HospitalInspections.org

Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

482.28: Food and Dietetic Services
482.41: Physical Environment
482.42: Infection Control

Based on a review of policy and procedure, observation, and staff interview, it was determined that the facility failed to ensure that the Patient's Bill of Rights is met.

Findings include:

Reference #1: Facility document, Hudson County Meadowview Psychiatric Hospital Patient and Family Handbook, Patient Rights section, states, "Every New Jersey hospital patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. These rights shall include at least the following:
.....
26. To have access to individual space in the patient's room for the patient's private use. If the patient is unable to assume responsibility for his or her personal items, there shall be a system in place to safeguard the patient's personal property until the patient or next of kin is able to assume responsibility for these items.
....."

Reference #2: Facility document, Hudson County Meadowview Psychiatric Hospital Patient and Family Handbook, Hospital Rules section, states, "In order to ensure that the Hospital runs smoothly and safely, the Hospital has established a contraband list of items that you may not have or may only have with staff supervision where indicated. Staff searches all patients and their belongings upon admission and after returning from shopping trips, day passes, and brief visits and after meeting with visitors. Still [sic] will immediately confiscate any items of contraband found and either store or dispose of the item(s) as appropriate. Further, the Hospital will notify law enforcement if any illegal or suspected illegal contraband is found. ....." The list of items included: "DVDs" (Digital Video Discs).

Reference #3: Facility policy, Unit Assignment and Transfer, states, "..."Procedures ...
II. Transfers Between Units:
.....
C. Nursing staff implements the order as follows:
.....
2. Transfers the patient with his/her belongings and all medical record volumes to the receiving floor.
....."

1. Behind a black metal cabinet in the Nurses Station on the 4th Floor Acute Unit, was a plastic bag containing two (2) opened letters from the County of Passaic, addressed to Patient #12. One envelope contained commitment documents, charity care documents, and patient rights documents and was postmarked 8/3/16. The other envelope contained copies of Patient #12's medical record and was postmarked 8/2/16. Review of a Receipt for the Patient's Valuables form and a Patient Belonging Form in the medical record, did not include an entry that possession of the letters was taken by staff. Administrator #32 stated that the patient was no longer on the unit.

2. Inside of a black metal cabinet in the Nurses Station on the 4th Floor Acute Unit was six (6) DVDs in a rubber band with the name of Patient #38 written on a piece of paper. Administrator #32 stated that the patient was no longer being cared for on the unit.

3. Atop a black metal cabinet in the Nurses Station on the 4th Floor Acute Unit, was an opened container of foot cream with the first name and first letter of a last name written on it. Administrator #2 stated that there was no patient with the name of the patient being cared for on the unit.

4. A wall shelf in the Valuables Room of the 4th Floor Acute Unit had a hair brush and personal care items in a bag with the name of Patient #9 on it. Administrator #32 stated that the patient was no longer being cared for on the unit.

Based on review of facilty documents and staff interview on 11/30/2016, it was determined that the facility failed to have performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital, specifically related to food safety.

Findings Include:

1. Review of five (5) of five medical records revealed the following information related to food safety:

a. Medical Record #20 showed that the patient had choked on a piece of chicken.

b. Medical Record #34 stated that the patient had choked on a piece of chicken on 6/30/2016

c. Medical Record #35 stated that the patient was allergic to cheese and was given cheddar cheese on 8/21/2016.

d. Medical Record #36 stated that the patient had choked on a piece of tomato.

e. Medical Record #37 stated that the patient had choked on a piece of yucca on 7/16/2016.

2. Upon request, Staff #27 was unable to provide documentation that would show the integration of food and dietetic service in the hospital wide QAPI and performance improvement activities that track adverse patient events.

3. The above findings were confirmed with Staff #1.

Based on review of three (3) of 3 medical records, review of policy and procedure, review of recognized standard of practice, and interview with administrative staff, it was determined that the facility failed to ensure that nursing personnel provided nursing care for each patient in accordance with the individual needs of each patient.

Findings include:

Reference #1: The Nurse Practice Act for the State of New Jersey states: "The practice of nursing as a registered professional nurse RN is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist."

Reference #2: Facility policy, Patient Hygiene, states,
"Policy:
.....
While there may be times that a "hands on" approach is required to ensure good patient hygiene for the benefit of the patient and/or others, no MPH staff member should on his/her own use "hands on" intervention without a physician's order.
.....
Procedures:
.....
F. The use of "hands on" intervention may be ordered by the treating physician in collaboration with the treatment team when all other efforts to achieve compliance are unsuccessful and it has been determined that this is in the best interest of the patient and/or others to prevent skin breakdown or infections.
1. This decision is documented on the individual patient's Problem List and Treatment Plan. The treating physician writes an order specifying "hands on" care and includes clinical rationale as part of the order.
2. A new order is written each time a "hands on" intervention is required
3. The ordering physician informs the Charge Nurse of the order and (s)he supervises the appropriate staff in the use of "hands on" for the specified personal hygiene activity(ies) [sic]. At all times, staff ensures that the patient is treated with dignity and a reasonable degree of privacy as well as patient safety.
4. Following the application of "hands on" the Charge Nurse documents the steps in a Progress Note.
5. The use of "hands on" for patient hygiene may last longer than five minutes, is considered a brief hold, and is documented as such on the restraint forms.
....."

Reference #3: Facility policy, Medication Management Process - Non-controlled Medications, states, "... Procedure
".....
V. Administration - Nurses and physicians administer medications in accordance with the Medication Administration policies and as follows:
.....
H. If a patient refuses a medication:
1. Documents on the MAR (Medication Administration Record) and notifies the prescribing or on-call physician, for medical medications and PRN (as needed) psychiatric medications only. .....
....."

