HospitalInspections.org

Repeat Deficiency

Based on document review, interview and observation, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient Rights
CFR 482.28 Dietary Services
CFR 482.56 Rehabilitation Services

Based on medical record reviews, observations, review of facility documents, and staff interviews, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to implement its PoC for integration of assessments from various disciplines, guidelines/ techniques for writing the initial treatment plan to the Master Treatment Plan, and the requirement for timely completion of the Update Initial Treatment/Stabilization Plan. (Cross Refer Tag 0129).

2. The facility failed to ensure that patients receive care in a safe setting. (Cross Refer Tag 0144).

3. The facility failed to implement its PoC for the revision of the Master Treatment Plans for patients with restraint use. (Cross Refer Tag 0166).

21953

New Deficiency

Based on document review and staff interview, it was determined that the facility failed to implement its PoC for integration of assessments from various disciplines, guidelines/ techniques for writing the initial treatment plan to the Master Treatment Plan, and the requirement for timely completion of the Update Initial Treatment/Stabilization Plan.

Findings include:

1. On 4/16/15, the facility's PoC for this deficiency was reviewed in the presence of Staff #1, #2, and #3. The PoC had a final completion date of 6/6/14. The PoC states the facility would conduct monthly ongoing record reviews and report compliance to the Provision of Care and Active Treatment Committee.

a. The Provision of Care and Active Treatment Committee meeting minutes were reviewed and lacked evidence of aggregated data to reflect the facility's compliance with integration of assessments from various disciplines, guidelines/techniques for writing the initial treatment plan to the Master Treatment Plan, and the requirement for timely completion of the Update Initial Treatment/Stabilization Plan.

2. Staff #1 and #2 stated in interview, that the facility has just completed the training with the treatment teams on the above, and they will begin to formally aggregate data to report to Provision of Care and Active Treatment Committee.

Repeat Deficiency

Based on observations and staff interview, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

1. During a tour of Larch Hall A Dorms #113 and #115, conducted at approximately 10:30 AM on 4/1/15 in the presence of Staff #1, #15, #16, and #81, the battery back-up for the exit signs were not operating properly.

a. The sign, at the fire exit door leaving Dorm #116 was tested.

i. Upon testing, the sign flashed red-green.

ii. Per the key provided on the sign, this indicated a high charge of the battery back-up.

iii. This indicates a charging problem with the battery.

b. The sign by patient room Dorm #116-H was observed.

i. The light was not able to be tested as the test button did not function.

c. The sign, at the fire exit door leaving Dorm #116 was tested.

i. Upon testing, the sign flashed red-red.

ii. Per the key provided on the sign, this indicated battery failure.

d. The sign, at the fire exit door leaving Dorm #115 was tested.

i. Upon testing, the sign flashed red-red.

ii. Per the key provided on the sign, this indicated battery failure.

e. The sign at the fire exit door leaving Dorm #115 and the sign at the door leaving Dorm 115 to go into the unit were tested.

i. Upon testing, the signs flashed red-red-red-red.

ii. Staff #81 was unable to determined what that code indicated.

f. The Plan of Correction, submitted by the facility, stated that Ancora Psychiatric Hospital Fire Department would be reviewing the 24 Hour Building Fire Reports [to ensure this problem was resolved] on a monthly basis.

i. When asked for documentation of these reviews Staff #3 was unable to produce evidence that the reviews had been completed.

2. During a tour of Birch Hall A Dorms #113 and #115, conducted at approximately 10:30 AM on 4/1/14 in the presence of Staff #1, #15 and #16, numerous non-vandal proof screws were found in patient dormitories.

a. Several non-vandal proof screws were found in patient bedroom #113-G, securing the electrical conduit to the wall.

b. Several non-vandal proof screws were found in patient bedroom #113-E, securing the electrical conduit to the wall.

c. Several non-vandal proof screws were found in patient bedroom #113-D, securing the electrical conduit to the wall.

d. Several non-vandal proof screws were found in patient bedroom #116-F, securing the electrical conduit to the wall.

e. Several non-vandal proof screws were found in patient bedroom #116-B, securing the electrical conduit to the wall.

f. Several non-vandal proof screws were found securing the clear, protective cover over the Exit sign just inside the dorm entering Dorm #116.

g. These findings were confirmed by Staff #1.

h. The Plan of Correction submitted by the facility, stated that the Weekly Environmental Checks, to ensure the absence of non-vandal proof screw in patient care areas, was to be reviewed by the Safety Committee quarterly.

