The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PUTNAM COUNTY MEMORIAL HOSPITAL 1926 OAK STREET, PO BOX 389 UNIONVILLE, MO 63565 Jan. 9, 2014
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
Based on policy review and interview the facility failed to ensure that a pharmacist reviewed patient medication profiles and physician's medication orders prior to administration of the medications for those patients admitted to the Behavioral Health Unit (BHU). These deficient practices had the potential to cause medication errors or drug interactions and could affect all patients admitted to the BHU. The facility census was 11 with six of those patients in the BHU.
Findings included:
1. Record review of Patient #8's medical record on 01/09/14 showed:
- Admission Order Set as telephone orders, dated 01/06/14 at 11:29 PM, with an order to continue current medications (see MRO [medication reconciliation orders]);
- Medication Reconciliation Physician Orders as a telephone order, dated 01/07/14 at 12:15 AM, for five medications that had the potential for negative side effects and interactions including antidepressants, antipsychotic drugs (Psychiatric medication primarily used to manage psychosis [delusions, hallucinations, or disordered thought]), and drugs used to reduce the side effects of antipsychotic treatment.;
- Three additional telephone orders received 01/07/14 for changes to the
above orders.

2. During a telephone interview on 01/09/14 at 11:25 AM, Staff Y, MD, Psychiatrist, stated that he was aware that Patient #8 had been admitted to the facility but that he had not seen the patient. Staff Y stated that the medication profiles and medication orders were reviewed by the pharmacy daily. Staff Y stated that he expected the facility pharmacist to review admission medication orders and any other medication orders that BHU patients might have throughout their stay at the facility.
3. During an interview on 01/09/14 at 1:45 PM, Staff T, Pharmacist stated that he did not have any responsibility in the review of the medication orders or medication profiles for the patients admitted to the BHU. Staff T stated that the BHU was not a part of the pharmacy contract and that he did not ever see Psych orders for medications.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based on observation, interview and policy review, the facility failed to ensure:
- That staff followed the facility's hand hygiene policy and isolation precautions policy during medication administration for two (#4 and #5) of two patients.
- That the Infection Control Officer (ICO) performed facility-wide surveillance to monitor for infection control issues throughout the facility.
- That the ICO/Employee Health Nurse maintained an infection control log of employees, volunteers and contracted staff.
- That policies and procedures were appropriately written and in place for all patient care areas.
- That the ICO had the authority for obtaining microbiological cultures from patients when indicated.
- That the Infection Control Committee was active and meeting regularly to address infection control issues.
- That new personnel were oriented to infections, communicable diseases, and the infection control program for six (D, I, J, S, V, and W) of 10 personnel records reviewed.
This had the potential to affect all patients, staff, volunteers and visitors to infections and communicable diseases that came to the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Infection Control-Hand Hygiene" reviewed 04/20/10, showed direction for facility staff to wash hands with non-antimicrobial or microbial soap and water after removing non-sterile and sterile gloves.

2. Observation on 01/08/14 at 9:40 AM, showed Staff P, Registered Nurse (RN), entered Patient #4's room to administer morning medications. After Staff P administered the patient's medications she removed her gloves. The patient requested for Staff P to assist her to the restroom. Staff P put on another pair of gloves but did not wash her hands with soap and water or use hand sanitizer before putting on the gloves.

3. During an interview on 01/09/14 at 3:05 PM, Staff J, RN, ICO, stated that she expected staff to wash their hands with soap and water or use hand sanitizer after removing gloves and before putting on another pair.

4. Record review of the facility's policy titled, "Guidelines for Isolation Precautions" reviewed 10/13/12, showed Healthcare personnel should wear a gown and gloves when close interactions with the patient and/or environment is anticipated.

5. Observation on 01/08/14 at 9:55 AM, showed a sign posted outside Patient #5's room that stated "Contact Precautions". Staff P entered the patient's room without putting on a gown. Staff P removed the patient's blanket and lifted up her gown to administer Lovenox (medication used to prevent blood clots) subcutaneous (SQ-under the skin).

6. During an interview on 01/08/14 at 2:50 PM, Staff P stated that when she administered medications to Patient #5 she did not think she would come into contact with any contaminated surfaces or areas. Staff P stated that she did have to remove the patient's blanket and lift up her gown when she administered the Lovenox SQ.

7. During an interview on 01/08/14 at 3:00 PM, Staff Q, RN, Unit Director, stated that if a patient was in contact precautions, he expected staff to wear gloves and a gown into patients room if they were going to render direct patient care or come into contact with contaminated areas/surfaces.