1. Review of Medical Record #2 revealed the following:

a. A Physician's Order sheet dated 9/27/16 included the orders: "Benadryl 25mg p.o. (orally) q6° (every six hours) PRN (as needed) for anti-anxiety augmentation x 3 days" and "Ativan 2mg p.o. q 6 hrs (hours) PRN for anxiety x 7 days." The nurse acknowledged the two orders and transcribed them to the MAR without clarifying the circumstances under which one medication should be given for anxiety as opposed to the other, or if both medications were to be administered concurrently.

b. A Physician's Order form included an order dated 9/27/16 at 2:03pm that stated:

"Sliding Scale with Coverage as follows doing accucheck BID 7:30 AM + 4:30 PM x 14 DAYS.
180-250 2 units regular insulin S.Q. (subcutaneously)
251-300 4 units regular insulin S.Q.
301-350 6 units regular insulin S.Q.
351-400 8 units regular insulin S.Q.
over 400 please administer 10 units S.Q. + call MD."

i. The nurse transcribed the order to administer 10 units of regular insulin for an Accu-Chek level over 400 mg/dL (milligrams per deciliter) even though the order did not include a type of insulin to be administered, nor was there evidence that he/she clarified the incomplete order prior to transcribing it.

ii. Review of the MAR indicated that at 4:30 PM on 9/28/16 the patient's Accu-Chek level was "436." It was documented that the patient received 10 units of an undocumented type of insulin. There was no documentation on the MAR, or anywhere else in the medical record that the physician was called.

iii. Administrator #3 agreed with the above findings.

c. An October 2016 Medication Administration Record indicated that 11 doses of various oral and topical scheduled medications, were not administered due to patient refusal in some instances. Some of the medications that were not administered did not include an entry on the Nurse's Medication Notes section of the MAR indicating why the doses were not administered. There was no documentation that the physician was called when the refused doses were not given. Facility policy was not implemented.

2. Review Medical Record #3 revealed the following:

a. A Doctor's Orders form included the order dated 7/12/16 at 10:10 AM that stated: "Topiramate 100mg po BID (twice daily) as a mood stabilizer for 30 days." The MAR did not include an entry for the 6:00pm dose of the medication indicating whether it was administered or not.

b. A Progress Notes form entry dated 7/12/16 at 12:50pm, made by a registered nurse stated: "..... Dr. _____ had adjusted pt's (patient's) medication - see pos (Physician Order Sheet).
Pt also place on hands on order for shower. ....." A MAR included the entry dated 7/12/16: "Hands on shower if pt refuses to shower himself/herself." There was no physician order to physically restrain the patient for a shower. Additionally, the entry in the MAR did not include a date or time that the patient was to be showered, giving the impression that it was entered as an "as needed" (PRN) order.

i. Administrator #3 agreed with the above findings.

c. A physician order dated 7/1/16 stated: Weekly weight x 4 weeks on Saturday before breakfast." The July 2016 MAR indicated that the patient's weight was not documented on the third week.

d. The July 2016 MAR indicated that the patient was administered a tuberculin skin test on 7/1/16 at 5:00 PM. There was no documentation on the MAR that the skin test was read, the results of the reading, or why the results weren't read. Another entry on the MAR dated 9:00am on 7/4/16 stated: "TST (Tuberculin Skin Test) 0.1mg - repeat TST/PPD on 7/9/16. Read in 48-72 hrs and document induration in mm (millimeters)." The MAR indicated that the patient refused the TST on 7/9/16. There was no documentation that the physician was notified of the refusal.

e. The July 2016 MAR included the entry: "Eucerin cream, apply q (every) 4 hours up to 3 times daily to dry skin x 30 days." The transcription indicated that the order was entered as a TID (three times daily) order as evidenced by the times entered: 10 AM, 2 PM, and 6 PM. It was documented that Eucerin cream was administered 50 times out of the 84 times documented as having been offered. The Nurse's Medication Orders section of the MAR only indicated that the patient refused the medication 4 times. It could not be determined why the medication was not administered on the other 30 times offered. There was no documentation that the physician was notified of any of the refusals.

3. Review of Medical Record #12 revealed the following:

a. The August 2016 MAR indicated that on 8/9/16 the patient was ordered to have: "Lorazepam 5mg PO q 6 hours PRN x 7days for anxiety" and "Diphenhydramine 25mg PO q 6 hours PRN x 7 days for anxiety." The nurse acknowledged the two orders and transcribed them to the MAR without clarifying the circumstances under which one medication should be given for anxiety, as opposed to the other, or if both medications were to be administered concurrently.

b. The August 2016 MAR indicated that the patient was not administered Lotrimin 1% cream at 8:00am on 8/3/16 as ordered and Urea 10% cream twice on 8/3/16, once on 8/5/16, and once on 8/6/16. There was no documentation on the MAR as to why the patient was not administered the medications according to the orders or that the physician was notified if the missed doses were refusals.

Based on four (4) of 4 medical records reviewed and staff interview on 11/28, 11/29 and 11/30/2016, it was determined that the facility failed to ensure that the medical record was complete and accurate and contained documentation of the patient assessments and progress notes in accordance with its interdisciplinary assessment process policy.

Findings include:

Reference #1: Facility policy, Interdisciplinary Assessment Process, states "... II. Initial Assessment Process: A. Each member of the patient's treatment team completes an initial discipline specific assessment of the patient within the first seven days following his/her admission in accordance with MPH policy. ..."

Reference #2: Facility policy, Frequency and Timeline of Medical Record Documentation, states, "Procedure:
V. Social Workers document in accordance to the following timeframes: ...
B. Progress Notes: 1. Initial Progress Note: At the completion of the Initial Assessment. 2. Ongoing: One time per week for the first 60-days of the patient's hospitalization and monthly thereafter.
VI. Therapeutic Services workers whose job entails documenting in the medical record, document in accordance to the following timeframes:
A. Initial Therapeutic Services Assessment: By day-7 following the patient's admission.
B. Progress Notes: 1. Initial Progress Note: At the completion of the Assessment. 2. Ongoing: One time per week for the first 60-days of the patient's hospitalization and monthly thereafter.
VII. MICA [mentally ill chemical abuser] clinicians document in accordance to the following time frames:
A. Initial MICA Assessment: By day-7 following the patient's admission.
B. Progress Notes: 1. Initial: At the completion of the Assessment. 2. Ongoing: One time per week for the first 60-days of the patient's hospitalization and monthly thereafter.
IX. Treatment Team Documentation: ... D. Treatment Team Meeting Notes Ongoing: Weekly notes for the first seven weeks after admission and monthly after the initial eight weeks."

1. Medical Record #25 indicated a date of admission of 8/31/16.

a. The Treatment Team Meeting weekly notes are as follows: 9/7/16, 9/14/16, 9/22/16, 9/28/16, 10/25/16 and 11/14/16.

i. There was no evidence of weekly treatment team notes from 9/28/16 through 10/25/16.

b. There was no evidence of a MICA clinician initial assessment performed within 7 days of the patient's admission.

i. MICA clinician notes were documented on 9/11/16, 9/29/16, 10/9/16, 10/23/16 and 11/5/16, as of the date of review on 11/30/16. Notes are documented every two weeks and not weekly.

