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Based on observations, review of documentations and interviews, it was determined that the Governing Body failed to ensure the facility's bylaws, rules, and regulation were implemented and enforced.
Findings were:Facility policy entitled "Urine Drug Screening" stated in part "When in-house UDS is used during a patient's continued stay, nursing staff will obtain an observed specimen (observed by same-sex staff member) which will be labeled with a patient label by the observer. The date and time of collection will be clearly written on the specimen container or label. A physician order is required."Tour of the facility on 11/28/12 revealed 4 of 8 urine samples found in specimen refrigerators that did not contain laboratory requisitions or time and date of the urine collection. The exam room specimen refrigerator on the Second floor contained 2 out of 4 urine specimens with no time or date of collection noted. On the Rehab/Detox Unit the specimen refrigerator contained 2 out of 4 urine specimens with no time or date of collection noted. In an interview with the CNO and PI Director, the incorrectly labeled urine samples were confirmed.

Facility policy entitled "Dietary Services, Cleaning Procedures" stated in part, "O. Grills: Keep outside, back, and under the grill clean at all times to avoid rancid odors, bacteria, and insects."
Facility policy entitled "Dietary Services, Sanitation and Safety" stated in part, "46. Range hoods, filters, and ducts should be cleaned regularly to eliminate the accumulation of grease. 47. Grease fires are common and dangerous."
· The grill in the kitchen had a visible thick layer of built up grease on the surface. The grill had compartments underneath that had grease dripping inside. There was an aluminum bucket in 1 of the compartments which was almost full of grease. Staff member #27 stated the facility cleans the grill approximately every 2 weeks and that the compartments underneath the grill had not been part of the cleaning schedule. Staff member #27 was unable to provide documentation of the cleaning log.
Facility policy entitled "Dietary Services, Handwashing" stated in part, "A hand washing and hand drying stations are located through out the kitchen area and dish room area. Proper hand washing techniques are known and observed by all Dietary personnel as an important link in the chain of infection prevention and control."

Facility policy entitled "Dietary Services, Infection Control" stated in part, "3. All food handlers must wash hands with soap and water before starting work and when necessary to prevent contamination of foods."
· 2 of the 3 employee hand washing stations failed to have a sign posted which stated employees must wash hands. This was a potential for transmission of infections to patients and personnel.
Facility policy entitled "Dietary Services, Dietary Checklist" stated in part, "The Dietary Service personnel will enforce a safe working environment. 4. Dietary employees will report unsafe conditions they observe to their supervisor."
Facility policy entitled "OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."
· Heating vents throughout patient treatment areas were very dusty and several had items forced down through the openings (i.e. food, pencils). Many vents in patient areas were bent and swollen which could propose a safety risk to the patients, increasing a risk for contamination. Visible dust was observed on high horizontal surfaces and ceiling tiles throughout the hospital which indicated inadequate cleaning, increasing the risk of exposure to airborne dust particles and possible bacterial exposure.
· Abrasions and holes in the sheet rock on walls were noted in several patient rooms. Molding was observed pulling away from the sheet rock in many patient areas, making thorough cleaning of the area unlikely. This creates an area which was not able to be properly cleaned or disinfected, increasing the risk for contamination and infection on the units.
· Cracked and missing laminate was observed to counter tops in nourishment area on the Women's Unit and nurse's station on the Military Unit, rendering the countertops unable to be properly cleaned or disinfected, increasing the risk for infection and contamination.
· Floor tiles surrounding toilets in patient areas, including the school area and Psychiatric Intensive Care Unit (PICU) patient rooms, were observed to be swollen, cracked, and/or loosened, which rendered the bathrooms unable to be properly cleaned or disinfected.
In an interview with staff members # 27, #19, and #11 the afternoon of 11/27/12, the above failure to follow facility policy and procedures was confirmed.
The facility policy entitled "Patient Home Meds and Administration" dated 10/2012 reflected in part "Upon admission, medications brought to the facility by the patient shall be obtained by the nursing staff during the nursing admission assessment (in the Care Center). Facility process is for medication(s) to be identified and approved by the pharmacy staff, care center nurse, mid level provider or physician after which medications may be utilized for patient with an order from the patient's provider ...A second staff member will count the medications that are scheduled II through V medications, both nurse and staff member will initial on 'Medication Orders and Reconciliation Form.'" The policy did not require controlled medications to be counted on return to the patient.