i. Safety Committee Meeting Minutes, from 6/14/14 to the day of the survey, 4/15/15, were reviewed at approximately 10:30 AM. There was no evidence of these reviews found.

ii. This finding was confirmed by Staff #3.

j. The Plan of Correction submitted by the facility, stated that Administrative Rounds would be conducted to ensure compliance with the plan and any issues identified would be addressed by the reviewer completing, and submitting a work order, to correct the problem.

i. At approximately 11:45, on 4/15/15, Staff #8 provided a list of work orders created in response to the findings of the individuals completing the Administrative Rounds in Larch Hall since the implementation of the Plan of Correction.

ii. There was no mention of non-vandal proof screws in any of these reports.

iii. This finding was confirmed by Staff #3.

3. The screws securing the door handle on patient bedroom #116-F were vandal proof screws. However they were loose and able to be removed by hand.

a. This findings were confirmed by Staff #1.

21496




21953

New Deficiency

Based on document review and staff interview, it was determined that the facility failed to implement its PoC for the revision of the Master Treatment Plans for patients with restraint use.

Findings include:

1. On 4/16/15, the facility's PoC for this deficiency was reviewed in the presence of Staff #1, #2, and #3. The PoC final completion date was 7/11/14. The PoC states the facility would conduct monthly medical record reviews and report compliance to the Provision of Care and Active Treatment Committee, for the revision of the Master Treatment Plans for patients with restraint use.

2. There was no evidence of aggregated data to report compliance with Master Treatment Plans for patients with restraint use.

This is a repeat deficiency.

Based on a tour of five patient care units and interview with direct-care staff, it was determined that unusable drugs were available for patient use.

Findings include:

1. During a tour of the Medication Room on Unit F1 on April 14, 2015, the thermometer in the medication refrigerator indicated that the internal temperature of the refrigerator was 33 degrees Fahrenheit. At that time, the refrigerator contained a vial of Levamir insulin, a vial of Novolog insulin, a vial of PPD (Purified Protein Derivative), and thirteen 2 mg (milligram) vials of injectable Ativan. The PPD box, the manufacturers instructions for the Ativan, and Levemir box all stated that the medications should be stored at a temperature between 36 and 46 degrees Fahrenheit. There was no documentation available in the Medication Room for the proper storage of Novolog.

a. A cabinet above the sink in the room, contained a box of "3 ml Sterile NaCl (sodium Chloride) Solution for Inhalation" vials. The box indicated that it contained 100 vials and was approximately 3/4 full. The expiration date on the vials was "2/2015."

2. During a tour of the Medication Room on Unit F2 on April 15, 2015, the thermometer in the medication refrigerator indicated that the internal temperature of the refrigerator was 34 degrees Fahrenheit. At that time, the refrigerator contained a vial of Humalog insulin, a vial of Novolog insulin, two vials of Lantus insulin, three vials of Novolin R insulin, and twelve 2 mg vials of Ativan.

a. Prior to leaving the Medication Room, a nurse (Staff #30) in the room called Staff #29, a pharmacist. Staff #30 stated that the pharmacist told him/her that all of the medications were acceptable for use unless they were frozen.

3. The medications were not stored in accordance with manufacturers instructions.




31655

Repeat Deficiency

Based on observation, review of facility documents, and staff interview, it was determined that the facility failed to ensure oversight of the daily management of the food services provided, in accordance with their policies and procedures.

1. The facility failed to ensure the director of food services provided effective daily management of the food services, and failed to ensure that all Food Service Training policies and procedures are implemented. (Cross Refer Tag 0620).

Repeat Deficiency

Based on document review, staff interview and observation, it was determined that the facility failed to ensure that the Food Service Supervisor #1 provides effective daily management of the food services department.

Findings include:

Reference #1. The Food Service Supervisor #1 job expectations states, "Plans and schedules the work of the Food Service Department ... Maintain quality standards for the department, in all areas of operation ... Responsible for professional management of all functions, services, facilities and staff associated with the storage, preparation and service of all food ... Initiate performance improvement activity ... Maintain proper health and sanitary conditions and comply with standards for handling, storing and preparing food ... Conducts weekly rounds of the Food Service areas. Observes the kitchen area, tray service line, tray line, patient cafeteria ... Provides appropriate follow up on deficiencies noted or comments on improvement for safe practices for food handling, supervision of work and implements a Food Service QAPI program."

1. On 4/14/15, during observations and interview in the presence of Staff #8, the Food Services Director failed to complete job responsibilities in accordance with the "Food Services Supervisor 1" job specifications and job expectations.

a. During interview Staff #18 was unable to produce documentation of weekly rounds conducted in the food services area, as required in Reference #1.

