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Based on document review, facility documents, medical record review and interview, the hospital failed to ensure care was provided in a safe setting when no psychiatric medication reconciliation was completed within 24 hours that resulted in an adverse reaction (increased tremors) due to not receiving a long term home medication for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the manufacturer data sheet for Ativan retrieved from www.accessdata.fda.gov documented, "...Abrupt discontinuation of product should be avoided... Abrupt termination of treatment may be accompanied by withdrawal symptoms. Symptoms reported following discontinuation of benzodiazepines include... irritability... derealization... numbness/tingling of extremities... tremor... agitation... short term memory loss..."

2. Review of the hospital's medication reconciliation policy revealed, "...A list of the patient's current medications will be obtained upon admission...The medications will be documented/entered into Meditech in the Admit History Intervention, psych admission Part B, under medication history, within 24 hours of admission...the Medication Reconciliation Order form must be updated with any identified discrepancies [any inconsistency or difference in the medication regimen noted during the reconciliation] within 24 hours of admission..."

3. Medical record review revealed Patient #1 was admitted to the hospital through the Emergency Department on 10/4/18 with a diagnosis of Major neurocognitive disorder with behavior disturbance. Additional medical history revealed Coronary Artery Disease, Hypertension, High Cholesterol, and had a pacemaker.

Review of a history and physical dated 10/4/18 at 7:00 PM, the Psychiatrist documented, "...Assessment & [and] Plan...currently involuntarily due to psychosis and hallucinations...Plan...She will have medication reconciliation...Electronically signed by [Named Psychiatrist] on 10/5/18 at 1300 [1:00 PM]..."

The hospital was unable to provide documentation to confirm a psychiatric medication reconciliation was completed by the Psychiatrist.

Review of the Medication Administration Record (MAR) revealed that Patient #1 did not receive Ativan (Lorazepam) from 10/4/18 to 10/6/18.

Review of the clinical documentation record dated 10/6/18 at 10:18 AM documented, "...REPORTS TREMORS MORE SEVERE TODAY: PHYSICIAN MADE AWARE, FAMILY REPORTS WORSE THAN THEY HAVE EVER SAW TODAY..."

Review of a physician's order dated 10/6/18 at 11:02 AM, revealed Ativan (Lorazepam) 1mg. IM (intramuscularly) ONCE. Review of the MAR revealed Patient #1 did receive 1 miligram (mg) IM one time on 10/6/18.

Review of a physician's order dated 10/6/18 at 11:02 AM, revealed Ativan (Lorazepam) 0.5 mg po (by mouth) three times per day. Review of the MAR revealed Patient #1 did receive Ativan 0.5mg three times per day from 10/7/18 until discharge.

Review of the clinical documentation record dated 10/6/18 at 3:15 PM, documented, "...Reassessment comments: Patient is alert, oriented to self only...Family here and reported patient is worse than they have ever seen. Patient with tremors to hands face unable to hold water glass. has difficulty drinking water due to shakes. (Named Psychiatrist) aware. Patient daughter and charge nurse discussed medications. Patient had been taking Ativan prior to admission. Ativan IM 1 mg given this morning per doctor order. Ativan scheduled and administered as ordered. shakiness slightly improved in the afternoon but patient continues to have difficulty holding her glass...unable to ambulate today due to shakiness..."

Review of the clinical documentation record dated 10/6/18 at 7:30 PM documented, "...TREMORS APPARENT BUT THEY SEEM TO HAVE REDUCED IN SEVERITY SINCE THE NIGHT BEFORE..."

Review of the clinical documentation record dated 10/7/18 at 10:20 AM documented, "...tremors: None..."

Review of the clinical documentation record dated 10/7/18 at 7:30 PM documented, "...tremors: Present/Exists..."

Review of the clinical documentation record dated 10/8/18 at 4:01 AM documented, "...10/7 PM...TREMORS HAVE REDUCED SINCE LAST NIGHT..."

Review of the clinical documentation record dated 10/8/18 at 10:06 AM documented, "...tremors: None..."

Review of the clinical documentation record dated 10/8/18 at 2:26 PM documented, "...Reassessment comments: 10/8/18-days...Requires assist with meals today due to tremors, however they are greatly improved to the hands from few days ago..."

Review of the clinical documentation record dated 10/8/18 at 7:30 PM documented, "...tremors: None..."