8. During an interview on 01/09/14 at 3:05 PM, Staff J, ICO stated that she expected staff to always wear gloves and a gown before going into a patient's room with "Contact Isolation" posted. Staff J stated that staff should wear a gown when having direct contact with patients, for example when giving a SQ injection.

9. Record review of the facility's "Infection Control Plan" reviewed 10/31/12 showed the following information:
- Surveillance: Monitoring patients and healthcare workers for acquisition of infection and/or colonization (presence of bacteria on a body surface).
- Surveillance will include HAIs (hospital acquired infections) among patients and healthcare workers. Targeted studies will be conducted on infections that are high-risk and high volume at this hospital. Surveillance by objective will be done on an as-needed basis.
- Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management:
- HAIs in all units;
- Device-related infections;
- Antibiotics-resistant organisms;
- HAI TB (tuberculosis);
- Other communicable diseases and
- Employee health trends

10. During an interview on 01/07/14 at 1:10 PM, Staff J, ICO stated that the Infection Control Program did not have the following policies or procedures:
- Measures for identifying and reporting hospital acquired infections and communicable diseases;
- Measures for assessing and identifying patients, healthcare workers, contract staff or volunteers that are at risk for infections and communicable diseases;
- Methods for obtaining reports of infections and communicable diseases for contract staff and volunteers in a timely manner;
- Measures for the prevention of infections related to intravascular (entry into a blood vessel) devices and tube feedings;
- Methods for monitoring and evaluating practices of housekeeping, liquid and solid waste disposal and separation of clean from dirty;
- A requirement that disinfectants, antiseptics and germicides be used in accordance with the manufacturer's instructions to avoid harming patients, particularly central nervous system effects on children;
-Measures for the screening and evaluation of contract staff and volunteers for communicable diseases and for the evaluation of exposure to patients with non-treated communicable diseases;
- Procedure for working with local, state, and Federal health authorities in emergency preparedness situations;
- Policies and procedures developed in coordination with Federal, state, and local emergency preparedness and health authorities to address communicable disease threats and outbreaks;
- Authority and indications for obtaining microbiological (simple life forms that include bacteria, fungi and viruses) cultures from patients.

During an interview on 01/07/14 at 2:30 PM, Staff J stated that she did not perform hospital-wide surveillance. Staff J stated that she did not do surveillance or make rounds in the dietary department to include monitoring food sanitation. Staff J stated that she did not do surveillance or monitor housekeeping staff to ensure they followed infection control during cleaning patient care areas or to see if staff followed infection control policies and procedures.

During an interview on 01/07/14 at 3:00 PM, Staff J stated that the facility did not have policy giving her the authority and indication to obtain microbiological cultures from patients.

During an interview on 01/07/14 at 3:40 PM, Staff J stated that she did not maintain a log of all incidents related to infections and communicable diseases for facility staff, contracted staff or volunteers.

11. Record review of the facility's "Infection Control Plan" reviewed 10/31/12 showed the following information:
- That the Infection Control Committee (ICC), through its Medical Director, has the ultimate authority to determine infection control policies for the healthcare organization with the approval of the facility's governing body.
- When problems or opportunities for improvement are identified, actions taken/recommended will be documented in the [facility's] Infection Control Committee minutes. Minutes are forwarded to Quality Assurance Department for review and assistance in resolution as necessary.
- The ICC/Infection Control Department Head has the responsibility for infection control activities throughout the facility. This committee is governed by a physician having knowledge of infections control practices and performance improvement methodologies, and guides the committee on decisions for improvement of care through the prevention and control of infections.

12. During an interview on 01/07/14 at 3:35 PM, Staff J stated that the facility had not had an ICC meeting since 2012.

During an interview on 01/09/14 at 3:05 PM, Staff J stated that she expected all staff to follow the facility's policy and procedures related to infection control.

13. Record review of personnel records showed no record of training for infection control and prevention during orientation for six of 10 records reviewed:
- Staff S, Pharmacy Technician;
- Staff I, Dietary Manager;
- Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO);
- Staff J, RN, Infection Control Coordinator;
- Staff V, RN, Agency staff;
- Staff W, RN, Agency staff.

14. During an interview on 01/09/14 at 1:30 PM, Staff U, Human Resources Director, stated that she could not show infection control and prevention was included in the orientation for six of the 10 personnel records reviewed.
VIOLATION: POLICIES - NUTRITION Tag No: C0279
Based on observation, interview and record review facility staff failed to ensure:
- Patients admitted to the Behavioral Health Unit (BHU) were provided nutritional screening for nutritional problems;
- Patients admitted to the BHU were provided a nutritional assessment and nutrition education by a licensed, Registered Dietitian (RD);
- The BHU maintained access to the approved facility Diet Manual;
- The Dietary Manager maintained and implemented policies and procedures directing nutritional screening, and nutritional assessment for BHU patients;
- The Dietary Manager implemented existing policies and procedures for safe, sanitary storage and handling of foods, including ice served to patients on the Medical/surgical unit; on the BHU and in the Dietary department.
These deficient practices had the potential to cause harm to patients by providing inadequate nutritional care and unsafe, unsanitary food service. The facility census was 11 with six of those on the BHU.

