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Based on interview and record review, it was determined the facility failed to ensure nursing care was provided as ordered by the Physician for one (1) of thirty (30) sampled patients (Patient #7). The facility failed ensure Patient #7's fluid restriction was maintained per the Physicain's order.

The findings include:

The facility admitted Patient #7 on 10/29/12 with diagnoses which included Moderate Mental Retardation and Impulse Control Disorder.

Review of the clinical record revealed Patient #7 was on a fifteen hundred (1500)milliliter (ml) per day fluid restriction ordered by the Physician on 02/25/13 due to low sodium. Continued review of the clinical record revealed there were two (2) places in the record where in the intake was recorded, the nursing assessment and the intake and output sheet. Review of these records revealed the intake did not match and numerous times Patient #7 went over he/his fluid restriction. On 4/19/13 Patient #7's fluid intake was 1900 mls, on 4/22/12 the intake was 1600 mls, on 4/23/13 the intake was 1700 mls, and on 04/24/13 the intake was not totaled. Continued review revealed no documented evidence the Physician was informed of the excess fluids.

Interview with the Mental Health Associate (MHA) assigned to Patient #7, on 05/02/13 at 10:32 AM, revealed if the patient drank all the fluids on his/her tray and the fluids at snack he/she would stay within the fluid restriction of 1500 mls. She further stated she never observed Patient #7 drinking from the water fountain.

Interview with Registered Nurse (RN) #5, on 05/02/13 at 10:45 AM, revealed Patient #7 was on a fluid restriction due to low sodium. She stated in report the staff would pass on that the patient was on a fluid restriction and how much the patient had taken in on their shift, that way they could monitor how much more Patient #7 could have for the rest of the day. RN #7 stated she thought the staff talked to Patient #7 when he/she went over his/her fluid restriction, but there was no documented evidence of intervention. RN #7 also stated no one monitored Patient #7's intake while the patient was gone to the recovery mall. She stated the intake and output record and the nursing assessment should have the same totals of fluids taken in for each day.

Based on interview, record review and review of the facility's policy, it was determined the facility failed ensure medications were administered per the Physician's order for two (2) of thirty (30) sampled patients (Patients #7 and #8). Patient #7 was not given a blood pressure medication until nine (9) days after the medication was initially ordered and Patient #8 was given an antianxiety medication without a Physician's order.

The findings include:

Review of the facility's Medication Management Policy, no date, revealed when processing medication orders, the order will be read by a nurse as soon as ordered. Stat and emergency orders are to carried out immediately, other orders must be transcribed to the appropriate form within two (2) hours. Nursing will ensure that a copy of the order is forwarded to pharmacy in a timely manner using the yellow copy or fax. When administering medication, check and compare the order and medication three (3) times, as medication is removed from the cart, before pouring or opening the individually wrapped medication and as medication is being replaced in the cart or as medication wrapper is discarded.

1. The facility admitted Patient #7 on 10/29/12 with diagnoses which included Moderate Mental Retardation and Impulse Control Disorder. Review of the clinical record revealed an order for Lisinopril (medication for high blood pressure) ten (10) milligrams (mg) ordered to began 01/14/13. Continued review revealed on 01/23/13, Patient #7 complained to the Physician of elevated blood pressure, the Physician noted the prior order for the Lisinopril to start on 01/14/13 had not been processed and the medication had not been administered to Patient #7.

Interview with Registered Nurse (RN) #5, on 05/02/13 at 10:45 AM, revealed the process for nurses taking off orders written by the Physician was for the Physician to fold over the page with the new order and place the order in a basket next to the unit secretary. She stated the nurse then transcribes the order on the medication administration record. She stated the nurse then noted that she/he had taken off the order by signing, dating and placing the time the order was transcribed on the page with the new order. She stated prior to the end of each shift, a nurse checked each chart to ensure no orders have been missed. RN #5 stated as an extra safe guard a night shift nurse checked each chart for orders that might have been missed. She further stated sh was not sure how that order could have been missed.

Interview with the Director of Nursing Services, on 05/03/13 at 5:00 PM, revealed he was alarmed about the medication error for Patient #7, because it had occurred even with all the facility's safeguards in place.

2. The facility admitted Patient #8 on 11/14/12 with diagnoses which included Mood Disorder, Rule out Schizoaffective Disorder, Rule Out Schizophrenia and Rule Out Personality Disorder.

