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Based on observation, interview, and record review, the facility's Governing body failed to ensure the facility's contracted Food Service was managed in a safe and sanitary manner, and implement and enforce an effective Infection Control program to prevent patient exposure to unsanitary environments.

Findings Include:

Review of the Committee of the Whole (Quality Meeting) dated June 27, 2017 reflected no Infection Control discussion or information.


Review of the Committee of the Whole (Quality Meeting) dated July 25, 2017 reflected "Infection Prevention: 2017 Infection prevention plan was presented. Infection prevention goals are: preventing the spread of disease, 100% compliance for hand hygiene, and get at least 90% of our staff vaccinations for flu. Caroline has been working to get secret shoppers on units to audit for hand hygiene."


Review of the Committee of the Whole (Quality Meeting) dated August 22, 2017, September 26, 2017, and October 24, 2017 reflected no infection prevention discussion or information.


Review of the Committee of the Whole (Quality Meeting) dated November 28, 2017 reflected IC: Hand hygiene audits - a secret shopper was implemented. Caroline will collect data first and them implement education.


There was no evidence of a December meeting.


Review of the Committee of the Whole (Quality Meeting) dated January 23, 2018 reflected "IC: Hand hygiene audits were presented. The goal is have 90% or above. Caroline is planning on doing more audits on each floor going forward."


Review of the Committee of the Whole (Quality Meeting) dated Feb. 21, 2018 reflected "IP: The 2018 Infection Control Plan was reviewed and approved. The 2017 goals and results were reviewed."


Review of the Committee of the Whole (Quality Meeting) dated March 21, 2018 reflected no minutes.


During an interview on the morning of 5/7/18, in a facility conference room, when asked how the facility provides oversite of the contracted food service and environmental services Staff #E14, Administrator stated, "I meet monthly with them. We have a standing meeting....we don't document what we discussed...." The facility did not provide the results of the meetings or the follow-up on items discussed.


During an interview on the morning of 5/9/18, in a facility conference room, Staff #E14, Administrator stated, " ...The Environment of Care rounds are completed monthly."


Review of the facility provided EOC monthly round document dated 8/16/2017, which was different from the annual Environment of Care round, reflected the infection control nurse's participation and reflected findings of insects and dirt built-ups in the facility. The facility did not provide a more current EOC form.


During an interview on the morning of 5/9/18, in a facility conference room, Staff #E13, Corporate Risk Manager stated, "There aren't any more EOC rounds .... That's the last one."


Cross Refer to A0618 Dietetic Services, and A0701 Maintenance of Physical Plant.

Based on observation, interview and record review the facility's Governing body failed to provide adequate oversite to ensure the facility's contracted Food Service was managed in a safe and sanitary manner.

Findings include:

Observations on the morning of 5/7/18 and afternoon of 5/8/17, in the facility's Dietary Department revealed:
- Items unlabeled and undated when opened:
(5) Spice jars
(13) fruit cups
(12) cups with tomatoes, onions and pickles
(2) bags of Frozen fish filets; one of the bags had been pierced open by the frozen fish
(2) bags of opened freezer burned bread rolls
(1) large container of mandarin orange slices
- The facility's electric food slicer had dried food debris on the inner blade shield exposing fresh items to the old dried food.
- The facility mixer was covered with old dried food debris splatters which could easily fall into fresh food products.
- The facility can opener had old dried food debris stuck in the gears and on the cutting blade tooth, exposing fresh items to the old dried food.
- The food prep shelves, clean dishes racks and shelves, dry food storage shelves, (2) food scales, (2) rolling food racks, (8) utensil drawers were dirty with dried food debris.
- (3) Three dirty large serving spoons had been stored with other clean utensils and were available for use.
- A large tub of devil foods cake had a bowl and metal scoop stored in the food product.
- (2) Two white plastic cutting boards had numerous deep gouges and a black substance was in the deep gouges.
- (3) Three floor drains were blackened with food debris.
- (2) Two large dead roaches were noted lying on the kitchen floor.
- Food debris was noted under the appliances and on the walls behind the equipment and appliances.
- The pot washing sink had black mold all along the wall and sink caulking was missing and blackened.
- The walk-in refrigerator/Freezer had a large piece of the metal threshold missing; food debris was stuck to the exposed area and was not cleanable.
- A black bus tub was sitting on the floor under a food preparation sink; the tub was half full of standing water. The tub had food debris and grease floating in the water, creating an unsanitary environment.
-(2) uncovered trash cans, not currently being used, were sitting in the food preparation areas.
- (5) Five dented food cans awaiting return to the vendor, were on an unlabeled shelf available for use.

