HospitalInspections.org

Based on interviews and record review, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice was evidenced by:
1)Failure of the admitting practitioner's to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#4) of 5 (#1-#5) patient records reviewed for the sample; and
2)Failure of the admitting practitioners' to update the Electronic Medical Record (EMR) with a new allergy identified during the Psychiatric Evaluation and/or History & Physical intake on 3 (#3, #4, #5) of 5 (#1-#5) patient records reviewed.
Findings:

1)Failure of the admitting practitioner's to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#4) of 3 (#1-#5) patient records reviewed for the sample.

Review of Patient #4's medical record revealed Patient #4 was admitted on 02/12/2025. Review of Patient #4's History & Physical dated 02/13/2025 revealed documentation by the provider that Patient #4 had a questionable diabetes diagnosis so the plan would be to monitor/trend CBGs. Further review of Patient #4's provider orders did not reveal an order to check CBGs. Review of Patient #4's Plan of Care dated 02/12/2025 Alteration of glucose related to diabetes as evidenced by history of diabetes was identified as problem #2 with an intervention of nursing to provide education on results of testing and a short term goal of CBGs within normal limits daily for 3 consecutive days within 7 days.

In an interview on 03/26/2025 at 1:57 PM, S1DON verified the above mentioned findings.

2)Failure of the admitting practitioners' to update the EMR with a new allergy identified during the Psychiatric Evaluation and/or History & Physical intake on 3 (#3, #4, #5) of 5 (#1-#5) patient records reviewed.

Review of Patient #3's medical record revealed Patient #3 was admitted on 02/07/2025. Review of Patient #3's Psychiatric Evaluation dated 02/07/2025 revealed the provider documented Patient #3 was allergic to Buspar. Further review of Patient #3's EMR revealed Patient #3's allergies were PCN, Lithium, Sulfa, Morphine, and Klonopin.

In an interview on 03/26/2025 at 10:46 AM, S1DON verified that the provider documented in Patient #3s Psychiatric Evaluation dated 02/07/2025 Patient #3 was allergic to Buspar, but Patient #3's EMR only had allergies to PCN, Lithium, Sulfa, Morphine, and Klonopin.

In an interview on 03/26/2025 at 10:46 AM, S1DON verified that the provider documented in Patient #3s Psychiatric Evaluation dated 02/07/2025 Patient #3 was allergic to Buspar, but Patient #3's EMR only had allergies to PCN, Lithium, Sulfa, Morphine, and Klonopin.

Review of Patient #4's medical record revealed Patient #4 was admitted on 02/12/2025. Review of Patient #4's History & Physical dated 02/13/2025 revealed the provider documented Patient #4 was allergic to Risperdal. Further review of Patient #4's EMR revealed Patient #4 had no known allergies.

In an interview on 03/26/2025 at 1:10 PM, S1DON verified that the provider documented in Patient #4's History & Physical on 02/13/2025 Patient #4 was allergic to Risperdal, and Patient #4's EMR revealed Patient #4 had no known allergies.

Review of Patient #5's medical record revealed Patient #5 was admitted on 02/13/2025. Review of Patient #5's History & Physical dated 02/13/2025 revealed the provider documented Patient #5 was allergic to peanuts. Further review of Patient #5's EMR revealed Patient #5 had no known allergies.

In an interview on 03/26/2025 at 2:35 PM, S1DON verified that the provider documented in Patient #5's History & Physical on 02/13/2025 Patient #5 was allergic to peanuts, and Patient #5's EMR revealed Patient #5 had no known allergies.

Based on observations and interviews, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice was evidenced by failure to ensure each patient has the right to personal privacy by failing to provide complete window coverings to obscure the view from the outside into 5 (Rooms A, E, G, I, J) of 10 (Rooms A-K) patient rooms observed.
Findings:

Observations during a tour on 03/27/2025 from 8:30 AM to 9:05 AM revealed 5 (Rooms A, E, G, I, J) of 10 (Rooms A-K) patient rooms lacked complete window coverings to obscure the view from outside into 5 (Rooms A, E, G, I, J)of 10 (Rooms A-K) patient rooms observed.

In an interview during the tour on 03/27/2025 at 8:50 AM, S1DON and S2ADON confirmed that the partial window coverings were not providing the patients with personal privacy.

