HospitalInspections.org

Based on observations, interview, review of facility policy and procedures, the hospital's governing body failed to ensure oversight for acceptable dietary standards for food preparation for patients, failed to ensure policies and procedures were developed and followed for the Re - Therm Unit(s) used in kitchen for food preparation for patients, failed to ensure scheduled maintenance of the Re-Therm Unit(s) used for food preparation for patients, and failed to provide documented education and training of staff involved in the use of the Re-Therm unit(s) for food preparation for patients and responsible food delivery procedures.

The findings are:

Cross Reference to A 0618: The hospital failed to ensure the education, management, and monitoring of patient foods prepared with its Re-Therm Cooking system were provided to prevent the potential spread of food borne illnesses in the health care setting.

Based on review of the hospital's contracted services and interview, the hospital failed to ensure that the hospital had a contract with all outside vendor services used by the hospital.


The findings are:


On 01/06/15 at 3:50 p.m., during an interview with the Dietary Manager, the Dietary Manager revealed the kitchen procured a portion of its food supplies from an outside vendor. Review of the hospital's list of contracted services revealed the outside vendor was not listed on the hospital's list of contracted services. On 01/06/15 at 3:00 p.m., during an interview with the Dietary Manager, the Dietary Manager revealed, "It's been over 10 years since the hospital has had any type of food contract once the old contracts ran out."

Based on record reviews and interviews, the hospital failed to ensure patients were informed of their rights prior to receiving care for 4 of 30 patient charts reviewed for patient rights. (Patient 17, 18, 19, and 23)


The findings are:


On 1/7/16 at 12:26 p.m., review of Patient 19's concurrent chart revealed there was no patient rights notification form with the patient's or the patient's representative's signature. On 1/7/16 at 12:58 p.m., Registered Nurse 3 verified the findings.

On 1/7/16 at 2:49 p.m., review of Patient 23's concurrent chart revealed there was no patient rights notification form with the patient's or the patient's representative's signature. On 1/7/16 at 3:09 p.m., Nurse Manager 1 verified the findings.

On 1/7/16 at 3:15 p.m., review of Patient 17's concurrent chart revealed there was no patient rights notification form with the patient's or the patient's representative's signature. On 1/7/16 at 3:36 p.m., Registered Nurse 3 verified the findings.

On 1/7/16 at 3:38 p.m., review of Patient 18's concurrent chart revealed there was no patient rights notification form with the patient's or the patient's representative's signature. On 1/7/16 at 4:02 p.m., Nurse Manager 1 verified the findings.

Based on observations, review of the hospital's patient rights, responsibilities, and grievance policy and interview, the hospital failed to ensure its policy included a time frame to assure the prompt resolution for patient grievances with a potential to affect any patient with a grievance.


The findings are:


On 01/06/16 at 10:40 p.m., review of the hospital's patient rights, responsibilities, and grievance policy revealed there was no time frame in the hospital's policy for prompt resolution of patient grievances. On 01/06/16 at 11:00 a.m., during an interview with Patient Advocate 1, he/she revealed, "We try to resolve the patient's grievance in the same day it is received, if possible. Most of the time I can manage to resolve the grievance with the assistance of a nurse or manager", but there is no set time period to resolve the grievance because our aim is to resolve the grievance the same day and so far it has been working."

Based on observations, record reviews, interview, and review of the hospital's policies and procedures, the hospital failed to ensure the safety of patients by ensuring that the hospital's food preparation system was functional and the temperatures of the foods served to patients was within acceptable ranges.

The findings are:

Cross Reference to A 0618: The hospital failed to ensure the education, management, and monitoring of patient foods prepared with its Re-Therm Cooking system were provided to prevent the potential spread of food borne illnesses in the health care setting.

Based on interview and review of the hospital's adverse event reports, the hospital failed to ensure that 1 of 2 hospital identified adverse events was analyzed to identify the cause(s) or contributing factor(s) pursuant to the adverse event and failed to develop and implement preventative actions based on its review of the causal or contributing factors identified.


The findings are:


On 01/07/16 at 4:50 p.m., review of hospital's identified adverse event reports revealed an adverse event report dated 07/2015. Review of the documentation in the adverse event report revealed there was no documentation related to an analysis of potential or identified cause(s) or potential or contributing factor(s) related to the adverse event. The was no documentation to support the hospital developed and implemented preventative action(s) to prevent the potential recurrence of the adverse event. On 01/07/16 at 5:05 p.m., during an interview with the Risk Manager, the Risk Manager revealed the hospital had no other documentation related to the hospital identified adverse event.

Based on record review, interview, and review of facility policy and procedure, the hospital failed to ensure physician orders were followed for 1 of 30 concurrent patient charts reviewed related to blood pressure medication (Patient 8), failed to obtain a physician order for laboratory work for 1 of 30 concurrent patient charts reviewed (Patient 17), and failed to obtain a physician ordered consult for 1 of 30 concurrent patient charts reviewed. (Patient 20)


The findings are:


On 01/06/16 at 1:20 p.m., review of Patient 8's chart revealed a licensed practitioner order, dated 11/06/15, for "Carvedilol 6.25 mg (milligrams) 1 (po) by mouth bid (twice a day), hold for heart rate less than 60, systolic less than 110 or diastolic less than 70".

Review of the patient's medication administration record revealed there was no documentation of the patient's blood pressure and/or heart rate and no documentation that the Carvedilol 6.25 mg was administered to the patient on 12/27/15 at 9 p.m..

Review of the patient's medication administration record dated 12/28/15 at 9 am revealed there was no documentation of the patient's blood pressure and/or heart rate and no documentation that the Carvedilol 6.25 mg was administered. On 01/06/16 at 1:50 p.m., the Assistant Director of Nursing revealed, "Vitals should be documented on the vital signs sheet and on the medication administration record."