During an interview on the morning of 5/7/18, at the food preparation sink, Staff E3, Cook stated, "The sink overflows when we empty it ..." When asked if a work order had been written, Staff E3 stated, "I told my supervisor." The facility did not provide evidence of a work order.
- On 5/5/18, 5/6/18, and 5/7/18 the facility's refrigerators #1,2,3,5,6,8, and 9's temperature logs had not been recorded. Additionally, Refrigerator #1's internal thermometer temperature was registering 48 degrees Fahrenheit.

During an interview on the morning of 5/7/18, in the facility's dietary department Staff E1, Dietary Supervisor confirmed the findings and stated, " ...it should be below 41 degrees ...it's 47 ...all the foods should be labeled and dated ..." The dietary supervisor did not check the internal temperatures of the food items in the refrigerator or discard the food items in the surveyor's presence.

During the tour of the facility's Dietary Department on the morning of 5/6/18, Staff #E12 confirmed the findings. When asked how the Governing Body determines if the contracted Food Services is being operated properly Staff #E12 stated, "The EOC (Environment of Care) does an annual review." Staff #E12 confirmed the Environmental Services is also a contracted service.

During an interview in the afternoon of 5/7/18, in the facility classroom, Staff E6, Registered Dietitian confirmed the Food Service is a contract service and stated, "I'm the Food Service Manager. I do rounds with the EVC (Environment of Care) .... there are no written reports, I tell the staff if something needs to be taken care of ..." When asked if anyone from the facility checks on the kitchen, Staff E6 stated, " .... EVS (Environmental Services) does a walk through ...."

Review of the facility provided EOC Rounds reflected completion on 12/28/17 and 12/8/16. The EOC Rounds form included General Safety, Security, hazardous Materials and Waste, Emergency Management and Life Safety; the form did not include the monitoring for safe food handling in a food establishment.

Based on observation, staff interviews, and review of facility documentation, the hospital failed to ensure that the Patient Safety & Performance Improvement Program & Plan provided ongoing oversight and direction which addressed infection control and environment of care issues. This had the potential of placing all patients at risk for infections due to an unsanitary hospital physical environment and a sparse infection control program which were not addressed by hospital quality activities.

Findings were:

Facility network policy entitled "Patient Safety & Performance Improvement Program & Plan," effective date 6/14/16, included the following:
"Structure
The reporting structure established for the PLAN provides for the execution of ongoing communication of all activities from the point of service through the site patient safety and process improvement committees, network patient safety and process improvement committees, and ultimately to the QPSC (Quality & Patient Safety Committee) of the Seton Family of Hospitals Board of Directors. Subsequently, ongoing communication of quality and safety activities to associates, clinical leadership, Medical Staff, and others is executed through established network and site leadership and department meetings ...
B. Councils and Committees that Report to QPSC ...
C. Site Patient Safety/PI Committees: Hospital-based multidisciplinary committees, which provide ongoing oversight, and direction to specific quality functions of each department within the hospital environment, ongoing accreditation compliance, continual survey readiness, environment of care, utilization of services and access to care, and safe medication practices. This committee performs a formal annual review, analysis, and update of PI activities and patient safety events and corresponding action plans to the QPSC ..."

A review of the Seton Shoal Creek Committee of the Whole meeting minutes from June 2017 through February 2018 included the following entries in their entirety:
June 27, 2017 -
EOC (Environment of Care) entry: "Injury rates have been pretty low. We had 1 slip/trip/fall injury in May resulting in a twisted ankle. Our OSHA recordable rate is 4.53." Infection Control topics were not discussed.

July 25, 2017 -
Safety/EOC entry: "There were 2 OSHA recordable injuries in June. We had the spring emergency management drill last month and are preparing for a fall drill focused on family reunification."

Infection Prevention entry: "2017 Infection prevention plan was presented. Infection prevention goals are: preventing the spread of disease, 100% compliance for hand hygiene, and get at least 90% of our staff vaccinations for flu. Caroline has been working to get secret shoppers on units to audit for hand hygiene."

