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Based on observations and staff interview, the Hospital failed to maintain floors, cove bases and furniture related to 4 of 4 patient care units (2 South, Dual Unit, Women's Unit and 3 South) such that the safety and well-being of patients was assured. Findings include:

1.) During the initial tours of 2 South, the Dual Unit, the Women's Unit and 3 South Unit, on 12/9/13 at 8:35 A.M., the Surveyors observed:

a.) In the Treatment Room, the Formica around the hand washing sink cabinetry was broken and the floor tiling had cracks and areas of chipped and missing pieces.

b.) The Front Door to the Janitor's closet had multiple signs of graffiti (drawings that have been scribbled with, scratched, or sprayed illicitly on a wall or other surface in a public place) drawn with a blue pen. The drawings were of a swastika, the star of David and a cross (religious symbols).

The Surveyor interviewed the Housekeeper at approximately 9:00 A.M. on 12/9/13. The Housekeeper said he opened and accessed the closet where the graffiti was written at least 12 times a day and did not notice it prior to 12/9/13.

The Surveyor interviewed the Charge Nurse and Mental Health Worked at 2:50 P.M. on 12/9/13. The Charge Nurse said normally patients are allowed pens once an assessment determines they are safe to have a pen which is considered a "sharps."
c.) On a white board in the Day Room of the Dual Unit, a vertical message read
Devils
Revenge
Upon
God
Servants (DRUGS)
and another message that read, -It's not the dog in the fight -It's the fight in the dog.

The Surveyor interviewed the Clinical Services Executive at 1:45 P.M. on 12/10/13. The Clinical Services Executive said she did not specifically know who wrote the message on the white board or when it was written but told the Surveyors the message could have been written by a patient during a group session. The Clinical Services Executive said the information would be removed from the board.

See Tag A 724, A749

Based on observations, review of hospital food storage policies and interviews, the hospital failed to ensure that equipment and supplies in the Hospital's Main Kitchen and patient care equipment on 4 of 4 patient units such as patient mattresses, pillows, an examination table and sink cabinetry were maintained to ensure safety and quality.

Findings include:

1.) During the entrance conference with the Interim Nurse Manager of 2 South, the Interim Nurse Manager said that the Hospital was a 66 bed facility with 4 patient care units; 2 South, Women's, 3 South and the Dual Unit. The Interim Manager of 2 South said the only unit open and accepting new admissions was 2 South and the current census was 11. The Interim Nurse Manager said the Massachusetts Department of Mental Health (DMH) closed 3 of the patient care units (Women's Unit, 3 South and the Dual Unit) to admissions because of the findings of an unannounced visit conducted on 10/24/13.

2.) During tours of the 2 South Unit on 12/9/13 at 8:30 A.M., the Surveyors observed the following:

a.) In the Treatment Room; the vinyl covering on the examination table was soiled with unknown dry substances, the permanent vinyl covering was frayed and had cracks, the Formica around the hand washing sink cabinetry was broken, the floor tiling had cracks and areas of chipped and missing pieces, visible dust was observed on the stand of a portable blood pressure cuff and a bag of trash was observed on a chair.

b.) In the Day Room, a piece of duct tape and tape residue was on the outside surface of the patient refrigerator which collects debris and is unable to be cleaned properly.

c.) In the Quiet Room there was an open split in the bed mattress.

d.) In patient rooms #2, #3, #4, there were open and split mattresses and pillows. In room #4 there was dried spillage on a patient bureau and on an open closet surface.

e.) In the Relaxation Room there were areas of dust accumulation in the corners and under a bench; a fabric chair was soiled with dried spillage; the cove bases were visibly dirty and the cove base was missing a piece along the wall.

3.) During a tour of the Dual Unit at 1:45 P.M. on 12/9/13, accompanied by the Chief Nurse Officer (CNO), the Surveyors observed split and torn mattresses in room 313 and room 321.
4.) During the tour of 3 South Unit at approximately 2:00 P.M. on 12/9/13, accompanied by the CNO, the Surveyors observed spilt and torn mattresses in room 302 and 308 and the mattress in room 308 had the appearance of dried stains.
5.) During the tour of the Women's Unit at approximately 2:15 P.M., on 12/9/13, the Surveyors observed that the mattress in room 213 contained a zipper which could be opened and the foam easily removed. A mattress with a zipper can not be appropriately cleaned sanitized. There were stains of dried spillage on a bedside bureau that came clean when the CNO washed the stain with a wet paper towel.
6.) The Surveyors toured the Main Kitchen on 12/9/13 at 12:40 P.M., accompanied by the Manager of Food Service. The Surveyors observed:
a.) The Main Kitchen had 4 refrigerators, #1 and #2 were in the main kitchen area and #3 and #4 were in the serving area.
b.) Refrigerator #1, a walk-in refrigerator, had storage shelving racks that were dirty with a build-up of grime and dirt and appeared to have not been cleaned as was the shelving of the freezer that was within the refrigerator. The temperature gauge for the freezer was missing. During an interview on 12/9/13 at 12:30 P.M., the Food service Manager said the freezer temperatures are supposed to be monitored daily to ensure the quality of the frozen foods.
c.) Refrigerator #2, a reach-in refrigerator, contained packages of wrapped meat that were not dated.
d.) Refrigerator #3, a reach-in refrigerator, had an opened package of cheese that was not dated as to when opened and
e.) Refrigerator #4, a countertop refrigerator, registered a temperature of 68 degrees Fahrenheit (F) and contained several small servings of pudding.
Hospital food storage policy indicated that all perishable food will be maintained at temperatures of 41 degrees F or below to maintain food safety and quality and all leftovers and opened food would be disposed of after 72 hours to maintain safety and quality.
f.) The dry storage room contained open packages of cake and muffin mix that were not dated and not sealed to maintain quality.