Findings included:

1. Record review of the facility's policy titled, "Nutrition Risk Screening For New Admissions," dated 02/09/09 showed direction for Dietary department staff to complete a nutrition screening on each newly admitted patient using pre-determined criteria established by the Registered Dietitian (RD).

Record review of the facility's policy titled, "Nutrition Screening Procedure," dated 02/09/10 showed direction for the Dietary Manager to conduct a nutrition screening using information found in the medical record including weight, low blood protein levels indicated by laboratory results; bed sores or identified nutritional deficiencies; visit the patient within 24 hours of admission and obtain food preferences.

2. During an interview on 01/08/14 at 10:20 AM, Staff I, Dietary Manager stated that she and the Dietary department staff were not allowed to enter the BHU so; she had no contact and had not performed any nutritional screenings for any patients on that unit.

3. Record review of an undated copy of the Dietitian's position description showed the essential functions of the person in the position were as follows:
- Counsel individuals and groups on basic good nutrition;
- Assess nutritional needs, diet restrictions and current health plans to develop and implement dietary care plans and provide nutritional counseling;
- Educate patients and their families on nutritional principles, dietary plans and diet modifications.

4. Record review of the facility's policy titled, "Medical Nutrition Therapy," dated 02/05/10 showed direction for the RD to review the patient's medical record and conduct a patient interview.

5. During an interview on 01/08/14 at 11:00 AM, Staff F, Nurse Manager for the BHU stated the RD does not come to the BHU and the RD doesn't have contact with any of the BHU patients.

6. During an interview on 01/09/14 at approximately 11:45 AM, Staff GG, RD, stated that she did not provide nutritional assessment or care on the BHU because she felt it was unsafe to be around those patients.

7. During an interview on 01/08/14 at approximately 2:52 PM, Staff A, BHU Registered Nurse (RN) stated that she did not know how to access and the unit did not have a copy of the approved facility diet manual to use as a reference for patient modified diet therapy.

8. During an interview on 01/09/14 at approximately 11:45 AM, Staff GG, RD stated that the Dietary Manager was not allowed to be on the BHU so, could not provide information on or access to the approved facility diet manual.

9. During an interview on 01/08/14 at 10:07 AM, Staff I, Dietary Manager stated the following:
-That she and the Dietary staff were not allowed to go onto the BHU to provide nutrition screening, tray delivery or delivery and monitoring of foods served to patients between meals;
- That the facility did not have any written policies and procedures directing that Dietary staff were not allowed on the BHU for nutritional screening or food service;
- That she had been informed verbally of the restriction.

10. Record review of the facility's policy titled, "Food Supply Purchasing, Receiving, and Storage," revised 01/08/08 directed staff to ensure food packages were in good condition with no obvious signs of contamination and Dietary staff were responsible for discarding out-of-date foods.

Record review of the facility's policy titled, "After-hours Meal Service," revised 04/05/11 directed nursing staff to provide specific measured quantities of foods including cold sandwiches and milk to patients on restricted diets (diabetic, low salt, pureed).

Record review of the facility's policy titled, "Infection Control for Nutritional Services," reviewed 10/31/12 showed the following direction:
-That the Dietary Manager was responsible for proper storage of all food supplies;
- That the Dietary Manager was responsible to ensure perishable foods were stored at or below 41 degrees Fahrenheit;
- That infection control practices shall include food storage areas that were cleaned weekly and inspected daily by the Dietary Manager;
- That refrigeration units were cleaned weekly;
- That foods, not in their original containers shall be stored in the smallest container possible, covered, labeled and dated.
- That individual portions of foods shall not be served again;
- That scoops used to handle ice shall be cleaned and sanitized daily;
- Temperatures of refrigeration units shall be checked and recorded daily by Dietary staff.

11. Observation on 01/07/14 at 9:56 AM in the Medical/surgical unit pantry showed staff stored an unknown volume of milk in a heavily soiled plastic pitcher in the refrigerator with a sticker dated "1/10" affixed to the lid.

