HospitalInspections.org

Based on record review and interview the facility failed to ensure staff provide Medicare recipients with the "Important Message From Medicare" within 2 days of admission and within 2 days prior to discharge as per policy in 2 of 30 medical records reviewed (Patient (Pt) # 9, 27), in a total sample of 30 medical records reviewed.

Findings included:

Review of policy and procedure titled, "Important Message From Medicare and Detailed Notice of Discharge" Origination date 02/13/2020 revealed the following:
-This message must be delivered to all Medicare Beneficiaries within 2 days of admission
-If the patient is discharged more than 2 days after receiving the initial Important Message (IM), a second copy of the IM must be delivered to the patient no more than 2 days prior to discharge, and no less than 4 hours before discharge.

Review of Pt #27's medical record revealed that Pt #27 was admitted on 07/07/2022 at 2:30 PM and discharged on 07/12/2022 at 2:15 PM, and Pt #27 was a Medicare beneficiary. Per medical record review, Pt #27 signed the "Important Message from Medicare" on 7/8/2022 at 8:41 AM and on the same day at 8:45 AM . Per review of Pt #27's medical record there was no documented evidence that staff provided Pt #27 with a second notice within 2 days of discharge.

Review of Pt #9's medical record revealed that Pt #9 was admitted to the hospital on 08/11/2022 at 2:05 PM and discharged on 08/23/2022 at 3:25 PM, and Pt #9 was a Medicare beneficiary. Per medical record review, Pt #9 signed the "Important Message from Medicare" on 08/18/2022 at 9:16 AM (6 days after admission), this is not within 2 days of admission.

On 08/30/2022 at 11:00 AM and 08/31/2022 at 3:55 PM during interview with Project Manager AA at the time of record reviews, Project Manager AA stated that she/he was unable to find additional documentation that Pt #27 and Pt #9 signed the "Important Message From Medicare."

Based on record review and interview, the facility failed to ensure accurate contact information for 1 of 1 Client Rights Specialist (X) for patients to file a grievance and the facility failed to investigate patient grievances and document follow-up in 3 of 4 patient complaint reports reviewed (Patient # 26 (2 reports) and #31) in one complaint grievance process.

Findings include:

A review of the facility policy titled, "Client Rights and Grievance and Complaint Procedures", last reviewed 08/25/2022, revealed: "... D. Client Right Specialist i. At least one CRS (Client Rights Specialist) will be appointed by the Division Managers to oversee grievance and complaint investigations ...The names and contact information of the primary CRS shall be posted in each facility and shall be identified in the Client Rights Brochures."

Record review of policy "Patient Rights and the Grievance Procedure" dated 8/17/2012 under Purpose revealed "All clients... may present a grievance to any member of the staff." Under Policy/Procedure revealed under #1 "When the complaint is not presented in writing, the staff member receiving the complaint shall assist the complainant in completing the complaint form." Under #5 "There shall be written documentation of the investigation, the decision, and the reasons for the decision." Under Informal Resolution Process revealed "If the problem is not resolved, the complaint will be forwarded to the Clients Rights Specialist for formal resolution. Complaints that are resolved informally will also be forwarded to the Clients Rights Specialist for review." Under Level I Grievance Investigation revealed "The Client Rights Specialist shall investigate the facts and document the investigation, the decision, and the reasons for the decision for hospital patients within 7 days."

Record review of policy "Caregiver Misconduct Investigations and Reporting" #CL86006, dated 8/26/2022 under Definitions revealed "Examples of abuse include... Verbal abuse - Threats of harm, saying things to intentionally frighten a client. Mental abuse - Humiliation, harassment, and intimidation." Under Procedure revealed "When a workforce member receives information related to caregiver misconduct...should... report to immediate supervisor as soon as possible to avoid any delay in the investigation of the claim."

Record review of inpatient brochure titled "Client Rights and the Grievance Procedure for Inpatient Services," last revision date 11/2015, revealed "contact your CLIENT RIGHTS SPECIALIST, whose name is shown below, if you would like to file a grievance or learn more about the grievance procedure... Your Client Rights Specialist is: [X] "

On 08/31/2022 at 9:18 AM during an interview with Nursing Services Coordinator B, when asked where the Client Rights Specialist is posted in the facility and who is designated, Coordinator B stated "It is in the lobby and it is Client Rights Specialist [X]."

