HospitalInspections.org

Based on observations, record review and interviews, the Governing Body/Board failed to ensure policies and procedures were formulated and specific to services provided for the immediate assessment of an emergent medical condition (EMC), the initial treatment, referral or transfer from the psychiatric facility. This failed practice had the likelihood for increased staff confusion and delay in treatment for patients, visitors and/or staff members who may experience an EMC. The Governing Body/Board failed to identify: 1. Steps and responsibilities for medical and nursing staff which included initial triage for patients, visitors and/or staff who present with an EMC. 2. Identify the qualifications, training and competency required for Registered Nurses to perform the initial assessment and referral/transfer of individual presenting with an EMC. 3. Identify all equipment necessary for response to medical emergencies.

Findings:

Observations made, 05/28/2019 at 2:50 PM, revealed a room in the Assessment and Referral area was identified by Staff #D as the emergency room. Continued observations of the equipment in the room revealed there failed to be suction equipment, available oxygen, or any type of emergency medications and the supplies needed to administer them.

Interviews, 05/28/2019 at 2:50 PM, with Staff #s B, D confirmed a lack documented policies and procedures that addressed different types of emergency medical conditions, necessary equipment, and the responsibilities of the medical and nursing staff.

Based on observations, interviews, and record reviews the hospital failed: 1. to provide adequate training and oversight to Mental Health Technicians (MHT) who served patients 3 meals per day, 7 days/week from banquet style service trays, on their respective units; and 2. to follow the hospital's established policies and procedures.

Findings:

Observations, made 05/27/19 at 11:00 AM-11:40 AM, revealed MHTs served patients on their respective units.
There failed to be dietary staff available to provide oversight for proper servings, and to ensure the food remained at serving temperature.

Interview, 05/28/19 at 1:30 PM, with Staff #L revealed the MHTs were responsible for serving the meals to the patients. When asked if the temperatures were monitored to ensure hot food remained hot and cold food remained cold, Staff #L replied the meals were brought over from contract Hospital AA in warmers and assumed the food remained at the proper temperature. Surveyors asked if MHTs recorded food temperatures on occasion to ensure the food was indeed served at the proper temperature; Staff #L replied, "don't think they are checked or recorded". Continued interview with Staff #L confirmed the MHTs were not using measured serving spoons, but disposable flat serving type spoons. Staff #L was asked how the MHTs ensured they were giving patients a proper serving; there was not a response.

Review of policies and procedures titled, "Nutrition Services for Youth and Adults" revealed: "...V. Inpatient nutrition services are standardized using the 'Manual of Medical Nutrition Therapy'. The manual is approved annually by the Medical Director and the Consultant Dietitian and a copy is available on the unit...VII. ...D. Nursing staff will serve meals in a safe, accurate and timely manner..."

Surveyors asked to see the Manual of Medical Nutrition Therapy; however, nursing staff could not produce one.

Review of a policy/procedure titled, "Food Services and Sanitation" revealed the following: "PROCEDURE: E. ...Diet/Temperature Sheet (See Form W 424) will be monitored by vendor (Hospital AA) on every meal each day after receiving meals from contracted service..."

Surveyors asked for the Diet/Temperature Sheet referred to above; however, none was produced.

The hospital has an active contract for Dietary Services to be provided by contract Hospital AA. The contract provided for 3 meals a day and one snack for all patients, along with all disposable plates, serving spoons and flatware.

Interview, 05/28/19 at 12:15 PM, with Staff #P revealed contract Hospital AA staff "wheels" the warming cart from Hospital AA to the Psychiatric hospital. Staff #P was asked approximately how long it would take "wheeling" the warming cart from one hospital to the other; Staff #P replied, "maybe 5 to 10 minutes depending on the weather and traffic." It should be noted, the food temperatures were checked prior to the warming carts leaving contract Hospital AA; however, there failed to be documentation the food temperatures were rechecked prior to being served to the patients.

Based on record reviews and interview the hospital failed to ensure there was a Therapeutic Diet Manual available for use by staff and that the Diet Manual had been approved by the Medical Staff and Dietitian.

Findings:

Review of Medical Staff meeting minutes from May 2018 through May 2019 revealed there failed to be documentation the Medical Staff had reviewed and approved the Therapeutic Diet Manual.

Interview, 05/28/19 at 12:05 PM, with Staff #C revealed when questioned if the hospital had a Therapeutic Diet Manual for use; Staff #C replied she thought they had one on the computer system.

Interview, 05/28/19 at 2:45 PM, with Staff #C confirmed there was not a Therapeutic Diet Manual for use by nursing staff.

Based on review and interview, the hospital failed to develop a system for identifying disease by not tracking and trending organisms that caused infections.
Findings

A review of the infection control logs from 05/218 through 04/2019 showed the hospital was not tracking and trending organism that caused infections. Further review showed there were no laboratory results in the medical record for the patients who were listed on the infection control log.

On 05/27/19 at 02:00 PM an interview was held with Staff C, who stated she was the Infection Control Officer. Staff C reviewed the infection control log and stated she was unaware organisms were to be tracked through infection control. Also, Staff C stated, the nurses on the units reports infections to her, but the nurses did not give her lab reports.