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Based on observation and interview, the facility failed to ensure 1 of 5 patient nursing units were free from a potential safety risk pertaining to 2 wall phone cords in patient care areas.

Findings:

During the initial tour of the Adolescent/Child Unit, conducted on 1/22/13 at 9:05 A.M., a wall phone with a long detachable cord, was observed in the hallway. The detachable cord was curly and wrapped around the phone several times. The cord measured 11-1/2 feet, when stretched out.

Another wall phone was observed in the Child Dayroom, with a curly cord wrapped around it several times. The detachable cord measured 10 feet, when stretched out. One child was observed in the room alone; staff were in the hallway.

Mental Health Worker 1 stated on 1/22/13 at 2:25 P.M., currently there were inpatients that had suicidal ideation, suicide attempts, and/or had homicidal thoughts.

On 1/22/13 at 2:35 P.M., Registered Nurse (RN) 1 said staff had removed the cords from the phones before due to agitated patients, but never thought it was a real safety risk.

Based on observation, the facility failed to protect patient confidential information by displaying patient information on white boards in public area on 4 of 5 nursing units (Adult Services Unit (ASU) 1, ASU 2, ASU 3, and Psychiatric Intensive Care Unit (PICU)).

Findings:

ASU 1 was toured on 1/22/13 at 9:05 A.M. Before entering the nursing unit, on a wall across from the nurses station, was a large white board. The board contained the following patient information: room numbers, patient's first name, physician, and information for each patient's treatment; Rehab (rehabilitation); mood disorder program (MDP); and/or chemical dependency (CD). There were 15 patient names listed, with 13 patients marked as having chemical dependency issues. The white board was viewable to staff members, visitors, and others not involved in the patient's care.

During the same tour, ASU 2 had a large white board that hung in the nurses station, that listed 12 patients. Five of the 12 patients were marked as having chemical dependency issues. The white board was viewable by staff members, visitors, and others not involved in the patient's care.

During the same tour, ASU 3 was observed with a white board located on a wall below ASU 2's white board. Seven patient first names and last initials, doctor, therapist, counselor, and program were filled in. Four of 7 patients were marked as having chemical dependency issues. The white board was viewable by staff members, visitors and persons not involved in the patient's care.

During the same tour, PICU was observed to have a large white board, located on a wall outside of the entrance to the nursing unit. Nineteen patient's names, doctor, program, special precautions, titration privileges and other notes were written on the board concerning each patient's status. The white board was located in an area that was viewable by staff members, visitors and persons not involved with the patient's care.


The facility's Conditions of Admission was reviewed on 1/22/12. Per the Conditions of Admission, "The confidentiality of alcohol and drug abuse patient record is protected by Federal law and regulations... Aurora may not disclose information to anyone outside of Aurora which would IDENTIFY any patient as an alcohol or drug abuser unless the patient has consented in writing...".

Based on interview and record review, the facility failed to conduct a shift RN Suicide Risk Assessment for 1 of 6 patients (108), that was on special observation precautions.

Findings:

Patient 108 was admitted to the facility on 1/21/13 at 7:05 A.M., per the facility face sheet. According to an emergency room treatment report dated 1/20/13 at 10:31 P.M., Patient 108 attempted an overdose on medications, and made a 2 centimeter laceration to her right wrist, which required stitches.

Patient 108's clinical record was reviewed on 1/22/13. According to the physician admitting orders, Patient 108 was to be placed on suicide precautions (SP3).

Per the facility procedure for Suicidal Evaluation Process for SP3, " Nurses still assess patient per shift to identify continued level needs. 15 minute checks. Potential exist/identified because of recent attempts or strong suicidal ideation prior to admission, but presently minimal with no intention to act on it at this time."

Patient 108's treatment plan, dated 1/21/13, listed intervention as, "RN to assess mood, behavior, affect and suicidal ideation every shift..."

Documentation on the RN Daily Shift Assessment dated 1/21/13 at 8 P.M. (evening shift), indicated that Patient 108 had no special precautions. The suicidal/homicidal section was left blank.