During an interview with the Physician Assistant on 2/20/19 at 10:32 AM, He stated that the standard is not to prescribe psychiatric medications. We would not start it (Ativan). He further stated that she had gout and cardiac arrhythmias. He stated that both medical and psych are to see the patient within 24 hours. He stated that the Psychiatrist was responsible to reconcile psychiatric medications.

During an interview on 2/19/19 at 1:03 PM, in the conference room, the Chief Quality and Patient Safety Officer (CQPSO) verified that Patient #1's home medications were not reconciled by a Psychiatrist. She further stated that the Psychiatrist is no longer employed at this hospital. The Psychiatrist voluntarily relinquished her privileges and moved out of state. She was unaware of how to get in touch with the Psychiatrist as her whereabouts were unknown.

During a telephone interview on 2/22/19 at 9:45 AM, with Patient #1's daughter (Power of Attorney POA) revealed the POA took Patient #1 to a regional hospital because she was becoming increasingly anxious and confused. Once the patient got to this hospital, the daughter tried to call and check on her but they would not tell me anything because I did not have a "code". Finally the daughter was able to talk to a nurse and asked if they had a list of the patient's medications. The daughter told the nurse the patient had her medications with her and to make sure she takes her Lorazepam 3 times a day. The nurse then told the patient's daughter could see the patient on Saturday at noon - that was the visitation time. When the patient's daughter saw her mother that Saturday, and the staff wheeled her in sitting in a wheelchair, the patient's daughter thought the patient was having seizures. The patient's daughter asked the nurse if the patient was getting her Lorazepam, and she went and got the chart. The next thing the daughter knew the nurse was bringing the patient an injection of Lorazepam. Patient #1's daughter stated her mother did not even know her sister when she got there. Patient #1's daughter stated Patient #1 spoke gibberish. She was coherent when her daughter left her at the 1st hospital. The patient did not receive any Lorazepam until Saturday when the family came to see her. They did not check the medications she was on at home.

Based on facility documents, observation and interview, the hospital failed to maintain a sanitary dietary department, failed to ensure the dietary staff followed established policies and procedures for hand hygiene, food preparation, equipment cleaning, and failed to ensure minimum dishwashing temperatures during 2 of 2 observations (3/4/19 and 3/5/19) of the kitchen.

The findings included:

1. Review of the hospital's Safety and Sanitation Checklist revealed that all personnel are to follow proper hand washing procedures.

2. Review of the hospital's welcome packet to the food and nutrition department revealed to leave cell phones in the employees locker or car and it is the expectation that the phones are not used while on duty. The packet further revealed that an employee with poor hygiene can contaminate the food, and proper handwashing techniques were detailed such as disposable gloves should be worn over thoroughly washed hands only.

3. Review of the hospital's food service hand hygiene policy revealed hands are washed with soap and water at the following times: Before handling clean utensils or equipment, before putting on gloves, after removing gloves, between handling raw and cooked foods, and after touching clothing.

4. Review of the hospital's food service infection control practices revealed kitchen staff are not to perform multiple activities while wearing gloves which will be used in food handling.

5. Observations on 3/4/19 beginning at 10:20 AM, in the kitchen revealed Cook #1 was checking temperatures during the cooking of chicken breasts without washing his hands or donning gloves. After he checked the temperature, he picked up a set of tongs and began moving the pieces of chicken around. He then laid the tongs on a cart and walked around to the stove. He donned gloves, but did not wash his hands prior to donning the gloves and began to check on the food cooking on the stove. Cook #1 then put his right gloved hand in his pocket. Cook #1 in the same gloves then picked-up a spray can and sprayed a clean pan. He then picked up a cardboard box with a blue plastic bag inside it and picked-up the box and poured rice into a large long shallow pan with the same gloves on. He then removed his gloves and washed his hands but did not dry his hands. With wet hands, he took a large long handled pot to a cooking sink and filled it with water and poured it over the rice. He covered the pan with aluminum foil and put the pan in the oven. He then donned gloves without washing his hands.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room with the Director of Food and Nutrition Services (DFNS), who is also a Registered Dietitian stated it was not acceptable to put his hand in his pocket and not perform hand hygiene after taking it out of the pocket. She stated the remainder of the above activities were acceptable as long as he was not touching ready to eat food. She stated that she would not expect him to wash his hands prior to donning gloves because wet hands are hard to don gloves.

