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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights as evidenced by failing to ensure patients received care in a safe setting that was free of ligature/suffocations risks. There were 17 patients on the unit on 05/30/18 with 6 (R1, R3, R5, R6, R7, R8) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with suicidal ideations and 2 (R4, R9) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with homicidal ideations. All patient entrance doors, patient bathrooms, the bathroom in the Dining/Activity Room, the Shower Room, and the bathroom in the Behavior Control Room had ligature risks. Patient rooms 103, 104, 105, 107, and 109 had hospital beds with multiple ligature points. Plastic bags containing disposable underwear that presented a risk for suffocation were in an unlocked cabinet in the Shower Room that was used by patients unattended by staff. Hospital gowns, with an approximate 8 inch tie at each side of the neck presented a ligature risk if tied together, were present in the Clean Utility Room (5 shelves with gowns), the Shower Room (where patients were allowed to shower unattended if the patient didn't need assistance) had 6 gowns on the shelf, and a gown was on the shelf in Room 101.
(See findings in tag A0144)

Based on record reviews and interviews, the hospital failed to implement its grievance policy as evidenced by failure to have a complaint voiced to S4RN by Patient #1's daughter documented as a grievance and to have the grievance investigated for 1 (#1) of 1 patient grievance confirmed by interview from a sample of 5 patients.
Findings:

Review of the policy titled "Grievances", presented as a current policy by S1DON, revealed the patient has the right to complain regarding the quality of care and will receive response from the organization that substantially addresses the complaint. Further review revealed a complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy and relief sought. Further review revealed upon receiving a verbal complaint, a complaint report form will be completed by the employee receiving the complaint. Administration or administrative on-call personnel will be notified immediately upon receipt of a complaint. Complaints will be referred to the Administrator, Corporate Compliance officer, DON, or Program Director, and a "Lead Investigator" will be assigned within 24 hours of receipt of a grievance. Within 72 hours of receipt of a grievance, the lead investigator will respond in writing to the complainant indicating the name of the contact person who will assist the patient and family in the resolution of problems. The lead investigator will ensure a complete investigation is conducted and prepare a report for the performance improvement committee. The lead investigator will provide the following written communication to the complainant within 7 days: description of the complaint, steps taken to resolve the complaint, and the date of completion/resolution.

In an interview on 05/31/18 at 8:325 a.m., S4RN indicated Patient #1 had bruises on both arms and hands. She further indicated the patient was always striking out and hitting the wall or the bed. She indicated she assumed that's how she got the bruises. S4RN indicated the family expressed concern during a visit about the bruising and marks on her arms. She indicated she heard the patient speak to the family about "they're always fighting." She further indicated the family said the patient reported someone was fighting, but doesn't remember if they said someone was fighting with her. When the surveyor asked S4RN if she reported the family's complaints to anyone in management as a complaint or grievance, she indicated she reported to the nurse who relieved her but not to management. She indicated she doesn't recall if she was trained on the difference between a complaint and a grievance, but she acknowledged she doesn't know the difference.

In an interview on 05/31/18 at 4:15 p.m., S1DON confirmed a grievance had not been submitted related to Patient #1's daughter's complaints voiced to S4RN.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to provide a safe environment free of ligature/suffocation risks. There were 17 patients on the unit on 05/30/18 with 6 (R1, R3, R5, R6, R7, R8) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with suicidal ideations and 2 (R4, R9) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with homicidal ideations. Patients were observed on 05/30/18 and 05/31/18 walking unattended in the hall with doors to patient rooms open. All patient entrance doors, patient bathrooms, the bathroom in the Dining/Activity Room, the Shower Room, and the bathroom in the Behavior Control Room had ligature risks. Patient rooms 103, 104, 105, 107, and 109 had hospital beds with multiple ligature points. Plastic bags containing disposable underwear that presented a risk for suffocation were in an unlocked cabinet in the Shower Room. Hospital gowns, with an approximate 8 inch tie at each side of the neck presented a ligature risk if tied together, were present in the Clean Utility Room (5 shelves with gowns), the Shower Room had 6 gowns on the shelf, (patients were allowed to shower unattended if the patient didn't need assistance), and a gown was on the shelf in Room 101.
Findings:

Observations on 05/30/18 at 9:03 a.m. during the tour of the hospital with S2MHT and a surveyor from the accrediting body present revealed the following ligature risks:
a) All patient bathrooms, the bathroom in the Dining/Activity Room, and the bathroom in the Behavior Control Room had the toilet plumbing contained that left a space below the contained section that had a metal circular joint from which a tie could be wrapped around as a ligature.
b) All patient room entrance doors and bathroom doors had the base on which the handle was placed that was flat and around which a tie could be used as a ligature. Each door had an inoperable lock on the interior of the door that presented a ligature risk as evidenced by the accrediting body surveyor wrapping a cord around the lock and pulling with force with the lock remaining in place.
c) All soap dispensers and paper towel dispensers in patient bathrooms and the bathroom in the Behavior Control Room presented a ligature risk as evidenced by the accrediting body surveyor wrapping a cord around each and pulling downward on the cord with force with the dispensers holding secure against the wall.
d) Hospital gowns with an approximate 8 inch tie at each side of the neck presented a ligature risk if tied together were present in the Clean Utility Room (5 shelves with gowns), the Shower Room (where patients were allowed to shower unattended if the patient didn't need) had 6 gown on the shelf and a gown on the shelf in Room 101.
d) The Shower Room had an unlocked cabinet that contained 10 plastic bags of disposable underwear. The plastic bags presented a risk for suffocation. There was a large Jacuzzi tub in a room in the Shower Room that had no door that prevented patients from entering. The tub had multiple ligature points on the handrails and faucet knobs.
e) Hospital beds with hand cranks at the foot of the bed and multiple ligature points on the cranks and siderails of the bed were being used in Rooms 103 and 107 (2 beds in the room) and in Rooms 104, 105, and 109 (1 bed was a hospital bed).
f) The faucet handle on the sink in the Dining/Activity Room extended out from the base and presented a ligature point (observation was made of Patient R1 who was diagnosed with suicidal ideations in the room with no staff present).

