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.

WESTWOOD PEMBROKE HEALTH SYSTEMS 45 CLAPBOARDTREE STREET WESTWOOD, MA 02090 Sept. 13, 2017
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on documentation, interview and review of personnel files, the Hospital failed to ensure food service personnel have completed sufficient training in food sanitation and safety. Findings include:

1. Review of food service employee personnel files at the Campus P, indicated that not all dietary employees have completed a training in food safety and sanitation sufficient to meet the standards of their job responsibilities.

During interview, on 8/30/17 at 1:50 P.M., the Director of Food Service said that he does not provide formal food service personnel with training; any training is verbal and he does not maintain records of verbal training. Although review of personnel files for dietary staff indicated a general Hospital competency checklist was completed the Director of Food Service had no documented records of in-service training specific for food safety training or prevention of food borne illness in food preparation.

2. According to interview with Dietary Staff #2 on 8/29/17, on weekends there are two dietary staff employees scheduled to work. This information was confirmed through work schedules and with the Director of Food Service. Further interview with Dietary Staff #2 said that food safety in-service training is not routinely provided and can not recall any in-service on hand washing.

3. Review of the dietary department work schedule for 8/20/17 to 8/26/17, indicated that on weekend days when only two employees are scheduled to work the entire day, neither employee (#3, #4, #5 and #6) had completed a course or had evidence of being provided with department operation policies and procedures for food safety and sanitation.

On 8/20/17 and 8/27/17, Dietary Staff #3 and #6, were the only dietary employees scheduled to work and be responsible for the food production, food safety and sanitation of the department. On 8/26/17, Dietary Staff #4 and #5, were the only Dietary Staff scheduled to work and be responsible for the food production, food safety and sanitation of the department.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on record review, the hospital failed to account for missing controlled substances for 1 out of 1 drug diversion reports and failed to follow reporting procedures.

Findings include:

The hospital policy titled Controlled Substance Management page 2 of 2 bullet point 5. reads "Complete DEA form 106 "Report of Theft or Loss of Controlled Substances" if the investigation requires it." This procedure was not followed.

The investigative report (untitled), dated 06/10/17, indicated tampering of Oxycodone 15mg packaging in the E2 medication room. Per the report, "2 out of the 6 tab packages had previously been opened and the pills were not in the packaging as previously indicated. The packaging had been resealed with what appears to be tape rolled, creating a double sided adhesive surface, which held the packaging together." In response, a hospital wide narcotic count was conducted in all units, as well as education to all nursing staff. There is no indication in the investigative report of a Drug Enforcement Administration (DEA) 106 form (Report of Theft or Loss of Controlled Substances) being completed.

The Surveyor interviewed the Director of Nursing and the Pharmacy Director via telephone on 9/12/17 at 2:30 PM. The Director of Nursing and Pharmacy Director said that a DEA 106 form was not completed.
VIOLATION: THERAPEUTIC DIETS Tag No: A0629
Based on observation, interview and documentation review, the Campus L failed to address menu planning. Findings include:

On 8/29/17 at 9:30 A.M., the posted menu in the food service department indicated the Week 2 menu was approved by the Dietitian on 10/29/15.

The Surveyor requested a copy of the day's menu. The DFS gave the Surveyor a separate menu for breakfast. The daily breakfast menu listed 3 rotating food items for each breakfast that included a hot cereal, a high protein food and a carbohydrate. The breakfast menu did not indicate any beverages including milk and did not indicate serving sizes.

The DFS indicated that milk and a variety of juices are available and patients choose their beverage at meal time according to their preferences.

The Lunch and Dinner menu were printed on the patient lunch and dinner selections sheets. These sheets did not indicate any beverages, any desserts and did not indicate serving sizes. The DFS indicated patients have their choice of beverage at meal time including milk.

The DFS said that the menu printed on the orange paper indicates a special diet and/or food allergies. The special menus were identical to the house menus printed on the white menu selections page. The DFS indicated that the food service staff write on the orange menu selection page any food allergies and special diets.

The DFS further said that the kitchen does not have planned written menus with serving amounts listed. In addition, the DFS said that the kitchen does not have planned menus for therapeutic and texture modified diets for staff to follow when serving a therapeutic diet.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, staff interview and review of documentation, the Hospital failed to have an effective governing body (GB) that was legally responsible for the conduct of the Hospital. Findings include:

1. The Hospital's GB failed to ensure all patients received care in a safe setting as evidenced by:

(a) failing to ensure that after an allegation of sexual assault the alleged victim (#1), as well as other patients on the unit, were protected from the alleged perpetrator (Patient #2) for more than 45 minutes;
(b) failing to provide an environment that was free of environmental hazards and ligature risks, which were previously identified in a survey during 5/2017, and were to be remediated no later than 8/20/17, per the Hospital's plan of correction;
(c) failing to properly disinfect glucometers (a metered device used to obtain capillary blood glucose levels by obtaining a blood sample from the patient) according to the manufacturer's guidelines. The Hospital was currently using the glucometer for multiple patients, including sampled Patient #27;
(d) The Hospital failed to have the necessary emergency equipment (suction machines) in the event of a medical emergency for 6 of 6 patient care units at Campus P, in accordance with Hospital policies for care and treatment of patients on seizure precautions.

See A-0115 Patient Rights

2. The Hospital's GB failed to ensure the Nursing Service provided quality of nursing care for nursing care as evidenced by;

(a) The nursing service failed to reconcile medications for Patient #15 on admission and the patient did not receive insulin for approximately 3 days, placing the patient at risk for life threatening unstable blood sugar conditions.
(b) The nursing service failed to ensure a comprehensive reconciliation of medications was performed for new admissions by nursing or medical staff and for at least one sampled patient (#11), who was not provided with seizure medication despite a diagnosis of seizure disorder. The patient later had a grand mal seizure, fell , suffered a head injury and was hospitalized in the intensive care unit and placed on a ventilator.
(c) The nursing services failed to provide all patients on seizure precautions, or who were at risk of seizures, with access to a suction machine to manage airway protection during a seizure in accordance with hospital policy, which placed patients at risk for immediate threat to health and safety.
(d) The nursing service failed to provide basic safe medication administration in accordance with national standards of practice.

See A-0385 Nursing Services


3. The Hospital's GB failed to ensure that the food and dietetic services were organized, directed and staffed in such a manner to ensure that the nutritional needs of the patients are met in accordance with practitioners' orders and acceptable standards of practice.

See A-0618

4. The Hospital's GB failed to maintain a safe environment at Campuses L and P to ensure safety for all patients and failed to fix previously identified ligature risk points at campus L in accordance with a plan of correction with a correction date of 8/20/17.

See A-0700

5. The Hospital's GB failed to provide an active program for the prevention, control and investigation of infections and communicable diseases. The Hospital's GB failed to ensure staff were knowledgeable and practiced proper disinfection of a shared point of care glucometer (blood glucose testing device) between patients, placing patients at immediate risk for health and safety for contracting potential blood born diseases such as hepatitis B and C and HIV (Human Immunodeficiency Virus).

See A-0747 and A- 0749.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Immediate Jeopardy

Based on observations, record review, review of Hospital security videos and staff interview, the Hospital failed to ensure all patients received care in a safe setting. Findings include:

1. The Hospital failed to ensure that after an allegation of sexual assault the alleged victim, as well as other patients on the unit, were protected from the alleged perpetrator for more than 45 minutes.

Review of the Hospital policy and procedure Subject: Sexual Misconduct/Allegations (#RI.061) dated as reviewed 11/2016 included the following:
a. The parties involved shall be separated and the patients' precautions shall be evaluated/reevaluated and if deemed appropriate shall be initiated and/or adjusted. In the case of an alleged sexual assault, the following additional steps shall occur:
b. The alleged perpetrator will be placed on special precautions as deemed appropriate by the physician.

The Hospital reported an allegation of a sexual assault occurred on 8/23/17 on the adult unit between Patient #1 and Patient #2.

Patient #1 clinical record review indicated he/she was on 15 minute checks.

Patient #2 clinical record review indicated he/she was on 5 minute checks because he/she was newly admitted the previous evening.

Surveyors review of the Hospital security video on 8/29/17 at 8:00 A.M., with the Hospital Risk Manager (RM) and Chief Nursing Executive (CNE) indicated the following:

a. On 8/23/2017, at 15:39:09, Patient #1 observed to be his/her room by the Mental Health Technician (MHT #4).
b. At 15:39:59, Patient #2 was observed by MHT #4 pacing the length of the unit hallway.
c. MHT #4 appeared to be looking for Patient #2 in the unit hallway then enters Patient #2's room at 15:46:11.
d. At 15:52:45, MHT #4 entered Patient #1's room and also had a unit nurse come into the Patient #1's room (per staff and record review Patient #2 was found behind the inside of Patient #1's door naked).

Review of a late entry nurses note dated 8/24/17, 7:15 A.M., indicated that at approximately 4:00 P.M., on 8/23/17 MHT #4 who was on checks, asked the nurse to check Patient #1's room, the nurse entered the room and found Patient #2 hiding behind the door naked. The record indicated Patient #2 was asked to dress and leave the room. The nurse note indicated Patient #1 said "he/she was sexually assaulted".

Further review of the security tape indicated:

a. At 15:54:15 Patient #2 exited Patient #1's room.
b. At 15:54:59 Patient #2 walked to Patient #1's room doorway.
c. At 15:57:45 Patient #2 walked up to Patient #1's room and stood across from the doorway as Patient #1 exited the room (accompanied by a nurse) and came face to face with Patient #2.

Review of Patient #2's clinical record indicated a Physicians order at 4:45 P.M., to discontinue the 5 minute checks and to place the patient on 1:1 observation.

The Patient #2 continued to walk the unit freely for more than 45 minutes and returned to the alleged victim's room (doorway) twice within 5 minutes after the alleged sexual assault was reported to staff.

During an interview with the Hospital Risk Manager on 8/30/17 at 2:00 P.M., she said that once the allegation is made both patients should be supervised until events are sorted out, each patient should have a staff member assigned to monitor them 1:1. She further said that the patients should absolutely be kept separate and that Patient #1 and #2 were not kept separate. The security video did show that checks were done appropriately before the incident; however, it did not show that a staff member was assigned to each patient after the allegation.

Patient #2 had physical access to the alleged victim after the alleged allegation of sexual assault although Patient #1 was accompanied by staff, this could cause potential intimidation of the alleged victim and psychological trauma.

2. The Hospital failed to provide an environment that was free of environmental hazards and ligature risks, which were previously identified in a survey on 5/2017 and were to be remediated no later than 8/20/2017, per the Hospital's plan of correction. For example:

a. Seclusion room doors on all units at Campus P swung into the room which posed a risk as patients could barricade themselves in the room.

b. Four of four patient bathrooms in South One wing at Campus P had toilets with exposed long toilet flush handles protruding 3 inches out of an opened access area from the plastic valve cover unit behind the toilet. The opened accessed area could allow patients to reach inside thus creating a ligature risk. A closure door approximately half-way onto the unit with a closure arm at the top, represented a ligature hazard. One black plastic trash bag was draped over a plastic waste basket in the Group Room that could easily be removed and create a potential ligature hazard and ingestion hazard for choking.

c. During a tour of unit West 1 at Campus P, at 9:45 A.M. on 8/28/17, the Surveyors observed the that four of four patient bathrooms had toilets with exposed long toilet flush handles protruding 3 inches out of an opened access area from the plastic valve cover unit behind the toilet. The opened accessed area could allow patients to reach inside thus creating a ligature risk.

d. During a tour of West 2 and South One on 08/29/17 at Campus P, the Patient Complaint boards were observed to consist of metal bins to hold forms, metal mailboxes, and sign plates secured to an approximate half-inch plywood board with Phillips head screws. The access door on the metal mailbox on West 2 was observed to be loose on 08/29/17 and the Surveyor was able to get her fingertips into opening, which consisted of sharp metal edges.

e. The access door on the metal mailbox on South 1 at Campus P was observed to be loose on 08/30/17 and the Surveyor was able to get her fingertips into opening, which consisted of sharp metal edges. During the tour, the Clinical Services Director said the mailbox access door on South 1 was normally loose. These metal edges posed cutting hazards to self injurious patients.

f. On East 2 unit at Campus P, an exposed, uncovered sprinkler head in the ceiling of the Seclusion room thus creating a ligature risk.

g. During a tour of the Adolescent Unit at Campus L, the fire doors in the hallway were equipped with closure devices featuring exposed hinge arms while the doors were in the open position. The open position is the normal position. The exposed hinge arms protruded approximately one foot from the face of the doors, which created an unnecessary ligature hazard.

h. During a tour of West 1 and West 2 units at Campus P from 9:50 A.M. to 10:10 A.M. on 8/28/17, the Surveyor observed black plastic trash bags draped over plastic waste basket in the Group Rooms that could easily be removed, create potential ligature or suffocation hazards and/or ingestion hazards for choking.

g. On the Adolescent Unit at Campus L, on the night of 8/26/17, approximately 5 patients from the adolescent unit attacked each other, staff and local police which had been summoned by staff to control the patient behavior, on the unit. Patients accessed drop ceiling tiles and used them to attack staff and each other. Patient interview indicated that patients removed tiles from the ceiling in the hallway and hit staff and police on the head with the tiles. Two patients interviews indicates that the patients said that they personally have removed ceiling tiles from the adolescent unit in the past and staff were aware. One patient said she/he has grabbed the exposed ceiling wires under the ceiling tiles and staff have had to intervene.