· In an interview on 11/27/12 at 2:45 pm, staff #9 confirmed that the patient personal prescription cabinets were unlocked and stated that they were left unlocked during the day because that is when patients were discharged, then the cabinets were locked when the pharmacy closed for the day. Staff #9 was asked if the personal prescription controlled medications were recounted on return to the patient. Staff #9 stated that they were not recounted on return to the patient.

In an interview on 11/28/12 at 8:50 am, staff #9 was asked if there was a policy regarding the handling of scheduled drugs in the pharmacy. Staff #9 stated that the policy would be located. In an interview on 11/28/12 at 2:40 pm, staff #18 stated that they were unable to locate a controlled substance policy and one was written that day to reflect current practice.

The facility policy entitled "Controlled Substances" dated 11/28/12 reflected in part "Controlled substance drugs are stored in a locked, secure place within the pharmacy. Schedules III, IV and V are stored in a locked cabinet separately from other drugs. Schedule II medications are stored in a double locked cabinet." This policy had not been approved by the facility's governing body at the time the survey was conducted.

· During a tour of the Women's Unit on the afternoon of 11/27/12, it was noted that the lock that secured the medication refrigerator in the medication room that held Ativan, a schedule IV drug, was disengaged. In an interview on 11/27/12, the charge nurse on Women's unit confirmed that the medication refrigerator was unlocked and contained Ativan.

Facility policy entitled "Medication Management" dated 12/09 reflected in part, "Controlled medications will be dispensed directly to a licensed nurse (RN or LVN) and must be immediately verified and counted prior to being placed in a locked cabinet in the Medication Room."
The facility policy entitled "Unusable Medication" dated 12/2009 reflected in part "1. Unusable medications and devices include those that are: expired ...2. Unusable medications and devices shall not be distributed or administered. Pharmacy staff, nursing and other personnel who discover unusable medications and devices will return them to the pharmacy staff for proper disposition. 3. The pharmacy staff will store unusable medications and devices in specially designated areas to prevent their distribution or administration and ensure they are disposed of safely."

During a tour of the pharmacy on the afternoon of 11/27/12 in the company of staff #9, the following expired medications were found in the pharmacy medication storage area available for patient use.
1. Promethazine HC 12.5 mg tablet unit dose, 7 expired 8/12, 2 expired 4/11.
2. Thiothixene, 5 mg, bottle of 100 expired 10/12; 5 mg unit dose, 14 expired 10/12, 2 expired 8/12.
3. Thiothixene, 2 mg unit dose, 69 expired 9/12.
4. Trifluoperazine 5 mg unit dose, 6 expired 6/12, 2 expired 10/12.
5. Heparin, 5,000 u/ml, 1 ml vials, 30 expired 10/12.
6. Ropinirole HCl, 1 mg, bottle of 100 expired 9/12; 1 mg unit dose, 27 expired 9/12.
7. Sodium Chloride 0.9% irrigation, 500 ml bottle, 10 expired 7/12.
8. Bupropion SR, 20 mg unit dose, 9 expired 9/12.
9. Nortriptyline 25 mg unit dose, 33 expired 9/12.

The facility policy entitled "Compressed Gas" dated 3/2010, stated in part, "The following general safety rules pertain to all types of compressed gases: a. Do not upset the cylinder or violently strike the regulator of valve (sic). Secure the cylinder to the wall or within the enclosure. Cap all cylinders not in immediate use ...f. When exchanging cylinders, do not leave empty cylinder unattended in the area. Return the cylinder immediately to the storage area and secure it properly by placing it in the rack or secure it with a chain."

