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.

OLD VINEYARD YOUTH SERVICES 3637 OLD VINEYARD ROAD WINSTON SALEM, NC 27104 June 22, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interviews, the nursing staff failed to document injection sites per hospital policy for 3 of 32 sampled medical records (#15, #31 and #32).
The findings include:
Review of policy, "Medication Administration" with revision date of April 2013, revealed ".......For all medications, appropriate documentation on the Medication Adminstration Record (MAR) is required." Review of policy revealed no instructions for documenting injection sites.
1. Open medical record review of Patient #15 revealed a [AGE] year old female admitted on [DATE] for SI (suicidal ideations). Further review revealed a history of IDDM (insulin dependent diabetes). Review of Physician admission orders written on 06/18/2016 revealed Lantus (insulin) 10 units sq (subcutaneous) q (every) HS (hour of sleep). Review of MAR (medication administration record) revealed nurses initials on 06/19/2016 (no time) and 06/20/2016 (no time) indicating administration of insulin. No documentation was found indicating the location of the injection site.
Interview on 06/21/2016 at 1130 with RN #1 revealed "I was not taught to write injection sites".
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."
2. Closed medical record review of Patient #31 revealed a [AGE] year old male admitted on [DATE] for DMDD (dysphoric mood dysregulation disorder), intermittent explosive disorder, conduct disorder childhood onset, and attention deficit hyperactivity disorder. Review of the MAR dated 04/06/2016 through 04/11/2016 revealed administration of Diphenhydramine (Benadryl-medication for calming) 50 mg (milligrams) IM (intramuscular) on 04/06/2016 at 0810 and 04/11/2016 at 1456. No documentation was found indicating the location of the injection sites. Further review revealed administration on 04/06/2016 at 0810 and 04/11/2016 at 1456 of Ziprasidone (Geodon-medication used for sedation) 20 mg IM. No documentation was found indicating the location of the injections sites.
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."
3. Closed medical record review of Patient #32 revealed a [AGE] year old male admitted on [DATE] for schizophrenia paranoid with acute exacerbation (mental disorder characterized by abnormal social behavior and failure to understand what is real). Review of MAR revealed orders on 05/13/2016 for Ziprasidone 20 mg IM every 6 hours if needed for agitation. Further review revealed adminstration of Ziprasidone 20 mg IM on 05/21/2016 at 2330 and 05/22/2016 at 0950. No documentation was found indicating the location of the injection sites. Further review of Patient #32's MAR revealed Ativan 2 mg IM ordered on [DATE] for agitation. Review revealed documentation of adminstration of Ativan on 05/21/2016 at 2330 and 05/22/2016 at 0950. No documentation was found indicating the location of the injection sites.
Interview with AS #1 on 06/21/2016 at 1355 revealed "charting injection sites is basic nursing. Nursing 101. I expect the nurses to chart injection sites."
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on hospital policy and procedure reviews, observations during dietary tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure: hand hygiene and glove changes were performed between clean and dirty tasks; frozen foods with excessive ice formation were discarded and were covered to prevent exposure to air and contaminants; kitchen surfaces and food preparation/cooking equipment surfaces were kept clean of excessive grease/grim/dust buildup; cookware and serving utensils were cleaned and stored in a sanitary condition; and potentially hazardous foods were not available for consumption in 1 of 1 Dietary Departments toured.

The findings include:

Review on 06/22/2016 of hospital policy, "Dinning Room Maintenance" revised 04/2016 revealed, "POLICY: Every dietary services employee is responsible for providing the residents and his/her peers with a clean, sanitary and well maintained dining environment. PROCEDURE: ...The sanitation schedule is a guideline for detailed cleaning..."

Review on 06/22/2016 of hospital policy, "Housekeeping and Sanitation: Infection Control Sanitation Recommendations" revised 04/2016 revealed, "POLICY: Due to the seriousness of infection transmitted from people to food in preparation, the kitchen itself must be of good cleanliness and the dietary service staff must work in a sanitary manner. PROCEDURE: ...F. Dishwasher Procedures ...3. The dish area should be clean. ...9. Dishes sent through machine are removed, allowed a few minutes to drain and dry before storage. ...11. Utensil may be run through the dishwasher only after thorough cleaning in the three compartment sink. G. Cleaning Equipment ...Ovens a) Remove shelves (if present) b) Use wire brush to remove burnt particles c) Spray with commercial oven cleaner. d) Washed with detergent solution ... f) Wipe exterior with detergent solution ...L. Personal Hygiene... 7. Gloves must be changed and hands must be washed when starting a new task."