See A-0700.

3. Hospital failed to have knowledge staff in the practice proper disinfection of a point of care glucometer (blood glucose testing device) shared between patients, placing all patients who require fingerstick blood testing at immediate risk for health and safety for contracting potential blood borne diseases such as hepatitis B and C and HIV (Human Immunodeficiency Virus).

a. For Patient #27, the Hospital failed to ensure proper infection control practices were maintained during a finger stick blood sugar procedure in order to prevent transmission of blood borne pathogens between patients.

Review of the Manufacturer's Directions for Use (MDFU), not dated, indicated that the meter should be cleaned and disinfected between patients.

Review of the Hospital's policy entitled, Glucometer Use and Glucometer Quality Control, reviewed 11/2016, included the procedure for obtaining a blood glucose levels, glucometer quality control and training of licensed personnel. The policy did not include cleaning and disinfection of the glucometer.

During observation of a finger stick blood sugar test at Campus L, on Unit A-1, on 8/29/17 at 11:00 A.M., Nurse #12 was observed using a blood glucose meter that is used for multiple residents, without using the appropriate disinfecting procedure, per the MDFU for cleaning and disinfecting blood glucose meters.

Nurse #12 was observed preparing to obtain a finger stick blood sugar reading for Patient #27. Nurse #12 took the blood glucose meter out of a black pouch, performed hand hygiene and applied gloves. She placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test. After obtaining this patient's blood sugar, Nurse #12 disposed of the contaminated lancet, removed her gloves and performed hand hygiene. Without disinfecting the blood glucose meter, Nurse #12 placed the meter back into the black pouch and said she was done with this procedure.

b. The Hospital failed to properly disinfect the glucometer (a device used to obtain capillary blood glucose levels by obtaining a blood sample from the patient) according to the manufacturer's guidelines. The Hospital was currently using the glucometer for multiple patients, including sampled Patient #27.

The Hospital was using the Clarity Blood Glucose 1000 glucometer to obtain finger stick blood sugars on all patients requiring testing of glucose at the Hospital.

On 8/28/17 at 10:30 A.M., two Surveyors observed a glucometer and alcohol pads in a cart in the medication room on the W-1 patient care unit. RN #7 was questioned regarding the cleaning of the glucometer and she said that she cleans the glucometer with an alcohol wipe after each patient use. At 10:44 A.M., RN # 9 said that she uses an alcohol wipe to clean the glucometer after each blood sugar testing on the patient.

The Hospital had approximately 8 to 10 patients who required Finger Stick Blood Sugar testing.

Review of the manufacturers directions for use (MDFU) indicated the following for Disinfection Instructions:

The glucometer must be cleaned and disinfected between patient uses by wiping it with a CaviWipes (a disinfecting wipe) in between tests. After cleaning the glucometer with a CaviWipe Towelette, use a second CaviWipe Towelette to thoroughly wet the precleaned glucometer surface. Allow it to remain wet for two minutes as specified by the CaviWipe manufacturer of the disinfectant wipes and allow to air dry. CAUTION: Do not use other cleaners or disinfectants because they may damage the glucometer.

Review of the current policy for disinfecting the glucometer did not specify how the glucometer was to be disinfected between patient use. The Hospital Staff Educator (SE) said that she does not have it written within the policy but just tells the nurses to use alcohol wipes.

Using a disinfectant other than what is specified by the manufacturer does not guarantee the monitor is properly disinfected against all bloodborne pathogens that can transmit infections.

c. For Patient #27, the located at Campus L, staff failed to ensure proper infection control practices were maintained during a finger stick blood sugar procedure.

Review of the Manufacturer's Directions for Use (MDFU), undated, indicated that the meter should be cleaned and disinfected between patients.

Review of the Hospital's policy entitled, Glucometer Use and Glucometer Quality Control, reviewed 11/2016, included the procedure for obtaining a blood glucose levels, glucometer quality control and training of licensed personnel. The policy did not include cleaning and disinfection of the glucometer.

During observation of a finger stick blood sugar test at Campus L, on Unit A-1, on 8/29/17 at 11:00 A.M., Nurse #12 was observed using a blood glucose meter that is used for multiple residents, without using the appropriate disinfecting procedure, per the MDFU for cleaning and disinfecting blood glucose meters.

Nurse #12 was observed preparing to obtain a finger stick blood sugar reading for Patient #27. The nurse took the blood glucose meter out of a black pouch, performed hand hygiene and applied gloves. She placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test. After obtaining this patient's blood sugar, Nurse #12 disposed of the contaminated lancet, removed her gloves and performed hand hygiene. Without disinfecting the blood glucose meter, Nurse #12 placed the meter back into the black pouch and said she was done with this procedure.

During interview on 8/29/17 at 11:05 A.M., the Surveyor asked Nurse #12 if there was a process for disinfecting the blood glucose meter. Nurse #12 said yes there is, but she forgot to do it.

During review of Nurse #12's personnel record indicated that Nurse #12 completed a competency for glucometer testing on 9/28/16. The competency did not include disinfection of the blood glucose meter. Further review indicated that Nurse #12 attended a skills fair on 8/1/17, and the cover sheet labeled "Re-Education Checklist" line listed various clinical competencies which included Glucometer Competency/Epipen competency. There was a line drawn through this competency and N/A (not applicable) listed next to it.


See A-0747

4. The Hospital failed to have the necessary emergency equipment (suction machines) in the event of a medical emergency for 6 of 6 patient care units at the Campus P, in accordance with Hospital policies for care and treatment of patients on seizure precautions.

The seizure precaution policy and procedure, last reviewed on 11/2016, required that availability of suction apparatus for any patients on seizure precautions.

The Surveyor observed during a tour the emergency equipment available on the West 2 Unit, South 2 Unit, East 2 Unit, East 1 Unit at 9:20 A.M. and 9:45 A.M. on 8/29/17, and no suction machine was observed available on the units.

The Surveyor interviewed Registered Nurse (RN) #2 at 9:20 A.M. on 8/29/17. RN #2 said that the Hospital no longer had suction machines on the units and the nurses did not have any access to a suction machine.

The Surveyor interviewed RN #15 at 9:30 A.M. on 8/29/17. RN #15 said the suction machine was kept in the medication room on South 2. The Surveyor asked RN #15 to locate the suction machine in the medication room. RN #15 looked in the medication room for the suction equipment and said that they did not have a suction machine.

The Surveyor interviewed RN #16 and RN #17 together at 9:33 A.M. on 8/29/17. RN #16 and RN #17 both said that the units did not have suction machines.

The Surveyor interviewed RN #18 and RN #19 together during a tour of East 1 Unit, at 9:35 A.M. on 8/29/17. RN #18 and RN #19 both said the suction machine was in the medication room.

The Surveyor also observed during the tour of East 1 RN #18 and RN #19 enter the medication room to locate the equipment. RN #18 and RN #19 exited the medication room and told the Surveyor, "we don't have one" or words to that effect.

The Surveyor interviewed RN #14 of West I unit at 9:50 A.M. on 8/29/17. RN #14 said there was no suction machine on the unit.

See A-0385
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the Hospital failed to have one patient's legal guardian (Patient #3) make informed decisions regarding the patient's care to include being involved in the patient's care planning and treatment decisions and being able to refuse treatment offered, in a total sample of 29. Findings include:

Patient #3 was admitted from an emergency room with a diagnosis of schizophrenia, intellectual disability, functioning at a 5th grade level and behavioral disorder. The patient had been living independently in the community but had developed difficulty related to behaviors.

Record review indicated the patient's mother had been appointed permanent legal guardian in 2006.

Record review indicated on admission in January 2017, the Hospital had the patient, who was not competent, sign the admission agreement and permission to release medical records to various interested parties. The admission data listed the patient's mother as the responsible party and legal guardian yet staff had the patient sign consents.

Record review also indicated the patient was placed on several antipsychotic medications for behaviors such as hitting and being aggressive to staff and others. Review of the record did not indicate any contact with the legal guardian before institution of psychoactive medications.

Review of the weekly treatment plan indicated, under family involvement or legal guardian, that no one was contacted for involvement because patient was "refusing contact."

On 5/23/17, the Hospital obtained a Roger's Guardianship from the Courts for the administration of antipsychotic medications. Under the Rogers Guardianship, the court approved for use in the treatment of Patient #3, the following antipsychotic medications: Zyprexa, Trilafon, Haldol, Clozaril, Thorazine and Depakote as an adjunctive therapy for mood disorder.

After 5/23/17, the Hospital continued to treat Patient #3 with antipsychotic medications not approved by the Roger's Guardianship to include: Seroquel and Abilify, violating the court ordered treatment plan and the patient's protections under the Roger's Guardianship.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and observation, the Hospital failed to ensure the safety of 7 of 7 patients (Patient #2, Patient #5, and Non-Sampled Patients #1, 2, 3, 4 and 5) and to protect against hazards on the Adolescent Unit.

During this complaint survey, held between 8/28/17 to 8/30/17, it was determined that the Hospital did not implement its written plan of correction for survey event ID: HQLT11, cite A 144, held between 5/24/17 to 5/25/17, with a completion date of 8/20/17. The Hospital failed to replace the hinge closure arms on the hallway fire doors, located on the Adolescent Unit.

See A 701 for cross reference.

Findings include:

1. The Surveyor reviewed the admission notes for Patient #2, Patient #5, Non-Sampled Patient #1 and #2. The admission notes indicated that each of these patients were at significant risk for harming themselves or others.

The Surveyor observed Campus L's Adolescent Unit between 9:35 A.M. and 9:55 A.M. on 8/29/17. The hallway fire doors (2) were equipped with hinge type closures that protruded approximately one foot from the face of the doors while the doors were in the open position. The doors were normally kept open, and the closure arms faced away from the nursing and medication stations. These factors created an unnecessary ligature risk hazard.

The Surveyor interviewed the Administrator at 2:02 P.M. on 8/29/17. The Administrator said the Hospital had a purchase order, dated 8/29/17, for replacement fire doors for the Adolescent Unit, and a scheduled installation completion date of 9/15/17. The Administrator said the new fire doors had a safe closure device, which did not pose a ligature hazard.

2. The drop (suspended) ceiling tiles (measuring 2 x 2 feet) on the Campus L Adolescent Unit were easily removed by patients and posed a safety hazard.

The Surveyor interviewed Patient #21 and Patient #24, at 10:45 A.M. and 11:20 A.M. (respectively), on 8/30/17. Patient #21 and Patient #24 said there was an incident during the night of 8/26/17, during which approximately 5 patients from the Adolescent Unit attacked each other, staff and local police on the Unit. Patient #21 and Patient #24 said that one of the means of assaulting staff and police were the drop ceiling tiles, which the patients were able to remove because of the low ceiling height. Patient #21 and Patient #24 said that patients hit staff and police on their heads with the tiles. Patient #21 and Patient #24 said that they personally have removed ceiling tiles in the past and staff were aware of these incidents. Patient #21 said she has grabbed exposed wires located under the ceiling tiles.

The Surveyor interviewed the Administrator at 2:00 P.M. on 8/30/17. The Administrator said he interviewed nursing staff who were present during the 8/26/17 incident on the Adolescent Unit and he reviewed video taken from the cameras on the Unit. The Administrator said that the patients had knocked the ceiling tiles loose and that a smoke alarm and speaker grate fell to the floor. The Administrator said there was a plan in place to secure the ceiling tiles, but that it had not yet been implemented.

The Surveyor observed the video taken on the Adolescent Unit, dated 8/26/17, between approximately 10:40 P.M. and 12:00 A.M. (8/27/17). The video showed patients jumping and pushing ceiling tiles loose, and some of the tiles fell to the floor. The video showed patients walking up and down the hallway with ceiling tiles in their hands and staff trying to get the tiles back from patients.

