom door contained regular door knobs, inside and out.
Main door to room contained 3 regular hinges on the inside.

Rooms 202, 204, 206, and 208 contained the same as above, plus an additional bed, overbed table, bedside table, light at head of additional bed, and light weight chair. Rooms 202 and 204 also contained a geriatric chair/recliner, with an open handle across the back of chair.

An Exam Room was located on the main hall, and is used for storage only. EI # 10, Director, New Day Senior Care, who was also present during the tour, stated patients needing exams are taken to their rooms. The Exam Room door does not have a lock to secure the door. The room contained 2 oxygenators, wheelchairs, and shelving units containing supplies for activities and games.

In the Dining Room, the following was observed:
1- broom, propped in the corner beside bathroom.
1- dust pan with long handle, propped in the corner beside bathroom.
1- large plastic garbage liner hanging from garbage container frame, beside bathroom door.
The floor around the refrigerator in the Dining Room was dirty, containing dust, crumbs, and hair.

In the Dining Room bathroom, the following was observed:
1- Portable raised toilet seat with open side rails, sitting over toilet.
1- sink with exposed plumbing underneath. Faucet had 2 lever handles and arched spout.
1- metal, flat topped paper towel dispenser.
The floor in the bathroom was stained with a brown substance and was dusty.
The bathroom door had regular door knobs inside and out. The door locks from the inside. There was silk tape over the latch that prevented the latch from catching in the door frame.

In the Medication Room the following was observed:
1- Oxygen tank, empty. No other tank present.
Located in the Medication Room was an alcove with an exterior door. Located in the alcove, was a large mop hopper. The hopper contained a large sponge covered in black grime. The base of the hopper contained approximately 1/2 inch of dried black grime/dirt. The floor contained black spots, grime, and 2 rags were behind the hopper on the floor. EI # 11, RN (Registered Nurse), explained housekeeping has access to the exterior door and uses this alcove to fill their mop buckets. The hopper was located less than 2 feet from the Med Dispense machine containing medications. The room also contained medications not in the Med Dispense, such as liquid medications and patient's own medications brought from home.

During an interview conducted on 4/15/19 at 2:30 PM with EI # 10, the above findings were confirmed.

2. MR # 13 was admitted to New Day Senior Care on 4/10/19 with diagnoses including Dementia with Behavioral Disturbances.

Review of the MR revealed the following nursing documentation on 4/15/19 at 1730 (5:30 PM), "Pt (patient) became combative with the staff while attempting to give him an injection..." At 1800 (6:00 PM) the nurse documented, "Pt attempted to pull the pants down of a female patient... Redirection ongoing." At 1840 (6:40 PM) the nurse documented, "Pt walked up and randomly hit the nurse in the face with bald up fists, and attempted to fist fight the nurse. The police were called to help staff subdue the pt. Pt received an injection to help reduce his agitation. Monitoring ongoing."

The next nursing documentation was at 2230 (10:30 PM), which was 3 hours and 50 minutes later, and documented the patient was sleeping.

There was no documentation a "Dr. Strong" was initiated for the patient's behaviors, per policy, or documentation the physician was notified of the patient's escalating behavior.

During an interview on 4/16/19 at 9:20 AM, EI # 10 stated he/she had called the House Supervisor on 4/15/19 around 6:00 PM, he/she called the physician at 6:30 PM, and the wife/ husband was called at 6:35 PM, to notify all of the above people they were going to call the police. The surveyor showed EI # 10 the nursing documentation for 4/15/19. EI # 10 stated, "That information should have been documented, I thought the nurse was documenting it."

3. MR # 14 was admitted to New Day Senior Care unit on 3/26/19 with diagnoses including Dementia with Behavioral Disturbances.

Review of the MR revealed the following documentation by the nurse on 4/7/19 at 0800 (8:00 AM), "Pt became irate, aggressive, and agitated after breakfast... Supervisor on floor during incident. Two MHTs (Mental Health Technicians) and two nurses attempted to redirect pt several times w/o (without) success.... 0815 (8:15 AM) Able to talk pt into sitting down in wc (wheelchair) in hall, but pt still refuses meds...Sister on phone notified of issues at hand and attempts to help calm down pt and still refuses medication and becomes emotional and refuses to speak with sister on phone anymore... No males available in building, and supervisor agrees that police should be notified for assistance with getting medication taken and pt calmed down. Family aware and police notified with supervisor on floor."

There was no documentation a "Dr. Strong" was initiated or the physician notified of the patient's behaviors according to policy.

Review of the New Day Daily Team Meeting form dated 4/10/19, revealed the following documentation, "(MR # 14): Family was upset b/c (because) police was called."

During an interview on 4/17/19 at 12:35 PM with EI # 3, Director of Nursing, the above findings were confirmed.