The Suicide Risk Assessment for the evening shift for 1/21/12 was blank. Patient 108 continued to be on suicide precautions, per the physician's admission order dated 1/21/13 and the patient treatment plan that was formulated on 1/21/13.

The Director of Nursing (DON) jointly reviewed Patient 108's clinical record on 1/22/13 at 10:45 A.M. The DON was unable to locate documentation that a nurse assessed Patient 108 for suicidal thoughts and plan for the evening shift of 1/21/13. The DON said Patient 108 was supposed to be assessed every shift while on SP3.

Per the facility's policy and procedure entitled, Levels of Observation, dated 4/2011 and revised 12/2012, Level 3 suicide precautions, "A daily Suicide/Assault Risk Assessment shall be completed by the assigned RN every shift. This note shall include the patient's behavior, condition, mood, and conversations as they relate to the patient's identified safety risk."

Based on observation, interview, and record review, the Food Service Director failed to ensure safe food handling and sanitation for the following: 1) Frozen food was undated, 2) Thawed food was undated to ensure it was used within three days, and 3) Food service equipment was not maintained in good condition.

Findings:

1. On 1/22/13 at 9:15 A.M., inside the walk-in freezer, there were large unopened and undated bags of frozen beef, that were located on the storage rack. There were a couple of frozen, unopened and undated bags that contained dough.

Chef 200 verified that the above items were not dated. Chef 200 stated that when dietary staff took items out of their shipping box that contained a date, they were supposed to individually label the bags with the date.

On 1/22/13 at 10:30 A.M., the Food Service Director acknowledged that without a date on the frozen food items there would not be a mechanism in place to ensure the products were used within the hospital's shelf life storage guidelines.

The facility's policy and procedure entitled, Food Purchasing, Storage, Inventory, Preparation and Service, last revised 5/02, indicated, "Shelf life guidelines for generic foods. Some foods may be stored longer than the suggested guidelines however the quality, texture and flavor will diminish with longer storage. Foods frozen at 0 degrees may be safely stored for longer periods of time than the suggested guidelines, but the quality of the food will not be as desirable ..." The freezer storage chart guidelines indicated that stew meat could be frozen 3 to 4 months. Steaks could be frozen for 6 to 12 months, and roasts for 4 to 12 months. The policy lacked specific guidance as to acceptable frozen storage time for the uncooked dough.

2. On 1/22/13 at 9:30 A.M., inside the walk-in refrigerator, on the lower shelf, was a container of thawed poultry. There was no date as to when the thawing process began. Chef 200 estimated that the poultry was about 25 pounds of uncooked chicken strips. Chef 200 was asked how long the poultry had been in the refrigerator to thaw, and he stated, "I'm going to say since Friday."

Chef 200 stated that the dietary staff was trained to allow meat and poultry to thaw in the refrigerator for no longer than three days. Chef 200 acknowledged that without a date as to when the thawing process began that there was not an effective system in place to ensure the item would be used within three days.

On 1/22/13 at 10:30 A.M., the Food Service Director acknowledged that dietary staff should have dated the start of the thawing process for the chicken strips to ensure they were cooked within three days.

3a. On 1/22/13 at 9:35 A.M., the door to the oven and stove range was observed to be very thick with grease build up. Chef 200 acknowledged the thick build up of grease. He said the oven was very old and in disrepair, as staff placed a piece of tin foil under the rim of a crevice in the stove, in order to secure a piece of the stove in place.

b. On 1/22/13 at 9:43 A.M., the blade to the industrial sized can opener was worn with metal shavings exposed. Chef 200 acknowledged that the blade needed to be replaced.

The hospital's policy and procedure entitled, Maintenance and Operation, last revised 8/09, indicated, "Purpose: The maintenance and operation of the Dietary Department will be met according to the Food Code...Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened."

c. On 1/22/13 at 9:59 A.M., the majority of the food service pans and muffin pans had thick build up of black discoloration and grease. In addition, several of the muffin pans contained rust.