Observation of a hospital-provided video on 05/30/18 at 3:30 p.m. with S1DON in attendance revealed on 05/29/18 at 1:27 p.m. Patient #4 entered the bathroom in the Dining/Activity Room with no staff present with him or in the room at the time of the observation. Further observation revealed patients were in the Dining/Activity Room with no staff present in the room from 1:10 p.m. to 1:38 p.m. Further observation revealed the sink was not visible to staff who were seated in the nursing station. Patient R1, who had a diagnosis of Depression with suicidal ideations, was present in the Dining/Activity Room during this time.

Observations at multiple times during the day on 05/30/18 and 05/31/18 revealed patients were observed walking in the hall where patient rooms were located , and some doors to patient rooms were open.

Review of the "Report Sheet", provided by S1DON as the current list of inpatients on 05/30/18, revealed there were 17 patients on the unit on 05/30/18 with 6 (R1, R3, R5, R6, R7, R8) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with suicidal ideations and 2 (R4, R9) of the patients admitted with a diagnosis of Depression/Major Depressive Disorder with homicidal ideations.

In an interview on 05/30/18 at 9:03 a.m. during the tour, S2MHT indicated patients were allowed to go the bathroom unattended and to shower unattended if no assistance from staff was needed.

In an interview on 05/31/18 at 4;15 p.m., S1DON confirmed the above documented observations included ligature/suffocation risks for patients on the unit. She further indicated the hospital did not have a plan in place to mitigate the ligature risk with the use of hospital beds with hand cranks and siderails.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services as evidenced by:

1) The RN failing to supervise and evaluate the nursing care of each patient as evidenced by:
a) The RN failed to assess and document the assessment of a patient's wound (#2) in accordance with the standard of practice by the AAWC for 1 (#2) of 1 patient record reviewed with a wound from a sample of 5 patients.
b) The RN failed to supervise the MHT's performance of patient care for a patient (#2) on contact precautions that resulted in breaches in infection control for 1 (#2) of 1 patient on contact precautions from a sample of 5 patients. Observations of breaches in infection control practice were made on 05/30/18 at 12:40 p.m. when S8MHT served lunch and on 05/31/18 at 3:50 p.m. when S8MHT and S13MHT provided perineal care for Patient #2.
c) The RN failed to assess and report to the physician and to request a nutritional consult when patients experienced decreased nutritional intake for 2 (#1, #2) of 5 patient records reviewed for nutritional intake from a sample of 5 patients.
d) The RN failed to ensure physician orders were implemented as evidenced by failure to have documented evidence that a wound care consult ordered by S6Psych on 05/23/18 at 10:20 p.m. was conducted as of the date of review of the medical record by the surveyor on 05/30/18. The RN failed to ensure Patient #2 was turned every 2 hours in accordance with the ordered "Skin/Wound Care Protocol."
(See findings in tag A0395)

2) The RN failed to develop and keep current a nursing care plan for each patient that included nursing interventions and treatment goals as evidenced by failure to have documented evidence of an individualized nursing care plan that addressed patient wounds/pressure ulcers, infection/contact precautions, decreased nutritional intake, and/or hypersexual behavior for 3 (#2, #3, #4) of 5 patient records reviewed for a current nursing care plan from a sample of 5 patients.
(See findings in tag A0396)

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to assess and document the assessment of a patient's wound (#2) in accordance with the standard of practice by the AAWC for 1 (#2) of 1 patient record reviewed with a wound from a sample of 5 patients.
2) The RN failed to supervise the MHT's performance of patient care for a patient (#2) on contact precautions that resulted in breaches in infection control for 1 (#2) of 1 patient on contact precautions from a sample of 5 patients. Observations of breaches in infection control practice were made on 05/30/18 at 12:40 p.m. when S8MHT served lunch and on 05/31/18 at 3:50 p.m. when S8MHT and S13MHT provided perineal care for Patient #2.
3) The RN failed to assess and report to the physician and to request a nutritional consult when patients experienced decreased nutritional intake for 2 (#1, #2) of 5 patient records reviewed for nutritional intake from a sample of 5 patients.
4) The RN failed to ensure physician orders were implemented as evidenced by failure to have documented evidence that a wound care consult ordered by S6Psych on 05/23/18 at 10:20 p.m. was conducted as of the date of review of the medical record by the surveyor on 05/30/18. The RN failed to ensure Patient #2 was turned every 2 hours in accordance with the ordered "Skin/Wound Care Protocol."
Findings:

1) The RN failed to assess and document the assessment of Patient #2's wound in accordance with the standard of practice by the AAWC:
Observation on 05/31/18 at 3:50 p.m. of Patient #2's wounds, with S8MHT and S13MHT assisting with turning Patient #2, revealed an approximate 2.5 cm Stage II pressure ulcer under the right thigh, an approximate 2 cm long pressure ulcer on the right sacrum that appears to possibly have tunneling (unable to determine if ulcer was Stage II or III without having a sterile Q-tip to determine if tunneling was present, and the RN did not return during the surveyor's observation to assess/meaure the wound), and an approximate 2.5 cm Stage II pressure ulcer to the right inner thigh. A request was made by the surveyor on 05/31/18 at 9:30 a.m. to S5RN to notify the surveyor when long-sleeved gowns used as PPE arrived, so an observation could be made of S5RN assessing Patient #2's wounds. When the surveyor was gowned (after having long-sleeved gowns delivered to the hospital) and gloved to observe the wounds of Patient #2 on 05/31/18 at 3:50 p.m., the surveyor was of the understanding that a RN would be assessing and measuring the wounds in the presence of the surveyor. Once the surveyor was in Patient #2's room, S1DON appeared at the door and indicated to the surveyor that the hospital did not have disposable tape measures to measure the wound. S1DON closed the door and walked away. No RN appeared to assess/measure the wounds in the presence of the surveyor. S8MHT and S13MHT were present and turned Patient #2, so the surveyor could observe the wounds.

