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.

THE BEHAVIORAL CENTER OF MICHIGAN 4050 E 12 MILE ROAD WARREN, MI Feb. 27, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview the facility failed to protect patient rights by: denying the right to speak with an attorney privately, failure to inform patients regarding "An Important Message from Medicare" within 48 hours of admission, failed to investigate and respond to allegations of abuse in a timely manner, failed to ensure that medications used for chemical restraint are within manufacturer and Food and Drug Administration indication for use, failed to release restraints once the unsafe behavior was no longer present and failure to conduct the one hour face-to-face evaluation after placing patients in restraints, resulting the loss of patient rights. See citations listed below:

(A-0117) Failed to protect patient rights by denying the right to speak with an attorney privately for one of one discharged patient (#8) and failure to inform patients regarding "An Important Message from Medicare" within 48 hours of admission for three of four current Medicare-insured patients (#1, #2 and #6).

(A-0145) Failed to investigate and respond to allegations of abuse in a timely manner for one of one discharged patients (#8).

(A-0160) Failed to ensure that medication orders used as a chemical restraint for one of one discharged patients (#14), are within the pharmaceutical parameters approved by the Food and Drug Administration and the manufacturer for the indication that it is manufactured and labeled to address, including listed dosage parameters.

(A-0174) Failed to discontinue restraints for one of three patients (#14) once the unsafe behavior was no longer present.

(A-0178) Failed to perform the one hour face-to-face evaluation for one of four patients (#18) that had been placed into restraints for aggressive behavior
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review 1 of 1 discharged patients (#8) was denied the right to speak to an attorney in private and 3 of 4 current Medicare patients (#1, #2 and #6) were not given "An Important Message from Medicare" within 48 hours of admission, resulting in increased risk of all patients being denied their rights. Findings include:

Policy Review:
On 2/27/14 at approximately 1500, review of undated policy MH-26, Patient Telephone Use, revealed the following statement, "A limitation on phone usage does not apply to a patient and an attorney, court, or any other individual if the communication involves matters that may be the subject of legal inquiry."

Record Review:
On 2/26/14 from 0930 - 1700, review of patient #8's clinical record revealed:
--A 12/24/12 (wrong year), 1105 note by staff N, stating: "Pt (patient #8) stated "My wife called an attorney because my knees are hurting, my diet is not being addressed, I was made to walk without shoes by a nurse..."
--A 12/24/1, 1201 note by staff N, stating: "Pt (patient #8) requested to talk to attorney in private. SW (staff N) told pt (#8) he could in conference room but would have to have a staff member present."
--A 12/24/13, 1400 note by staff N, stating: "SW (staff N) and Pt (#8) were in conference room for pt phone call to attorney."

Interview:
On 2/27/14 at 1315 staff N stated that patient #8 was denied the right to speak with his attorney in private (on the phone on 12/24/13) because he had "escalated" when talking about care complaints that morning. Staff N stated that "escalated" involved a raised voice but no threats, violence or immediate threats of self-harm. Staff N stated that the patient #8's right to speak with an attorney in private was not guaranteed for phone calls.




On 02/25/2014 between 1100 and 1430 reviews were completed with the Director of Nursing for three open records for patients #1, #2 and #6 in regards to completion of the Important Message from Medicare (IMM). The review revealed the following:
Patient #1 was admitted to the facility on [DATE], the IMM for the patient was signed but lacked a date. Due to the missing date, reviewers are unable to determine if the facility was in compliance with the giving the patient the information within 48 hours of admission.
Patient #2 was admitted to the facility on [DATE]. The IMM for the patient was not signed until 02/25/2014.
Patient #6 was admitted to the facility on [DATE], the IMM for the patient was signed on 02/20/2014.