Reference #2. The Assessment of Service policy and procedure states: "Purpose to identify and implement measurable tools of quality assurance and provide the continuing assessment of the service perimeters ... Operational audits are intermittently performed in each area. The specific action and follow-up are determined for each problem ... Cafeteria service is monitored routinely by supervisory verifications of quality standards, portion control, temperature control, sanitation standards and safety standards ... patient food service is monitored routinely by supervisory verifications of quality standards, portion control, temperature control, sanitation standards and safety standards ... Corrective action and follow-up is the overall responsibility of the Food Service Supervisor or designee ... Results of specific assessment tools and significant results of other information sources are shared with the department staff. Documentation of this information is reported to the hospital Quality Assurance Department."

a. On 4/14/15, during observations and interview in the presence of Staff #8, the Food Service Supervisor #1 was unable to produce specific assessment tools, corrective action and follow-up documentation reported to the hospital QA (Quality Assurance) Department as required in Reference #2.

Reference #3. The QA Monitoring of Temperatures of freezers, refrigerators and dish machines policy states, "The Head Cooks on both first and second shift will complete the Food Service QA Temperature Monitoring form while checking all refrigerators, freezers and dish machines on a daily basis. The findings will be aggregated on a quarterly basis by the food service supervisor and report to the Chief of Medicine, Executive Committee of the Medical Staff (ECMS) and the CEO ... Immediate corrective plan is completed and corrective action for areas of non-compliance. Additionally, this corrective action plan may require immediate notification by the Food Service Supervisor to the Maintenance Department by telephone followed by a work order ... A monthly and quarterly report will be forwarded to the Chief of Medicine, ECMS and the CEO for review."

1. On 4/14/15 at 11:45 AM, tray line freezer #1, located behind the tray line, contained seven of fourteen AM (morning) temperatures and five of thirteen PM (afternoon/ evening) temperatures recorded on the freezer log, indicating the freezer was maintaining temperatures above the required maximum of zero degrees F (Fahrenheit). The required one hour temperature recheck and any additional corrective action reported and completed was not recorded on the log.

a. On 4/1/15, 4/7/15 and 4/11/15 in the PM column, 1 degree F was recorded.

b. On 4/12/15 in the PM column, 3 degrees F was recorded.

c. On 4/13/15 in the PM column, 20 degrees F was recorded.

d. On 4/4/15 in the AM column, 1 degree F was recorded.

e. On 4/5/15 in the AM column, 10 degrees F was recorded.

f. On 4/10/15 in the AM column, 1 degree F was recorded.

g. On 4/11/15 in the AM column, 8 degrees F was recorded.

h. On 4/12/15 in the AM column, 3 degrees F was recorded.

i. On 4/13/15 in the AM column, 15 degrees F was recorded.

j. On 4/14/15 in the AM column, 30 degrees F was recorded.

2. On 4/14/15 at 12:15 PM, the patient cafeteria dish machine temperature log, contained four of fourteen AM final rinse temperatures indicating the final rinse temperature was below the required minimum of 180 degrees F. Additional corrective action reported and completed was not recorded on the log.

a. On 4/4/15 in the AM column, 179 degrees F was recorded.

b. On 4/5/15 in the AM column, 170 degrees F was recorded.

c. On 4/6/15 in the AM column, 172 degrees F was recorded.

d. On 4/7/15 in the AM column, 170 degrees F was recorded.

3. On 4/14/15 the Food Service Supervisor #1 was unable to produce requested monthly and quarterly Food Service QA Temperature monitoring reports that were forwarded to the Chief of Medicine, ECMS and the CEO for review, as required in Reference #3

Reference #4. The QA Monitoring for Food Service Sanitation policy states, "The Head Cook will complete the Food Service Sanitation Monitoring form in a weekly basis after completion of a walk through of the entire kitchen focusing on the following areas: dry storage, all types of kitchen equipment, cleaning supplies, other environmental and maintenance issues ... Any areas of non-compliance will have a plan of action developed to address these issues with follow-up to the responsible person(s), with an assigned target date for correction. The findings will be aggregated both on a monthly and a quarterly basis by the Food Services Supervisor and reported to the to the Chief of Medicine, ECMS and the CEO for review."

1. On 4/14/15, during observations and interview in the presence of Staff #8, Food Service Supervisor #1 was unable to produce the weekly Food Service Sanitation Monitoring form including areas of non compliance observed and corrective plan of action aggregated on a monthly and quarterly basis and reported to the Chief of Medicine, ECMS and the CEO for review, as required in Reference #4.