Review of the AAWC's Venous and Pressure Ulcer Guidelines revealed a physical exam should be conducted that includes a head-to-toe assessment with attention to bony prominences and any skin surfaces in contact with removable devices. There should be documentation of alterations in skin sites at risk of developing a pressure ulcer for the following characteristics: color; texture (unusual hardness/induration, softness, or rough surface for this site); sensation; skin temperature at and around the site. The following wound features should be assessed and documented: anatomic location; size (length, width, depth) by measuring using a consistent, reliable method within the hospital; reliable estimates of wound area of longest length by longest perpendicular width or head-to-toe length and side-to-side width; exudate type such as bloody, serous, purulent, foul and amount (such as none, moist, small, moderate or large amount of exudate usually based on appearance of dressing; infection signs such as erythema, edema, odor, purulent or foul-smelling exudate, increase in ulcer pain, exudate, fever, friable or irregular granulation tissue; undermining, sinus tracts, and tunneling; Stage of the pressure ulcer: deep tissue injury, I, II, III, IV, Unstageable; tissue types and amounts such as epithelium, granulation, yellow/white fibrin/slough, or black, brown or gray necrotic tissue; ulcer margin abnormalities such as epiboly, exuberant granulation; periwound skin such as erythema or edema; evaluate for complications as indicated by ulcer severity or chronicity, and if treated, document treatment and its duration; conduct a pain assessment using an age-appropriate validated pain scale; repeat above assessments regularly at same intervals based on patient risk and institutional guidelines or on any change in patient condition.

Review of the policy titled "Scope of Services - Nursing", presented as a current policy by S1DON, revealed the patient's skin will be assessed at the beginning of every shift. If the skin assessment revealed skin abnormalities, the nurse was to document findings of the assessment on the front and back body illustration and document and date and time all facets of the assessments which require physician notification. A follow-up assessment is to be done every shift or as directed per physician orders. There was no documented evidence the policy addressed what was to be documented related to the wound appearance.

Review of the policy titled "Initial Nursing Assessment, presented as a current policy by S1DON, revealed the RN was to complete an initial assessment within 8 hours of admission. A physical and mental assessment was to be performed and documented on the initial assessment form. Special attention was to be given to appearance of bruises, lacerations, or scars. There was no documented evidence the policy required the RN to document an assessment of patient wounds/pressure ulcers in accordance with the AAWC guidelines for pressure ulcers.

Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed a "Skin/Wound Care Protocol" for pressure ulcer treatment and wound treatment signed by S6Psych with no documented evidence of a date and time documented. Further review revealed the form had a check box for treatment of Stage 1 Pressure Ulcer and Stage 2 Pressure Ulcer listed under pressure ulcer treatment and a check box for treatment of Venous Stasis Ulcer and Skin Tear under wound treatment with no documented evidence that any check box had been selected by S6Psych. There was no documented evidence that a RN had clarified the incomplete order with S6Psych.

Review of S9RN's nursing admit assessment of Patient #2 conducted on 05/23/18 at 7:00 p.m. revealed the skin assessment included fair turgor, normal color, normal condition, 4 scars (marked on the body figure diagram) and 4 "Stage II to III wounds" marked on the body figure diagram in the buttocks/sacral area. Further documentation revealed "2 wounds draining min. (minimal) to mod. (moderate) (nonfoul) serosanguinous drainage", no photos taken, no impaired skin integrity treatment plan indicated, and no wound care protocol/flow sheet initiated. Review of the EMR "Summary/Admission Note" documented by S9RN on 05/23/18 at 11:21 p.m. revealed "Stage II-III wounds noted to perineum and BLE found after pt went to bed." There was no documented evidence of wounds or ulcers to the BLE noted on the body figure diagram documented by S9RN. There was no documented evidence of wound measurements and description in accordance with the AAWC standards of practice.

Review of a multi-disciplinary note documented on 05/26/18 at 1:50 a.m. by S4RN revealed skin care was provided in the perineal/sacral and buttock areas with multiple Stage II pressure ulcers noted between the crevice of the buttocks near the sacral area, and some of the wounds were showing small amounts of serous drainage. There was no documented evidence of wound measurements and description in accordance with the AAWC standards of practice.

In an interview on 05/31/18 at 9:05 a.m., S4RN indicated Patient #2 had pressure ulcers in the perineum and buttocks. S4RN reviewed the chart and confirmed there was no documented evidence of a wound assessment that included wound measurements and description of the wound, wound bed, and surrounding tissue. S4RN reviewed the hard copy medical record and confirmed there was no evidence of a documented medical consult for the wounds.

In an interview on 05/31/18 at 9:52 a.m., S5RN confirmed there was no documented evidence of an assessment by the RN of the wound measurement and description. He confirmed he has not documented a wound assessment. He indicated he thought having photos of the wound was sufficient as measurements.

In an interview on 05/31/18 at 4:30 p.m., S1DON confirmed the hospital did not have paper tape measures to be used by nurses to measure wounds. She confirmed there was no documentation in Patient #2's medical record of an assessment of her pressure ulcers in accordance with the AAWC's pressure ulcer guidelines.