36397

On 1/7/16 at 1:25 p.m., review of Patient 20's chart revealed the patient had a dental consult on 7/31/15 with the consultation in the patient's chart, but there were no physician order for the consult and treatment. On 1/7/16 at 1:59 p.m., Nurse Manager 1 verified the findings.

On 1/7/16 at 3:15 p.m., review of Patient 17's chart revealed the patient had blood drawn on 12/5/15 with the results in the patient's chart, but there were no physician orders for the laboratory work. On 1/7/16 at 3:36 p.m., Registered Nurse 3 verified the findings.

Based on record review and interview, the hospital failed to ensure that 1 of 30 inpatient medical records reviewed contained available information for the physician. (Patient 15)


The findings are:


On 01/16/15 at 11:45 a.m., review of Patient 15's record revealed that Patient 15 was admitted on 12/16/15 with initial laboratory orders. However, there was no evidence of laboratory results for initial physician laboratory orders dated 12/16/15 on the patient's chart for physician review. On 01/16/15 at 11:55 a.m., Registered Nurse 2 revealed, "I'm not sure why the lab results are not in the chart with the physician signature on it stating that it was reviewed. Here is a copy of the lab results that I print off the computer but it doesn't have the physician signature."

Based on observations, interviews, review of the hospital's policies and procedures, and review of staff personnel files, the hospital failed to ensure the education, management, and monitoring of patient foods prepared with its Re-Therm Cooking system were provided to prevent the potential spread of food borne illnesses in the health care setting.


The findings are:


Cross Reference to A 0619: The hospital failed to ensure its dietary service organization developed policies and procedures that address the safety and handling of patient foods related to the monitoring and management of out of range food temperatures, policies for routine and ongoing maintenance of equipment used in the kitchen to prepare patient foods, education of staff related to the handling of its dietary equipment and the management and actions required for out of range food temperature requirements, and policies for the maintenance of equipment used in its dietary department for food preparation.

Cross Reference to A 0620: The hospital failed to ensure safety practices for handling food and failed to provide for emergency food supplies.

Cross Reference to A 0622: The hospital failed to provide staff training on new equipment for 13 of 13 dietary staff members. (Director of Dietary, Food Service Supervisor 1, Food Service Supervisor 2, Food Service Supervisor 3, Cook 1, Cook 2, Cook 3, Cook 4, Cook 5, Cook 6, Cook 7, Cook 7, Cook 8, and Cook 9).


Cross Reference to A 0701: The hospital maintenance department failed to ensure preventative maintenance of the food preparation unit for the hospital.

Based on observations, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure its dietary service organization developed policies and procedures that address the safety and handling of patient foods related to the monitoring and management of out of range food temperatures, policies for routine and ongoing maintenance of equipment used in the kitchen to prepare patient foods, education of staff related to the handling of its dietary equipment and the management and actions required for out of range food temperature requirements, and policies for the maintenance of equipment used in its dietary department for food preparation.


The findings are:


On 1/5/16 at 11:50 a.m., random observations in the hospital's kitchen revealed the hospital uses a Re- therm system to prepare patient meals. On 1/5/16 at 11:50 a.m., observations of Cook 1 revealed the cook removed the patient food trays from the Re-therm cart unit located in the kitchen, placed the patient food trays on a delivery cart, and delivered the patient food trays to Lodge G at 11:55 a.m. Using the hospital's thermometer, Cook 1 obtained the following temperatures for foods on a random patient tray:
Turkey with gravy 112.5 degrees Fahrenheit(F) which was less than 135 degrees F,
cooked dressing degrees 79 F which was less that 135 degrees F,
green beans 83.2 degrees F which was less than 135 degrees F,
cranberry sauce 70.1 degrees F which was higher than 40 degrees F, and sweet potatoes pie 78.5 degrees F. On 1/5/16 at 11:50 a.m., Cook 1 reported that he/she might have moved the laser too soon.

On 1/5/15 at 12:00 p.m., review of the hospital's food temperature log dated 1/5/16 revealed there was no documentation of the temperatures of the foods that were on the patient lunch meal trays after the patient trays were removed from the Re-therm cart unit and prior to transport to the patient lodges. On 1/5/15 at 12:00 p.m., Cook 1 verified the findings, and stated, "To be honest, they don't test these trays."

On 1/6/15 at 11:58 a.m., random observations in the kitchen area revealed the delivery cart was in preparation to leave the kitchen. When asked what the temperature of the foods on the patient food trays were, Food Service Supervisor 2 obtained the temperature of the foods on the patient's trays and they were:
Carrots: 63 degrees F which was less than 135 degrees F,
Beef Steak 134 degrees F,
Potato: 114.5 degrees F which was less than 135 degrees F,
Jello: 48 degrees F which was warmer than 40 degrees F.
Food Service Supervisor 2 rubbed his/her hands on the bottom of the food tray and reported, "The carrot section feels cold and the meat section feels warm. It's not working". The food tray was placed back on the delivery cart and taken to Lodge J. On 1/6/15 at 11:58 a.m., the Director of Dietary verified the findings.

On 1/6/15 at 12:10 p.m., review of the hospital's dietary food temperature log dated 1-6-16 revealed there was no documentation of the lunch meal food temperatures after removal from the re-therm unit and prior to transport. On 1/6/15 at 12:10 p.m., Food Service Supervisor 2 verified there was no documentation on the dietary food temperature log for the lunch meal on 1/6/2015.

