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.

MEDICAL BEHAVIORAL HOSPITAL - MISHAWAKA 1625 EAST JEFFERSON BLVD MISHAWAKA, IN Dec. 17, 2015
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review and interview, the facility failed to implement written policies and procedures related to ongoing assessment of competence for prevention of patient abuse/neglect for 2 of 7 (P2 and P7) personnel files reviewed; and misappropriation of resident property for 3 of 10 (#3, 6 and 10) patient medical records reviewed.

Findings:
1. Review of policy titled, Staff Competencies, revised/reapproved 10/14, confirmed in order to provide quality patient care, all members of the hospital shall be competent to fulfill their assigned responsibilities...all staff are required to have education annually...at the conclusion of the probationary period, competence of the employee is assessed by the department Director and/or Supervisor with input from employees who have participated in the training process as appropriate.
2. Review of personnel files on 12/17/15 at approximately 1559 hours confirmed staff P2 (Registered Nurse) and P7 (Certified Nursing Assistant) lacked annual training related to prevention of patient abuse/neglect.
3. In interview, on 12/17/15 at approximately 1745 hours, staff P13 (Human Resource Director), confirmed abuse/neglect training is lacking for personnel P2 and P7 and policy/procedure states employees will have their competencies completed by the end of their 90 day probationary period. P2 was hired 5/15/15 and P7 was hired 4/7/15.

4. Review of policy titled, Patient Valuables, revised/reapproved 10/14, confirmed patient belongings will be recorded on the patient belonging inventory list on admission and that all belongings documented on admission were documented as being returned to the patient upon discharge.

5. Review of patient medical records on 12/16/15 at approximately 1315 hours and 12/17/15 at approximately 1008 hourse, confirmed:
A. patient 3's Patient Belongings Inventory list dated 12/9/15 documented glasses, red/white/blue hat, and dark blue/dark green pajama pants on admission and were not documented as being returned to patient upon discharge.
B. patient 6's Patient Belongings Inventory list dated 12/5/15 documented glasses, 2 shirts, 2 pair jeans, pajama pants and a jacket on admission and were not documented as being returned to patient upon discharge.
C. patient 10's Patient Belongings Inventory list dated 12/5/15 documented full dentures on admission and were not documented as being returned to patient upon discharge.

6. In interview, on 12/16/15 at approximately 1620 hours and 12/17/15 at approximately 1728 hours, staff P9 (Interim Director of Nursing), confirmed:
A. patient belongings are gone through with the patient on admission. They have locked closets in their room to place their belongings in and they are locked to keep other patients out. The Certified Nursing Assistants lock up the closets and open them when patients request an item or when a patient needs a change of clothes. Any valuable belongings are stored in our locked safe located in the reception area. The belonging list is two parts and belongings are documented on admission and checked on discharge so belongings can be sent with the patient.
B. patient 10's Patient Belongings Inventory list dated 11/5/15, lists full dentures on admission, but that section is blank on discharge. Protocol is for staff to document on this list that the items documented on admission were returned to the patient on discharge. This is lacking for this patient.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on document review and interview, the facility failed to ensure all drugs and biologicals are administered in accordance with policy and procedure for 1 of 10 (#9) patient medical records reviewed.

Findings:
1. Review of policy titled, General Medication Administration, revised/reapproved 10/14, confirmed the medication nurse will check for medication allergies prior to administration of all medications. Also, all medication errors occurring during administration will be reported immediately to the attending physician. A medication variance report will be sent to the Director of Nursing and Pharmacy Services by the end of the shift in which the error occurred.

2. Review of patient #9's medical record on 12/16/15 at approximately 1315 hours and 12/17/15 at approximately 1008 hours, confirmed an allergy to Zoloft on admission on 10/29/15. Physician orders dated 11/18/15 at 1546 hours state to start Zoloft 50 mg by mouth daily for depression. Medication Administration Record confirmed Zoloft 50 mg by mouth was given daily at 0900 hours on 11/18/15 through 11/25/15. Physician orders on 11/25/15 state to stop Zoloft due to history of allergy.

