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Based on observation, interview, and record review, the facility failed to ensure a clear procedure for patient grievances for 1 (Patient #27) of 20 current patients sampled. Contrary to facility policy, a verbal complaint of patient harm was made with no response.

The findings include:

Facility policy for Patient Rights entitled Grievance - Procedure Patient & Family (NO: PR1013), approved 1/2013, was reviewed. Page 2 of the policy included, "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered to be a grievance."

The grievance procedure includes, on page 4, item 7.0 "The Risk Manager will attempt to respond in writing to all grievances..."

On 1/15/13 at 4:06 p.m., Patient #27 was observed in a wheelchair with leg brace on.

In an interview on 1/15/13 at 4:06 p.m., Patient #27 said she complained, at time of admission, she was feeling weak and needed a wheelchair. At that time, she did not get one. Soon after, she went to the toilet and fell off, fracturing her patella (knee). She said she complained about this to staff, but suspected they would "bury" it.

In a second interview on 1/16/13 at 9:25 a.m., Patient #27 repeated that she made a verbal complaint to staff about the incident. She said she was told by the social worker that she must sign a written complaint in order to get a response. The patient said she completed a written grievance form the next day.

In an interview on 1/17/13 at 10:06 a.m., the Social Worker said, "If a patient has a complaint, we give them (the form). If they don't want to fill out a grievance, I try to fix the problem. I document or try to. We can't make them fill out a grievance form, can we? I notify the nurse, doctor, and the team."

Review of the patient records failed to find documentation by the social worker of the patient's verbal complaint.

Based on observation and staff interview, the facility failed to ensure that 1 (Patient #32) of 1 patient, observed receiving an injection, was provided with privacy during the procedure.

The findings include:

On 1/15/13 at 4:15 p.m., Staff Nurse A was observed to take a glucometer to Patient #32's room. The nurse checked the patient's blood sugar. The nurse returned the glucometer to the case, zipped it up, and returned the case to the medication room. The patient required insulin. After preparing the insulin in the medication room, the nurse went to the patient's room and administered the insulin injection in the patient's right upper arm. During the administration of the insulin, the door to the bedroom was open. The bathroom door was opened approximately 20 inches. The patient was observable from the hallway.

In an interview with Staff Nurse A, at that time, revealed the patient was not stable and closing the bedroom door was not safe. When asked how she could ensure the privacy, she stated she usually opens the bathroom door all the way to block the patient from view from the hallway and demonstrated by opening the bathroom door all the way. The nurse said she had forgotten to open the bathroom door before giving the insulin injection.

Based on observations and staff interviews, the facility failed to safeguard and protect patient confidentiality for the patient population receiving electroconvulsive therapy (ECT) in that treatment area of the facility. The facility failed to maintain confidentiality of (Patient #25's) records during the provision of treatment.

The findings include:
1. On 1/16/13, Patient #25 was followed throughout the ECT treatment process. Patient #25 was admitted at 7:09 a.m. as an outpatient for pre-procedure evaluation in the recovery area of the treatment suite. During the evaluation, the medical record was placed on a chair outside the privacy curtain area. The record was not covered and medical information - including Patient #25's name, date of birth, and treatment plan were visible to other patients passing the chair. During post-procedure, the record was observed on the same chair. During observation of ECT treatments, multiple patient records were observed on the chair. The identification (ID) labels (hospital stickers - including name, date of birth, and admission date) were visible as the records were stacked with the ID stickers visible. Patients who had completed their therapy were observed in wheelchairs next to the chair with the medical records. The patients in wheelchairs had clear views of those medical records. Patient identification in the ECT suite revealed that those patients were specifically receiving ECT.

Post-procedure, Patient #25 was brought to the recovery area. She was placed in the area designated "Bed 5." A male patient was observed on a stretcher already in the Bed 5 area. The area did not have privacy curtains available between the 2 patients now in the Bed 5 area. Staff was observed providing care for Patient #25 in view of the male patient. The care included removal of the intravenous (IV) tubing and evaluating physical condition.