On 1/6/15 at 12:12 p.m., when asked about the hospital's
policy and procedures for the Re- therm heating system, obtaining food temperatures, and actions for handling of patient foods when the food temperatures are out of range, the Director of Dietary stated., "We have none. We thought the Re-therm unit will be a catch for all."

On 1/6/15 at 12:43 p.m., the Director of Dietary reported revealed discovering more Re-therm shelves in three (3) Re-therm units were not working: D 01, D 06, and D 09. On 1/6/15 at 12:45 p.m., the Director stated, "It takes time to complete the checks on all of the re-therm units. Therefore, I will finish checking them tomorrow and assure you I will correct the problem."

On 1/6/16 at 4:51 p.m., random observations in the kitchen area revealed a random tray for Lodge H (Tray 1) was tested for food temperatures by Food Service Supervisor 3:
Apple Crisp 130 degrees F which was less than 135 degrees F, Chicken:134 degrees F which was less than 135 degrees F,
Coleslaw 48 degrees F which was warmer than 40 degrees F, and bun 50 degrees F.

On 1/6/16 at 4:54 p.m., random observations in the kitchen area revealed a random tray for Lodge H (Tray Two) was tested for food temperatures by Food Service Supervisor 3:
Apple Crisp 130 degrees F (less than 135 degrees F),
Coleslaw 50 degrees F (higher than 40 degrees F),
tomatoes 51 degrees F (higher than 40 degrees F),
bun 53 degrees F.

On 1/6/16 at 4:59 p.m., random observations in the kitchen area revealed Re-therm cart #55 did not heat as scheduled. Observations showed Food Service Supervisor 3 placed the Re - therm cart in manual Re-therm. On 1/6/16 at 5:00 p.m., Food Service Supervisor 3 stated, "We just re-start."

On 1/6/16 at 5:00 p.m., Cook 1 revealed Lodge K was notified of a late delivery of 45 minutes. When asked how the Re-therm unit alerted staff of a malfunction, Cook 1 reported that the green light was on but the message on display, read, "Cart engaged, hold cycle" but Cook 1 could not explain what had happened or why.

On 1/6/16 at 5:02 p.m., random observations in the kitchen area revealed a random patient tray was selected for Lodge J (Tray 1)for testing the temperature of the food by Service Supervisor 3 and the findings revealed:
Apple Crisp 130 degrees F (less than 135 degrees),
Coleslaw 55 degrees (higher than 40 degrees F),
tomatoes 57 degrees F (higher than 40 degrees F),
bun 60.

On 1/6/16 at 5:03 p.m., random observations in the kitchen area revealed a random patient tray was selected for Lodge J (Tray 2)for testing the temperature of the food by Food Service Supervisor 3 and the findings revealed:
Coleslaw 149 degrees F (higher than 40 degrees F),
tomatoes 49 (higher than 40 degrees F), and
bun 53 degrees F.

On 1/6/16 at 5:07 p.m., random observations in the kitchen area revealed a random patient food tray for Lodge G Patient Tray 1 was selected for testing the temperatures of the food by Food Service Supervisor 3 and the findings revealed:
Coleslaw 43 degrees F (higher than 40 degrees F), tomatoes 43 degrees F (higher than 40 degrees F),
and bun 47 degrees F.

On 1/6/16 at 5:07 p.m., random observations in the kitchen area revealed a random patient food tray was selected for Lodge G patient tray #2) for testing the temperature of the foods by Food Service Supervisor 3 and the findings revealed:
Tomato 50 degrees F which was higher than 40 degrees F, and
milk 61 degrees F which was greater than 40 degrees F.

On 1/6/16 at 5:35 p.m., random observations in the kitchen area revealed a random patient food tray was selected for temperature testing for patient food tray #1 Lodge K by Food Service Supervisor 3 and the findings revealed:
Coleslaw 52 degrees F which was less than 40 degrees F, and
tomatoes 51 degrees F which was less than 40 degrees.

On 1/6/16 at 5:35 p.m., random observations in the kitchen area revealed a random patient food tray was selected for temperature testing for patient food tray #2 for Lodge K by Food Service Supervisor 3, and the findings revealed:
Coleslaw 51 degrees F which was higher than 40 degrees,
tomatoes 53 degrees F which was higher than 40 degrees F.

On 1/6/16 at 5:57 p.m., review of the hospital's food temperature log sheet from October 1, 2015 to January 5, 2016 revealed out of range food temperatures daily with no documented actions taken.

Review of hospital policy and procedure, titled, "Infection Control", reads, "The internal temperature of potentially hazardous foods shall be 140 degrees F or above, or 45 degrees or below, during display, service and transportation.....".

Review of the hospital's dietary manual, titled, "Temperature as a method of bacterial growth control", reads, ".....Code requires the following temperature controls: Hot foods must be kept at a temperature higher than 145 F. Foods reheated from chilled must be heated to no less than 165 F. Cold foods must be kept at no more than 40 F. Frozen foods must be kept below 0 F."

On 1/4/16 at 4:32 p.m., random observations during a tour of the kitchen area with the Director of Dietary Services revealed
2 empty full length metal pans sitting on top of the oven and a small covered pot with an unidentifiable substance with no label to include date and time.

Observations of the rolling convection oven (upper and lower) revealed a sticky brown substance, old aluminum foil from previous use on the oven racks that were black in color, a sticky greasy substance covering the oven windows in streaks obstructing visibility of the oven's contents. There was a scoop inside a labeled flour bin located under the table, center aisle, near the re-therm cooler. On 1/4/16 at 4:32 p.m., the Dietary Director verified the findings, and was not able to identify the substance observed in the small pot located on the top of the oven. The Dietary Manager stated, "looks like fat congealed."