· During a tour of the kitchen on the afternoon of 11/27/12 in the company of staff # 19 and 27, two grey carbon dioxide gas cylinders were observed to be standing on the floor, uncapped and not secured in any manner in the dish hallway.

"Freedom Care Program Manual" dated 10/1/12, stated in part, "Comprehensive clinical and command updates are conducted weekly during the patient's stay."
"Freedom Care Standard Communication Protocol" dated 10/2/12 stated in part, "The FC Program Director will personally provide or oversee the clinical communication with clinical and command personnel ...If a military patient requests a discharge, the clinical contact will be notified immediately so that they can intervene. Patients leaving without consent of their command are subject to disciplinary action and should be fully informed and have the opportunity to speak with their military command."
Freedom Care program form entitled "Military Consent to Release Information" stated in part, "Should be signed within 24 hours of admission. By signing below, I hereby authorize Freedom Care to release any obtain information with respect to any physical, psychiatric or drug/alcohol related condition, including treatment of Acquired Immune Deficiency Syndrome (AIDS) and/or HIV testing obtained during the course of diagnosis and/or treatment to/from the individuals or health care providers indicated below. The type of information authorized for disclosure includes, but may be limited to, that which is indicated below ...
1. Commander:
· Name and Phone
· Purpose of Disclosure: To facilitate treatment involvement and communication
· Type of Information to be Disclosed: Notification of admission and discharge, Psychological Evaluation, History and Physical
· Patient Initial: Yes___, No___"
· 4 of 9 military patient records reviewed on 11/28/12 revealed no written informed consent to contact the patient's Commanding Officer.

The above findings were confirmed in an interview with the facility Chief Executive Officer on 11/29/12.

Based on review of documentations and interviews, it was determined that the facility failed to always obtain written informed consent from its military clientele when contacting their Commanding Officers.
Findings were:
"Freedom Care Program Manual" dated 10/1/12, stated in part, "Comprehensive clinical and command updates are conducted weekly during the patient's stay."
"Freedom Care Standard Communication Protocol " dated 10/2/12 stated in part, "The FC Program Director will personally provide or oversee the clinical communication with clinical and command personnel ...If a military patient requests a discharge, the clinical contact will be notified immediately so that they can intervene. Patients leaving without consent of their command are subject to disciplinary action and should be fully informed and have the opportunity to speak with their military command."
Freedom Care program form entitled "Military Consent to Release Information" stated in part, "Should be signed within 24 hours of admission. By signing below, I hereby authorize Freedom Care to release any obtain information with respect to any physical, psychiatric or drug/alcohol related condition, including treatment of Acquired Immune Deficiency Syndrome (AIDS) and/or HIV testing obtained during the course of diagnosis and/or treatment to/from the individuals or health care providers indicated below. The type of information authorized for disclosure includes, but may be limited to, that which is indicated below ...
1. Commander:
· Name and Phone
· Purpose of Disclosure: To facilitate treatment involvement and communication
· Type of Information to be Disclosed: Notification of admission and discharge, Psychological Evaluation, History and Physical
· Patient Initial: Yes___, No___"
4 of 9 military patient records reviewed on 11/28/12 revealed no written informed consent to contact the patient's Commanding Officer.
In an interview with the Freedom Care Program Director on 11/28/12, the missing written informed consents were confirmed.

Based on review of records and interview with staff, the facility Nursing Services failed to verify that nursing personnel for whom current licensure is required, had a valid and current licensure for 5 of 5 agency nurses whose personnel records were reviewed.

Findings were:

The facility has a current contract with a local nurse staffing agency in order to obtain licensed nursing personnel to staff their units when needed. Five personnel records of agency nurses were reviewed and all had evidence of current nursing licensure; however, the proof of licensure was not obtained by the facility prior to the nurses working at the facility.