August 22, 2017 -
Safety/EOC: "There were 0 OSHA recordable injuries in July. There was 1 needle stick in August. Finalizing the family reunification plan for the fall drill. We have the highest rate of workplace violence in the network due to the nature of our work. There was a high rate of occurrences of seclusion and restraint and workplace violence in July, but 0 OSHA recordable injuries." Infection Control topics were not discussed.

September 26, 2017 -
Safety/EOC entry: "One OSHA recordable in both July and August. During EOC roundings expired medical supplies and incomplete temperature logs were found." Infection Control topics were not discussed.

October 24, 2017 -
Environment of Care was not discussed. Infection Control topics were not discussed.

November 28, 2017 -
Infection Control entry: "Hand hygiene audits - a secret shopper was implemented. Caroline will collect data first and them implement education."

Safety/EOC entry: "There were 4 OSHA recordables in October, 4 in September, and 1 in November. Events took place on the 2nd floor and PICU."

No December 2017 meeting.

January 23, 2018 -
Infection Control entry: "Hand hygiene audits were presented. The goal is have 90% or above. Caroline is planning on doing more audits on each floor going forward."

Safety/EOC entry: "There were no OSHA recordable injuries in December. We are the worst in the network for our OSHA recordable injury rate."

February 21, 2018 -
Infection Control entry: "The 2018 Infection Control Plan was reviewed and approved. The 2017 goals and results were reviewed."

Safety/EOC entry: "Workplace injuries have crept up again. CPS kids have attributed to all but 1 workplace violence injuries for the year. The emergency management spring drill will be scheduled sometime between 5/2 and 6/30. The injuries for January were reviewed. All were caused by 1 patient on 2nd floor."


Numerous infection control and environment of care issues were noted by surveyors during tours of the facility on May 8-9, 2018. These issues were not documented as having been identified by the facility as areas of concern for patient safety and quality assessment/performance improvement activities. Thus, there was no possibility of accurate reporting of these issues to the overall governing body.

In an interview with the facility Staff #C16, Chief Administrative Officer, Staff #C17, Chief Medical Officer, and Staff #C18, Quality Lead, on the morning of 5/9/18 in a hospital meeting room, Staff #C16 stated the hospital was conducting biweekly environment of care rounds. When surveyor tour findings were brought up, she stated that patient care areas were sometimes difficult to keep clean.

Based on observation, interview, and record review, the facility failed to provide Food Services in a clean and sanitary manner as evidenced by improperly storing food items and improper cleaning of counters and equipment.

Findings include:

Observations on the morning of 5/7/18 and afternoon of 5/8/17, in the facility's Dietary Department revealed:

- Items unlabeled and dated when opened:

(5) Spice jars

(13) fruit cups

(12) cups with tomatoes, onions, and pickles

(2) bags of Frozen fish filets; one of the bags had been pierced open by the frozen fish

(2) bags of opened freezer burned bread rolls

(1) large container of mandarin orange slices

- The facility's electric food slicer had dried food debris on the inner blade shield exposing fresh items to the old dried food.

- The facility mixer was covered with old dried food debris splatters which could easily fall into fresh food products.

- The facility can opener had old dried food debris stuck in the gears and on the cutting blade tooth, exposing fresh items to the old dried food.

- The food prep shelves, clean dishes racks and shelves, dry food storage shelves, (2) food scales, (2) rolling food racks, and (8) utensil drawers were dirty with dried food debris.

- (3) Three dirty large serving spoons had been stored with other clean utensils and were available for use.

- A large tub of devil foods cake had a bowl and metal scoop stored in the food product.

- (2) Two white plastic cutting boards had numerous deep gouges and a black substance was in the deep gouges.

- (3) Three floor drains were blackened with food debris.

- (2) Two large dead roaches were noted lying on the kitchen floor.

- Food debris was noted under the appliances and on the walls behind the equipment and appliances.

- The pot washing sink had what appeared to be black mold all along the wall and sink caulking was missing and blackened.

- The walk-in refrigerator/Freezer had a large piece of metal threshold missing; food debris was stuck to the exposed area and was not cleanable.

- A black bus tub was sitting on the floor under a food preparation sink; the tub was half full of standing water. The tub had food debris and grease floating in the water, creating an unsanitary environment.

-(2) uncovered trash cans, not currently being used, were sitting in the food preparation areas.

- (5) Five dented food cans awaiting return to the vendor, were on an unlabeled shelf available for use.


During an interview on the morning of 5/7/18, at the food preparation sink area, Staff E3, Cook stated, "The sink overflows when we empty it ..." When asked if a work order had been written, Staff E3 stated, "I told my supervisor." The facility did not provide evidence of a work order.