Patient #25 was asked to sit at side of the stretcher, then was asked to utilize the bathroom and get dressed. Patient #25 walked from the bathroom to a chair in the discharge area. The chair was located at the foot of Bed 6. Bed 6 was occupied by another male patient. The privacy curtain was not closed and Patient #25 was in view of the patient in Bed 6. The discharge staff asked for the telephone number of the person who would pick up Patient #25. The relationship of the person picking up the patient was discussed. Patient #25 received care including removal of the IV access device. Discharge information, including the next treatment date, was disclosed.

2. On 1/16/13, additional observations of the ECT suite were conducted. The recovery area is used as the space for patients before anesthesia, and after the procedure for recovery from anesthesia. The recovery area had multiple IV poles (metal poles usually used to elevate and hold IV solution bags). The IV poles had clear plastic bags hanging and labeled as "Patient Belongings." The bags had handwritten entries including patient first and last names.

In an interview on 1/16/13, the recovery nurse was asked about the bags. She explained that each patient receiving treatment has "their own bag." The bags, labeled with the patient names, contain "the respiratory tubing and airway supplies for each patient," and are kept in the recovery area. Additional "Patient Belonging" bags were observed, with patient names, on wall hooks next to the recovery area beds. These are visible to each patient placed in the recovery area before and after procedures.

During the tour of the ECT suite, a cart was observed with medical record charts (binders) in the pre-procedure area. Each binder had medical records identified with first initials and last names, first names and last name initials, or first names and last names. The medical charts were in view of the patients in the pre-procedure area, the discharge area and post-procedure area. Patient identification in the ECT suite revealed that those patients were specifically receiving ECT.

In an interview on 1/16/13 during the tour at 9:15 a.m., the Acting Director of Nursing (DON) commented that the plastic bags and the medical charts "just have the first name and last name initial." She observed the "Patient Belongings" plastic bags and stated, "Yes, I see that the bags have first and last name." The Acting DON then observed the medical charts in the pre-procedure area. She stated, "Oh, yes I see that;" verifying patient name identifiers were also on some of the medical charts.

The Acting DON and the ECT Coordinator were interviewed regarding the proximity of patients in the post-procedure and discharge areas. The ECT Coordinator confirmed that there are times when multiple patients are placed in an area designated for one patient stating, "Sometimes that happens." She continued to explain that it happens due to patient recovery needs. She stated, "I can see that now, especially with male and female patients in the same area; but yes, this area is set up for one patient."

The designated discharge area at the foot of Bed 6 was also observed with the Acting DON and the ECT Coordinator. The Acting DON commented the area is "very close" and offered, "I can see that, and all of these can be addressed."

Based on observation and staff interviews, the facility failed to provide adequate staffing and supervision in the electroconvulsive therapy (ECT) procedure area for the patients receiving ECT.

The findings include:

On 1/16/12 at 7:09 a.m., Patient #25 was observed for the ECT procedure, from admission through discharge. At one point, Patient #25 experienced a drop in blood oxygen levels and an increase in blood pressure (BP) requiring additional oxygen delivery and anesthesiologist intervention. During this time the ECT Coordinator requested nursing assistance from the Recovery Nurse (RN) who was acting as the recovery nurse. The RN was attending to another patient who was in the recovery area post-procedure. The RN left the patient in the recovery area to assist with Patient #25 in the procedure area (next to recovery). As the RN left the recovery area, she said to the surveyor, "Keep an eye on my patient for me."

The RN entered the procedure area and assisted with the BP cuff, while the ECT Coordinator managed the pulse oximeter (a device to measure blood oxygen levels). The RN was asked to return to the recovery area by the psychiatrist. The RN returned to the recovery area.

