HospitalInspections.org

Based on observation, record review, and interviews the facility failed to
A. follow its own policy and procedures for complaint and grievance reporting in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Refer to Tag A0118
B. follow its own policy and procedures to ensure safety to the patients from injuries and abuse in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Refer to Tag A0144
C. follow its own policy and procedure for a timely medical record access and retrieval.
Refer to Tag A0148
D. ensure the patients' rights to be free from restraint or seclusion in 1(#1) out of 5 (#1, 3, 4, 6, and 7) charts reviewed. Patient #1 was on 1:1 observation and was kept secluded at the nurse's station due to insufficient staffing and staff convenience.
Refer to Tag A0154

Based on chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedures for complaint and grievance reporting in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Review of the policy and procedure "Patient Complaint/Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on (facility's) intranet. All complaints filed in Occurrence Insight are forwarded to the patient Relations Coordinator for investigation. Information should include at a minimum the patient's name, details of the compliant/grievance and contact information for follow up".
Review of patient 1's chart revealed he was admitted in the behavioral health unit on 7/3/2014 at 11:45AM. Patient #1 was admitted as an involuntary patient with an Emergency Detention Warrant dated 7/3/2014.
Review of the physician admission orders dated 7/3/2014 at 10:50AM revealed patient #1 was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute observations.
Review of the Nurses Notes dated 7/4/2014 at 9:40PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff.
Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted.
Physician notified and received order to give Geodon 10mg IM and Ativan 1 mg IM for sever agitation. 12:00AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
Review of patient #1's chart revealed no documentation of the size, length, depth, or other surrounding tissue of the injury to patient #1's neck, any wound care to the neck wound, or any vital signs taken after the injury or after the emergency dose of medication. The next set of vital signs was taken at 8:00AM on 7/5/2014. There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation.
Review of the physician discharge summary dated 7/6/2014 stated, "The patients wife was unhappy with his care and had a variety conflicts with the nursing staff. Ultimately, on 7/5/2014 during this stay, she demanded to take him home. The evening before the patient had sustained a small (blank) in his neck and some subcutaneous bleeding due to abrasion obtained during the prevention of fall. He had no serious injury noted, but his wife felt that this represented some sort of abuse to the patient. I assured her that the staff had reported that this had occurred when they were trying to prevent him from falling forward. She remains skeptical."
Review of patient #1's chart revealed he left Against Medical Advice (AMA) on 7/5/2014. There was no written complaint or grievance found concerning patient #1' s wife complaint of abuse.
Review of the patient #1's medical record revealed the patient was brought to the emergency room on 7/6/2014 for multiple bruises on face, neck, chest wall, and a new skin tear to the left upper arm. Patient #1 ' s wife requested that the Paris Police are notified of abuse and she wanted to make an official report.
An occurrence report was found on patient #1 on 7/6/2014. The occurrence report stated, "Patient wife states she thinks her husband was abused in the Gero Psych Unit because he now has multiple skin tears and when she signed him out and took him home he was drooling and slept for hours, patient presented to the ER requesting to file an abuse complaint, she demanded to speak with the police, date and time of event or events unknown."
A police report was taken and pictures were taken by the police officer. The patient was discharged home and a letter was sent to the patient and wife explaining the near fall.
An interview with staff #14 on 8/13/2014 revealed patient #1 was in the nurse's station in a chair. Staff #12 was sitting with him. Staff #14 was in the medication room and did not witness the near fall. When staff #14 walked back into the nurse's station staff #12 was holding patient #1 in a bear hug trying to keep him from falling. Staff #12 grabbed at the patients shirt causing a skin tear on this neck. Staff #14 reported she cleaned and covered the wound.
Staff #14 reported she had given a head to toe assessment to patient #1 but no documentation was found. Staff #14 confirmed she did not write an occurrence report. Staff #14 stated, "I did not write an occurrence report or call his wife. I realize that I really should have now."
Staff #14 confirmed that patient #1 was in a wheel chair in the nurse's station from the beginning of her shift from 7:00PM till 10:00PM. Staff #14 confirmed that patients are brought to the nurses station to be closely watched when they are shorthanded. Staff #14 confirmed the Geriatric Psychiatric Unit has been short staffed nurses and MHT's on multiple occasions.
Review of patient #2's chart revealed the patient was admitted to the Rehabilitation unit on 12/8/2014 after a lengthy acute care stay. Patient #2 had a stroke leaving her expressive dysphasic (the patient understands but cannot answer appropriately.)
Review of the policy and procedure "Patient Complaint/ Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on Paris Regional Medical Center's intranet. All complaints filed in Occurrence Insight are forwarded to the patient Relations Coordinator for investigation. Information should include at a minimum the patient's name, details of the compliant/grievance and contact information for follow up."
Review of patient #2's complaint revealed patient #2's daughter stated," 12/9/2013 Mom reported to us today that staff #21 had told my mother "God must really be mad" and mom reports after she said this she looked around to make sure no one was around."
Patient #2's daughter continued to report her mother told her of staff #21's abusive comments and being left in a chair with no call light, or water in reach, the daughter went to talk to the charge nurse. The daughter requested that staff #21 was not to be anywhere near her mother again.
On 12/12/2013 the daughter had stated, "Today mom told me that staff #21 had been looking in her room and approached her in the dining room. I left the director a message. "On 12/13/2014 Staff #24 spoke with the daughter and assured her staff #21 would not have any contact with the patient. It was reported that staff #21 was taking the patient #2's blood sugar after being instructed to stay away from the patient.
Review of staff #21's employee file revealed staff #21 had been disciplined on 8/14/11, 2/10/12, and 12/10/2013 for inappropriate comments, inappropriate sexual comments, derogatory comments about staff, offensive conversation, and vulgar language.
Review of an email on 12/14/2013 revealed staff #21 had been terminated. There was no occurrence report or patient complaint found that resulted in an employee termination.
On 8/13/2014, an interview with staff #24 was performed. Staff #24 stated,"I remember patient #2. I did speak with patient #2 about the incident concerning staff #21. I also spoke with her daughter later that afternoon. I did terminate staff #21 because she had previous issues and write ups."
Staff #24 stated, "I felt like I handled the problem and patient #2 seemed to be ok with our talk." Staff #24 stated, "I did not fill out an occurrence or complaint report. I didn 't think I needed to if I could handle it myself. "Staff #2 or #8 confirmed they were unaware of patient #2's complaint of intimidation and verbal abuse.