12. During an interview on 01/07/14 at 9:56 AM, Staff D, Chief Nursing Officer (CNO) stated the following:
- That the milk was routinely provided in bulk by the Dietary department;
- That the plastic pitcher was soiled;
- That the sticker dated "1/10" indicated the milk could be served to patients until 01/10/14;
- That expiration date stamped on the original milk carton from the dairy was unknown.

13. During an interview on 01/07/14 at 2:30 PM, Staff J, Infection Control Officer (ICO) stated the following:
-That the Dietary department staff had routinely placed large plastic pitchers of milk in the unit refrigerators for nursing staff to serve to patients between meals;
- That she (the ICO) never went into the Dietary department to watch processes or procedures for safe, sanitary food handling practices;
- That she would expect the Dietary department staff to follow infection control policies.

14. Observation on 01/08/14 at 10:07 AM in the Medical/Surgical Unit pantry showed staff failed to place a thermometer in both the refrigeration and freezer units (making it impossible to know if the refrigerator was at or below 41 degrees Fahrenheit).
Record review of an undated sign posted on the wall in the Medical/surgical unit pantry next to the patient food refrigerator showed the following information, "Once a container has been opened it cannot be placed back in the patient fridge!! Please do not do this you will have to throw it away!!"

15. During an interview on 01/08/14 at 10:11 AM Staff I, Dietary Manager stated the following:
-That the sign cautioning not to return foods back to the patient refrigerator had to be posted because a nurse served a boxed lunch (with sandwich) to a patient then, returned the half eaten sandwich and other foods to the same refrigerator;
- That she (Staff I) felt it had only happened once;
- That she had to discard all foods in the refrigerator because she did not know what other containers had been served and returned to the refrigerator;
- That the refrigerator was routinely stocked with individual servings of juice, sodas, and other foods available for late admissions.

16. Observation on 01/08/14 at 10:24 AM in the Dietary department (kitchen) showed staff stored the following:
- Stained plastic beverage containers in a refrigerator;
- Two containers with stickers dated 1/6;
- One container with a sticker dated 1/9;
- Lids on two of the containers were cracked (creating an incomplete seal).
- The containers were not labeled with the food/contents of the containers (as directed by the facility policy).

17. Observation on 01/07/14 at 10:40 AM in the BHU showed a large Rubbermaid liquid dispensing cooler sitting on the table in the staff break-room. The cooler had several soiled spots on the lid. Staff F, Nurse Manager of BHU, lifted the lid from the cooler showing the cooler was 2/3 filled with ice, a plastic ice scoop was inside and partially visible above the ice, and what appeared to be four dirty finger marks were along the inside top on one side.
18. During an interview on 01/07/14 at 10:40 AM, Staff F stated that the ice cooler was used to store ice for patients on the BHU. Staff F stated that the cooler was sent to Dietary with the breakfast trays daily to be cleaned and refilled with ice. Staff F could not explain the soiled areas on the cooler. Staff F stated that the ice scoop should not have been in the container.
19. Observation on 01/08/14 at 11:05 AM on the BHU showed staff stored ice in an insulated cooler with a soiled lid (exterior surface had adhesive tape residue) and staff placed a plastic ice scoop in a sandwich bag on the table next to the cooler.

20. During an interview on 01/08/14 at 11:05 AM, Staff D, CNO stated that she had ordered a holder for the ice scoop but, it had not been delivered as yet.

21. Observation on 01/08/14 at 11:15 AM in a BHU store room showed staff stored five cases of Styrofoam cups on the floor of the room and a stack of large Styrofoam containers without the protective plastic sleeve on a shelf (rim
of the container that would contact the patients mouth was in direct contact with the shelf).

22. Observation on 01/08/14 at 11:16 AM in the BHU Nurse's station showed staff stored the following in a patient food refrigerator:
-A hard plastic container with a soiled lid labeled "SF chocolate" dated 1/5 and use by 1/9" (unknown type of food);
- The contents of the plastic container labeled SF chocolate was a lemon yellow color;
- A second hard plastic container with soiled lid labeled "use by 1/12" that appeared to be a chocolate food (label did not identify the type of food).

23. Record review of the BHU refrigerator temperature log dated 01/14 showed the following:
- Staff recorded temperatures of 42 degrees Fahrenheit from the first through the seventh days of the month on the day shift;
- Staff recorded the temperature as 44 degrees Fahrenheit on the eighth day for the day shift;
- Evening shift recorded temperatures of 41 to 44 degrees Fahrenheit for the same time periods;
- The form did not list the acceptable temperature range (per facility policy) for staff to use as reference.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: C1000
Based on interview the facility failed to develop policies regarding the visitation rights of patients, including restrictions or limitations. This failed practice had the potential to affect the rights and safety of all patients admitted to the facility. The facility census was 11.