The patient was provided an airway by the Anesthesiologist. Additional oxygen was administered via ambu bag (a device placed over an airway with oxygen filling a squeezable bag-like apparatus; the bag is squeezed to deliver oxygen into lungs). The patient's oxygen levels and vital signs (BP, heart rate, respirations) stabilized. The patient was monitored and then moved to the recovery area.
Patient #25 received post-procedure care including oxygen provided by nasal cannula (tube inserted into nostrils for the delivery of oxygen). The patient required an increase of the oxygen from 2 liters per minute (lpm) to 3 lpm via nasal cannula. The RN was informed by the ECT Coordinator that another patient was ready for recovery. The RN left the bedside of Patient #25 to attend to another patient entering the recovery area. The RN, a second time, asked the surveyor to keep an eye on a patient (Patient #25) while she attended to the another patient in recovery. The RN was observed opening the privacy curtain between Patient #25 and the second patient now in recovery. The RN was observed providing care between the 2 patients in recovery. The RN spoke to Patient #25 while at the other patient's bedside.

In an interview on 1/16/12 at 3:00 p.m., the Acting Director of Nursing (DON) described the staffing as one registered nurse in recovery, one RN in pre-procedure and one licensed practical nurse in the procedure area. The staffing schedule was reviewed with the Acting DON. The staffing schedule did not delineate each nurse's assignment to the recovery, pre-procedure, and procedure areas.

Further review of the staffing schedule revealed the facility did not identify a staff nurse as a responder to emergencies in the ECT area. The Acting DON said the registered nurse assigned to pre-procedure could respond and the nurse supervisor would respond to an emergency in any area of the hospital.

The Acting DON stated the ECT schedule could be changed to include nurse area assignments and include additional staff for recovery and assign a nurse to respond to emergent situations specific to the ECT area.

The Acting DON explained she was in charge of the ECT Department and referred to the Organizational Chart. The chart delineates the Acting DON as over the ECT Department as a supervisor. The ECT Coordinator's personnel file was reviewed. The job description for the ECT Coordinator identified the DON as the direct supervisor over the department.

A review of the Acting DON's personnel file revealed the job description does not include the direct supervision over the ECT Department. The Acting DON stated, "I need to get with HR (Human Resources) to see if they have any other information." The Acting DON returned with the Director of HR. The HR Director said the departmental supervision was an oversight in the DON's job description. The HR Director presented a new job description for the DON which included the departmental supervision of the ECT Department.

Based on observation, interviews, and review of the policy and procedure manual, the facility failed to ensure current and accurate pharmacy records for scheduled drugs - in particular, the anticonvulsants Lyrica (pregabalin) and Clonazepam.

The findings include:

1. During the initial tour of the pharmacy on 1/15/13 at 1:30 p.m., while verifying the pharmacy's controlled drug perpetual inventory, two errors were noted.

a. Controlled Drug Inventory Form indicated there should be 15 capsules of Lyrica 25 milligram (mg) in stock since 1/11/13. On 1/15/13 at 1:30 p.m., the Pharmacy Manager stated there were 105 Lyrica 25 mg capsules in stock and acknowledged the discrepancy.

Further record review revealed:
-On 1/3/13, the pharmacy had 40 capsules of Lyrica 25 mg on hand.
-On 1/10/13, the pharmacy received a bottle of 90 capsules of Lyrica 25 mg. The Pharmacy Manager stated that this bottle was missed and not added to the Controlled Drug Inventory.
-On 1/11/13, the Pharmacy Manager dispensed 25 capsules and subtracted this from the 1/3/13 count (40), showing the on-hand quantity as only 15 capsules. The Pharmacy Manager stated he should have noted the missed bottle received on 1/10/13 and added it to the inventory at this point.
-On 1/15/13, after surveyor intervention, the Pharmacy Manager corrected the inventory error.

b. Controlled Drug Inventory Form indicated 40 tablets of Clonazepam 0.25 mg should be in stock, since 1/8/13. On 1/15/13 at 1:30 p.m., the Pharmacy Manager stated there were 20 tablets of Clonazepam 0.25 mg tablets in stock and acknowledged the discrepancy.