On 1/4/16 at 4:47 p.m., random observations of the 3 compartment sink area revealed a small red & white plastic container with loose test strips and labeled QAC QR test strips code 2951 with an expiration date of January 2015. On 1/4/16 at 4:47 p.m., Cook 6 verified the findings.

On 1/4/16 at 4:55 p.m., random observations in the produce cooler revealed a bowl of cheese grits dated 1-1-16, a 1/2 roll of sliced ham dated 1-1-16, and a 1/2 cucumber with no date, a 1/2 gallon of cultured buttermilk by Southern Home with an expiration date of 1-1-16, and 3 large full sized pans of Jello (2 with fruits, 1 plain) that were not covered on a rolling cart rack, multiple opened containers of condiments: 2 bottle of 24 oz.(ounces) Kraft mustard, 16 oz. buttermilk ranch salad dressing, and 24 oz. cucumber ranch dressing with no labeled opened date. On 1/4/16 at 5:00 p.m., Cook 6 verified the findings.

On 1/4/16 at 5:00 p.m., the Director of Dietary revealed, when asked how long left over foods are good, stated, "I will check our policy, but 3 days I believe it is."

Hospital policy and procedure, titled, "Ongoing Equipment Maintenance For Nutritional Services", reads, ".....Most equipment will be cleaned on a weekly basis; however, there are a few pieces of equipment which will be inspected on a monthly basis. All equipment must be cleaned daily after each use....".

Hospital policy and procedure, titled, "Infection Control" reads, ".....All food shall be from approved sources and shall be clean, free from spoilage, free from contamination, properly labeled and safe for human consumption....Leftover food shall be used within 48 hours....The internal temperature of potentially hazardous foods shall be 140 degrees F or above, or 45 degrees F or below, during display, service and transportation.....".












30011

On 01/06/16 at 4:15 p.m., Food Service Supervisor 3 revealed, "All supervisors are responsible for taking the temperatures for foods on the patient trays. Food Service Supervisor 3, when asked what the acceptable temperature range is for foods required to be kept cold was, reported, "I don't know." Food Service Supervisor 3, when asked what the acceptable temperature range is for foods required to be kept hot was, reported, "135 degrees and up". When asked what the hospital's procedure is if a food's temperature falls out of range, Food Supervisor 3 reported, "We put it in the microwave."

On 01/06/16 at 5:40 p.m., the Dietary Manager revealed, "We move food out of the danger zone and we do a pretty good job of ensuring that the food is at an acceptable range. I review the daily temperature log sheets" which are filled out by the food service supervisors."

On 01/06/16 at 3:25 p.m., review of the preventative maintenance records for the hospital revealed no documentation of items preventatively maintenance by plant operations and preventative maintenance of the Timenet Wizard Controller. On 01/06/16 at 3:18 p.m., interview with the plant operations director revealed "we don't keep an inventory of all the items in the kitchen. We discuss with the staff if there are any issues of the Timenet Wizard Controller".

Based on observations, interviews, review of the hospital's dietary manual, and review of the hospital's policy and procedure, the hospital failed to ensure safety practices for handling food and failed to provide for emergency food supplies.

The findings are :

Cross Reference to A 0619: The hospital failed to ensure its dietary service organization developed policies and procedures that address the safety and handling of patient foods related to the monitoring and management of out of range food temperatures, policies for routine and ongoing maintenance of equipment used in the kitchen to prepare patient foods, education of staff related to the handling of its dietary equipment and the management and actions required for out of range food temperature requirements, and policies for the maintenance of equipment used in its dietary department for food preparation.





30011

On 01/05/16 at 11:00 a.m., random observations in the kitchen storage room revealed the hospital had no emergency food supply for patients if a disaster occurred. On 01/05/16 at 11:00 a.m., the Dietary Manager verified the hospital has no emergency food supply for disasters.

Based on record review and interview, the hospital failed to provide staff training on new equipment for 13 of 13 dietary staff members. (Director of Dietary, Food Service Supervisor 1, Food Service Supervisor 2, Food Service Supervisor 3, Cook 1, Cook 2, Cook 3, Cook 4, Cook 5, Cook 6, Cook 7, Cook 7, Cook 8, and Cook 9).


The findings are:


On 01/07/15 at 11:22 a.m., review of Cook 7's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 12:20 p.m., review of Cook 6's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 12:48 p.m., review of Cook 1's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 12:50 p.m., review of Cook 2's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 12:55 p.m., review of Cook 3's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:00 p.m., review of Food Service Supervisor 1's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:07 p.m., review of Cook 8's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:15 p.m., review of Cook 4's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:30 p.m., review of Cook 5's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:40 p.m., review of Food Service Supervisor 3's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).

On 01/07/15 at 1:45 p.m., review of Food Service Supervisor 2's personnel record revealed no documentation of training for the "Timenet Wizard Controller (re-therm unit).







30011

On 01/07/16 at 1:10 p.m., review of the personnel record for Cook 9 revealed there was no documentation of training related to the "Timenet Wizard Controller" (Re-Therm) unit used to prepare patient foods.

On 01/07/16 at 1:30 p.m., review of Dietary Manager 1 revealed there was no documentation of training related to the "Timenet Wizard Controller" (Re-therm) unit used to prepare patient foods. On 01/05/16 at 3:00 p.m., the Dietary Manager reported the Timenet Wizard Controller has been in use by the hospital since 04/11/2006.

Based on observations, interview and review of the hospital's policy and procedure diet manual, the hospital failed to have therapeutic menus to meet the individual nutritional needs of the patients.


The findings are:


On 1/4/16 at 4:32 p.m., random observations in the kitchen area revealed the regular weekly menu was posted with portion sizes but there was no therapeutic menu posted. On 1/4/16 at 4:22 p.m., the hospital submitted a copy of the menus for regular diets only dated 12/20/15 - 1/9/16. On 1/6/16 at 5:37 p.m., the Director of Dietary stated, "I will get them to you". By the end of the survey, no therapeutic diet menus were presented for review.