Review of an inventory list of damaged items from the incident, provided by the Hospital, dated 8/31/17, indicated there were 10 damaged ceiling tiles, a damaged open grate speaker, and four light fixtures pushed up into the ceiling.

3. Review of a police report, observation of video and interviews with patients and staff, indicated that a significant incident on the Adolescent Unit occurred on 8/26/17, during which Hospital staff did not manage patient behaviors which led to patient-to-patient assaults and the hospitalization of 4 patients.

Review of the police report, dated 8/26/17, indicated police responded to a "riot" at Campus L's Adolescent Unit at approximately 11:00 P.M. The report indicated when police entered the Unit there was screaming and yelling, the floor was filled with trash and broken ceiling tiles, ceiling tiles were hanging and light fixtures were damaged. The police officers were required to restrain and handcuff four of the seven patients on the unit due to their out of control and assaultive behaviors toward staff and police. The report indicated that, per staff, earlier the patients were attacking each other. The report indicated that staff told police they had lost the ability to manage the patients and that was why they had called the police. The report indicated that the Physician who was present on the Unit at the time of the riot was fearful for her life and had remained locked behind the nursing station. The report indicated that Patient #2, Non-Sampled Patient #3, #4 and #5 were restrained and hospitalized for psychiatric emergencies.

The Surveyor observed the video taken on the Adolescent Unit, dated 8/26/17, between approximately 10:40 P.M. and 12:00 A.M. The video showed patients jumping and pushing ceiling tiles loose, and some of the tiles fell to the floor. The video showed patients running/walking up and down the hallway with ceiling tiles in their hands and staff trying to get the tiles back from patients. The video showed multiple patients hitting staff, staff restraining multiple patients, patients interfering with restraints, patients lifting each other up to remove ceiling tiles, patients moving in groups in the hallway.

The Surveyor interviewed the Administrator at 2:00 P.M. on 8/30/17. The Administrator said that during the night of 8/26/17 there was an incident involving the patients on the Campus L Adolescent Unit. The Administrator said the Hospital was still conducting its investigation of the incident but that it had determined that the Physician had not sufficiently utilized as needed medications for the patients to de-escalate the situation.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview, the nursing service failed to develop and /or keep current a nursing care plan for two patients (#3 and #8) that addressed medical nursing needs for patients, in a total sample of 29. Findings include:

1. The nursing service failed to develop a nursing care plan for Patient #3, to address frequent and recurrent urinary tract infections (URI).

Patient #3 was admitted to Campus W in January 2017 with diagnoses of schizoaffective disorder, behaviors and urinary tract infection.

Patient #3 had the mental capacity of a 5th grader and had a legal guardian. Patient #3 required cueing for personal care.

During the course of the 6 month Hospital stay, Patient #3 developed two urinary tract infections requiring antibiotic treatment and pyelonephritis (a kidney infection) requiring a trip to the emergency room .

Review of the nursing care plan indicated the plan was never updated to address these frequent infections.

2. For Patient #8, nursing staff failed to revise/update and keep current, care plans according to the needs of the patient.

Review of the care plan for Patient #8, noted the last two problems entered were identified as Problem Letter E and Problem Letter F on the initial multidisciplinary treatment plan. The problems were bilateral ankle wounds and open area on right inner buttocks. Goals for both were to "remain free from infection" and the specific intervention focus was "wound care as ordered".

Specific wound orders written on 6/29/17 also indicated, "encourage not to be on back, encourage to rest on side", if laying on back or side, attempt to elevate heels and place on pillow, when up in wheelchair use doughnut and no briefs."

On 7/1/17, the patient was, "punched in the face by another patient with a closed fist that resulted with bloody upper lip."

The care plan of 6/27/17 was not updated to include any of the interventions specific to the wound management nor the physical altercation resulting with the lip injury.

Interview with registered nurse (RN) #14, on 8/29/17 at 2:10 P.M., stated that treatment plans were always updated weekly but recently it was changed to Monday, Wednesday and Friday.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, record review and interview, the Hospital failed to follow basic safe medication administration practices. Findings include:

1. According to the US Pharmacopeia 797, which is the national standard for compounding of intravenous medications and solutions, "opened or needle-punctured single-dose containers, such as bags, bottles, syringes, and vials of sterile products and compounding sterile preparations (CSP), shall be used within one hour if opened." The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that spiked IV solutions be used within one hour of being prepared.

The Hospital failed ensure staff adherence to accepted standards of practice required to prevent healthcare-associated infections related to medication preparation and/or administration.

On 8/28/17 at 10:47 A.M., an Electroconvulsive therapy (ECT) treatment suite tour was conducted.

ECT is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses.

Upon entering the pre-op areas which contained 3 stretchers it was noted that hanging on each stretcher was an Intravenous (IV) pole was a 500 milliliter (ml) bag of Normal Saline (NS) 0.9%. There had not been a patient placed in the pre ECT stretcher at this time. The time noted that the IV bag had been prepared was 6:30 A.M. on 8/28/17.

Interview with Registered Nurse (RN) # 5, at 8/28/17 at 10:47 A.M., said that the time on the bag and the IV tubing was the time the bags were primed and prepped for the day. RN #5 further stated that the IV bags are prepared in the treatment room each day prior to patients arriving, depending on how many cases are scheduled for the day. RN #5 stated that for example if there are 8 patients scheduled to receive ECT treatment for the day, she would prepare 6 sets of NS with tubing. She stated that they would only prepare 6 not 8 because of cancellations that might happen.

The IV bags of NS had expired at 7:30 A.M. and were no longer considered sterile for injection since they were spiked over one hour prior and should not be used on patients due to being not safe for injection.

2. For Patient #11, the Hospital failed to ensure that the medication being given to the patient was the prescribed dose and that the patient did not have documented allergy to the medication.

Patient #11 was admitted to the Hospital on 4/2017 with diagnosis of bipolar depressive disorder, seizure disorder and a history or craniotomy for a benign tumor in 2007. The nursing database, dated 4/5/17, identified an allergies to the following medications: Ability (antipsychotic), sulfa drugs, Bactrim (antibiotics), Ativan (antianxiety). For Ativan the reaction was listed as "disinhibition." Review of the physician orders and medication administration record indicated the Patient 11 was ordered and received the medication Ativan. by mouth for behavioral control along with other medications on 4/12, 4/13, 4/15, 4/16, 4/17, 4/18, 4/20 and 5/9/17.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the Hospital failed to review and revise the care plan for the use of restraints at the weekly treatment meeting per Hospital procedure for one patient (#3), in a total sample of 29, for 6 of 13 restraint applications in a 5 month period. Findings include:

Patient #3 had frequent episodes of assaultive behavior towards staff and peers requiring time out by seclusion or use of physical holds and chemical restraint.

Record review indicated that between 1/23/17 and 5/25/17, the Hospital staff restrained Patient #3 thirteen times with physical and/or chemical restraints due to assaultive behaviors, which included hitting, punching, and aggression towards staff and peers.

During an interview on 8/29/17 at approximately 10:00 A.M., the Chief Executive Officer said that the treatment team reviewed all restraint use at the weekly team meetings for the purpose of reduction and to plan for better interventions.

Record review indicated that Patient #3 was restrained on 2/3/17, but there was no review of the physical hold employed at the team meeting held on 2/3/17. Team meeting notes indicated no restraint.

Record review indicated that Patient #3 was physically and chemically restrained on 3/17/17, but the restraint use was not reviewed on the following team meeting on 3/27/17.

Record review indicated Patient #3 was restrained on 4/10, 4/12 and 4/14/17 using a physical hold and/or seclusion. There was no review or revision to the restraint care plan at the treatment plan meeting held on 4/17/17.

Record review indicated Patient #3 was restrained on 5/15/17, using a physical hold and seclusion but at the treatment meeting held on 5/22/17, the use of restraints was not reviewed and the care plan was not revised.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interview, for one patient (Patient #3), the Hospital failed to obtain a physician's signed order for the use of physical and chemical restraints and failed to have a physician or other licensed independent practitioner (LIP), evaluate Patient #3 within one hour of the emergency restraint as required, immediately after initiating an emergency restraint, in a total sample of 29 patients. The Hospital policies and procedures also allowed non-LIPs to initiate emergency restraints for one hour before an authorized LIP or physician authorizes through an order the use of the restraint but not immediately, as required. Findings include:

The Hospital policy for Seclusion and/or Restraint Use, dated 11/16, indicated that initiation of a mechanical or physical restraint or use of seclusion shall be made by an authorized physician who is present when an emergency occurs. Such order along with the reason for its issuance and criteria for release shall be recorded in writing and signed at the time of its issuance by such physician. The order shall only be in effect for a maximum time of two hours. If an authorized physician is not present when an emergency justifying the use of mechanical or physical restraint or seclusion occurs, a patient may be placed in restraint or seclusion at the initiation of an authorized staff person, subject to conditions and limitations as follows: the authorized staff persons records the reasons for initiation and signs the time; the authorized time limit shall be for no more than one hour and shall terminate whenever a decision is made, and an authorized physician shall examine the patient as soon as possible but not later than one hour of such initiation.

Patient #3 had frequent episodes of assaultive behavior towards staff and peers requiring time outs by seclusion or use of physical holds and chemical restraint. Record review indicated the following:

a. On 2/3/17, nursing staff wrote an order for a physical hold up to one hour for assaultive behavior, until Patient #3 was calm and cooperative, at 9:00 A.M. The attending physician did not evaluate Patient #3 or co-sign the order until 2:00 P.M.

b. On 2/8/17 at 7:05 P.M., nursing staff wrote an order for a physical hold for up to 2 hours due to increased assaultive behavior toward staff, and for the administration of as needed doses of trazadone (for depression and insomnia) 100 milligrams(mgs), Benadryl (antihistamine and insomnia) 50 mg, and Depakote (for bipolar disorder) 1250 mg orally. The order was not signed by a physician until 7:30 P.M. Emergency orders for restraints cannot be written for more than one hour, per Hospital policy.

c. On 3/29/17, at 3:15 A.M., the nursing staff wrote an order for seclusion and a physical hold and chemical restraint for up to 6 hours due to Patient #3's assaultive behavior toward staff, and hitting and kicking. Nursing staff administered to Patient #3 the antipsychotic drug Thorazine 100 mg and Benadryl 50 mg IM (intramuscularly). The attending physician did not evaluate or sign the restraint orders until 7:00 A.M.

d. On 4/4/17 at 6:10 P.M., nursing staff took a telephone order for a physical hold for 20 minutes due to Patient #3's assaultive behavior toward staff, and that staff may release Patient #3 when he/she was calm. The order indicated that staff were to administer a chemical restraint of Haldol (an antipsychotic) 10 mgs IM and Benadryl 50 mg IM once immediately (NOW). The restraint order stamp was signed by the registered nurse but was not signed or dated by the ordering physician.

e. On 4/5/17 at 6:10 P.M., nursing staff wrote an order for a physical hold and a chemical restraint for up to one hour due to Patient #3 slapping, punching and throwing water and medications. Nursing staff administered Haldol 10 mg IM and Benadryl 50 mg IM. The attending physician signed at 7:30 P.M. that he/she evaluated Patient #3 and signed the orders one and one-half hours after the initiation of the emergency restraint.

The Hospital failed to evaluate Patient #3 immediately after the initiation of emergency restraints, failed to obtain physician orders for emergency restraints immediately after the application of restraints, and failed to have policies and procedures in place that were consistent with regulatory requirements.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview and record review, the Hospital failed to ensure that 1 of 1 staff who participated in restraints was trained in relevant first aid techniques.

Findings include:

Review of Mental Health Technician's educational and training file indicated there was no documentation that she was trained or certified in first aid, or had demonstrated first aid skills.

The Surveyor interview the Clinical Coordinator at 10:05 A.M. on 8/30/17. The Clinical Coordinator said the Hospital provided education and competency testing to Mental Health Technicians to recognize signs and symptoms of physical and physiological distress, for obtaining vital signs, and determining respiratory and circulatory status. The Clinical Coordinator said the Hospital did not train its Mental Health Technicians in the event a patient required first aid intervention.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview, the Hospital failed to have a Quality Assurance Program that measured, analyzed and tracked quality indicators related to infection control within the Hospital and used such data to monitor the effectiveness and safety of services and quality of care provided to its patients. Findings include:

Review of the infection control minutes from Westwood/Lowell campuses indicated there were no quarterly minutes as required since 11/2016. The 11/2016 minutes indicated there would be a separate annual risk assessment for the P campus and W /L campus. It also indicated that both campuses had a 2% Hospital infection control rate. The L campus had a recent gastrointestinal (GI) outbreak among employees in July 2016 and the W/L campuses reported 5 GI cases in July and August 2016. There were no further IC minutes for W/L campuses.

