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Based on observation and interview with administrative staff it was determined the facility failed to:

1. Ensure the patients' rooms and bathroom areas were clean.
2. Ensure Plexiglass windows were maintained to prevent a potential cutting hazard and prevent patients from placing trash and paper behind the window.

This had the potential to affect all patients.


Findings include:

On 5/22/12 at 9:30 AM, the surveyors conducted a tour of the modular building outside and down the steps of the hospital to the area which housed the children age 6 years to 12 years.

The following was observed during the tour:

Room 704 the right side of the Plexiglass covering the window was loose and could be pushed in. This is a potential hazard if a child's fingers were caught between the glass and the frame.

Room 706 the vent in the ceiling of the room was rusty and had an accumulation of dust build up.

Room 710 the back side of the door and area on the linoleum to the wall was coated with dust and grime. The bed was unsecured, in the middle of the room, and the back of the bed frame was open. The following items were observed under the bed; a bed sheet, scraps of paper and a stuffed animal. The wall paper border around the top of the wall had been torn and removed in sections. Employee Identifier # 1, Director of Nursing accompanied the surveyor on the tour and assured the surveyor the bed would be replaced.

Room 711 the wall paper border around the top of the wall had been torn and removed in sections, trash was noted behind the Plexiglass. The surveyor observed a cut out area at the top of the window on both sides, a potential cutting hazard for the patients. Trash and paper were observed behind the Plexiglass.

A crack in the ceiling ran the entire length of the building through the large open group room. This is room the children complete activities, meals and participate in group therapy.

In an interview on 5/22/12 at 11:00 AM, Employee Identifier # 1, Director of Nursing, confirmed the above observations.

On 5/24/12 at 8:30 AM, the surveyor returned to Room 710 and the bed had been bolted to the floor.

Based on hospital policy, medical record review, observation and interview the facility failed to ensure the nursing staff provided care as ordered for 1 of 1 patients on constant observation. This affected Medical Record (MR) # 15 and had the potential to affect all patients.

The findings include:

Policy and Procedure
Level of Observation
Revised 9/11
Policy: All patients will be routinely observed in compliance with physician orders and prescribed protocols.
Procedure: 8. Line of Sight Observation (LOS) or Constant Observation (CO)
Staff will maintain constant visual observation through direct observation.
When patients shower, change clothes, or use the bathroom, the staff will remain outside the bedroom or bathroom door with the door slightly open and visually check the patient at least every 30 seconds. Staff will attempt to maintain the patient's privacy as much possible; however, the safety of the patient must be the main consideration.
Staff assigned to line-of-sight (LOS) or constant observation must hand-off responsibility for maintaining observation of the assigned patient(s) for any break.

Medical Record Findings:
MR# 15 was admitted on 4/11/12 with a diagnosis of psychosis.

A Progress Note dated 5/21/12 at 9:20 AM, documented, "Persisting behavioral problems continues to endorse suicidal ideations with a plan to hurt self."

A Physician's Order Sheet dated 5/23/12 at 9:00 AM, documented, "Constant observation round the clock."

MR # 15 was observed in the bed on 5/23/12 at 2:08 PM. There was no staff in the area and the staff chair by the door was empty. A Medical Technician, Employee Identifier (EI) # 11, stated MR # 15 was on Constant Observation "while awake".

The Nurse Progress Notes dated 5/23/12 documented MR # 15 was on constant observation and on suicide precautions.

The Mental Health Technician's Progress Note- Adult/PICU (psychiatric intensive care unit) dated 5/23/2012 documented, "1500 (3:00 PM) Pt (patient) upset yelling, crying, screaming non compliant needs redirection. Failure to comply with staff redirection. Pt given PRN (when needed medication)."

MR # 15's Rounding Sheet for 5/23/12 was reviewed and there was documentation at the top of the sheet "Constant observation C/O (constant observation) w/a (while awake)."

On 5/24/12 during an interview with EI # 10, PICU Unit Manager, was asked what does c/o WA mean on MR # 15's Rounding Sheet and she responded "Constant Observation while awake."

The facility staff failed to follow physician orders by not maintaining constant observation of MR # 15.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to the Life Safety Code survey findings.

Findings include:

Facility Policies

Policy: FNS(Food and Nutrition Services)-N.009

Subject: Sanitation-Food and Nutrition Services

Revised Date: 9/96

I. Policy

Sanitation procedures will be part of FNS Department Inservices.

II. Purpose

To insure proper cleaning methods and proper temperatures

III. Procedure

Equipment

G. Mixers-Sanitize bowls and beaters immediately after use. Sanitize with 1 ounce Clorox to 4 gallons of water. Sanitize mixer with 1 ounce Totil to 4 gallons of water. Dry with a clean cloth.