Based on observation and interview, the hospital maintenance department failed to ensure repairs of the walls and proper maintenance of a disposal sink observed in the dietary kitchen.


The findings are:


On 01/05/16 at 10:10 a.m., random observations in the dietary kitchen revealed walls with cracked peeling paint by the electrical switches, and cracks in the walls and plaster located behind the dishwasher in the dish room below eyewash station.


36397

On 1/4/16 at 4:47 p.m., random observations in the kitchen area underneath the disposal sink and on the floor next to the 3 compartmental sink was leaking and there was a large amount of dried scaled sediment that was white and green in color. On 1/4/16 p.m., the Director of Dietary verified the findings, and stated, "I will call maintenance".

Based on interview and review of preventative maintenance records, the hospital maintenance department failed to ensure preventative maintenance of the food preparation unit for the hospital.


The findings are:


On 01/06/16 at 3:25 p.m., review of the preventative maintenance records for the hospital revealed no documentation of items preventatively maintenance by plant operations and preventative maintenance of the Timenet Wizard Controller. On 01/06/16 at 3:18 p.m., interview with the plant operations director revealed "we don't keep an inventory of all the items in the kitchen. We discuss with the staff if there are any issues of the Timenet Wizard Controller".
On 01/05/16 at 9:35 a.m., random observations in the dietary kitchen revealed a portable fan sitting on a countertop facing the deep fryer blowing a strong current of air. Staff observed preparing chicken salad and frying steak in the direction of the fan. On 01/05/16 at 11:20 a.m., the Dietary Director revealed, "We are using the fan because our hood system is broken and has been since 12/23/15. The parts for the hood have been ordered, but they can't fix it because its been raining".

On 01/05/16 at 10:20 a.m., random observations of walk-in refrigerator cooler 3 revealed a shelf in the cooler with lunch coolers, drinks, and various food items labeled for staff located beside food items prepped for patient consumption. On 01/05/16 at 10:35 a.m., the Dietary Manager revealed "staff can place their personal items on the designated shelf inside of the patients walk-in refrigerator".

On 01/05/16 at 10:20 a.m., random observation of the kitchen walk-in refrigerator 3 revealed chunky bleu cheese salad dressing expired 08/15/15, green goddess salad dressing expired 08/17/15, mustard expired 09/26/15, (5) 8 pound (lb) containers of potato salad expired 12/25/15 and (1) 8 lb container of pace picante sauce expired 07/26/15. On 01/05/16 at 10:35 a.m., the Dietary Director revealed expired items in the patient food refrigerator "belong to the staff members. Staff can place their personal items on the designated shelf". The shelf was noted to contain (6) lunch coolers and drink containers.

Based on review of documentation and interview, the infection control officer failed to ensure policy and procedures were in place for infection control risk assessment (ICRA).


The findings are:


On 01/05/16 at 3:00 p.m., review of the hospital's Infection Control Policy revealed there was no policy or procedure for ICRA related to renovation, construction, demolition and/or repairs. On 01/05/16 at 3:50 p.m., the Infection Control Nurse stated, "I don't think there is anything like that, but the Risk Manager may have some information". On 01/06/16 at 3:33 p.m., the Risk Manager revealed, "We do have an assessment tool for construction, renovation. We just meet and put our heads together and make sure that the barriers are in place. The last renovation was in dietary and that what we did at that time." On 01/07/16 at 2:20 p.m., the Risk Manager revealed, "The policy that we have is right here." The Risk Manager pointing to a circled #13 on the "Infection Control Plan".

Hospital policy and procedure, titled, "Infection Control Plan" for "Nursing Services", reads, "...13. Construction and renovation activities are assessed and necessary precautions taken to prevent the potential dispersal of any air-borne or water-borne agents...".

Based on observations, record reviews, interviews, and review of the hospital's policy and procedures, 1 of 9 Cooks (Cook 1) failed to perform hand hygiene and change gloves in accordance with acceptable principles in the dietary area, and 2 of 6 Registered Nurses (RN 4 and 6) failed to disinfect patient equipment used in procedures to prevent the potential transmission of infectious agents in the hospital setting.


The findings are:

On 01/05/16 at 11:35 a.m., observations of a finger stick blood glucose procedure revealed Registered Nurse 6 completed the task, removed gloves, performed hand hygiene, and returned the glucose meter to the case, but failed to disinfect the glucose meter prior to returning the glucose meter to the case. On 01/05/16 at 11:40 a.m., Registered Nurse 6 stated, "The glucose meter is cleaned on third shift".




36295

On 01/05/16 at 4:00 p.m., random observations revealed Registered Nurse 4 transported a supply tray into the patient's room for a blood glucose check. RN 4 placed the supply tray on the patient's bed with a barrier. RN 4 failed to perform hand hygiene before donning gloves. RN 4 cleansed the patient's middle finger with an alcohol swab, did a finger prick with a lancet, and applied a Band-Aid over the patient's middle finger. Then RN 4 transported the supply tray to medication room. RN 4 cleaned the glucometer, but failed to clean the supply tray that had been placed on the patient's bed with no barrier. On 01/05/16 at 11:29 a.m., RN 4 verified the finding after reviewing the procedure.