2. On 4/14/15, during observations and interview in the presence of Staff #8, Food Service Supervisor #1 stated that the food service supervisors and head cooks complete a daily checklist to identify any areas on non-compliance in the food services area. The Food Service Supervisor #1 was unable to produce the daily checklist for 12/10/14 to 3/22/15, and 4/4/15 to 4/14/15.

3. On 4/14/15 the Food Service Supervisor #1 was unable to produce requested monthly and quarterly Food Service Sanitation monitoring reports submitted to Chief of Medicine, ECMS and the CEO for review, as required in Reference #4.

Reference #5. The Storage policy states, "The objective is to maintain high quality food at approved temperature and conditions to insure retention of quality, safe conditions and nutritive value. Light ventilation and humidity are such as to prevent condensation of moisture and growth of mold. The ingredient room must be ventilated and temperature controlled (temperature not below 42 degrees or above 70 degrees F) ... For reach in refrigerators, spills are cleaned immediately ... Spills are immediately cleaned up in the walk-in freezers and refrigerators ... No containers of food are stored on the floor."

1. During observations on 4/14/15 at 11:45 AM, tray line freezer #1, located behind the tray line, contained two cartons of orange sherbet and one carton of 'Tony's' individual frozen pizza stored directly on the freezer floor in a very large orange liquid puddle similar to defrosted/melted orange sherbet. This freezer was in use during the lunch tray line service that ended at 11:45 AM. The tray line staff failed to observe the melted orange liquid, immediately clean the spill and report this problem to the food services supervisor for corrective action.

2. During observations on 4/14/15 at 11:45 AM, tray line freezer #2, located behind the tray line, had a sign on it indicating out of service. The interior floor and wall perimeter had a heavy build up of a mold-like substance. The freezer was not maintained clean.

3. During observations on 4/14/15 at 12:05 PM, the ingredient room temperature log for April 2015 was blank for five of the fourteen days (4/315, 4/4/15//4/5/15, 4/11/15, and 4/12/15). Two of the fifteen temperatures recorded on the log were above 75 degrees F on 4/8/15 and 4/13/15. Additional corrective action reported and completed was not recorded on the log, as required in Reference #5.

Reference #6. The Pot and Pan Washing policy states, "To insure proper cleaning and sanitation of cooking equipment, a uniform procedure will need to be performed in the cleaning of pots and pans washing ... The following steps are to be performed in the cleaning of pot and pan washing to insure cleansing and sanitation of cooking equipment ... 1. Prepare wash sink ... Fill wash sink with hot soapy water ... Prepare rinse sink ... fill rinse sink with hot water ... Prepare Sanitizing sink ... Fill the last sink with hot water. Add sanitizing agent in recommended dilution. Use test strips to determine the correct concentration ... Sanitize ... Submerge pots, pans and utensils in the sanitizing solution for recommended time."

Reference #7. The Wescodyne Plus manufacturers directions for use states, "The color of a Wescodyne Plus solution is proportional to the titratable iodine concentration. Prepare a fresh solution daily, or when there is a noticeable change in its rich amber color, or more often if the solution becomes diluted or soiled ... Sanitize equipment and utensils by immersing them in a solution of 1 ounce Wescodyne Plus per 5 gallons of luke warm water (Provides 25 ppm titratable iodine). Allow one minute contact time (or longer if required by local sanitation codes). Fresh solution should be prepared daily or more often if the solution becomes diluted or soiled. Use an approved iodine test kit to check for proper concentration."

Reference #8. The Chapter 24 of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24), N.J.A.C. 8:24-4.8(j)2 states, "An iodine solution shall have a: Minimum temperature of 75 degrees F ... Concentration between 12.5 mg/L and 25 mg/L."

1. On 4/14/15 at 12:40 PM, Staff #25 was observed washing pots and utensils in the pot wash area of the main kitchen. During interview Staff #25 was unable to explain the Pot and Pan Washing procedure regarding the iodine solution sanitizing dilution requirements, water temperature and testing for the proper concentration of the final sanitizing solution, as required in Reference #6, #7 and #8.

a. Staff #25 was asked to demonstrate how he/she checks the concentration of the iodine sanitizing solution. First he/she attempted to check the solution with a chlorine sanitizer test. The food service supervisor instructed Staff #25 to use the iodine test kit. The iodine test strip recorded a 0 ppm for the sanitizer solution in the sink. Staff #25 did not know the required concentration for the Iodine sanitizing solution. The 0 ppm reading was below the required 25 ppm as stated in reference #6 and #8.