3. In interview on 12/16/15 at approximately 1553 hours and 12/17/15 at approximately 1531 hours, staff P3 (Assistant Director of Nursing) confirmed patient 9 was documented as having an allergy to Zoloft, but it was prescribed to patient on 11/18/15 and stopped on 11/25/15. Patient did get several doses according to their Medication Administration Record during this time. A medication variance report was not completed and the attending physician was not notified as required per facility policy and procedure.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the facility failed to ensure that policies & procedures were followed for cleaning regarding the refrigerator and microwave for 1 of 1 (Inpatient Care Unit 200 Kitchenette) area toured.

Findings:
1. While on tour on 12/17/15 at approximately 1714 hours, accompanied by staff P9 (Interim Director of Nursing), the following was observed in the Inpatient Care Unit 200 Kitchenette:
A. the refrigerator had cracks in the gasket around the main door and was soiled inside the door shelves. The freezer door shelf was also soiled;
B. the microwave was soiled and had food particles stuck inside.

2. Review of policy titled, Refrigerator, revised/reapproved 10/15, confirmed weekly cleaning of the refrigerator includes: scrubbing shelving with sanitizing solution and washing walls with sanitizing solution and a clean cloth.

3. Review of policy titled, Microwave Oven, revised/reapproved 10/15, confirmed the microwave oven is to be cleaned by wiping down the inside of the microwave and paying special attention to inside of oven door to provide adequate seal to prevent microwave leakage.

4. In interview on 12/16/15 at approximately 1620 hours and 12/17/15 at approximately 1728 hours, staff P9 (Interim Director of Nursing), confirmed the refrigerator in the Inpatient Care Unit 200 Kitchenette had cracks in the gasket around the main door and was obviously soiled inside the door shelves. The freezer door shelf was also soiled. The microwave was soiled and had food particles stuck inside. Dietary staff is responsible for cleaning this refrigerator and microwave weekly.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review and interview, the infection control officer failed to develop a system for controlling infections and communicable diseases related to tuberculosis (TB) testing for 1 of 7 (P5) personnel files reviewed.

Findings:

1. Review of policy titled, Tuberculosis (TB) Screening & Plan, revised/reapproved 10/15, confirmed this policy follows the National Tuberculosis Indicators - 2013 State Comparison - Centers for Disease Control (CDC), Division of Tuberculosis Elimination as a reference. In this reference, the website for the CDC TB at www.cdc.gov/tb states under the Testing & Diagnosis link, "A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm. The health care worker will look for a raised, hard area or swelling, and if present, measure its size using a ruler."

2. Review of personnel files on 12/17/15 at approximately 1559 hours confirmed staff P5 (Certified Nursing Assistant) had their annual PPD (purified protein derivative) tuberculin test administered on 10/6/15 at 1150 hours and read on 10/8/15 at 1015 hours, which is prior to 48 hours and not within the 48-72 hour window for interpreting the test.

3. In interview, on 12/17/15 at approximately 1419 hours, staff P11 (Licensed Practical Nurse), confirmed tuberculosis testing is provided to employees free of charge. Policy and procedure for annual PPD testing was not followed for the above-mentioned employee.
VIOLATION: DELIVERY OF SERVICES Tag No: A1134
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to ensure the provision of care related to physical therapy was in accordance with policy and procedure for 1 of 10 (#10) patient medical records reviewed.

Findings:
1. Review of policy titled, Patient Scheduling, revised/reapproved 10/14, confirmed patient therapy shall be coordinated with consideration to patient needs and wishes as well as needs of the multidisciplinary care team and a schedule will be provided at an agreed upon time, date, and location. The scheduling of patient therapy treatment times shall be communicated to nursing staff.

2. Review of patient medical records on 12/16/15 at approximately 1315 hours and 12/17/15 at approximately 1008 hours, confirmed patient 10 had a physical therapy evaluation ordered on [DATE], and a physician order dated 11/19/15 at 1200 hours confirmed physical therapy was to be done two times per week for two weeks. The evaluation was not done until 11/19/15 and no other physical therapy was done prior to discharge on 11/24/15. There was also lack of documentation of communication of a schedule of patient therapy treatment times to nursing staff.

3. In interview on 12/16/15 at approximately 1553 hours and 12/17/15 at approximately 1531 hours, staff P3 (Assistant Director of Nursing) confirmed physical therapy for patients is not scheduled; and according to policy and procedure the dates, times, and locations of physical therapy are to be communicated to nursing staff. This was not done for patient 10.