Based on the review of medical records, policy and procedures, and observations the facility failed to follow its own policy and procedures to ensure safety to the patients from injuries and abuse in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
During a tour of the Geriatric Psychiatric Unit the following issues were found;
1.) The bathroom outside of the seclusion room was found to have an exposed heat lamp socket. The bulb was gone leaving an exposed electrical lamp holder. All of the patient bathrooms had lamp holders with heat lamps in them. The heat lamps were not covered and secured. Each patient room had an unsecured arm chair that could easily be moved into the bathroom. The heat lamp was next to the shower and could easily be removed exposing the patient to electrocution, consumption of glass, laceration of neck or wrist, injury to staff or other patients, and possible death.
2.) Each patient room had non- break away curtains. This would allow for the patient to perform a possible hanging and possible death.
3.) The restraint /seclusion room had no chair or mattress. When the seclusion room is needed the patient would have no barrier from the bare floor.
Review of patient 1's chart revealed he was admitted in the behavioral health unit on 7/3/2014 at 11:45 AM. Patient #1 was admitted as an involuntary patient with an Emergency Detention Warrant dated 7/3/2014. Review of the physician admission orders dated 7/3/2014 at 10:50 AM revealed patient #1 was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute observations.
Review of the Initial Screening and Nursing Assessment dated 7/3/14 stated, "On Coumadin, bruises, legally blind, Macular degeneration, wears glasses. "Review of the skin assessment section stated, "Lt shoulder scar from skin tear. No open areas. Dressing removed from rt forearm. Skin tear almost healed. 1 cm open area no drainage noted." There is no further documentation of bruises or skin tears found. There were no photographs of skin tears or bruising.
Review of the "Specials Precautions Observation Log" dated 7/3/2014 revealed documentation of the patient #1 behavior and locations. Patient #1 was admitted at 11:45 AM and revealed the patient was up in a chair from 11:45 AM to 10:15 PM. Documentation revealed patient #1 was in the nurse's station from 2:00 PM-9:30 PM.
Review of the Nurses notes integumentary (skin) dated 7/3/2014 stated, "Bruises hands and arms." There was no further documentation of which hands or arms, how many bruises, size, color, or when the bruises occurred.
Review of the Nurses Notes dated 7/3/2014 at 5:00 PM stated, "In w/c in nurse's station after numerous attempts to stand alone. Is too weak to stand without assist. Continues to ask "where his kids are" and "why don't you just shoot me with a gun." Later stated, just let me start running and shoot me in the back. Making a gun with his hand pointing it at his head while making a popping noise." There was no further documentation of interventions performed to alleviate patient #1's behaviors.
Review of Nurses Notes dated 7/3/2014 at 9:30 PM revealed the patient was yelling and attempting to get out of his wheel chair. Staff #19 was on the unit and ordered Ativan .5mg by mouth x 1. Patient #1 spit out the medication. Staff #19 ordered Ativan .5mg by injection x 1. The medication was administered.
Review of Nurses Notes dated 7/3/2014 at 10:00 PM revealed the patient continued to yell and get out of his chair. The physician was called and the patient was ordered Geodon 10 mg IM x 1 now and was ordered to be placed on a 1:1 (within arm's length of a staff member) due to fall risk. The 1:1 must be reordered within 24 hours.
Review of the Nurses Notes dated 7/4/2014 at 9:40 PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff. Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted. Physician notified and received order to give Geodon 10 mg IM and Ativan 1 mg IM for sever agitation. 12:00 AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
Review of patient #1's chart revealed no documentation of the size, length, depth, or other surrounding tissue of the injury to patient #1's neck, any wound care to the neck wound, or any vital signs taken after the injury or after the emergency dose of medication. The next set of vital signs was taken at 8:00 AM on 7/5/2014. There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation.
Review of the physician discharge summary dated 7/6/2014 stated, "The patients wife was unhappy with his care and had a variety conflicts with the nursing staff. Ultimately on 7/5/2014 during this stay, she demanded to take him home. The evening before the patient had sustained a small (blank) in his neck and some subcutaneous bleeding due to abrasion obtained during the prevention of fall. He had no serious injury noted, but his wife felt that this represented some sort of abuse to the patient. I assured her that the staff had reported that this had occurred when they were trying to prevent him from falling forward. She remains skeptical."
Review of patient #1's chart revealed he left Against Medical Advice (AMA) on 7/5/2014. There was no written complaint or grievance found concerning patient #1's wife complaint of abuse.
Review of the patient #1's medical record revealed the patient was brought to the emergency room on 7/6/2014 for multiple bruises on face, neck, chest wall, and a new skin tear to the left upper arm. Patient #1's wife requested that the Paris Police are notified of abuse and she wanted to make an official report.
An occurrence report was found on patient #1 on 7/6/2014. The occurrence report stated, "Patient wife states she thinks her husband was abused in the Gero Psych Unit because he now has multiple skin tears and when she signed him out and took him home he was drooling and slept for hours, patient presented to the ER requesting to file an abuse complaint, she demanded to speak with the police, date and time of event or events unknown."
A police report was taken and pictures were taken by the police officer. The patient was discharged home and a letter was sent to the patient and wife explaining the near fall.
An interview with staff #14 on 8/13/2014 revealed patient #1 was in the nurse's station in a chair. Staff #12 was sitting with him. Staff #14 was in the medication room and did not witness the near fall. When staff #14 walked back into the nurse's station staff #12 was holding patient #1 in a bear hug trying to keep him from falling. Staff #12 grabbed at the patients shirt causing a skin tear on this neck. Staff #14 reported she cleaned and covered the wound.
Staff #14 reported she had given a head to toe assessment to patient #1 but no documentation was found. Staff #14 confirmed she did not write an occurrence report. Staff #14 stated, "I did not write an occurrence report or call his wife. I realize that I really should have now."
Staff #14 confirmed that patient #1 was in a wheel chair in the nurse's station from the beginning of her shift from 7:00 PM till 10:00 PM. Staff #14 confirmed that patients are brought to the nurses station to be closely watched when they are shorthanded. Staff #14 confirmed the Geriatric Psychiatric Unit has been short staffed nurses and MHT's on multiple occasions.
Review of patient #2's chart revealed the patient was admitted to the Rehabilitation unit on 12/8/2014 after a lengthy acute care stay. Patient #2 had a stroke leaving her expressive dysphasic (the patient understands but cannot answer appropriately.)
Review of the policy and procedure "Patient Complaint/ Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on (facility's) intranet. All complaints filed in Occurrence Insight are forwarded to the patient Relations Coordinator for investigation. Information should include at a minimum the patient's name, details of the compliant/grievance and contact information for follow up."
Review of patient #2's complaint revealed patient #2's daughter stated,"12/9/2013 Mom reported to us today that staff #21 had told my mother "God must really be mad" and mom reports after she said this she looked around to make sure no one was around."
Patient #2's daughter continued to report her mother told her of staff #21's abusive comments and being left in a chair with no call light, or water in reach, the daughter went to talk to the charge nurse. The daughter requested that staff #21 was not to be anywhere near her mother again.
On 12/12/2013 the daughter had stated, "Today mom told me that staff #21 had been looking in her room and approached her in the dining room. I left the director a message. "On 12/13/2014 Staff #24 spoke with the daughter and assured her staff #21 would not have any contact with the patient. It was reported that staff #21 was taking the patient #2's blood sugar after being instructed to stay away from the patient.
Review of staff #21's employee file revealed staff #21 had been disciplined on 8/14/11, 2/10/12, and 12/10/2013 for inappropriate comments, inappropriate sexual comments, derogatory comments about staff, offensive conversation, and vulgar language.
Review of an email on 12/14/2013 revealed staff #21 had been terminated. There was no occurrence report or patient complaint found that resulted in an employee termination.
On 8/13/2014 an interview with staff #24 was performed. Staff #24 stated, "I remember patient #2. I did speak with patient #2 about the incident concerning staff #21. I also spoke with her daughter later that afternoon. I did terminate staff #21 because she had previous issues and write ups."
Staff #24 stated, "I felt like I handled the problem and patient #2 seemed to be ok with our talk." Staff #24 stated, "I did not fill out an occurrence or complaint report. I didn't think I needed to if I could handle it myself. "Staff #2 or #8 confirmed they were unaware of patient #2's complaint of intimidation and verbal abuse.

