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Based on record review and interview, the facility failed to ensure that medical record entries were complete. This failure resulted in 3 of 6 patients (Patient #1, #2 and Patient #8) had incomplete records. This was evidenced by:
1) No documentation of any discharge instructions regarding medications on the Discharge Medication Reconciliation form for Patients #2 and #8.
2) The discharge medications were not listed on the Discharge Medication Reconciliation form for Patient #8.
3) There was no signature by Patient #8 on the Discharge Medication Reconciliation form acknowledging receipt of the form.
4) The Discharge Summary for Patient #1 had no documentation of the thought processes, thought content (homicidal or suicidal), mood, affect, insight, and judgement. In addition, the status on day of discharge was "okay."


Findings included:

Patient #2.
Record review of Discharge Plan and Discharge Medication Education for Patient #2 showed: Discharge medications were listed (lithium, Ambien, and Invega Sustenna) by Staff M (RN) on 8/22/2019 at 1:39 PM. N/A was checked for "Patient / Family Demonstrates Knowledge / Understanding of potential drug / food interactions, medications / side effects / how to administer, and how to contact physician if experiencing side effects."


Patient #8.
Record review of the Discharge Medication Reconciliation form for Patient Meranda Rivoire dated 6/29/2019 at 4:12 PM showed that none of the discharge medications had been listed. Staff T (RN) wrote that medications would be called into the pharmacy by Dr. Starbranch's office. The patient did not sign the Discharge Medication Reconciliation form.

During an interview with Staff M (RN) on 10/3/2019 at 9:25 AM, she reviewed the Discharge Plan and Discharge Medication Education for Patient #2. Staff M (RN) stated she should not have checked N/A. She also stated she should have assessed the patient's understanding of the medications and provided education based on that assessment.

During an interview with Staff D (CNO) on 10/2/2019 at 10:35 AM, he reviewed the Discharge Plan and Discharge Medication Education for Patient #2. Staff D (CNO) stated Staff M (RN) should NOT have checked the N/A box for: "Patient / Family Demonstrates Knowledge / Understanding of potential drug / food interactions, medications / side effects / how to administer, and how to contact physician if experiencing side effects." Staff D (CNO) concluded by saying that an assessment of education needs is part of the discharge medication education and reconciliation and should have been provided by Staff M (RN).


Patient #1.
Record review of Hand-Off Risk Notification by Staff Y (RN), dated 5/18/2019 at 12:46 AM showed Patient #1 had a plan to hang self, history of sexual abuse age 6 by maternal grandfather and history of cutting left wrist four (4) years ago.

Record review of Physician's Preadmission Examination Orders and Preliminary Plan of Care by Staff U (Admitting MD), dated 5/17/2019 at 11:58 PM showed that Patient #1 was placed on suicide precautions, self-harm precautions, and unit restrictions at the time of admission.

Record review of Psychiatric Evaluation by Staff K (Attending MD), dated 5/18/2019 at 2:45 PM showed that Patient #1 was a 16-year-old male with suicidal plan to hang self. He attempted hanging four (4) years ago. Admitting diagnosis: major depressive disorder, severe; post-traumatic stress disorder, attention deficit hyperactivity disorder, and marijuana use.

In an interview with Staff J (Covering MD) on 10/2/2019 at 3:45 PM, he reviewed the Discharge Summary he provided on Patient #1. He stated didn't realize the Discharge Summary was incomplete. He also stated the items left blank should have been addressed. He concluded by saying his document of "okay" for status of the patient on the day of discharge was "vague."

Record review of the policy, "Discharge Summary," policy # 900.03, revised 1/1/2018, showed: ...A discharge summary shall be a part of every patient's medical record ... [and] shall include ... The condition at discharge of the individual served."

Based on observation, interview, and record review, the facility failed to adequately train 1 of 1 kitchen employees (Staff R). This failure resulted in the promotion of Staff R from lead cook to the Dietary Manager without additional training and oversight.

Findings included:

During a tour of the kitchen on 10/3/2019 at 12:00 PM, the following items were observed:
a) There were no splash guards on the bottom shelf of three (3) metal shelving units. Two (2) were in a storage pantry and one (1) was in the kitchen. The two (2) shelves in the storage pantry had supplies and equipment stored on the bottom shelf. The one in the kitchen had clean equipment stored on the bottom shelf.
b) An apron was hanging on the side of a metal shelving unit that housed clean pots, pans, and other kitchen utensils.
c) A shelving unit that housed clean pots, pans, and other kitchen utensils was adjacent to the dirty cleaning area.
d) Used oven mitts were found on top of spices and other supplies in the clean food prep area.
e) Fish had been left out on a counter awaiting to be breaded and fried when/if needed.

