HospitalInspections.org

Based on observation, review of facility documents, and staff interview, it was determined the facility failed ensure adverse events are documented and submitted to Quality Assurance Performance Improvement (QAPI) for tracking and trending.

Findings include:

During an interview on 9/29/23 at 10:44 AM, in the Raycroft Building, Staff #9 (S9), a Food Handler, stated that approximately two weeks prior, an incident occurred while he/she was unloading food trays from the food cart. Upon removing the food trays, he/she observed maggots located under the trays. S9 stated he/she informed his/her supervisor and the food trays were thrown away. S9 stated that an emergency meal was cooked and delivered from the Main Cafeteria in response to this event.

During an interview on 9/29/23 at 12:51 PM, Staff #6 (S6), the Food Service Supervisor I, stated he/she was alerted to the incident and at that time he/she found that there were maggots in the food cart. S6 stated the food in the cart was disposed of and he/she had an emergency replacement meal made and provided to patients in the Raycroft Building. S6 stated that the contaminated food cart was thrown away. When asked to provide documentation of the cart's removal or an incident event report, S6 was unable to provide documentation.

A review of facility policy titled, "Incident Reporting," revised on 1/2020, stated, "... II. POLICY ... C. All incidents, regardless of how minor in nature, are to be reported immediately and an Incident Report completed as soon as possible but no later than the end of the shift. Incidents shall be reported on the TPH [Trenton Psychiatric Hospital] Incident Report Form ... III. DEFINITIONS ... F. Incident ... Unusual incidents also include situations with DHS staff or contractors or affecting the operations of the facility. ... IV. PROCEDURE FOR INCIDENT REPORTING ... A. Initial Actions for All Incident Categories. When any type of incident occurs, the first staff member on the scene or the staff person having first knowledge of an incident shall immediately initiate the incident reporting process. This individual shall immediately notify the Charge Person or Supervisor and begin to prepare the applicable Incident Report Form. ..."