36397

On 1/5/16 at 9:49 a.m., random observations of procedures at the three compartment sink in the kitchen area revealed Cook 1 donned a pair of gloves and washed the dirty pots and pans from the disposal wash period, then, the manual wash period, then the rinse period, then the sanitizer rinse period, and then, placed all of the clean dishes on the wire rack for storage. Observations showed Cook 1 exited the three compartment sink area and entered the dishwasher room. Cook 1 failed to change gloves or perform hand hygiene between dirty and clean procedures in the three compartment sink area and prior to exiting the three compartment sink area and entering the dishwasher room. On 1/5/16 at 9:57 a.m., the Director of Dietary verified the findings.

Hospital policy and procedure, titled, "Cleaning Equipment", reads, ...III. Refrigerator: A...Cleaning and defrosting when needed...C. Patient food refrigerator will contain only patient food...Environmental Services (EVS) will be responsible for cleaning and defrosting the patient food refrigerators. D. Staff food refrigerator will contain only staff's food...IV. B. The responsibility of equipment cleaning is assigned to nursing personnel...D. Blood Pressure cuff, stethoscopes, glucometers, and pulse oximeters. 1. Equipment should be cleaned when visibly soiled or in contact with non-intact skin, blood or other potentially infectious material (OPIM) and daily on third shift with an appropriate disinfecting cleanser (i.e. Clorox wipes) provided by EVS."

Hospital policy and procedure, titled, "Hand Hygiene", reads, "...B. Indications for Hand Hygiene using Alcohol Based Hand Sanitizer If hands are not visibly soiled, an alcohol-based hand sanitizer may be used for routinely decontaminating hands in the following clinical situations: 1. Before having direct contact with patients...7. After removing gloves...D. Gloves and Hand Hygiene...3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient...4. Perform hand hygiene after removing gloves...".

Based on record review and interview, the hospital failed to ensure adequate screening process for discharge planning for 1 of 3 discharged patients. (Patient 6)


The findings are:


On 1/6/16 at 10:47 a.m., review of Patient 6's closed chart revealed the patient was admitted on 12/17/15 with "harm to self and paranoia" and discharged on 12/30/15. Review of the psychiatric inpatient setting-discharge screener's (suicide) form revealed the form was blank. The form had only the staff member's signature, date, and time with no other documentation. On 1/6/15 at 1:42 p.m., Social Worker 1 verified the finding and stated, "Adequate screenings are important to a successful discharge."

Based on interview and document review the facility failed to manage patients presenting violent/aggressive behavior without the on-going assistance of law-enforcement. Law enforcement agents (public safety officers) attend all behavioral codes throughout the facility and assist, as necessary, in the seclusion/restraint of patients. In some cases the patients are restrained with metal handcuffs by the public safety officer(s). This results in a) conflict between treatment and law enforcement actions, and b) a breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens. (Refer to B125)

Based on interview and record review, the facility failed to develop and document master treatment plans based on the individual needs of eight (8) of eight (8) sample patients (G3, G8, G15, H1, H4, J10, K2 and K17). This failure resulted in the absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

A. Record review

Review of the treatment plans revealed that the master treatment plans were preprinted plans that were based on a selected problem (e.g. altered thought process, symptoms as delusions or hallucinations, mood instability, or violence). These forms included a list of up to 16 patient goals and a list of staff interventions that consisted of generic interventions, discipline role functions and guides to be considered for the patient's care. Selected goals and interventions were identified by a date and the initials of the responsible staff member. None of the selected goals and interventions were modified based on the specific needs of the patients, nor were these altered based on patient changes. This practice resulted in all plans being almost the same with no individualization to guide care of each patient.

B. Interviews:

1. During interview, including review of treatment plans, on 12/29/15 at 11:25 a.m., the Director of Social Services stated, "We want to see behavioral (plans); ours are not written appropriately."

RN6 acknowledged that some of the goals initiated by the treatment team were not appropriate for the patient at this time. Physician 1 stated that the plans were not individualized based on the patients findings.

2. In an interview on 12/29/15, the Clinical Director stated that "our treatment planning process needs improvement" in terms of individualization, patient specificity, and follow-up. She acknowledged that the treatment plans of the sample patients lacked these qualities.

Based on interview and document review the facility failed to manage patients presenting violent/aggressive behavior without the on-going assistance of law-enforcement. Law enforcement agents (public safety officers) attend all behavioral codes throughout the facility and assist, as necessary, in the seclusion/restraint of patients. In some cases the patients are restrained with metal handcuffs by the public safety officer(s). This results in a) conflict between treatment and law enforcement actions, and b) a breach in the patient ' s right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens.

Findings include

A. Patient Review:

1. Medical records related to the use of seclusion/restraint for three (3) of eight (8) sample patients (G3, G8 and H1) were reviewed. Of these three patients, Patient G8 had been handcuffed by public safety officers. According to a nursing progress note on 12/9/15, Patient G8 was handcuffed and held while the nurse administered an injection and then taken to seclusion while in handcuffs. Public Safety Officer 1 stated during interview on 12/29/15 at 9:00 a.m. that this event occurred in the dayroom of Pod 1 in Lodge G with other patients present in the area.

During interview on 12/28/15 at 12:00 p.m., Patient G8 only recalled that s/he did not think they should have made [him/her] receive the injection. During interview the patient became agitated and the subject was changed by the surveyor.

3. Three additional records (provided by management) for patients who had been handcuffed by public safety officers since 11/1/15 were reviewed:

a. Non-sample Patient G7: According to a nursing progress note, on 12/25/15 at 10:10 a.m. Patient G7 was restrained and escorted to seclusion by two (2) public safety officers. Even though the public safety officers reported that handcuffs had been applied, nursing had not documented this information in Patient G7's progress note.

b. Discharge Patient L1: According to a nursing progress note, on 11/20/15 at 11:15 a.m. Patient L1 was "escorted in handcuffs" and was placed in seclusion.

c. Discharge Patient L2: According to a nursing progress note and monitoring form, Patient L2 was placed in four (4) point restraints. Even though the public safety officers reported that handcuffs had been applied, nursing had not documented this information in Patient G7's progress note provided to the surveyor.