4. A review of the personnel file for EI # 10 revealed a signed Job Specifications and Evaluation for Nurse Manager/ Clinical Supervisor - Psychiatric Unit, dated 5/13/13. The Supervisor Signature and Date line were left blank.

Review of the Job Specifications revealed the position requires the Nurse Manager to maintain current CPR and crisis intervention certification.

The file contained a BLS (Basic Life Support) card with an expiration date of September 2018.

There was no documentation of crisis intervention certification, current or expired.

During an interview conducted on 4/17/19 at 11:30 AM with EI # 16, Human Resources Director, the above findings were confirmed.

On 4/18/19, an email was received from the facility with an attached letter from CPI (Crisis Prevention Institute) addressed to Montgomery Area Mental Health Authority verifying EI # 10 participated in a Nonviolent Crisis Intervention training class on August 9, 2011. There was no evidence of certification provided, or if certification maintained.

5. Review of the NetLearning transcript, dated 6/24/14 to current, for EI # 11, RN, revealed a Course Class titled, "Responding to Emergencies in the Gerospych Unit" on 9/26/16. There was no evidence of annual training since that date.

During an interview on 4/15/19 at 1:30 PM, EI # 10 stated he provided de-escalation training annually to employees on the New Day Senior unit.

An interview was conducted on 4/17/19 at 11:30 AM with EI # 16, who confirmed there was no documentation of annual training of de-escalation training for EI # 11. EI # 10 failed to maintain a yearly plan for in-services, per job description.

Based on review of medical records (MR), policy and procedure, and interview, it was determined the facility failed to ensure the staff:

a) Notified the physician of new wounds.

b) Obtained and followed the physician's orders for wound care.

c) Performed wound assessments and measured wounds per policy.

d) Documented specific wound care performed.

This affected MR # 22, MR # 15, 2 of 2 records reviewed with wounds, and had the potential to affect all patients treated at the hospital.

Findings include:

Policy: Wound Care.
Date on Policy: 8/26/09

1. Wounds are to be measured weekly and whenever an obvious change occurs (improvement or worsening).
2. Wounds are to be assessed daily unless the order is for greater than 24 hours between dressing changes. If the wound does not have a dressing, it is to be assessed every shift...
4. Wound care is to be per physician order... Wound care orders are to be obtained on admission, if the wound occurs after admission, the physician is to be notified and orders obtained as soon as possible.

1. MR # 22 was admitted to the hospital on 3/29/19 with diagnoses including Hypokalemia, UTI, and Dementia.

Review of the MR revealed a nursing assessment dated 3/29/19. At 1800 (6:00 PM) the nurse documented, "Pt (patient) repositioned on side and reddened area with small break in skin noted to sacral area, discussed with charge nurse." There was no further assessment of the wound or wound measurements documented. There was no documentation the physician was notified and wound care orders obtained.

On 3/30/19 at 0709 (7:09 AM) the nurse documents dressing is "Clean, dry, intact" and type of dressing, "Occlusive." There was no location of the wound documented, or what type of dressing was used.

On 3/31/19 at 0952 (9:52 AM) the nurse documented under Basic Statement Skin: "...No wounds present." Wound location "Right Foot." There was no further assessment of the right foot. The nurse documented under Wound Assessment: Dressing: "clean, intact." Type of dressing: "occlusive." The surveyor is unable to determine which wound has been assessed.

At 1626 (4:26 PM) the nurse documented Wound location: "r (right) foot." There is no assessment of the right foot wound. There is no documentation the physician has been notified of the right foot wound, or if wound care was ordered. Under Wound Assessment, the nurse documents Dressing: "clean." The surveyor is unable to determine which wound has a dressing. The sacral wound is not mentioned.

On 4/1/19 at 0009 (12:09 AM) the nurse documented under Skin Assessment, "...no wounds present..." and then under Wound Assessment documented, "Dressing: clean, dry, intact. Type of dressing: Occlusive."

During an interview on 4/17/19 at 12:45 PM with Employee Identifier (EI) # 3, Director of Nursing, the surveyor received 2 Skin Integrity Assessment Sheets dated 3/29/19 and 4/1/19. The 4/1/19 sheet was marked "Discharge Assessment" and listed the following wounds:

-Site A Decubitus, Left Breast 2.25 cm (centimeter) x 2.00 cm. There was no depth listed for the wound, and no previous documentation of a Left Breast wound in the nursing notes.

-Site B Red Area, Right Breast. There was no previous documentation of a Right Breast reddened area in the nursing notes.

-Site C Red Area, Pubic Area. There was no previous documentation of a pubic area reddened area in the nursing notes.