For P campus, minutes of the IC committee were found in the Environment of Care (EOC) committee minutes for January 2017, April 2017 and June 2017. However, there was no patient logs of infection available from the P campus despite repeated requests for these documents and there was no discussion in the minutes of any patient infections only employee illness. However, the minutes listed infection rate for the Hospital each month as being 2.3% for January, 2.4% for April and 1.5% for June but there was no data to base these numbers on. In the January minutes hand hygiene audit results were listed for January, February and March 2017 even though those months had not yet occurred, calling into question the legitimacy of these results.

The last annual risk assessment for W/L campuses was completed in July 2016. The P campus had an annual risk assessment dated July 2017.

Patient #3 was admitted with a urinary tract infection UTI) in January 2017 and had two other UTI during the admission treated with antibiotics. There were no infection control logs listing this patient with infections at the W/L campuses available for review.

During an interview on 8/29/2017 at 11:30 A.M., the Chief Nursing Executive (CNE) said the infection control nurse went on leave in February 2017, so the lead nurse at L campus has been trying to cover and will be attending basic infection control training soon. The CNE said there is a trained ICN at P campus. The CNE said she was not invited to the EOC meeting.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview, the Hospital failed to use indicator data collected on from the Partial Hospital Program for Campus L to identify opportunities for improvement and changes that would lead to improvement. Findings include:

Review of the Quality Council meeting minutes from 12/2016 through 8/17/17, indicated the following:
a. Review of data for January 2017 indicated that the Campus L Partial Hospital Program indicators included new patients being evaluated by the 2nd business day; patients being seen by the nurse practitioner (NP) at least twice a week; treatment plan goals being met; and the history and physical (H & P) being done timely.

b. Review of the January 2017 data indicated that for the patient care outcome indicator of patients being evaluated by the 2nd business day, the indictor had not been met from January 2016 through June 2016 and in December of 2016. The indicator of being seen twice a week by the NP had not been met each month from January 2016 through December 2016. The indicator of treatment plan goals was not met for the months of February, March, April, May and December 2016. The indicator of H & P being done timely was not met for each month from January through December 2016, except for October.

c. There was no performance improvement plan evident to address the unmet indicators to improve patient outcomes.

d. Review of August 2017 QC minutes indicated that Campus L did not show any improvement in the above indicators.

e. During an interview on 8/30/17 at 12:30 P.M., the Risk Manager (RM) said that the Hospital had a plan that involved using physicians and extra NPs to meet goals at Campus W but not at Campus L, thus goals were met at one site but not the other. The RM said there currently was no performance improvement plan to meet the indicator goals at the Campus L.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Immediate Jeopardy

Based on observations, record reviews and staff interviews, the Hospital failed to provide quality of nursing care when the nursing service failed to (1) reconcile medications for Patient #15 on admission and the patient did not receive insulin for approximately 48 hours, placing the patient at risk for life threatening unstable blood sugar conditions, (2) The Hospital failed to ensure a comprehensive reconciliation of medications was performed for new admissions by nursing or medical staff for at least one sampled patient ( #11) and (3) nursing services failed to provide all patients on seizure precautions or at risk of seizures with access to a suction machine to manage airway protection during a seizure in accordance with Hospital policy, placing patients at risk for immediate threats to health and safety, in a total sample of 28. Findings include:

1. For Patient #15 the Hospital failed to administer the patient's regular home dose of insulin for the medical condition of insulin dependent diabetes for an approximate 48 hour delay in obtaining insulin orders, placing the patient at risk for life threatening unstable blood sugars.

The Hospital policy for medical reconciliation, last reviewed on 4/2017, indicated that as part of the admission process and initial assessment and prior to administration of any medication, the admitting nurse competing the assessment obtains a list of medication that the patient is currently prescribed and /or taking. The medication list may be obtained from the patient, family/significant others, the patient's pharmacy, or documents accompanying the patient on admission, such as ER records. It may also be obtained by the medication management computer system. The medication will be listed with full name, dosage and schedule, indication, if available and last dose taken will be included.

Patient #15 was admitted on [DATE] at 5:00 P.M., from the Emergency Department (ED) with diagnoses including schizoaffective disorder and diabetes. The initial nursing assessment indicated that the patient was alert and oriented.

Clinical record review indicated an Admission History & Physical (H & P) was completed by the Doctor on Call (DOC) who indicated that the patient had a diagnoses of [DIAGNOSES REDACTED].

Further clinical record review indicated the following conflicting medical information:

Patient observation rounds documentation, dated 8/19/17-8/28/17 indicated that the patient had Non-Insulin Dependent Diabetes Mellitus (NIDDM).

Initial Multidisciplinary Treatment Plan, dated 8/19/17, indicated that the patient had Diabetes, but did not specify as to whether it was diet controlled, NIDDM or that the Diabetes was Insulin Dependent (IDDM).

Initial admitting orders, dated 8/19/17, indicated that the patient had Diabetes but again did not specify as to whether it was diet controlled, NIDDM or that the Diabetes was Insulin Dependent (IDDM).

The Consultation/Physical Evaluation performed by the doctor on-call, dated 8/19/17, indicated the patient had Diabetes. The Consultation/Physical Evaluation indicated the medical problem which should be addressed during this episode of treatment was increased blood sugars. However, the treatment modality for the management of increased blood sugars were not addressed until 8/21/17, approximately 48 hours after admission.

Comprehensive Interdisciplinary Assessment under the review of systems section indicated that the patient had Diabetes which was in ongoing condition. The nutritional screening section did not indicate that the patient had Diabetes. The Psychiatric Assessment section indicated that the medical history was significant for Diabetes.

On 8/20/17 at 10:30 A.M., a nursing progress record indicated that the patient reported that she/he felt neglected due to not getting medications. The nurse spoke further with the patient who reported that she/he gets insulin twice a day, however could not remember the name of the insulin or how much she/he was receiving. The nurse further wrote that the community pharmacy had no record of the patients insulin. The DOC was made aware and the nurse wrote that she would attempt to contact the patient's primary care physician.

A Fasting Glucose obtained on 8/21/17 at 7:50 A.M. indicated a glucose of 226. The reference range was 65-99 mg/dl. A hemoglobin A1c (The hemoglobin A1c test may be used to screen for and diagnose diabetes and prediabetes in adults. It is a measure of three months of blood sugar control) was also obtained and was 7.8%. For a person with known diabetes a value of greater than 7% indicates sub-optimal control.

On 8/21/17 at 11:00 A.M., a nursing progress record indicated that the patient gave permission to contact her/his primary care physician, who stated that the patient was on Lantus (long-acting) insulin 50 units at hour of sleep and also was to receive sliding scale insulin which was administered with meals according to the Finger Stick Blood Sugar (FSBS).

On 8/21/17 at 1:01 P.M. a one time order for a FSBS was obtained and it was recorded at 339 mg/dl. At this time the patient received 8 units of Humalog (ultra rapid-acting) insulin as a one time dose.

Review of the medication record administration report indicated that the patient did not receive her/his first dose of the Lantus Insulin 50 units at hour of sleep until 8/21/17 at 9:00 P.M. which was 3 days after admission. Record review indicated staff did not complete a medication reconciliation on admission as required.

On 8/30/17 at 8:10 A.M., Registered Nurse #15 said that the patient was admitted on the weekend and the PCP was not available. She further stated that the Hospital was unaware that the patient was to receive insulin until it was brought to the attention of the staff by the patient and that it was on Monday 8/21/17 that the Insulin orders were obtained.

There was a delay in addressing a patients medical needs (IDDM) which resulted in a delay in treatment.

2. The Hospital failed to ensure a comprehensive reconciliation of medications was performed for new admissions by nursing or medical staff.

The Hospital policy for medical reconciliation, last reviewed on 4/2017, indicated that as part of the admission process and initial assessment and prior to administration of any medication, the admitting nurse competing the assessment obtains a list of medication that the patient is currently prescribed and /or taking. The medication will be listed with full name, dosage and schedule, indication, if available and last dose taken will be included. The policy for patient comprehensive assessment. dated 6/2017, indicated that within 24 hours of admission, the attending psychiatrist or physician will complete the Admission Note/Initial Treatment Plan which will include current medications.

For Patient #11, the Hospital failed to ensure the physician and or nursing staff conducted a medication reconciliation on admission that met all the criteria of the Hospital's policy.

Patient #11, admitted [DATE], had diagnoses of [DIAGNOSES REDACTED]

The admission consultation/Physical evaluation, dated 4/5/2017 at 11:45 P.M., indicated that the patient had a seizure disorder with a history of a [DIAGNOSES REDACTED]. Current medications were listed as Depakote and Lithium (antiseizure drugs which can also be used for mood stabilization), Seroquel (anitpsychotic), Levoxyl (hormone replacement), and two other medications which could not be read due to illegibility of the physician's hand writing. No indications for use or doses or frequencies were listed as per the policy for medication reconciliation. The nursing database indicated that the patient was followed by a neurologist in the community and lived in a group home, but there was no evidence of a consultation to see if the Depakote was used to treat the patient's seizure disorder.

On admission, the patient was not ordered to receive Depakote. A Depakote level was ordered on [DATE] and indicated the patient had a therapeutic blood level (must be in range to control seizures) of 60.3 (in range is 50 -100). This also indicated the patient had been receiving regular doses of Depakote prior to Hospital admission.

On 4/21/17, 16 days after admission, the psychiatrist ordered Depakote long-acting 500 mg at bedtime for mood and on 5/1/17, the medication was reduced to 250 mg at bedtime and was discontinued on 5/4/17. Review of the medication administration record indicated the medication was never administered during the patient's admission.

On 5/9/17, the patient had a petit mal seizure resulting in loss of consciousness. Record review indicated the patient fell , striking his/her chin on a counter and then hit his/her head on the floor. A code blue was summoned and EMS called. The patient then had a grand mal seizure and was taken to the emergency room .

The medical and nursing staff failed to reconcile medications on admission and determine what medications the patient required to continue and why the patient was taking Depakote. The patient had a history of seizures and Depakote is a seizure control medication. The patient had a grand mal seizure one month after admission when all Depakote was stopped requiring an emergency room visit due to loss of consciousness with a head trauma due to an unprotected fall.

3. Based on observation and staff interview, is was determined that for 6 of 6 patient care units, the Hospital did not have the necessary emergency equipment (suction machines) in the event of a medical emergency, in accordance with Hospital policies for care and treatment of patients on seizure precautions.

The seizure precaution policy also required the availability of suction apparatus for any patients on seizure precautions.

The Surveyor observed during a tour of the West 2 Unit at 9:20 A.M. on 8/29/17, that the emergency cart had oxygen, but no suction machine was noted.

The Surveyor interviewed Registered Nurse (RN) #2 at 9:20 A.M. on 8/29/17. RN #2 said that the Hospital no longer had suction machines on the Unit and the nurses did not have any access to a suction machine.

The Surveyor observed during a tour of the South 2 Unit at 9:25 A.M. on 8/29/17, a sign posted over the emergency cart which indicated oxygen and suction equipment was at the emergency cart. The Surveyor also observed the emergency cart had no suction machine or equipment related to suctioning, despite the posted sign.

The Surveyor interviewed RN #15 at 9:30 A.M. on 8/29/17. RN #15 said the suction machine was kept in the medication room. The Surveyor asked RN #15 to locate the suction machine in the medication room. RN #15 looked in the medication room for the suction equipment and said we do not have a suction machine.

The Surveyor observed during a tour of the East 2 Unit at 9:33 A.M. on 8/29/17, that the emergency cart had no suction machine.

The Surveyor interviewed RN #16 and RN #17 together at 9:33 A.M. on 8/29/17. RN #16 and RN #17 both said that the units did not have suction machines.

The Surveyor observed during the tour of the East 1 Unit at 9:35 A.M. on 8/29/17, that there was no suction machine located on the emergency cart.

The Surveyor interviewed RN #18 and RN #19 together during a tour of the East 1 Unit, at 9:35 A.M. on 8/29/17. RN #18 and RN #19 both said the suction machine was in the medication room.

The Surveyor also observed during the tour of East 1 RN #18 and RN #19 enter the medication room to locate the equipment. RN #18 and RN #19 exited the medication room and told the Surveyor, "we don't have one" or words to that effect.