B. Interviews:

1. During interview on 12/28/15 at 10:00 a.m., Public Safety Officer1 reported that even though the officers are assigned to this hospital, they do not report to Patrick B. Harris management but report directly to the South Carolina Department of Mental Health. He stated that the safety officers are law enforcement officers (not hospital security personnel). He reported that although the officers carry firearms, these weapons are not carried into patient areas; however, metal handcuffs are carried into patient areas. He related that at least one Public Safety Officer attends all behavior management patient codes to assist nursing staff, approximately 75 codes monthly and "if the patient becomes combative, the safety officer may choose to apply the metal handcuffs to restrain the patient while escorting the patient to the seclusion/restraint room." He added that out of 75 calls, handcuffs may be used about three (3) times. When asked if he helps hold the patient while staff administers a medication, he responded, "Yes." He stated that the safety officer works under the direction of the nurse during the code and added, "If we have to lay hands on the patient, we then would put handcuffs on the patient and then may walk down the hall with hands on (the patient). We need to corral them (patients)."

2. During a follow-up interview on 12/29/15 at 9:00 a.m., Public Safety Officer 1 said that the decision to use handcuffs on a patient may be made by the safety officer or a "combined decision" made by nursing personnel with the safety officer. He stated, "The nurse may say, 'Let's restrain him.' " When asked about the use of metal handcuffs with sample Patient G8, Public Safety Officer 1 reported than when he was called to G Lodge, staff said, "(Patient) is going to fight. When I arrived on Pod I (Lodge G) the patient took off (his/her) shirt and struck me one time." He reported that he then handcuffed Patient G8. When asked if this was in the presence of other patients, he responded, "Other patients were present in the Pod, but I don't remember which ones."

3. During an interview on 12/29/15 at 10:20 a.m., the Director of Nursing reported that when a patient "situation is going on, the safety officers globally operate under the RN. If it gets to an assault, they (safety officers) use their discretion." The DON acknowledged "that this could be a conflict between treatment and law enforcement."

4. During an interview on 12/30/15 at 9:00 a.m., the Clinical Director reported that s/he had not been present during a situation when safety officers have handcuffed a patient. She added, "We have not been as aware as we should have been of the CMS regulations."

C. Policy Review

1. Review of the South Carolina Department of Mental Health's policy, "Handling Mentally-Ill or Intoxicated Persons (dated 5/3/05)," revealed the following statements:

a. "Mechanical Restraints will only be used under the following circumstances...2. When escorting combative patients from one building to another due to management problems, etc.
3. When escorting combative patient from A&D [admission] Office to the ward...5. When the appropriate responsible medical authority within the facility requesting assistance from Public Safety has evaluated the situation prior to officers arrival and has deem it necessary to us mechanical restraints...6. In extreme emergency situation where adequate staff is not present to safely restrain a patient."

During interview on 2/29/15 at 9:00 a.m., Public Safety Officer 1 verified that mechanical restraints in this policy refer to the use of metal handcuffs. He reported that the officers do not use any other type of mechanical restraints.

2. Review of SC Department of Mental Health policy, "Clinical Staff and Public Safety Collaboration (dated March 2015)" revealed the following statement:

The Division if Inpatient Services (DIS) recognizes the mutual efforts required of the clinical staff and the DMH Public Safety Division to maintain a safe and therapeutic treatment environment for patients and safe work environment for staff. Treatment emphasis will always be therapeutic communication and verbal de-escalation; however, hospital staff requests the assistance of Public Safety when non-physical and physical interventions (BEST) are not effective and actions beyond the scope of the clinical staff is needed.

Based on observation, interview and document review, the facility failed to:

I. Staff adequate numbers of Registered Nurses on the day and evening tours of duty for four (4) of four (4) Lodges (G, H, J and K). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the absence of the RN from the Unit resulting in a potential safety risk for patients and staff. (Refer to B150)

II. Provide adequate clinical leadership in medical and nursing to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in B144 and lack of supervision of active nursing care delivered as documented in B148;

Based on record review and interview, it was determined that the Clinical Director failed to:

I. Ensure the development of master treatment plans based on the individual needs of eight (8) of eight (8) sample patients (G3, G8, G15, H1, H4, J10, K2 and K17). This failure resulted in the absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. Ensure proper policy that supports staff to manage patients presenting violent/aggressive behavior without the on-going assistance of law-enforcement. Law enforcement agents (public safety officers) attend all behavioral codes throughout the facility and assist, as necessary, in the seclusion/restraint of patients. In some cases, patients are restrained with metal handcuffs by the public safety officer(s). This results in a) conflict between treatment and law enforcement actions, and b) a breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens. (Refer to B125)

Based on observation, interview and document review, the Director of Nursing failed to:

I. Ensure nursing interventions were included in treatment plans based on the individual needs of eight (8) of eight (8) sample patients (G3, G8, G15, H1, H4, J10, K2 and K17). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. Ensure that nursing personnel manage patients presenting violent/aggressive behavior without the on-going assistance of law-enforcement. Nursing staff allowed law enforcement agents (public safety officers) to assist in the seclusion/restraint of patients, and in some cases, allowed the safety officer(s) to restrain patients with metal handcuffs. This results in a) conflict between treatment and law enforcement actions, and b) a breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens. (Refer to B125)

III. Staff adequate numbers of Registered Nurses on the day and evening tours of duty for four (4) of four (4) patient care Lodges (G, H, J and K). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the absence of the RN from the Unit resulting in a potential safety risk for patients and staff. (Refer to B150)

I. Based on observation, interview and document review, the Director of Nursing failed to staff adequate numbers of Registered Nurses on the day and evening tours of duty for four (4) of four (4) patient care Lodges (G, H, J and K). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the absence of the RN from the Unit resulting in a potential safety risk for patients and staff.