-Site D Coccyx Area, 2 cm x 0.1 cm x 0.1 cm. New. No drainage, No odor. The surveyor was unable to tell if this was the same sacral wound documented on 3/29/19.

-There was an additional Site A and Site B listed, with the markers on the diagram at Left Ankle and Right Toes, with description "Reddened area."

During the same interview on 4/17/19 at 12:45 PM, EI # 3 confirmed there was no documented physician notification of the wounds, and no documented orders for wound care.



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2. MR # 15 was admitted to the facility swing bed program on 3/29/19 for diagnoses of Calculus of Gallbladder with Chronic Cholecystitis Without Obstruction and Muscle Weakness (Generalized).

Review of the Swing Bed Care Plan dated 3/29/19 revealed documentation under skin integrity interventions of "Assess wounds daily..."

Review of the Patient Progress Notes dated 3/29/19 through 4/11/19 revealed documentation of a "surgical incision" to the "abdomen."

Review of the Patient Progress Notes dated 3/29/19 through 4/11/19 revealed no documentation of measurements of the surgical incision to the abdomen

Review of the MR revealed no documentation of a physician's order for wound care to the surgical incision to the abdomen.

An interview was conducted on 4/15/19 at 1:5 PM with EI # 1, Swing Bed Coordinator, who confirmed the above findings.

Based on review of Medical Records (MR), facility's policies, and interviews with the staff it was determined the facility failed to ensure that all physician's orders were written and entered into the patients MR. This affected 2 of 3 outpatient MR's reviewed including MR # 11, # 16, and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Physician's Orders
Revised: 12/13/16

"Policy:

...2. Telephone/verbal physician orders.

E. Telephone, verbal and relayed orders should be signed by the prescribing practitioner ... the next time the prescribing practitioner provides care to the patient, assesses the patient, or writes information in the patient's medical record...

Procedure:

...2. Enter the order in the computer as a verbal or phone order and indicate that the order was read back.

3. If the computer system is down:

a. Write the order legibly on the physician's order sheet immediately after receipt and indicate phone order (P.O.) or verbal order (V.O.) and the order was read back (R.B.).

b. Record the name and title of the individual giving the order...

c. Record the time and date the order was received on the physician's order sheet".

Facility Policy: I.V. (Intravenous) Procedure
Revised: 9/8/17

"Policy:

...2. I.V. therapy may only be initiated upon the physicians order or in an emergency situation".

1. MR # 11 admitted to the facility on 4/15/19 for a Colonoscopy.

Review of the G.I. (Gastrointestinal) Lab Nurses Notes dated 4/15/19 revealed the following:

"Pre Procedure Assessment & (and) Instructions:

...IV started: Time: 0900 (9:00 AM), Site: L (left) wrist, Fluid: 1/2 NS (Normal Saline), Rate: KVO (Keep Vein Open)...

Discharge Summary:

10:02 AM: Check by Dr. (Doctor)...
10:25 AM: IV D/C (Discontinued): Yes ... Discharged to: ... relative".

There were no physician's orders for the IV initiation or discontinuation and discharge of the patient as directed per the facility policy and procedure.

An interview was conducted on 4/17/19 at 12:06 PM with Employee Identifier (EI) # 8, Registered Nurse (RN), GI Coordinator, who verified there were no physician's orders for the above findings.

2. MR # 16 was admitted to the facility on 12/5/18 for an Esophagogastroduodenoscopy (EGD).

Review of the G.I. Lab Nurses Notes dated 12/5/18 revealed the following:

"Pre Procedure Assessment & (and) Instructions:

...IV started: Time: 10:00 AM, Site: R (right) hand, Fluid: 1/2 NS, Rate: KVO ...

Discharge Summary:

10:05 AM: IV D/C: Yes ...
11:20 AM: Check by Dr. (Name) ...
11:42 AM: Discharged to ... spouse".

There were no physician's orders for the IV initiation or discontinuation and discharge of the patient as directed per the facility policy and procedure.

An interview was conducted on 4/17/19 at 12:06 PM with EI # 8 who verified there were no physician's orders for the above findings.

Based on review of the facility's policy and procedure, observation, and interview it was determined the facility failed to ensure:

a) Expired medications were removed and not available for patient use.
b) Beyond use dated medications were removed and not available for patient use.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Policy: Handling of Medicines, Medical Consumables and Chemicals
Date Reviewed: 8/23/12

Purpose:
1. To identify expired products/ items (medications...).
2. To avoid the use of expired medications...
3. To arrange return/ disposal of the expired medications...

Policy
...2. Expiration:
...B. All medications... are to be considered expired on the manufacturer stated day of expiration or at the last day of the manufacturer stated month of expiration.
C. Medications...which have expired are not to be used in the facility.
D. ...The expiration date for multiples-dose vials..will be 28 days or less based upon the manufacturer's expiration date listed on the vial and manufacturer's recommendations...