2) The RN failed to supervise the MHT's performance of patient care for Patient #2 who was on contact precautions (due to wounds that were cultured with moderate growth E-coli, positive for Extended Spectrum Beta-Lactamase Production, and multi-drug or pan-resistant organism and potential pathogen that mandated the institution of contact precautions) that resulted in breaches in infection control:
Observation on 05/30/18 at 12:04 p.m. revealed S8MHT was in the Dining/Activity room with gloves on that she wore while serving patients lunch. With the same gloved hands, S8MHT, while in the Dining/Activity Room, donned a face mask and a paper gown. She carried the lunch tray for Patient #2 out the Dining Room with her gown flapping untied in the back. While walking down the hall, another MHT tied the lower part of S8MHT's gown but couldn't get the neck to stay attached. S8MHT entered Patient #2's room with contaminated gloves, gown, and mask. She offered lunch and juice to Patient #2. Patient #2 indicated she wasn't hungry and was "sick to her stomach." Patient #2 indicated her heel hurt, and S8MHT touched her heel with gloved hands. At 12:10 p.m. after encouraging Patient #2 to eat, S8MHT exited the patient's room in her PPE, carried the lunch tray into the Dining Room, and placed the tray on the tray stand. S8MHT exited the Dining Room and walked to the nursing station door. She touched the door to the nursing station with the same contaminated gloves worn to serve patient lunch trays, attempt to feed Patient #2, and used to touch patient #2's heel. S8MHT removed her contaminated PPE once she was in the nursing station and sanitized her hands.

Observation on 05/31/18 at 9:30 a.m. revealed S5RN and an accrediting body surveyor were in Patient #2's room, who was on contact precautions, wearing a sleeveless paper isolation gown. S5RN's arms were bare.

Observation in Patient #2's room on 05/31/18 at 3:50 p.m. revealed S8MHT and S13MHT were preparing to provide peri care to Patient #2. They were both wearing gowns, gloves, and masks. The MHTs separated Patient #2's legs with gloved hands for the surveyor to observe her right inner thigh wound. Without changing gloves and performing hand hygiene, both MHTs turned Patient #2 to her side and held her buttocks for the surveyor to observe. With the same contaminated gloves, S13MHT touched the bag of wipes to get wipes to clean the patient. Both MHTs cleaned the patient with same gloves worn from the beginning of peri care and wore the same gloves to apply barrier cream and apply a diaper after they had cleaned the wounds. Both MHTs removed their gloves and didn't perform hand hygiene before beginning their next task.

Review of the policy titled "Transmission Based Precautions", presented as a current policy by S1DON, revealed contact precautions apply to patients with draining wounds and pressure ulcers. The procedure included performing hand hygiene before touching a patient and prior to wearing gloves. PPE included wearing gloves when touching the patient and the patient's immediate environment or belongings and wearing a gown if substantial contact with the patient or environment is anticipated. Hand hygiene was to be performed after removal of PPE.

Review of CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed contact precautions were intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on Contact Precautions were to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the
patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Hand hygiene was to be performed before having direct contact with patients, after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient), if hands will be moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves.

Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

In an interview on 05/30/18 at 12:15 p.m., S8MHT indicated Patient #2 had "MRS" and then asked another MHT what she had and was told it was "E-coli." She indicated they have to use "safety precautions." When the surveyor asked what she meant by safety precautions, she indicated she has to gown with the proper PPE, mask, gown, and gloves to protect herself. The surveyor reviewed the observations with S8MHT, and she confirmed she breached infection control practices.

In an interview on 05/31/18 at 9:52 a.m., S5RN confirmed the hospital doesn't presently have proper PPE gowns and doesn't have signage on Patient 32's door indicating she was on contact precautions. He indicated they ran out of gowns about 1 hour prior to the accrediting body surveyor asking him to go to Patient #2's room.

In an interview on 05/31/18 at 4:10 p.m. with S8MHT and S13MHT present, the surveyor reviewed the observations made during personal care performed by both. Both MHTs confirmed the observations included breaches in infection control.

3) The RN failed to assess and report to the physician and to request a nutritional consult when patients experienced decreased nutritional intake:
Review of the policy titled "Dietary Manager Scope of services", presented as a current policy by S1DON, revealed the purpose of the policy was to provide weekly monitoring under the direction of the Registered Dietitian. Further review revealed there was no documented evidence of what was to be included in the weekly monitoring and which staff member would conduct the monitoring.

Review of the policy titled "Scope of Services - Nursing", presented as a current policy by S1DON, revealed patients were to be weighed on admit and weekly every Saturday morning to assess weight. The nurse was to assess for increase or decrease in appetite and document notification of the physician.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 04/19/18 at 9:50 a.m. with a diagnosis of Bipolar I Disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior.

Review of Patient #1's graphic sheet revealed she weighed 161 pounds at admit. There was no documented evidence she was weighed on Saturday, 04/21/18, as required by hospital policy.

Review of Patient #1's nursing shift assessments revealed each RN documented her "Nutrition/Fluids" as adequate. Review of her graphic sheet revealed her meal intake was documented as follows:
04/20/18 - 75% 3 meals (breakfast, lunch, supper)
04/21/18 - 25%, 75%, 75%
04/22/18 - 25%, 0, 0
04/23/18 - 0, 25%, 25%
04/24/18 - 0, 0, 25%
04/25/18 - 0, 0 (supper was not documented as Patient #1 was transferred to the acute care hospital before the supper meal).
There was no documented evidence in Patient #1's medical record that the RN notified the psychiatrist or NP of Patient #1's decreased meal intake throughout her hospital stay.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

Review of Patient #2's graphic sheet revealed she weighed 275 pounds at admit. Further review revealed her meal intake was documented as follows:
05/24/18 - 0, 0. 0
05/25/18 - 0, 0, 0
05/26/18 - 0, 75%, 0
05/27/18 - not documented at 8AM and 12PM, 100% at 10PM
05/28/18 - 75%, 75%, 75%
05/29/18 - 0, 0, 0.
There was no documented evidence in Patient #2's medical record that the RN notified the psychiatrist or NP of Patient #2's decreased meal intake as of the date of review of the medical record on 05/30/18 at 1:25 p.m.

Review of Patient #2's nursing shift assessments revealed each RN documented her "Nutrition/Fluids" as adequate.

In an interview on 05/31/18 at 8:325 a.m., S4RN indicated when she documents nutrition/fluids as adequate, she determines this by what she sees is eaten on her shift (which is a snack on her shift). She indicated she does review the graphic sheet related to meals, because on Monday, Wednesday, and Friday the night RN has to do a chart audit that includes a review of meal intake. S4RN reviewed the audit sheets done by the RNs and confirmed meal intake isn't addressed on the form. The surveyor asked S4RN if she had reported decreased intake to the physician or NP and requested a dietary consult for Patient #1 and Patient #2, and she answered "I did not."