On 1/22/13 at 10:30 A.M., the Food Service Director acknowledged that the majority of the stainless steel pans, and muffin pans were in poor condition, and stated, "I have not requested to administration that the pans be replaced."

d. On 1/22/13 at 10:06 A.M., was a mobile food storage cart, that contained uncovered muffins from the day before, was loosely covered with a cover that was not zipped up. The cover had extensive yellow discoloration, and contained dry food debris. At that time, the discoloration was observed by the clinical dietitian (RD 201).

The hospital's policy and procedure entitled, Cleaning of Equipment And Utensils, last revised 8/09, indicated, "Purpose: The cleaning of equipment and utensils will be met according to the Food Code ..., equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, non food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris."

Based on observation, interview, and record review, the Food Service Director failed to ensure that two dietary employees were competent in checking the effectiveness of a sanitizer used for food preparation surfaces.

Findings:

On 1/23/13 at 10:43 A.M., the Food Service Director (FSD) stated that the Dietary Aides and the Cooks were responsible for cleaning and sanitizing their individual food preparation areas at their workstations.

On 1/23/12 at 10:49 A.M., a Dietary Aide (DA 203) was asked how she sanitized her food preparation countertop. DA 203 stated she would either use a cloth towel and soak it from the pre-diluted sanitizer dispenser, or she would use a spray bottle that contained a sanitizer. DA 203 was asked to check the effectiveness of the sanitizer that was located in the sanitizer spray bottle. DA 203 proceeded to the dish machine area where she obtained a chlorine chemical (chem) test strip to test the quaternary-based sanitizer, in which the chem strip remained in its original white color. DA 203 said, "I really don't use them [the chem strips]." DA 203 had been employed as a dietary aide at the hospital for 5 ½ years.

On 1/23/12 at 10:55 A.M., Chef 200 was asked to test the effectiveness of the sanitizer in the sanitizing spray bottle. Chef 200 proceeded to obtain a chlorine chem strip to test the effectiveness of a quaternary-based sanitizer, in which the chem strip remained white due to no reaction. Chef 200 pointed to the color coded graph on the chlorine strip vial and pointed to the purple color, and stated, "It should be between 50 - 100 PPM [parts per million]." Chef 200 had been employed by the hospital for 4 years.

At that time, the surveyor provided Chef 200 the correct chem strip for the quaternary-based sanitizer, that was located in the FSD office. Chef 200 proceeded to test the sanitizer. Chef 200 had the color coded graph from the quat chem strip vial and pointed to the matching green color from the chem strip that was dipped into the quat sanitizer, and stated, "It is 300 PPM." When Chef 200 was asked what the sanitizer should have been in order to be an effective sanitizer, he stated, "300 PPM."

The FSD was unable to locate guidance that would be available to the dietary staff, within the food and nutrition department, that would have informed the dietary staff of the correct chem strip to use, and correct concentration that would be acceptable for that individual product to remain effective as a sanitizer.

The FSD provided a copy of the last time the dietary staff had been in-serviced on the topic of sanitizing food preparation areas, dated 2/24/09. The signature line, indicating those dietary staff members who had received the in-service, was blank next to DA 203's name. The in-service information had not included when, and how, to check the effectiveness of the sanitizer, prior to using.

In addition, the FSD stated the method used for assessing understanding of the information provided, was a quiz. The FSD had not applied return demonstration technique in order to observe dietary staff 's competency for that particular task, of using a chem strip to check effectiveness of a sanitizer.

The hospital's policy and procedure entitled, Sanitation of Equipment and Utensils, last revised 8/09, indicated, "Equipment food-contact surfaces and utensils shall be sanitized."

Based on interview and record review, the hospital failed to ensure that 2 of 32 sampled patients (101, 106) had a diet ordered by the practitioner responsible for the care of the patient, prior to the patient's receiving food from the hospital.