3. Medications:
...C. Expired medications are to be returned to the pharmacy for disposal.

Procedure
...5. Staff are to check the expiration date of the products on a regular basis...
7. All products are to be checked monthly for expiration...

1. A tour conducted on 4/15/19 at 1:45 PM of the New Day Senior Care unit supply room revealed the following expired medication in the refrigerator:

1-vial, unopened, Humulin 70/30 insulin, expiration date 3/2017.

An interview was conducted on 4/15/19 at 1:45 PM with Employee Identifier (EI) # 11, Registered Nurse, who was also present on the tour, confirmed the above findings.



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2. A tour of the Emergency Department (ED) was conducted on 4/15/19 at 9:45 AM with EI # 2, Infection Control Nurse.

The following medications were found opened and available for patient use in the ED medication room:

Amoxicillin 250 mg/ 5 ml 100 ml with no date for when it was opened.
Amoxicillin and Clavulanate Potassium 200 mg/28.5 mg 5 ml with opened date of 3/29/19. Manufacturer's label recommendation located on the bottle stated "discard after 10 days" when opened.
Stomach Relief (Bismuth Subsalicylate) 525 mg 118 ml bottle with no date for when it was opened.
Rocuronium Bromide 50 mg/5 ml vial opened with no date for when it was opened.

EI # 2 confirmed the above findings during the tour of the ED.

3. A tour of the ICU (Intensive Care Unit) was conducted on 4/15/19 at 2:00 PM with EI # 3, Director of Nursing.

The following medications were found in the ICU, available for patient use, and expired:
ICU room # 4:
Airlife Sterile Water Inhalation 500 ml x 1 with the expiration date of 5/18
0.9 % sodium Chloride Injection(s) 5 ml x 2 with the expiration date of 1/2018
0.9 % sodium Chloride Injection(s) 5 ml x 2 with the expiration date of 1/2019
0.9 % sodium Chloride Injection(s) 5 ml x 12 with the expiration date of 3/1/2019

ICU room # 5:
0.9 % sodium Chloride Injection(s) 5 ml x 1 with the expiration date of 2/1/2019

Nursing Station:
0.9 % sodium Chloride Injection 30 ml multi-dose vial with the opened date of 1/30/2019

EI # 3 confirmed the above finding prior to the end of the tour.

4. A tour of the medical/surgical 3rd floor was conducted on 4/16/19 at 8:10 AM with EI # 3.

The following medications were found, available for patient use, and expired:
Pedia Lax Enema 66 ml x 1 with the expiration date of 1/19
Pedia Lax Enema 66 ml x 2 with the expiration date of 3/19
5 % Dextrose and 0.9% Sodium Chloride Injection 500 ml x 6 with the expiration date of 12/18
1 % Xylocaine 200 mg/ 20 ml x 4 with the expiration date of 2/19
0.9 % Sodium Chloride Injection 5 ml x 2 with the expiration date of 2/1/19

EI # 3 confirmed the above finding prior to the end of the tour.

Based on observations, Facility Policy and Procedure, and staff interview it was determined the hospital failed to ensure the MRI (Magnetic resonance imaging) machine and equipment were secured and unavailable when facility staff were not present. This had the potential to affect all patients and personal.

Findings include:

Policy and Procedure for Securing the MRI Mobile Unit When Not in Use:
Date: 4/16/19

The MRI unit will be securely locked by the MRI technologist when he/she leave the MRI unit unattended. The technologist will lock the roll door from the inside by flipping the roll down off switch. The technologist will exit through the man (main) door that he/she securely locks behind themselves.

1. A tour was conducted on 4/16/19 at 2:30 PM with Employee Identifier (EI) # 15, Director of Radiology, of the radiology department.

During the tour, EI # 15 verbalized the facility MRI Mobile Unit was at the back of the hospital and the technologist were off and not at the facility.

EI # 15 lead the surveyor to the MRI Mobile Unit and used the unsecured roll door to access the unit.

The surveyor observed inside the MRI Mobile Unit the door to the MRI machine (on the left), the door to the control room of the MRI machine (on the right), and the medical supplies in the middle of the unit were all left unsecured.

The surveyor requested a facility policy for securing the MRI Mobile Unit during the tour.

An interview was conducted on 4/17/19 at 8:05 AM, during the interview the surveyor received the policy for Securing the MRI Mobile Unit dated 4/16/19 by EI # 15. EI # 15 stated the facility had "no policy before" 4/16/19.

Based on observations, interview, and policies and procedures it was determined the hospital failed to ensure food was stored in a safe manner, expired food was disposed of properly, and prepared foods were labeled as to content and date. This had the potential to negatively affect all persons served by the hospital.