6. Observations on 3/4/19 beginning at 10:20 AM, in the kitchen revealed Cook #2 was at the stove and picked up a pot of gumbo with no gloves on and poured the gumbo into a long shallow pan, picked up the pan and walked out to the retail area and put the pan of gumbo out. Cook #2 did not wash his hands but when entering back into the kitchen, Cook #1 asked him to check on the chicken. Cook #2 picked up the thermometer without washing his hands or donning gloves and wiped the thermometer off with a sanitizing pad and began to check the chicken temperatures. Cook #2 then put the cooked chicken into a pan and carried the pan of chicken across the kitchen to the stove with no gloves on. He then picked up a large spoon and began to drizzle a gravy like substance over the cooked chicken breasts and took the pan out to the retail area. Cook #2 came back into the kitchen and went into the walk in refrigerator, and pushed a cart out with chicken breasts in a large bowl. He did not wash his hands but donned gloves and picked up the chicken breasts with his gloved hands and laid them in the large tilt pan.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room with the DFNS, she stated all of the above activities were acceptable regarding Cook #2 because he did not touch food with his bare hands. She further stated that she had been employed about 1.5 years. She stated the prior company's policys and procedures are what they were using. During a review of the policies she submitted, the DFNS stated they were the old company's policies and she will be getting the hospital's current food service policies. She stated she was told about 1.5 months ago that she now has the ability to "tweak" the hospital's current policies. She stated that she will be deleting the procedure to wash hands before and after donning gloves.

7. Observations on 3/4/19 beginning at 12:30 PM, during a kitchen tour with the Executive Chef revealed the following:
a. Patient Service Representative (PSR) #1 laid 2 cell phones on the counter in the food preparation area. The Executive Chef stated the phones should be in their pocket.
b. Two drip pans under the range top of the patient stove had a heavy accumulation of blackened greasy debris on top of the foil liner. Further observation revealed an accumulation of blackened sticky debris under the foil liner. Cook #1 stated they should be cleaned every night. The Executive Chef stated there is a cleaning schedule for all equipment.
c. The high temperature dishwashing machine had a wash temperature of 144 degrees Fahrenheit. The Executive Chef stated he would call service on that, but the final rinse is what really counts to sanitize the dishes.

8. Review of the dishwasher troubleshooting guide revealed symptoms related to ware not clean with possible causes to include "incorrect water temperature" and spotting of ware with possible causes to include "Incorrect final rinse water temperature (minimum 180 F)".

Review of the minimum temperature requirements permanently displayed on the dishwasher revealed the wash temperature should be a minimum of 150 degrees Fahrenheit.

Observations on 3/5/19 at 11:04 AM, in the kitchen, the wash temperature was 148 degrees Fahrenheit. The DFNS stated that the final rinse was what was important.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room, the DFNS was asked about the wash temperature being less than 150 degrees for 2 of 2 observations. She stated that there is no manufacturer information that addresses that. She stated that it was always the final rinse temperature that was important and that sanitizes the dishes.

During a telephone interview on 3/5/19 at 2:06 PM, the manufacturer's local service manager was asked what the wash temperature should be. He stated, "It should not be less than 150 F...you need to see 150 or above, that gets the soils off the ware..." He was asked what should occur if the temperatures were 144 and 148. He stated, "Place a service call, see if the O rings are in place...less than 150 will not get the dishes as clean..."

Based on facility documents, personnel file review and interview, the facility failed to ensure kitchen personnel were trained and competent in their respective duties for 5 of 5 (Cook #1, 3, 4, 5, and Patient Service Representative (PSR) #1) kitchen personnel files reviewed.

The findings included:

Review of the hospital's "Food & Nutrition Orientation Checklist" revealed topics that included a position specific competency validation checklist, and a handwashing demo and showback (return demonstration).

Review of the personnel files for Cook #1 hired on 1/1/18, Cook #3 hired on 12/13/15, Cook #4 hired on 3/7/16, Cook #5 hired on 12/12/12, and PSR #1 hired on 5/15/16 and rehired on 2/10/19, revealed no documentation of a specific job orientation checklist, or competency checks.

During an interview on 3/5/19 at 12:49 PM, in the Quality conference room with the Director of Food and Nutrition Services (DFNS) and the Vice President of Human Resources (VPHR) revealed the DFNS had been employed with this facility approximately 1.5 years, the DFNS stated that to her knowledge there was no confirmation or documentation of any training. She stated that she developed the Food & Nutrition Orientation Checklist, but has not utilized it yet. The VPHR stated that any specific job orientation should be in their paper personnel files and the only orientation that was kept electronically was the hospital wide orientation.