b Staff #25 stated that the sanitizer is checked by the head cook at the beginning of each shift and that he/she was not trained in the pot and pan washing procedure.

c. On 4/14/15 the Food Service Supervisor #1 was unable to produce the requested pot washing training for Staff #25.

d. On 4/14/15, Food Service Supervisor #1, Head Cooks and Food Supervisor #3s did not know the required water temperature for the sanitizing solution as stated in reference #6 and #8.

e. On 4/14/15, Food Service Supervisor #1, Head Cooks and Food Supervisor #3s did not know the required dilution ratio of water to sanitizer and the required concentration for the Iodine sanitizing solution as stated in Reference #6 and #8.

Reference #9: The Hand Hygiene for Food Service Workers policy states, "Wash your hands before and after contact with food. After contact with a source of microorganisms ... After removing gloves (wearing gloves does not remove the need to wash hands). Before handling food (the patient's and your own). After using the toilet. Whenever visibly soiled."

Reference #10: N.J.A.C. 8:24-2.3 (f) states, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles."

1. On 4/14/15 at 12:40 PM, an employee in the main kitchen was observed leaving the prep area with gloves on, and came back with the same pair of gloves on, covered a pot with a lid and continued to prep dinner entrees. The employee did not wash his/her hands when entering into the main kitchen prep area to continue the task of preparation, and the employee did not put on a new set of gloves as stated in Reference #9 and #10.

Reference #11: Tray Line Operation Maintenance of Meal temperatures policy states, "Temperatures will be taken: A. Before leaving main kitchen, B. Upon arrival to serving areas and prior to serving ... The designated cook is responsible for preparing the food ensuring that the hot food is 140 degrees F or more and the cold food 41 degrees or less ... Upon arrival at the serving areas, the operations manager is to record the temperature of the food on the serving area temperature log."

1. On 4/14/15 at 12:20 PM, Staff #20 and Staff #21 in the employee/patient cafeteria stated that they do not take food temperatures, or complete the temperature logs for all the food items received upon arrival to the service area, or prior to serving, for both sides as stated in Reference #11.

Reference #12: N.J.A.C. 8:24-4.2(c)(2) states, "Temperature measuring devices shall meet the following requirements: ... 2. A temperature measuring device with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin foods such as meat patties and fish filets."

1. On 4/14/15 at 12:20 PM, Staff #20 and Staff #21 in the employee/patient cafeteria stated that they do not have a thermometer available to measure the food temperatures. They stated that the thermometers issued to them were off site and not available for use as stated in Reference #12.

Reference #13: The "Monthly Food Service Training" policy and procedure states: "In-servicing of the Head Cook 1, Area Operations Managers and Cooks is conducted on a monthly basis ... Clinical Dietitian will inservice the Head Cook 1, Area Operations Managers and Cooks on a monthly basis according to the established schedule. Hand-outs will be provided to all and a training roster will be signed. Intermittently other auxiliary departments will conduct training in their areas of expertise, Housekeeping, infection control and nursing ... The Head Cook 1 and the Area Operations Managers will then train/inservice their respective staff on the monthly topic ... hand-outs will be provided to staff during this training and training rosters will be signed by all Food Service workers who received training ... Training rosters will be compiled and placed in the Food Service Training Manual by the Food Service Supervisor."

1. On 4/14/15 at 11:30 AM, Staff #18 was unable to provide for review the monthly training hand-outs and rosters completed for all food service staff from 6/26/15 to 3/10/15, except for "Cleaning of Igloo Type Coolers" completed on 1/17/15 as stated in Reference #13.

a. The "Cleaning of Igloo Type Coolers" training handout failed to include the specific sanitizing solution type, dilution, temperature, concentration and soaking time requirements.

b. Staff #18 stated that one of the two shifts was trained on "Cleaning of Igloo Type Coolers."

2. The above was confirmed by Staff #18 on 4/14/15 at 3:00 PM.


20328

A. Based on tours of five patient care units, in the presence of Administrators #4 and/or Administrator #31, and review of facility policy, it was determined that the facility failed to ensure that supplies were maintained at an acceptable level of safety and quality.