Findings include:

Policy: Labeling and Dating Foods
Date on Policy: 2016

1. Date marking for dry storage food items:

...Once a case is opened, the individual food items from the case are dated with the date the item was received into the facility, and placed in/on the proper storage unit... first in - first out.

Expiration dates on commercially prepared, dry storage food items will be followed.

2... Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines...

3. Date marking for freezer storage food items:

...Once a package is opened, it will be re-dated...

4. Prepared food or opened food items should be discarded when:

-The food item does not have a specific manufacturer's expiration date and has been refrigerated for 7 days.

-The food item is leftover for more than 72 hours.

Policy: Code of Dress and Personal Appearance
Date on Policy: 2016

...Procedure:

...m. All eating will take place outside the kitchen area.

A tour of the Dietary Department was conducted on 4/15/19 at 9:10 AM. The following was observed:

In the patient refrigerator:
1- large pitcher of brown liquid, unlabeled with content or date.
8- cups of yellow pudding/ jello, unlabeled with content or date.
21- cups of a red substance, unlabeled with content or date.
6- cups of a red jelled substance, unlabeled with content or date.
1- large bucket labeled 'Unsweet' dated 4/8/19.
1- pitcher of brown liquid, unlabeled with content or date.

In the food prep area:
1- gallon Dale's seasoning, opened and no date.
1- bucket rice, unlabeled with content or date.
1- bucket labeled Fish Batter, no opened date.
1- 16 oz (ounce) white pepper, opened 2/12/18.
1- 14 oz ground pepper, opened, no date.
1- 17 oz Herb de Provence, opened, no date.
1- 20 oz organic minced garlic, opened, no date.
1- 16 oz chili powder, opened, no date.
1- 35 oz meat tenderizer, opened, no date.
1- 29 oz Montreal Steak seasoning, opened, no date.
1- Seasoned salt- opened, no date.

In the walk in cooler:
1- container of red substance, unlabeled with content or date.
1- container of Sysco strawberry topping, opened and no date.
1- container of left over meat sauce dated 3/28/19.
1- opened container of chopped turkey, no date.
1- large plastic container of raw chicken in water, no date.

In the walk in freezer:
1- bag of baby baked potatoes, opened and no date.
1- 5 lb (pound) pizza topping, opened and no date.
1- large pan left over chicken and dumplings dated 2/28/19.
1- plastic wrapped unidentified item, no date or content.
1-bag breaded chicken, opened and unsealed, no date.
1- large bag of fries, opened and unsealed, no date.
1- bag of frozen peas, opened and no date.
The top shelf of the freezer had approximately 3 inches of ice, the ceiling and walls had greater than one inch of ice in places, and the floor was approximately 50 % covered in ice.

In the dry storage room:
1- 6.56 lb can marinara sauce, can was dented and on shelf for use.
2- 1 lb bags of fettuccine, opened and no date.
1- large bag egg noodles, opened and no date.
3- gallons of peaches labeled 4/8, no year.
2- gallons hot dog chili sauce labeled 4/8, no year.

In the general kitchen area, a personal drink with a straw was setting in the food prep area. A large stand mixer with a cover was covered in dust and is no longer used according to Employee Identifier (EI) # 9, Cook. The oven had a brown sticky substance on doors, and white residue on the glass. The stove had two knobs missing and is controlled by the stem. The prep table drawers contained crumbs. The mounted can opener contained black grime.

The employee handwashing sink was dirty with brown grime around the handles and dusty. A sign hanging above the sink is old, brown, crinkled and unable to read.

During an interview conducted on 4/15/19 at 10:00 AM with EI # 9, who was also present on the tour, the above findings were confirmed.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of facility policies and procedures, Refrigerator Cleaning and Temperature Log, Patient Nourishment Temperature Log, and interviews it was determined the facility failed to:

1. Ensure equipment was monitored to maintain safety of patients in the New Day Senior Care Unit

2. Provide the patients with a method of alerting staff for needs while being treated in the Emergency Department (ED) due to not having operable Call System.

3. Ensure supplies available for patient use in the ED were not stored with patient nourishment supplies

4. Medical supplies available for patient use were not expired in the Radiology Department and ICU (Intensive Care Unit)

This had the potential to affect all patients served by the hospital.

Findings include:

Refrigerator Cleaning and Temperature/ Microwave Cleaning Instructions
Date Revised: 4/2003

...3. Thermometer Reading: The thermometer should be read as soon as the refrigerator is opened and before cleaning is started. The appropriate temperature is 34 - 45 degrees Fahrenheit. Any temperature higher or lower than this must be reported to the nurse manager.