Review of the personnel record of Staff #35 revealed that the registered nurse worked the facility Adolescent/Children Unit on 11/6/12, but did not have evidence of current licensure provided to the facility until 11/28/12. Staff #36 was assigned to the hospital on 10/6/12 and 11/24/12 but did not have evidence of current licensure provided to the facility until 11/27/12. Staff #37 was assigned to various units between 4/27/12 -9/5/12; however evidence of current licensure was not provided to the facility until 11/14/12. RN Staff #38 worked at the hospital on 9/1/12 and 9/4/12; however, evidence of current licensure was not provided to the facility until 11/21/12. Staff #39 worked at the facility on 10/28/12 and 11/4/12; evidence of current licensure was not provided to the facility until 11/14/12.

An in-person interview was conducted with the Chief Nursing Officer, Staff #11, the morning of 11/28/12 in a facility conference room. Staff #11 acknowledged the above findings and stated there was not a procedure in place to monitor current licensure of agency nurses.

Based on observation, review of documents and interviews with facility staff, the facility failed to have pharmaceutical services that met the needs of patients. Expired medications were found in patient care areas, available for patient use and scheduled drugs were not properly secured or accounted for. This potentially could have resulted in patients receiving ineffective or unsafe medications and the misappropriation of scheduled drugs. This was in violation of facility policies.

The findings were:

Based on observation, review of document and interviews with facility staff, the facility failed to keep current and accurate records of the receipt and distribution of all scheduled drugs as patient personal prescriptions of scheduled drugs were not counted on return to the patient upon discharge. The patient personal prescriptions were observed to be not secured in the pharmacy and several staff members had a key to the personal prescription cabinet. This potentially could have resulted in misappropriation of scheduled drugs. The facility policy regarding patient home medications did not require controlled medications to be counted on return to the patient.

Cross refer to A0494

Based on observation, review of documents and interviews with facility staff, the facility failed to properly secure Schedule II and IV drugs as patients' personal prescriptions of hydrocodone were found in an unlocked cabinet in the pharmacy and Ativan was found in an unlocked refrigerator on a nursing unit. This potentially could have resulted in misappropriation of scheduled drugs. The facility also failed to have a written policy on the securing of scheduled drugs in the pharmacy.

Cross refer to A0503

Based on observation, review of documents and interviews with facility staff, the facility failed to make outdated medications unavailable for patient use as expired medications were found in the medication storage area of the pharmacy available for patient use in violation of facility policy. An undated multidose vial was found in a nursing unit medication room. This potentially could have resulted in patients receiving ineffective or unsafe medications. The facility failed to have a written policy regarding the use of multidose medication vials.

Cross refer to A0505

Based on observation, review of document and interviews with facility staff, the facility failed to keep current and accurate records of the receipt and distribution of all scheduled drugs as patient personal prescriptions of scheduled drugs were not counted on return to the patient upon discharge. The patient personal prescriptions were observed to be not secured in the pharmacy and several staff members had a key to the personal prescription cabinet. This potentially could have resulted in misappropriation of scheduled drugs. The facility policy regarding patient home medications did not require controlled medications to be counted on return to the patient.

The findings were:

During a tour of the facility conducted on the afternoon of 11/27/12 in the company of staff #19 and staff # 9, a wooden cabinet on the left hand wall of the first room in the pharmacy was observed to have three unlocked padlocks on the two upper doors and the lower right hand door. The cabinet was observed to contain plastic bags with patient personal prescriptions. There was a prescription bottle belonging to patient #1 which contained 48 hydrocodone 5mg/500mg, a schedule II drug, and one belonging to patient #2 which contained 11 hydrocodone 5mg/325m, a schedule II drug. There was a form entitled "Patient Home Medications" in each patient's plastic bag which listed each medication and had a count of the controlled medications recorded. The form was signed by the patient or guardian and one staff member.