In an interview on 05/31/18 at 9:45 a.m., S5RN indicated when he documents nutrition/fluids as adequate, he asks the MHTs how the patient is eating and sometimes he looks back in the record. He indicated the graphic sheet accounts for the meals but doesn't capture the snacks and any other meals given during the day. He indicated the nurse speaks with the physician and NP and discuss any "high points" including if patient isn't eating properly. He further indicated he should document his report to the physician, but he doesn't recall calling Patient #1 to the physician's attention. He indicated the dietitian does come for dietary consults. There is a nutritional screening that can trigger a dietary consult upon admission, and at any point a physician can order a dietary consult. He indicated if a patient was continually not eating and not taking snacks, this would warrant a dietary consult. After reviewing Patient #1's and Patient #2's graphic sheet, S5RN indicated he should have asked a doctor to order a dietary consult.

In an interview on 05/31/18 at 2:00 p.m., S14NP indicated if a patient continually refuses food or has documented poor intake, the nurse should notify her or the psychiatrist to obtain an order for a dietary consult.

4) The RN failed to ensure physician orders were implemented for a wound care consult and for turning a patient every 2 hours:
Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN. Further review revealed an order on 05/23/18 at 10:20 p.m. received by S9RN by telephone order from S6Psych for a medical consult for wound care for pressure ulcers to BLE and bilateral buttocks.

Review of Patient #2's medical record revealed a "Skin/Wound Care Protocol" signed by S6Psych that revealed patients with Stage I and Stage II pressure ulcers were to be turned every 2 hours.

Review of Patient #2's nursing documentation revealed a note on 05/24/18 at 5:53 p.m. by S10RN that a wound care consult was needed. Further review revealed a nursing note by SS9RN on 05/28/18 at 10:16 p.m. and on 05/29/18 at 9:04 p.m. that a wound care consult was needed. There was no documented evidence in Patient #2's medical record that a wound care consult had been performed and documented as of the review of the record by the surveyor on 05/30/18 at 2:35 p.m.

In an interview on 05/30/18 at 12:15 p.m., S8MHT was asked by the surveyor what time had Patient #2 been turned on 05/30/18. She indicated Patient #2's position had not been changed since 5:45 a.m. "this morning" (6 hours 30 minutes without turning or offering toileting or diaper change). She confirmed she had not turned Patient #2 or checked her for toileting since that time, because "I was busy getting stuff together, and it takes more than one tech to change her."

In an interview on 05/31/18 at 9:05 a.m., S4RN indicated Patient #2 had pressure ulcers in the perineum and buttocks. She reviewed the hard copy medical record and confirmed there was no evidence of a documented medical consult for the wounds as ordered by S6Psych.

In an interview on 05/31/18 at 3:50 p.m. during the observation of peri care, S13MHT indicated Patient #2 had been transferred from the geri chair (where she had been observed to be sitting on 05/31/18 at 9:30 a.m.) to her bed at 3:45 p.m. She confirmed Patient #2 had not been turned, repositioned, or checked for toileting from 9:30 a.m. until 3:45 p.m. (6 hours 15 minutes).

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN developed and kept current a nursing care plan for each patient that included nursing interventions and treatment goals as evidenced by failure to have documented evidence of an individualized nursing care plan that addressed patient wounds/pressure ulcers, infection/contact precautions, decreased nutritional intake, and/or hypersexual behavior for 3 (#2, #3, #4) of 5 patient records reviewed for a current nursing care plan from a sample of 5 patients.
Findings:

Observation on 05/30/18 at 3:10 p.m. in the Dining/Activity Room revealed Patient #3 leaning over Patient #4 and kissing him on the forehead.

Observation of a hospital-provided video on 05/30/18 at 3:30 p.m. of 05/29/18 from 1:01 p.m. to 1:51 p.m. with S1DON present revealed the following observations:
1:01 p.m. Patient #3 and patient #4 were seated at a table in the Dining Room. Patient #3 was facing the camera, and Patient #4's back faced the camera.
1:16 p.m. Patient #3 reaches across the table and touches Patient #4 (unable to see where Patient #4 was touched due to the view of the camera).
1:22 p.m. Patient #3 pats Patient #4 (can't see where she touches him), and Patient #4 has an arm over Patient #3's arm.
1:24 p.m. Patients #3 and #4 appear to be holding hands.
1:33 p.m. Patient #3 touches Patient #4's shoulder and leans forward toward him.
1:34 p.m. Patients #3 and #4 were holding hands, and Patient #3 was touching Patient #4's shoulder as Patient #4 maneuvered his w/c from the bathroom.
1:36 p.m. Patient #3 rubs Patient #4's shoulder.
1:41 p.m. Patient #3 reaches towards Patient #4's face.
1:50 p.m. Patient #3 touches Patient #4's shoulder. They hold hands and Patient #4 reaches for Patient #3's face.

Review of the policy titled "Treatment Plans", presented as a current policy by S1DON, revealed each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. It is initiated upon admission and revised throughout the patient's hospitalization to reflect progress towards the treatment goals. Within 24 hours of admission, a nurse completes an initial Treatment Plan that is based on an assessment of presenting problems, physical health and emotional and behavioral status. All newly identified patient problems or diagnoses will be incorporated into the plan of care, and the treatment plan will be modified to reflect these changes.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

Review of Patient #2's lab results revealed she had wounds that were cultured on 05/24/18 with results on 05/27/18 of Moderate Growth Escherichia coli, Multi-drug or Pan-resistant organism and potential pathogen that mandates the institution of contact precautions, and Moderate Growth Gram Negative Rods.