Patient Nourishment Refrigerator Temperature Log, New Day Senior Care

Instructions: Dietary will record temps (temperatures). Please notify maintenance if temp is above 41 degrees F (Fahrenheit), and circle that date.

Policy: Refrigerator and Freezer Temperatures
Date on Policy: 2016

Guidelines: In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators in nourishment rooms.

Procedure:

1. Dining Services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on all temperature report logs daily...

Facility Policy: Infection Control Manual
Policy IC001
Reviewed: 10/3/17

...C. Work Practice Controls...
7. Other Work Practice Controls
...c. Food and drinks may only be stored in a refrigerator intended for food storage and separated from clinical or research materials.


1. A tour of the New Day Senior Care unit was conducted on 4/15/19 at 1:15 PM. The following was observed:

A review of the temperature logs for the Patient Nourishment refrigerator located in the Dining Room revealed no temperatures were recorded for the following dates: 4/7/19, 4/8/19, and 4/9/19. For the freezer, no date was recorded on 4/9/19. In the refrigerator was an opened pudding cup, with no name or date.

During an interview conducted on 4/15/19 at 1:30 PM with Employee Identifier (EI) # 10, Director, who was also present on the tour, the above findings were confirmed.

A review of the temperature logs for the medication refrigerator located in the supply room had no temperatures documented for the following dates: 1/31/19, 2/3/19, 2/10/19, 3/1/19, 3/2/19, 3/3/19, 3/14/19, 3/15/19, 3/16/19, 3/17/19, 3/29/19, and 3/31/19.

During an interview conducted on 4/15/19 at 2:30 PM with EI # 11, RN (Registered Nurse), who was also present on the tour, the above findings were confirmed.


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2. A tour of the ED was conducted on 4/15/19 at 9:45 AM with EI # 2, Infection Control Nurse.

The surveyor observed 5 private treatment rooms within the ED with a door or curtain to close for privacy. The patients' beds were not visible from the nurses' station.

The ED had a total of 5 out of 5 private treatment rooms that contained no operational call lights at the bedside.

The surveyor observed the patient nourishment refrigerator, located in the medication room, which contained a Dual Lemen Stomach Tube located in the freezer section along with ice cream available for patient use.

An interview was conducted on 4/15/19 at 9:45 AM with EI # 2, who confirmed the above findings.

3. A tour of the Radiology Department was conducted on 4/16/19 at 2:30 PM with EI # 15, Director of Radiology.

The following were found in the MRI (Magnetic resonance imaging) Mobile Unit and available for patient use:
20 - 23 G x 3/4" winged infusion sets with expiration date of 9/17.
14 - 25 G (gauge) x (by) 3/4" (inch) winged infusion sets with expiration date of 2/19.

EI # 15 confirmed the above finding prior to the end of the tour.

4. A tour of the ICU was conducted on 4/15/19 at 2:00 PM with EI # 3, Director of Nursing.

The following supplies were found in the ICU, available for patient use, and expired:
ICU room # 4: Monitoring Electrode(s) (3 each) x (times) 4 packs with expiration date of 12/5/18
ICU supply cart: Airlife Tri-Flo Suction Cath-n-Glove Kit(s) x 12 with expiration date of 3/19.

EI # 3 confirmed the above finding prior to the end of the tour.

5. 4. A tour of the medical/surgical 3rd floor was conducted on 4/16/19 at 8:10 AM with EI # 3.

Two Lo-Pro Oral/Nasal Tracheal Tube cuffed 3.0 mm (millimeters) where found in the Crash Cart with expiration date of 10/18.

EI # 3 confirmed the above finding prior to the end of the tour.

Based on observations, review of facility policies and procedures, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections and interviews with the staff, it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand hygiene and gloving.

b) Cleaned the septum of medication vials prior to piercing the vial per CDC guidelines.

c) Discarded contaminated supplies and maintained clean surfaces in the Operating Room (OR).

d) Cleaned Computer on Wheels between patient interactions.

This did affect 2 of 3 outpatient medical records (MR's) with observations, including MR # 11, MR # 12 and 3 unsampled inpatients and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Infection Control Manual
Policy IC001
Reviewed: 10/3/17

IV. Methods of Compliance

C. Work Practice Controls

...2. Hand Hygiene

Hand hygiene is the cornerstone of Infection Control and is the single most important act in preventing the spread of infection to other patients and to the employee. Handwashing is an imperative procedure following the removal of gloves...

If gloves are not visibly soiled, use an alcohol-based hand rub or wash hands with an antimicrobial soap and water to decontaminate hands in all clinical situations described below:

Decontaminate hands before having direct contact with patients
...Decontaminate hands after contact with a patient's intact skin...
Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
Decontaminate hands after removing gloves...

7. Other Work Practice Controls

...c. Food and drinks may only be stored in a refrigerator intended for food storage and separated from clinical or materials.