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by:

1)Failure to ensure patients were being monitored per provider order on 1(#1) of 5 (#1-#5) patients medical record reviewed;

2)Failure to ensure 2 hour observation rounds were performed by Registered Nurse on 15 (#R1-#R15) of 15 (#R1-#R15) patients on the unit; and

3)Failure to test glucometer controls to meet the safety needs of the patients.
Findings:

1)Failure to ensure patients were being monitored per provider order on 1(#1) of 5 (#1-#5) patients medical record reviewed.

Review of the hospital policy number AS-01 titled, "Assessment Process Inpatient," last revised date 09/01/2024, revealed in part: "PURPOSE: To provide a comprehensive assessment process which improves efficiency and maximizes interdisciplinary cohesiveness and integration for each patient across the continuum of care. To assess the immediate presenting problem for acuity criteria and determine the appropriate intensity of care. Admitting Physician: 1. If admission is necessary, will give approval and provide medical certification for admission. The admission order set will contain an admitting preliminary diagnosis, precautions, orders for treatment, legal status, preliminary plan of care, and diagnostic impression. 2. Initiates initial treatment plan problem(s) to be followed up on by nursing, to include goals and interventions to meet patient transition/safety/discharge planning needs."

Review of Patient #1's medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1's Admit orders dated 01/26/2025 at 4:24 AM revealed in part: Choking Precautions with diet of mechanical soft chopped meat, cardiac moist and assist with feeding. Further review of Patient #1's plan of care did not address the choking precautions or diet needs.

Review of Patient #1's nursing progress note dated 02/02/2025 at 10:55 PM Patient #1 received Ativan 2mg, Benadryl 50mg, and Haldol 5mg IM for severe psychosis. Then at 11:32 PM on 02/02/2025 the RN reached out to medical provider to report Patient #1's oxygen saturation levels were between 86-88% on room air so Patient #1 was placed on oxygen via non-rebreather mask. Further review of Patient #1's nursing progress note dated 02/03/2025 at 12:57 AM documented Patient #1 experiencing gurgling with low oxygen saturation and medical provider notified who ordered Patient #1 to be transferred to higher level of care. Patient #1 was transferred to Hospital B on 02/03/2025 at 12:42 AM.

Review of the medical record for Patient #1 from Hospital B revealed the patient was in respiratory distress upon arrival and was immediately intubated. Patient was admitted to ICU at Hospital B with diagnosis of Aspiration Pneumonia.

In an interview on 03/25/2025 at 12:50 PM, S1DON verified the above mentioned findings.

2)Failure to ensure 2 hour observation rounds were performed by Registered Nurse 15 (#R1-#R15) of 15 (#R1-#R15) patients on the unit.

Review of the hospital policy number CS-23 titled, "Level of Observations", revealed in part: "PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for patient's needs for autonomy while ensuring safety. PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate sections(s) of the form."

Observations during a tour of Campus B on 03/27/2025 from 8:30 AM to 9:05 AM revealed a census of 15 patients. Review of the Observation Check Sheets for all 15 patients on the unit revealed no RN rounding from 7:00 AM to 9:00 AM.

An interview on 03/27/2025 at 9:03 AM, S2ADON verified the RN had not documented rounding on the Observation Check Sheets for the 15 patients on Unit C.

On 03/27/2025 at 1:25 PM, review of video footage navigated by S1ADON of Campus B on 03/27/2025 from 6:45 AM to 7:25 AM revealed at 7:22 AM RN exited the nursing station and walked around the Unit C looking into one doorway which S1ADON identified as the Group Room but couldn't confirm if patients were in the Group Room. S3RN was not seen looking in any other Patient doorways or coming into contact with any patients on the Unit C returning to the nurses' station at 7:25 AM.

On 03/27/2025 at 1:30 PM, S1ADON verified the RN made a walking round around the Unit C at Campus B from 7:22 AM to 7:25 AM, but couldn't confirm the RN rounded on patients or oversee the MHT monitoring patients.

3)Failure to test glucometer controls to meet the safety needs of the patients.