Based on review of patient charts, policy and procedures, and interviews the facility failed to follow its own policy and procedure for a timely medical record access and retrieval.
Review of policy and procedure "ADM\Patient Rights\Ethics Confidentiality and Release of Medical Records of Health Care Information" states, "A patient has the right to request a copy of his health care information from the hospital or to examine the record during regular business hours. If the patient or personal representative is granted access, the hospital will comply with the request within 15 days of its receipt, or notify the patient within 15 days that the requested information does not exist or cannot be found."
Review of patient #2's complaint states, "7/2/2014 I wanted to get my medical records and they kept putting me off. They said it would be around 300.00 dollars. When I wanted to pay that they said the doctor had not signed off on my records? This is five months later. I'm not sure what's going on. So after many phone calls they have increased the price to 900.00 dollars."
An interview with staff #25 on 8/13/2014 at 3:50 PM revealed patient #2 had requested her medical records. Staff #25 stated a contracted service handles the copies of medical records and usually has a 24 hour turn around. Staff #25 stated the contracted company has employees in the hospital but they are supervised by staff #25.
Staff #25 reported she had no idea why the patient was quoted two different prices. Staff #25 reported that the patients can contact the contracted company and negotiate a price. The contracted company's computer was down and they could not offer any information to the surveyor.

Based on review of policy and procedures, observations, and interviews the facility failed to ensure the patients' rights to be free from restraint or seclusion in 1 (#1) out of 5 (#1, 3, 4, 6, and 7) charts reviewed. Patient #1 was on 1:1 observation and was kept secluded at the nurse's station due to insufficient staffing and staff convenience.

Review of the policy and procedure "Observations and Precautions" states," 1.) One to one (1-1) observation is defined as constant visual observation with staff remaining in the same room with the patient at all times unless the physician specifies in order that staff are to remain within arm's length at which point staff maintain the above and remain within arm's length of the patient at all times."
Review of patient #1's chart revealed he was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute checks.
Review of the "Specials Precautions Observation Log" dated 7/3/2014 revealed documentation of the patient #1 behavior and locations. Patient #1 was admitted at 11:45 AM and revealed the patient was up in a wheel chair from 11:45 AM to 10:15 PM. Documentation revealed patient #1 was in the nurse's station from 2:00 PM-9:30 PM.
Review of the Nurses Notes dated 7/3/2014 at 5:00 PM stated, "In w/c in nurse's station after numerous attempts to stand alone. Is too weak to stand without assist. Continues to ask "where his kids are" and "why don't you just shoot me with a gun." Later stated, just let me start running and shoot me in the back. Making a gun with his hand pointing it at his head while making a popping noise." There was no further documentation of interventions performed to alleviate patient #1's behaviors.
Review of Nurses Notes dated 7/3/2014 at 9:30 PM revealed the patient was yelling and attempting to get out of his wheel chair. Staff # 19 was on the unit and ordered Ativan .5mg by mouth x1. Patient #1 spit out the medication. Staff #19 ordered Ativan .5mg by injection x1. The medication was administered.
Review of Nurses Notes dated 7/3/2014 at 10:00 PM revealed the patient continued to yell and get out of his chair. The physician was called and the patient was ordered Geodon 10 mg IM x 1 now and was ordered to be placed on a 1:1 (within arm's length of a staff member) due to fall risk. The 1:1 must be reordered within 24 hours.
Review of the Nurses Notes dated 7/4/2014 at 9:40 PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff. Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted. Physician notified and received order to give Geodon 10 mg IM and Ativan 1 mg IM for sever agitation. 12:00 AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation on 7/4/14.
An interview with staff #14 stated, "We sometimes bring patients that are 1:1's to the nurse's station if the MHT is busy. "
An interview with staff #9 on 8/11/14 stated, "If we don ' t have enough aides to watch the patients that are on 1:1's we have to leave them in the nurse's station." Staff #9 confirmed the patient cannot go to their room and lay down if no one is available to go to the patient room with them. Staff #9 stated,"If we let the high risk patients go to their rooms they could fall and we would not know it."

Based on review of staffing sheets, staffing grid, and interviews the facility failed to adequately staff the Geriatric Psychiatric Unit to ensure the safety of the patients and staff. The facility failed to have sufficient staff to prevent falls, injuries, and possible death to the patients in the unit.

Refer to Tag A0392.

Based on review of staffing sheets, staffing grid, and interviews the facility failed to adequately staff the Geriatric Psychiatric Unit to ensure the safety of the patients and staff. The facility failed to have sufficient staff on 11 of 62 shifts reviewed to prevent falls, injuries, and possible death to the patients in the unit.
Review of the staffing sheets and grid for the Geriatric Psychiatric Unit from 7/1/2014 to 7/31/2014 revealed the following (7:00 AM- 7:00 PM is the day shift. 7:00 PM-7:00 AM is the night shift.);
Out of 62 shifts, 8 shifts were short a licensed person and 11 shifts were short a Mental Health Technician(MHT.)
7/3/14- short 1 MHT days - 1 RN and 1 MHT nights.
7/4/14- short 1 LVN days - 1 RN and 1 MHT nights
7/5/14- short 1 LVN day and night shift.
7/7/14- short 1 MHT days and 1 RN on nights.
7/8/14- short 1 MHT days and 1 RN at night.
7/9/14- short 1 MHT days and 1 LVN nights.
7/11/14- short 1 MHT nights.
7/12/14- short 1 MHT day and night shift.
7/13/14- short 1 MHT nights.
7/27/14- short 1 MHT nights.
Review of patient #1's stay from 7/3-7/5/2014 revealed the staff was short an RN, LVN, and MHT. On 7/3-7/4/2014 Nurses notes revealed the patient was on a 1:1 (staff at arm ' s length). Staff #12 was assigned to the patient as the 1:1 leaving the unit without a MHT to care for the remaining patients.
An interview with staff #14 on 8/13/14 revealed the census had increased and there was not enough staff to perform the 1:1 on 7/4/14. Staff #14 reported the patient was brought to the nurse's station for the nurses to watch the patient while the MHT did other duties. Staff #14 reported the patient was with the MHT in the nurse's station when the near fall with injury occurred.
An interview with staff #11 on 8/11/14 revealed staff #26 works as a activity counselor (AC) and a MHT on the same shift. Staff #11 stated, "We have been short but we are trying to hire people." Staff #11 confirmed that the unit schedule did not show 1:1 assignments. The staffing schedule did not make allowances for 1:1 needs. Staff #11 confirmed he did not have a log of 1:1's on his unit.
An interview with staff #26 on 8/11/14 confirmed she works as an AC and a MHT at the same time. Staff #26 confirmed that she tries to get everyone in group so she can chart the 15 observation but when a patient does not want to come to group then one of the nurses must do the checks.