The Surveyor observed during a tour of the South 1 Unit at 9:45 A.M. on 8/29/17, the emergency cart had oxygen, but no suction equipment was observed.

The Surveyor interviewed RN #8 at 9:45 A.M. on 8/29/17. RN #8 said that a suction machine was in the medication room. RN #8 looked in the medication room and said she could not find a suction machine.

The Surveyor observed during a tour of the West 1 Unit at 9:50 A.M. on 8/29/17, there was no suction machine located with the emergency equipment.

The Surveyor interviewed RN #14 at 9:50 A.M. on 8/29/17. RN #14 said there was no suction machine on the unit.

The Surveyor interviewed the Director of Nursing (DON) at approximately 9:45 A.M. on 08/29/17. The DON said the emergency carts on each unit did not contain suction machines. The DON said staff did not have access to either electrical or manual suction machines on any of the units in the Hospital because the Hospital was not required to have them.

The policy and procedure titled Seizure Precautions and Procedures, dated 11/2016, indicated the following:

-Following a physician's order for seizure precautions, the following precautions will be implemented.

-The nurse will verify airway equipment is readily available, including but not limited to:

*Oxygen delivery systems
*Ambu-bag and mask
*Suction equipment.

It further indicated the procedure to follow during and after a seizure if suction was needed.

Further investigation and interviews with all clinical staff indicated that the Hospital had approximately (4) patients who were currently on Seizure Precautions.

On 8/30/17 at 7:00 A.M., RN #6 said that the current policy regarding seizure precautions was incorrect and that the policy needed to be revised as the Units did not have any suction equipment.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon medical record review and interview, nursing staff failed to ensure that physician orders for a physical therapy consult were followed for one patient (#8) in a total sample of 29. Findings include:

Patient #8 was admitted on [DATE] with diagnoses that included a status post cerebral vascular accident and compromised skin integrity. The nursing admission note of 6/27/17 indicated that the patient, "ambulated on toes d/t (due to) bilat (bilateral) dressings on ankles d/t having blisters; had used walker d/t prior stroke".

On 6/29/17 at 9:30 A.M., an order was written for PT (physical therapy) consult to evaluate the need for short term rehabilitation.

The Director of Nurses (DON) on 8/29/17 at 1:30 P.M., was unable to provide evidence of the results of the completed physical therapy consult. Later that same day at 2:10 P.M., RN #8 (Registered Nurse), indicated that the consults were done by an outside agency and that the consulting PT agency had five business days to respond.

Review of the policy and procedure for therapy services failed to provide any specific time allowance for the agency to respond to consult orders.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation and record review, the Hospital failed to ensure the contract anesthesiologist locked unattended anesthesia carts with medications in them as required.

Findings include:

On 8/28/17 at 11:00 A.M., the Surveyors entered the unlocked procedure/treatment room where the Electroconvulsive therapy is administered. (ECT is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses).

The Surveyors approached the anesthesiologist's cart and were able to open the cart and remove medications. The anesthesiologist was not in the treatment room at the time the cart was accessed/opened by the Surveyors.

The Surveyors removed the following medications from the unlocked and unsupervised anesthesia cart:

-Brevital Sodium 500 mg/50ml vial (a barbiturate which slows the activity of your brain and nervous system.
It is used to cause you to fall asleep before a surgery or other medical procedure. The open Brevital had already been reconstituted with a diluent added.

-Succinylcholine 20 mg/ml, 10 ml vial (It is neuromuscular blocking agent and is typically a drug of choice for short procedures usually 3 minutes or less)

-Labetalol is (a beta-blocker that affects the heart and circulation e.g. blood flow through arteries and veins). Labetalol is used to treat hypertension (high blood pressure).
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation and staff interview the Hospital failed to ensure that expired medications were discarded and not available for patient use. Findings include:

On the South 1 medication room on 8/28/17 at 10:44 A.M., the following was observed:

-Open vial of Humalog insulin (fast-acting insulin) with an expiration date of 8/24/17.

-Open vial of Lantus insulin (long-acting insulin) with an expiration date of 8/23/17.

Multiuse Insulin vials should be discarded 28 days after being opened or in accordance with the specific manufacturer recommended Insulin use guidelines.

Interview with RN #9 on 8/28/17 at 10:47 A.M. said, "the Night Nurse checks the expired medications."
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
The Hospital failed to ensure that the specific food and dietetic services organization requirements are met as evidenced by:
(a). The Hospital failed to ensure the Hospital food service operated under the management and direction by established dietary service policies and procedures. There were no current policy and procedures for dietary services that included acceptable safety practices for food handling and food temperatures; proper kitchen sanitation, supervision of work and personnel performance; overall policy and procedures for food supplies, meal distribution to patients, essential records and a QAPI (quality assurance performance improvement) service program.

See A-0620
(b) The Hospital failed to ensure food service personnel have completed sufficient training in food sanitation and safety.

See A-0622
(c) Campus L failed to address menu planning and failed to meet the nutritional needs in accordance with physician orders for 1 sampled patient (#28).

See A-0629 and A-0630

(d) Campus P did not have an accessible, signed and dated diet manual that was approved by the dietitian and medical staff.

.See A-0631
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on document review, observation and interview, the Hospital failed to ensure the Hospital food service operated under the management and direction by established dietary service policies and procedures. There were no current policy and procedures for dietary services that included acceptable safety practices for food handling and food temperatures; proper kitchen sanitation, supervision of work and personnel performance; overall policy and procedures for food supplies, meal distribution to patients, essential records and a QAPI (quality assurance performance improvement) service program.

Interview with the Director of Food Service (DFS) at Campus P, on 8/29/17 said that he did not have any written food service policies and procedures other than nursing policy related dietary services.

Review of Director of Food Services personnel file on 8/30/17, indicated that an essential function of the Director of Food Services job duties included the development and writing of policies and procedures for all non clinical operating areas of the dietary department. The policies are to be reviewed bi-yearly and new policies written as needed. Further interview on 8/30/17 at 1:50 P.M., the DFS said he was not aware and did not have food service policies or procedures for the Hospital's food service operations or department.

Follow-up interview with the Consultant Dietitian on 9/1/17, at 12:30 P.M. indicated he was not aware that the Dietary department did not utilize food service operation safety policies and procedures.

1. Sanitation concerns included the following:

a). Observation of the flooring throughout the main kitchen on the Campus P, on 8/29/17 (day 2 of survey visit) found the cleanliness unsanitary. The flooring tiles had a dark build-up of dirt/debris that was visible, with heavy dark soiled areas noted under and around large food service equipment, steam tables and shelving. Review of a month (8/2017) of daily cleaning schedules indicated that kitchen floor was to be cleaned as needed/EOD (end of day). Although the daily cleaning scheduled indicated it was cleaned daily, the flooring was in unsanitary condition. The tile surface was poor design for food establishments as it was not smooth or easily cleanable. This was discussed with the DFS on 8/29/17, who agreed the wrong tile was used and said the Hospital staff is aware with future plans to replace.

b.) A community hand brush hung on a string at the hand wash sink in the main kitchen. There was no procedure for cleaning it or proper use. The Director of Food Service said it was replaced when worn.

c.) An ice scoop dispenser on the wall next to the ice machine was dirty and had no drainage to prevent the scoop from sitting in pooled water.

2. Observations revealed improper food safety and hand hygiene techniques as evidenced by the following:

a.) Dietary staff failed to ensure proper hygienic food handling practices on 8/29/17 at 8:20 A.M., during the breakfast service to prevent contamination. The Surveyor observed Dietary Staff #1 handling cooked bacon and cooked French toast sticks with bare hands from the serving container and placing the items onto the patients' plate containers, the use of serving utensils was not consistent. Dietary Staff #1 was observed to open new product (French toast) boxes and place the food into the fryolater then proceed to serve the French toast bare handed without hand washing between tasks.

b.) Dietary Staff #4 was observed to perform more than one task while preparing and working with uncooked (raw poultry) chicken without proper hygienic practices to avoid potential cross contamination. Dietary Staff #4 was observed wearing gloves while handling and trimming raw chicken with a knife. Without removing soiled gloves and proper hand washing, Dietary Staff #4 proceeded to open and close the oven door with soiled gloved hands while holding the unclean knife, and then returned to the task of handling raw chicken. These concerns were shared with the Director of Food Services on 8/29/17.

c.) Observations of dish room operations at Campus P, included the following:

On 8/29/17, at 9:00 A.M. Dietary Staff #4 was observed to handle soiled equipment, push the dish racks through the dish machine, and proceeded to handle the equipment after it was clean, without proper hand hygiene.

On 8/30/17, Dietary Staff #5 was observed in the dish room at 9:40 A.M. handling soiled dishware, although dietary staff #5 sprayed hands with water, after touching the soiled dishes and rack, proper hand hygiene (soap and water hand wash or use of alcohol based hand rub gel over entire hands for several seconds until dry) was not performed before proceeding to the clean side of the dish machine to handle the clean dishes/rack.

The Director of Food Service was informed of these staff observations (#4 and #5) handling soiled food service equipment and then proceeded to handle the clean dish racks without proper hand hygiene and /or the removal of gloves (followed by hand washing) between tasks. Further interview, the DFS said that he has provided in-services for hand washing, although most dietary in-services are verbal, the DFS did not have food service department records of food service training.

For each observation, only one dietary staff employee was present in the dish room to perform both tasks of washing dirty dishes and handling clean dishes/equipment. Interview on 8/30/17 at 1:50 P.M., the DFS said the dietary department did not have written food service policies and procedures for dish room, dishwashing and proper handling procedures. However, the expectation was for staff to follow ServSafe guidelines.

3. Food safety temperatures / nutritional palatability:

The Hospital failed to assure the distribution services of meals to patients units is provided in a manner to assure food safety and palatable foods served to patients.

The Hospital food service provides meals to patients in three distribution methods. First, patients may be served according to a menu plan in the cafeteria by dietary staff, and also self-serve items from the salad bar as the individual patient's medical care plan and treatment allow. Secondly, a covered meal tray with entree foods is plated in the main kitchen (according to menu plan and diet restrictions) and is delivered on a cart to the patient unit nourishment kitchen to be distributed by nursing/health care attendants. Patients eat on the unit in a dining area and or room. Third, an entree meal is plated onto a paper/Styrofoam container, bagged in plastic and delivered to the patient unit nourishment kitchen to be distributed by nursing/health care attendants for the patient to eat on the unit in a dining area and or room. There are no food carts or elevator for this two story building. Dietary staff carried bags of "take out" Styrofoam meals up to the second floor patients via stairwell.

According to interview with Dietary Staff #2, on weekends only two dietary staff are scheduled, therefore on weekends, the health care attendants deliver the meals to patients.

The instructions attached to patient meals served to the units in Styro/paper include a delivery time to the unit and discard time, which the meal must be consumed or wrapped, dated, labeled and refrigerated by the discard time. If the meal is refrigerated, there are Re-heating instructions: Do Not Heat Longer than 2 1/2 minutes. Also if the meal is properly wrapped, dated, labeled and refrigerated it still must be discarded prior to the next meal.

During the 8/30/17 breakfast service kitchen food temperatures were documented as follows in Fahrenheit degrees: waffle 150; sausage 170; omelette at 182; home fried cheese potato 168; and oatmeal 180.

Patient meal distribution was observed on the S2 unit. Multiple Styrofoam containers were left in the nourishment kitchen on the counter with labels dated 8/30/17; Delivery time: 8:00 A.M. Discard time: 8:30 A.M. As patients awake and arrive to the dining area they are offered their meal and assistance from the nourishment unit by the health care attendants, with self serve beverages in the dining area. Some patients choose not to eat by the 8:30 A.M., and the un-served meals in Styrofoam containers were labeled and refrigerated by the health care attendant at 8:31 A.M. At 8:40 A.M., a patient arrived at the nourishment unit and asked for a meal. The health care attendant offered the patient two choices (omelette or waffles) and took the Styrofoam container from the refrigerator and presented it to the patient. The patient requested the waffles. Although the meal was in refrigerator (approximately 10 minutes) The meal was not re-heated.

At that time, a sample meal #1 was tested . The food temperatures of the test meal registered 106-108 for the sausage links; the home fried cheese potato was 110; and the waffle was spongy and barely warm to touch. The temperature results were not palatable and foods were not held in a manner to maintain proper hot holding temperatures.

A second meal #2 was tested after following the Re-heat microwave instructions. Although the temperature results after reheating 2 1/2 minutes were hot: waffle at 190; sausage 202; and home fried cheese potato 200, the texture of the food items were not palatable.