On 08/31/2022 at 10:20 AM interview with Support Staff Supervisor E, during a tour of the facility entrance lobby with Support Staff Supervisor E, observed "Patient Rights" posted on the entrance lobby wall that revealed the facility's Client Rights Specialist is Administrator (A), not the Client Rights Specialist (X) documented in the Client Rights Brochure. Support Staff Supervisor E stated, "The wrong name is listed as the Patient Rights Specialist."



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Record review of form titled "Complaint Report" on Patient #26, date reported "6/14/22." Under Describe the nature of your complaint revealed "Nurse smelled like booze breath - never came back 2 help clean vomit in my bathroom... other nurse... looked like on dope. Breathalyze (sig) & drug test these 2 nurses. Under #4 Date report filed, with "6-14-22" hand-written in. Box labeled "Date Reviewed," Outcome (describe resolution of problem or forwarding information if appropriate), and Staff Signature was blank. There was no documentation of investigation, decision, or resolution of the problem, documented.

Record review of form titled "Complaint Report" on Patient #26, date reported "6/14/22." Under Describe the nature of your complaint revealed RN T "is scary threatening with needle... Temper... All patients scared of [RN T] anger/temper! Hostile/Aggressive." Under #4 Date report filed with "6-14-22" hand-written in. Box labeled "Date Reviewed," Outcome (describe resolution of problem or forwarding information if appropriate), and Staff Signature were blank.There was no documentation of investigation, decision, or resolution of the problem, documented.

Record review of form titled "Complaint Report" Patient Information on Patient #31, date reported "6/15/22." Under Describe the nature of your complaint revealed "[RN S] 2nd shift told me to [F___ Off]. In box labeled "Date Reviewed," date reviewed was left blank. Under #4 Date report filed with "6-15-22" hand-written in. Under Outcome revealed "Informed [Patient #31 Nursing Admin (Administration) would speak with [RN S]." There was no documentation of investigation or reason for decision documented.

On 8/31/2022 at 11:07 AM during interview with Administrator A, Administrator A stated there was no Client Rights and Grievance and Complaint Procedures policy prior to 8/25/2022. When asked when the complaint investigations of Patient #26 and Patient #31 complaints were documented, Administrator A stated they were documented in the "Misconduct Incident Reports" dated 8/10/2022 and 8/15/2022 (months after the complaints-greater than 7 days per policy).

On 8/31/2022 at 10:22 AM during interview with Client Rights Specialist (CRS) X, CRS X stated s/he does not review all of the patient complaints, s/he only gets involved when he is asked by Administrator A to do an investigation. CRS X stated s/he was not asked to investigate Patient #26 or Patient #31's complaints until 8/10/2022 after a visit "on a Chapter 94" anonymous complaint investigation and that he did not see the complaint from Patient #32.

On 8/31/2022 at 3:03 PM during interview with Administrator A, when asked if complaint investigations were documented, Administrator A stated no, "that will be a good process improvement opportunity."

On 8/31/2022 at 3:40 PM during interview with Nursing Services Coordinator (NSC) B, NSC B stated "of course I asked people" about the complaints on Patient #26 and Patient #31 and they were discussed with Administrator A. There was no documented investigation or follow-up of complaints documented until 8/10/2022.

Based on observations and interviews the facility failed to ensure that cleaning/disinfectant solution and cleaning supplies were kept secured and out of the reach of patients on the psychiatric unit in 1 of 1 observations of Housekeeping staff cleaning a patient room (Housekeeper Q).

Findings Include:

Per observations on 08/29/2022 from 11:45 AM to 12:00 PM, observed Housekeeper Q cleaning room #153 on the psychiatric inpatient unit B. Per observations, Housekeeper Q's cleaning cart was located just outside the door to room #153, Housekeeper Q proceeded to clean the bathroom, mattress, and floors in the room which did not allow Housekeeper Q to have a view of the cleaning cart at all times to prevent patient access. Per observations, the cleaning cart contained 3 bottles and a bucket filled with cleaning/disinfectant solutions.

Per interview with Clean Power Manager P on 08/29/2022 at 3:42 PM, Manager P stated that housekeeping staff should be in view of cleaning cart at all times while on the unit. Manager P stated that Housekeeper Q should have pulled the cleaning cart into the room while cleaning the patient room and then moved it out with her/him while finishing up the floors.