Further review of the records revealed:
-On 1/8/13, the pharmacy had 40 tablets of Clonazepam 0.25 mg on hand.
-On 1/9/13, the Pharmacy Manager dispensed 20 tablets of Clonazepam 0.25 mg and did not update the Controlled Drug Inventory. The Pharmacy Manager stated he should have updated the Controlled Drug Inventory.
-On 1/15/13, after surveyor intervention, the Pharmacy Manager corrected the inventory error.

2. On 1/15/13, review of Controlled Medication Policy (MM-PHR-128) revealed, in section 4.2.4, "The Pharmacy Department must maintain, on a current basis, a complete and accurate record of each controlled substance received," and 4.12, "A perpetual controlled substance inventory shall be maintained at all times." The facility did not have an accurate controlled substance inventory.

Based on observation and interview, the facility failed to properly dispose of and store trash on the grounds. Improper trash disposal poses a risk of indirect disease transmission.

The findings include:

On 1/15/13 at 9:45 a.m., accompanied by the Housekeeping/Laundry Manager and the Plant Operations Director, the surveyor toured the trash containment area. Approaching the area, several Styrofoam cups and used purple exam gloves littered the area in front of the fenced trash containment area. Upon opening the gate, the dumpster was observed fully open. One of the two dumpster lids was was in an open position. The other lid was completely detached and laying on the pavement.

In an interview on 1/15/13 at 9:46 a.m., the Housekeeping/Laundry Manager confirmed that the dumpster lids should be closed. The Plant Operations Director admitted the lid had been broken "since last week."

Based on observation, interviews, and review of the facility's policy and procedure manuals, the facility failed to ensure hospital-wide infection control measures and effective systems. The facility failed to ensure glucometer test equipment is properly disinfected after use; the facility failed to ensure proper hand sanitation practice; the facility failed to ensure the adequate drying of dishes; the facility failed to ensure employees washed hands when handling clean dishes; the facility failed to ensure dishwashing equipment was working properly; and the facility failed to ensure proper pot and pan sanitation.

The findings include:

1. On 1/15/13 at 4:05 p.m. at the 3-West medication room, the surveyor observed Staff Nurse B performing a blood sugar check on a patient. After performing the blood sugar check, the nurse placed the glucometer back in the case without cleaning the device. Staff Nurse B administered the insulin as ordered, then left the med room to chart.

In an interview at 4:10 p.m., Staff Nurse B stated, "Night shift is responsible for cleaning the device." When asked if he cleans the glucometer device, the nurse replied, "No, am I supposed to?"

Review of Policy & Procedure for Cleaning of Patient Care Equipment (M11-00-122) included Policy D. "All medical equipment used for patient care must be cleaned and disinfected using a System approved disinfectant or wipes before use on another patient."

2. On 1/15/13 at 4:30 p.m., the surveyor observed Staff Nurse C check Patient #2's blood sugar. Upon return to the nurses' station, Staff Nurse C wiped the glucometer with alcohol pads.

In an interview at the time, the nurse said the procedure was to wipe it for 2 minutes with alcohol pads.

Review of Policy & Procedure for Cleaning of Patient Care Equipment (M11-00-122) included Policy A. describing patient care equipment having had contact with blood to be wiped with a "germicidal wipe maintaining the wet surface for the length of time per manufacturer's instruction..." The Procedure section did include a description of disinfecting patient care equipment such as a glucometer.

3. On 1/16/13, the surveyor observed Patient #25 from admission through discharge of the ECT procedure. This included observations of infection control methods approved, implemented and enforced by the administration of the hospital.
During the recovery phase of Patient #25, the Recovery Nurse received another patient in the recovery area. The Recovery Nurse provided care to Patient #25. After providing care to Patient #25, the recovery nurse was observed going to the bedside of the newly-admitted patient in the recovery area, without removing the gloves, or performing hand washing or hand hygiene.

The nurse was observed returning the bedside of Patient #25 and continued providing care wearing the same gloves.