Based upon observation and interview, the facility failed to provide an organized sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.

Refer to Tag A0619

Based upon observation and interview, the facility failed to provide an organized sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.
During a tour of the Dietary Department on 8/12/2014 the following items were found;
1. Under the food preparation area the floor drain was dirty with trash and a thick brown substance in the bottom. The surrounding floor was dirty with a greasy black sticky substance. The exposed pipes going into the floor drain was dirty with mineral build up and a greasy substance.
2. A multi-shelved cart used to put dirty kitchen trays on was found in the kitchen "clean area" next to the food preparation area. The cart was coated in dried and thick greasy substances on each shelf. Staff #2 reported it was supposed to be in the dirty side of the kitchen and was pushed over to the clean side till the dishwasher could get to it.
3. Nine "clean" baking sheets were found to have carbon and greasy build-up around the lip and sides of the sheets. This build-up does not allow the pans to be properly cleaned.
4. 13 clean kitchen pots and strainers were sitting on shelves covered in hair, dried food particles, and a fine greasy substance.
5. The wheels and metal frame of a food cart was covered in a greasy buildup of dirt, hair, and dried food particles. A second cart had two shelves of kitchen linen unwrapped. The opened linen was sitting on a soiled greasy shelf.
7. Six fryer baskets were found stacked on a tray coated in food particles. The first fryer vat had a foul smell, black colored grease with thick food particles, and a greasy substance built up along the sides.
8. The second fryer vat had black colored grease with coated food particles, and a thick greasy build-up inside the vat.
9. The back splash between the fryers and the other side of the kitchen was covered in a greasy substance with food particles. A space between the grill area and drawers was covered in a greasy substance, food particles, and dust. A dirty wire brush was coated in a greasy substance.
10. The front of the stove was covered in grease, dust, dirt, and food particles. The side of the stove was covered in a thick greasy substance, food particles, and dust.
11. The outer surface of the grill and oven was soiled in a greasy substance; the doors to the ovens had a build-up of grease, and food particles.
12. The floor under the grill and oven was coated in dirt, grease, dried food particles, and hair.
13. The bottom of the second double oven had rust corrosion, greasy build-up and dried food particles on the legs and wheel base. The bottom door handles and outside of oven was greasy with rust and dried food particles.
14. The bottom oven was coated in grease; dried food, spilled food particles, and carbon build up.
15. The second floor drain, under a food preparation area, had corrosion on the pipes and the drain pan was rusted with chipped paint in the pan. The underneath of the preparation table was coated in a greasy substance.
16. In the warmer next to the coolers an unmarked styro foam dish was found with a serving of broccoli and cheese. There were no dates. The kitchen staff could not state when that item may have been put in the warmer.
17. In the warmer next to the cooler another styro foam box was found with no dates. The box contained dried up crusty food.
18. The outside of the cooler was coated in a dusty, greasy substance.
19. Cardboard shipping boxes were found in the cooler. The cooler shelves were dirty with food particles and a greasy substance.
20. Prepared foods were found opened, uncovered, with no dates in the cooler. The kitchen staff was unsure when the foods were opened.
22. Shipping boxes were found in the walk -in cooler.
23. Three containers of prepared meats covered in plastic wrap, sitting next to eggs, were found in the cooler with no dates or sources of where the meat came from. A container of thawing chicken was found with an orange plastic bag, lying half way across the chicken.
24. The toaster in the food preparation area was coated in a greasy substance with a buildup of food particles.
25. A black portable table fan was found in the kitchen coated in a greasy dust covered substance.
26. Floor drains in the kitchen dish washing area were caked in a thick crusty brown and gray substance. The grates were clogged with trash particles, hair, and dirt like substance.
27. 56 pots and pans were found stacked wet. Staff# 6 confirmed the pots and pans had not been allowed to dry properly before they were stacked.
28. The walk- in freezer was found to have a large amount of ice build-up around the door and a frozen floor covered in ice.
29. The walk in freezer had a thick coat of frost on the food products. The ceiling of the walk in freezer had an icy condensation.
30. Food was found on the bottom shelf of a wire rack. There was no plastic barrier on any of the lower shelves in the freezers or walk in coolers. The wire racks were covered in a greasy, caked on dried food particles, and dust. Foods in shipping boxes were placed on the wire shelf with no barrier in the walk in freezers. Boxes of food were found on the floor under the shelves. The floor was covered in trash and food particles.

Based upon observation and interview, the facility failed to
A. provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.
Refer to Tag A0619
B. ensure the infection control officer had a system for observing and investigating the kitchen as a sanitary hospital environment. Failure to monitor the kitchen and kitchen staff places the patient and visitors at a high risk of receiving a food borne illness.

Refer to Tag A0748
C. ensure the infection control officer provided monitoring and surveillance measures for the early identification of patients who require isolation in accordance with CDC guidelines. Failure to identify patients with infectious diseases places staff, visitors, and patients at risk of contracting a disease and possible death.
Refer to Tag A0749

Based on review of the Infection control logs and interviews, the infection control officer failed to have a system for observing and investigating the kitchen as a sanitary hospital environment. Failure to monitor the kitchen and kitchen staff places the patient and visitors at a high risk of receiving a food borne illness.

An interview with staff #23 on 8/13/2014 at 4:30 PM, revealed the facility was not conducting environmental rounds on a consistent base. Staff # 23 reported the facility had a new Maintenance Director (MD). The Maintenance Director was in charge of the rounds. Staff #23 reported the MD wanted to do rounds first Wednesday of the month but did not have the kitchen as a department to review on regular basis. Staff #23 reported she did not have any recent environmental rounding reports to show the surveyor. Staff #23 stated, "We have not been in the kitchen to do rounds. I had no idea it was that bad."

Based on review of the Infection control logs and interviews, the infection control officer failed to monitor and implement surveillance measures for the early identification of patients who require isolation in accordance with CDC guidelines. Failure to identify patients with infectious diseases places staff, visitors, and patients at risk of contracting a disease and possible death.
Review of patient #2's physician progress notes dated 12/11/2014 stated, "I had a face to face visit with the patient today and I personally interviewed and examined her. She continues to complain of quite a bit of pain on her R buttock, and after re-evaluation today it is consistent with very distal S1 shingles. Discussed risks and benefits of Valtrex, agreed to start this medicine."
Valtrex three times a day for 7 days was ordered on 12/11/2014. Patient #2 shared a bathroom and attended group exercises with another patient on the rehab unit.
Review of patient #2's chart revealed the nurse documented the infection control nurse was notified of the diagnosis of shingles on 12-11-2014. Review of the infection control log revealed patient #2 was not on the list.
An interview with staff #23 on 8/13/2014 at 4:45 PM revealed patient #2 was diagnosed with shingles. Staff #23 reported the nurse had documented that she had notified the infection control nurse but it was never logged in the computer. The primary care nurse must place a consult order in for the infection control nurse. Staff #23 confirmed she was never informed of the diagnosis and the patient was not placed in contact isolation.