Record review of the food temperature log for the serving line showed that the log had not been completed for 10/2/2019. There were no food temperatures recorded during breakfast and the beginning of lunch on 10/3/2019. There were only two (2) temperatures recorded per meal on 10/1/2019.

In an interview with Dietary Manager DeWayne Thomas on 10/3/2019 at 12:30 PM, he stated he did not know if the apron hanging on the shelving unit was clean. He also stated he did not know that:
a) A splash guard was needed on the bottom shelf of metal shelving units.
b) A used apron cannot be hung on shelving that contains clean equipment.
c) The shelving unit that housed clean pots, pans, and other kitchen utensils cannot be stored adjacent to the dirty cleaning area.
d) The used oven mitts did not belong on the clean food prep area.
e) The fish could not be left on the counter to be breaded and fried if/when it was needed.
f) Three temperatures were needed for food placed on the serving line: beginning, middle, and end times.
He concluded by saying he needed additional training for the role of Dietary Manager.

Record review of "Personnel Action Request," dated 8/16/2019 (not timed) showed that DeWayne Thomas was promoted from dietary cook to Dietary Manager. Job requirements included a "knowledge of hygiene factors involved in food preparation; knowledge of cleaning products and the appropriate methods of cleaning a variety of surfaces." Signatures included DeWayne Thomas and Daniel Key on 8/16/2019.

In an interview with RM Daniel Key on 10/3/2019 at 12:45 PM, he stated that DeWayne Thomas could benefit from a refresher course in handling food. He also stated that more oversight of the kitchen was needed by the Infection Control Practitioner.

Based on observation, interview, and record review, Staff Q (Infection Control Practitioner) failed to provide adequate supervision of the kitchen. This failure resulted in multiple infection control issues were identified in the kitchen. These included:
a) Dust and dirty equipment,
b) Expired food,
c) Dented metal cans of food,
d) Missing splash guards,
e) Storage on the floor,
f) Improper storage of bowls,
g) Clean items stored next to dirty items,
h) Improper storage of refrigerated items, and
i) Improper documentation of food temperature.

Findings included:

During a tour of the kitchen on 10/3/2019 at 12:00 PM, the following items were observed:
a) There was a heavy layer of dust on top of the ice maker and other flat areas throughout the kitchen.
b) A bin of panko bread crumbs had expired April 2019.
c) Two dented metal cans of chocolate pudding were in the pantry.
d) There were no splash guards on the bottom shelf of three (3) metal shelving units. Two (2) were in a storage pantry and one (1) was in the kitchen. The two (2) shelves in the storage pantry had supplies and equipment stored on the bottom shelf. The one in the kitchen had clean equipment stored on the bottom shelf.
e) Two (2) oven racks were stored on the floor in the storage pantry.
f) Two (2) bowls, stored on a metal rack, were not turned upside down.
g) An apron was hanging on the side of a metal shelving unit that housed clean pots, pans, and other kitchen utensils.
h) A shelving unit that housed clean pots, pans, and other kitchen utensils was adjacent to the dirty cleaning area.
i) A scoop was in the sugar bin.
j) Used oven mitts were found on top of spices and other supplies in the clean food prep area.
k) The inside of the oven was dirty with layers of baked on food.
l) Fish had been left out on a counter awaiting to be breaded and fried when/if needed.
m) The temperature log binder for documenting serving line temperatures was rusty and dirty.

Record review of the food temperature log for the serving line showed that the log had not been completed for 10/2/2019. There were no food temperatures recorded during breakfast and the beginning of lunch on 10/3/2019. There were only two (2) temperatures recorded per meal on 10/1/2019.

In an interview with Staff Q (Infection Control Practitioner) on 10/3/2019 at 12:30 PM, she stated that she was over the kitchen staff. She also stated that:
a) Surfaces in the kitchen are to be clean and dust free.
b) Food products out of date are to be discarded.
c) Dented metal food cans are to be discarded or returned to the vender.
d) A splash guard is to be on the bottom shelf of the metal shelving units.
e) Kitchen equipment is not to be stored on the floor.
f) Bowls are to stored upside down.
g) Aprons are not to be stored on shelving units that house clean equipment or supplies.
h) Scoops are not to be kept in bins of consumer goods.
i) The dirty oven mitts are not to be stored on the clean food prep area.
j) The oven and kitchen needed a deep cleaning.
k) The fish is to be stored in the refrigerator until it is needed.
l) The temperature log binder for documenting serving line temperatures needs to be replaced.
m) Staff on the serving line are to document three temperatures for the food: beginning, middle, and end times.
In conclusion, Staff Q stated that additional training and ovesight was needed for Staff R (Dietary Manager).