D. Personal Protective Equipment:

1. Gloves

...d. Gloves should be changed between tasks and procedures on the same patient...

f. Gloves must be removed promptly after use, before touching items surfaces that are not contaminated... Gloves must never be worn outside of the immediate work area.

Facility Policy: Recommendations for Protection of Personnel
Revised: 08/2016

Policy:

Protection of endoscopy unit personnel can best be accomplished by applying consistent practices whenever and wherever the potential for spread of infectious agents and risks for danger from chemical exists.

Procedure:

"1. Gloves MUST be worn for touching blood, body fluids, ... for all clean up procedures".

Facility Policy: Cleaning of Non-Critical, Reusable Patient Care Equipment
Date: 7/27/15

Policy: This policy establishes a process for the cleaning of non-critical, reusable, patient care equipment.

Procedures:
...5. For routine practice non critical, reusable, patient care equipment...must be cleaned between each patient...

CDC Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

1. An observation was conducted by the surveyor on 4/15/19 at 9:20 AM in Endoscopy Room # 1 on MR # 11 for a Colonoscopy.

At 9:35 AM the procedure was completed and Employee Identifier (EI) # 5, Registered Nurse (RN), removed his/her gloves without performing hand hygiene. EI # 5 then obtained Sani-Hands disinfectant wipes and cleaned and disinfected the stretcher side rails without applying gloves as directed per the facility policy.

An interview was conducted on 4/15/19 at 1:20 PM with EI # 8, RN, Gastrointestinal (GI) Coordinator, who verified the staff failed to follow the facility policies for hand hygiene and gloving.

2. An observation was conducted by the surveyor on 4/15/19 from 10:30 AM to 11:41 AM in OR # 2 on MR # 12 for a Laparoscopic Cholecysectomy and the following was observed:

At 10:35 AM EI # 4, Certified Registered Nurse Anesthetist (CRNA), intubated the patient and removed his/her gloves without performing hand hygiene.

Further observations at 10:35 AM revealed EI # 7, Surgery Coordinator, RN Circulator, applied pads to MR # 12's leg and removed his/her gloves without performing hand hygiene. EI # 7 then re-applied gloves, removed shaved chest hair with a tape piece of tape and removed his/her gloves without performing hand hygiene.

At 10:39 AM EI # 7 applied sterile gloves and performed a sterile prep using Chloraprep and removed his/her gloves without performing hand hygiene.

At 11:20 AM EI # 4 retrieved 4 vials of IV medications (3 vials of Robinul and 1 vial of Neostigmine) from the Anesthesia medication cart. EI # 4 opened the vial's and withdrew the medication into a syringe without cleaning the vial tops with an alcohol sponge as directed per facility policy and CDC guidelines. EI # 4 failed to perform hand hygiene prior to entering the medication cart and preparing the IV medications.

At 11:25 AM EI # 6, Physician/Surgeon, completed the procedure and removed his/her gown and gloves without performing hand hygiene.

At 11:26 AM EI # 7 wearing gloves, retrieved the IV fluids used for irrigation during the procedure and proceeded out the OR door into the hallway and hung the IV bag of fluids in the OR scrub sink to drain, thus contaminating the OR scrub sink. EI # 7 then returned to the OR and removed his/her gloves without performing hand hygiene.

At 11:40 AM EI # 4 extubated the patient and EI # 4 and EI # 7 prepared MR # 12 for transport to the Post-Anesthesia Care Unit (PACU). EI # 4 removed his/her gloves without performing hand hygiene.

At 11:41 AM EI # 4 and EI # 7 transported MR # 12 down the hallway to PACU. EI # 7 failed to remove his/her dirty gloves and perform hand hygiene prior to transporting MR # 12 down the hallway as directed per facility policy.

Further observations at 11:41 AM in PACU revealed EI # 7 removed his/her glove on the left hand, connected the patient to a heart monitor and then re-applied a glove to his/her left hand. EI # 7 failed to remove his/her gloves and perform hand hygiene between glove changes as directed per the facility policy.

An interview was conducted on 4/16/19 at 12:15 PM with EI # 4 who verified the aforementioned findings.

An interview was conducted on 4/16/19 at 12:30 PM with EI # 7 who verified the aforementioned findings.


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3. A medication observation was conducted on 4/15/19 at 9:40 AM in Emergency Department room # 5.

EI # 12, RN, entered exam room, removed medication from dose pack, placed medication in a cup, opened a drink can, poured drink into cup, handed medication and drink cup to the patient, then exited exam room # 5.

EI # 12 failed to perform hand hygiene at any time during the observation.

An interview was conducted on 4/15/19 at 9:45 AM with EI # 2, Infection Control Nurse, who confirmed the above findings.