The facility policy entitled "Patient Home Meds and Administration" dated 10/2012 reflected in part "Upon admission, medications brought to the facility by the patient shall be obtained by the nursing staff during the nursing admission assessment (in the Care Center). Facility process is for medication(s) to be identified and approved by the pharmacy staff, care center nurse, mid level provider or physician after which medications may be utilized for patient with an order from the patient's provider ...A second staff member will count the medications that are scheduled II through V medications, both nurse and staff member will initial on 'Medication Orders and Reconciliation Form.'" The policy did not require controlled medications to be counted on return to the patient.

In an interview on 11/27/12 at 2:45 pm, staff #9 confirmed that the patient personal prescription cabinets were unlocked and stated that they were left unlocked during the day because that is when patients were discharged, then the cabinets were locked when the pharmacy closed for the day. Staff #9 was asked if the personal prescription controlled medications were recounted on return to the patient. Staff #9 stated that they were not recounted on return to the patient.

In an interview on 11/29/12 at 9:25 am, staff #9 was asked who had keys to the patient personal prescription cabinets. Staff #9 stated that all pharmacy staff and the nursing supervisor had keys to the patient personal prescription cabinets.

Based on observation, review of documents and interviews with facility staff, the facility failed to properly secure Schedule II and IV drugs as patients' personal prescriptions of hydrocodone were found in an unlocked cabinet in the pharmacy and Ativan was found in an unlocked refrigerator on a nursing unit. This potentially could have resulted in misappropriation of scheduled drugs. The facility also failed to have a written policy on the securing of scheduled drugs in the pharmacy.

The findings were:

During a tour of the facility conducted on the afternoon of 11/27/12 in the company of staff #19 and staff # 9, a wooden cabinet on the left hand wall of the first room in the pharmacy was observed to have three unlocked padlocks on the two upper doors and the lower right hand door. The cabinet was observed to contain plastic bags with patient personal prescriptions. There was a prescription bottle belonging to patient #1 which contained 48 hydrocodone 5mg/500mg, a schedule II drug and one belonging to patient #2 which contained 11 hydrocodone 5mg/325m, a schedule II drug.

The facility policy entitled "Patient Home Meds and Administration" dated 10/2012 did not specify that patient personal prescriptions of narcotics would be kept locked while in the pharmacy.

In an interview on 11/27/12 at 2:45 pm, staff #9 confirmed that the patient personal prescription cabinets were unlocked and stated that they were left unlocked during the day because that is when patients were discharged, then the cabinets were locked when the pharmacy closed for the day. In an interview on 11/29/12 at 9:25 am, staff #9 was asked who had keys to the patient personal prescription cabinets. Staff #9 stated that all pharmacy staff and the nursing supervisor had keys to the patient personal prescription cabinets.

In an interview on 11/28/12 at 8:50 am, staff #9 was asked if there was a policy regarding the handling of scheduled drugs in the pharmacy. Staff #9 stated the policy would be located. In an interview on 11/28/12 at 2:40 pm, staff #18 stated that they were unable to locate a controlled substance policy and one was written that day to reflect current practice.

The facility policy entitled "Controlled Substances" dated 11/28/12 reflected in part "Controlled substance drugs are stored in a locked, secure place within the pharmacy. Schedules III, IV and V are stored in a locked cabinet separately from other drugs. Schedule II medications are stored in a double locked cabinet." This policy had not been approved by the facility's governing body at the time the survey was conducted.

During a tour of the Women's Unit on the afternoon of 11/27/12, it was noted that the lock that secured the medication refrigerator in the medication room that held Ativan, a schedule IV drug, was disengaged.

In an interview on 11/27/12, the charge nurse on Women's unit confirmed that the medication refrigerator was unlocked and contained Ativan.