2. Medical Record #16 indicated a date of admission of 9/28/16.

a. The Treatment Team Meeting weekly notes are as follows: 10/5/16, 10/14/16, 10/18/16, 10/27/16 and 11/22/16.

i. There was no evidence of weekly treatment team notes from 10/27/16 to 11/22/16.

b. The Therapeutic Services initial assessment was completed on 10/13/16 and not within the 7 days following the patient's admission.

i. There was no evidence of therapeutic services weekly notes.

3. Medical Record #5 indicated a date of admission of 9/9/16.

a. The Treatment Team weekly notes are as follows: 9/16/16, 9/23/16, 9/30/16, 10/7/16, 10/26/16 and 11/4/16.

i. There was no evidence of a treatment team note for the week of 10/9/16 and 10/16/16.

b. The Therapeutic Services lacked documentation of a weekly note for the week of 10/9/16.

c. The MICA Services lacked documentation of an initial assessment. The only documented notes were on 10/9/16 and 10/23/16, and not weekly notes for the first 60 days of admission.

4. Medical Record #4 indicated that the patient was admitted on 1/22/15.

a. The Treatment Team meetings notes for 2016 were as follows: 1/19/16, 3/9/16, 5/10/16, 9/20/16 and 11/22/16.

b. The Treatment Team meeting notes were not completed monthly for 2016.

5. The above findings were confirmed with Staff #18 and Staff #2l.

Based on observation and staff interview conducted on 11/29/16, it was determined that the facility failed to ensure implementation of a policy and procedure addressing medication distribution through a 24 hour unit dose cassette exchange.

Findings include:

Reference: Facility policy, Medication Management Process - Non-controlled Medications, states, "Procedure:...III. Delivery: A. The pharmacy dispenses and delivers medications:...2. Utilizing a unit dose drug distribution system for all medications including individually prescribed over-the-counter medications, with individual cassettes or containers that bear each patient's identification..."

1. A box of 14 Nicotine Patches 13 mg/24 hr was dispensed to Patient #23 on 11/16/16.

2. A 12 ounce bottle of Maalox was dispensed to Patient #23 on 11/15/16.

3. A box of 30 Metamucel packets 3.4 gm was dispensed to Patient #29 on 11/28/16.

4. A 118 ml bottle of Bromfed DM was dispensed to Patient #40 on 9/16/16.

5. These findings were confirmed by Staff #23.

Based on observation, staff interview, and review of facility provided documents, it was determined that the facility failed to be in compliance with Federal and State licensure requirements for food and dietary personnel as well as food service standards, laws and regulations.

Findings include:

1. The facility failed to ensure that the Director of Food & Nutrition provides effective daily management of the Food Service Department in accordance with Federal, State and Local Regulations.

(Refer to Tag A0620 and A0724)

Based on observation, document review, and staff interview on 11/29/2016 and 11/30/2016, it was determined that the facility failed to ensure that the director of food services provides effective daily management of the Nutritional Services Department.

Findings Include:

Reference #1: Facility document, Food Service Operation at Meadowview Psychiatric Hospital, states, "... E-1 Food Service Director...This Food Service Director shall demonstrate knowledge of foodborne disease prevention, and hazard analysis, critical control point (HACCP) principals and the requirements of the New Jersey State Sanitary Code. ...Safety practices for food handling that include but is not limited to, all applicable New Jersey and Federal codes and regulations...Emergency food supplies and water for a minimum of 96 hours in accordance with all New Jersey Stare and Federal Codes and regulations and other accrediting bodies...Orientation, work assignments, supervision of work and personnel performance. ...Menu planning, purchasing of food and supplies, retention of essential records....Service QA/PI program ..."

Reference #2: N.J.A.C. 8:24-4.9(i)(2)(3)(K) (2)STATES, "The temperature of the wash solution in spray type warewashers that use hot water to sanitize shall not be less than: 2. For a stationary rack, dual temperature machine, 150°F; 3. For a single tank, conveyor, dual temperature machine, 160°F; or (k) In a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194°F, or less than, 2. For all other machines, 180°F."

Reference #3: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows drying; and (ii) Covered or inverted."

Reference #4: N.J.A.C. 8:24-2.4(c)(1) states, "The following requirements shall apply to hair restraints:..employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens; and unwrapped single-service and single-use articles."

Reference #5: N.J.A.C. 8:24-6.4(f) states, "After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment or supplies."

Reference #6: The facility document titled, "Test tray Evaluation Temperature monitoring Tool" states, "... Food Service Director or designee monitors three tray meals per week, one for each meal, rotating the floors each time...Temperature of Cold Foods should be < 41...Temperature of Hot Foods should be > 140. ...."

1. During a tour of the kitchen area on 11/29/2016, at approximately 11:00 AM, in the presence of Staff #22, the following observations were made:

a. Wet mops and a broom were observed near the door of the utility closet. There was a wet mop in the mop bucket inside the utility closet. There were hooks inside the utility closet for hanging mops and brooms, but were not being utilized.

b. A full tray (about 20 cups) of individually portioned pudding, was not labeled.

c. The juice containers in the refrigerator did not contain expiry dates or labels.

d. Food Service staff was observed going in and out of the kitchen area without hair covering. Hairnets were not available at the kitchen entrance.

e. During interview, Staff #27 stated, "Only dietary staff are allowed in the kitchen and they keep their hairnets in their lockers."

2. During a tour of the kitchen on 11/30/2016, at 10:30 AM in the presence of Staff #27 and Staff #22, the following observations were made:

a. Staff #27 demonstrated the ware washing machine. The ware washing machine did not meet the wash and rinse temperatures. Wash temperature reached 155 degrees Farenheit and the rinse temperature reached 165 degrees Farenheit. The required temperature is 160 degrees for the wash cycle and 180 degrees for the rinse cycle.

b. Wet stainless steel pans and aluminum cooking sheets were observed stacked on top of each other in the pot washing and dish washing areas and were not allowed to air dry.

3. A lunch meal tray temperature was checked, on the second floor at 12:15 PM, in the presence of Staff #22. The following food temperatures were revealed:

a. Flank Steak: 100 degrees Farenheit, Potatoes: 136 degrees Farenheit, Broccoli: 120 degrees Farenheit, Butter nut squash soup: 116 degrees Farenheit.

b. During interview, Staff #22 and Staff #27 stated the Food Temperatures are not checked on each individual unit, just checked in the kitchen prior to delivery to the units.

4. During a tour of the kitchen area, during the lunch meal, it was observed that the facility was using Styrofoam plates and cups to serve patient food. During interview, Staff #27 stated that they were using paper products as he/she has to order more plates.