On 02/25/2014 during review of all three of the above medical records the DON was present and confirmed the dates or lack there of on the IMMs. The DON stated that "admissions (department personnel) are supposed to do these when the patients come in."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to investigate and respond to allegations of abuse and neglect in a thorough and timely manner for 1 of 1 discharged patients (#8) resulting in the increased risk of abuse and neglect for all patients. Findings include:

(Policy review was done on 2/26/13, from 0900-1700.)
Policy Review:
Identifying Abuse and Neglect, dated 10/1/13, states:
"Investigation shall be initiated immediately in cases involving alleged abuse, neglect, serious injury, or death of a recipient involving an apparent or suspected rights violation." This Policy review was done on 2/27/14 at approximately 1500.
Abuse Class II: "A non-accidental act, or provocation to act, by an employee...with or without apparent harm."
Neglect Class II: "Acts of commission or omission by an employee which result from non-compliance with a standard of care or treatment required by law, rules, policies, guidelines, written directives, procedures, or individual plan of service and which cause, or contribute to, non-serious physical harm or emotional harm to a recipient."
Identification of Patients on Therapeutic Diets, dated 7/1/2012, states:
1. "Nursing staff shall update 'dietary census' form nightly."
2. "Updated dietary census form shall be delivered to the dietary department by 6 am daily."
Record Review:
1. Record review on 2/26/14 from 0900-1700, revealed that patient #8 was admitted on [DATE] with a diagnosis of Irritable Bowel Syndrome. On 12/19/13 a Dietitian (staff K) ordered "Large Portions" for patient #8. This Dietitian's order did not appear on the kitchen's "Dietary Sheet Census" form.
2. Record review on 2/26/14 from 0900-1700, revealed a Progress Note dated 12/20/13 by staff S stating: "Patient (#8) states, "I'm concerned that I'm not having enough calories in my body and I already told the dietitian." There was no documentation of any response to this complaint.
3. Record review on 2/27/14 at approximately 1400, revealed a written complaint by patient #8, dated 12/21/13, stating, "Nurse (staff I) ordered me to walk up and down the hallway...I was given an order that caused pain and physical damage to my knees." This complaint was stamped as received by the the Recipient Rights Office on 12/23/13, two days later, and not classified as an abuse or neglect allegation. An immediate investigation was not initiated as required by policy (stated above).
4 On 2/27/14 at approximately 1430, review of the investigation file for patient #8's abuse/neglect allegation (above #3) revealed no interview notes with patient #8 nor other patients, who may have witnessed the incident.
5. Record review on 2/27/14 at approximately 1435, revealed a letter from the Office of Recipient Rights to patient #8, dated 12/24/13, acknowledging that the patient received "food that was not compliant with your (ordered) diet on your lunch tray" on 12/23/13. The only "recommended action" was to retrain dietary staff regarding, "on what is compliant with different diets to prevent incorrect diet orders in the future." It was unclear how this action would address this problem, caused by kitchen staff not preparing trays in accordance with the "Dietary Sheet Census" and not verifying that the patient's tray was correct by initialing the column, used for that purpose on the form.
6. Record review on 2/27/14 at approximately 1440 revealed a written complaint by patient #8, dated 12/25/13, stating: "For dinner tonight I was given a packet of Classic Italian Dressing...very spicy."
7. Record review on 2/26/13 at approximately 1700 revealed that the "Dietary Sheet Census" form's column for kitchen staff to initial that patient #8's Special Diets was correct was left blank for all meals on; 12/19/13, 12/20/13, 12/21/13, 12/22/13, 12/24/13, 12/25/13 and 12/26/13.