Observations during a tour of Campus A on 03/24/2025 from 12:45 PM to 2:00PM revealed an open bottle of Glucose Control Solution that were not dated for day opened or expiration date. The log titled Glucose Control Log Sheet for Unit A for February and March 2025 were reviewed. Further review of the Glucose Control Log Sheet failed to reveal that daily quality controls were completed for the glucometer on 03/18/2025.

Observations during a tour of Campus A on 03/24/2025 from 12:45 PM to 2:00PM revealed a log titled Glucose Control Log Sheet for Unit B for February and March 2025. Further review of the Glucose Control Log Sheet failed to reveal that daily quality controls were completed for the glucometer on 02/27/2025, 02/28/2025, 03/04/2025, 03/05/2025, 03/16/2025, 03/17/2025, and 03/18/2025.

In an interview on 03/24/2025 at 1:10 PM, S1DON verified the glucose controls are to be checked daily.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1)Failure of the Registered Nurse to obtain a MD order to perform a tasks;
2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy;
3)Failure of the Registered Nurse to assign Observation Levels for 5 of 5 (Patients #1-#5) Patients' Observation Check Sheets reviewed;
4)Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed for 4 (#2, #3, #4, #5) of 5 (#1-#5) Patients' Observation Check Sheets reviewed; and
5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 5 (#1-#5) Patients' Observation Check Sheets reviewed.
Findings:

1)Failure of the Registered Nurse (RN) to obtain a MD order to perform a task.

Review of Patient #1's medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1's Nursing Assessment dated 01/30/2025 at 12:48 PM revealed the RN removed a fecal impaction. Review of Patient #1's Nursing Assessment dated 01/30/2025 at 6:44 PM revealed the RN inserted a 16 french/5cc ballon foley catheter. Further review of Patient #1's medical record failed to reveal a MD order for removal of a fecal impaction or foley catheter insertion.

In an interview on 03/25/2025 at 12:58 PM, S1DON verified the RN performed the above mentioned tasks without an MD order.

2) Failure of the Registered Nurse to document patient observations every 2 hours per policy.

Review of the Patient #1's Observation Check Sheet dated 01/25/2025, failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN:
01/25/2025 between 10:15 PM - 6:45 AM.

In interview on 03/25/2025 at 1:09 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Review of Patient #2's Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN:
-On 08/22/2024 at 3:00 PM and 5:00 PM RN observations not performed
-On 08/25/2024 between 7:00 AM to 5:00 PM RN observations not performed
-On 08/27/2024 between 7:00 AM to 5:00 PM RN observations not performed

In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Review of Patient #3's Observation Check Sheet dated 02/14/2025 failed to reveal documentation that the RN performed observations every 2 hours per hospital policy on 02/15/2025 at 5:00 AM.

In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Review of Patient #4's Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN:
-On 02/15/2025 at 5:00 AM RN observation not performed.
-On 02/20/2025 at 5:00 AM RN observations not performed.

In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Review of Patient #5's Observation Check Sheet dated 02/14/2025 failed to reveal documentation that the RN performed observations every 2 hours per hospital policy on 02/15/2025 at 5:00 AM.

In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

3)Failure of the Registered Nurse to assign Observation Levels for 5 (#1-#5) of 5 (#1-#5) Patients' Observation Check Sheets reviewed.

A review of the Patient Observation Check Sheet for Patient #1 dated 01/25/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 03/25/2025 at 1:09 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheet per hospital policy.

A review of the Patient Observation Check Sheets for Patient #2 dated 08/26/2024 and 08/27/2024, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

A review of the Patient Observation Check Sheets for Patient #3 dated 02/07/2025, 02/11/2025, 02/12/2025, 02/13/2025 and 02/17/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

A review of the Patient Observation Check Sheets for Patient #4 dated 02/12/2025, 02/16/2025, 02/17/2025, and 02/21/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

A review of the Patient Observation Check Sheets for Patient #5 dated 02/17/2025 and 02/21/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

4)Failure of the Registered Nurse to supervise staff to ensure timely Mental Health Technician (MHT) observation rounds performed every 15 minutes for 4 (#2, #3, #4, #5) of 5 (#1-#5) Patients' Observation Check Sheets reviewed.

Review of Patient #2's Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times:
-08/25/2024 between 11:45 AM to 5:45 PM
-08/27/2024 between 7:00 AM to 7:00 PM

In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy.