5. The above findings were confirmed with Staff #1, #22, and #27.

Based on observation, interviews with administrative staff, review of policy and procedure, and review of related documentation, it was determined that the facility failed to be constructed and maintained to ensure the safety of patients and to provide facilities appropriate to the needs of the patient community.

Findings include:

1. The facility failed to ensure the overall hospital environment was maintained for the safety and well-being of the patients, staff, and public. (Refer to Tag A-0701)

2. The facility failed to maintain equipment to ensure an acceptable level of safety and quality. (Refer to Tag A-0724)

Based on observation and interview with administrative staff, it was determined that the facility failed to ensure that the overall hospital environment was maintained to protect the safety and well-being of patients.

1. A tour of the 4th Floor Acute Care Unit revealed:

a. Pantry:

i. There was dust on top of the wall cabinets.

ii. There was grit in the corners of the drawers in the metal cabinets.

iii. There was dust, salt packets, potato chip pieces, a sugar packet, grit, broken pieces of sheetrock and gypsum particles, beneath and behind the refrigerator. Atop and between the recesses of the refrigerator gasket were stains, dried rice, and food particles. The interior temperature of the refrigerator was 42 degrees Fahrenheit as indicated by the thermometer inside.

iv. The metal frame for the microwave oven was rusted, had dried food particles, stains, dust, grit, and a black sticky substance on it.

v. The microwave oven had dust atop it.

vi. There was a large cutout hole (approximately 1 foot x 1.5 foot) in the wall behind a cabinet beneath the sink. The back wall of the cabinet was also almost entirely cutout. There were broken pieces of sheetrock on the base of the cabinet and peeling paint on the section of the wall that was not cutout. The hinges on the cabinet door were heavily rusted.

vii. There was heavy dust, grit, paper scraps, a hole in the wall, broken and crumbling sheetrock, a puddle of water, a soaked sugar packet, and a live brown ant behind and or beneath the ice machine. There was a heavy accumulation of dust atop the ice machine.

b. Nurses Station:

i. A metal cabinet outside of the Pantry door was rusted to the floor. Beneath and behind the cabinet was heavy dust, grit, paper scraps, and a stained Auto Shopper magazine that was stuck to the floor. On the side of the cabinet there were holiday decorations, patient art work, an unopened letter addressed to Patient #3, and an unopened Christmas envelope with the name "Charlyn" on it. All of the items had a heavy accumulation of dust on them.

ii. A metal cabinet beneath the counter holding a monitor had a heavy accumulation of dust, grit, sugar packets, a coin, rolls of plastic bags, paper scraps, and a plastic spoon beneath it.

iii. A metal cabinet beneath the counter below a wall clock had a heavy accumulation of dust, grit, paper scraps and other refuse beneath it.

c. Medication Room:

i. There was heavy dust atop the wall cabinets.

ii. There was heavy dust on the soap dispenser.

iii. There was heavy dust atop the refrigerator. Beneath and behind the refrigerator was heavy dust, grit, medication wrappers, raised stains, paper clips, paper scraps, and other refuse. Surgical tape was holding the thermometer wires to the door of the refrigerator.

iv. The sink faucet handles were in disrepair and loose on their stems. There was heavy rust on the sections of the sink where the porcelain was worn away or broken off exposing uncleanable base material.

d. The Valuables Room refrigerator had food particles and grit atop and within the recesses of the gasket between the door and the body of the refrigerator. The gasket was ripped and cracked in areas.

e. The "Back Room" located between the Valuables Room and the Pantry:

i. A shelf beneath the computer station desk had two empty bottles of soda, a used plastic coffee cup lid, and an accumulation of heavy dust.

ii. A metal cabinet had a heavy accumulation of dust atop it.

iii. There was dust on the wall shelves.

f. Seclusion Suite:

i. There was unpainted plaster behind the toilet in the bathroom.

ii. There was a crack in the wall with exposed plaster.

g. The Liquid Bleach dispenser on a washing machine in the Laundry Room was heavily encrusted with a dry powdery particulate on the interior and surrounding it.

h. The N-4 Wing Emergency Exit Door:

i. The floor of the landing outside of the door leading to the staircase had pieces of plaster on it.

ii. The ceiling appeared to be crumbling in an area.


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2. A tour of the third floor Transitional Unit on 11/28/16, revealed the following:

a. The floors throughout the unit had brown and rust colored stains.

b. The Pantry area located behind the nursing desk:

i. The inside of the microwave was covered with food debris.

c. Medication Room:

i. The porcelain sink was cracked and chipped on the edges, and around the drain.

ii. The counter top surrounding the sink was cracked and had areas that were covered with gray tape.

d. The seclusion room bathroom wall had been spackled, but was not painted.

e. Room #353/Activity Room had three (3) green chairs with frayed material and two (2) red chairs with splits in the material.

f. Linen Room:

i. The room was over crowded with four (4) linen carts, that were not easily accessible.

ii. Two (2) linen carts were only loosely covered with a linen sheet on the front of the cart.

iii. The wall had been spackled, but was not painted.

iv. The wall to the right when exiting, had a gray plastic material that was taped to the wall with gray tape.

g. Laundry Room

i. One (1) of two (2) washers had a build up of blue/white liquid debris in the center agitator dispenser.

ii. One (1) of two (2) dryers had an accumulation of gray/brown debris and lint build up under the lint tray.

3. The above findings were confirmed with Staff #3 and Staff #21.

4. On tour of the second floor Continuous Care Unit on 11/29/16, the following observations were made:

a. The floors throughout the unit had brown and rust colored stains.

b. In the Pantry area located behind the nursing desk:

i. The ice machine had a visible black substance around the seals of the door.

ii. The caulking around the stainless steel colored sink was peeling off and black in areas.

iii. The stainless steal colored sink had gray tape applied in areas.

iv. The patient snack refrigerator had visible build up of a black substance around the door seals.

v. The pantry walls had visible build up of brown grit.

c. The Medication Room porcelain sink was cracked and chipped with rust colored stains.

d. The two (2) seclusion rooms had visible brown/white debris on beds and floors, with no patients actively occupying the rooms.

e. In the Treatment Room, a large couch had a tear in the material and a sign placed on the couch marking it for removal. Staff #3 and Staff #20 were unsure how long the couch was marked for removal.

f. Patient Room #236:
i. There was cracked floor tiling behind the bathroom door.

ii. The bathroom floor and toilet had visible build up of brown grit.

g. Patient Shower Room #237:

i. The shower floor was cracked near the drain.

ii. The concrete/tile step into the shower area was cracked.

h. Patient Shower Room #244:

i. There was a black and orange substance on the floor.

i. Patient Shower Room #214:

i. There was a black and orange substance on the caulking and brown grit throughout tub area.

j. Patient Shower Room #210:

i. There was a black substance throughout the shower.

k. Patient Shower Room #261:

i. The plastic shower curtain was covered in an orange colored substance.

ii. The walls had peeling paint.

iii. The walls had been spackled, but were not painted.

l. The Linen Room had two (2) linen carts that were not covered.

m. Laundry Room:

i. Three (3) of three (3) washers had a build up of blue/white liquid debris in the center agitator dispenser.

ii. Three (3) of three (3) dryers had an accumulation of gray/brown debris and lint build up under the lint tray.