Findings:

1. On 1/22/13 at 12:30 P.M., Patient 101's medical record was reviewed. Patient 101 was admitted to the hospital on 1/14/13. The section under "Diet" was left blank on the Physician's Admitting Orders, that were completed on 1/14/13. The Nutrition Screening form, that was completed by a nurse for Patient 101 at the time of admission, on 1/14/13, had a check mark next to, "No Concentrated Sweets (NCS)."

RD 201 reviewed Patient 101's physician orders and verified that the practitioner responsible for the care of the patient, had not ordered Patient 101 a diet. According to Patient 101's nursing kardex, and the dietary kardex, the patient had been on a "diabetic diet" since admission.

On 1/22/13 at 12:36 P.M., LN 202 reviewed Patient 101's medical record, and pointed to the NCS diet that was completed by a nurse and stated, "There's the diet order right there. That is a diabetic diet." When LN 202 was asked if that was a physician's diet order, she stated, "There is not usually a physician's diet order. We just ask the patient what they follow and provide that."

On 1/16/13 a physician wrote an order for a "Nutrition Consult: DM [diabetes mellitus] Diet." On 1/16/13, RD 201 completed a nutritional assessment for Patient 101. RD 201 assessed Patient 101's individualized estimated nutrition needs to require 2,220 - 2,590 calories per day and 59-74 grams of protein a day. RD 201 documented a plan of action that indicated, "FSBS TID [fasting blood sugar three times a day] before meals and q [every] hs [night]; 8 - 8.5 cups of fluids daily. F/u [follow-up] with pt [patient] in 1 day to educate pt on carb [carbohydrate] intake and recommendations."

On 1/22/13 at 12:45 P.M., RD 201 stated that she had educated the patient the following day based on Patient 101's nutrition assessment for 2,220 - 2,590 calories a day. RD 201 stated that she was unaware there never was a physician's diet order for Patient 101. RD 201 stated that usually she would have crossed-referenced, to the physician's diet order, to ensure that the hospital was providing the diet as ordered, at the time she completed a nutrition assessment, but in that case she had not. RD 201 added that when a physician orders a "diabetic diet" the hospital's default definition was an 1800 calorie diabetic diet. RD 201 stated that she had educated the patient on a higher calorie level, thus higher carbohydrate pattern per meal than what a 1800 calorie diet would have provided. RD 201 acknowledged that she was not an independent practitioner and that diet orders need to be physician driven. RD 201 acknowledged that she was unaware there was not an actual physician's diet order. RD 201 acknowledged that as far as she knew at the time, the patient was on a "diabetic diet," which meant 1800 calorie diabetic diet a day. RD 201 acknowledged that she should have left recommendations for the physician to modify the therapeutic diet order, in accordance with Patient 101's assessed nutrition needs, instead of independently modifying a therapeutic diet.

The hospital failed to ensure that the practitioner, responsible for the care of the patient, had directed the patient's diet order since time of admission. The registered dietitian failed to provide the physician recommendations for an appropriate diabetic diet order, in accordance with the patient's assessed nutritional needs. Failure of clear communication on diet orders, and the quantity of calories and carbohydrates the patient was actually consuming, had the potential to impact patient care and discharge diet planning.

The hospital's policy and procedure entitled, Special Diets, last revised 7/03, indicated, "Purpose: The Dietary Department will provide special therapeutic diets for individual patients as prescribed by the attending physician..."

According to the hospital's policy and procedure entitled, Patient Diet Order Process, last revised 10/08, "2.1.1. All diet orders are prescribed by physician."

2. On 1/23/13 at 2:25 P.M., Patient 106's medical record was reviewed. Patient 106 was admitted to the hospital on 1/20/13 at 8:50 P.M. The section under "Diet" was left blank on the Physician Admitting Orders, that were completed on 1/20/13.

The Nutrition Screening form, that was completed by a nurse for Patient 106 at time of admission, on 1/20/13, had a check mark next to six small meals, pescatarian (diet includes fish but no other meat), and no concentrated sweets (NCS). The use of that section of the nurse's nutrition screening form was to ask the patient what diet they had normally been on prior to being admitted to the hospital.