Based on observation, record review, and interviews the facility failed to
A. follow its own policy and procedures for complaint and grievance reporting in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Refer to Tag A0118
B. follow its own policy and procedures to ensure safety to the patients from injuries and abuse in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Refer to Tag A0144
C. follow its own policy and procedure for a timely medical record access and retrieval.
Refer to Tag A0148
D. ensure the patients' rights to be free from restraint or seclusion in 1(#1) out of 5 (#1, 3, 4, 6, and 7) charts reviewed. Patient #1 was on 1:1 observation and was kept secluded at the nurse's station due to insufficient staffing and staff convenience.
Refer to Tag A0154

Based on chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedures for complaint and grievance reporting in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
Review of the policy and procedure "Patient Complaint/Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on (facility's) intranet. All complaints filed in Occurrence Insight are forwarded to the patient Relations Coordinator for investigation. Information should include at a minimum the patient's name, details of the compliant/grievance and contact information for follow up".
Review of patient 1's chart revealed he was admitted in the behavioral health unit on 7/3/2014 at 11:45AM. Patient #1 was admitted as an involuntary patient with an Emergency Detention Warrant dated 7/3/2014.
Review of the physician admission orders dated 7/3/2014 at 10:50AM revealed patient #1 was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute observations.
Review of the Nurses Notes dated 7/4/2014 at 9:40PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff.
Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted.
Physician notified and received order to give Geodon 10mg IM and Ativan 1 mg IM for sever agitation. 12:00AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
Review of patient #1's chart revealed no documentation of the size, length, depth, or other surrounding tissue of the injury to patient #1's neck, any wound care to the neck wound, or any vital signs taken after the injury or after the emergency dose of medication. The next set of vital signs was taken at 8:00AM on 7/5/2014. There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation.
Review of the physician discharge summary dated 7/6/2014 stated, "The patients wife was unhappy with his care and had a variety conflicts with the nursing staff. Ultimately, on 7/5/2014 during this stay, she demanded to take him home. The evening before the patient had sustained a small (blank) in his neck and some subcutaneous bleeding due to abrasion obtained during the prevention of fall. He had no serious injury noted, but his wife felt that this represented some sort of abuse to the patient. I assured her that the staff had reported that this had occurred when they were trying to prevent him from falling forward. She remains skeptical."
Review of patient #1's chart revealed he left Against Medical Advice (AMA) on 7/5/2014. There was no written complaint or grievance found concerning patient #1' s wife complaint of abuse.
Review of the patient #1's medical record revealed the patient was brought to the emergency room on 7/6/2014 for multiple bruises on face, neck, chest wall, and a new skin tear to the left upper arm. Patient #1 ' s wife requested that the Paris Police are notified of abuse and she wanted to make an official report.
An occurrence report was found on patient #1 on 7/6/2014. The occurrence report stated, "Patient wife states she thinks her husband was abused in the Gero Psych Unit because he now has multiple skin tears and when she signed him out and took him home he was drooling and slept for hours, patient presented to the ER requesting to file an abuse complaint, she demanded to speak with the police, date and time of event or events unknown."
A police report was taken and pictures were taken by the police officer. The patient was discharged home and a letter was sent to the patient and wife explaining the near fall.
An interview with staff #14 on 8/13/2014 revealed patient #1 was in the nurse's station in a chair. Staff #12 was sitting with him. Staff #14 was in the medication room and did not witness the near fall. When staff #14 walked back into the nurse's station staff #12 was holding patient #1 in a bear hug trying to keep him from falling. Staff #12 grabbed at the patients shirt causing a skin tear on this neck. Staff #14 reported she cleaned and covered the wound.
Staff #14 reported she had given a head to toe assessment to patient #1 but no documentation was found. Staff #14 confirmed she did not write an occurrence report. Staff #14 stated, "I did not write an occurrence report or call his wife. I realize that I really should have now."
Staff #14 confirmed that patient #1 was in a wheel chair in the nurse's station from the beginning of her shift from 7:00PM till 10:00PM. Staff #14 confirmed that patients are brought to the nurses station to be closely watched when they are shorthanded. Staff #14 confirmed the Geriatric Psychiatric Unit has been short staffed nurses and MHT's on multiple occasions.
Review of patient #2's chart revealed the patient was admitted to the Rehabilitation unit on 12/8/2014 after a lengthy acute care stay. Patient #2 had a stroke leaving her expressive dysphasic (the patient understands but cannot answer appropriately.)
Review of the policy and procedure "Patient Complaint/ Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on Paris Regional Medical Center's intranet. All complaints filed in Occurrence Insight are forwarded to the patient Relations Coordinator for investigation. Information should include at a minimum the patient's name, details of the compliant/grievance and contact information for follow up."
Review of patient #2's complaint revealed patient #2's daughter stated," 12/9/2013 Mom reported to us today that staff #21 had told my mother "God must really be mad" and mom reports after she said this she looked around to make sure no one was around."
Patient #2's daughter continued to report her mother told her of staff #21's abusive comments and being left in a chair with no call light, or water in reach, the daughter went to talk to the charge nurse. The daughter requested that staff #21 was not to be anywhere near her mother again.
On 12/12/2013 the daughter had stated, "Today mom told me that staff #21 had been looking in her room and approached her in the dining room. I left the director a message. "On 12/13/2014 Staff #24 spoke with the daughter and assured her staff #21 would not have any contact with the patient. It was reported that staff #21 was taking the patient #2's blood sugar after being instructed to stay away from the patient.
Review of staff #21's employee file revealed staff #21 had been disciplined on 8/14/11, 2/10/12, and 12/10/2013 for inappropriate comments, inappropriate sexual comments, derogatory comments about staff, offensive conversation, and vulgar language.
Review of an email on 12/14/2013 revealed staff #21 had been terminated. There was no occurrence report or patient complaint found that resulted in an employee termination.
On 8/13/2014, an interview with staff #24 was performed. Staff #24 stated,"I remember patient #2. I did speak with patient #2 about the incident concerning staff #21. I also spoke with her daughter later that afternoon. I did terminate staff #21 because she had previous issues and write ups."
Staff #24 stated, "I felt like I handled the problem and patient #2 seemed to be ok with our talk." Staff #24 stated, "I did not fill out an occurrence or complaint report. I didn 't think I needed to if I could handle it myself. "Staff #2 or #8 confirmed they were unaware of patient #2's complaint of intimidation and verbal abuse.