5. The above findings were confirmed with Staff #3 and Staff #20.

6. On tour of the first floor Treatment Room on 11/30/16, the following observations were made:

a. The sink outside of the patient bathroom had visible brown grit.

b. The patient bathroom floor had visible brown grit and paper towels debris.

Based on observation, review of facility documents, and staff interview, it was determined that the facility failed to maintain their supplies and equipment to ensure an acceptable level of safety and quality.

Findings include:

Reference #1: Facility policy, Food Safety and Vendor Responsibility, states, "... B. That the staff prepares food using proper sanitation and maintains appropriate lighting, temperature, moisture, ventilation, and security in accordance with Chapter XXIV of the New Jersey Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (NJAC 8:24)."

Reference #2: Facility policy, Food Service, states, "... III. Snacks: C. Nursing staff stores the snacks on the unit pantry or refrigerator as needed, ensuring the maintenance of proper sanitation, temperature, moisture, ventilation, and security. ..."

Reference #3: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #4: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #5: N.J.A.C. 8:24-3.2 states, "Food Packages: shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants."

1. A tour of the 4th Floor Acute Care Unit revealed:

a. The bottom drawer of a metal cabinet, outside of the Pantry door, in the Nurses Station contained:

i. A bucket with specimen cups inside it. The interior of the bucket had black particulate.

ii. One (1) BD Vacutainer Urinalysis Transfer Straw Kit with an expiration date of "2016-03" (3/31/16).

iii. One (1) BD Vacutainer Urinalysis Transfer Straw Kit with an expiration date of "2015-09" (9/30/15).

iv. One (1) Aptima Endocervical and Male Uretheral Swab Specimens Kit with an expiration date of "2015-09-03" (3/9/15).

b. A metal cabinet beneath the counter in the Nurses Station contained one (1) BD Vacutainer C&S Transfer Straw Kit with an expiration date of "2015-09" (9/30/15).

c. A box with the words "Specimen box" set atop a counter in the Nurses Station contained one (1) BD Vacutainer C&S Transfer Straw Kit with an expiration date of "2015-09" (9/30/15).

d. The medication cart in the Medication Room had heavy raised stains on the sides. Bins on the side of the cart contained a heavy accumulation of dust, grit, black particulate, paper scraps, and other refuse. Wrapped tongue depressors were placed inside the bins atop the referenced unclean contents. A drawer on the back of the medication cart contained a leaking tube of A&D ointment with the name of Patient #38 on a partially torn sticker.

e. There was heavy staining on the plastic cup bin in the Medication Room.

f. In the Medication Room, an orange plastic Rubbermaid water cooler containing water had two pieces of a dark particulate at the interior bottom of the cooler.


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2. The medication cassette drawer for Patient #26 contained a pink sticky residue.

3. The medication cassette drawer for Patient #27 contained a red sticky residue.

4. The medication cassette drawer for Patients #30 and #21 contained a white sticky residue.

5. These findings were confirmed by Staff #23.


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6. During a tour of the facility at 10:45 AM, in the presence of Staff #22, the following observations were made:

a. The pantry area located on the second floor had a refrigerator which showed an internal temperature of 50 degrees.

i. The gaskets on the refrigerator door were visibly black and did not seal the refrigerator door to a complete closed seal.

ii. There was no thermometer in the freezer section. There was excessive ice accumulation in the freezer. Staff #22 stated that the freezer needed to be defrosted.

iii. There were (3) three white Styrofoam cups in the freezer area of the refrigerator, filled with an unknown substance. The cups were unlabelled. Staff #22 was not familiar with the content of the cups.

b. Several packets of salad dressings, which appeared to be visibly full of dirt, were found in the cabinets with no labels or expiry dates.

7. The pantry areas on the third floor had a refrigerator which showed the internal temperature as 36 degrees.

a. Four ounce juice cups were found in the refrigerator that were not labeled.

8. The pantry area on the fourth floor had a large battery, which was used as an emergency flash light.

a. The battery was being charged next to the microwave.

i. The battery was in the path of the microwave door, making it difficult to use the microwave.

b. The microwave was visibly full of dirt and debris on the outside. It had visible residue of food splashes in the inside heating compartment.

c. The refrigerator located in the pantry area had an internal temperature of 50 degrees. The refrigerator was visibly dirty. The door gaskets had visible dirt and debris and failed to make a complete seal to close the refrigerator.

d. There were five (5) unlabeled juices in the refrigerator which showed an internal temperature of 58 degrees.

e. There was (1) one milk carton which had an internal temperature of 45 degrees.

9. During interview, Staff #22, stated that the kitchen staff does not label anything.

10. Upon request, the facility was unable to provide the cleaning schedule for the unit pantry's and refrigerator's.

11. The above findings were confirmed with Staff #1 and Staff # 22.


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12. A tour of the Treatment Room on 11/30/16 was conducted with Staff #3, and the following was observed:

a. On a shelf next to the examination table, a vacutainer for laboratory specimens was found in the blood specimen rack. There was a needle attached to the vacutainer. The needle was not secured with a safety device. The needle was not stored safely.

b. A sharps container was noted on the counter top across from the examination table. The container was unsecured and had a large opening that exposed contaminated sharps and lab tubing.

c. An electrical power cord strip with multiple cords attached was taped to the wall at the foot of the examination table. This left very limited space to safely exit the examination table.

Based on observation, facility documentation review, and staff interview conducted on 11/28/16 and 11/29/16, it was determined that the facility failed to ensure that an adequate infection control program that seeks to minimize infections and communicable diseases is implemented.

Findings include:

1. The facility failed to provide a functional and sanitary environment for the provision of patient care services by adhering to professionally acceptable standards of Infection Control. (Cross refer to Tag 0749)

2. The facility failed to ensure that an active Infection Control program for the prevention, control and investigation of infections and communicable diseases is implemented. (Cross refer to Tag 0748 and Tag 0749)

3. The facility failed to ensure that a qualified Infection Control Professional (ICP) is designated to oversee the facility's Infection Control Program. (Cross refer to Tag 0748)

Based on observation, staff interview, and employee personnel file review conducted on 11/28/16 and 11/29/16, it was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) was designated to oversee the facility's Infection Control Program.