4. On 1/15/13 at 8:30 a.m. in the kitchen, observed Dietary Aide D placing 26 just washed, clean trays underneath the food service tray line. The dishes were visibly wet and were stacked or "wet nested" on top of each other.

On 1/15/13 at 8:32 a.m. in an interview, Dietary Aide D stated the "dishes can be stacked when wet to let them dry." She added that the dishes "just need to be dry before being used."

On 1/15/13 at 8:33 a.m. in an interview, the Food Service Manager acknowledged the dishes were visibly wet and were stacked on top of each other. The Food Service Manager stated, "They do not have enough room to dry all the dishes ... It is alright to stack them to allow them to dry." He added staff "dry the dishes with a towel before serving patients, if they are still wet" and there is "no problem if they (dishes) are dry before serving patients."

On 1/15/13, review of Dietary Policy and Procedure for Personnel and Infection Control (PI 3, IC 4) found the following documentation: "Sanitation and Safety Policies: 8) All utensils and trays are allowed to air dry; toweling of these utensils is not permitted."

In the afternoon of 1/15/13, the Food Service Manager acknowledged this policy and stated he will inform his staff to allow the dishes to air dry and not to "wet nest" them.

On 1/16/13 at 8:20 a.m., the surveyor observed Dietary Aide F stacking wet dishes and not letting the dishes air dry. The Food Service Manager acknowledged that Dietary Aide F was "wet nesting" dishes stating that aide was not the routine dishwasher.

5. On 1/15/13 at 8:35 a.m. in the kitchen, the surveyor observed Dietary Aide D wearing gloves and rinsing dirty dishes from breakfast. She placed the rinsed dirty dishes inside the washing machine and began the cycle. Once the washing machine completed the cycle, the dietary aide pushed the clean dish tray out of the washing machine wearing the same gloves she wore while rinsing the dishes. Dietary Aide D did not remove the gloves, or wash her hands, prior to handling clean dishes for 3 more washing machine cycles.

On 1/16/13 at 8:20 a.m. in the kitchen, the surveyor observed Dietary Aide F wearing gloves and rinsing dirty dishes from breakfast. He was observed handling clean dishes without removing the gloves or washing his hands.

On 1/16/13 at 8:30 a.m. in an interview, the Food Service Manager acknowledged Dietary Aide F was not removing the gloves or washing his hands prior to handling clean dishes. The Food Service Manager stated the dietary aide was not the routine dishwasher and verified that staff should be changing gloves and washing hands after handling dirty dishes.

On 1/16/13 at 12:30 p.m., review of Dietary Policy and Procedure for Personnel and Infection Control (PI 3, IC 4) revealed: "Essentials: 3) n) Dietary personnel handling the dirty dishes, stripping trays, etc. in the Dish Room must wear a non-absorbent apron and wash their hands before handling 'clean' dishes." Review of Dietary Policy and Procedure for Hand-Washing (IC 4) revealed: "Gloves are not an acceptable substitute for proper hand-washing."

6. On 1/14/13 at 12:45 p.m. in the kitchen, observation of the washing machine "wash cycle" read 140 Fahrenheit (F) degrees during the entire "wash cycle" and the "rinse cycle" read 200 F degrees during the entire "rinse cycle." Dishes were being washed at this time for patient use.

On 1/14/13 at 12:45 p.m., review of the Dishwasher Temperature Log revealed that Dietary Aide E was the only person documenting the temperatures for the past 14 days from 1/1/13 until 1/14/13. The log revealed that the "wash cycle" was 150 F degrees and the "rinse cycle" was 180 F degrees for both the AM and PM recordings for each of those 14 days. No issues were documented about the temperatures or the machine.

On 1/14/13 at 12:45 p.m. in an interview, the Food Service Manager stated the "wash cycle" should be 150 F degrees and the "rinse cycle" should be 180 F degrees. He stated the low reading of 140 F degrees during the "wash cycle" was "alright, since the 'rinse cycle' is meeting the temperature requirement."