Interviews:
1. On 2/26/14 from 1040-1130, Dietitian K was interviewed. Staff K stated that the "Dietary Sheet Census" form is used to communicate special diets and that kitchen staff are required to initial a column (on the form) verifying that special diet trays are correct.
2. On 2/26/14 at approximately 1040 Staff K stated that patient #8's physician ordered a Regular Diet and that she added the following orders on 12/19/13: "Low Fiber- Lg.(large) portions." Staff K verified that the Dietary Order slip that was placed on patient #8's tray in the kitchen read: "REGULAR, LOW FIBER, no nuts, no corn, NO ONION, NO GREEN P(Peppers), NO SPICY F (Food)." Staff K verified that "Lg Portions" was left off and stated: "it should have been on the slip."
3. On 2/26/14 at approximately 1130 staff K confirmed that the kitchen staff failed to initial that patient #8's special diet was correct on the patient's meal trays on the dates listed in #7 (above).
4. On 2/27/14 at approximately 1400 Recipient Rights staff A and V were interviewed in regard to patient #8's complaints. Both staff verified that patient #8's complaints about improper care were not classified as allegations of abuse or neglect nor investigated immediately. Both staff verified that there were no patient interview notes for the complaint allegations noted above.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, policy review and published documentation the facility failed to ensure that medication orders, used as a chemical restraint for 1 of 1 discharged patients (#14) are within the pharmaceutical parameters approved by the Food and Drug Administration (FDA) and the manufacturer, for the indications that it is manufactured and labeled to address, including listed dosage parameters resulting in the potential for an adverse medication reaction and poor patient outcome. Findings include:

A review was conducted on the closed medical record for patient #14 on 02/25/2014 at 1700. The medical record revealed that the patient was admitted to the facility on [DATE] due to aggressive behavior in the community. The medication record contained documentation that on 09/14/2013 at 2000 the patient was administered a PRN (Latin abbreviation for pro re nata - as needed; as circumstances require) dose of medication consisting of Ativan 1 mg and Haldol 5 mg for "agitation." The medication record also contains documentation in regards to the patient's response to the PRN as being "effective" but lacked a time for when that reassessment was completed. The patient then required a PRN dose of the same medications due to "aggression toward staff" on 09/15/2013 at 1000 with it again being documented as "effective" at 1150.
Then on 09/15/2013 at 1530 a telephone order was obtained for "Thorazine 100 mg PO/IM with Ativan 1 mg PO/IM (by mouth/intramuscular) every 4 hours as needed-severe agitation." The patient then received a dose of Thorazine and Ativan at 1600 on 09/15/13. The patient's response to the medication was documented as "ineffective" but no time was documented as to when the reassessment was completed. On 09/15/2013 at 1615 (45 minutes after the first order was obtained and 15 minutes after the first dose of Thorazine and Ativan was administered) another telephone order was obtained for "Thorazine 100 mg PO/IM with Ativan 1 mg PO/IM every 2 hours until sedated as needed-maximum 10 doses a day for severe agitation/aggression threatening behavior or not responding to redirection."

On 02/26/2014 at 1000, when staff L (Nurse Educator) was queried as to what guide does the facility use for a drug reference guide she produced a book titled "Mosby's 2012 Nursing Drug Reference 25th Edition." On page 291 the drug Chlorpromazine (Thorazine), functional class: Antipsychotic, in the section titled "Dosages and Routes for Psychosis Adult PO 10-50 mg q (every) 1-4 hours initially, then increase up to 2 g (grams)/day if necessary. IM 10-50 mg q 1-4 hours, usual dose 300-800 mg per day." During the conversation with staff L when asked what the order meant by "until sedated as needed" she replied "I am not sure how to interpret that."

On 02/26/2014 at 1400, during further discussion with the CEO when asked if he was aware of what a chemical restraint was he stated "I'm not really sure." After explaining that when a physician orders a medication that is not a part of the patient's standard treatment or that medications are ordered in large doses to restrict the patient's freedom of movement it then becomes a chemical restraint. After the explanation, the CEO stated that he could see why it could be a chemical restraint.

A review of the facility's policy on 02/26/2014 at 1430 titled "Restraint and Seclusion", policy #2.4, effective date July 27, 2012 reads, "Chemical Restraints are defined as a drug used to manage a patient's behavior or restrict the patient's freedom of movement and is NOT a standard treatment or dosage for the patient's condition. The use of medication to control behavior must be specifically indicated in the standard treatment of the patient's disorder, e.g. to control manic excitement. Standard treatment would include:
- medication is within parameters approved by the FDA and manufacturer;
- follows national professional practice standards;
-treats a specific patient's clinical condition
Usage of medications as PRN's under standard treatment are recognized as appropriate clinical treatment of patients who are suffering from mental illness and need therapeutic doses of medication to improve their level of functioning so that they can more actively participate in their treatment. Medication should never be used for patient discipline or staff convenience."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on record review, interview and policy review the facility failed to discontinue restraints for 1 of 3 patients (#14) once the unsafe behavior was no longer present, resulting in the loss of the patient's right to be free from restraint. Findings include:

On 02/26/2014 at 1600, during review of the medical record for patient #14 revealed that on 09/15/2013 at 1610 the patient was placed into 4-point leather restraints due to aggression. At 1700, staff F performed the one hour face-to-face evaluation on the patient and documented the findings on the "Seclusion/Restraint Documentation Form." The evaluation of the patient reads in the following sections "Patient's immediate situation - patient calm and cooperative, Reaction to Intervention - Accepting, Behavioral Condition - Patient calm." In the section where asked if there was a "Need to continue restraints - "no" was circled and then crossed out and the "yes" was circled.

A review of the every 15-minute documentation completed by staff P reads that at "1615 the patient was confused and quiet." At 1630 staff documented "the patient as confused, lying (still) and quiet." The 15-minute check documentation completed on the patient from 1615-1900 makes no reference of the patient being aggressive, threatening or not following redirection.

On 09/15/2014, Staff Q (RN) documented at 1800 that "One arm was also taken out of restraints at 1725." At 1930 staff Q documents that the patient was "Out of restraints at 1910."

On 02/26/2014 at 1655, during an interview with staff L, she confirmed the findings. When asked if the documentation supported the patient remaining in the restraints until 1910 she stated "No, it does not."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on record review, interview and policy review, the facility failed to perform the one hour face-to-face evaluation for 1 of 4 patients (#18) that had been placed into restraints for aggressive behavior resulting in the potential for a loss of the patient's right to be free from restraint. Findings include:

On 02/26/2014 at 1400 during review of the medical record for patient #18, revealed that the patient was placed into 4-point restraints on 02/05/2014 at 1705 due to the patient being "agitated, yelling at staff, spitting, non redirectable." The one hour face-to-face evaluation was completed by the RN on 02/05/2014 at 1820, (one hour and fifteen minutes later).

On 02/26/2014 at 1430 during review of the medical record staff L was present and confirmed that the documentation showed that the face-to-face evaluation was not completed within one hour. When queried as to who can complete the one hour face-to-face evaluation of the patient she stated, "the physician and trained nursing staff." When asked which nurses are trained at this facility to perform the evaluation she stated, "they all are."

On 02/26/2014 at 1530 a review of the "Restraint and Seclusion Policy", policy # 2.4, Effective Date: July 27, 2012 reads,
"One Hour Face-to-Face Assessment-
The purpose of this assessment is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of restraint poses no undue risk to the patient's medical or psychological well-being. This comprehensive review of this patient's condition is to determine if other factors such as illicit drug or medication interactions, electrolyte imbalance or hypoxia are contributing to the patient's violent or self-destructive behavior.
1. When restraint/seclusion/physical hold is used for management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or other, a Physician must see the patient face-to-face within one hour after the initiation of the intervention. If a Physician is not available, a Registered Nurse (RN) trained in accordance with the requirements of this policy may conduct the face-to-face assessment within one hour of initiation.
2. The trained practitioner must evaluate and document the following on the 'SECLUSION/RESTRAINT DOCUMENTATION FORM':
? Patient ' s immediate situation (current behavioral/cognitive presentation)
? Reaction to the intervention of physical restraint
? Medical condition/complete review of systems assessment (i.e. H&P, labs, VS, progress notes, medications, IPE)
? Changes in the medical condition (if yes, document in progress note)
? Behavioral Condition/behavioral assessment
? Need to continue or terminate restraint

3. If the face to face assessment is conducted by a trained registered nurse (RN), the RN must consult the attending physician who is responsible for the care of the patient as soon as possible after the completion of the face to face assessment.