Based on record review and interview staff failed to ensure there was a Provider order for each episode of Seclusion and/or Restraint in 1 of 2 medical records reviewed (Patient (Pt) #21) in a total sample of 30 medical records reviewed.

Findings Include:

Review of the policy and procedure titled, "Seclusion" last reviewed 08/27/2020 revealed the following:
-Orders for seclusion shall not be standing orders or PRN, also known as "as needed."
-Orders of seclusion shall be for no more than four hours.
-An authorized Prescriber Order for seclusion will be obtained and the order must specify reason for seclusion and duration of the seclusion (not to exceed 4 hours).

Per review of Pt #21's medical record, Seclusion was ordered for Pt #21 on 1/22/2022 from 8:58 PM to 12:57 AM (4 hours). Review of Provider order revealed, "(Pt #21) to sleep in (seclusion) tonight for patient and staff safety." Per review of Pt #21's Provider orders there was no documented evidence of a Seclusion order being renewed every 4 hours while patient was in Seclusion.

Review of nursing Progress note dated 01/23/2022 at 6:32 AM revealed, "Patient (Pt #21) spent the night in seclusion..." Per nursing Progress note, Pt #21 came out of Seclusion at 6:20 AM (5 hours and 23 minutes after the order expired).

Per interview with Nursing Services Coordinator B on 08/30/2022 at 10:00 AM, B stated that there are no additional orders for seclusion covering the overnight hours that Pt #21 was in seclusion. B stated that staff should have obtained a new order for seclusion.

Based on record review and interview, the facility failed to collect data and investigate a patient incident in 1 of 2 restraint and seclusion records reviewed (Patient #25) in a total of 30 medical records reviewed.

Findings include:

Record review of policy "Accident/Incident Report" #CL86005, last revision date of 12/17/2020, Under Procedure C. revealed "The RN will notify the attending physician.. will complete a ... Patient/Visitor Incident Report form."

Review of Patient #25's medical record (pulled from the restraint and seclusion log) nursing progress note 3/02/2022 at 10:44 AM revealed Patient #25 "punched a window sustaining an open cut to his right first knuckle."

On 8/31/2022 at 11:00 AM during interview with Quality Assurance Performance Improvement (QAPI) Nurse R, QAPI Nurse R stated the incident report log included all reported incidents received from August 1, 2021 to present. Patient #25's incident was not in the incident report log.

On 8/31/2022 at 11:55 AM during interview with Support Staff Supervisor E, Supervisor E confirmed there were no incident reports completed on Patient #25.

Based on record review and interview the facility failed to ensure that all patients are assessed and evaluated for their risk of nutritional deficiencies and/or need for therapeutic diets in 2 of 30 medical records reviewed (Patient (Pt) #1 and Pt #23) in a total sample of 30 records reviewed.

Findings Include:

Review of policy and procedure titled, "Nutrition Screening, Evaluation, Assessment and Monitoring" last 08/28/2020 revealed the following:
-All patients admitted to the (mental health facility) inpatient units will have a Nutritional Screen, a nutrition evaluation, and nutritional monitoring.
-A Nutritional Evaluation will be completed by the FSS or RD.
-High Nutrition Risk (Nutritional Screening score of 8 or higher) will be reviewed by the FSS or RD within one business day; results of the review, nutrition evaluation and recommendations will be entered as an inpatient Progress Note in the patients EHR (electronic health record) within one business day of admission.
-Moderate Nutrition Risk (Nutritional Screening score of 5 to 7) will be reviewed by the FSS or RD within 2 business days of admission; results of the review, nutrition evaluation and recommendations will be entered as an inpatient Progress Note in the patients EHR (electronic health record) within two business days of admission.
-If a patient expresses a diet or nutrition concern to the inpatient staff, the FSS, or RD will be contacted and meet with the patient within two business days to discuss their concerns.

Pt #23:

Review of Pt #23's medical record revealed Pt #23 was admitted to the hospital on 8/15/2022 at 7:30 PM with a primary diagnosis of Schizophrenia; Pt #23 was a current inpatient at the time of medical record review on 08/30/2022 at 12:00 PM. Review of Pt #23's History and Physical revealed Pt #23 had a diagnosis of Diabetes Mellitus (DM) Type 2 and Obesity. Per Pt #23's History and Physical, Pt #23 was offered "Nutritional Counseling" and "Patient accepted".