RD 201 reviewed Patient 106's physician's orders and verified that the practitioner, responsible for the care of the patient, had not ordered Patient 106 a diet until 1/22/13. The Food Service Director was present and acknowledged that there was not a physician prescribed diet order for Patient 106, despite receiving food from the food and nutrition department on 1/21/13. According to Patient 106's nursing kardex, and according to the dietary kardex, the patient received a pescatarian, six small meals diet, without a physician's order.

The hospital's policy and procedure entitled, Special Diets, last revised 7/03, indicated, "Purpose: The Dietary Department will provide special therapeutic diets for individual patients as prescribed by the attending physician..."

According to the hospital's policy and procedure entitled, Patient Diet Order Process, last revised 10/08, "2.1.1. All diet orders are prescribed by physician."

Based on interview and patient menu nutrient analysis review, the hospital failed to ensure that the planned patient menus for regular and therapeutic diets were nutritionally analyzed to provide a mechanism in which the nutritional needs of the patients could be met, in accordance with the recommended dietary allowances and physician orders.

Findings:

On 1/22/13 at 10:15 A.M., the dietary form entitled, Nutrition Services Diet/Food Monitor list, was reviewed. The list indicated that the following diets were current diet orders of patients receiving treatment at the hospital: low fiber diet, diabetic diet, pescatarian diet, low fat/low cholesterol diet, vegan diet and regular diet.

On 1/22/13 at 10:16 A.M., RD 201 provided the hospital's week menu for 1/20/13 through 1/26/13. RD 201 said that was the menu used for the regular diets, as well as for the therapeutic diets. The Registered Dietitian (RD) would make daily modifications to the menu for the therapeutic diet orders.

On 1/22/13 at 10:25 A.M., both the Food Service Director (FSD) and RD 201 stated that the menu for the regular or the therapeutic diets had not been comprehensively nutritionally analyzed to ensure that the recommended dietary allowances (RDA) or the dietary reference intakes (DRI) of the Food and Nutrition Board of the National Research Council were met, in accordance with recognized dietary practices, which would include trace minerals, vitamins and fiber.

RD 201 stated that she had reviewed some of the nutrients primarily focusing on the macronutrients, fat and cholesterol, and sodium as it pertained to some patients, and had a nutrition fact sheet posted in the cafeteria for patients to view those items. However, RD 201 acknowledged there was not a system in place to ensure that the RDAs or DRIs for trace minerals, vitamins, and fiber were provided for the planned patient menu.

In addition, the hospital's approved diet manual described a low fiber diet as providing 8 grams of fiber a day. RD 201 and the FSD, stated they go through the menu daily and help guide patients on what items to choose, based on dietary principles, such as choosing white bread over wheat bread and canned fruit over fresh fruit. Both RD 201 and the FSD, acknowledged that without conducting a nutrient analysis for the specific food products purchased or prepared for the daily menus, which were different every week for four weeks, there was not a way to be certain that the planned menus were providing no more than 8 grams of fiber for a low fiber diet, in accordance with the physician's order, as indicated in the hospital's approved diet manual.

The hospital's approved diet manual indicated that the hospital's low fat/low cholesterol diet parameters were less than 200 milligrams (mg) per day, keep fat intake between 50 grams to 75 grams per day if on a 2,000 calorie a day diet, and get 20 grams to 30 grams of dietary fiber a day. The FSD and RD 201 was unable to demonstrate that the planned menus for a low fat/low cholesterol diet was in accordance with physician's orders, as per the hospital's approved diet manual, since a comprehensive nutrient analysis had not been conducted.

The FSD stated that the hospital did not have a computer program or software to conduct a comprehensive nutritional analysis, and that it had not been done for the regular diet and therapeutic diets. According to the hospital's policy and procedure entitled, Patient Diet Order Process, last revised 10/08, therapeutic diet orders provided by the dietary department included regular, six small meals, lacto/ovo vegetarian or vegan, mechanical soft or pureed, low sodium, low fat, calorie restrictions 1200, 1400, 1600, 1800, 2000, 2200, no concentrated sweets or calorie diabetic, gluten free or lactose free diet.