H. Meat Slicer. Turn off machine, unplug cord from socket. Adjust knob to zero. Remove meat grip arm, blade cover, carriage tray. Sanitize with 1 ounce Clorox to 4 gallons of water. Dry with clean cloth. Sanitize slicer, blade and other parts of machine with 1 ounce Clorox and 4 gallons of water. Dry with clean cloth. Assemble meat slicer, tightening all parts.

L. Pot and Pan Wash ...

Sanitize pots and pans in the third sink: Water should be 180 degrees F. (Fahrenheit) for one minute to sanitize all pots and pans. This hot rinse also assures fast air drying.

Policy IC-G.008 FNS-0.001

Subject: Infection Control Guidelines for Food and Nutrition Services

Revised 11/99

I. Policy

Establish infection control guidelines for Food and Nutrition Services Department.

II. Purpose

Maintenance of strict sanitary conditions is of utmost importance in the Food and Nutrition Department in order to eliminate food contamination and to prevent the growth of disease producing organisms and the production of bacterial toxins.

III. Procedure

4. Meat Slicer and Meat Preparation Areas

b. Remove covers and wash entire machine after use with soap and water; rinse well.


U. S. Department of Health and Human Services 2009 Food Code

4-9 Protection of Clean Items

Drying

4-901.11 Equipment and Utensils, Air-Drying Required.

After cleaning and Sanitizing, Equipment and Utensils:

(A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR (Code of Federal Regulations) 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface Sanitizing solutions), before contact with Food; and

(B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Storing

4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.

(A)Except as specified in (D) of this section, cleaned Equipment and utensils ....shall be stored:

(1)In a clean, dry location

(2)Where they are not exposed to splash, dust, or other contamination ....

(B) Clean Equipment and Utensils shall be stored as specified under (A) of this section and shall be stored:

(1) In a self-draining position that allows air drying; and

(2) Covered or inverted.

Code of Federal Regulations
Title 21, Volume 3
Revised as of April 1, 2011
Cite: 21CFR178.1010
PART 178 -- INDIRECT FOOD ADDITIVES: ADJUVANTS, PRODUCTION AIDS, AND SANITIZERS
Subpart B--Substances Utilized To Control the Growth of Microorganisms
Sec. 178.1010 Sanitizing solutions. Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions:(a)Such sanitizing solutions are used, followed by adequate draining, before contact with food. (b) The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. (1) An aqueous solution containing potassium, sodium, or calcium hypochlorite, with or without the bromides of potassium, sodium, or calcium ... (c) The solutions identified in paragraph (b) of this section will not exceed the following concentrations: (1) Solutions identified in paragraph (b) (1) of this section will provide not more than 200 parts per million of available halogen determined as available chlorine...
1. The initial tour of the dietary department was conducted on 5/22/12 from 9:55 AM until 11:55 AM. The surveyor observed the following:

A stack of three ? length pans, a stack of 10 shotgun pans and a stack of 9 shotgun pans were stored wet nested on the "clean" rack in the Pot and Pan area of the kitchen.

There were no posted instructions in the pot and pan 3 compartment sink area with regarding the process for sanitizing the pots and pans in the sanitizing sink.

There were no sanitizing check logs posted in the pot and pan 3 compartment sink area.

The mixer was not covered and had white specks inside the mixer bowl and a few dried food specks on the mixer stand.

The meat slicer was uncovered and had food residue on front of the blade and on the back side where the sliced meat falls after being cut.

2. On 5/23/12 at 8:30 AM, the surveyor made the following observations in the dietary department:

A stack of 8 shotgun pans were stored wet nested on the "clean" rack in the pot and pan area of the kitchen.

There were still no posted instructions in the pot and pan 3 compartment sink area regarding the process for sanitizing the pots and pans in the sanitizing sink.

There were still no sanitizing check logs posted in the pot and pan 3 compartment sink area.

The mixer was not covered and still had white specks inside the mixer bowl and a few dried food specks on the mixer stand.

The meat slicer was uncovered and still had food residue on front of the blade and on the back side where the sliced meat falls after being cut.

On 5/23/12 at 8:30 AM, Employee Identifier (EI) # 6, the Dietary Manager, confirmed the mixer and meat slicer were not clean and were not covered to prevent being contaminated with dust or splashing. EI # 6 confirmed the aforementioned utensils had wetnesting and had the potential for bacteria formation on pot and pan surfaces. EI # 6 confirmed that the pots and pans were supposed to have been thoroughly dried before being stored.

During an interview on 5/23/12 at 8:32 AM, EI # 3, the cook, confirmed the mixer nor the meat slicer had been used during the food preparation on 5/23/12.

3. On 5/23/12 the surveyor made the following observations:

At 8:45 AM, EI # 4, a kitchen employee, began filling the pot and pan 3 compartment sinks with water.