Facility policy entitled "Medication Management" dated 12/09 reflected in part, "Controlled medications will be dispensed directly to a licensed nurse (RN or LVN) and must be immediately verified and counted prior to being placed in a locked cabinet in the Medication Room."

Based on observation, review of documents and interviews with facility staff, the facility failed to make outdated medications unavailable for patient use as expired medications were found in the medication storage area of the pharmacy available for patient use in violation of facility policy. An undated multidose vial was found in a nursing unit medication room. This potentially could have resulted in patients receiving ineffective or unsafe medications. The facility failed to have a written policy regarding the use of multidose medication vials.

The findings were:

The facility policy entitled "Unusable Medication" dated 12/2009 reflected in part "1. Unusable medications and devices include those that are: expired ...2. Unusable medications and devices shall not be distributed or administered. Pharmacy staff, nursing and other personnel who discover unusable medications and devices will return them to the pharmacy staff for proper disposition. 3. The pharmacy staff will store unusable medications and devices in specially designated areas to prevent their distribution or administration and ensure they are disposed of safely."

During a tour of the pharmacy on the afternoon of 11/27/12 in the company of staff #9, the following expired medications were found in the pharmacy medication storage area available for patient use.
1. Promethazine HC 12.5 mg tablet unit dose, 7 expired 8/12, 2 expired 4/11.
2. Thiothixene, 5 mg, bottle of 100 expired 10/12; 5 mg unit dose, 14 expired 10/12, 2 expired 8/12.
3. Thiothixene, 2 mg unit dose, 69 expired 9/12.
4. Trifluoperazine 5 mg unit dose, 6 expired 6/12, 2 expired 10/12.
5. Heparin, 5,000 u/ml, 1 ml vials, 30 expired 10/12.
6. Ropinirole HCl, 1 mg, bottle of 100 expired 9/12; 1 mg unit dose, 27 expired 9/12.
7. Sodium Chloride 0.9% irrigation, 500 ml bottle, 10 expired 7/12.
8. Bupropion SR, 20 mg unit dose, 9 expired 9/12.
9. Nortriptyline 25 mg unit dose, 33 expired 9/12.

In an interview on 11/27/12 at 3:30 pm, staff #9 confirmed that the above listed medications were expired and stored with medications available for patient use.

During a tour of the Psychiatric Intensive Care Unit medication room on the afternoon of 11/27/12 in the company of staff #9, a 10 ml. multidose vial of lidocaine 1% 10mg/ml was found in the medication cabinet and observed to be open and not dated as to when it was opened or when it expired.

In an interview on 11/27/12 at 3:45 pm, staff #9 and #17 confirmed that the multidose vial was opened and not dated. When asked what the facility policy was regarding multidose vials, staff #9 stated that multidose vials should be marked with the expiration date which should be 28 days from the date of opening.

In an interview on 11/28/12 at 8:50 am, staff #9 was asked if there was a policy regarding the use of multidose vials. Staff #9 stated the policy would be located. In an interview on 11/29/12 at 10:10 am, staff #18 stated that they were unable to locate a multidose vial policy and one was written that day to reflect current practice.

The facility policy entitled "Multidose Injectables and Liquids" dated 11/29/12 reflected in part "At the time of first puncture/use, nurses will note expiration date on a label on multidose vial that is no more than 28 days from date of first use." This policy had not yet been approved by the facility's governing body at the time of this survey.

Based on observation and interviews with staff, the facility failed to ensure that specific food and dietetic services requirements were met.

Findings included:

Observation of the Dietary Services on 11/27/12 beginning at 1:35 pm, revealed a "City of El Paso, City Development Department food License" posted behind the serving line on the wall which had expired 11/15/12. The facility was unable to provide a current food license. The facility was out of compliance for 12 days.

Facility policy entitled, "Dietary Services, Sanitation and Safety" stated in part, "18. The Dietary Department will be operated in compliance with all applicable federal, state, and local sanitation and safety laws and regulations."