Based on the review of medical records, policy and procedures, and observations the facility failed to follow its own policy and procedures to ensure safety to the patients from injuries and abuse in 2 (#1 and #2) out of 10 (#1-10) charts reviewed.
During a tour of the Geriatric Psychiatric Unit the following issues were found;
1.) The bathroom outside of the seclusion room was found to have an exposed heat lamp socket. The bulb was gone leaving an exposed electrical lamp holder. All of the patient bathrooms had lamp holders with heat lamps in them. The heat lamps were not covered and secured. Each patient room had an unsecured arm chair that could easily be moved into the bathroom. The heat lamp was next to the shower and could easily be removed exposing the patient to electrocution, consumption of glass, laceration of neck or wrist, injury to staff or other patients, and possible death.
2.) Each patient room had non- break away curtains. This would allow for the patient to perform a possible hanging and possible death.
3.) The restraint /seclusion room had no chair or mattress. When the seclusion room is needed the patient would have no barrier from the bare floor.
Review of patient 1's chart revealed he was admitted in the behavioral health unit on 7/3/2014 at 11:45 AM. Patient #1 was admitted as an involuntary patient with an Emergency Detention Warrant dated 7/3/2014. Review of the physician admission orders dated 7/3/2014 at 10:50 AM revealed patient #1 was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute observations.
Review of the Initial Screening and Nursing Assessment dated 7/3/14 stated, "On Coumadin, bruises, legally blind, Macular degeneration, wears glasses. "Review of the skin assessment section stated, "Lt shoulder scar from skin tear. No open areas. Dressing removed from rt forearm. Skin tear almost healed. 1 cm open area no drainage noted." There is no further documentation of bruises or skin tears found. There were no photographs of skin tears or bruising.
Review of the "Specials Precautions Observation Log" dated 7/3/2014 revealed documentation of the patient #1 behavior and locations. Patient #1 was admitted at 11:45 AM and revealed the patient was up in a chair from 11:45 AM to 10:15 PM. Documentation revealed patient #1 was in the nurse's station from 2:00 PM-9:30 PM.
Review of the Nurses notes integumentary (skin) dated 7/3/2014 stated, "Bruises hands and arms." There was no further documentation of which hands or arms, how many bruises, size, color, or when the bruises occurred.
Review of the Nurses Notes dated 7/3/2014 at 5:00 PM stated, "In w/c in nurse's station after numerous attempts to stand alone. Is too weak to stand without assist. Continues to ask "where his kids are" and "why don't you just shoot me with a gun." Later stated, just let me start running and shoot me in the back. Making a gun with his hand pointing it at his head while making a popping noise." There was no further documentation of interventions performed to alleviate patient #1's behaviors.
Review of Nurses Notes dated 7/3/2014 at 9:30 PM revealed the patient was yelling and attempting to get out of his wheel chair. Staff #19 was on the unit and ordered Ativan .5mg by mouth x 1. Patient #1 spit out the medication. Staff #19 ordered Ativan .5mg by injection x 1. The medication was administered.
Review of Nurses Notes dated 7/3/2014 at 10:00 PM revealed the patient continued to yell and get out of his chair. The physician was called and the patient was ordered Geodon 10 mg IM x 1 now and was ordered to be placed on a 1:1 (within arm's length of a staff member) due to fall risk. The 1:1 must be reordered within 24 hours.
Review of the Nurses Notes dated 7/4/2014 at 9:40 PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff. Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted. Physician notified and received order to give Geodon 10 mg IM and Ativan 1 mg IM for sever agitation. 12:00 AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
Review of patient #1's chart revealed no documentation of the size, length, depth, or other surrounding tissue of the injury to patient #1's neck, any wound care to the neck wound, or any vital signs taken after the injury or after the emergency dose of medication. The next set of vital signs was taken at 8:00 AM on 7/5/2014. There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation.
Review of the physician discharge summary dated 7/6/2014 stated, "The patients wife was unhappy with his care and had a variety conflicts with the nursing staff. Ultimately on 7/5/2014 during this stay, she demanded to take him home. The evening before the patient had sustained a small (blank) in his neck and some subcutaneous bleeding due to abrasion obtained during the prevention of fall. He had no serious injury noted, but his wife felt that this represented some sort of abuse to the patient. I assured her that the staff had reported that this had occurred when they were trying to prevent him from falling forward. She remains skeptical."
Review of patient #1's chart revealed he left Against Medical Advice (AMA) on 7/5/2014. There was no written complaint or grievance found concerning patient #1's wife complaint of abuse.
Review of the patient #1's medical record revealed the patient was brought to the emergency room on 7/6/2014 for multiple bruises on face, neck, chest wall, and a new skin tear to the left upper arm. Patient #1's wife requested that the Paris Police are notified of abuse and she wanted to make an official report.
An occurrence report was found on patient #1 on 7/6/2014. The occurrence report stated, "Patient wife states she thinks her husband was abused in the Gero Psych Unit because he now has multiple skin tears and when she signed him out and took him home he was drooling and slept for hours, patient presented to the ER requesting to file an abuse complaint, she demanded to speak with the police, date and time of event or events unknown."
A police report was taken and pictures were taken by the police officer. The patient was discharged home and a letter was sent to the patient and wife explaining the near fall.
An interview with staff #14 on 8/13/2014 revealed patient #1 was in the nurse's station in a chair. Staff #12 was sitting with him. Staff #14 was in the medication room and did not witness the near fall. When staff #14 walked back into the nurse's station staff #12 was holding patient #1 in a bear hug trying to keep him from falling. Staff #12 grabbed at the patients shirt causing a skin tear on this neck. Staff #14 reported she cleaned and covered the wound.
Staff #14 reported she had given a head to toe assessment to patient #1 but no documentation was found. Staff #14 confirmed she did not write an occurrence report. Staff #14 stated, "I did not write an occurrence report or call his wife. I realize that I really should have now."
Staff #14 confirmed that patient #1 was in a wheel chair in the nurse's station from the beginning of her shift from 7:00 PM till 10:00 PM. Staff #14 confirmed that patients are brought to the nurses station to be closely watched when they are shorthanded. Staff #14 confirmed the Geriatric Psychiatric Unit has been short staffed nurses and MHT's on multiple occasions.
Review of patient #2's chart revealed the patient was admitted to the Rehabilitation unit on 12/8/2014 after a lengthy acute care stay. Patient #2 had a stroke leaving her expressive dysphasic (the patient understands but cannot answer appropriately.)
Review of the policy and procedure "Patient Complaint/ Grievance" stated, "Employees who receive complaints are to enter them in Occurrence Insight located on (facility

Based on review of patient charts, policy and procedures, and interviews the facility failed to follow its own policy and procedure for a timely medical record access and retrieval.
Review of policy and procedure "ADM\Patient Rights\Ethics Confidentiality and Release of Medical Records of Health Care Information" states, "A patient has the right to request a copy of his health care information from the hospital or to examine the record during regular business hours. If the patient or personal representative is granted access, the hospital will comply with the request within 15 days of its receipt, or notify the patient within 15 days that the requested information does not exist or cannot be found."
Review of patient #2's complaint states, "7/2/2014 I wanted to get my medical records and they kept putting me off. They said it would be around 300.00 dollars. When I wanted to pay that they said the doctor had not signed off on my records? This is five months later. I'm not sure what's going on. So after many phone calls they have increased the price to 900.00 dollars."
An interview with staff #25 on 8/13/2014 at 3:50 PM revealed patient #2 had requested her medical records. Staff #25 stated a contracted service handles the copies of medical records and usually has a 24 hour turn around. Staff #25 stated the contracted company has employees in the hospital but they are supervised by staff #25.
Staff #25 reported she had no idea why the patient was quoted two different prices. Staff #25 reported that the patients can contact the contracted company and negotiate a price. The contracted company's computer was down and they could not offer any information to the surveyor.