Findings included:

1. During an interview on 01/07/14 at 3:30 PM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO), stated that the facility did not have written policies concerning patient visitation.

2. During an interview on 01/08/14 at 9:50 AM, Staff Q, RN, Medical/Surgical Department Manager, stated that there were some limitations on visitors regarding age and isolation and that he was not aware of a written policy for patient visitation.
VIOLATION: AGREEMENTS Tag No: C0197
Based on interview and record review the facility failed to have a written telemedicine (use of medical information exchanged from one site to another via electronic communications using two-way video to review and improve a patient's clinical health status) agreement for Psychiatric services provided to the Behavioral Health Unit (BHU) thru Telemedicine. This deficient practice placed all patients admitted to the BHU at risk for care provided by unqualified medical staff. The facility census was 11 with six of those patients in the BHU.

Findings included:

1. During an interview on 01/09/14 at 10:20 AM, Staff A, Registered Nurse (RN), Charge Nurse, stated that the Psychiatric History and Physical (H&P) and daily rounds by Psychiatry were completed utilizing the Telemedicine unit (robot) to interview the patient. Staff A stated that the notes were completed off site and faxed to the facility.

2. During a telephone interview on 01/09/14 at 11:25 AM, Staff Y, MD, Psychiatrist, stated that he did not have any signed agreement to provide Psychiatric Services or for the provision of Telemedicine Services to the facility. Staff Y stated that he saw patients admitted to the facility BHU soley thru the robot. Staff Y stated that he had collaborative practice agreements with two Nurse Practitioners (NP) that also saw patients at the facility using Telemedicine.

3. During an interview on 01/09/14 at 1:00 PM, Staff B, Chief Operating Officer (COO), stated that the facility did not have a specific agreement or contract with Staff Y for Telemedicine coverage. Staff B stated that he was of the opinion that the services of Staff Y were included in the Management Services Agreement for the Behavioral Health Unit.

4. Record review of a memo provided by Staff E, Director of Credentialing and Compliance on 01/07/14 showed the facility did not have a separate telemedicine service agreement with Staff Y. Staff E referred to the Management Services Agreement to address telemedicine services.

5. Record review of the unsigned Management Services Agreement, effective date 07/01/13, showed no reference to the provision of Psychiatric Services through Telemedicine.
VIOLATION: GOVERNING BODY Tag No: C0241
Based on record review and interview the facility governing body failed to ensure:
- That individuals providing patient care services were appointed members of the medical staff with approved, specific privileges;
- That the Infection Control Program (ICP) had appropriate written policies in place to prevent the spread of infections and communicable diseases to patients, health care workers, contracted staff, and volunteers; and
- That the facility's policies directing appropriate nutrition screening, assessment, diet education and safe, sanitary food service were followed for Behavioral Health Unit (BHU) patients.
These deficient practices failed to ensure care was provided by qualified medical staff and placed all patients presenting to the facility for care at risk for hospital acquired infection and communicable diseases, and failed to ensure a safe and sanitary environment. The facility census was 11 with six of those patients in the BHU.

Findings included:

1. Review of the facility Medical Staff By-Laws, last amended 04/15/09, showed:
- The purpose of this organization shall be to foster a high level of professional performance of all practitioners authorized to practice in the facility through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital.
- Membership on the Medical staff is a privilege which shall be extended only to professionally competent physicians and other practitioners including dentists and podiatrists.
- Only physicians, dentists and podiatrists who can document their background, experience, training and demonstrated competence to assure the Medical Staff and the Board of Trustees that any patient treated by them in the hospital would be given a high quality of medical care, shall be qualified for membership on the Medical Staff or to exercise of particular clinical privileges.
- Appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Board of Trustees, in accordance with these By-Laws.
- Entries into the inpatient medical record by a nurse practitioner (reports, notes, progress notes, orders, etc.) shall be co-signed by a physician with whom the nurse practitioner has a collaborative practice agreement.
The Medical Staff By-Laws did not include a method for the credentialing or privileging of mid level providers including Nurse Practitioners (NP).

2. Record review of the Medical Staff Minutes, dated 12/16/13, showed "generic privileges for nurse practitioners will be developed".

3. During an interview on 01/09/14 at 10:20 AM, Staff A, Registered Nurse (RN), stated that Staff Y, MD, Psychiatrist, had been on vacation and Staff FF, Nurse Practitioner (NP) had been seeing the BHU patients. Staff A stated that the NP interviewed the BHU patients daily using Telemedicine, managed the care of the patients, gave verbal orders and completed progress notes that were submitted to the facility by fax.