Findings include:

Reference: The PROCEDURE section of policy titled "Patient Clothing and Belongings" stated: "... 4. Personal grooming items are labeled with the patient's name using the preprinted labels from the front of the medical record. If the patient refuses to have items labeled, this is noted on the inventory form and the Program Coordinator (PC) is informed. ... "

1. During a tour of Unit F1 on 4/14/15 the following observations were made:

a. Nurses Station: A drawer closest to the door to the hallway contained multiple personal care items, including shampoos, body lotions, hair spray, etc. Multiple items did not have any identification of the patients to whom they belonged. Staff #31 stated that the unidentified items should have had the required stickers adhered to them.

b. In Room F-133, rolls of flannel restraints in the top drawer of a cabinet were set, unwrapped, atop a sticky yellow substance.

c. In Room F-154:

i. The thermometer in the refrigerator containing food for patients indicated the internal temperature of the refrigerator to be 44 degrees Fahrenheit. The temperature check log attached to the refrigerator indicated that the acceptable temperature range was 33 - 41 degrees Fahrenheit.

ii. The top drawer of a metal cabinet contained a plastic spatula and large plastic serving spoon with food residue and a greasy substance on them.

2. During a tour of Unit F-2 on April 15, 2015 the following observation was made:

a. Medication Room:

i. The "Spoons/Straws" drawer in the medication cart had stains and a rusted screw on the interior with unwrapped plastic spoons inside of the drawer touching the stains and screw.

ii. The top drawer to the left of the sink contained an open sleeve of 30 cc (cubic centimeter) plastic medication cups. Some of the cups were out of the package and were laying sideways on the bottom of the drawer which had heavy stains, grit, and rust.

iii. The top drawer to the right of the sink contained a packet of "Thicken Up Clear" that had an expiration date of "20 JAN 2015".

iv. The interior of the metal narcotic box in the medication refrigerator had an accumulation of dried white particulate on the interior bottom.

B. Based on tours of five patient care units, in the presence of Staff #4 and/or Staff #31, it was determined that the facility failed to ensure that all equipment and environmental surfaces were kept clean to sight and touch.

Findings include:

1. During a tour of Unit F-1 on 4/14/15 the following observations were made:

a. Room F-128:

i. Dust and grit was behind a cabinet and atop a printer.

ii. An air conditioner vent tube leading through a Plexiglas window to the exterior of the building had heavily stained paper stuffed around the hole in the Plexiglas. There was also heavy tape and tape residue with dust and grit.

b. Room F-129 (Examining Room): Cloth tape with a black substance was on the bottom left corner of a marker board.

c. Observation Room: The restraint chair had a heavy accumulation of candy wrappers, a sugar packet, gunk, and grit between the seat cushion and the side rails.

d. Medication Room: Dust clumps and a candy wrapper were beneath and behind the refrigerator.

2. During a tour of Unit Birch A on 4/15/15 the following observations were made:

a. Nurses Station: The Formica counter had tape and tape residue on it.

b. Day Room: One ceiling light cover had two dead bugs atop it, and one ceiling light had nine dead bugs atop it.

3. During a tour of Unit F-2 on 4/15/15 the following observations were made:

a. Hallway:

i. The ceiling tiles outside of Room F-220, had what appeared to be dried food on them.

ii. A ceiling light cover had heavy yellow stains on the outside of it and three dead bugs atop it.

iii. A ceiling light cover outside of Room F-217 had dead bugs atop it.

b. Room 228 (Day Room): All three ceiling light covers had dead bugs atop them.

c. Room 227 (Day Room): All four light covers had dead bugs atop them. There were two stained ceiling tiles in the room.

d. Medication Room:

i. The interior of the Fosamax drawer had dried, browned surgical tape and yellow and brown stains.

ii. The window had dust on the ledges and tape and tape residue on the glass and ledges.

4. During a tour of Unit Holly D on 4/15/15 the following observations were made:

a. Medication Room:

i. The plywood base on which a refrigerator was set was unfinished plywood and particle board which are uncleanable surfaces.

ii. The shelf beneath the counter on which the refrigerator was set was raw wood, and not a cleanable surface.

C. Based on tours of five patient care units and the medical records department, in the presence of Staff #4 and/or Staff #31, it was determined that not all facilities and environmental surfaces were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. During a tour of Unit F-1 on 4/14/15 the following observations were made:

a. Room F-129 (Examining Room): A ceiling tile above the window was dislodged exposing chipping paint on the exposed ceiling. A chipped ceiling tile was in the space next to the dislodged tile.

b. Room F-123 (Rest Room): Broken plaster was around a sprinkler head on the wall.

c. Medication Room: An over-bed table had exposed, chipped particle board on all edges.

d. Day Room: Three chairs had an accumulation of grit, paper scraps, and other refuse between the seat cushions and the side rails.

e. Room F-154:

i. There was no hot or warm water available from the faucet of the sink.

ii. The top of a Formica table had jagged edges of broken Formica and exposed particle board.