Based on review of policy and procedures, observations, and interviews the facility failed to ensure the patients' rights to be free from restraint or seclusion in 1 (#1) out of 5 (#1, 3, 4, 6, and 7) charts reviewed. Patient #1 was on 1:1 observation and was kept secluded at the nurse's station due to insufficient staffing and staff convenience.

Review of the policy and procedure "Observations and Precautions" states," 1.) One to one (1-1) observation is defined as constant visual observation with staff remaining in the same room with the patient at all times unless the physician specifies in order that staff are to remain within arm's length at which point staff maintain the above and remain within arm's length of the patient at all times."
Review of patient #1's chart revealed he was admitted with a diagnosis of Dementia with Depression and Behavioral disturbance. He was ordered to be on 15 minute checks.
Review of the "Specials Precautions Observation Log" dated 7/3/2014 revealed documentation of the patient #1 behavior and locations. Patient #1 was admitted at 11:45 AM and revealed the patient was up in a wheel chair from 11:45 AM to 10:15 PM. Documentation revealed patient #1 was in the nurse's station from 2:00 PM-9:30 PM.
Review of the Nurses Notes dated 7/3/2014 at 5:00 PM stated, "In w/c in nurse's station after numerous attempts to stand alone. Is too weak to stand without assist. Continues to ask "where his kids are" and "why don't you just shoot me with a gun." Later stated, just let me start running and shoot me in the back. Making a gun with his hand pointing it at his head while making a popping noise." There was no further documentation of interventions performed to alleviate patient #1's behaviors.
Review of Nurses Notes dated 7/3/2014 at 9:30 PM revealed the patient was yelling and attempting to get out of his wheel chair. Staff # 19 was on the unit and ordered Ativan .5mg by mouth x1. Patient #1 spit out the medication. Staff #19 ordered Ativan .5mg by injection x1. The medication was administered.
Review of Nurses Notes dated 7/3/2014 at 10:00 PM revealed the patient continued to yell and get out of his chair. The physician was called and the patient was ordered Geodon 10 mg IM x 1 now and was ordered to be placed on a 1:1 (within arm's length of a staff member) due to fall risk. The 1:1 must be reordered within 24 hours.
Review of the Nurses Notes dated 7/4/2014 at 9:40 PM revealed Patient #1 was in the Nurses Station in a wheel chair. Patient #1 was agitated and attempting to hit staff. Staff #14 documented, "Pt almost fell out of wheel chair but was caught by staff. No fall noted. Multiple attempts at redirection unsuccessful. Skin tear with bruising noted to right side of neck. No other injuries noted. Physician notified and received order to give Geodon 10 mg IM and Ativan 1 mg IM for sever agitation. 12:00 AM Pt resting in bed appears to be asleep. Respirations even and unlabored no signs and symptoms of distress noted. 1:1 observation. Will continue to monitor."
There was no documentation of an occurrence report, family notification, or a physician's order to continue the 1:1 observation on 7/4/14.
An interview with staff #14 stated, "We sometimes bring patients that are 1:1's to the nurse's station if the MHT is busy. "
An interview with staff #9 on 8/11/14 stated, "If we don ' t have enough aides to watch the patients that are on 1:1's we have to leave them in the nurse's station." Staff #9 confirmed the patient cannot go to their room and lay down if no one is available to go to the patient room with them. Staff #9 stated,"If we let the high risk patients go to their rooms they could fall and we would not know it."

Based on review of staffing sheets, staffing grid, and interviews the facility failed to adequately staff the Geriatric Psychiatric Unit to ensure the safety of the patients and staff. The facility failed to have sufficient staff to prevent falls, injuries, and possible death to the patients in the unit.

Refer to Tag A0392.

Based on review of staffing sheets, staffing grid, and interviews the facility failed to adequately staff the Geriatric Psychiatric Unit to ensure the safety of the patients and staff. The facility failed to have sufficient staff on 11 of 62 shifts reviewed to prevent falls, injuries, and possible death to the patients in the unit.
Review of the staffing sheets and grid for the Geriatric Psychiatric Unit from 7/1/2014 to 7/31/2014 revealed the following (7:00 AM- 7:00 PM is the day shift. 7:00 PM-7:00 AM is the night shift.);
Out of 62 shifts, 8 shifts were short a licensed person and 11 shifts were short a Mental Health Technician(MHT.)
7/3/14- short 1 MHT days - 1 RN and 1 MHT nights.
7/4/14- short 1 LVN days - 1 RN and 1 MHT nights
7/5/14- short 1 LVN day and night shift.
7/7/14- short 1 MHT days and 1 RN on nights.
7/8/14- short 1 MHT days and 1 RN at night.
7/9/14- short 1 MHT days and 1 LVN nights.
7/11/14- short 1 MHT nights.
7/12/14- short 1 MHT day and night shift.
7/13/14- short 1 MHT nights.
7/27/14- short 1 MHT nights.
Review of patient #1's stay from 7/3-7/5/2014 revealed the staff was short an RN, LVN, and MHT. On 7/3-7/4/2014 Nurses notes revealed the patient was on a 1:1 (staff at arm ' s length). Staff #12 was assigned to the patient as the 1:1 leaving the unit without a MHT to care for the remaining patients.
An interview with staff #14 on 8/13/14 revealed the census had increased and there was not enough staff to perform the 1:1 on 7/4/14. Staff #14 reported the patient was brought to the nurse's station for the nurses to watch the patient while the MHT did other duties. Staff #14 reported the patient was with the MHT in the nurse's station when the near fall with injury occurred.
An interview with staff #11 on 8/11/14 revealed staff #26 works as a activity counselor (AC) and a MHT on the same shift. Staff #11 stated, "We have been short but we are trying to hire people." Staff #11 confirmed that the unit schedule did not show 1:1 assignments. The staffing schedule did not make allowances for 1:1 needs. Staff #11 confirmed he did not have a log of 1:1's on his unit.
An interview with staff #26 on 8/11/14 confirmed she works as an AC and a MHT at the same time. Staff #26 confirmed that she tries to get everyone in group so she can chart the 15 observation but when a patient does not want to come to group then one of the nurses must do the checks.

Based upon observation and interview, the facility failed to provide an organized sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.