At 9:10 AM, EI # 4 obtained a gallon jug of Bleach from the Dietary Manager's office and brought the jug into the Pot and Pan area of the kitchen. EI # 4 continued filling the sanitizer sink with hot water.

At 9:15 AM, EI # 4 poured a cup of bleach into the sanitizer sink. EI # 4 checked the water with a testing strip and then added ? cup more of bleach to the water. EI # 4 stated that they are not using the hot water temperature for sanitizing but are using bleach. The sink continued to fill with water. EI # 4 did not check the bleach concentration of the water for the PPM after adding the additional bleach and did not turn off the water.

At 9:20 AM, EI # 5, another kitchen employee, came to the pot and pan area. The water continued to fill the sanitizing sink up to the top and was pass the water fill line level. EI # 5 turned off the water. EI # 5 washed a pot in the wash sink, rinsed it in the rinse sink and then placed it in the sanitizing sink. EI # 5 started to take the pot out of the sanitizer sink. The surveyor asked EI # 5 if he/she had checked the PPM of the sanitizer sink and he/she confirmed he/she had not checked the PPM. EI # 5 confirmed he/she did not know if EI # 4 had checked the PPM. EI # 5 then checked the PPM and it was 100 PPM.

AT 9:30 AM, the surveyor asked EI # 5 if they write down the PPM results anywhere. EI # 5 confirmed they do not record the PPM results anywhere.

During an interview on 5/23/12 at 9:40 AM, EI # 6, the Dietary Manager, confirmed there was no documentation being kept of the sanitation checks of the 3 compartment sink to verify that proper sanitation of pots and pans was being accomplished. EI # 6 confirmed they are no longer using the hot water sanitation in the sanitizing sink. EI # 6 confirmed they are using bleach now and sometimes Quat for sanitizing in the sanitizing sink.

Based on a review of medical records and interview it was determined the facility failed to plan for discharge and offer one of one discharged patients who received a home health referral a choice of who would provide services in the patient's home. This affected Medical Record (MR) # 2 and had the potential to affect all patients discharged who required home health services.

Findings include:

1. MR # 2 was admitted to the facility on 12/14/11 with diagnoses of Schizoaffective Disorder, Bipolar Type, Alcohol Abuse and Diabetes Mellitus uncontrolled.

The progress notes from MR # 2 chart documented on 1/5/12 at 11:00 AM, "SW (social worker) faxed patient's information to ... at St.Vincent's Home Health for referral."

The progress notes from MR # 2 chart documented on 1/5/12 at 12:00 AM, "SW received message from ... at St.Vincent's Home Health that they are a provider for patient's insurance and they will accept the patient and follow up with him."

There was no choice list of home health providers in the medical record and no signature of the patient or caregiver of a choice of home health providers being made available prior to discharge to the patient.

In an interview on 5/24/12 at 12:03 PM, with Employee Identifier # 1, the Director of Nursing, it was confirmed the patient/caregiver was not given a documented choice of home health agencies available for care.



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EI # 12, a Social Worker, was interviewed on 5/22/12 at 2:20 PM. She was asked how the facility informed the patient or family which home health agencies were available for care after discharge. EI# 12 stated there was not list but there were some brochures available downstairs.

Based on observation and a tour of the suite utilized for ECT (electroconvulsive therapy) under anesthesia, interview with the Director of Nursing and review of the standards from the Malignant Hyperthermia Association of the United States, it was determined the hospital failed to ensure there was an adequate amount of Dantrolene in stock. This had the potential to affect all patients served by this facility.

Findings include:

On 5/23/12 at 9:30 AM, during a tour of the suite utilized for ECT the surveyor observed in the crash cart 6 vials of Dantrium(Dantrolene). The anesthesiologist, Employee Identifier (EI) # 2 was asked during the tour on 5/23/12 at 9:30 AM if there was 36 vials of Dantrolene available as required. EI # 2 stated that they would stabilize the patient and transfer them out if a problem occurred. The surveyor asked again if 36 vials of Dantrolene was available. EI # 2 stated that the pharmacy would know.

Review of the standards from the Malignant Hyperthermia Association of the United States revealed the following documentation, "The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH (Malignant Hyperthermia)."

The surveyor asked EI # 1, Director of Nursing if 36 vials of Dantrolene was available on 5/23/12. EI # 1 stated that she would have to check with the pharmacy. EI # 1 was asked for a policy to treat Hyperthermia on 5/24/12. EI # 1 did not produce a policy related to Hyperthermia treatment.



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During an interview on 5/24/12 at 8:30 AM, EI # 9, the Pharmacist, confirmed that they only keep 6 vials of Dantrium (Dantrolene) in stock. EI # 6 stated that they only keep enough Dantrium onsite to initiate the therapy for Malignant Hyperthermia and they send the patient out as soon as they are stabilized.