HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the consulting dietician approved patient menus for therapeutic appropriateness for 4 (#1, #2, #3, #5) of 4 current patients sampled.

Findings:

Review of the hospital policy titled Dietary Services revealed in part:
The contracted dietician reviews and approves all therapeutic diet menus.

In an interview on 03/13/2020 at 10:05 a.m. with S2Dietician, she said she is the hospital's contracted dietician. She said she is supposed to approve the menus for the facility. She said if her signature is not on the menus she has not approved. S2Dietician said she was not sure if the hospital had changed their menus.

In an interview on 03/13/2020 with S1ADON, she said she did not have a signed copy of the menus being approved by the dietician. No approved menus were provided to the surveyor upon exit.

Based on observation and interview, the hospital failed to ensure the environment was maintained in such a manner to assure the safety and well-being of the patients. This deficient practice is evidenced by:

1) failing to ensure the environment in the psychiatric hospital was free from ligature risks; and

2) failing to ensure the hospital was cleaned to maintain the well-being of the patients.

Findings:

1) failing to ensure the environment in the psychiatric hospital was free from ligature risks.

An observation on 03/12/2020 at 10:13 a.m. revealed a vestibule outside of rooms 5 and 6 with 7 foot ceilings containing acoustical tiles. The vestibule was accessible to patients and unable to be viewed from the nurses' station. 3 random tiles were pushed and they were not secured allowing access above the ceiling to hide contraband or pose a ligature risk. Above the tiles were wires and air conditioner ducts.

An observation on 03/12/2020 at 10:17 a.m. was made of a vestibule off of the main hall that was accessible by patients. The vestibule contained 4 doors with automatic closures that protruded and posed a ligature risk.

An observation on 03/12/2020 at 10:25 a.m. revealed a vestibule outside of a consultation room accessible to patients and not visible from the nurse's station. The area had 7 foot ceilings with acoustical tiles in the ceiling. 3 random tiles were not secured allowing access into the ceiling.

In an interview on 03/12/2020 at 10:40 a.m. with S1ADON, she verified the above mentioned findings

2) Failing to ensure the hospital was cleaned to maintain the well-being of the patients.

An observation on 03/12/2020 at 10:20 a.m. of the medication room revealed the crash cart had a layer of dust on all of the exposed surfaces and equipment. Beneath and behind the crash cart was the handle from a pair of glasses, dust, paper and hair. A patient sticker was attached to an IV pole on the crash cart which cannot be adequately disinfected. On the other side of the medication room were several vial caps on the floor, a medicine cup and dust. Inside the medication refrigerator was black specks that looked like coffee grounds. Observation of a second medication refrigerator revealed hair, debris and a rubber band.

An observation on 03/12/2020 at 10:30 a.m. of the dining room revealed a table used to heat trays of food. The table had 3 openings to place pans over heating elements. There were brown and black stains in the bottom of the openings and dust on a shelf beneath the heating section. The refrigerator in the room had pink stains and hair in the bottom.

In an interview on 03/12/2020 at 10:40 a.m. with S1ADON, she verified the above mentioned findings and said the medication room should have been cleaned. She also said the crash cart should have been cleaned as needed when it was being checked daily.