On 1/15/13 at 8:37 a.m. in the kitchen, the surveyor observed the washing machine "wash cycle" read 125 F degrees during the entire "wash cycle" and the "rinse cycle" read 200 F degrees during the entire "rinse cycle. Dishes were being washed at this time for patient use.

On 1/15/13 at 8:45 a.m. in an interview, Dietary Aide D stated she records the machine temperatures using the gauges and the "wash cycle" should be above 150 F degrees and the "rinse cycle" should be above 180 F degrees. She pointed to a sticker on the side of the washing machine that verified the "wash cycle temperature" should be 150 F degrees for 40 seconds and the "rinse cycle temperature" should be 180 F degrees for 8 seconds. Dietary Aide D acknowledged the "wash cycle" reading of 125 F degrees was low and stated she has been washing dishes for patient use all morning. She acknowledged she did not notice the low temperature today and had not recorded the temperature in the Dishwasher Temperature Log yet.

On 1/15/13 at 8:50 a.m., the Food Service Manager acknowledged the "wash cycle" reading of 125 F degrees.

On 1/15/13 at 9:00 a.m., the Ecolab dishwasher technician arrived. The technician stated the machine should be working within the parameters posted on the machine. He stated sometimes the machine "may take a few cycles" to warm up, but said the machine was not working correctly at this time. After reviewing the Dishwasher Temperature Log with the exact same readings each time, he expressed concern. He explained, "You should see variation in temperatures."

On 1/15/13 at 9:00 a.m., the Food Service Manager acknowledged the facility should not be washing dishes at 125 F degrees and the temperature log should have been completed prior to using the washing machine today.

On 1/16/13 at 8:20 a.m. in the kitchen, the surveyor observed Dietary Aide F washing dishes for patient use using the dishwasher. At 9:00 a.m., review of the Dishwasher Temperature Log showed the dishwasher temperatures for 1/16/13 AM had not been recorded yet. The Food Service Manager acknowledged this and stated they "do not need to record temperatures until the machine has warmed up - at around 9 a.m." He also stated it was "alright to wash dishes in the washing machine before the machine warmed up."

On 1/16/13 at 12:30 p.m., review of Dietary Policy and Procedure for Dishwasher Compliance Standards revealed, "It is the policy of the Food Service Department to check the temperatures at each meal and record on temperature logs" and "1) Temperature standards are as follows: a) minimum standard wash cycle 160 F degrees."

On 1/17/13 at 8:00 a.m., review of Dietary Aide E's time cards revealed that Dietary Aide E did not work on 1/4/13 and, did not work on 1/13/13. On 1/1/13, the employee arrived at 11:50 a.m., on 1/2/13, the employee arrived at 11:55 a.m., on 1/6/13, the employee arrived at 11:57 a.m., and on 1/9/13, the employee arrived at 11:50 a.m. Review of the Dishwasher Temperature Chart Log showed that Dietary Aide E documented the AM dishwasher temperatures even though he came in during the lunch time meals.

By the manufacturer, as well as facility policy, the minimum standard for the wash cycle was not being met.

7. On 1/15/13 at 9:00 a.m., review of the Pot and Pan Sanitation Log revealed that Dietary Aide E was the only person to document the pH readings for the past 14 days - from 1/1/13 until 1/14/13. The log revealed the pH was 400 parts per million (ppm) the 3 times it was tested each day. Times of when the pH was read were not documented in the log.

On 1/15/13 at 9:00 a.m., the Ecolab Dishwasher Technician demonstrated the proper procedure for testing the sanitation sink used for pot and pan cleaning. The technician explained how it was very unlikely for the facility to have a pH reading of 400 ppm every day. He explained that if the testing strip stays in the water longer than what the manufacturer recommends, or if the strip is shaken, it will provide false results.

On 1/15/13 at 9:00 a.m., review of the Pot and Pan Sanitation Log revealed the dietary aide documented a pH reading of 400 ppm. The dishwasher technician tested the same sanitation sink, according to manufacturer recommendations, and it had a pH reading of only 250 ppm.