Refer to Tag A0619

Based upon observation and interview, the facility failed to provide an organized sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.
During a tour of the Dietary Department on 8/12/2014 the following items were found;
1. Under the food preparation area the floor drain was dirty with trash and a thick brown substance in the bottom. The surrounding floor was dirty with a greasy black sticky substance. The exposed pipes going into the floor drain was dirty with mineral build up and a greasy substance.
2. A multi-shelved cart used to put dirty kitchen trays on was found in the kitchen "clean area" next to the food preparation area. The cart was coated in dried and thick greasy substances on each shelf. Staff #2 reported it was supposed to be in the dirty side of the kitchen and was pushed over to the clean side till the dishwasher could get to it.
3. Nine "clean" baking sheets were found to have carbon and greasy build-up around the lip and sides of the sheets. This build-up does not allow the pans to be properly cleaned.
4. 13 clean kitchen pots and strainers were sitting on shelves covered in hair, dried food particles, and a fine greasy substance.
5. The wheels and metal frame of a food cart was covered in a greasy buildup of dirt, hair, and dried food particles. A second cart had two shelves of kitchen linen unwrapped. The opened linen was sitting on a soiled greasy shelf.
7. Six fryer baskets were found stacked on a tray coated in food particles. The first fryer vat had a foul smell, black colored grease with thick food particles, and a greasy substance built up along the sides.
8. The second fryer vat had black colored grease with coated food particles, and a thick greasy build-up inside the vat.
9. The back splash between the fryers and the other side of the kitchen was covered in a greasy substance with food particles. A space between the grill area and drawers was covered in a greasy substance, food particles, and dust. A dirty wire brush was coated in a greasy substance.
10. The front of the stove was covered in grease, dust, dirt, and food particles. The side of the stove was covered in a thick greasy substance, food particles, and dust.
11. The outer surface of the grill and oven was soiled in a greasy substance; the doors to the ovens had a build-up of grease, and food particles.
12. The floor under the grill and oven was coated in dirt, grease, dried food particles, and hair.
13. The bottom of the second double oven had rust corrosion, greasy build-up and dried food particles on the legs and wheel base. The bottom door handles and outside of oven was greasy with rust and dried food particles.
14. The bottom oven was coated in grease; dried food, spilled food particles, and carbon build up.
15. The second floor drain, under a food preparation area, had corrosion on the pipes and the drain pan was rusted with chipped paint in the pan. The underneath of the preparation table was coated in a greasy substance.
16. In the warmer next to the coolers an unmarked styro foam dish was found with a serving of broccoli and cheese. There were no dates. The kitchen staff could not state when that item may have been put in the warmer.
17. In the warmer next to the cooler another styro foam box was found with no dates. The box contained dried up crusty food.
18. The outside of the cooler was coated in a dusty, greasy substance.
19. Cardboard shipping boxes were found in the cooler. The cooler shelves were dirty with food particles and a greasy substance.
20. Prepared foods were found opened, uncovered, with no dates in the cooler. The kitchen staff was unsure when the foods were opened.
22. Shipping boxes were found in the walk -in cooler.
23. Three containers of prepared meats covered in plastic wrap, sitting next to eggs, were found in the cooler with no dates or sources of where the meat came from. A container of thawing chicken was found with an orange plastic bag, lying half way across the chicken.
24. The toaster in the food preparation area was coated in a greasy substance with a buildup of food particles.
25. A black portable table fan was found in the kitchen coated in a greasy dust covered substance.
26. Floor drains in the kitchen dish washing area were caked in a thick crusty brown and gray substance. The grates were clogged with trash particles, hair, and dirt like substance.
27. 56 pots and pans were found stacked wet. Staff# 6 confirmed the pots and pans had not been allowed to dry properly before they were stacked.
28. The walk- in freezer was found to have a large amount of ice build-up around the door and a frozen floor covered in ice.
29. The walk in freezer had a thick coat of frost on the food products. The ceiling of the walk in freezer had an icy condensation.
30. Food was found on the bottom shelf of a wire rack. There was no plastic barrier on any of the lower shelves in the freezers or walk in coolers. The wire racks were covered in a greasy, caked on dried food particles, and dust. Foods in shipping boxes were placed on the wire shelf with no barrier in the walk in freezers. Boxes of food were found on the floor under the shelves. The floor was covered in trash and food particles.

Based upon observation and interview, the facility failed to
A. provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, bowls, and plates) storage, and poor general sanitation practices was found throughout the dietary department. Failure to provide a sanitary environment may lead to food borne illnesses and possible death.
Refer to Tag A0619
B. ensure the infection control officer had a system for observing and investigating the kitchen as a sanitary hospital environment. Failure to monitor the kitchen and kitchen staff places the patient and visitors at a high risk of receiving a food borne illness.

Refer to Tag A0748
C. ensure the infection control officer provided monitoring and surveillance measures for the early identification of patients who require isolation in accordance with CDC guidelines. Failure to identify patients with infectious diseases places staff, visitors, and patients at risk of contracting a disease and possible death.
Refer to Tag A0749

Based on review of the Infection control logs and interviews, the infection control officer failed to have a system for observing and investigating the kitchen as a sanitary hospital environment. Failure to monitor the kitchen and kitchen staff places the patient and visitors at a high risk of receiving a food borne illness.

An interview with staff #23 on 8/13/2014 at 4:30 PM, revealed the facility was not conducting environmental rounds on a consistent base. Staff # 23 reported the facility had a new Maintenance Director (MD). The Maintenance Director was in charge of the rounds. Staff #23 reported the MD wanted to do rounds first Wednesday of the month but did not have the kitchen as a department to review on regular basis. Staff #23 reported she did not have any recent environmental rounding reports to show the surveyor. Staff #23 stated, "We have not been in the kitchen to do rounds. I had no idea it was that bad."

Based on review of the Infection control logs and interviews, the infection control officer failed to monitor and implement surveillance measures for the early identification of patients who require isolation in accordance with CDC guidelines. Failure to identify patients with infectious diseases places staff, visitors, and patients at risk of contracting a disease and possible death.
Review of patient #2's physician progress notes dated 12/11/2014 stated, "I had a face to face visit with the patient today and I personally interviewed and examined her. She continues to complain of quite a bit of pain on her R buttock, and after re-evaluation today it is consistent with very distal S1 shingles. Discussed risks and benefits of Valtrex, agreed to start this medicine."
Valtrex three times a day for 7 days was ordered on 12/11/2014. Patient #2 shared a bathroom and attended group exercises with another patient on the rehab unit.
Review of patient #2's chart revealed the nurse documented the infection control nurse was notified of the diagnosis of shingles on 12-11-2014. Review of the infection control log revealed patient #2 was not on the list.
An interview with staff #23 on 8/13/2014 at 4:45 PM revealed patient #2 was diagnosed with shingles. Staff #23 reported the nurse had documented that she had notified the infection control nurse but it was never logged in the computer. The primary care nurse must place a consult order in for the infection control nurse. Staff #23 confirmed she was never informed of the diagnosis and the patient was not placed in contact isolation.