The meal distribution was observed on 8/30/17 on the E1 unit. Meals were marked as delivered at 8:30 A.M. and discard by 9:00 A.M. At 9:05 A.M., a meal tray was served from a covered tray in the nourishment to a patient. Although the time was after 9:00 A.M., the meal was not re-heated. At that time, a test meal #3 was sampled. The meal was on a paper plate inside the covered tray with food temperatures registering the following: omelette 106; sausage 104; and cheese home fried potato 102 degrees Fahrenheit. At 9:20 A.M., the un-served meals remained on the counter and were not refrigerated or discarded.

Patient meals were not properly held according to food safety standards to maintain safe food delivery to patients and avoid time temperature abuse and potential bacteria contamination.

3. For Campus L, the Hospital failed to have a full-time employee who serves at the Director of the Food and Dietetic Services and who is responsible for daily management of dietary services.

Review of the Director of Food Service (DFS) personnel file on 8/30/17 indicated that the DFS was qualified for the position but was not at Campus L full time. The DFS divided his time between Campus L and Campus W.

Interview with the DFS on 8/29/17 indicated that he spends approximately 60% of his time at Campus W and 40% at Campus L. The DFS indicated that another employee, the Food Service Manager (FSM), works as a full time employee at Campus L and assumes responsibility for the daily management.

Review of the FSM personnel file on 8/30/17 indicated that the Manager has a serve safe certificate but did not possess further training or experience for the daily management of food service which requires implementing training programs for dietary staff and assuring that established policies and procedures are maintained.

At Campus P, the Hospital failed to ensure that the Food and Dietetic Services operated under the management and direction of established policies and procedures.

On 8/29/17 at 10:00 A.M., during an interview, the DFS indicated that he did not have any written Food Service Policies and Procedures. The DFS said that he would be able to write up some of the requested policies related to diet manuals, meal times, diet ordering and tray delivery, diet order changes, diet compliance and late/early meals.

On 8/29/17 at 2:10 P.M., the Corporate Clinical Services Representative gave the Surveyor the above requested policies, four hours after the initial request. The policies did not indicate the Policy Number, the effective dates of the policies and the policy review dates.

On 8/30/17 at 10:30 A.M., the Surveyor requested to review the Food and Nutrition staff training programs and training records. The DFS indicated that there is no department training program for food and nutrition staff. The DFS said that only Hospital wide training is available for food service staff.

The Surveyor also requested to review the policy on the Food and Nutrition Department's integration into the Hospital wide QAPI (quality assessment and improvement) Program. The DFS indicated that there was no written policy on the department's participation with QAPI. However, he indicated that the monthly temperature logs of the dishmachine and refrigerators/freezers are sent to the Committee. In addition, the DFS indicated that the Dietitian sends timelines when patient assessments are completed. The DFS also indicated that patient meal satisfaction surveys are completed quarterly, but had no further information on the results. The DFS indicated that there is not generally much feedback from QAPI program.

The Surveyor also requested to review the policy on Emergency Food Supplies. The DFS indicated that the emergency food supplies policy is not at his fingertips or words to that effect.
VIOLATION: DIETS Tag No: A0630
Based on observation, staff interview and documentation review, the Campus L failed to meet the nutritional needs in accordance with physician orders for 1 sampled patient (#28) out of a sample of 29 patients. Findings include:

On 8/29/17 at 12:30 P.M., the Surveyor requested to review the list of patients with therapeutic diet orders. The DFS (Director of Food Service) indicated that the kitchen does not have a list of patients on therapeutic diets. The DFS further indicated that when a physician orders a therapeutic diet, nursing sends the diet order to the kitchen before meals. The diet order is then written onto a menu selection sheet for the patient to fill out each day.

On 8/29/17 at 1:00 P.M., the Surveyor reviewed the Dinner Menu Selection for Patient #28 that indicated the patient had a diet order for a "Soft, Low Sodium, Low Fat Diet with Double Portions." Review of the Hospital's menus indicated no written menu for a Soft Diet, a Low Sodium Diet and a Low Fat Diet. The menu slip indicated the patient would receive a hamburger on a bun with lettuce/tomato and french fries.

The Surveyor inquired if the patient meal selection complied with the diet order. The DFS and FSM (food service manager) indicated that the patients make up their own menus.

The DFS also said that the kitchen does not have planned menus for therapeutic and texture modified diets for staff to follow. In addition, there was no evidence staff receive training on providing therapeutic diets as ordered.
VIOLATION: THERAPEUTIC DIET MANUAL Tag No: A0631
Based on observation and interview, Campus P did not have an accessible, signed and dated diet manual that was approved by the dietitian and medical staff. Findings include:

During interview with the Director of Food Services on 8/29/17 at 9:45 A.M., the Director said that the diet manual was available on the Hospital computer and was able to accessed. Although nursing staff was also aware it was located on the computer, not all nursing staff could easily locate the manual for access.

Review of the Diet and Nutrition Care Manual on 8/29/17, there was no indication that the manual had been reviewed and approved by the medical staff and dietitian consultant. Although the Director of Nurses provided a copy of a signature page on 8/30/17, it was undated.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Immediate Jeopardy

Based on observations, record review and interviews, the Hospital failed to maintain a safe environment at Campus L and Campus P to ensure safety for all patients, and failed to fix previously identified ligature risk points and environmental hazards at Campus L in accordance with a plan of correction with a correction date of 8/20/17.

The patient population of this institution is prone to seek methods of self-injury and prone to self-injurious and suicidal behavior, thus making the environmental hazards a significant risk to the patients.

Findings include:

A. During a tour of West 2 at Campus P from 9:50 A.M. to 10:10 A.M. on 8/28/17, the Surveyor observed the following:

1) One black plastic trash bag was draped over a plastic waste basket in the Group Room that could easily be removed, created a potential ligature or suffocation hazard and/or ingestion hazard for choking.

2) One cabinet in a set of four cabinets in the Group Room was unlocked with exposed hinges created a ligature risk.

3.) A portable piece of medical equipment used to obtain vital signs which contained cords and wires that could be used as ligatures, was left unattended, outside the locked Nurses' Station, in an alcove, in a common patient area.

The Surveyor interviewed Mental Health Associate #2 at 10:10 A.M. on 8/28/17. Mental Health Associate #2 said he took the medical equipment on wheels from the Nurses' Station to an area accessible to patients, adjacent to the locked Nurses' Station and would use the equipment when he needed to take patient vital signs. He left the medical equipment there during his shift.





B. During a tour of unit West 1 at Campus P, at 9:45 A.M. on 8/28/17, the Surveyors observed the following:

1) Four of four patient bathrooms had toilets with exposed long toilet flush handles protruding 3 inches out of an opened access area from the plastic valve cover unit behind the toilet. The opened accessed area allowed patients to reach inside thus creating a ligature risk.

2) The door of the Seclusion Room opened into the Seclusion Room thus creating a barrier and hazard risk, as the patient in seclusion can barricade him/herself in the room using the door.

3) One black plastic trash bag was draped over a plastic waste basket in the Group Room that could easily be removed and created a ligature hazard and ingestion hazard for choking.

4) Peeling paint around the window frame and door frame in the Seclusion Room and around the window in the Group Treatment Room could easily be removed and ingested thus creating a choking risk.


C. During a tour of South 1 at Campus P, at 10:35 A.M. on 8/28/17, the Surveyors observed the following:

1) Four of four patient bathrooms had toilets with exposed long toilet flush handles protruding 3 inches out of an opened access area from the plastic valve cover unit behind the toilet. The opened accessed allowed patients to reach inside thus creating a ligature risk.

2) The doors of Seclusion Room #1 and Seclusion Room #2 opened into each room thus creating a barrier and hazard risks (Patient would be able to barricade themselves in room).

3) One black plastic trash bag was draped over a plastic waste basket in the Group Room that could easily be removed and created a ligature hazard and ingestion hazard for choking.

D. During a tour of East 2 at Campus P, at 9:33 A.M. on 8/29/17, the Surveyors observed the following:

1) The door of the Seclusion Room opened into the Seclusion Room thus creating a barrier and hazard risk as a patient would be able to barricade themselves in the room.

2) There was an exposed, uncovered sprinkler head in the ceiling of the Seclusion room, thus creating a ligature risk.


E. During a tour of West 2 at Campus P, at 9:20 A.M. on 8/29/17, the Surveyors observed the following:

1) The door of the Seclusion Room opened into the Seclusion Room, thus creating a barrier and hazard risk (barricade).


F. During a tour of South 2 at Campus P, at 9:25 A.M. on 8/29/17, the Surveyors observed the following:

1) The door of the Seclusion Room opened into the Seclusion Room, thus creating a potential barrier and hazard risk.

G. During a tour of East 1 at Campus P, at. 9:30 A.M. on 8/29/17, the Surveyors observed the following:

1) The door of the Seclusion Room opened into the Seclusion Room, thus creating a barrier and hazard risk potential.


H. During a tour of West 2 and South One on 08/29/17, the Patient Complaint boards were observed to consist of metal bins to hold forms, metal mailboxes, and sign plates secured to an approximate half-inch plywood board with Phillips head screws. The access door on the metal mailbox on West 2 was observed to be loose on 08/29/17 and the Surveyor was able to get her fingertips into the opening, which consisted of sharp metal edges. The DON said during the tour that the mailbox access door on West 2 should not have been loose.

The access door on the metal mailbox on South 1 was observed to be loose on 08/30/17, and the Surveyor was able to get her fingertips into opening, which consisted of sharp metal edges. During the tour, the Clinical Services Director said the mailbox access door on South 1 was normally loose.

These metal edges posed cutting hazards to self injurious patients.


I. During a tour of the Adolescent Unit at Campus L, from 9:35 A.M. to 10:00 A.M. on 8/29/17, the Surveyor observed the following:

1) The fire doors in the hallway were equipped with closure devices featuring exposed hinge arms while the doors were in the open position. The open position is the normal position. The exposed hinge arms protruded approximately one foot from the face of the doors, which created an unnecessary ligature hazard.

Per a plan of correction submitted from a previous CMS authorized survey completed on 5/25/17, the Hospital indicated on the plan that these closure devices would be replaced no later than 8/20/17, but as of 8/30/17, the fire doors and closure arms had not been replaced.

J. The drop (suspended) ceiling tiles (measuring 2 x 2 feet) on the Campus L Adolescent Unit were easily removed by patients and exposed pipes and electrical wires and posed a safety hazard.

The Surveyor interviewed Patient #21 and Patient #24, at 10:45 A.M. and 11:20 A.M. (respectively), on 8/30/17. Patient #21 and Patient #24 said there was an incident during the night of 8/26/17, during which approximately 5 patients from the Adolescent Unit attacked each other, staff and local police on the Unit. Patient #21 and Patient #24 said that one of the means of assaulting staff and police were the drop ceiling tiles, which the patients were able to remove because of the low ceiling height. Patient #21 and Patient #24 said that patients hit staff and police on their heads with the tiles. Patient #21 and Patient #24 said that they personally have removed ceiling tiles in the past and staff were aware of these incidents. Patient #21 said she has grabbed exposed wires (located above the ceiling tiles) and staff have had to intervene.

The Surveyor interviewed the Administrator at 2:00 P.M. on 8/30/17. The Administrator said he interviewed nursing staff who were present during the 8/26/17 incident on the Adolescent Unit and he reviewed video taken from the cameras on the Unit. The Administrator said that the patients had knocked the ceiling tiles loose and that a smoke alarm and speaker grate fell to the floor.

The Surveyor observed the video taken on the Adolescent Unit, dated 8/26/17, between approximately 10:40 P.M. and 12:00 A.M. The video showed patients jumping and pushing ceiling tiles loose, and some of the tiles fell to the floor. The video showed patients walking up and down the hallway with ceiling tiles in their hands and staff trying to get the tiles back from patients.

Review of an inventory list of damaged items provided by the Hospital, dated 8/31/17, indicated there were 10 damaged ceiling tiles, a damaged open grate speaker, and four light fixtures pushed up into the ceiling.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the Hospital failed to ensure the safety of 4 of 4 patients (Patient #2, Patient #5, Non-Sampled Patient #1 and #2) and to protect against hazards on the Adolescent Unit.

During this complaint survey, held between 8/28/17 to 8/30/17, it was determined that the Hospital did not implement its written plan of correction for survey event ID: HQLT11, cite A 144, held between 5/24/17 to 5/25/17, with a completion date of 8/20/17. The Hospital failed to replace the hinge closure arms on the hallway fire doors, located on the Adolescent Unit.