4. The RN conducting the one hour face-to-face assessment should be a trained RN other than the RN who initiated the physical restraint."
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview and policy review, 2 of 2 staff , (Staff E and H) were unable to demonstrate the steps needed to perform control test using the blood glucose monitor resulting in a possible delay of treatment for all diabetic patients being treated at the facility. Findings include:

On 02/25/2014 at 1045, during a tour of the 3rd floor, staff E (RN) was queried if she knew how to perform the control test on the blood glucose monitor. Staff I replied, "That is done on the midnight shift." When asked again if she knew how to perform the glucose test she stated, "to be honest I do not."

On 02/25/2014 at 1145 during tour of the 2nd floor, staff H (LPN) was queried about the blood glucose monitor and she stated, "Controls are done by the night shift." When queried if she knew how to perform the glucose test she stated, "yes." When asked to demonstrate the testing procedure, staff I removed a test strip, placed it into the machine, added the solution, waited for the reading to appear on the screen but then did not know where to look to see if the reading was within the correct (high/low) range.

On 02/25/2014 at 1200 during an interview with staff L, (Nursing Educator), when queried if she was aware that staff do not know how to perform the blood glucose control test she stated "they probably don't because it is done by the night shift." When asked about running the controls on the machine if there is doubt about the accuracy of the reading or when opening a new bottle of test strips she stated, "I can see where we need to make sure that all nurses are competent with running the test."

On 02/26/2014 at 0730 review of the facilities policy titled "Blood Glucose Testing", policy # 5.31, dated "January 30,2014" reads in the section titled Policy III "E. Blood glucose testing is performed upon a physician's order by RN's and LPN's who have successfully completed an in-service or competency in the procedure. H. Control tests high/low must be performed: 1. Daily; 2. Or if you open a new test strip package; 3. Or if readings appear inaccurate; 4. Or if the machine is dropped."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to keep current a plan of care for 1 of 1 discharged patients (#8) by failing to monitor the patient's weight and ensure that physician ordered lab work was done, resulting in increased risk of poor health outcomes for all patients. Findings include:

Policy Review: Policies listed below were reviewed on 2/27/14 at approximately 1500.
Nursing Services, dated 2/26/13, states:
D. "Patient baseline weight is taken upon admission and recorded on the Multidisciplinary Assessment form. Patient weights are monitored weekly thereafter, unless otherwise ordered, and documented on the Patient Care Flow Sheet..."
Laboratory Services, dated 4/1/05, states:
"It is the policy of the hospital to provide a comprehensive range of laboratory services for the diagnosis and treatment of patients during periods of hospitalization ..."
"The provision of laboratory services, through a contact with ____is the responsibility of the Director of Nursing."

Record Review:
On 2/26/14 from 0930-1700, review of patient #8's clinical record, including documents titled, "Patient Care Flow Sheets," revealed:
1. Patient #8 was a hospitalized from [DATE]-12/27/13 and had no documentation of a weight after admission on 12/16/13.
2. Patient #8's "History and Physical" by physician U, dated 12/17/13, states, "Hyponatremia, likely reactive. We will check lytes (electrolytes) in a.m. (the morning)"
3. A 12/23/13 note by physician U stating, "Hyponatremia. Still awaiting for repeat lytes."
4. No lab results for electrolytes during patient #8's admission were found in the patient's closed record.

Interview:
1. On 2/26/14 at 1055 the Dietitian (staff K) reviewed patient #8's record and confirmed that neither lab results for ordered electrolytes nor a weekly weight could not be found.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review, interview and policy review the facility failed to ensure that staff perform blood glucose testing per the physician's order for 3 of 3 patients (#1, #4, #6) resulting in the potential for untreated hypo/hyperglycemia. Findings include:

On 02/25/2014 at 1115 during review of the medical record for patient #6, revealed that the physician wrote an order on 02/15/2014 at 2045 for "accu-checks (blood glucose test) to be done AM & PM times 3 days." Review of the documentation showed that the accu-checks were not performed on 02/17/2014 or 02/18/2014 at 2100.
On 02/25/2014 at 1130 staff D was queried as to what time the PM accu-check would be completed and they responded, "9 PM." Staff D at this time also confirmed that the accu-checks were not performed per the physician's order.