4. During a telephone interview on 01/09/14 at 11:25 AM, Staff Y, MD, Psychiatrist, stated that he had collaborative practice agreements with two (NP) that assisted him with seeing patients. Staff Y stated that during his vacation and time off the NP's managed the care of the facilities BHU patients.

5. During an interview on 01/07/14 at 1:10 PM, Staff J, RN, Infection Control Officer (ICO), stated that the Infection Control Program did not have the following policies or procedures:
- Measures for identifying and reporting hospital acquired infections and communicable diseases;
- Measures for assessing and identifying patients, healthcare workers, contract staff or volunteers that are at risk for infections and communicable diseases;
- Methods for obtaining reports of infections and communicable diseases for contract staff and volunteers in a timely manner;
- Measures for the prevention of infections related to intravascular (entry into a blood vessel) devices and tube feedings;
- Methods for monitoring and evaluating practices of housekeeping, liquid and solid waste disposal and separation of clean from dirty;
- A requirement that disinfectants, antiseptics and germicides be used in accordance with the manufacturer's instructions to avoid harming patients, particularly central nervous system effects on children;
-Measures for the screening and evaluation of contract staff and volunteers for communicable diseases and for the evaluation of exposure to patients with non-treated communicable diseases;
- Procedure for working with local, state, and Federal health authorities in emergency preparedness situations;
- Policies and procedures developed in coordination with Federal, state, and local emergency preparedness and health authorities to address communicable disease threats and outbreaks;
- Authority and indications for obtaining microbiological (simple life forms that include bacteria, fungi and viruses) cultures from patients.

6. During an interview on 01/09/14 at approximately 11:45 AM, Staff GG, Registered Dietitian (RD) stated the following:
- That the BHU patients were not provided any nutritional screening to find if any of them had nutritional problems and were at nutritional risk;
- That the Dietary Manager was responsible for performing nutritional screening and she was not allowed to be on the BHU;
- That she (Staff GG) was afraid of the patients on the BHU and because of that fear did not perform nutritional assessment or diet education;
- A previous BHU Director had asked the Dietary Manager and all other Dietary staff to stay off the BHU so, there was no monitoring for safe, sanitary food and ice service on the BHU.
There were no written, approved policies and procedures directing nutritional screening and assessment of patients on the BHU and the existing Dietary department policies and procedure directing safe, sanitary handling of foods and ice were not followed on the BHU.
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on observation, interview, record and policy review, the facility failed to:
-Ensure that written policies were in place throughout the facility that offered health care services for those seeking care;
-Ensure that the pharmacist reviewed all medication orders for appropriateness before the first dose was administered to the patients admitted to the Behavioral Health Unit (BHU);
-Ensure that the Infection Control Program (ICP) had written policies in place to prevent the spread of infections and communicable diseases to patients, health care workers, contracted staff, and volunteers;
-Ensure that the ICP had in place an active Infection Control Committee;
-Ensure that the ICP had an active facility-wide surveillance program for monitoring infection control practices throughout the facility;
-Ensure that the environment where patients received care and services was clean;
-Ensure that the nursing department had policies related to patient care;
-Ensure that patients admitted to the BHU were provided nutritional screenings for nutritional problems;
-Ensure that patients admitted to the BHU who were identified at nutritional risk (after nutritional screening) were provided a nutritional assessment by a licensed, Registered Dietitian (RD);
-Ensure that the BHU maintained access to the facility approved Diet Manual;
-Ensure that the Dietary Manager maintained and implemented policies and procedures for the nutritional assessments, sanitary storage and handling of foods served to patients on the Medical-Surgical Unit, on the BHU, and in the Dietary Department;
-Ensure that the Dietary Manager directed and maintained safe, sanitary patient food service including storage and handling of foods and ice used for patient consumption.
The facility census was 11 with six of those patients in the BHU.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with the Condition of Participation: Provision of Services.
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
Based on interview and policy review, the facility failed to establish and maintain written policies and procedures directing the following:
- The activities of the Infection Control Program (ICP);
- The Nursing Services and
- The Dietary department for nutrition screening of patients on the Behavioral Health Unit (BHU) and nutrition assessment by a licensed Registered Dietitian (RD) on the BHU.
These deficient practices had the potential to place the patients, visitor, volunteers and staff at risk for infection; adversely affect the safety and welfare of patients cared for by nursing staff without consistent direction; and adversely affect the nutritional care of patients on the BHU. The facility census was 11 with six of those on the BHU.