Review of the clinical record revealed on 04/20/13 Patient #8 was given Ativan (antianxiety medication) two (2) mg by mouth. Continued review of the record revealed no documented evidence of a Physician's order for the Ativan 2 mg on 04/20/13.

Interview with the Nurse Manager/Leader #1, on 05/03/13 at 10:32 AM, revealed Patient #8 was on the Intensive Support Unit due to attempting to divert other patients' medication. Nurse Manager/Leader #1 stated on 04/20/13 Patient #8 was acting out, the nurse assumed Patient #8 had Ativan ordered. He stated Ativan was usually given to calm patients down as needed. He stated after the nurse administered the Ativan, and went to document on the Medication Administration Record (MAR), she realized there was no order for the Ativan.

Interview with the Director of Nursing Services, on 05/03/13 at 5:00 PM, revealed the medication error with Patient #8 sounded like a performance problem. He stated the nurse should have checked the MAR prior to giving the medication.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a documented Physician's Order was obtained for release of Unsampled Patient A's home medications to be sent home with him/her.

The findings include:

Review of the facility policy, "Medication Management Policies", dated 05/12, revealed when a patient was discharged, medications could be sent home with the patient if approved by the Physician. If a patient returned to request his/her medications at a later date, the Pharmacist was to attempt to contact the Physician.

Review of Unsampled Patient A's medical record revealed the facility admitted the patient on 02/23/13 and discharged the patient on 02/26/13. Review revealed no evidence of a documented Physician Order to return the patient's home medications to him/her on 03/05/13.

Review of a grievance, dated 03/05/13, submitted to the facility by Unsampled Patient A revealed he/she was discharged from the facility on 02/26/13. Review revealed the patient had brought his/her home medications with him/her when admitted to the facility. Continued review of the grievance form revealed Unsampled Patient A was discharged from the facility without his/her home medications being returned. Review revealed the patient did not realize he/she did not have the home medications until later on. Unsampled Patient A indicated he/she contacted the facility on 03/01/13, however had to leave a voicemail. Further review of the grievance form revealed the Risk Manager who had assisted Unsampled Patient A on 03/05/13, documented all of the patient's "medicinal items" were left at the switchboard and returned to the patient at 11:05 AM on 03/05/13.

Interview, on 05/03/13 at 3:55 PM, with the Pharmacy Director revealed when patients bring home medications to the facility they were stored in the pharmacy. She stated before the home medications were returned to the patient, pharmacy staff had to obtain a Physician Order in order to release the medication to the patient. She stated "sometimes" nurses obtained a verbal order for the release of home medications from the Physician on the patient's unit. According to the Pharmacy Director, pharmacy staff could then release the home medications to the patient. However, she stated there should always be a written order in the medical record for the release of the home medications to the patient.

Based on interview and record review it was determined the facility failed to ensure timely processing of Unsampled Patient A's home medications brought to the facility by the patient.

The findings include:

Review of the facility policy, "Medication Management Policies", dated 05/12 revealed when a patient presents to the facility with home medications these medications were to be labelled, placed in a plastic bag and sent to Pharmacy. Pharmacy staff were to complete a receipt of the medications, issue this to the patient's unit and make an entry into the computer of this information.

Review of Unsampled Patient A's medical record revealed the patient was admitted to the facility on 02/23/13 and discharged on 02/26/13. Review revealed no documented evidence of a Pharmacy receipt for the patient's home medications as indicated by the policy.

Review of a grievance dated 03/05/13 submitted to the facility by Unsampled Patient A revealed he/she was discharged from the facility on 02/26/13. Review revealed the patient had brought his/her home medications with him/her when admitted to the facility. Continued review of the grievance form revealed Unsampled Patient A was discharged from the facility without his/her home medications being returned. Review of the grievance revealed the patient did not realize he/she did not have the home medications until later on. Further review of the grievance form revealed the Risk Manager who had assisted Unsampled Patient A on 03/05/13 with filing the grievance, documented all of the patient's "medicinal items" were left at the switchboard and returned to the patient at 11:05 AM on 03/05/13.

Review of the Pharmacy computerized log revealed an undated entry beside Unsampled Patient A's name that indicated the patient was discharged before his/her home medications were "signed in" to the facility's pharmacy.

Interview, on 05/03/13 at 4:08 PM, with the Risk Manager, who assisted Unsampled Patient A with filing the grievance, revealed the patient had complained of not having his/her home medications returned to him/her on discharge.