Review of Pt #23's Initial Nursing Assessment dated 08/15/2022 at 9:27 PM revealed, Pt #23's Nutritional Screening score was 5-7 (Moderate Risk).

Per review of Pt #23's progress notes, there was no documented evidence of Pt #23 receiving "Nutritional Counseling" as per Pt #23's accepted offer for Nutritional Counseling as documented in the History and Physical.

Review of Pt #23's Progress notes from Registered Dietician (RD) Z dated 08/18/2022 at 4:14 am, revealed RD Z documented a "Recommendation" to "Change diet to Consistent Carbohydrate (Carb), 17-19 Carb servings per day/Lactose-restricted," due to Pt #23 having DM Type 2 and reporting an intolerance to lactose.

Review of Pt #23's Diet orders dated 08/15/2022 at 7:35 PM, revealed Pt #23 had a "General Diet" ordered on admission; per review of Pt #23's orders, there was no evidence of Pt #23's General diet being changed to a Consistent Carbohydrate diet and Lactose-restricted based on RD Z's nutritional evaluation and recommendations.

Per interview with RD Z on 09/01/2022 at 1:00 PM, RD Z stated that patients who have DM are generally placed on a Consistent Carbohydrate diet. Per RD Z, she/he puts in the recommendations to the Provider and usually checks the same day or the next day to ensure the orders are changed to the appropriate recommended diet. Per interview with RD Z, if the patient is offered Nutritional Counseling from the Provider and accepts, it is the RD's responsibility to follow up with the patient within 24 hours to offer this counseling. Per RD Z, evidence of this nutritional counseling should be documented in the patient's medical record along with specific interventions and the patient's response.

Pt #1:

Review of Pt #1's closed medical record revealed Pt #1 was admitted to the hospital on 06/19/2022 at 1:14 AM with a diagnosis of Schizo Affective Disorder; Pt #1 was discharged on 06/21/2022 at 6:40 PM. Review of Pt #1's History and Physical dated 06/19/2022 at 12:57 PM, revealed Pt #1 had a history of Irritable Bowel Syndrome (IBS).

Review of Pt #1's Initial Nursing Assessment dated 06/19/2022 at 1:14 AM revealed Pt #1 had a Nutrition Risk score of 8 or higher (High Nutrition Risk).

Per review of Pt #1's medical record, there was no documented evidence of a Nutritional Assessment/Evaluation completed by the RD or FSS from date of admission on 06/19/2022 through the date of discharge on 06/21/2022, as per policy.

On 8/31/2022 at 3:30 PM, during interview while reviewing Pt #1's medical record with Projects Analyst AA, Analyst AA stated that she/he was unable to find documentation of Pt #1's Nutritional Assessment/Evaluation.

Based on observation, staff interviews, and review of maintenance records between 08/29/2022 and 08/30/2022, the facility did not construct, install and maintain the building systems to ensure life safety for patients.

The cumulative effect of environment deficiencies are not compliant with 42 CFR 482.41(a) was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies:
K256 Sleeping Suites
K351 Sprinkler System - Installation
K353 Sprinkler System - Maintenance and Testing
K511 Utilities - Gas and Electric

Refer to the full description at the cited K tags.

Based on observation, staff interviews, and review of maintenance records between 08/29/2022 and 08/30/2022, the facility did not construct, install and maintain the life safety systems for patients.

The cumulative effect of environment deficiencies with 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies.
K256 Sleeping Suites
K351 Sprinkler System - Installation
K353 Sprinkler System - Maintenance and Testing
K511 Utilities - Gas and Electric

Refer to the full description at the cited K tags.

Based on observation, record review and interview, the facility failed to ensure hospital equipment was maintained on a preventive maintenance schedule to ensure an acceptable level of safety and quality for 1 of 1 emergency medical equipment box, 2 of 2 automated blood pressure cuffs (Spot Vital Signs) and 1 of 1 Electrocardiograph (ECG) machine in a sample of 2 nursing inpatient units (inpatient psychiatric unit A and unit B) where equipment is utilized.

Findings include:

A review of the facility policy titled, "Emergency Medical Equipment", last reviewed 08/28/2020, revealed: " ...PROCEDURE 1. The emergency box will be inspected and checked by the consultant Registered Pharmacist (RPh) every month ...4. The emergency medical box is kept on Unit B in the medication room ..."