Findings included:

1. During an interview on 01/07/14 at 1:10 PM, Staff J, Registered (RN), Infection Control Officer (ICO) stated that the Infection Control Program did not have the following policies or procedures:
- Measures for identifying and reporting hospital acquired infections and communicable diseases;
- Measures for assessing and identifying patients, healthcare workers, contract staff or volunteers that are at risk for infections and communicable diseases;
- Methods for obtaining reports of infections and communicable diseases for contract staff and volunteers in a timely manner;
-Measures for the screening and evaluation of contract staff and volunteers for communicable diseases and for the evaluation of exposure to patients with non-treated communicable diseases;
- Procedure for working with local, state, and Federal health authorities in emergency preparedness situations;
- Policies and procedures developed in coordination with Federal, state, and local emergency preparedness and health authorities to address communicable disease threats and outbreaks.

During an interview on 01/07/14 at 2:30 PM, Staff J stated that she did not perform hospital-wide surveillance.

During an interview on 01/07/14 at 3:35 PM, Staff J stated that the facility had not had an Infection Control Committee meeting since 2012.

2. During an interview on 01/07/14 at 3:30 PM, Staff D, RN, Chief Nursing Officer (CNO), stated that Nursing Services did not have the following policies and procedures:
- Written policies for the guidance of who could accept a verbal order and situations when verbal orders were acceptable, or the elements required to be included in a verbal order;
- Written policy covering who was authorized to administer medications;
- Written policies regarding the use of overtime and mandatory overtime;
- Written policies for required documentation in the patient's medical record reflecting care planning.

3. During an interview on 01/09/14 at approximately 11:45 AM, Staff GG, Registered Dietitian (RD) stated the following:
- That the BHU patients were not provided any nutritional screening to find if any of them had nutritional problems and were at nutritional risk;
- That the Dietary Manager was responsible for performing nutritional screening and she was not allowed to be on the BHU;
- That she (Staff GG) was afraid of the patients on the BHU and because of that fear did not perform nutritional assessment or diet education;
- A previous BHU Director had asked the Dietary Manager and all other Dietary staff to stay off the BHU so, there was no monitoring for safe, sanitary food and ice service on the BHU.
The facility Dietary department failed to have written policies and procedures directing nutrition, screening, nutrition assessment by the RD and safe, sanitary food and ice service on the BHU.
VIOLATION: NURSING SERVICES - CARE PLANS Tag No: C0298
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to develop comprehensive nursing care plans that addressed all patient needs that included measurable goals, individualized interventions and timetables based upon the history and assessment for two (#4 and #5) of four current patients reviewed. This failure had the potential to deny all patients admitted to the facility care based upon their individual needs. The facility census was 11.
Findings included:

1. Record review of the Nursing Department policies showed no policy for Care Plans.

2. During an interview on 01/09/14 at 10:15 AM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO), stated that the facility did not have a policy for Care Plans.

3. Record review of Patient #4's Admission assessment dated [DATE] showed under the Fall Risk Assessment staff assessed and documented: High Risk Fall Prevention Interventions were implemented, based on a score of greater than 25 (a score of 25 or more staff were to implement Fall Prevention Interventions) obtained using the Fall Assessment and Intervention policy. Fall Risk Score=45. Patient has fallen since admission or within the last three months.

4. Record review of the patient's Active Problems/Plans of Care dated 01/07/14 showed that staff had added Hyperglycemia (high blood sugar) and Nausea/Vomiting as active problems. Staff did not include goals, interventions or timetables for the two listed active problems. Staff did not include in the patient's Active Problems/Plan of Care fall prevention after they had assessed and documented the patient was a high fall risk.
Staff documented in the Admission assessment dated [DATE] that they had implemented and initiated fall prevention and interventions but review of the patient's Active Problems/Plans of Care showed falls had not been included.

5. Record review of Patient #5's medical chart showed she was admitted to the facility on [DATE] with complaints of left hip fracture, left distal femur (thighbone just above the knee) fracture, left clavicle (collarbone) fracture and right great toe fracture due to fall on the ice.

6. Record review of the patient's Admission assessment dated [DATE] showed under the Fall Risk Assessment staff assessed and documented: High Risk Fall Prevention Interventions were implemented, based on a score of greater than 25 obtained using the Fall Assessment and Intervention policy. Fall Risk Score=115. Patient has fallen since admission or within the last three months. There is a secondary diagnosis noted which could increase the risk of fall. Ambulatory aid: Walker. Gait/Transferring: Impaired. Mental Status: forgets limitations.