Based on observation, review and polices and interview, the Hospital failed to provide a sanitary environment to avoid sources and transmission of infection and communicable diseases. Findings include:

The Hospital failed to (a) consistently ensure a sanitary kitchen environment to prevent food borne illness in preparation and serving of food and (b) ensure that patient use equipment such as mattresses and room furniture were clean and could be appropriately disinfected between patients to prevent the spread of infection, in 4 patient care units ( 2 South, Dual Unit, Women's Unit and 3 South).

The scope of the findings warrant conditional level noncompliance.

Please see A0749.

Based on observations, review of Hospital food storage policies and interviews, the Hospital : a.) failed to consistently ensure a sanitary kitchen environment to prevent food borne illness in preparation and serving of food and b.) failed to ensure that patient use equipment such as mattresses and room furniture were clean and could be appropriately disinfected between patients to prevent the spread of infection in 4 patient care units ( 2 South, Dual Unit, Women's Unit and 3 South). Findings include:

1.) Observations during the survey tours on 12/9, 12/10 and 12/12/13 of the Kitchen and 4 patient care units; 2 South Unit, the Dual Unit, the Women's Unit and the 3 South Unit. The Surveyors observed the following:

a.) During the tour of 2 South conducted on 12/9/12 at 8:30 A.M., it was noted that the vinyl examination table in the Treatment Room was soiled with an unknown dry substance and the permanent vinyl covering was frayed and had cracks, creating surfaces that could not be properly cleaned and sanitized between patient uses.

b.) In the Day Room, a piece of duct tape and tape residue was on the outside surface of the patient refrigerator,(creating surfaces that could not be properly cleaned and sanitized.

c.) A fabric chair was soiled with dried spillage. The chair surface could not be cleaned and disinfected and had to be removed from service.

d.) During tours of the 4 patient care units there were a total of 8 mattresses that were either torn or split open, 2 additional mattresses had a zipper in the covering and three pillows were worn and split, creating surfaces that could not properly cleaned and sanitized. When the mattresses were lifted there was debris between the mattresses and the wooden frames (indicating the bed frame surfaces were not cleaned). Several of the mattresses had dried stains of unknown substances. This was unsanitary and created an environment for cross contamination and infection.

2.) The Surveyors toured the Main Kitchen on 12/9/13 at 12:40 P.M. accompanied by the Manager of Food Service. The Surveyors also toured the Main Kitchen on 12/12/13 at 7:30 AM, 9:30 A.M. and at 12:00 P.M. accompanied by the Food Service Manager.
The Main Kitchen had 4 refrigerators, #1 and #2 were in the main kitchen area and #3 and #4 were in the serving area.
a.) Refrigerator #1, a walk-in refrigerator, had storage shelving racks that were dirty with a build-up of grime and dirt and appeared to have not been cleaned as was the shelving of the freezer that was within the refrigerator. The temperature gauge for the freezer was missing indicating an inability to monitor safe freezer temperatures.
b.) Refrigerator #2 and #3, reach-in refrigerators, contained packages of wrapped food and opened containers of condiments that were not dated when opened.
According to Hospital policy regarding food storage, all refrigerated foods will be labeled and dated, to ensure food safety and quality.
c.) Refrigerator #4, a countertop refrigerator, registered a temperature of 68 degrees Fahrenheit (F) and contained several small servings of pudding.
Hospital policy regarding stored refrigerated foods indicated that all perishable food will be maintained at temperatures of 41 degrees F or below., to ensure food safety from food borne illnesses.
d.) The front and sides of the stove, the microwave and the puree machine were soiled with built-up layers of spillage and splatterings, creating unsanitary conditions.
e.) In the dish washing room, the storage shelves for cleaned cooking pans were located next to a trash receptacle. Observed lying on one of the cleaned pans was an ice bucket which had a discarded used glove and paper products in it, indicating improper separation of cleaned and soiled items. This creates an environment of cross contamination and encourages transmission of food borne illnesses.
f.) Three fans located in the Kitchen were visibly soiled with dust, debris and grime; two of the fans were located in the dish washing area and one large floor fan was located in the patient serving area, causing cross contamination of food sources and preparation areas from dirty fans.
g.) The dry storage room contained open packages of cake and muffin mix that were not dated and sealed, placing the items at risk for pest/bug infestation.
3.) The Surveyors interviewed the Infection Control Practitioner (ICP) on 12/12/13 at 11:00 A.M. The ICP said she made infection control rounds in the Kitchen, but her focus was looking at temperature control logs and not at the cleanliness. The ICP stated she needed to focus more on sanitation in an effort to decrease the potential risks for foodborne illness.