On 1/16/13 at 4:30 p.m., the surveyor asked Dietary Aide E to demonstrate how he performs the pot and pan sanitation check. Dietary Aide E attempted to obtain a pH from the first compartment sink and the third compartment sink. The first compartment sink is filled with water and soap (not sanitizer). The second compartment is clear rinse water. The third compartment sink has the sanitizer. Dietary Aide E was unable to demonstrate how to record his findings on the log. Review of the log shows that only the pH for the third compartment is needed.

On 1/16/13 at 4:45 p.m., the Food Service Manager came over to assist the dietary aide. The Food Service Manager attempted to obtain a pH reading from the first compartment sink and was unable to obtain an accurate result. The Food Service Manager acknowledged the Pot and Pan Sanitation Log for 1/16/13 breakfast and lunch has not been recorded yet. The Food Service Manager said that on the following day, the dishwasher technician will provide an in-service on proper pH testing for the pots and pans.

On 1/17/13 at 8:00 a.m., review of Dietary Aide E's time cards revealed that Dietary Aide E did not work on 1/4/13 and did not work on 1/13/13.

On 1/17/13 at 8 a.m., review of Dietary Policy and Procedure for Pots and Pans Cleaning revealed "Chemical strips shall always be available to test adequate sanitizing strength in the third sink. The color codes indicated on the strip container must be verified prior to submersion into the third solution (sanitizer)."

Adequate sanitizing strength was not verified prior to washing dishes.

8. On 1/17/13 at 8:00 a.m., review of Dietary Policy and Procedure for Cleaning revealed, "To maintain a sanitary working environment ... 4) Management performs a formal sanitation inspection on a monthly basis (informal inspection occurs on an ongoing basis)."

On 1/17/13 at 12:30 p.m. in an interview, the Dietician stated she began at the facility on 12/27/12. The Dietician stated she oversees the food service program and provides oversight to the kitchen, making recommendations to both the hospital and the food service program. The current organizational chart, dated 1/14/13, does not address the dietician's role in the supervision of the kitchen.

The Dietician also stated she will be responsible for completing these sanitation reports to submit to the Quality Assurance Team; however she has not been here a month yet.

On 1/17/13 at 12:30 p.m., review of Dietary Policy and Procedure for Sanitation Surveys found the following documentation, "the sanitation and infection control survey will be completed each month."

The facility was unable to provide any copies of any previous completed sanitation surveys.


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Based on staff interview and medical record review, the facility failed to provide a discharge order for 1 (Patient #25) of 1 patient sampled who was receiving electroconvulsive therapy (ECT).

The findings include:

Beginning on 1/16/13 at 7:09 a.m., the surveyor observed Patient #25 from admission into the ECT department through the procedure, including discharge from the hospital. The medical record was reviewed. The medical record contained a post-procedure assessment conducted by the Recovery Nurse. The Recovery Nurse documented that Patient #25 returned to her pre-procedure baseline.

In an interview at 2:40 p.m., the Recovery Nurse explained the scoring of the patient after each procedure is performed; the anesthesiologist reviews the documentation and then discharges the patient. The Recovery Nurse referred to the facility form entitled "ECT - Post-Anesthesia Evaluation." The document includes criteria of "vital signs in patient's normal range;" "respiratory function stable: airway patent;" "cardiovascular function and hydration status stable;" "mental status recovered: patient participates in evaluation;" "pain control satisfactory;" and "nausea and vomiting control satisfactory."

A comment section on the Patient #25's completed form includes a hand-written entry, "No apparent anesthesia complications." The document is signed by the anesthesiologist, dated 1/16/13 at 8:56 a.m. Patient #25 was discharged at 9:34 a.m.