1. Observations during tour of the hospital's main kitchen on 06/20/2016 at 1230 and 1405 onward, revealed the following:

In the main kitchen service line area:
a. Observation on 06/20/2016 at 1230 of the hospital's main kitchen service line revealed, Dietary Staff #1 serving meals with gloves on. Observation revealed Dietary Staff #1 walked to the push-through warmer, opened the door with gloved hands, removed a tray of rolls, returned to the food service line steam bar, removed a roll with the same gloved hand used to obtain the tray of rolls, and placed it on the patient tray without performing hand hygiene or changing gloves.

Interview on 06/20/2016 at 1450 with the Administrative Dietary Manager #1 revealed dietary staff wear gloves when serving food. Interview revealed it is not uncommon for staff to move between the service line and the push-through cabinets, hot or cold, to replenish the line. Interview revealed staff use the same gloved hands to continue to serving, handling the service end of the serving utensils only. Interview revealed concerns of possible cross contamination from the push-through cabinet to hand food had not historically been an issue. Interview revealed barriers for use when obtaining food such as rolls, garlic bread, cornbread, etc. had not been used; however, it would be a consideration going forward. Interview confirmed observation findings.

In refrigeration storage area:
b. Observation inside the Freezer unit located beside the Fresh Vegetable preparation station revealed two (2), partially full boxes of individually packaged frozen slices of toast bread and three (3) loaves of bread. Observation revealed excessive (thick layer) build up of ice crystals inside each of the individually packaged slices of toast bread and the three (3) loaves of bread.

Interview during tour with the Administrative Dietary Manager #1 at 1410 revealed there should not be excessive ice crystals on food stored in the freezer. Interview revealed food with excessive ice crystals should not be available for patient use and should be discarded. Interview verified the observation findings.

In the walk-in freezer area:
c. Observation of the walk-in freezer revealed an open box of frozen peas. Observation revealed the box lid flaps were bent down, exposing the plastic packaging inside the box. Observation revealed a large hole in the plastic packaging, leaving the frozen peas exposed to open air.

Interview with the Administrative Dietary Manager #1 revealed food stored in the walk-in freezer or any other food storage area should be covered once opened. Interview revealed staff should obtain the required food, close the bag, and close the lids down on the box. Interview revealed peas, or any other foods with the exception of fruits and some vegetables, should not be left uncovered in any storage area in the kitchen. Interview verified observation findings.

In the food preparation area:
d. Observation of the food preparation area revealed a food preparation table across from the food storage area. Observation revealed dehumidifier stationed at the end of the table, with the same height as the top of the preparation site. Observation revealed the top and front panel of the humidifier were covered in a sticky substance with excessive (thick layer) dust accumulation. Observation revealed a large, uncovered tote stored on a shelf underneath the food preparation table with a commercial mixer, food scales, and other undefined kitchen aide equipment inside. Observation revealed a sticky substance covering the outside of the tote and all items inside the tote with an excessive (thick layer) of dust present. Observation revealed three (3) metal brackets where shelving once hung, along the wall behind the food preparation table, covered in a sticky substance with excessive (thick layer) dust accumulation.

Interview with the Administrative Dietary Manager at 1405 revealed the humidifier was just recently provided to the kitchen sometime during the week prior to survey (week of 06/13/2016). Interview revealed the dehumidifier was not cleaned prior to being placed into use in the food preparation area. Interview revealed the unit should have been cleaned prior to being delivered for use and should not be in the food preparation area as it was. Interview revealed the tote beneath the food preparation table appeared to be covered in "grease" and should not be stored in the manner it was. Interview revealed kitchen aides inside the tote were no longer used and should not be located in the food preparation area. Interview revealed the tote would be removed from the area. Interview revealed the brackets along the back wall of the food preparation table were used as support for the shelving and were no longer needed. Interview revealed the brackets would be removed. Interview verified observation findings.