On 02/25/2014 at 1300, a review was completed on the medical record for patient #4 with staff B. The record revealed a physician's order for accu-checks. The order was written on 02/19/2014 at 1700 and read, "Accu-checks fasting and 4 PM." When Staff B was queried as to when the fasting accu-check would be completed he stated "around 0630." The documentation of the accu-checks revealed that on 02/23/2014 and 02/24/2014 the 0630 accu-checks were not performed. The findings were confirmed by staff B during the record review on 02/25/2014 at 1300.

On 02/25/2014 at 1330 during review of the medical record for patient #1 with Staff I revealed that a physician's order was written on 02/15/2014 at 2045. The order was for "accu-checks AC & HS (AC=before meals, HS=hours sleep/before bedtime) times 3 days.." Documentation of the accu-checks being performed revealed that on 02/17/2014 the accu-check was not performed at HS. Staff I confirmed the findings during the record review and stated that, "she is refusing everything now." When staff I was asked if there was documentation in the record showing that the patient refused the test, he was unable to locate any such documentation.

On 02/26/2014 at 0730 a review of the facility's policy titled "Blood Glucose Testing", policy #5.31, dated January 30, 2014 reads "E. Blood glucose testing is performed upon a physician's order by RN's or LPN's who have successfully completed an in-service or competency in the procedure."
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
Based on observation, interview and record review, the facility did not have an organized dietary service that provided therapeutic diets in accordance with policies and procedures, placing all patients with special diet needs at risk for health decline related to improper diet. Findings include:

(A-0628)--The facility failed to provide 1 of 1 discharged patients (#8) with a diet to meet the patient's needs, resulting in increased risk of health problems for all patients with special dietary requirements.

(A-0630)--The facility failed to follow the prescribed diet as ordered by the physician for 8 of 8 current patients (#1, #3, #5, #6, #7, #9, #11, #12) reviewed resulting in the potential for adverse patient outcomes. (A total universe of 14 patients were on special diets at the time of survey.)
VIOLATION: DIETS Tag No: A0630
Based on observation, record review and interview the facility failed to follow the prescribed diet as ordered by the physician for 8 of 8 (#1, #3, #5, #6, #7, #9, #11, #12) inpatients reviewed resulting in the potential for adverse patient outcomes. A total universe of 14 patients were on a special diet at the time of survey.

On 02/25/2014 at 1130 during tour of the 3rd floor with the DON, the patients were just eating lunch. During an observation in the dining room, it was noted that patients had a ticket on their tray stating what type of diet they were on. Patients that had a NAS (no added salt) on the ticket were noted to have salt packets on their trays. After the meal was completed and the trays were placed back into the cart, staff P was asked about the patients that had a ticket that reads "NAS" and why they would have a salt packet available on their tray. Staff P replied, everyone gets the salt packet it is part of the packet that comes with the plastic silverware.
Patient trays for patients #6, #7, #9, #11 and #12 were all observed at this time with salt packets on their lunch trays. This was confirmed by staff P and the DON.

On 02/25/2014 between 1130 and 1430 reviews were completed on the medical records for patients #1, #3, #5, #6, #7, #9, #11 and #12 in regards to the diet ordered by the physician. All eight (8) of the patients had "NAS diets" ordered.

On 02/25/2014 at 1715 during an interview with staff J (PM cook) when queried about the NAS diet she stated that, "it means that we just don't add salt when we cook it in the kitchen." When asked about the patients getting the salt packet in the utensil packet she stated, 'they come that way and they all have a knife, fork, spoon, napkin and salt and pepper." When asked for a "diet manual", she produced an undated folder that had a page that read "NAS Diet (No added salt), NO salt packet on tray; only Mrs Dash. Only unsalted crackers."

On 02/26/2014 at 1145 an observation was made of the lunch trays for patients #1,#3 and #6. Each of the patients had salted saltine crackers available on their tray. This was confirmed by staff L who removed the crackers from the trays.