The national standards for the RDA's or RDI's were developed to, "Provide health professionals ...references for planning for the nutrient needs of individuals and groups of people (Institute of Medicine of the National Academies, 2006)."

The hospital's policy and procedure entitled, Clinical Diet Manual and Nutrition Resources, last revised 10/09, indicated, "2.1.1.2 Menu selections meet the most current established RDA's."

The hospital's policy and procedure entitled, Special Diets, last revised 7/03, indicated, "Purpose: The Dietary Department will provide special therapeutic diets for individual patients as prescribed by the attending physician ..."

According to the hospital's policy and procedure entitled, Patient Diet Order Process, last revised 10/08, "The hospital's philosophy of providing patients daily nutrients is to provide foods that are adequate for the patients prescribed medical nutrition therapy ..., 2.1.1. All diet orders are prescribed by physician."

Based on observation, interview, and record review, the hospital failed to maintain a system to ensure the hospital would have adequate water supplies at the hospital to meet the needs of patients, staff and potential visitors in the event of an external disaster.

Findings:

On 1/23/13 at 10:30 A.M., the Director of Plant Operations (DPO) stated that he was responsible for developing and maintaining the disaster water supply that would be used in the event of a disaster. He stated the hospital's plan was to have 450 gallons of bottled water on-site, to cover a 60 hour period. The DPO was asked for how many people a day was the planned 450 gallons of bottled water on site anticipated to accommodate, and he said, "For the 80 bed licensed bed capacity." When the DPO was asked if the hospital had discussed the number of staff that was determined would need to be working during the event of a disaster and potential visitors or in-patients that might be coming in during a disaster, he said, "We haven't considered that. I don't have a number."

The DPO provided a document entitled, 60 - Hour Purchasing Checklist, that indicated the plan was to have 450 gallons of water on site to meet needs for 60 hours.

The disaster water supply was quantified by the Food service Director (FSD) and the surveyor, in which there were 250 gallons of non-expired water, which also included distilled water. There were 175 gallons of expired bottled water, which was identified as nonpotable water by signage over those gallons of expired water. The hospital had a total of 425 gallons of water on-site, despite the hospital's written plan to have 450 gallons of disaster water supply on-site. The DPO declined to jointly observe the quantity of disaster bottled water, as he stated the FSD already did so.

The DPO acknowledged that the hospital's disaster water plan needed to be assessed further to determine the anticipated needs in terms of number of people per day, to include staff and visitors, how much potable water for consumption per person per day, and that a 60 hour period for a plan was less than community standards.

According to the Disaster Menu that was posted in the kitchen, the hospital's plan was to have 1 gallon of water per person per day. However, the hospital had not determined their baseline number of people they assessed may be on-site during the event of a disaster in order to maintain a par level of water, to meet the 1 gallon per person per day, per the hospital's disaster plan.

Based on observation, interview, and record review, the infection control program failed to ensure that an appropriate sanitizer was used for the food contact surfaces, located in a nourishment room near the patient care areas.

Findings:

On 1/23/13 at 12:55 P.M., inside a nourishment room that the hospital called "the galley," located near the PICU nursing station, was a container of Super Sani-Cloth Germicidal Disposable Wipes located on the counter.

A mental health worker (MHW 204) walked into the galley and was asked about the use of the Super Sani-Cloth wipes. He stated, "I use them to wipe down the countertops in the galley."

The Food Service Director (FSD) stated that the hospital's designated infection preventionist nurse said it was ok. When the FSD was asked if the infection preventionist said it was ok specifically for food contact surfaces, such as for the countertops in the galley, she stated, "Oh, I don't know if it was that specific."

According to the manufacturer's label on the Super Sani-Cloth Germicidal Disposable Wipes, "To Disinfect and deodorize: To disinfect nonfood contact surfaces only." The label further indicated, "It is a violation of federal law to use this product in a manner inconsistent with its labeling."