A review of "EMERGENCY BOX CONTENTS" checklist located on inpatient unit B in the medication room revealed, checks were done by Registered Nurses and "DATE CHECKED" were done on 04/07/2022, 06/01/2022, 07/01/2022 and 07/27/2022.
During an interview on 08/30/2022 at 9:55 AM with Charge Registered Nurse J, when asked who checks the emergency box contents and expiration dates on supplies, Charge Nurse J stated "We check expiration dates monthly and box is checked nightly by third shift." When asked who does quality checks on the two automated blood pressure cuffs on the inpatient units, Charge Nurse J stated that Nursing Services Coordinator (B) manages them and they are about "3 months old." When asked who does quality checks on the EKG machine, Charge Nurse J stated "I think Biomed checks, but ask [Patient Services Coordinator B]."

During an interview on 08/31/2022 at 9:45 AM with consultant Registered Pharmacist L, when asked who is responsible for checks on the emergency box located on the inpatient unit B medication room, Pharmacist L stated "Monthly checks are done by myself or another Pharmacist if I can't get there." When asked about the Registered Nurse signatures on the Emergency Box Checklist. Pharmacist L stated that the RN (Registered Nurse) signatures are when they have to go into the box they check it. There was no evidence that a pharmacist checked the emergency box.

A review of the "CP 150 12-lead resting electrocardiograph" (ECG machine) and "Spot Vital Signs" (automated blood pressure cuffs) manufacturers recommendations for Service revealed, "Download and install the Welch Allyn Service Tool on your computer, then connect and register your supported devices to: *Receive free software upgrades *Add new device features *Review error and event log files *Assign devices to locations on the floor *Verify and calibrate your devices. The Welch Allyn Service Tool is remote diagnostic software that streamline the maintenance and servicing process ..."

During an interview on 08/29/2022 at 4:30 PM with Nursing Services Coordinator B, when asked if there is a preventative maintenance policy for nursing equipment (ECG machine and automated blood pressure cuffs) used on the inpatient units, Coordinator B stated "No" and confirmed that the blood pressure cuffs are new and "they haven't had to be checked yet by the company we purchased from." Coordinator B confirmed that the two automated blood pressure cuffs were received on 04/27/2022 and the ECG machine was received on 03/19/2021-per packing slips from the purchasing companies. Coordinator B could not provide any quality checks/calibration done on the two automated blood pressure cuffs and ECG machine currently being used on the inpatient units.

Based on observation, record review and interview, the facility failed to employ a method for tracking and trending antibiotic use in 1 of 1 of its antibiotic stewardship programs and failed to maintain a clean and sanitary environment free from potential sources of contamination for 2 of 2 nursing units (inpatient psychiatric unit A and unit B) observed and 9 of 13 hospital areas observed (Occupational Therapy room, Housekeeping, soiled linen room, storage room unit A, Maintenance Shop room, food preparation room, and food storage areas) in a total of 13 areas.

Findings include:

Antibiotic Stewardship:

Review of policy and procedure titled, "Antibiotic Stewardship" Origination date 05/12/2021 revealed the following:
-The Nursing and Patient Services Coordinator holds the position of Infection Control Officer...
-The facility shall ensure that systems are in place for the tracking of all infection surveillance, prevention, control, and antibiotic use activities in order to demonstrate the implementation, success, and sustainability of such activities.
-Antibiotic stewardship shall encompass medical, nursing, and pharmacy services.

Per interview with Nursing Services Coordinator B (Infection Control Officer) on 08/31/2022 at 9:20 AM, B stated that he/she was unable to find any documented evidence of staff tracking and trending antibiotic use activities as per policy.

A review of the facility policy titled, "Client Rights and Grievance and Complaint Procedures", last reviewed 08/252/022, revealed: " ... C. PERSONAL RIGHTS Every client has the right to: i. Receive treatment in a safe, psychologically, and physically humane environment ...Every inpatient client has the right to:...Safe and clean surroundings..."

During a tour of the OT (Occupational Therapy) Rehabilitation room #1085 with COTA (Certified Occupational Therapy Assistant) CC on 08/30/2022 at 9:09 AM, observed paint peeling above the sink, chipped paint on the wall where the alarm button is attached and chipped paint next to the phone hanging on the wall.