Review of Patient #3's Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times:
-02/12/2025 between 7:00 PM to 8:00 PM
-02/13/2025 between 7:00 PM to 7:45 PM
-02/17/2025 at 7:00 PM

In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy.

Review of Patient #4's Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times:
-02/12/2025 at 8:00 PM
-02/13/2025 between 7:00 PM to 7:45 PM
-02/17/2025 at 7:00 PM MHT did not document observation rounds every 15 minutes.
-02/18/2025 between 6:00 PM to 6:45 PM and 9:00 PM
-02/20/2025 at 5:15 PM and 5:30 PM

In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy.

Review of Patient #5's Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times:
-02/17/2025 between 6:15 PM to 7:00 PM
-02/20/2025 between 5:15 PM and 5:30 PM

In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy.

5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 5 (#1-#5) Patients' Observation Check Sheets reviewed.

Review of Patient #1's medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1's Nursing Admission Assessment dated 01/26/2025 at 5:00 AM revealed Patient #1 was incontinent of urine with unsteady gait with recent falls and wheelchair bound. Further review of Patient #1's Observation Check Sheets revealed the MHT did not offer the patient water, perform incontinence care, or reposition every 2 hours on the following dates/times:
-01/25/2025 between 10:15 PM to 01/26/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours.
-01/29/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 01/30/2025 6:45 AM Patient #1 was not repositioned every 2 hours.
-01/30/2025 between 7:00 AM to 9:45 AM and 5:00 PM MHT did not document that Patient #1 was repositioned every 2 hours
-01/31/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 02/01/2025 6:45 AM Patient #1 was not repositioned every 2 hours.
-02/01/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 02/02/2025 6:45 AM Patient #1 was not repositioned every 2 hours..
-02/02/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 11:45 PM Patient #1 was not repositioned every 2 hours.

In an interview on 03/25/2025 at 12:58 PM, S1DON verified above findings mentioned.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 2 (#1, #4) of 5 (#1-#5) patient reviewed for completed and updated care plans.
Findings:

A review of the hospital's policy, "Treatment Planning: Integrated/Multidisciplinary," Policy Number: CS-02, revised date of 07/01/2024, revealed in part: PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. PROCEDURE: 2. The admitting nurse is responsible for the following: formulating the initial treatment plan based on physician's orders/ initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 hours of admit or sooner if patient's needs warrants immediate action. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwillingness shall be documented in the patient's medical record.

A review of the hospital's policy number NSG-39 last revised 10/01/2023 titled, "Skin/Wound Care", revealed in part: PURPOSE: To identify patients at risk for skin break down and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment, and treatment of such. PROCEDURE: Braden Scale Risk Assessment: 2. If the Braden score is less than 18, the start of care skin care guideline will be initiated. 3. An impaired skin integrity treatment plan will be initiated or updated according ot the patient's assessed results.
Review of Patient #1's medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1's Admit orders dated 01/26/2025 at 4:24 AM revealed in part: Choking Precautions with diet of mechanical soft chopped meat, cardiac moist and assist with feeding. Further review of Patient #1's plan of care did not address the choking precautions or diet needs.

Review of Patient #1's plan of care dated on 01/26/2025 addressed impaired skin integrity related to actual evidenced by skin tear, but didn't address a Braden score of 12 that indicates a high risk to develop pressure injury requiring different interventions and goals needed for Patient #1.

In an interview on 03/25/2025 at 2:11 PM, S1DON verified the above mentioned findings.

Review of Patient #4's medical record revealed Patient #4 was admitted on 02/12/2025 with the following diagnoses Schizoaffective Disorder Bipolar Type and Anxiety Disorder. Review of admit orders indicated an order for violence precautions which was not addressed on the Patient #4's care plan.

In an interview on 03/26/2025 at 1:57 PM, S1DON verified the above mentioned findings.