In the cooking areas:
e. Observation of the fried food preparation area revealed a tilt skillet. Observation revealed a red regulator knob located on the side. Observation revealed sticky substance with an excessive (thick layer) of dust covering it. Observation revealed a double oven with excessive (thick layer) grease splattered on interior door and thick burnt particles in oven bottom. Observation revealed excessive (thick layer) grease dripped down front side of oven doors. Observation revealed a floor grade drain located in front of the tile skillet and double oven with excessive (thick layer) of sticky substance covered with dirt and dust. Observation revealed one commercial dough proofer cabinet (used too aid yeast bread fermentation process). Observation revealed a water pan located in the base of the cabinet with a layer of blackened substance in the bottom of the pan. Observation revealed the substance was easily wiped clean with a paper towel. Observation revealed two adjustable temperature knobs located at the bottom of the cabinet, near the floor, with a sticky substance and excessive (thick layer) of grit and dust on both temperature knobs. Observation revealed a microwave oven located on a shelf just before entering the dish washing area, plugged in a wall receptacle. Observation revealed a excessive (thick layer) of a sticky substance with dust along the top portion of the wall plate.

Interview during tour with Administrative Dietary Manager #1 at 1450 revealed the kitchen staff follow the hospital's "Dining Room Maintenance" guidelines for scheduled cleaning. Interview revealed the policy's "Sanitation Schedule" is completed by the Director of Dietary Services and posted in the kitchen on a weekly basis for staff to follow. Interview revealed the schedule for the week of 06/19/2016 - 06/25/2016 was not posted for review. Interview revealed the "Kitchen Weekly Task Cleaning Schedule" was last performed the week of 06/12/2016 - 06/18/2016. Interview observations during the tour did not appear to indicate the scheduled cleaning duties had been performed within the past week, some in previous weeks. Interview revealed observations of the sticky substance appeared to be "grease" and "grim" build up. Interview verified the observation findings.

In dish machine area:
f. Observation of the dish machine area revealed a drying tray with pitchers, plastic lids, and measuring cups. Observation revealed 3 of 3 measuring cups and 1 of 1 measuring spoons were stored face up with water standing in each. Observation revealed a double sink with excessive (thick layer) of a brownish-tan substance around fixtures and a white substance across the top of the back portion of the sink and on the back splash. Observation revealed substances were easily removed with paper towel. Observation revealed chunks of potato in the floor drain beneath the dish machine. Follow-up observation on 06/22/2016 at 1330 revealed potato chunks in the floor drain beneath the dish machine.

Interview during tour with Administrative Dietary Manager #1 at on 06/20/2016 at 1450 revealed the draining pitchers and measuring cups had been sanitized and were drying for storage and use. Interview revealed measuring cups and spoons should not be stored face up. Interview revealed food should not be in the floor drain and that if food were to inadvertently fall into the drain, it should be removed at least during the evening kitchen clean and moping. Interview on 6/22/2016 at 1330 revealed potato chunks were present in the floor drain and should have been removed immediately upon discovery. Interview verified observation findings.

In cookware/dishware dry storage area:
g. Observation revealed solid portion serving spoons, ice cream scoops, and perforated portion serving spoons stored face up. Observation revealed 2 of 5 sampled serving spoons had dried food particles noted on interior surfaces and 1 of 5 had a circular film with a scant amount of water present on the interior surface. Observation revealed 1 of 2 sampled ice cream scoops had standing water with a translucent white cloudy appearance in the interior surface. Observation revealed 3 of 4 metal pans sampled were stacked face down with clear liquid on the exterior surfaces. Observation revealed sticky brown residue build-up on cart holding, ready-for-use dishware.

Interview during tour with Administrative Dietary Manager #1 at 1450, revealed the stored cookware and dishware was clean and available for use by staff. Interview revealed cleaned items should not have residual dried food particles stuck on their surfaces after being cleaned and sanitized. Interview revealed cookware and dishware should not be stored face up or stacked wet. Interview revealed there should be no sticky residue. Interview verified the observation findings.