Facility policy entitled, "Dietary Service Department, Philosophy and Goals" stated in part, "Food Preparation and service constitutes a large part of the work of the Dietary Service Department. All foods should be prepared under strict sanitary conditions in accordance with local and state Public Health regulations."

In an interview with staff member #13 on 11/27/12 at 4:15pm, it was confirmed that the facility's food license had expired in on 11/15/12. The facility was issued a food license on 11/27/12.

Based on observation and interviews with staff, the facility failed to have available to all medical, nursing, and food service personnel, a current therapeutic manual approved by the dietitian and medical staff.

Findings included:

Observation of the Dietary Services on 11/27/12 beginning at 1:35pm, revealed a dietary manual in the office of the Director of Nutritional Services with a last revised date of 2006. The dietary manual also revealed the following:

1.) The Dietitian last signed the manual on 10/22/09.
2.) The Director of Food and Nutritional Services last signed the manual 10/22/09.
3.) The Medical Staff Committee member signed the manual on 5/7/10.

Facility policy entitled "Dietary Services, Diet Manual" stated in part "1. A current diet manual approved by the dietitian and Medical staff shall be available for use in the Dietary Services Department ... 3. The Diet Manual is reviewed annually and revised as necessary by a qualified dietitian, dated, to identify the review, and any revisions made and approved by the Medical Staff thorough its designated mechanisms."

The facility failed to follow its own policy, maintain and review the current diet manual annually.

In an interview with staff member # 27 and #19 on 11/27/12 at approximately 4:00pm, it was confirmed that the diet manual was not current and was not reviewed annually as per facility policy.

Based on observation, review of documents and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety as gas cylinders were observed in the kitchen to be unsecured in violation of facility policy. This resulted in a potential safety hazard if the cylinders were to tip over causing the valve to break off.

The findings were:

The facility policy entitled "Compressed Gas" dated 3/2010, stated in part, "The following general safety rules pertain to all types of compressed gases: a. Do not upset the cylinder or violently strike the regulator of valve (sic). Secure the cylinder to the wall or within the enclosure. Cap all cylinders not in immediate use ...f. When exchanging cylinders, do not leave empty cylinder unattended in the area. Return the cylinder immediately to the storage area and secure it properly by placing it in the rack or secure it with a chain."

During a tour of the kitchen on the afternoon of 11/27/12 in the company of staff # 19 and 27, two grey carbon dioxide gas cylinders were observed to be standing on the floor, uncapped and not secured in any manner in the dish hallway.

In an interview on 11/27/12 at 2:00 pm, staff #27 confirmed that the carbon dioxide gas cylinders were uncapped and not secured in any manner.



30010

Based on observation and interviews with staff, the facility failed to ensure that the facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality.
Finding included:

Observation of the Kitchen the afternoon of 11/27/12 revealed the following:

1.) In the freezer there was a patch of ice on the floor which was a potential fall hazard for staff members.

2.) In the Disposables Room (stored paper goods) - there were 2 broken ceiling tiles. These openings could become contaminated with moisture and airborne bacterial particles and provided an opening for dirt particles, rodents and insects.

3.) In the Dishwashing Area underneath the sink there were broken wall tiles around the pipes, which could become contaminated with moisture and airborne bacterial particles and provided an opening for dirt particles, rodents and insects

4.) Two large boxes of Styrofoam cups were on the floor and available for patient use, which presents a risk of contamination.

Facility policy entitled "Dietary Services, Food & Supply Storage" stated in part, "Food products shall be stored in a safe, sanitary manner. Each item of use in the Dietary Department has an assigned place. When not in use, food and supplies should be returned to their proper places. Characteristics of good food storage will include: 3. Rodent and insect free area; 4. Clean and orderly place; 6. Shelving specifications that comply with state & local health codes and other regulatory agencies."

Facility policy entitled "Dietary Services, Dietary Checklist" stated in part, "The Dietary Service personnel will enforce a safe working environment. 4. Dietary employees will report unsafe conditions they observe to their supervisor."