Findings include:

Reference: CMS [Centers for Medicare and Medicaid Services] Interpretive Guidelines for 42 CFR 482.42 states, "CDC [Centers for Disease Control and Prevention]
has defined 'infection control professional' as a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control. ... In designating infection control officers hospitals should assure that the individuals so designated are qualified through education, training, experience, or certification (such as that offered by the Certification Board of Infection Control and Epidemiology Inc. (CBIC), or by the specialty boards in adult or pediatric infectious diseases offered for physicians by the American Board of Internal Medicine (for internists) and the American Board of Pediatrics (for pediatricians)."

1. Upon review of the employee personnel file for Staff #16 (Infection Control Nurse), the file lacked evidence of CBIC certification and/or recent specialized training in Infection Control.

2. Upon review of the employee personnel file for Staff #8 (Infection Control Committee Chairperson) on 11/29/16, the file lacked evidence of CBIC certification or an Infection Control specialty certification through the American Board of Internal Medicine and/or recent specialized training in Infection Control.

3. During an interview with Staff #16 at 1:00 PM on 11/28/16, he/she stated, "Patients with signs and symptoms of infection are referred to their PCP [Primary Care Physician]. (The facility) does not have an ID [Infectious Disease] consultant."

4. The facility failed to ensure that its designated infection control officer or officers, who have oversight of its Infection Control program, are qualified.

A. Based on observation, review of facility documentation and disinfectant label instructions, and staff interviews conducted on 11/28/16, it was determined that the facility failed to ensure an Infection Control program for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel is implemented.

Findings include:

Reference: CDC website page titled, "Frequently Asked Questions about Clostridium difficile for Healthcare Providers" (https://www.cdc.gov/hai/organisms/cdiff/cdiff_faqs_hcp.html) states, "Implement an environmental cleaning and disinfection strategy:
-Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
-Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores.) Hypochlorite-based disinfectants may be most effective in preventing Clostridium difficile transmission in units with high endemic rates of Clostridium difficile infection."

1. During an interview with Staff #16 and Staff #19 between 1:45 PM to 2:00 PM regarding facility disinfectants and cleaning procedures, both stated that the facility has no sporicidal disinfectants available onsite to address cleaning of the environment for Clostridium difficile or other sporicidal contamination.

a. Staff #19 stated, "The bleach disinfectants are stored offsite."

2. Staff #16 and Staff #19 stated that the facility is "using PDI Sani-Cloth disinfecting wipes and a quaternary disinfectant."

a. The quaternary disinfectant manufacturer's instructions for use (IFU) was requested and not received.

3. PDI Sani-Cloth and quaternary disinfectants lack documented efficacy against bacterial spores.

These findings resulted in Immediate Jeopardies which immediately curtailed this practice. The Immediate Jeopardies were removed on 11/29/16, upon receipt of an acceptable plan of correction.

B. Based on observation, review of professionally recognized guidelines, and staff interview conducted on 11/28/16, it was determined that the facility failed to ensure hand hygiene in accordance with CDC guidelines is implemented.

Findings include:

Reference: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states,
"Recommendations:
1. Indications for Handwashing and Hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J
C. Decontaminate hands before having direct contact with patients
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter.
E. Decontaminate hands before inserting...peripheral vascular catheters, or other invasive devices that do not require a surgical procedure
F. Decontaminate hands after contact with a patient's intact skin...
G. Decontaminate hands after contact with ... a patient's nonintact skin
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
J. Decontaminate hands after removing gloves.
...
2. Hand Hygiene Technique
...
B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet ...
...
6. Other Aspects of Hand Hygiene
A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk ...
B. Keep natural nail tips less than ¼-inch long
C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes and nonintact skin could occur.
D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses for different patients ...
7. Health-care worker educational and motivational programs ...
D. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance of the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by HCWs."

1. During a tour of the 3rd floor at 10:45 AM, in the presence of Staff #3 and Staff #21, Staff #9 was observed removing a pair of soiled gloves without sanitizing his/her hands while performing housekeeping duties in the janitorial closet.

2. The closet lacked hand washing facilities and an alcohol-based hand rub (ABHR) dispenser.

a. This finding was confirmed with Staff #3 and Staff #12.

3. During a tour of the 2nd floor at 11:30 AM, in the presence of Staff #3 and Staff #12, the janitorial closet lacked hand washing facilities and an alcohol-based hand rub (ABHR) dispenser.

a. This finding was confirmed with Staff #3 and Staff #12.

4. The facility failed to ensure hand hygiene facilities (i.e., handwashing sink and ABHR dispenser) are available to facilitate compliance to CDC hand hygiene guidelines.

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 11/28/16, upon receipt of an acceptable plan of correction.

5. At 11:30 AM, while touring the 2nd floor, Staff #13 was observed to perform housekeeping duties.

6. While performing his/her housekeeping duties, Staff #13 was observed to remove a pair of soiled gloves without sanitizing his/her hands.

7. Staff #13's fingernails were observed to be >2 inches long.

8. These findings were confirmed with Staff #3 and Staff #12.

9. The facility failed to ensure compliance with CDC hand hygiene guidelines.

C. Based on observation, lack of facility documentation, and staff interview conducted on 11/28/16, it was determined that the facility failed to ensure compliance with OSHA regulations.

Findings include:

Reference: OSHA 29 Code of Federal Regulations Section 1910.134(c)(1)(iii) states, "In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: ... Fit testing procedures for tight-fitting respirators"

1. During an interview with Staff #16 and Staff #19 at 1:40 PM, they were asked regarding the facility's use of N-95 respirators.

2. They stated that the facility has N-95 respirator masks available for use.

3. Staff #16 and Staff #19 were asked by this surveyor regarding the facility's fit-testing procedures.

4. Both answered that the facility does not conduct fit-testing for the N-95 respirators.

5. The facility failed to ensure compliance with OSHA regulations.

D. Based on observation and staff interview conducted on 11/28/16, it was determined that the facility failed to ensure a safe and sanitary environment for its patients and its staff.

Findings include:

1. During a tour of the 3rd floor janitorial closet at 10:45 AM, in the presence of Staff #3 and Staff #21, a mop head was observed to be stored on top of the faucet handle to air dry.