4. A medication and IV start observation was conducted on 4/16/19 at 8:55 AM with EI # 13, RN, in room # 303.

EI # 13 entered patient room with computer on wheels, placed IV start supplies on the patient's bedside table beside patient personal items without providing a barrier or cleaning the bedside table.

EI # 13 obtained a paper towel and wiped liquid from the patient's bedside table.

EI # 13 obtained gloves and place clean gloves on the patient's bedside table without providing a barrier or cleaning the bedside table.

EI # 13 performed hand hygiene, donned gloves and performed the IV start to the patient's left hand.

EI # 13 removed gloves, removed a pen from the right uniform pocket and used pen to write on IV sticker placed on IV site without hand hygiene.

EI # 13 returned pen to right uniform pocket without cleaning.

EI # 13 returned to nursing station with computer on wheels. Computer on wheels was not cleaned prior to leaving patient's room or at the nursing station.

At the nursing station the Computer on wheels is given to another nurse who is then observed taking the computer on wheels into another patient's room without cleaning prior.

EI # 13 obtained the Computer on wheels from another nurse and re-entered the patient's room to administer IV medications with the computer.

EI # 13 performed hand hygiene, documented on the computer and donned gloves without performing hand hygiene after contact with computer.

EI # 13 administered the IV medication then returned to the nurses station with computer on wheels without cleaning computer prior to leaving patient room or at the nurses station.

An interview was conducted on 4/17/19 at 8:16 AM with EI # 1, Director of Nursing, who confirmed the above findings.

5. A medication observation was conducted on 4/16/19 at 9:30 AM with EI # 14, RN, in room # 319.

EI # 14 entered patient room with Computer on Wheels, obtained clean gloves and placed on computer without cleaning computer prior or providing barrier prior to placement of gloves.

EI # 14 donned gloves, scanned medications into computer, poured water into cup, and administered the patient's medications.

EI # 14 exited patient room with computer and returned to nurses station to obtain additional medication and IV Lasix.

EI # 14 obtained medication, Lasix, needle, and syringe at the nurses station then re-entered patient room with Computer on Wheels.

EI # 14 performed hand hygiene, donned gloves, scanned medications into computer, poured water into cup, and administered the patient's medication.

EI # 14 prepared and administered Lasix IV without removing gloves and performing hand hygiene.

EI # 14 returns to nursing station with Computer on Wheels without cleaning Computer on Wheels prior to leaving patient room or at the nurses station.

An interview was conducted on 4/17/19 at 8:21 AM with EI # 1, who confirmed the above findings.

Based on review of medical record (MR), Facility Policy and Procedure, and staff interviews, it was determined the facility failed to ensure all patient activity needs and goals for care were met, which included documentation of activities planned, organized and offered during normal waking hours.

This affected 1 of 1 Swing Bed discharged patient records, including MR #15, and had the potential to negatively affect all patients admitted to the Swing Bed unit.

Findings include:

Policy: Activity Program
Date: 10/15

Policy: The facility provides for daily activities...

Procedure:
...6. Documentation of activities offered will be made under "Social Activities" in the daily nursing documentation as to what was offered, refused or participated in.

1. MR # 15 was admitted to the facility swing bed program on 3/29/19 for diagnoses of Calculus of Gallbladder with Chronic Cholecystitis Without Obstruction and Muscle Weakness (Generalized).

Review of the Swing Bed Care Plan dated 4/1/19 revealed documentation of the following interventions under Swingbed Activities: TV (television) (assistance needed), Read magazines, read newspaper, word search puzzle, and crocheting.

Review of the Patient Progress Notes with the following dates and times revealed Social Activities documentation of "Activity Offered" with no documentation of what activity was offered or if patient refused or participated in activity:

3/29/19 at 4:58 PM
3/29/19 at 5:35 PM
3/29/19 at 6:10 PM
3/30/19 at 7:34 PM
3/31/19 at 6:33 PM
3/31/19 at 7:38 PM
4/1/19 at 1:07 PM
4/2/19 at 2:26 PM
4/4/19 at 9:56 AM
4/7/19 at 1:52 PM
4/8/19 at 6:02 PM
4/8/19 at 7:41 PM
4/8/19 at 9:07 PM
4/9/19 at 5:10 AM
4/9/19 at 10:53 PM
4/9/19 at 3:28 PM
4/9/19 at 6:17 PM
4/9/19 at 7:23 PM
4/10/19 at 6:07 PM
4/10/19 at 7:29 PM
4/10/19 at 8:56 PM
4/10/19 at 10:47 PM
4/11/19 at 5:30 AM

An interview was conducted on 4/15/19 at 1:5 PM with EI # 1, Swing Bed Coordinator, who confirmed the above findings.