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Based on review of medical records (MR), review of facility policy and procedures and interview with staff (EMP) it was determined that the facility failed to maintain a complete medical record for one of one medical records reviewed (MR1).

Findings include:

A review of facilty policy "Documentation: revision date 8/29/11" revealed " Policy: Documentation of patient care must be performed to communicate the treatment provided and its results. The Documentation is to be concise, legible and accurate. Procedure:...4. The medical record is a legal document; thus it includes facts, not speculation. Entries are to describe patient behavior, interventions utilized, response to interventions and plans. Entries are to be specific, observable terms..."

The review of nursing documentation for October 12, 2016 revealed "RN Daily Progress Note date 10/112/2016, Time 02:37 Shift 1900-0700...10/12/16 02:39 Discipline: Nursing: ____(name redacted) is in distress because bed bugs were found in her room. Presents with neutral mood and restricted affect. She had a good appetite today. She is not sleeping at this time. Will continue to monitor for safety."

An interview conducted on December 1, 2016, at 10:00 AM with EMP3 revealed after review of MR1 there is no documentation in the medical record that the clothing was treated and that the patient showered and her room was changed.

Based on a review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a safe and sanitary environment when they failed to ensure a medication refrigerator and dish washing machine were properly functioning and gases were properly stored.

Findings include:

A review on December 2, 2016, of the "Medication Storage" policy revealed, " ... 2. Medications requiring refrigeration shall be stored in the designated medication refrigerator in the locked medication room. The refrigerator will contain a thermometer to verify that medications are kept at a temperature between 36 and 46 degrees Fahrenheit. ... "

1) A review of the "Pharmacist Review of Medication Storage and Security" revealed, " ... Date in facility 10/19/2016 ... Several of the temperature log readings also showed a temperature of 32 degrees. I asked the nurse to notify maintenance to check the refrigerator as it is out of range. (36-46 degrees). This is the second month that this problem is being noted. Insulin may freeze at 35 degrees which is why refrigerator temperatures should not be below 36 degrees ... "

A review of the "Temperature Log-Unit 3 Medication Refrigerator" revealed, " ... temperature must be maintained between 36 - 46 Fahrenheit. If temperature falls outside of this range please notify Plant Operations Manager." Further review revealed the following dates/temperatures out of range: November 1, 2016, AM Temperature 33, PM Temperature 34; November 3, 2016, AM Temperature 32, PM Temperature 32; November 6, 2016, PM Temperature 28; November 7, 2016, AM Temperature 30; November 14, 2016, AM Temperature 28, PM temperature 32; November 15, 2016, AM Temperature 30, PM Temperature 32; November 16, 2016, PM Temperature 30; November 17, 2016, AM Temperature 32, PM Temperature 34; November 18, 2016, PM Temperature 34; November 18, 2016, PM Temperature 34; November 19, 2016, AM Temperature 30, PM Temperature 34; November 20, 2016, AM Temperature 34; November 21, 2016, AM Temperature 34, PM Temperature 34; November 29, 2016, AM Temperature 32; November 30, 2016, AM Temperature 28, PM Temperature 32.

Observation on December 1, 2016, during the tour revealed the medication refrigerator on the Adult Unit was 62 degrees Fahrenheit and contained 10 vials of Hepatitis B Vaccine, one vial on Lantus insulin and one multidose vial of Tuberculosis Purified Protein Derivative (PPD). The product labels for vaccine, insulin and PPD indicated the temperature range for refrigeration to be 36 to 46 degrees Fahrenheit.

Interview on December 1, 2016, at 11:00 AM with EMP7 confirmed the refrigerator was not at proper temperature.