During a tour of inpatient psychiatric units A and B with Charge Registered Nurse J on 08/30/2022 at 10:00 AM, observed black bugs crawling on the floor in patient room #'s 147, 148 and 149, leaking water from the bottom of the sink in patient room #146 and black staining on the base of the shower caulking in patient room #'s 150, 151, 152, 153, 154, 156, 157, 158 and 159.

During an interview on 08/30/2022 at 10:24 AM, Charge Registered Nurse J stated, "It looks like the caulking is coming off around the base of the showers and black mold/mildew is forming, I am closing down room #152 now because that shower is bad." When asked about the black bugs crawling on the floors in multiple patient rooms, Nurse J stated "Looks like we are having a beetle infestation again."

During an interview on 08/31/2022 at 1:48 PM with Facilities Mechanic C, when asked if there have been any maintenance orders submitted for paint peeling and chipped on the walls of the OT room, shower repairs/black staining around shower bases and bugs in the patient rooms, Mechanic C stated "No." When asked if he/she would see those maintenance requests if they were submitted, Mechanic C stated that he/she would see all maintenance requests made, "they are shipped right to me." Mechanic C also stated, "the bug guy is here the 1st Tuesday of the month."



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Housekeeping:

Review of policy and procedure titled, "Hand Washing and Hand Hygiene" last reviewed 12/09/2020 revealed, "Apply the alcohol based product to the palm of one hand, then rub hands together, between fingers, your finger tips and the back of your hands. Continue to rub hands together until hands are dry."

Observations on 08/29/2022 beginning at 11:45 AM, of Housekeeper Q cleaning patient room 153 (discharged patient room), revealed the following issues:

-During 4 opportunities for hand hygiene after removing gloves, Housekeeper Q applied hand sanitizer to the palm of his/her hands and rubbed hands together for 2-3 seconds. Housekeeper Q did not rub hand sanitizer on all front and back surfaces of his/her hands and in between fingers. Per observations, Housekeeper Q was wearing a black sleeve covering part of the hand and wrist underneath the gloves, this did not allow Housekeeper Q to sanitize all surfaces of the hand. Housekeeper Q did not apply sanitizer to the wrist/hand sleeve (porous surface).

-Housekeeper Q cleaned and disinfected the top of the desk, than proceeded to pick up the desk chair and place it on top of the desk while mopping the floors (allowing cross contamination from the floor to the top of the desk). Housekeeper Q did not perform repeat cleaning and sanitization of the desk, after removing the chair from the desk and placing back onto the floor.

Per interview with Clean Power Manager P on 08/29/2022 at 3:45 PM, Housekeeper Q should have placed the chair upside down on top of the desk to prevent cross contamination. Per Manager P, Housekeeper should not have placed the chair upright on top of the desk.

During tour with Clean Power Manager P and Housekeeping Supervisor O, on 08/30/2022 between 3:30 PM and 4:00 PM, observed the following infection control issues:
Housekeeping room:
-Visible dust, debris, cobwebs, and packaging material on the floor, around multiple pallets holding housekeeping supplies, and under large supply carts.
-3 Visibly dirty dust cloths on the shelf of the supply cart
-White powder scattered on shelf of supply cart
-2 visibly dirty yellow dust clothes attached to stick on shelf of supply cart
-2 jugs with purple solution not labeled and dated.

Soiled Linen Room:
-Observed soiled linen falling out of an unsecured plastic bag.

Storage Room (Room #1101):
-Observed 12 large plastic bins on the bottom shelf of supply carts, containing clean clothes for patients; the plastic bins were all uncovered allowing for potential contamination with dust and debris.

Maintenance Shop Room:
-Observed dust, debris, cobwebs, and packaging materials on the floor and under supply carts.
-Observed a visibly dirty towel with green staining laying on the floor.

Per interview with Clean Power Manager P and Supervisor O, during the tour on 08/30/2022 between 3:30 PM and 4:00 PM, Manager P stated that used dust cloths should be discarded immediately after use and should not be stored on the supply carts. Per Manager P, housekeeping is responsible for cleaning the Housekeeping Room once per week, but stated that there are no set assignments. Manager P stated that all disinfectants should be labeled, including expiration date. Per interview with Supervisor O, clean patient linen should be covered and soiled patient linen should be secured in a plastic bag.