2. A swivel sponge cleaner was observed to be stored in the sink.

3. The mop head and swivel sponge cleaner were observed to be stored in a manner that does not maintain cleanliness after being cleaned and disinfected.

4. During a tour the 3rd floor Activity Room at 11:00 AM, in the presence of Staff #10, the Men's Room wall was observed to contain a large hole in the ceiling.

a. Staff #10 stated that the hole has been there for 1 1/2 months.

5. The window screen in the Ladies' Room on the same floor was observed to contain a thick layer of dust.

6. These findings were confirmed with Staff #10.

7. During a tour of the 2nd floor Medication Room, in the presence of Staff #3 and Staff #12 at 11:20 AM, the following were observed:

a. The sink contained rust and corrosion around the rim.

b. The faucet contained cracks and white and green stains at the base of the handles.

c. These surfaces evidence an unsanitary environment.

d. These findings were confirmed with Staff #3 and Staff #12.

8. During a tour of the 4th floor, in the presence of Staff #3 and Staff #14, the following were observed:

a. The handwashing sink in the Medications Room contained cracks and reddish/brown stains.

b. The counter in Room #421 Janitorial Closet contained chips, cracks and missing laminate.

i. The missing laminate surface contained exposed wood.

c. These surfaces are uncleanable.

d. These findings were confirmed with Staff #3 and Staff #14.

9. During a tour of the facility at 12:00 PM in the presence of Staff #3, and Staff #15, a crack on the floor of the elevator was observed to be repaired with duct tape.

a. The area with duct tape is not a cleanable surface.

b. This finding was confirmed with Staff #3 and Staff #15.

E. Based on observation, lack of manufacturer's instructions for use (IFU) and staff interview conducted on 11/28/16, it was determined that the facility failed to ensure manufacturer's instructions for use (IFUs) are available and followed.

Findings include:

Reference: Ultratrak Ultimate Glucometer manufacturer's IFU states, "Cleaning 1. To clean the meter exterior, wipe it with a cloth moistened with tap water or a mild cleaning agent."

1. During a tour of the 2nd floor at 11:20 AM, in the presence of Staff #3 and Staff #12, the manufacturer's IFU for the glucometer was requested and not received.

2. The glucometer is used for multiple patients.

3. The facility failed to ensure the manufacturer's IFUs are available at the point of use and followed.

Based on record review and interview, the facility failed to develop MTPs for eight (8) of eight (8) active sample patients (A1, A2, A3, C1, C2, C3, T1, and T2) that included active treatment interventions with a specific focus. Interventions were either generic monitoring or discipline functions to be performed by physician, nurses, and social workers. Some interventions simply list the names of a particular group to be offered to a patient. In addition, the interventions did not include frequency and duration. These deficiencies resulted in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each. These failures will potentially result in inconsistent and/or ineffective treatment resulting in prolonged patient stay.

Findings include:

A. Record Review

A review of medical records revealed that the treatment plans only listed routine, generic discipline functions as interventions rather than individualized interventions to assist patients accomplish their treatment goals. The interventions for all the sample patients were list of groups without purpose, frequency and duration. The following are interventions identified on the MTPs for each of the active sample patients.

1. Patient A1 (Master Treatment Plan (MTP) dated 11/21/16)
Problem 1.1 "Psychological problems - thought Disorder." Interventions are "Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds."

Problem 3.1 "Low frustration tolerance." Interventions listed, "coping skills, Interpersonal skills and relationship, Mental Health Awareness, Psychoeducation group, Self-Expression, Social skills group, Stress Management and symptoms and symptoms Management."

Problem 4.1 "Non-adherence with medication will con." (sic) Interventions listed are "Nursing will encourage compliance and participation in group activities on a daily basis." "Nurse group." "Medication management."

Problem 4.1a, "Placement difficulties - Homelessness." Interventions listed are "Discharge Planning Group," "Individual meeting with social worker," and "Social Worker will involve PACT (Patient Aligned Care Treatment) in treatment planning and discharge Planning."

2. Patient A2 (MTP dated 10/20/16) For the problem "thought disorder" included following interventions. "Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds." For the problem of "Non-Adherence with medication", interventions included "Nurses group, medication management, nursing will encourage compliance and participation in group activities on a daily basis."

3. Patient A3: MTP dated 11/16/16 had a list of following interventions for the problem "Thought Disorder". "Individual Psychotherapy, Medication Group, Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds, Stress Management, MICA Education, Nursing will encourage compliance and participation in group activities on a daily basis."

4. Patient C1 (MTP dated 11/15/2016)
Problem 1.1 "Limited interpersonal skills," the following groups were listed as interventions: communication skills, coping skills, interpersonal skills & relationships and Mental Health awareness. There is no indication when these groups will meet, the frequency of the group and who is responsible for providing the groups.

Problem 2:1 "Thought Disorder; evidence by agitated behavior, delusion and paranoid ideations, causing, combative and responding to internal stimuli." Intervention states "Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine rounds." "Psychoeducation."

Problem 3.1 "General - Patient fails to understand the importance of personal hygiene." Intervention states: "Nursing will encourage patient to shower." "Nursing will encourage patient to clean room." "Nursing group." "Nursing will encourage compliance and participation in group activities on daily basis."

There is no intervention on the MTP for social work.

5. Patient C2 (MTP dated (11/28/2016)
Problem 1.1 "Broad skill deficits - Poor insight and judgment due to addiction issues." Intervention as follows: "Nursing will prompt patient for medication administration." "Nursing will provide medication education when needed to patient." "MICA (Mentally Ill Chemical Abuser) education." "MICA Process." "Nursing will encourage compliance and participation in group activities on a daily basis."

Problem 2.1 Patient name "tends to be impulsive, intrusive, and demanding in his/her interactions with others causing interpersonal difficulties which interfere with his/her daily functioning." Interventions listed as "Communication skills, coping skills, Individual Psychotherapy and social skills groups."

There was no intervention on the MTP for psychiatrist, social work, and therapeutic therapy.

6. Patient C3 (MTP dated 11/16/2016)

Problem 1.1 "Thought Disorder - Disorganized, confused cognition caused by psychotic process and as a result no group participation or normal interests." Interventions states "Nursing will encourage compliance and participation in group activities on a daily basis." "Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds."

Problem 1.1b "Psychological Problems - Thought Disorder." Interventions listed are current Events, Communication skills, Creative Arts, and "Men's and women's issues."

Problem 2.1 "Nonsexual - Socially inappropriate behavior due to lack of awareness of social norms." Interventions listed are "Communication skills, coping skills, Current events, Men's and women's Issues, Creative Arts and Self Expression."