Review of Patient #2's graphic sheet revealed her meal intake was documented as follows:
05/24/18 - 0, 0. 0
05/25/18 - 0, 0, 0
05/26/18 - 0, 75%, 0
05/27/18 - not documented at 8AM and 12PM, 100% at 10PM
05/28/18 - 75%, 75%, 75%
05/29/18 - 0, 0, 0.

Review of Patient #2's nursing care plan revealed her identified problems in her nursing care plan included anxiety with depression, ineffective coping, and risk for falls. There was no documented evidence a plan was developed that included nursing interventions and treatment goals related to pressure ulcers, infection, contact precautions, and decreased nutritional intake.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 05/24/18 at 7:30 p.m. with diagnoses of Major Depressive Disorder, Dementia with Behavioral Disturbances, Hypertension, and Gastroesophageal Reflux disease.

Review of Patient #3's "Multi-Disciplinary Note" revealed the following notes by the nursing staff:
05/28/18 at 2:37 a.m. by S4RN - was up in w/c in dining room fighting with staff, screaming, and making crying noises when "staff would pull her off of a certain male patient, and bring her into the hall";
05/28/18 at 5:26 p.m. by S10RN - can become uncontrollable and combative at times when taken away from Patient #4;
05/29/18 at 5:04 p.m. by S10RN - holding hands with patient #4; becomes uncontrollable and combative at times when taken away from Patient #4;
05/30/18 at 10:51 a.m. by S5RN - frequently flirtatious with male peers;
05/30/18 at 10:03 p.m. by S4RN - continues to go up to a certain male patient; requiring staff to assist and/or remove this patient from said male patient's presence; this patient is touching male patient repeatedly, usually on his hands, arms, shoulders.

Review of Patient #3's nursing care plan revealed her plan included identified problems of altered thought process, ineffective coping, and risk for falls. There was no documented evidence that a nursing care plan had been developed for hypersexual activity.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 05/22/18 at 7:45 p.m. with diagnoses of Dementia, Type II Diabetes mellitus, Hypertension, Hypercholesterolemia, and Overactive Bladder.

Review of Patient #4's medical record revealed no documented evidence of nurses documenting above-documented behaviors with Patient #3.

Review of Patient #4's nursing care plan revealed problems identified included dementia with behavioral disturbance, potential for deficient knowledge, and risk for falls. There was no documented evidence that a nursing care plan had been developed for hypersexual activity.

In an interview on 05/30/18 at 9:03 a.m. during a tour of the hospital in the Dining/Activity Room, Patient R1 indicated staff has allowed Patients #3 and #4 to "sexually harass each other" by allowing each to stick their fingers in the other patient's mouth and "fondle each other." She further indicated the surveyor could check her chart, because she was refusing to take any medications (meaning she was cognizant of her surroundings). Patient R1 indicated both nurses and MHTs have observed these interactions between Patient #3 and Patient #4.

In an interview on 05/30/18 at 9:03 a.m. during a tour of the hospital in the Dining/Activity Room, Patient R2 joined the discussion after Patient R1 had reported the above. Patient R2 was not in the room when Patient R1 told the surveyor the above information. Patient R2 indicated Patient #3 and Patient #4 were "lovebirds." She further indicated she observed them holding hands and rubbing each other's body (touched her chest to demonstrate where they rub) and kisses each other on the mouth. She further indicated she thinks they touch each other's private areas, but she can't be sure, but she did observe Patient #3's hands in the area of Patient #4's private area.

In an interview on 05/31/18 at 4:30 p.m., S1DON confirmed the above patients did not have nursing care plans for wounds/pressure ulcers, infection, contact precautions, decreased nutritional intake, and hypersexual behaviors. She confirmed that these care plans should have been developed.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation of Food and Dietetic Services as evidenced by:

1) Failing to ensure a full-time employee served as director of the food and dietetic services and was responsible for the daily management of the dietary services and was qualified by experience or training. The hospital had no full-time employee responsible for dietary services.
(See findings in tag A0620)

2) Failing to ensure individual patient nutritional needs were met as evidenced by failure to have documented evidence that patients with decreased nutritional intake were offered substitutes of equal nutritional value, the decreased intake was reported to the physician or NP, and care plans were developed to address the decreased nutritional intake for 2 (#1, #2) of 5 patient records reviewed with decreased nutritional intake from a sample of 5 patients.
(See findings in tag A0629)

Based on record reviews and interviews, the hospital failed to ensure a full-time employee served as director of the food and dietetic services and was responsible for the daily management of the dietary services and was qualified by experience or training. The hospital had no full-time employee responsible for dietary services.
Findings:

Review of the list of employees presented by S1DON revealed no documented evidence that a Dietary Manager was included in the list.

In an interview on 05/31/18 at 4:15 p.m., S1DON indicated the hospital did not have a full-time employee who was responsible for the daily management of the dietary services. She further indicated the Registered Dietitian is contracted and does not work for the hospital full-time.

Based on record reviews and interviews, the hospital failed to ensure individual patient nutritional needs were met as evidenced by failure to have documented evidence that patients with decreased nutritional intake were offered substitutes of equal nutritional value, the decreased intake was reported to the physician or NP, and care plans were developed to address the decreased nutritional intake for 2 (#1, #2) of 5 patient records reviewed with decreased nutritional intake from a sample of 5 patients.
Findings:

Review of the policy titled "Dietary Manager Scope of Services", presented as a current policy by S1DON, revealed the purpose of the policy was to provide weekly monitoring under the direction of the Registered Dietitian. Further review revealed there was no documented evidence of what was to be included in the weekly monitoring and which staff member would conduct the monitoring.

Review of the policy titled "Scope of Services - Nursing", presented as a current policy by S1DON, revealed patients were to be weighed on admit and weekly every Saturday morning to assess weight. The nurse was to assess for increase or decrease in appetite and document notification of the physician.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 04/19/18 at 9:50 a.m. with a diagnosis of Bipolar I Disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior.

Review of Patient #1's graphic sheet revealed she weighed 161 pounds at admit. There was no documented evidence she was weighed on Saturday, 04/21/18, as required by hospital policy.