Interview, on 05/03/13 at 3:55 PM, with the Pharmacy Director revealed when patients bring home medications to the facility they are sent to pharmacy to be stored until patients are discharged. She stated home medications are processed by the Pharmacy Techs usually on Wednesdays as they don't have time to perform this task on other days. The Pharmacy Director stated patient's home medications could sometimes "sit" in the pharmacy for three (3) to four (4) days before being processed. She stated again that this was because the Pharmacy Techs did not have time to process the medications as they were busy performing other tasks. She state that entries on the pharmacy computerized log should be dated and initialed by the staff person making the entry.

Based on observation, interview, review of manufacturer's recommendation and review of the facility's policy, it was determined the facility failed to ensure the laboratory did not use outdated solution to calibrate the Dimension Clinical Chemistry system.

The findings include:

Review of the Laboratory's policy and objectives with an effective date of 07/19/91, revealed upon receipt in the lab - reagents and chemicals shall be label with the date received, dated opened and if applicable - strength, date reconstituted and expiration date.

Observation during tour of the laboratory area, on 05/03/13 at 10:30 AM, revealed a container of Dilution Check solution with an opened date of 09/07/12, but no expiration date, was in the laboratory refrigerator for use.

Interview with Laboratory Technician #1, on 05/03/13 at 10:40 AM, revealed the solution was used to calibrate electrolytes, sodium, potassium and chloride for the Dimension Clinical Chemistry system, which was calibrated every day. She stated she was not aware of the expiration date after the solution was opened.

Review of the manufacturer's insert revealed when in use the Dilution Check solution expired after six (6) months.

Continued interview with Laboratory Technician #1, on 05/03/13 at 10:45 AM, revealed the technicians checked for out dated supplies on a monthly bases. She stated there was a form that was turned in every month.

Interview with the Director of Nursing Services, on 05/03/13 at 5:00 PM, revealed the laboratory should have a process in place so that expired control solution were not in use.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure that established policies and procedures were maintained for safe food handling practices. The facility failed to ensure opened food products were labeled and dated.

The findings include:

Review of the facility's policy titled "Dietetic Services", with a review date of 01/13, revealed all dry herbs, spices, seasonings, flavorings, and oils without a listed expiration date shall be used within 1 year of the delivery date listed on the packing.

Observation during the initial kitchen tour, on 04/03/13 at 12:35 PM, revealed the spice rack had one (1) black pepper, two (2) Mrs. Dash and one (1) garlic powder containers without a listed expiration date and without listed delivery date on the packaging.

Interview with the Director of Dietary, on 04/03/13 at 12:40 PM, revealed he had just checked the spice rack and they all should have been labeled and dated.

Based on interview, review of Centers for Disease Control and Prevention (CDC) guidelines, review of healthcare worker (HCW) Tuberculin Skin Test (TST) records and facility "Infection Control Plan," undated, it was determined the facility failed to ensure the results of the TST were recorded and the HCW did not read their own TST for one (1) of nine (9) sampled HCW's, HCW #1.

The findings include:

Review of CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," Morbidity and Mortality Weekly Report, December 30, 2005, revealed the TST was the first step and most widely used diagnostic test for M. tuberculosis infection in the United States. The guideline further revealed the TST should be read by a designated, trained HCW forty-eight (48) to seventy-two (72) hours after the TST was placed. It also stated patients and HCW's should not be allowed to read their own TST results because HCW's were not typically reliable in doing so. The guideline further revealed TST result interpretation depended on measured TST induration in millimeters and the HCW's risk for being infected with M. tuberculosis and risk for progression to TB disease if infected.

Review of facility "Infection Control Plan," undated, revealed TST results would be documented in the HCW's health file. The plan further revealed there was no mention of who was required to perform or read the TST.

Review of HCW #1's health file revealed her annual TST was done on 07/25/12 at 8:25 AM by the Infection Control Nurse. The file further revealed the TST had a reading date of 07/27/12 at 9:00 AM, and the form used to record the findings was signed by HCW #1; also, the space for recording millimeters of induration to determine whether the test had a positive or negative reading was blank.

Interview with the Director of Nursing, on 05/03/13 at 4:50 PM, revealed if the TST did not have documented results it was incomplete and would be as if the test had not been done. He also stated, although it was not in the facility protocol, it was not a good idea for a HCW to read his/her own TST.