2) Review of the "Roxbury Treatment Center Dishwasher Temperature Log" revealed, " ... November 2016 ... Wash Cycle 150 Rinse Cycle 180 ... Action Key A = Adjusted equipment to reach correct temperature ... B= Called for service to adjust unit. ..." Further review revealed the following dates and morning, afternoon and evening temperatures as follows: November 1, 2016 Morning rinse 173; November 2, 2016, morning rinse 179; November 4, 2016, morning rinse 170, afternoon rinse 175; November 5, 2016, morning rinse 175, evening rinse 178; November 6, 2016, morning rinse 169; November 7, 2016, morning rinse 169; November 8, 2016, morning wash 146, morning rinse 168, afternoon wash 146, afternoon rinse 170 and evening rinse 170; November 9, 2016, morning rinse 170, evening wash 132; November 10, 2016, morning rinse 170, November 11, 2016, morning rinse 169, evening wash 133, November 12, 2016, morning rinse 160, afternoon rinse 160 and evening rinse 160; November 13, 2016, morning rinse 163, afternoon rinse 163 and evening rinse 159; November 14, 2016, morning rinse 168, afternoon wash 148, afternoon rinse 178 and evening rinse 163; November 15, 2016, morning rinse 170, afternoon wash 146, afternoon rinse 176, evening wash 149, evening rinse 165; November 16, 2016, afternoon rinse 179; November 17, 2016, morning rinse 175, afternoon wash 146, afternoon rinse 176 and evening rinse 164; November 18, 2016, morning rinse 176, afternoon wash 143, afternoon rinse 176 and evening rinse 165; November 19, 2016, morning rinse 176, afternoon rinse 178, evening wash 148, evening rinse 160; November 20, 2016, morning rinse 176, afternoon wash 147, afternoon rinse 179; November 21, 2016, morning wash 145 morning rinse 155, afternoon wash 148, afternoon rinse 160; November 22, 2016, morning wash 147, morning rinse 153, afternoon wash 149, and evening rinse 164; November 23, 2016, morning wash 147, morning rinse 159, afternoon wash 136, afternoon rinse 169 and evening rinse 164; November 24, 2016, morning wash 146, morning rinse 169, afternoon wash 136, afternoon rinse 169 and evening rinse 173; November 25, 2016, morning wash 139, morning rinse 150, afternoon wash 147, afternoon rinse 151 and evening rinse 174; November 26, 2016, morning wash 140, morning rinse 150, afternoon wash 120, afternoon rinse 140, evening wash 140 and evening rinse 160; November 27, 2016, morning wash 142, morning rinse 151, afternoon wash 120, afternoon rinse 140, evening wash 142 and evening rinse 160; November 28, 2016, morning wash 148, morning rinse 169, afternoon rinse 179, evening rinse 170; November 29, 2016, evening rinse 173; November 30, 2016, afternoon rinse 160, e evening wash 147 and evening rinse 179. Further review revealed there was no action documented in the "Action" section of the form.

Tour on December 1, 2016, at 11:20 AM of the Dietary Service revealed there were two unsecured carbon dioxide cylinders.

Tour on December 1, 2016, at 11:30 AM of the Dietary Service and observation of the dish machine function demonstrated by EMP7 confirmed the rinse cycle temperature did not warm to 180 degrees.

An interview on December 1, 2016, with EMP7 confirmed the carbon dioxide cylinders were to be secured and the dish machine did not reach appropriate temperature for proper function.

Based on review of facility policies, medical record (MR), and interview with staff (EMP), it was determined the facility did not properly implement the discharge plan, by failing to provide education for one discharge medical records (MR) reviewed (MR1).

Findings include:
A review of facility policy "Bed Bug Policy: revised 03/19/2015" revealed "Policy:...Procedure:...5. Immediately bag all of the patient's personal belongings(including cloths patient is wearing). Use a clear dissolvable laundry bag for any washable clothing. Immediately place clothing in washer(heat setting) then on high heat in dryer...If patient's clothing cannot be washed immediately by staff and /or family is unable to take home all of patient's belongings the following steps should take place immediately;(all bagging should occur prior to moving belongings). a. A "blue tablet"(NUVAN Pest Strip) which can be found in the House Supervisor's office is to be placed in bag with belongings/clothing which will eradicate the bugs. Gloves should be worn while dealing with tablet. The tablet should be placed in white case accompanying the tablet to protect patient's clothing. Double bag and seal bags or bin tightly. b. Label the bin or bag with the patient's name. Include a sign that reads "Do Not Open For 72 Hours" and place the date and time 72 hours after sealed. Leave in contraband area in basement segregated from other items. c. Have patient shower and don hospital attire until clothing is processed either by fryer heat or blue tablet method....d. Clothing and belongings in bin with tablet; After 72 hours, it is the responsibility of staff to place all clothing that has been bagged with a blue tablet to be washed prior to returning to patient..."
The review of nursing documentation for October 12, 2016 revealed "RN Daily Progress Note date 10/112/2016, Time 02:37 Shift 1900-0700...10/12/16 02:39 Discipline: Nursing ____(name redacted) is in distress because bed bugs were found in her room. Presents with neutral mood and restricted affect. She had a good appetite today. She is not sleeping at this time. Will continue to monitor for safety."

A review of the "Nursing Shift Report" revealed "...10/11--Patient found bed bugs in her room. The bed bugs were observed by the nurse. Patient and her roommate's belongings were quarantined. Patient was afraid to go back to her room because of bed bugs...10/12 cloths will be ready to wash Friday might, moved rooms. DC(discharged) 10/15
The review of MR1 revealed the discharge instruction did not contain instruction on what the patient was to do with her bag of belongings after discharge.
An interview conducted on December 2, 2016, at 2:00 PM with EMP6 revealed the patient said they were bed bugs and we followed the policy about bed bugs. The staff placed a Nuvan pest strip in with her belonging, we have found that it works better then washing the clothing because we can treat all the clothing, shoes and coats or jackets at the same time. We don't have to worry about the shoes and other non-washable items. The patient was discharged prior to the 72 hours being up and we sent the clothing home with the patient.
An interview conducted on December 1, 2016 with EMP6 confirmed there is no documentation in the medical record that the clothing was treated and that the patient showered and her room was changed. Further interview confirmed that there was no documentation in the discharge instruction as to what the patient was to do with her bagged belongings.