Based on record review and interview, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 4 (#1-#4) of 5 (#1 - #5) patient medical records reviewed.
Findings:

Review of Patient #1's medication administration record revealed the following PRN medications were administered:
01/31/2025 at 11:51 PM Geodon 10mg IM X one dose for severe psychosis.
02/01/2024 11:35 PM Ativan 2mg, Haldol 5mg, Benadryl 50mg IM X 1 dose for psychotic disorder
Further review of Patient #1's medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 03/25/2025 12:32 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Review of Patient #2's medication administration record revealed the following PRN medication was administered on 08/25/2024 11:34 PM Seroquel 100mg PO for insomnia. Further review of Patient #2's medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 03/25/2025 4:11 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Review of Patient #3's medication administration record revealed the following PRN medication was administered on 02/12/2025 8:34 PM Clonidine 0.1mg PO PRN SBP >160 DBP >90 for BP 150/094. Further review of Patient #3's medication administration record failed to reveal a re-evaluation of Patient #3's BP to ensure the effectiveness of the medications listed above.

In an interview on 03/26/2025 11:30 AM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Review of Patient #4's medication administration record revealed the following PRN medication was administered on 02/14/2025 10:45 AM Ativan 2mg, Haldol 5mg, Benadryl 50mg IM X 1 dose for aggression. Further review of Patient #4's medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 03/26/2025 1:20 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour of Campus B on 03/27/2025 8:30 AM - 9:08 AM revealed slimy reddish discoloration in the ice machine tray in Room K.

In an interview during the hospital tour, S2DON and S4LPNQ confirmed the Room K's ice machine had been serviced on 03/10/2025, but were unsure the last time the ice machine was cleaned.

Based on observation and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by failure to ensure the emergency cart was inspected daily.
Findings:

A review of the hospital's policy number CS-28 last revised 07/01/2024 titled, "Emergency Cart", revealed in part: PURPOSE: To provide access to life support medical equipment, the facility has made available an emergency cart to house needed supplies. PROCEDURE: 6. The emergency cart is inspected daily by the designated nursing staff on the designated shift. This inspection includes the following: a. Inspection, stock, and clean cart as needed. B. Identify, remove, and replace any expired items. C. Document the completed emergency cart checks on the provided checklist.

Observations during a tour on 03/24/2025 from 12:50 PM to 2:00 PM revealed an Emergency Cart log on Unit A missing daily checks on 03/22/2025 and 03/23/2025.

In an interview on 03/24/2025 at 1:10 PM, S1DON confirmed the findings above and verified that the Emergency Cart should be checked daily.

Based on record review and interview, the facility failed to ensure infection control standards were maintained. The deficient practice is evidenced by failure to ensure food was free from spoilage and bacterial growth.
Findings:

A review of the hospital's policy number: NS-34 last revised 07/01/2024 titled, "Food Preparation", revealed in part: PURPOSE: To provide guidelines to ensure the preparation of quality products according to preplanned menus under safe and sanitary conditions for hospitals who operate a kitchen. PROCEDURE: 15. Temperature checks using metal stem thermometers are made using frequently during preparation and holding to guarantee safety of prepared food. 18. COOKING: Food is cooked/reheated to required temperatures. Final cooking temperatures are recorded on the Production and Food Temperature Log.

Tour of the Campus A room L on 03/24/2025 at 1:25 revealed March 2025 Food Temperature Log missing temperature checks for 03/18/2025 for breakfast and lunch and 03/21/2025 for dinner.

In an interview on 03/24/2025 at 1:30 PM, S6DC verified the food temperature log was missing temperatures for 03/18/2025 for breakfast and lunch and 03/21/2025 for dinner. S6DC further stated that she was unaware of the food temperature parameters.

Tour of Campus B room K on 03/27/2025 at 8:44 AM revealed March 2025 Food Temperature Log missing temperature check on 03/24/2025 for dinner.

In an interview on 03/27/2025 at 8:45 AM, S1ADON verified the Food Temperature Log was missing a temperature check on 03/24/2025 for dinner.

Based on record review and interview the facility failed to ensure social service records included all interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history. This deficiency is evidenced by failure of social services to complete the psychosocial assessment for 1 (#4) of 5 (#1-#5) patients medical records reviewed.
Findings:

Review of Patient #4's Psychosocial Assessment dated on 02/13/2025 at 4:29 PM revealed the assessment was completed by S5MSWI and not co-signed by a MSW.

In an interview on 03/26/2025 at 1:55 PM, S4Adm verified S5MSWI was a student who should have a MSW review and sign Patient #4's psychosocial assessment. S4Adm also verifies that the psychosocial assessment is incomplete without the MSW review/signature.