- On 5/5/18, 5/6/18, and 5/7/18, the facility's refrigerators #1, 2, 3, 5, 6, 8, and 9's temperature logs had not been recorded. Additionally, Refrigerator #1's internal thermometer temperature was registering 48 degrees Fahrenheit.

During an interview on the morning of 5/7/18, in the facility's dietary department, Staff E1, Dietary Supervisor confirmed the findings and stated, " ...it should be below 41 degrees ...it's 47 ...all the foods should be labeled and dated ..." The dietary supervisor did not check the internal temperatures of the food items in the refrigerator or discard the food items.

During the tour of the facility's Dietary Department on the morning of 5/6/18, Staff #E12, Safety Officer II, confirmed the findings. When asked how the Governing Body determines if the contracted Food Services is being operated properly, Staff #E12 stated, "The EOC (Environment of Care) does an annual review." Staff #E12 confirmed the Environmental Services is also contracted.

During an interview in the afternoon of 5/7/18, in the facility classroom, Staff E6, Registered Dietitian stated, "I'm the Food Service Manager. I do rounds with the EVC (Environment of Care) .... there are no written reports, I tell the staff if something needs to be taken care of ..." When asked if anyone from the facility checks on the kitchen, Staff E6 stated, " .... EVS (Environmental Services) does a walk through ...."

Review of the facility provided document Scope of Service - Food & Nutrition Services Fiscal Year 2018 Performance Indicators for the Contracted food service does not reflect a requirement or a review for the compliance of safe food handling and infection control guidelines.


Review of the facility provided policies:

Policy #B006 - Food supply and Storage Procedures reflected, " ...All food, non-food items and supplies used in food preparation shall be stored in such a manner at to prevent contamination to maintain the safety and wholesomeness of the food for human consumption

Policy #F013 - Sanitation and Infection Control reflected, " ...Food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable ...the food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil .... Nonfood contact surfaces of equipment ...shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris ...."

Policy #F011- Solid Waste Disposal reflected, " ...Garbage containers are kept clean using clear trash can liners and covered at all times. During periods of constant use in food production ...garbage cans may remain uncovered ...."

Policy#B006 - Food Supply and Storage Procedures reflected, "Maintain designated area for items that are damaged ... Post a sign so items will not be used. (QAS -2 sign 'This area for holding of damaged, spoiled or recalled food only. Do NOT use') ...."

Policy #B007 - Storage Temperatures reflected, "Temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures ...Refrigerated Storage Minimum 34 degrees Fahrenheit, Maximum 41 degrees Fahrenheit ..."

Based on tour of facility, policy review, and staff interview, the facility failed to provide a clean and sanitary environment in the patient care areas as per their facility policies and procedures.

Findings were:

During a tour of the 3rd floor of the facility on the afternoon of 5/8/18 the following maintenance issues were noted:

* laminate was missing on the walls and drawers of the nursing desk in the patient treatment area;

* chair at the nurses station had cracked vinyl seat;

* dirt, debris of papers and food was noted in the day room, hallway, and patient rooms;

* seclusion room on the right had debris on the floor and had rodent droppings on the floor in the corners behind the mattress located on the floor (this room has been used for a patient at various times during the date of 5/7/18 and 5/8/18;

* seclusion room on the left had paint debris all over the floor and a few rodent droppings was noted in the corners by the mattress on the floor; 2 used towels were noted on the mattress in the room;

* dust was noted on all window sills and floor boards throughout the 3rd floor patient treatment areas;

* room 317 had cove base attached to wall; not sealed continuous with gaps noted; the wall was very soft behind the cove base in an area by the door leading to the hallway;

* paint was noted to be peeling off multiple doors and doorframes in patient rooms;

* exit light outside room 321 was noted to be hanging down from ceiling;

* metal was exposed on a corner protector in the patient day room area;

* plastic cover on air conditioning unit in dayroom had broken pieces that could be easily moved;

* lint/dust debis was noted on surfaces in patient laundry room;

* washing machine in patient laundry room had wet debris and gray slime material on rubber seal inside washing machine;

* a soiled towel was noted to be laying on the floor in front of the door to the soiled utility room;

* ceiling tiles were noted to be raised in patient supply room over clean supplies;

* bins holding supplies in patient supply room was noted to have dirt/dust/debris;

* bins in medication room holding patient supplies were noted to have white/gray debris in the bins over the patient supplies;

* top of medication cart had dust on surface where medication cups were located in both medication rooms.