7. Record review of the patient's Active Problems/Plans of Care dated 01/06/14 showed Staff did not include in the patient's Active Problems/Plan of Care fall prevention after they had assessed and documented the patient was a high fall risk.
Staff documented in the Admission assessment dated [DATE] that they had implemented and initiated fall prevention and interventions but review of the patient's Active Problems/Plans of Care showed falls had not been included.
VIOLATION: RECORDS SYSTEM Tag No: C0307
Based on interview, record review, policy review, and Medical Staff By-Laws, the facility failed to ensure all physicians' orders were dated and signed for two patients (#5 and #8) of two current patients reviewed and for two patients (#7 and #14) of two discharged patients reviewed. This had the potential to affect the safety of all patients seen by facility physicians'. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Physician Orders" reviewed 03/13, showed that all verbal or phone orders must be signed by the physician within 48 hours.

Record review of the facility's policy titled, "Physician Requirements for Acute Care Medical Records" revised 11/19/13 showed direction for physicians to sign and date orders and for ordering providers to sign and date telephone or verbal orders within 48 hours after the order was given.

2. Record review of the facility's Medical Staff By-Laws, By-Laws Amendment, Article XI Subparagraphs C and D dated 04/15/09, showed the following:
- C. All orders for treatment shall be directed by a Medical Staff member as set forth in these by-laws, written, dated, timed, and signed by the physician or other practitioner to direct patient care and shall be accompanied by a provisional diagnosis or given verbally.
- D. Verbal orders and telephone orders shall be signed by the person accepting the order with the physician's name and his/her name, date and time. The physician must acknowledge this order by signing, dating and timing the order at the time of his/her next visit or in case of patient discharge within 30 days of discharge.

3. Record review of Patient #5's Active Pharmacy Orders dated 01/05/14 showed the physician had not dated or signed the order for Lovenox (medication used to prevent blood clots) as of 01/08/14 at 11:05 AM.

4. During an interview on 01/08/14 at 11:05 AM, Staff P, Registered Nurse (RN), stated that she had taken the verbal order for Lovenox from the patient's physician.

5. Record review of Patient #8's medical record on 01/09/14 showed:
- Admission Order Set as telephone orders, dated 01/06/14 at 11:29 PM, with an order to continue current medications (see MRO,[medication reconciliation orders]);
- Medication Reconciliation Physician Orders as a telephone order, dated 01/07/14 at 12:15 AM, for five medications that had the potential for negative side effects and interactions including antidepressants, antipsychotic drugs (psychiatric medications primarily used to manage psychosis, which are delusions, hallucinations, or disordered thought), and drugs used to reduce the side effects of antipsychotic treatment.
- Three additional telephone orders received 01/07/14 for changes to the
above orders.
The physician did not date or co-sign the telephone orders for Patient #8.

6. Record review of discharged Patient #7's Physicians Orders showed from 07/27/13 through 08/01/13 the physician had not dated or signed one verbal order and four telephone orders as of 01/09/14.

7. Record review of discharged Patient #14's Physicians Orders showed from 09/17/13 through 09/25/13 the physician had not dated or signed one verbal order and seven telephone orders as of 01/09/14.
VIOLATION: QA - MEDS & INFECTIONS Tag No: C0338
Based on interview and policy review, the facility failed to ensure staff utilized a methodology to evaluate Hospital Acquired Infections (HAI).
This failure had the potential to affect all patients, staff, volunteers and visitors to infections and communicable diseases that came to the facility.
The facility census was 11.

Findings included:

1. During an interview on 01/07/14 at 1:10 PM, Staff J, Registered Nurse (RN), Infection Control Officer (ICO), stated that the Infection Control Program did not have the following policies or procedures:
- Measures for identifying and reporting hospital acquired infections and communicable diseases;
- Measures for assessing and identifying patients, healthcare workers, contract staff or volunteers that are at risk for infections and communicable diseases;
- Methods for obtaining reports of infections and communicable diseases for contract staff and volunteers in a timely manner;
- Measures for the prevention of infections related to intravascular (entry into a blood vessel) devices and tube feedings;
- Authority and indications for obtaining microbiological (simple life forms that include bacteria, fungi and viruses) cultures from patients.

During an interview on 01/07/14 at 2:30 PM, Staff J stated that she did not perform hospital-wide surveillance. Staff J stated that she did not do surveillance or make rounds in the dietary department to include monitoring food sanitation. Staff J stated that she did not do surveillance or monitor housekeeping staff to ensure they followed infection control during cleaning patient care areas or to see if staff followed infection control policies and procedures.

During an interview on 01/07/14 at 3:00 PM, Staff J stated that the facility did not have a policy giving her the authority and indication to obtain microbiological cultures from patients.

During an interview on 01/07/14 at 3:40 PM, Staff J stated that she did not maintain a log of all incidents related to infections and communicable diseases for facility staff, contracted staff or volunteers.

During an interview on 01/07/14 at 3:35 PM, Staff J stated that the facility had not had an Infection Control Committee meeting since 2012.