Based on review of contracted service documents and interview, the facility failed to follow procedures for the prompt disposal of trash.

The findings included:

Review of the Environmental Services (EVS) "PATIENT ROOM CLEANING-DAILY CLEANING SERVICE" revealed, "...daily cleaning service for patient rooms...Before you clean the room, you need to remove trash..."

During an interview on 3/4/19 at 4:35 PM, in the Quality conference room with the hospital Associate Administrator (AA), the AA was asked if he was aware of a patient complaint regarding overflowing trash on a weekend. The AA stated, "Yes, there was a call out [employee called in sick] of an EVS employee that affected that unit. [Progressive Care Unit [PCU]. On Sunday, it was taken care of...On Monday, I personally checked that afternoon around 4:00 PM. She (Patient's family) had not realized that everything had been done that Monday..."

During an interview on 3/5/19 at 12:38 PM, in the Quality conference room with the Assistant Director for EVS (ADEVS), she was asked about the concern in PCU on the weekend when trash was not emptied from a patient's room. The ADEVS stated that on that Saturday, the unit was not covered (no EVS employee serviced the unit). She stated that the rooms should be cleaned at least one time daily. She stated that the goal is to hit every room before noon.

During an interview on 3/5/19 at 4:23 PM, at the PCU nursing desk, Registered Nurse (RN) #1 was asked if EVS empties the trash cans in patient rooms daily on the weekends. RN #1 stated, "I would assume they [EVS] must be shorter because there is not someone here all the time [on weekends]..."

During an interview on 3/5/19 at 4:23 PM, at the PCU nursing desk, RN #2 was asked if EVS empties the trash cans in patient rooms daily on the weekends. RN #2 stated, "...I have seen trash overflowing..."

Based on facility documents, observation and interview, the hospital failed to ensure food products were stored under appropriate sanitary conditions.

The findings included:

Review of the hospital's Safety and Sanitation Checklist revealed that refrigerators and freezers are clean and the floors are free of food spoilage or build-up. All refrigerator and freezer items are to be covered, dated and labeled.

Review of the hospital's dating procedure for shelf life of foods revealed ready to eat foods shall be marked to indicate the date by which the food must be consumed.

Observations on 3/4/19 beginning at 12:30 PM, during a kitchen tour with the Executive Chef revealed the following:
a. A personal bottle of water was found in the prep freezer. The Executive Chef stated that the bottle of water is not a brand they use, and it shouldn't be in the freezer.
b. The floor area in the large freezer under the racks around the interior perimeter of the refrigerator had an accumulation of paper, tape, dirt, dust and an unsecured rusty support beam on the freezer floor. The Executive Chef stated that it should not look like that and it will be cleaned up.
c. A pan in the meat refrigerator (meat box) containing cooked macaroni and cheese had a plastic wrap cover that was not secured to the pan on one corner, therefore exposing the contents to potential contamination. There was no date/label on the macaroni and cheese. The Executive Chef stated it looked like someone tore open the corner and took a serving out and did not recover it. The Executive Chef confirmed there was no date on the macaroni and cheese.
d. A used disposable glove was lying on the floor of the dessert freezer floor. The Executive Chef reached and picked it up and put it in a trash receptacle.
e. There was an approximately 4-5" icicle hanging from a pipe in the ceiling of the dessert freezer. Directly under the icicle there was an approximately 1.5 inch frozen patch of ice that had dripped onto an open cardboard box with frozen bagged croissants visible. The Executive Chef stated that was new to him, he had not seen it before now and he would put in a call to get it repaired.

Based on facility documents and interview, the hospital failed to ensure food and dietary service developed a monitoring system that identified, monitored and reported hand hygiene data to the Infection Control Committee.

The findings included:

Review of the hospital's monthly Infection Prevention Committee Meeting Minutes dated January, 2018 through January, 2019 revealed there has been no one from food and dietary services in attendance and no hand hygiene data had been submitted from the kitchen.

During an interview on 3/5/19 at 3:00 PM, in the Quality conference room, the Chief Quality and Patient Safety Officer (CQPSO) was asked who monitors the infection control and hand washing in the kitchen. She stated that the managers monitor this in every area in the hospital. There is a monthly meeting of the infection prevention committee and handwashing is monitored and reported on a monthly basis. She stated that every department are tasked with monitoring hand washing with 10 random observations each week and those results are turned in to Infection Control every Friday. She stated that Kitchen is a part of our hand hygiene program but they have not submitted any data. They get the communication each week, so they are aware of the program.