Dietary:

Review of policy and procedure titled, "Food Storage" Origination date 08/18/2021 revealed the following:
-Frozen products shall be labeled indicating product name and date (month, day, and year) product was received.
-Dry goods shall be stored for a period not to exceed the expiration date listed on the packaging. Any item without an expiration date, shall expire one year from the date of receipt.
-Canned goods shall be stored for a period not to exceed the expiration date listed on the packaging.
-Refrigerated items shall have a label indicating product name and date (Month, day, year) product was received or used.
-Perishable foods shall be refrigerated or frozen.

Review of policy and procedure titled, "Personal Hygiene--Food Service" Origination date 08/18/2021 revealed that "Hair restraints shall be worn by Food Service workforce members when handling food in the food-handling and storage areas."

Per observations of the food storage areas on 08/29/2022 between 11:10 AM and 12:30 PM, observed the following issues:

Food Preparation Room:
-Apples and Oranges on bottom shelf of cart not covered or stored in the refrigerator as per policy for perishable food.
-Raised black colored residue on floor near the base boards under the dish washing sink.

Refrigerators in Food Preparation Room:
-Bag of Mozzarella cheese opened 08/19/2022 (not discarded within 7 days).
-Bag of Cheddar cheese opened 08/08/2022 (not discarded within 7 days).
-Honey packets no date received/expiration date
-lemon juice packets no date received/expiration date
-Ocean Spray Cranberry Juice jug no open date

Dry food Storage Room:
-2 packages of Ready Pasta no received/expiration date
-Package of sugar cookies expired 08/28/2022
-Rice Crispy Treats no received/expiration date
-Can of diced potatoes expired 10/21/2021
-Can of peeled tomatoes expired 08/28/2022
-Ben's Whole Grain Brown Rice expired 06/2022

Freezer in Food Preparation Room:
-Meatless Crispy Tenders no date opened/received
-Plant based Ground beef no date opened/received
-White Castle burgers no date opened/received

Unit B Refrigerator:
-13 Cranberry Juice containers no expiration date
-15 Apple Juice containers no expiration date
-8 Apple Cherry Juice containers no expiration date
-Box of creamers no expiration date

Unit B Microwave (used to warm up patient food):
-Observed food debris stuck on the cooking cavity of the microwave.
-Observed a rust color exposed from under peeling material of the inner surfaces of the microwave.

Per observations on 08/29/2022 between 11:10 AM and 12:30 PM, observed Kitchen Technician N with hair coming out of the back of her/his hair net.

Per interview with Food Service Specialist M on 08/29/2022 between 11:10 AM and 12:30 PM, food should be discarded 7 days after opening; Per M, Staff should be labeling food with a received date and an opened date. Per M, staff should have a hair net covering all of the hair while in the food preparation area.

Based on record review and interview the facility failed to ensure that interdisciplinary progress notes reflect the Treatment Plan interventions and patient's response to the interventions in 6 of 30 medical records reviewed (Patient (Pt) #2, 9, 17, 18, 23, 25), in a total sample of 30 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Documentation" last revision date 04/2012, revealed the following:
1. The medical record will contain sufficient information to justify the admission and continued hospitalization, support the diagnosis, treatment, and end results, and describe the patient's progress and response to medication and services.

Pt #2:

Review of Pt #2's medical record revealed Pt #2 was admitted to the hospital on 06/08/2022 at 8:45 PM with a diagnosis of Schizophrenia.

Review of Pt #2's Comprehensive Treatment Plan dated 08/14/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing will offer (Pt #2) Coping Skills group 2-3 times per week to help educate him on ways of dealing with crisis stressors and stress management and to help learn positive communication skills though group communication.
2. Patient Engagement Specialist will coordinate with (Pt #2) to be seen individually or in group when not involved in group programming to expand coping skills to help deal with hopelessness and suicidal ideation (SI).

Per review of Pt #2's medical record, there was no documented evidence of Pt #2 being offered the above group session or being seen by a Patient Engagement Specialist as per documented in Pt #2's Comprehensive Treatment Plan.

Pt #9:

Review of Pt #9's medical record revealed Pt #9 was admitted to the hospital on 08/11/2022 at 2:05 PM with a diagnosis of Schizoaffective disorder, bipolar type, anxiety disorder, and opioid use disorder.