In an interview with staff members # 27 and #19 the afternoon of 11/27/12, the above findings were confirmed.

Based on observation and interviews with staff, the facility failed to maintain a system for identifying, reporting, investigating, and controlling infections.

Findings included:

Observation of the Facility on 11/27/12 and 11/28/12 revealed the following infection control issues:

1.) The grill in the kitchen had a visible thick layer of built up grease on the surface. The grill had compartments underneath that had grease dripping inside. There was an aluminum bucket in 1 of the compartments which was almost full of grease. Staff member #27 stated the facility cleans the grill approximately every 2 weeks and that the compartments underneath the grill had not been part of the cleaning schedule. Staff member #27 was unable to provide documentation of the cleaning log.

2.) 2 of the 3 employee hand washing stations failed to have a sign posted which stated employees must wash hands. This was a potential for transmission of infections to patients and personnel.

3.) Facility document "Senior Unit Meal Time Temperature Log" from dates 11/5/12 to 11/25/12 revealed the staff failed to check the temperature of the food delivered to the geriatric patients on approximately 16 meals. This was infection control issues as food must be at a proper temperature and was a potential hazard to the patients.

4.) Facility document "Daily Food Log" revealed, of the 5 days (15 meals) reviewed, the facility failed to document the temperature check on 5 meals. The adult, adolescent, and children psychiatric units were going through this serving line for meals. Food items served as part of the meals that the facility failed to check temperature on included ground beef and pork.

5.) Heating vents throughout patient treatment areas were very dusty and several had items forced down through the openings (i.e. food, pencils). Many vents in patient areas were bent and swollen which could propose a safety risk to the patients, increasing a risk for contamination.

6.) Visible dust was observed on high horizontal surfaces and ceiling tiles throughout the hospital which indicated inadequate cleaning, increasing the risk of exposure to airborne dust particles and possible bacterial exposure.

7.) Abrasions and holes in the sheet rock on walls were noted in several patient rooms. Molding was observed pulling away from the sheet rock in many patient areas, making thorough cleaning of the area unlikely. This creates an area which was not able to be properly cleaned or disinfected, increasing the risk for contamination and infection on the units.

8.) Cracked and missing laminate was observed to counter tops in nourishment area on the Women's Unit and nurse's station on the Military Unit, rendering the countertops unable to be properly cleaned or disinfected, increasing the risk for infection and contamination.

9.) Floor tiles surrounding toilets in patient areas, including the school area and Psychiatric Intensive Care Unit (PICU)patient rooms, were observed to be swollen, cracked, and/or loosened, which rendered the bathrooms unable to be properly cleaned or disinfected.

Facility policy entitled "Dietary Services, Cleaning Procedure " stated in part, O. Grills: Keep outside, back, and under the grill clean at all times to avoid rancid odors, bacteria, and insects."

Facility policy entitled "Dietary Services, Sanitation and Safety" stated in part, "46. Range hoods, filters, and ducts should be cleaned regularly to eliminate the accumulation of grease. 47. Grease fires are common and dangerous."

Facility policy entitled "Dietary Services, Handwashing" stated in part, "A hand washing and hand drying stations are located through out the kitchen area and dish room area. Proper hand washing techniques are known and observed by all Dietary personnel as an important link in the chain of infection prevention and control."

Facility policy entitled " Dietary Services, Infection Control " stated in part, " 3. All food handlers must wash hands with soap and water before starting work and when necessary to prevent contamination of foods. "

Facility policy entitled "Dietary Services, Dietary Checklist" stated in part, "The Dietary Service personnel will enforce a safe working environment. 4. Dietary employees will report unsafe conditions they observe to their supervisor."

Facility policy entitled "OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

In an interview with staff members # 27, #19, and #11 the afternoon of 11/27/12, the above findings were confirmed.