Review of Patient #1's nursing shift assessments revealed each RN documented her "Nutrition/Fluids" as adequate. Review of her graphic sheet revealed her meal intake was documented as follows:
04/20/18 - 75% 3 meals (breakfast, lunch, supper)
04/21/18 - 25%, 75%, 75%
04/22/18 - 25%, 0, 0
04/23/18 - 0, 25%, 25%
04/24/18 - 0, 0, 25%
04/25/18 - 0, 0 (supper was not documented as Patient #1 was transferred to the acute care hospital before the supper meal).
There was no documented evidence in Patient #1's medical record that the RN notified the psychiatrist or NP of Patient #1's decreased meal intake throughout her hospital stay or that substitutes of equal nutritional value were offered when meals were refused.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

Review of Patient #2's graphic sheet revealed she weighed 275 pounds at admit. Further review revealed her meal intake was documented as follows:
05/24/18 - 0, 0. 0
05/25/18 - 0, 0, 0
05/26/18 - 0, 75%, 0
05/27/18 - not documented at 8AM and 12PM, 100% at 10PM
05/28/18 - 75%, 75%, 75%
05/29/18 - 0, 0, 0.
There was no documented evidence in Patient #2's medical record that the RN notified the psychiatrist or NP of Patient #2's decreased meal intake as of the date of review of the medical record on 05/30/18 at 1:25 p.m. There was no documented evidence that substitutes of equal nutritional value were offered when meals were refused..

Review of Patient #2's nursing shift assessments revealed each RN documented her "Nutrition/Fluids" as adequate.

In an interview on 05/31/18 at 8:325 a.m., S4RN indicated when she documents nutrition/fluids as adequate, she determines this by what she sees is eaten on her shift (which is a snack on her shift). She indicated she does review the graphic sheet related to meals, because on Monday, Wednesday, and Friday the night RN has to do a chart audit that includes a review of meal intake. S4RN reviewed the audit sheets done by the RNs and confirmed meal intake isn't addressed on the form. The surveyor asked S4RN if she had reported decreased intake to the physician or NP and requested a dietary consult for Patient #1 and Patient #2, and she answered "I did not."

In an interview on 05/31/18 at 9:45 a.m., S5RN indicated when he documents nutrition/fluids as adequate, he asks the MHTs how the patient is eating and sometimes he looks back in the record. He indicated the graphic sheet accounts for the meals but doesn't capture the snacks and any other meals given during the day. He indicated the nurse speaks with the physician and NP and discuss any "high points" including if patient isn't eating properly. He further indicated he should document his report to the physician, but he doesn't recall calling Patient #1 to the physician's attention. He indicated the dietitian does come for dietary consults. There is a nutritional screening that can trigger a dietary consult upon admission, and at any point a physician can order a dietary consult. He indicated if a patient was continually not eating and not taking snacks, this would warrant a dietary consult. After reviewing Patient #1's and Patient #2's graphic sheet, S5RN indicated he should have asked a doctor to order a dietary consult.

In an interview on 05/31/18 at 2:00 p.m., S14NP indicated if a patient continually refuses food or has documented poor intake, the nurse should notify her or the psychiatrist to obtain an order for a dietary consult.

In an interview on 05/31/18 at 4:15 p.m., S1DON indicated the hospital did not have a full-time employee who was responsible for the daily management of the dietary services. She further indicated the Registered Dietitian is contracted and does not work for the hospital full-time.

Based on observations, record reviews, and interviews, the hospital failed to meet the Condition of Participation of Infection Control as evidenced by:

1) Failing to ensure a person was designated as the infection control officer to develop and implement policies governing control of infections and communicable diseases and assures this individual is qualified through education, training, experience, or certification. The hospital's infection control officer had no prior experience in infection control and did not have education or training in infection control.
(See findings in tag A0748)

2) Failing to implement policies and procedures for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
a) Failing to implement policies and procedures for contact precautions and to use isolation precautions as recommended by the CDC for 1 (#2) of 1 patient observed on contact precautions from a sample of 5 patients.
b) Failing to have appropriate PPE (long-sleeved isolation gowns) on 05/31/18 at 9:30 a.m. while an inpatient whose wounds were cultured with E-coli and Multi-drug or Pan-resistant organism and potential pathogen that mandated the institution of contact precautions was present in the hospital and required turning, peri care, and wound care.
c) Failing to ensure expired food items were not available for use as observed during the hospital tour on 05/30/18 at 9:03 a.m.
(See findings in tag A0749)

Based on record review and interview, the hospital failed to ensure a person was designated as the infection control officer to develop and implement policies governing control of infections and communicable diseases and assures this individual is qualified through education, training, experience, or certification. The hospital's infection control officer had no prior experience in infection control and did not have education or training in infection control.
Findings:

Review of S1DON's personnel file revealed no documented evidence of prior work experience or training or education in infection control.

In an interview on 05/31/18 at 4:15 p.m., S1DON indicated she was the hospital's infection control officer. She further indicated she just joined APIC in April 2018 and have not taken any infection control courses. She further indicated she had no prior work experience in infection control.

