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Based on interviews and employee files the facility failed to have a Director of Psychiatric Nursing (DPN) with the required qualifications.
Refer to Tag A0386

Based on interviews and employee files the facility failed to have a Director of Psychiatric Nursing (DPN) with the required qualifications.
Findings include:
Review of employee files on 3/18/15 revealed staff #13 was employed as the DPN on 2/9/2015. Review of staff #13's employee file revealed staff #13 did not have the required qualifications of a Bachelor's or Master's degree in Nursing.
An interview on 3/18/2015 with staff #2 and #3 confirmed staff #13 did not have a bachelor or master's degree in nursing. Failure to have the required qualifications to properly supervise a psychiatric unit has the likelihood to cause harm to all patients.

Based on observation, interview and record review the facility failed to ensure a sanitary environment in 5 of 5 areas in the hospital (Main campus dietary department, Psych dietary department, Emergency room, Medical-surgical unit, and laundry room).
This deficient practice had the likelihood to cause harm in all patients.
Findings included:

During a tour of the facility on 03/18/2015 the following was found:

* Main campus dietary department
The bottom of the food warming cart and track of the door on the cart had a build-up of dirt and grease. The outer portion of the food warmer was covered in grease, dried food particles and dried spills.
The base of the tray line was soiled with a build-up of grease.
A warming oven was found with a supply of clean towels stored in it. The inside of the warmer was soiled with a greasy substance, hair, dust and food particles.
Containers of food were found in the warmer without any kind of identifying labels.
The door seal to the cooler was cracked and had a buildup of mildew. The outside of the door of the cooler was covered with food particles and dry spills. The bottom portion of the door also had a cracked door seal and a build-up of condensation.
The door seal to the freezer was cracked, mildewed and would not seal properly. This allowed the freezer to have an ice-build-up on the inside. Also noted was a brown liquid substance which had been spilled in the freezer and on top of a package of ice cream.
The back inner panels on both fryers were covered with a thick brown and black greasy substance.
Inside a cooler were containers of vegetables that had been removed from the salad bar line. They were not dated or labeled.
The stove /griddle had two ovens and a middle grease trap drawer. The grease trap drawer held the grease and would slide out for easy emptying. When the door of the ovens was opened the grease trap was found to have a leak and a soiled hand towel was tucked underneath to collect the grease. The towel was saturated with grease that was dripping down onto the oven door and the floor. The towel was mildewed and had a foul odor. A pan of cooking utensils and pans were stored on the inside of one the ovens. The utensils and pans were soiled with grease and food particles.
The cutting board being used was stained and had gashes in it. There was no way the board could be properly sanitized.

A blender was stored on a shelf wet. The inside of the blender was also found to have a build-up of brown substance.
Knives and cooking utensils were stored in a drawer. The inside of the drawer and the utensils were soiled with food particles and a greasy substance.
Dishes and utensils were stored on a shelf that was soiled with food particle and grease. The racks on the shelves were covered in rust. There was no way the shelves could be sanitized.
Food still in shipping boxes was found in the walk-in cooler.
Supplies still in shipping boxes were stored on shelves in the clean food storage area.
A metal cart being used found near the dish washing area was covered with rust.
The floor underneath the dishwasher was covered with a layer of dirt and spills.
Clean pans were stacked on a shelf next to the dishwasher. They were stacked so tight that it would not allow for proper air drying.
Five plus steam table pans were stored on a shelf wet. This created a medium for bacteria growth.
A wall near the dishwashing area was found with 2 holes in the bottom portion of the wall tile.

* Psych unit dietary department
The top of the plate warmer was found to be broken. The top of the warmer and underneath the plates had a build-up of dust, food particles and grease.
A printer was sitting on a cart next to the plate warmer. The cart was covered in dust and food particles.
A spatula was removed from the food prep area was chipped and cracked. The spatula was not sanitizable.
Five plus dry good bins were observed to be soiled with food particles and grease. The top on one of the bins was cracked and broken leaving an entry for rodents. The scoops were inside the bins directly on the dry good products.
The commercial can opener and the holder was found with a build-up of black substance.
Just before you exit the kitchen and go into the dining room area a cooler was found with the door sealing covered with mildew.
A metal cabinet in the dishwashing area was found to be rusted at the bottom. There was a metal table next to the cabinet which had legs which had a build-up of dirt and were rusted.
A food cart used to store clean food trays was found and the top surface had burnt areas, holes, food particles and grease. The top surface of the cart was not sanitizable.

*Laundry room
A trashcan which contained murky water was underneath the soap dispenser. Liquid was leaking from the dispenser onto the wall and into the trashcan. The wall underneath the area had peeling paint and the baseboard had separated away from the wall. The floor in the same area was rusted and turning brown.
Staff #s' 1, 3, and 15 confirmed the observations in the dietary areas and laundry.
*Emergency Department
In Bay #1 the bed frame on the stretcher was soiled with a dried substance which had the appearance of blood.
In Bay #2 the bed frame on the stretcher was soiled with a dried substance which had the appearance of blood. The frame was also found with chipped and missing paint. The base of the stretcher had a build-up of dirt and hair.
A plastic caddy containing intravenous and lab clean supplies was found on a cabinet in the medication room. Inside the handle of the caddy was soiled with dried blood.
A linen cart was observed parked in the hallway with clean linen stored on it. The entire cart had mesh covering which had holes. The mesh covering could not protect the linen from spills or debris.
Staff #3 confirmed the observations.
Medical-surgical unit
A Dynamap was found with soiled tape wrapped on the handle. The attached blood pressure cuff was soiled with dried blood.
A desk at the nursing station was missing sections of the Formica covering and the wood underneath was exposed. The table surface could not be sanitized.
Staff #s' 1 and 3 confirmed the observations.

Review of March 2015 environmental round revealed no documentation of the problems found in the dietary department.
During an interview on 03/18/2015 after 3:00 p.m., Staff #3 reported the last environmental rounds in the dietary department was on 03/06/2015 and there was no documentation of those rounds.



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