Findings include:

A. Overview Information:

All four lodges (G, H, J and K) serve acutely ill psychiatric patients, some with medical issues. On many shifts of duty, there was only one Registered Nurse assigned to 1-4 of the patient care lodges. On these shifts of duty, when the assigned RN left the lodge for meals, breaks or to carrying out other off-lodge duties, the lodge was left without immediate RN coverage. During these times, the non-professional nursing personnel (usually the LPN) from the lodge had to call an RN located in an-lodge office or in another patient lodge for assistance or direction.

B. Specific Lodge Findings:

1. Lodge G is a 44-bed acute admission unit for adult males.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (12/28/15) revealed that Lodge G had a census of 38 patients - 5 patients required diabetic checks; 7 patients required skin care; 26 patients had to be escorted off ward for meals; 6 patients were potentially assaultive; 12 patients presented hallucinations/delusions; 2 patients had problems taking medications; 1 patient was under line of sign supervision and 8 patients were on every 15 minute monitoring.

b. Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (12/28/15), revealed the following shifts of duty on Lodge G where the assigned RN had no RN relief when s/he had to leave the lodge:

--On 12/26/15 there was only one RN assigned on the day shift.

2. Lodge H is a 44-bed acute admission unit for female adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (12/28/15) revealed that Lodge H had a census of 24 patients-1 patient required dressing changes; 5 patients required diabetic checks; 5 patients required skin care; 12 patients had to be escorted off ward for meals; 3 patients required every 15 minute monitoring and 5 patients had problems taking medications.

b. Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (12/28/15), revealed the following shifts of duty on Lodge H where the assigned RN had no RN relief when s/he had to leave the lodge:

--On 12/23/15 there was only one RN assigned on the evening shift.
--On 12/24/15 there was only one RN assigned on the evening shift.
--On 12/25/15 there was only one RN assigned on the day shift.
--On 12/26/15 there was only one RN assigned on the day shift.
--On 12/27/15 there was only one RN assigned on the day and evening shifts.
-- On 12/28/15 there was only one RN assigned on the evening shift.

3. Lodge J is a 44-bed unit for female intermediate (required longer hospitalization) adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (12/28/15) revealed that Lodge J had a census of 23 patients - 3 patients required diabetic checks; 7 patients required skin care; 1 patient was on seizure precautions; 4 patients had to be escorted off ward for meals; 4 patients were potentially assaultive; 12 patients presented hallucinations/delusions; 11 patient took medications reluctantly; 3 patients were demanding of staff time and 4 patients required monitoring due to eating disorders.

b. Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (12/28/15), revealed the following shifts of duty on Lodge J where the assigned RN had no RN relief when s/he had to leave the lodge:

--On 12/22/15 there was only one RN assigned on the evening shift.
--On 12/23/15 there was only one RN assigned on the evening shift.
--On 12/24/15 there was only one RN assigned on the day and evening shifts.
--On 12/25/15 there was only one RN assigned on the day and evening shifts.
--On 12/26/15 there was only one RN assigned on the day and evening shifts.
--On 12/27/15 there was only one RN assigned on the day and evening shifts.
-- On 12/28/15 there was only one RN assigned on the day and evening shifts.

4. Lodge K is a 44-bed unit for male intermediate (required longer hospitalization) adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (12/28/15) revealed that Lodge K had a census of 24 patients-9 patients required diabetic checks; 1 patient required range of motion exercises; 10 patients were on seizure precautions; 1 patient required skin care; 6 patients had to be escorted off ward for meals; 5 patients were potentially assaultive; 1 patient was a low risk for suicide; 9 patients presented hallucinations/delusions; 2 patients were demanding of staff time; 6 patients required monitoring due to eating disorders and 3 patients were on line of sight supervision.

b. Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (12/28/15), revealed the following shifts of duty on Lodge K where the assigned RN had no RN relief when s/he had to leave the lodge:

--On 12/22/15 there was only one RN assigned on the evening shift.
--On 12/23/15 there was only one RN assigned on the evening shift.
--On 12/24/15 there was only one RN assigned on the day and evening shifts.
--On 12/25/15 there was only one RN assigned on the day and evening shifts.
--On 12/26/15 there was only one RN assigned on the day and evening shifts.
--On 12/27/15 there was only one RN assigned on the day shift.

C. Interviews:

1. During interview on 12/28/15 at 12:10 p.m. on Lodge J, LPN1 reported that the RN was off the lodge at lunch. She stated that she was in charge of the lodge at this time. When asked what she would do if there was a patient incident, she responded that she would call the supervisor's office and if there was no answer, she would call the supervision on the walkie talkie.

2. During interview on 12/28/15 at 12:20 p.m., RN2 was in charge of Lodge J at this time. She related that she left the LPN in charge of the lodge when she has to leave the patient unit. She stated that on each shift she leaves the lodge for meals, up to two 15-minute breaks and in addition, may leave to see personnel about her personal time, go to the supervisor's office, pick of medications and to assist in a behavior code on another lodge.

3. During interview on 12/28/15 at about 3:00 p.m. on Lodge G, RN3 reported that when he has to leave the ward when there is not another RN available, he makes sure that the LPN is in the lodge.

4. During interview on 12/29/15 at 10:05 a.m., the DON verified that there is no scheduled relief for the RN on each lodge when there is only one RN assigned to a lodge. He reported that this staffing pattern is usually seen on weekends and holidays.