2. During a tour of Unit Birch A on 4/15/15 the following observations were made:

a. Nurses Station: The temperature of the water coming from the faucet on the handwashing sink was 128 degrees Fahrenheit.

b. Day Room: The insulation covering four pipes was torn exposing Fiberglass.

21953

Repeat Deficiency

A. Based on medical record review and staff interview, it was determined that the facility failed to ensure that physical therapy treatment is provided to patients in accordance with physician orders.

Findings include:

The facility failed to ensure that the recommended treatment for physical therapy was ordered by the physician. (Refer to Tag A-1132).

New Deficiency

B. Based on medical record review and review of facility protocol for completion of Physical Therapy (PT) evaluations it was determined that the facility failed to ensure all PT evaluations are completed per protocol.

Findings include:

The facility failed to complete all PT referrals within five (5) working days. (Refer to Tag A-1134).

21953

Repeat Citation

Based on medical record review and staff interview, conducted on 4/15/15, it was determined that the facility failed to ensure that physical therapy treatment was delivered in accordance with physicians orders and facility protocol in 3 of 4 medical records reviewed (#7, #8, #10).

Findings include:

Reference: The Patient Evaluation, Assessment and Treatment protocol states "... 8. Upon written completion of the evaluation & referral a copy will be made and put in the patient's physical therapy file which is kept in the Physical Therapy department. The original referral and evaluation will be sent to the referring physician. ... It will be the responsibility of the physician to sign the Plan of Care on the evaluation. ..."

1. Review of Medical Record # 7 indicated the following:

a. A physician order dated 2/24/15 at 3:00 PM to "Refer to PHYSICAL THERAPY (RIGHT KNEE PAIN & GAIT TRAINING)".

i. The Physical Therapy treatment log was reviewed with Staff # 28. Per the log and per Staff #28, Patient #7 refused his/her PT evaluation on 3/3/15, and on 3/8/15 and 3/9/15 there was not enough staff to escort the patient to the PT department.

b. The REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form indicates the PT evaluation was completed on 3/12/15 at 11:00 AM.

i. The Plan of Care section of this form indicates the PT therapist recommended a front wheel walker for the patient, and the physician was notified. In addition, the plan for treatment was PT three times per week for an eight week duration.

ii. A physician order dated 3/12/15 at 3:35 PM for the "PATIENT TO USE WALKER AT ALL TIMES WHEN AMBULATING FOR GAIT STABILITY & CHRONIC RIGHT KNEE PAIN UNTIL FURTHER ORDERS."

c. THE PHYSICIAN ACKNOWLEDGEMENT section of the REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form was signed by the physician on 4/7/15, indicating his/her agreement with the PT Plan of Care.

d. The Physical Therapy treatment log was reviewed with Staff # 28. Per the log and per Staff #28, the patient received PT on 3/15/15, 3/17/15, and 3/23/15. The patient received PT three times prior to the physician signing the THE PHYSICIAN ACKNOWLEDGEMENT section of the REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION, indicating his/her agreement with the complete PT Plan of Care.

2. Review of Medical Record # 8 and indicated the following:

a. An ANCILLARY REHABILITATION SERVICES CONSULTATIONS form for Physical Therapy for the patient's right shoulder pain, signed by the ordering physician on 2/25/15.

b. The REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form indicates the PT evaluation was completed on 3/24/15 at 10:40 AM.

c. THE PHYSICIAN ACKNOWLEDGEMENT section of the REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form was signed by the physician on 4/6/15, indicating his/her agreement with the PT Plan of Care.

d. The Physical Therapy treatment log was reviewed with Staff # 28. Per the log and per Staff #28, the patient received PT on 3/27/15 and 4/1/15. The patient received PT two times prior to the physician signing the THE PHYSICIAN ACKNOWLEDGEMENT section of the REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION, indicating his/her agreement with the PT Plan of Care.