Problem 3.3 "Violence - Assaultive and Threatening." Interventions listed as "Communication Skills, Mental Health Awareness, Group Psychotherapy, Psychotherapy (PD), Reality focus and Self Expression."

Problem 4.1: "Broad skill deficits - Confusion and disorientation due to organic impairment." "Interventions listed infections control (2x/month (RN), Nurses group, Symptoms and Symptoms Management." "Nursing will ensure that patient does not use bathroom for 30 minutes after ingestion", "Nursing will provide medication education" and "Independent Living Skills."

Problem 5.1 "Placement difficulties - Appropriate placement not available." Intervention listed as "Individual meeting with social worker and discharge planning group."


7. Patient T1 (MTP dated 10/21/16) Problem: "Poor communication skills." Included the following interventions, "Communication Skills, Coping Skills, Creative Writing, Fitness on the floor, Independent Living Skills."

8. Patient T2: (MTP dated 10/19/16) had the following intervention for the problem "Thought Disorder." "Medication group. Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds."

B. Staff Interviews:

1. In an interview on 11/29/16 at 3:30 P.M. with the Chief Nurse Officer (CNO) the interventions on the sample patient's the MTPs were discussed. The CNO agreed that the intervention was generic, staff job tasks and that some do not include frequency and duration. She stated, "we will be working hard to fix these interventions."

2. During interview with review of treatment plans on 11/30/16 at 10:35 a.m., the Director of Social Work acknowledged that the social work interventions were not individualized. She stated, "We were told the interventions are what the social worker is going to do." She also stated, "this will be an easy fix."

3. In the interview on 11/29/16 at approximately with 3:15pm with the Medical Director, interventions in the sample patients' MTPs were discussed. The Medical Director agreed that the interventions were not individualized and acknowledged that they were generic in nature.

Based on record reviews and staff interviews, the Medical Director failed to ensure that the Master Treatment Plans of eight (8) of eight (8) sample patients (A1, A2, A3, C1,C2,C3, TI, T2) included specific and individualized interventions for the problems listed. Such failures resulted in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed, resulting in prolonged patient stay. (Refer to B122)

Based on interview and document review, the Chief Nursing Officer failed to ensure nursing interventions included in the Master Treatment Plans (MTPs) was based on the individual needs of eight (8) of eight (8) active sample patients (A1, A2, A3, C1, C2, C3, T1 and T2). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery. (Refer to B122)

Findings Include:

A. Record review

1. Patient A1 (Master Treatment Plan (MTP) dated 11/21/16)
Problem 4.1 "Non-adherence with medication will con." (sic) Interventions listed are "Nursing will encourage compliance and participation in group activities on a daily basis." "Nurse group." "Medication management."

2. Patient A2 (MTP dated 10/20/16) For the problem of Non-Adherence with medication, interventions included "Nurses group, medication management, nursing will encourage compliance and participation in group activities on a daily basis."

3. Patient A3 (MTP dated 11/16/16) For the problem "Thoughts Disorder" interventions included "Nursing will encourage compliance and participation in group activities on a daily basis."

4. Patient C1 (MTP dated 11/15/2016)
Problem 3.1 "General - Patient fails to understand the importance of personal hygiene." Intervention states: "Nursing will encourage patient to shower." "Nursing will encourage patient to clean room." "Nursing group." "Nursing will encourage compliance and participation in group activities on daily basis. "

5. Patient C2 (MTP dated (11/28/2016)
Problem 1.1 "Broad skill deficits - Poor insight and judgment due to addiction issues." Intervention as follows: "Nursing will prompt patient for medication administration." "Nursing will provide medication education when needed to patient." "MICA (Mentally Ill Chemical Abuser) education." "MICA Process." "Nursing will encourage compliance and participation in group activities on a daily basis."

6. Patient C3 (MTP dated 11/16/2016)
For the problem 1.1: "Thought Disorder - Disorganized, confused cognition caused by psychotic process and as a result no group participation or normal interests." Interventions states "Nursing will encourage compliance and participation in group activities on a daily basis." Psychiatrist will evaluate patient symptoms, medication effectiveness and side effects during routine unit rounds."

7. Patient T1 (MTP dated 10/21/16) for the problem "Poor Communication Skills" included following interventions "Communication Skills, Coping Skills, Creative Writing, Fitness on the Floor, Independent Living Skills."

8. Patient T2 (MTP dated 10/19/16) For the problem of "Thought Disorder," included the following intervention, "Medication group."

B. Interview:

1. In an interview on 11/29/16 at 3:30 P.M. with the Chief Nurse Officer (CNO) the interventions on the sample patient's MTPs were discussed. The CNO agreed that the interventions were generic, nursing functions and not specific to the individual patient's needs and that frequency and duration is absent. She stated, "we have been working on making the treatment plans better, we will be working harder to fix to fix it."

Based on record review and staff interview, the Director of Social Work failed to ensure social work interventions included in the MTPs was based on the patient specific needs for eight (8) of eight (8) active sample patients (A1, A2, A3, C1, C2, C3, T1 and T2). In addition, sample patients (A2, A3, C1, C2, T1 and T2) MTPs had no social work interventions. These deficiencies potentially prolong hospital stay and prevent patients from utilizing having all available community resources in their decision making for discharge. (Refer to B122)

Findings Include:

A. Record review

1. Patient A1 (Master Treatment Plan (MTP) dated 11/21/16)
Problem 4.1a, "Placement difficulties - Homelessness." Interventions listed are "Discharge Planning Group," "Individual meeting with social worker," and "Social Worker will involve PACT (Patient Aligned Care Treatment) in treatment planning and discharge Planning."

2. Patient A2 MTP dated (10/20/16) has no Social work intervention included.

3. Patient A3 MTP dated (11/16/16) has no Social work intervention included.

4. Patient C1 MTP dated (11/15/16) has no Social work intervention included.

5. Patient C2 MTP dated (11/28/16) has no Social work intervention included.

6. Patient C3 MTP dated (11/16/16) Problem 5.1 "Placement difficulties - Appropriate placement not available." Intervention listed as "Individual meeting with social worker and discharge planning group."

7. Patient A2 MTP dated (10/20/16) has no Social work intervention included.

8. Patient A2 MTP dated (10/20/16) has no Social work intervention included.

B. Interview

1. During interview with review of treatment plans on 11/30/16 at 10:35 a.m., the Director of Social Work acknowledged that the social work interventions were not individualized. She stated, "we were where told the interventions are what the social worker is going to do." She also stated, "this will be an easy fix."