Review of Pt #9's Comprehensive Treatment Plan dated 08/20/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing staff will facilitate Coping group therapy 3-5 times per week to help (Pt #9) develop and identify 2 positive alternatives or coping skills to address anxiety, depressive thoughts, and sleeplessness.
2. Nursing Staff will coordinate with Patient Engagement Specialist to for (Pt #9) to be seen individually or in group when not in group programming to improve social interaction skills.

Per review of Pt #9's medical record, there was no documented evidence of Pt #9 being offered the above group session or being seen by a Patient Engagement Specialist as per documented in Pt #9's Comprehensive Treatment Plan.


Pt #23:

Review of Pt #23's medical record revealed Pt #23 was admitted to the hospital on 8/15/2022 at 7:30 PM with a primary diagnosis of Schizoaffective disorder, bipolar type.

Review of Pt #23's Initial Treatment Plan dated 08/15/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing will meet with (Pt #23) in Symptom Management and Medication Management groups 1-2 times each week to provide education on the benefits of psychotropic medications in controlling (Pt #23's) bizarre and delusional thoughts/behaviors.
2. Patient Engagement Specialists will coordinate with (Pt #23) to be seen individually or in group when not in group programming to improve social interaction skills.

Per review of Pt #23's medical record, there was no documented evidence of Pt #23 being offered the above group sessions or being seen by a Patient Engagement Specialist as per documented in Pt #23's Initial Treatment Plan.

Pt #25:

Review of Pt #25's medical record revealed Pt #25 was admitted to the hospital on 03/1/2022 with the diagnosis of Schizophrenia.

Review of Pt #25's Comprehensive Treatment Plan dated 03/29/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing will facilitate Coping group 3 to 5 times weekly to assist Pt #25 in recognizing symptoms and identify 2 new coping skills to lessen those symptoms 3 days prior to discharge.
2. Nursing to schedule time with Patient Engagement Specialist when not in scheduled groups to assist with evaluation of thought process and coping skills to lessen symptoms.

Per review of Pt #25's medical record, there was no documented evidence of Pt #25 being offered the above group sessions or being seen by a Patient Engagement Specialist as per documented in Pt #25's Comprehensive Treatment Plan.




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Pt #17:

Review of Pt #17's medical record revealed Pt #17 was admitted to the hospital on 08/25/2022-08/30/2022 with a diagnosis of Schizoaffective disorder, bipolar type.

Review of Pt #17's Comprehensive Treatment Plan dated 08/25/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing staff will coordinate with Patient Engagement Specialists for (Pt #17) to be seen individually or in-group when not in group programming to improve social interaction skills.
2. Social Worker will encourage (Pt. #17) to attend SUD (substance use disorder) group 2-3 times per week to assist (Pt. #17) with identifying triggers/cravings that lead to substance use and identify Healthy coping skills (Pt. #17) can use to manage MI.

Per review of Pt #17's medical record, there was no documented evidence of Pt #17 being offered the above group session or being seen by a Patient Engagement Specialist as per documented in Pt #17's Comprehensive Treatment Plan; these findings confirmed by Inpatient Medical Coder DD during medical record review.

Pt #18:

Review of Pt #18's medical record revealed Pt #18 was admitted to the hospital on 08/21/2022-08/24/2022 with a diagnosis of Major depressive disorder, recurrent, moderate.

Review of Pt #18's Comprehensive Treatment Plan dated 08/22/2022 revealed documentation of the following staff treatment "Interventions":
1. Nursing staff will coordinate with Patient Engagement Specialists for (Pt #18) to be seen individually or in-group when not in group programming to improve social interaction skills.
2. Social Worker will encourage (Pt. #18) to attend SU (substance use) group 2-3 times per week to assist (Pt. #18) with identifying triggers that lead to SI (suicidal ideation) and thoughts and identify healthy coping skills they can use to manage MI and pain.

Per review of Pt #18's medical record, there was no documented evidence of Pt #18 being offered the above group session or being seen by a Patient Engagement Specialist as per documented in Pt #18's Comprehensive Treatment Plan; these findings confirmed by Program Projects Analyst AA during medical record review.

Per interview with Nursing Services Coordinator (NSC) B on 08/31/2022 at 9:20 am, B stated that they do not currently have a Patient Engagement Specialist and are in the process of hiring for that position. Per NSC B, the Psychiatric Technicians were working in that role but NSC B stated, "Well you know how that is."