Findings include:

1. The Surveyor reviewed the admission notes for Patient #2, Patient #5, Non-Sampled Patient #1 and #2. The admission notes indicated that each of these patients were at significant risk for harming themselves or others.

The Surveyor observed Campus L's Adolescent Unit between 9:35 A.M. and 9:55 A.M. on 8/29/17. The hallway fire doors (2) were equipped with hinge type closures that protruded approximately one foot from the face of the doors while the doors were in the open position. The doors were normally kept open, and the closure arms faced away from the nursing and medication stations, which obscured staff's view. These factors created an unnecessary ligature risk hazard.

The Surveyor interviewed the Administrator at 2:02 P.M. on 8/29/17. The Administrator said the Hospital had a purchase order, dated 8/29/17, for replacement fire doors for the Adolescent Unit, and a scheduled installation completion date of 9/15/17. The Administrator said the new fire doors had a safe closure device, which did not pose a ligature hazard.

2. The drop (suspended) ceiling tiles (measuring 2 x 2 feet) on the Campus L Adolescent Unit were easily removed by patients and posed a safety hazard.

The Surveyor interviewed Patient #21 and Patient #24, at 10:45 A.M. and 11:20 A.M. (respectively), on 8/30/17. Patient #21 and Patient #24 said there was an incident during the night of 8/26/17, during which approximately 5 patients from the Adolescent Unit attacked each other, staff and local police on the Unit. Patient #21 and Patient #24 said that one of the means of assaulting staff and police were the drop ceiling tiles, which the patients were able to remove because of the low ceiling height. Patient #21 and Patient #24 said that patients hit staff and police on their heads with the tiles. Patient #21 and Patient #24 said that they personally have removed ceiling tiles in the past and staff were aware of these incidents. Patient #21 said she has grabbed exposed wires located under the ceiling tiles.

The Surveyor interviewed the Administrator at 2:00 P.M. on 8/30/17. The Administrator said he interviewed nursing staff who were present during the 8/26/17 incident on the Adolescent Unit and he reviewed video taken from the cameras on the Unit. The Administrator said that the patients had knocked the ceiling tiles loose and that a smoke alarm and speaker grate fell to the floor.

The Surveyor observed the video taken on the Adolescent Unit, dated 8/26/17, between approximately 10:40 P.M. and 12:00 A.M. The video showed patients jumping and pushing ceiling tiles loose, and some of the tiles fell to the floor. The video showed patients walking up and down the hallway with ceiling tiles in their hands and staff trying to get the tiles back from patients.

Review of an inventory list of damaged items from the incident, provided by the Hospital, dated 8/31/17, indicated there were 10 damaged ceiling tiles, a damaged open grate speaker, and four light fixtures pushed up into the ceiling.
VIOLATION: INFECTION CONTROL Tag No: A0747
Immediate Jeopardy
Based on observation, record review and interview, the Hospital failed to provide an active program for the prevention, control and investigation of infections and communicable diseases. Hospital staff failed to be knowledgeable and practice proper disinfection of a shared point of care glucometer ( blood glucose testing device) between patients placing patients at immediate risk for health and safety for contracting potential blood born diseases such as hepatitis B and C and HIV (Human Immunodeficiency Virus). Findings include:

Surveyor: Davison, Brenda

1. For Patient #27, the Hospital failed to ensure proper infection control practices were maintained during a finger stick blood sugar procedure.

Review of the Manufacturer's Directions for Use (MDFU), not dated, indicated that the meter should be cleaned and disinfected between patients.

Review of the Hospital's policy entitled, Glucometer Use and Glucometer Quality Control, reviewed 11/2016, included the procedure for obtaining a blood glucose levels, glucometer quality control and training of licensed personnel. The policy did not include cleaning and disinfection of the glucometer.

During observation of a finger stick blood sugar test at Campus L, on Unit A-1, on 8/29/17 at 11:00 A.M., Nurse #12 was observed using a blood glucose meter that is used for multiple residents, without using the appropriate disinfecting procedure, per the MDFU for cleaning and disinfecting blood glucose meters.

Nurse #12 was observed preparing to obtain a finger stick blood sugar reading for Patient #27. The nurse took the blood glucose meter out of a black pouch, performed hand hygiene and applied gloves. She placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test. After obtaining this patient's blood sugar, Nurse #12 disposed of the contaminated lancet, removed her gloves and performed hand hygiene. Without disinfecting the blood glucose meter, Nurse #12 placed the meter back into the black pouch and said she was done with this procedure.

During interview on 8/29/17 at 11:05 A.M., the Surveyor asked Nurse #12 if there was a process for disinfecting the blood glucose meter. Nurse #12 said yes there is but she forgot to do it.

During review of Nurse #12's personnel record indicated that Nurse #12 completed a competency for glucometer testing on 9/28/16. The competency did not include disinfection of the blood glucose meter. Further review indicated that Nurse #12 attended a skills fair on 8/1/17 and the cover sheet labeled "Re-Education Checklist" line listed various clinical competencies which included Glucometer Competency/Epipen competency. There was a line drawn through this competency and N/A (not applicable) listed next to it.


Surveyor: Wilkinson, Tina
2. The facility failed to properly disinfect the Glucometer ( a device used to obtain capillary blood glucose levels by obtaining a blood sample from the patient) according to the manufacturer's guidelines. The facility was currently using the Glucometer for multiple patients.

The facility was using the Clarity Blood Glucose 1000 glucometer to obtain the finger stick blood glucoses on all patients at the facility who required such testing.

On 8/28/17 at 10:30 A.M., two Surveyors observed a glucometer and alcohol pads in a cart in the medication room on the W-1 patient care unit. RN #7 was questioned regarding the cleaning of the glucometer and she said that she cleans the glucometer with an alcohol wipe after each patient use. At 10:44 A.M., RN # 9 said that she uses an alcohol wipe to clean the glucometer after each blood sugar testing on the patient.

The facility had approximately 8 to 10 patients who required Finger Stick Blood Sugar testing.

Review of the manufacturer's directions for use (MDFU) indicated the following for Disinfection Instructions:

"The glucometer must be cleaned and disinfected between patient uses by wiping it with a CaviWipes (a disinfecting wipe) in between tests. After cleaning the glucometer with a CaviWipe Towelette, use a second CaviWipe Towelette to thoroughly wet the precleaned glucometer surface. Allow it to remain wet for two minutes as specified by the CaviWipe manufacturer of the disinfectant wipes and allow to air dry. CAUTION: Do not use other cleaners or disinfectants because they may damage the glucometer."

Review of the current policy for disinfecting the Glucometer did not specify how the glucometer was to be disinfected between patient use. The facility Staff Educator (SED) said that she does not have it written within the policy but just tells the nurses to use alcohol wipes.

On 8/29/17 at 7:22 A.M. the facility SED said that the staff should have been using the CaviWipes and not the alcohol wipes which was the current practice.


3. According to the Infection Control (IC) Plan for the Hospital, last review in July 2016, the IC program is comprised of measures to restrict and or minimize the spread of existing diseases or infection to the fullest extent possible, by identification of contagious diseases or infections, an ongoing system of for reporting, evaluating and maintaining records of infections and or risk factors among patients and employees,; ongoing surveillance activities and teaching and promoting Standard precautions for healthcare workers. The plan indicated the Hospital would do an annual risk assessment, develop infection control protocols, policies and procedures that would be available to all staff and patients, provide special care and precautions as applicable for specifically identified diseases and implement corrective measures as recommended through infection control and quality improvement activities and keep logs of infections in the Hospital that include patient identification and location, date of admission and onset of infection, type of infection , cultures if taken and results, antibiotics administered, and name of the attending physician. It would be the responsibility of the infection control committee to analyze this data for unusual trends, cluster of infection, infections due to unusual pathogens and any occurrence of Hospital acquired infection that exceeds the usual baseline level. Findings, recommendation, actions taken and the results of actions taken are documented and reported via the Quality Council to the Medical Staff for review and evaluation.

4. Review of the infection control minutes from Campuses W and L indicated there were no quarterly minutes as required since 11/2016. The 11/2016 minutes indicated there would be a separate annual risk assessment for Campuses P, W and L. It also indicated that all campuses had a 2% hospital infection control rate. Campus L had a recent gastrointestinal (GI) outbreak among employees in July 2016, and Campuses W and L reported 5 GI cases in July and August 2016. There were no further IC minutes for Campuses W and L.

5. For Campus P, minutes of the IC committee were found in the Environment of Care (EOC) committee minutes for January 2017, April 2017 and June 2017. However, there was no patient logs of infection available from Campus P despite repeated requests for these documents and there was no discussion in the minutes of any patient infections only employee illness. However, the minutes listed infection rate for the Hospital each month as being 2.3% for January, 2.4% for April and 1.5% for June but there was no data to base these numbers on. In the January minutes hand hygiene audit results were listed for January, February and March 2017 even though those months had not yet occurred, calling into question the legitimacy of these results.

6. The last annual risk assessment for Campuses W and L was completed in July 2016. Campus P had a annual risk assessment dated July 2017.

7. Patient #3 was admitted with a urinary tract infection UTI) in January 2017 and had two other UTI during the admission treated with antibiotics. There were no infection control logs listing this patient with infections at Campuses W and L for review.

8. During an interview on 8/29/2017 at 11:30 A.M., the Chief Nursing Executive (CNE) said the infection control nurse went on leave in February 2017, so the lead nurse at Campus L had been trying to cover and will be attending basic infection control training soon. The CNE said there is a trained ICN at Campus P. The CNE said she was not invited to the EOC meetings at the Campus P and should have been since she is a member of the Infection control committee.








1. For Patient #27, the Hospital failed to ensure proper infection control practices were maintained during a finger stick blood sugar procedure.

Review of the Manufacturer's Directions for Use (MDFU), not dated, indicated that the meter should be cleaned and disinfected between patients.

Review of the Hospital's policy entitled, Glucometer Use and Glucometer Quality Control, reviewed 11/2016, included the procedure for obtaining a blood glucose levels, glucometer quality control and training of licensed personnel. The policy did not include cleaning and disinfection of the glucometer.

During observation of a finger stick blood sugar test at Campus L, on Unit A-1, on 8/29/17 at 11:00 A.M., Nurse #12 was observed using a blood glucose meter that is used for multiple residents, without using the appropriate disinfecting procedure, per the MDFU for cleaning and disinfecting blood glucose meters.

Nurse #12 was observed preparing to obtain a finger stick blood sugar reading for Patient #27. The nurse took the blood glucose meter out of a black pouch, performed hand hygiene and applied gloves. She placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test. After obtaining this patient's blood sugar, Nurse #12 disposed of the contaminated lancet, removed her gloves and performed hand hygiene. Without disinfecting the blood glucose meter, Nurse #12 placed the meter back into the black pouch and said she was done with this procedure.

During interview on 8/29/17 at 11:05 A.M., the Surveyor asked Nurse #12 if there was a process for disinfecting the blood glucose meter. Nurse #12 said yes there is but she forgot to do it.

During review of Nurse #12's personnel record indicated that Nurse #12 completed a competency for glucometer testing on 9/28/16. The competency did not include disinfection of the blood glucose meter. Further review indicated that Nurse #12 attended a skills fair on 8/1/17 and the cover sheet labeled "Re-Education Checklist" line listed various clinical competencies which included Glucometer Competency/Epipen competency. There was a line drawn through this competency and N/A (not applicable) listed next to it.





2. The facility failed to properly disinfect the Glucometer (a device used to obtain capillary blood glucose levels by obtaining a blood sample from the patient) according to the manufacturer's guidelines. The facility was currently using the Glucometer for multiple patients.

The facility was using the Clarity Blood Glucose 1000 glucometer to obtain the finger stick blood glucoses on all patients at the facility who required such testing.

On 8/28/17 at 10:30 A.M., two Surveyors observed a glucometer and alcohol pads in a cart in the medication room on the W-1 patient care unit. RN #7 was questioned regarding the cleaning of the glucometer and she said that she cleans the glucometer with an alcohol wipe after each patient use. At 10:44 A.M., RN # 9 said that she uses an alcohol wipe to clean the glucometer after each blood sugar testing on the patient.

The facility had approximately 8 to 10 patients who required Finger Stick Blood Sugar testing.