Facility policy titled "Infection Prevention-Environmental Cleaning and Disinfection" states in part "It is the policy of SETON to maintain a clean and sanitary environment. Seton Associates are responsible for maintaining a clean and sanitary environment in their areas. Housekeeping personnel are responsible for regular scheduled cleaning as determined by the leaders in each area. Cleaning is performed daily or as scheduled by the housekeeping department in all clinical areas."


The facility has no approved policy for cleaning and disinfecting the washer and dryer after use.


In an interview with the nurse preparing medications, she stated she had wiped the top of the medication cart with disinfectant wipes that morning. She acknowledged the top of the cart was dusty and had debris where the medication cups were located.

In an interview with the nursing director at the time of the findings she acknowledged the deficient practices.

In an interview with the Environmental Services Manager he stated they do environmental rounds in their designated areas. He stated they have not met as a group with the rounds in 3-4 months. He stated if the nursing staff does not notify them when the seclusion room is not in use they are unable to clean the room.



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During a tour of the ECT (electroconvulsive therapy) area with Staff #7, Nurse Manager, on the morning of 5/8/18, the following items were noted:

- Chipped laminate on sink surround approximately 4" long.

- An open multi-dose vial of lidocaine in anesthesia cart with no date of when opened or when it would expire.

- Thick dust in metal slider areas under windows in the ECT procedure room, pre-procedure area and post-procedure area.

- A small refrigerator was completely full of beverages for post-procedure patients. None of the beverage items were dated. Thus, there was no way to know when the facility received the beverages.

- The small refrigerator noted above had temperatures noted only on dates the ECT area was open. There was no memory on the refrigerator thermometer, and thus no way of knowing if temperatures were out of range on those days (Tuesdays, Saturdays & Sundays).

- Tape on items throughout the entire ECT area made thorough cleaning impossible


Based on observation, staff interview, and review of facility documentation, the facility failed to establish a maintenance schedule and perform calibrations on the hospital electroconvulsive therapy (ECT) machine which met State regulatory requirements of at least semi-annual calibrations.

Contract policy #4806199 entitled Preventive Maintenance (PM) of TRIMEDX, last revised 04/2018, and provided by Seton Shoal Creek Hospital included the following:

"It is the policy of TRIMEDX that all devices managed by TRIMEDX will have an Operation Verification Procedure (OVP) Performance Assurance performed prior to initial use and have Preventive Maintenance at periodic intervals as defined by an assigned Preventive Maintenance (PM) Schedule based on Risk Evaluations, Regulatory Requirements, Contractual Requirements or Manufacturer's Recommendations ..."


During a tour of the ECT procedure room on the morning of 5/8/18 with Staff #C7, Nurse Manager, a sticker on the ECT machine indicated the most recent preventive maintenance performed on the machine was 8/17. In an interview with Staff #C2, ECT RN, and #C7 during the tour, they both stated maintenance on the ECT machine was done on an annual basis. Staff #7 stated any maintenance on the machine was performed by the hospital's biomed provider.


In an interview with individual #C15, contract provider of facility equipment maintenance with biomed company TRIMEDX, on the morning of 5/9/18 in the facility conference room, he stated, "We have this machine down for annual maintenance on our schedule." He added, "That schedule is set by Seton Shoal Creek. We can change it as they request ..."

Based on observation, interview, and record review the facility failed to enforce an effective Infection Control Program as evidenced by,

- The facility's contracted food service was not being provided in a sanitary manner.
- (2) Two seclusion rooms contained dirt, trash, dust on floorboards, and rodent droppings in the rooms.
- The adult patient laundry washer had debris and slime on the rubber seal, and lint/dirt and debris was observed behind the washer and dryer.
- The child/adolescent unit washer was caked with an unknown substance. There was discoloration on the outside of the washer and an unknown substance built-up.
- Patient room #317's cove base was not sealed and the wall moved when touched allowing access to insects.
- The Medication room contained bins with patient supplies, needles, and syringes; debris was noted in the bottom of the bins.
- The top of the medication cart, where the medications are being prepared, was noted to have dirt and debris
- Tour of the admission department on 5/8/18 revealed stained ceiling tiles in the children's waiting area. This indicated a possible water leak.
- Tour of the 4th floor medication room revealed dirty bins that stored medical supplies.
- (2) Ceiling tiles in the class room, indicative of a water leak.