In an interview at 2:50 p.m., the Medical Director explained the anesthesiologist is in charge of post-procedure evaluation and would write the discharge order. The Medical Director pointed to the "ECT - Post-Anesthesia Evaluation" and stated, "That would be the discharge note." The Medical Director said the comment on the facility form does not include an order for discharge. The Medical Director agreed the comment section does not state to discharge patient and does not include any parameters for discharge. The Medical Director stated, "No, that is not a discharge order."

In a telephone interview on 1/17/13 at 9:30 a.m., the Director of Anesthesiology stated, "The psychiatrist would write the discharge order." Patient #25's "ECT - Post-Anesthesia Evaluation" form was reviewed with the Director of Anesthesiology. The Director commented that form is the post-anesthesia evaluation stating, "That is not a discharge order." The Director of Anesthesiology stated changes to the post-operative forms could serve as a discharge order, and "That could be easily added to discharge with parameters or goals met." He continued to explain a collaboration with the Medical Director to review forms and procedures and policy to insure delineation of duties including discharge was indicated.

The Director continued to state the desire is to be in compliance with all regulations. The Director explained he would meet with the Medical Director to insure each patient would have a clear written discharge order and the facility would review and revise facility forms and policy and procedures as required.

Based on clinical record review and staff interview, the facility failed to ensure that a post-anesthesia evaluation was performed for 1 (Patient #5) of 5 patients who received outpatient anesthesia and experienced unexpected post-operative conditions.

The findings include:

Clinical record review, on 1/17/13 for Patient #5, shows the patient received electroconvulsive therapy (ECT) on 12/17/12, 12/19/12, 12/21/12, 12/26/12, 1/9/13, 1/14/13 and 1/16/13.

1) On 12/19/12, post-ECT for Patient #5, the nurse documented "see attached note" in the notes section of an unnamed form. An unsigned, undated typed note in the record shows the patient's lips turned dark blue and his/her oxygen level dropped to the 80s. The anesthesiologist was called to the bedside in the recovery area and the patient was oxygenated with artificial respirations via an ambu bag (a mouth piece with a bag attached used to force air into the lungs). The patient was transferred back to the unit after improvement, but later had seizures on the unit and was sent out to the Emergency Department. The Anesthesiologist signed the ECT-Post Anesthesia Evaluation form on 12/19/12, at 11:34 a.m. The documentation shows that the patient's vital signs, respiratory function were stable. There is a section for comments which is preceded by "Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary." No comments were documented by the anesthesiologist to show that the patient experienced complications after the ECT.

2) On 1/7/13, the Registered Nurse (RN) documented that Patient #5 complained of chest pain described as an "8" on pain scale (0 to 10) stating, "feels like an elephant is sitting on my chest." The RN documented the patient's apical pulse was 66, with strong steady beats, and the anesthesiologist was notified with no new orders. The unit nurse was notified to have the medical doctor assess the patient when the patient returned to the unit. This note is not timed. The last documentation regarding the patient's vital signs was at 10:15 a.m. and the pulse was between 80 and 70 beats per minute. The anesthesiologist signed the ECT-Post Anesthesia Evaluation form on 1/7/13 at 10:31 a.m., which shows that the patient's vital signs, respiratory function were stable and pain control was satisfactory. No comments were documented by the anesthesiologist to show that the patient's complaints were evaluated by a qualified practitioner (an anesthesiologist or certified nurse anesthetist) or to show awareness of the patient's complaints of chest pain or the change in the patient's pulse, which dropped from the 70-80 range to 66.

3) On 1/9/13, post ECT, the nurse documented that Patient #5 complained of pressure on his/her chest - 7 on pain scale. O2 (oxygen) 95 at 1L (liters) NC (nasal cannula). The last recorded vital signs for the patient were at 9:50 a.m. The nurse documented that the discharge criteria was met at 9:51 a.m. The anesthesiologist signed a ECT-Post Anesthesia Evaluation form on 1/9/13 at 9:57 a.m., which shows that the patient's vital signs, respiratory function were stable and pain control was satisfactory. No comments were documented by the anesthesiologist to show that the patient was evaluated for the complaints of chest pain and required further monitoring on the unit.