Based on observations, record reviews, and interviews, the infection control officer failed to implement policies and procedures for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) Failing to implement policies and procedures for contact precautions and to use isolation precautions as recommended by the CDC for 1 (#2) of 1 patient observed on contact precautions from a sample of 5 patients.
2) Failing to have appropriate PPE (long-sleeved isolation gowns) on 05/31/18 at 9:30 a.m. while an inpatient whose wounds were cultured with E-coli and Multi-drug or Pan-resistant organism and potential pathogen that mandated the institution of contact precautions was present in the hospital and required turning, peri care, and wound care.
3) Failing to ensure expired food items were not available for use as observed during the hospital tour on 05/30/18 at 9:03 a.m.
Findings:

1) Failing to implement policies and procedures for contact precautions and to use isolation precautions as recommended by the CDC:
Observation on 05/30/18 at 12:04 p.m. revealed S8MHT was in the Dining/Activity room with gloves on that she wore while serving patients lunch. With the same gloved hands, S8MHT, while in the Dining/Activity Room, donned a face mask and a paper gown. She carried the lunch tray for Patient #2 out the Dining Room with her gown flapping untied in the back. While walking down the hall, another MHT tied the lower part of S8MHT's gown but couldn't get the neck to stay attached. S8MHT entered Patient #2's room with contaminated gloves, gown, and mask. She offered lunch and juice to Patient #2. Patient #2 indicated she wasn't hungry and was "sick to her stomach." Patient #2 indicated her heel hurt, and S8MHT touched her heel with gloved hands. At 12:10 p.m. after encouraging Patient #2 to eat, S8MHT exited the patient's room in her PPE, carried the lunch tray into the Dining Room, and placed the tray on the tray stand. S8MHT exited the Dining Room and walked to the nursing station door. She touched the door to the nursing station with the same contaminated gloves worn to serve patient lunch trays, attempt to feed Patient #2, and used to touch patient #2's heel. S8MHT removed her contaminated PPE once she was in the nursing station and sanitized her hands.

Observation in Patient #2's room on 05/31/18 at 3:50 p.m. revealed S8MHT and S13MHT were preparing to provide peri care to Patient #2. They were both wearing gowns, gloves, and masks. The MHTs separated Patient #2's legs with gloved hands for the surveyor to observe her right inner thigh wound. Without changing gloves and performing hand hygiene, both MHTs turned Patient #2 to her side and held her buttocks for the surveyor to observe. With the same contaminated gloves, S13MHT touched the bag of wipes to get wipes to clean the patient. Both MHTs cleaned the patient with same gloves worn from the beginning of peri care and wore the same gloves to apply barrier cream and apply a diaper after they had cleaned the wounds. Both MHTs removed their gloves and didn't perform hand hygiene before beginning their next task.

Review of the policy titled "Transmission Based Precautions", presented as a current policy by S1DON, revealed contact precautions apply to patients with draining wounds and pressure ulcers. The procedure included performing hand hygiene before touching a patient and prior to wearing gloves. PPE included wearing gloves when touching the patient and the patient's immediate environment or belongings and wearing a gown if substantial contact with the patient or environment is anticipated. Hand hygiene was to be performed after removal of PPE.

Review of CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed contact precautions were intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on Contact Precautions were to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the
patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Hand hygiene was to be performed before having direct contact with patients, after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient), if hands will be moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves.

Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

Review of Patient #2's labs revealed wound cultures had been done on 05/24/18 and reported on 05/27/18 indicating Moderate growth Escherichia coli, a Multi-drug or Pan-resistant organism and potential pathogen that mandates the institution of contact precautions, and Moderate Growth Gram Negative Rod.

In an interview on 05/30/18 at 12:15 p.m., S8MHT indicated Patient #2 had "MRS" and then asked another MHT what she had and was told it was "E-coli." She indicated they have to use "safety precautions." When the surveyor asked what she meant by safety precautions, she indicated she has to gown with the proper PPE, mask, gown, and gloves to protect herself. The surveyor reviewed the observations with S8MHT, and she confirmed she breached infection control practices.

In an interview on 05/31/18 at 4:10 p.m. with S8MHT and S13MHT present, the surveyor reviewed the observations made during personal care performed by both. Both MHTs confirmed the observations included breaches in infection control.

2) Failing to have appropriate PPE (long-sleeved isolation gowns) on 05/31/18 at 9:30 a.m.:
Observation on 05/31/18 at 9:30 a.m. revealed S5RN and an accrediting body surveyor were in Patient #2's room, who was on contact precautions, wearing a sleeveless paper isolation gown. Further observation revealed S5RN's arms were bare.

Review of Patient #2's medical record revealed she was admitted on 05/23/18 at 7:00 p.m. with a provisional diagnosis of Dementia with Behavioral Disturbances, Delusional, Hallucinating. Further review revealed she had 4 "Stage II to III wounds" as documented at admit by S9RN.

Review of Patient #2's labs revealed wound cultures had been done on 05/24/18 and reported on 05/27/18 indicating Moderate growth Escherichia coli, a Multi-drug or Pan-resistant organism and potential pathogen that mandates the institution of contact precautions, and Moderate Growth Gram Negative Rod.

In an interview on 05/31/18 at 9:52 a.m., S5RN confirmed the hospital doesn't presently have proper PPE gowns and doesn't have signage on Patient 32's door indicating she was on contact precautions. He indicated they ran out of gowns about 1 hour prior to the accrediting body surveyor asking him to go to Patient #2's room.

3) Failing to ensure expired food items were not available for use as observed during the hospital tour on 05/30/18 at 9:03 a.m.
Observation on 05/30/18 at 9:03 a.m. during the tour of the hospital revealed a patient nourishment refrigerator was in the Dining/Activity Room. Further observation revealed the following food items were stored in the refrigerator available for patient use and had surpassed their expiration dates or were not labeled with the date the item was placed in the refrigerator:
1 biscuit in a paper bag with no label with a date when it was placed in the refrigerator;
6 paper bags, each containing slices of bread with no date/label on the bag;
2 opened gallons of milk with a "use by" date of 05/27/18 and 05/29/18;
6 (4 oz.) containers of Dannon Creamy Yogurt that expired 04/29/18;
3 containers (4 oz. each) of Yoplait Yogurt that expired 05/19/18.

Review of the policy titled "Dietary Manager Scope of Services", presented as a current policy by S1DON, revealed all food shall be stored, distributed, and served under sanitary conditions to prevent food borne illness. Staff shall not store personal items in patient dining room or patient food storage areas. There was no documented evidence that policy addressed the process to be used by staff to assure expired food and nourishment items were not expired and available for use.

In an interview on 05/30/18 at 9:03 a.m., S2MHT confirmed the above items were expired or had no label with the date the item was placed in the refrigerator.