Findings Include:

During an interview on the afternoon of 5/8/18 on the third floor nursing unit, Staff #E11, RN stated, "I wipe the top of the med cart before the shift."

During an interview in the afternoon of 5/7/18, in the facility classroom, Staff # E6, Registered Dietitian stated, "I'm the Food Service Manager. I do rounds with the EVC (Environment of Care) .... there are no written reports, I tell the staff if something needs to be taken care of ..."

Review of the facility provided policy F002 reflected, " ...Working with Facility/Community Infection Control Department ... The Department Implements Infection Control policies that relate to operation of the department ...Department managers/supervisors conduct walk-through's of the department to evaluate food safety procedures every day. A standardized format, such as the Steritech/EcoSure food safety audit, is used .... Invite Infection Control to accompany department managers/supervisors during the walk-through's every month ...Establish and maintain a working relationship with Infection Control that is not limited to attendance at Infection Control Committee activities. Maintain regular participation in the facility's Infection control committee activities, such as meeting, and submission of departmental information."

During an interview on the morning of 5/8/18, in the conference room Staff #E5, Infection Control Director when asked how the facility ensures the Contract Food services compliance with infection control standards stated, " ... Through Environment of Care Rounds (EVC) ... it's done rotationally ...A clean kitchen is part of infection control .... I don't know when the last one was done ...."

Review of the facility provided EOC Rounds reflected completion on 12/28/17 and 12/8/16. The EOC Rounds form included General Safety, Security, hazardous Materials and Waste, Emergency Management and Life Safety; the form did not include the monitoring for safe food handling in a food establishment. The infection control nurse was not included in the annual EOC round.

During an interview in the afternoon of 5/8/18, in an administrative office, Staff #E9, Facility Manager stated, "We complete the Environment of Care rounds ...because we are facilities we are mainly looking at the facility for things that need to be repaired ...."

Cross Refer to A0618 Food and Dietetic Services

Based on interview and record review the facility failed to invite the patient or patient representative to attend or participate in the patient's treatment plan for (4) four out of (9) nine patient records reviewed for treatment plans. (Patient # E1, E2, E9 and E14)

Findings Include:

Review of the facility provided policy Multidisciplinary Treatment Planning Process (dated 3/13/18) stated, " ...Each patient will have an individual written treatment plan which best meets his/her bio needs ...biopsychosocial needs .... The treatment plan is explained to, understood by and responded to by the patient and/or legal guardian and so documented .... Nursing staff presents and discusses the comprehensive treatment plan and all treatment plan reviews to the patient and/or legal guardian, obtaining the patient's and/or legal guardian's input and signature on each plan. Patient goals/suggestions for treatment are recorded and the patient is asked to comment and sign. If the patient is unable to participate in the development of his/her treatment plan due to mental condition, or refuses to sign the treatment plan a notation is made in the medical record ...."

Review of Patient # E1's treatment plan reflected a 61-year-old female did not attend the 72- hour treatment plan dated 4/25/18. There was no evidence the patient participated in her treatment plan.

Review of Patient # E2's treatment plan reflected a 14-year-old female did not participate in the minor's treatment plan and there was no evidence the parent/guardian had been contacted or informed of the treatment plan meeting, in order to participate.

Review of Patient # E9's treatment plan reflected a 27-year-old female did not attend the 72- hour treatment plan dated 4/22/18. There was no evidence the patient participated in her treatment plan.

Review of Patient # E14's treatment plan reflected an 11-year-old minor female did not participate in the minor's treatment plan and there was no evidence the parent/guardian had been contacted or informed of the treatment plan meeting, in order to participate.

During an interview on the morning of 5/8/18, on the fourth floor unit, when asked do you involve the patient in the treatment plans Staff #E1, RN stated, "That's a good question."

During an interview on the morning of 5/8/18, Staff #E7, Social Worker Director stated, "We were finding gaps in the signatures ...we have the key members at the treatment plans, we contact the family, the staff need to document the interaction."

Review of the facility's Committee of the Whole (Quality) Meeting dated February 21, 2018 reflected "We are revamping the treatment Planning forms and hopefully that patient participation in treatment planning will improve ..."

During an interview on the morning of 5/9/18, in a facility conference room, Staff #E15, Interim Quality Director when informed that at least two of the treatment plan findings were dated two months after the February meeting, stated, "It's still not resolved."