3. Review of Medical Record #10 indicated a REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form for a PT re-evaluation was completed on 12/8/14 at 10:00 AM.

a. This form had a physician signature on 12/10/15, then later documented a corrected notation that the original signature date of 12/10/15 was corrected to 12/10/14 on 4/15/15.

b. On 4/15/15 Staff #28 reported in interview that the physician had not signed off on the PT re-evaluation as of 2/5/15.

c. The Physical Therapy (PT) treatment log was reviewed with Staff # 28. Per the log and per Staff #28, the patient received PT following his/her re-evaluation on the following dates in December 2014 thru February 2015:

i. December 2014: 8-12, 15-16, 18, and 30.

ii. January 2015: 2, 5-7, 9, 12-13, 15-16, 21, 23, 26, and 28-30.

iii. February 2015: 3-5.

d. Per Staff #28's interview that the physician had not signed off on the PT re-evaluation of 12/8/14 as of 2/5/15, it was documented on the PT treatment log that the patient received twenty-six (26) PT therapy sessions without the physician's signed authorization indicating agreement with the continued PT Plan of Care.

e. Per the corrected signature date by the physician on 12/10/14 [not timed], the patient received one or two PT therapy sessions prior to the physician's signed authorization indicating agreement with the continued PT Plan of Care.

f. The facility's PoC for the original citation indicated the Physical Therapy Staff shall complete a monthly review of all patient records with active Physical Therapy consultations and evaluations/treatment.

g. The monthly audits by Physical Therapy were reviewed with Staff #1 and Staff #28 on 4/15/15. There was no evidence that Patient #10 was captured in the monthly audits. Without Patient #10's inclusion in the monthly audits, it could not be determined if the physician's actual approval date of the PT Plan of Care was per Staff #28's interview after the date of 2/5/15, or per the physician's corrected signature date of 12/10/14.

4. The facility's PoC for the original citation indicated the Supervisor of Physical Therapy shall report monthly process compliance to the hospital's Rehabilitation Services Department Head Meeting and Performance Improvement Council, for the new physician PT referral process, and physician review and signature to indicate agreement/ disagreement with the PT Plan of Care. The PoC completion date was 6/30/14.

a. On 4/14/15 at 12:00 PM, the Rehabilitation Services Department Head Meeting minutes were reviewed for the 2014 meetings in June, July, September, and December, and the 2015 meetings in January, February, and March. There was no evidence of a monthly process compliance report by the Supervisor of Physical Therapy for the new physician PT referral process and physician review and signature to indicate agreement/ disagreement with the PT Plan of Care. This was confirmed by Staff #1.

b. On 4/14/15 at 11:30 AM, the Performance Improvement Council meeting minutes were reviewed. The minutes reflected discussion of the PT Department's corrective action plan in the minutes for 6/11/14. There was no evidence of a monthly process compliance report by the Supervisor of Physical Therapy for the new physician PT referral process and physician review and signature to indicate agreement/ disagreement with the PT Plan of Care, in the July, August, September, October, or December 2014 meetings, or the January, March, or April 2015 meetings. This was confirmed by Staff #3.

5. The facility failed to demonstrate an improved process for physician approval of PT Plans of Care prior to the PT Department initiating treatment.

6. The facility failed to implement its PoC for reporting to the Rehabilitation Services Department Head Meeting and the Performance Improvement Council.

New Deficiency

Based on medical record review, staff interview, and review of facility protocol on 4/15/15, it was determined that the facility failed to implement its protocol for completion of physical therapy evaluations in two (2) of four (4) medical records reviewed (Medical Records #8 and #9).

Findings include:

Reference: The Patient Evaluation, Assessment and Treatment protocol states "Initial Evaluation 1. Upon receipt of the Rehabilitation Department P.T. referral for Physical Therapy Services signed by a physician, the client will be evaluated for Physical Therapy within 5 [five] working days."

1. Review of Medical Record #8 indicated the following:

a. An ANCILLARY REHABILITATION SERVICES CONSULTATIONS form for Physical Therapy for the patient's right shoulder pain, signed by the ordering physician on 2/25/15.

b. The REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form indicates the PT evaluation was completed nineteen (19) working days later on 3/24/15 at 10:40 AM.

2. Review of Medical Record #9 indicated the following:

a. A physician order dated 3/3/15 at 3:00 PM to refer to Physical Therapy.

b. A COMPREHENSIVE MEDICAL PROGRESS NOTE dated 3/3/15 at 3:00 PM indicated the patient had low back pain and strain, and was referred to Physical Therapy for further evaluation and treatment.

c. An INTERDISCIPLINARY PROGRESS NOTE dated 4/15/15 at 9:45 AM indicated the patient was evaluated in the PT department. The PT evaluation was completed thirty (30) working days after the physician order for PT.

4. The PT evaluations of Patient #8 and Patient #9 were not completed in 5 (five) working days, as per the above referenced protocol.

a. Staff #28 stated in interview that Patient #9 was out on a brief visit, but was unable to report for what time period.