In the dining room service-line area:
h. Observation revealed a steam/ice table used to for food preparation during meals. Observation during the kitchen tour revealed four bowls, partially covered with paper towels on the steam table in the serving area at 1615. Observation revealed pasta salad, sliced cucumbers, tomatoes, and mixed greens were separately placed in the bowls. Observation revealed the bowls were not sitting in ice or being cooled. Observation revealed a metal serving spoon remained inside the bowl of pasta salad. Observation revealed the mixed greens appeared wilted and discolored.

Interview during the tour with the Administrative Dietary Manager #1 revealed the food should not be in the steam table without ice or some way of keeping it cool. Interview revealed the food was not covered appropriately for future use, if it were to be reused. Interview revealed the pasta salad was a mayonnaise based dish and should be refrigerated following use. Interview revealed the mixed greens were not acceptable for reuse and should be disposed of. Interview verified the observation findings.
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
Based on observations as referenced in the Life Safety Report of Survey completed June 21, 2016 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01

1. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The loss of normal power to generator automatic transfer switch required greater than ten seconds to restore power to the facility.

b. There is no generator annunciator panel to monitor emergency power supply system in the Adams Building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144

Building 02

2. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The emergency power system generator located on the exterior of the building does not have a remote manual stop switch located outside the generator housing unit. All level 1 and level 2 generator instillation's shall have a remote manual stop station located other than where the prime generator is located.
b. The facility has exposed electrical wiring inside the generator housing unit that were not enclosed in an electrical junction box.
~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144

Building 04

3. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The EPS supplying load indicator did not function with test of the emergency power supply system. The generator annunciator panel failed to function properly with automatic transfer switch "ES" in emergency mode.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on observations as referenced in the Life Safety Report of Survey completed June 21, 2016, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

The findings include:

Building 02

1. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There are holes in the cross corridor smoke barrier between room 109 and therapist office.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025

Building 02

2. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There is dust and debris accumulation on duct smoke detector sampling tubes - located above corridor ceiling between room 109 and therapist office.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 054

Building 02

3. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The sprinkler tamper switch supervisory signal fails to sound with main control valve in the closed position. The audible signal could be silenced with the valve in the closed position.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061

Building 04

4. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The ceiling of the gas fired hot water heater room.

b. The ceiling and corridor wall of the maintenance / main electrical room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029

Building 04

5. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The front entrance exit door utilizes an electromagnetic lock, without a key switch adjacent to door release hardware for rapid removal of occupants in the event of an emergency.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032


Building 04

6. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. Main sprinkler control valves in outside valve pit are monitored by non-listed supervisory switches. Existing switches use cord and plug arrangement not permitted for NFPA 13 Sprinkler system supervision.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061

Building 04

7. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. Blow-off caps are missing from range hood fire suppression nozzles located above cooking equipment in kitchen area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 069

Building 04

8. Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The facility has unsecured carbon dioxide cylinders in the dry storage room across from the dietary department. Gas cylinders should be properly and individually chained or supported in a proper cylinder stand or cart.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of policy, observations during tours, and staff interviews, the nursing staff failed to maintain the facility in a manner to ensure an acceptable level of safey and quality as evidenced by improper storage of oxygen cyliners by storing empty and full containers of oxygen (one empty and five full) in same storage container for 1 out of 5 patient care floors.
The findings include:
Review of policy "Storage of Compressed Gas", with revision date of 02/16 revealed "...4. Cylinders shall be marked empty or full and shall be kept separate."
Observations on 06/21/2016 at 1130 on patient care floor #1 revealed a metal storage container which held a total of 6 oxygen cylinders. Observation revealed five green oxygen tanks labeled "full" and one green oxygen tank labeled "empty" stored together.
Interview with AS #2 on 06/21/2016 at 1530 revealed the storage of full and empty oxygen cylinders together needed to be corrected immediately.
Interview with RN #1 on 06/21/2016 revealed the maintenance personnel is usually called to take the empty O2 tanks downstairs. Further interview revealed RN #1 was unsure of the amount of time the empty oxygen tank had been sitting in metal container with the full oxygen tanks.
Interview with RN #2, a nurse covering for the floor manager, revealed RN #2 was unsure where the empty oxygen tanks should be stored while waiting for maintenance to remove them.
Interview with Nurse Manager on 06/22/2016 at 0915 revealed he was unaware of the requirement for the oxygen tanks to be separated.