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Based on document review and interview, it was determined that 1 of 9 (Pt #6) clinical records reviewed the Hospital failed to ensure physician orders were followed as written.

Findings include:

1. Pt #6 was a 58 year old female admitted on 11/24/14 with a diagnoses of Schizoaffective Disorder and Obesity. Physician order dated 12/12/14 at 10:20 AM stated "Food and Fluid intake monitoring".

2. The clinical record of Pt #6 was reviewed at Stevenson Hall on 1/6/15 at 12:30 PM with the Clinical Nurse Manager (E #5). From 12/12/14 at 12:00 PM until 12/29/14 at 12:20 PM there were 42 food and fluid entries not documented on the Food and Fluid Log.

3. An interview was conducted on 1/6/15 at 12:45 PM with E #5. E #5 stated there were 42 food and fluid entries not documented on the Food and Fluid Log.

Based on document/record review, and staff interview, it was determined in 1 of 8 patient's (Pt #10) the Hospital failed to ensure the psychosocial assessment was completed in a timely manner per Hospital policy, potentially affecting all patients receiving care. (current census 132)

Findings include:

1. A review of Hospital policy "Psychosocial Assessments" (revised 6/30/14) was conducted on 1/7/15 at 3:00 PM. Under "Psychosocial Assessment Process B." it indicated "A Psychosocial Assessment will be completed on all individuals admitted to the hospital by the third day of admission."

2. The medical record of Pt #10 was reviewed on 1/6/15 at 10:45 AM. Pt #10 was involuntarily admitted on 12/23/14 due to suicidal ideation. Documentation on the "Psychosocial Assessment" indicated it was completed by the social worker (E #7) on 12/29/14, six days after admission.

3. On 1/6/15 at 10:50 AM an interview with the Quality Manager from Central Office (E #2) was conducted. E #2 confirmed the psychosocial assessment on Pt #10 was completed on 12/29/14, six days after admission and verbalized the assessment should have been done within three days of admission.

Based on observation and interview it was determined the Hospital failed to retain medical records for five years, potentially affecting all patients receiving care at the Hospital (current census 132 patients).

Findings include:

1. On 1/6/15 at 2:00 PM a request was made for copies of the medical record for Pt #7. The Hospital was unable to provide copies of the paper portion of the medical record because it was sent to another facility.

2. On 1/7/15 at 9:50 AM an interview with the Director of Quality (E #4) was conducted. E #4 indicated the Hospital used both electronic and paper form of medical record. E #4 indicated Pt #7 was transferred to another facility on 1/6/15 and the paper portion of the medical record was sent with the patient and not available. E #4 indicated when patient's are transferred from the Hospital to another state mental health facility, the entire medical record (original paper portion) is forwarded to the receiving facility and no copies of the paper medical record are maintained on site. E #4 also indicated the electronic medical record is maintained but the paper portion of the medical record is retrievable, when needed, by contacting the receiving facility and asking for the paper portion of the medical record. E #4 indicated that "95% of the patients that we transfer return to our facility so we get the complete medical record when the patient returns." E #4 indicated "this practice was driven by a Department of Mental Health practice."

Based on document review and staff interview, it was determined in 1 of 1 Controlled Substance Log dated 11/11/14 - 1/5/15 reviewed on Lincoln North Unit, the Hospital failed to ensure the accuracy of controlled medication inventory (Lorazepam 2 mg oral). This had the potential to effect all 26 patients (census) on Lincoln North Unit.

Findings include:

1. Hospital Policy "Pharmaceutical Services", (revised 9/19/14) was reviewed on 1/7/15 at 2:30 PM. Under "III. Nursing Medication Rooms, B", the policy stated..."A count for accuracy of inventory is taken by the incoming and outgoing personnel at change of each shift."

2. During a tour of Lincoln North Unit on 1/5/15 at 11:00 AM a physical count of Lorazapam 2 mg, oral was completed with a total count of 43 tablets. The Controlled Substance Log inventory count for Lorazapam 2 mg, oral was 44 tablets.

3. A interview with Clinical Nurse Manager (E #1) was completed on 1/8/15 at 11:30 AM. E #1 stated "a miss count occured on 1/2/15 on the 3 PM to 11 PM shift. There was no medication missing, staff continued to annotate the controlled substance log with the wrong number for ten shifts."

Based on document review, observation and interview, it was determined in one (1) of one Dietary Department, the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment, potentially affecting all patients and staff receiving dietary food services in the Hospital.

Findings include:

1. Hospital policy "FOOD STORAGE" (revised 2/28/14) was reviewed on 1/5/15 at 11:00 AM. Under "5." it indicated Bulk foods (such as beans, oats, rice, etc.) when opened, shall be placed in plastic barrels with airtight lids. These containers must be labeled."

2. On 1/5/15 at 11:00 AM a tour of the Dietary Department was conducted with (E #1). During the tour, in one (1) of three (3) coolers, there were three (3) containers of oatmeal, five (5) bags of tortilla shells, and one (1) bag of bacon with no label, indicating what the food items were.

3. On 1/5//15 at 11:10 AM an interview with the Food Service Supervisor (E #1) was conducted. E #1 confirmed the food was not labeled and verbalized it should have been.

4. On 1/5/15 at 11:00 AM a tour of the Dietary Department was conducted with (E #1). During the tour, one (1) of one (1) table top, commercial can opener blade had old dried food particles on it.

5. On 1/5//15 at 11:10 AM an interview with the Food Service Supervisor (E #1) was conducted. E #1 verbalized the can opener was dirty and should have been cleaned after every use.

6. Hospital policy "PERSONAL HYGIENE & HEALTH OF DIETETIC PERSONNEL" (revised 2/28/14) was reviewed on 1/5/15 at 10:00 AM. Under "6." it indicated "Hair is to be restrained and entirely covered to keep it from contacting exposed food, utensils, equipment and food contact surfaces. Effective hair restraints include hairnets, bouffant bonnets which are disposable and provided by the hospital, beard cover and clothing that covers body hair."

7. On 1/6/15 at 11:00 AM a tour of the Dietary Department was conducted with the Quality Manager, Central Office (E #2). During the tour the Food Service Supervisor (E #1) was behind the food line serving food while wearing a baseball cap and not wearing a hairnet.

8. On 1/6/15 at 11:10 AM an interview with E #2 was conducted. E #2 confirmed E #1 was wearing a ball cap and verbalized E #1 should have been wearing a hair net.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 5 & 6, 2015, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 5 &6, 2015, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated January 6, 2015.