Review of the manufacturer's directions for use (MDFU) indicated the following for Disinfection Instructions:

"The glucometer must be cleaned and disinfected between patient uses by wiping it with a CaviWipes (a disinfecting wipe) in between tests. After cleaning the glucometer with a CaviWipe Towelette, use a second CaviWipe Towelette to thoroughly wet the precleaned glucometer surface. Allow it to remain wet for two minutes as specified by the CaviWipe manufacturer of the disinfectant wipes and allow to air dry. CAUTION: Do not use other cleaners or disinfectants because they may damage the glucometer."

Review of the current policy for disinfecting the Glucometer did not specify how the glucometer was to be disinfected between patient use. The facility Staff Educator (SE) said that she does not have it written within the policy but just tells the nurses to use alcohol wipes.

On 8/29/17 at 7:22 A.M. the facility SE said that the staff should have been using the CaviWipes and not the alcohol wipes which was the current practice.


3. According to the Infection Control (IC) Plan for the Hospital, last review in July 2016, the IC program is comprised of measures to restrict and or minimize the spread of existing diseases or infection to the fullest extent possible, by identification of contagious diseases or infections, an ongoing system of for reporting, evaluating and maintaining records of infections and or risk factors among patients and employees,; ongoing surveillance activities and teaching and promoting Standard precautions for healthcare workers. The plan indicated the Hospital would do an annual risk assessment, develop infection control protocols, policies and procedures that would be available to all staff and patients, provide special care and precautions as applicable for specifically identified diseases and implement corrective measures as recommended through infection control and quality improvement activities and keep logs of infections in the Hospital that include patient identification and location, date of admission and onset of infection, type of infection , cultures if taken and results, antibiotics administered, and name of the attending physician. It would be the responsibility of the infection control committee to analyze this data for unusual trends, cluster of infection, infections due to unusual pathogens and any occurrence of Hospital acquired infection that exceeds the usual baseline level. Findings, recommendation, actions taken and the results of actions taken are documented and reported via the Quality Council to the Medical Staff for review and evaluation.

4. Review of the infection control minutes from Campuses W and L indicated there were no quarterly minutes as required since 11/2016. The 11/2016 minutes indicated there would be a separate annual risk assessment for Campuses P, W, and L. It also indicated that all campuses had a 2% hospital infection control rate. Campus L had a recent gastrointestinal (GI) outbreak among employees in July 2016 and Campuses W and L reported 5 GI cases in July and August 2016. There were no further IC minutes for Campuses W and L.

5. Campus P's minutes of the IC committee were found in the Environment of Care (EOC) committee minutes for January 2017, April 2017 and June 2017. However, there was no patient logs of infection available from Campus P despite repeated requests for these documents and there was no discussion in the minutes of any patient infections only employee illness. However, the minutes listed infection rate for the Hospital each month as being 2.3% for January, 2.4% for April and 1.5% for June but there was no data to base these numbers on. In the January minutes hand hygiene audit results were listed for January, February and March 2017 even though those months had not yet occurred, calling into question the legitimacy of these results.

6. The last annual risk assessment for Campuses W and L was completed in July 2016. Campus P had a annual risk assessment dated July 2017.

7. Patient #3 was admitted with a urinary tract infection UTI) in January 2017 and had two other UTI during the admission treated with antibiotics. There were no infection control logs listing this patient with infections at Campuses W and L available for review.

8. During an interview on 8/29/2017 at 11:30 A.M., the Chief Nursing Executive (CNE) said the infection control nurse went on leave in February 2017, so the lead nurse at Campus L had been trying to cover and will be attending basic infection control training soon. The CNE said there is a trained ICN at Campus P. The CNE said she was not invited to the EOC meetings at Campus P and should have been since she is a member of the Infection control committee.

9. The Hospital did not have a functional infection control program according to its IC plan.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, records reviewed and interviews, the Hospital failed to consistently follow infection control standards and Hospital policy related to TB screening for four staff (Nurse #10, #12 and registered Dietitian (RD) #1 and #2), expired medications, dating multidose vials when opened, following safe intravenous (IV) medication preparation and administration standards of practice and providing education to food handlers on handwashing and safe food handling practices (Dietary staff #4 and #5). Findings include:

2. For 4 of 12 employee health records reviewed, the Hospital failed to ensure that Mantoux tuberculin testing was completed upon hire and annually thereafter as required by Hospital policy.

Review of the Campus L policy and procedure, entitled Tuberculosis Screening of Employees, reviewed 7/2016, indicated that it is the policy to have mandated Mantoux TB screening for all employees upon hire, and annually thereafter.

Review of employee health records indicated the following:
* For Nurse #12, employed since 12/2016, there was no evidence that a Mantoux test was performed.
* For Nurse #10, employed since 4/2017, there was no evidence that a Mantoux test was performed.

Review of personnel files for Consultant dietitians (Campus P RD #1 and RD #2) indicated there was no evidence of Tuberculosis skin testing for employment health screen purposes.

Interview with Human Resource Office at Campus P, on 8/30/17 1:30 P.M., confirmed that TB and Drug testing were the only health requirements for employment.

3. The Hospital failed to ensure that opened, undated and/or expired medications were removed from use and discarded on 3 of 3 units.

The Centers for Disease Control recommends that multi-dose medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends if a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

a. During an inspection of the A-1 Unit medication room on 8/28/17 at 12:15 P.M., with Nurse #11, one vial of Tuberculin Purified Derivative (TB) solution was opened and not dated.

During interview on 8/27/17 at 12:15 P.M., Nurse #11 said that tuberculin solution should be dated once it was opened and discarded after 28 days.

b. During an inspection of the Adolescent Unit medication room on 8/28/17 at 12:40 P.M., with the Nursing Supervisor, the following was observed:

* One multidose vial of Humalin R insulin was opened with an expiration date of 8/21/17.
* One vial of Tuberculin Purified Derivative (TB) solution was opened with an expiration date of 8/18/17.

c. On 8/28/17 at 11:00 A.M., the Surveyors entered the treatment room where the Electroconvulsive therapy is administered at Campus P (ECT, is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses).

The Surveyors approached the anesthesiologist's cart and were able to open the cart and remove medications.

Within the top draw of the anesthesiologist cart were 3 open Multi-use vials as follows:

-Brevital Sodium 500 mg/50 ml vial (a barbiturate which slows the activity of your brain and nervous system.
It is used to cause you to fall asleep before a surgery or other medical procedure. The open Brevital had already been reconstituted with a diluent added. Reconstituted solutions of BREVITAL are chemically stable at room temperature for 24 hours, according to the manufacturer's directions for use.

-Succinylcholine 20 mg/ml, 10 ml vial (a neuromuscular blocking agent and is typically a drug of choice for short procedures with a duration of action from 1-3 minutes with total dissipation of paralysis in about 10 minutes). Multiple-dose vials are only stable up to 14 days at room temperature per the manufacturer's directions for use.

-Labetalol is (a beta-blocker that affects the heart and circulation e.g. blood flow through arteries and veins). Labetalol is used to treat hypertension (high blood pressure).

Further investigation of the above 3 vials indicated that there was no time or date as to when the above medications were opened or accessed.

4. The Hospital failed ensure staff adherence to accepted standards of practice required to prevent healthcare-associated infections related to medication preparation and/or administration.

According to the US Pharmacopeia 797, which is the national standard for compounding of intravenous medications and solutions, "opened or needle-punctured single-dose containers, such as bags, bottles, syringes, and vials of sterile products and compounding sterile preparations (CSP), shall be used within one hour if opened." The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that spiked IV solutions be used within one hour of being prepared.

On 8/28/17 at 10:47 A.M. an Electroconvulsive therapy (ECT) treatment suite tour was conducted. Upon entering the pre-op areas which contained 3 stretchers it was noted that hanging on each stretcher was an Intravenous (IV) pole was a 500 milliliter (ml) bag of Normal Saline 0.9%. There had not been a patient placed in the pre ECT stretcher at this time. The time noted that the IV bag had been prepared was 6:30 A.M. on 8/28/17.

Interview with Registered Nurse (RN) #5, at 8/28/17 at 10:47 A.M., said that the time on the bag and the IV tubing was the time the bags were primed and prepped for the day. RN #5 further stated that the IV bags are prepared in the treatment room each day prior to patients arriving, depending on how many cases are scheduled for the day. RN #5 stated that for example if there are 8 patients scheduled to receive ECT treatment for the day, she would prepare 6 sets of Normal Saline with tubing. She stated that they would only prepare 6 not 8 because of cancellations that might happen.

The IV bags of NS had expired at 7:30 A.M. and were no longer considered sterile for injection since they were spiked over one hour prior and should not be used on patients due to being not safe for injection.

5. During an interview on 8/29/17 at 9:45 A.M., at Campus P, the Director of Food Service said that he did not participate in the Hospital infection control program or QAPI. The DFS said that he is aware that nursing conducts a quarterly report and infection control nurse has observed dietary staff and food handling.

The last Environment of Care Meeting minutes, dated 6/20/17 indicated there was a dietary inspection of the kitchen by the infection control nurse in which unlabeled food was found in the walk in refrigerator and that food temperatures were "okay." No plan of action was evident of the unlabeled food.

6. On 8/29/17, at 9:00 A.M. Dietary Staff #4 was observed to handle soiled equipment, push the dish racks through the dish machine, and proceeded to handle the equipment after it was clean, without proper hand hygiene.

On 8/30/17, Dietary Staff #5 was observed in the dish room at 9:40 A.M., handling soiled dishware, although Dietary Staff #5 sprayed hands with water, after touching the soiled dishes and rack, proper hand hygiene (soap and water hand wash or use of alcohol based hand rub gel over entire hands for several seconds until dry) was not performed before proceeding to the clean side of the dish machine to handle the clean dishes/rack.

During an interview on 8/30/17 at 8:20 A.M., Mental Health Care Attendant #3 was asked if any training had been provided for proper hand washing and food safety, and said no, and that it should be just common sense.
VIOLATION: PRE-ANESTHESIA EVALUATION Tag No: A1002
Based on observation and staff interview, the Hospital failed to ensure the contract anesthesiologist (Anesthesiologist #1) followed the Hospital ECT Services polices for medication management and failed to follow national standards for safe injection practices for intravenous medications, as required. Findings include:

The Centers for Disease Control recommends that multi-dose medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends if a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The CDC also mandates that the injection port and the rubber septum of vials be cleaned with alcohol before injecting IV medications or withdrawing IV medications from a vial to prevent cross contamination.

On 8/28/17 at 11:00 A.M., the Surveyors entered the treatment room where the Electroconvulsive therapy (ECT, is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses) was administered.

The Surveyors approached the anesthesiologist's cart and was able to open the cart and remove medications. The anesthesiologist was not in the treatment room at the time the cart was accessed/opened by the Surveyors.

Within the top draw of the anesthesiologist cart were 3 open Multi-use vials as follow:

-Brevital Sodium 500 mg/50 ml vial (a barbiturate which slows the activity of your brain and nervous system.
It is used to cause you to fall asleep before a surgery or other medical procedure.)
The open Brevital had already been reconstituted/diluent added.

-Succinylcholine 20 mg/ml, 10 ml vial (It is neuromuscular blocking agent and is typically a drug of choice for short procedures usually 10 minutes or less)

-Labetalol is (a beta-blocker that affects the heart and circulation e.g. blood flow through arteries and veins). Labetalol is used to treat hypertension (high blood pressure).

Further investigation of the above 3 vials indicated that there was no time or date as to when the above medications were opened/accessed

The policy for medication administration/drug storage dated 7/2016, indicated the following regarding Multi-dose liquids are as follows:

Multi-dose liquid and injectable medications shall have an expiration date of 28 days from date opened, not to exceed manufacturer date.

The BREVITAL, Succinylcholine and Labetalol had had been opened and stored in the top draw of the anesthesiologists cart with no date, and or time that the vials were opened/accessed/diluted and easily accessed by the Surveyors. On 8/28/17 at 11:00 A.M., the issue of the medications not being labeled with a time and date and the unlocked anesthesia cart draw were brought to the attention of the Anesthesia on duty (Anesthesiologist #1)

During observation of an actual ECT treatment on 8/28/17 at 11:00 A.M., it was noted that Anesthesiologist #1 began to administer 3 different IV medications. Anesthesiologist #1 was administering the anesthetic agents through a port into the patients IV. Before and during each medication administration the anesthesiologist did not disinfect the port with alcohol wipes, which is a standard of practice for the administration of IV medications to prevent infections in the IV.

Interview at 12:47 P.M. on 8/30/17, Anesthesiologist #2, indicated that standards of practice for IV medication administration is to label all medications when they are opened and that the cart should be locked at all times when not in attendance. He also said that the IV ports should be wiped with alcohol before and in between the administration of the drugs into the IV ports.