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.


Based on observations, staff interviews, and document review, it was determined that facility staff failed to implement a system for protecting the physical and emotional safety of behavioral health patients identified as having suicidal and or homicidal behaviors to ensure patients received care in a safe environment.

This finding resulted in the identification of Immediate Jeopardy (IJ), which is cited at the Condition of Participation level, after the facility provided an acceptable Plan of Removal.

See Tag A-0115. The plan of correction is listed below.

The plan of removal was (MDS) dated [DATE] at 5:45 p.m., and evidenced the following Action Plan:

ED Nursing Education:
-How to document suicide screening and safe environment intervention
_How to view physician orders for level of observation
-Process for obtaining sitter/ED staff to monitor patient until sitter is available
-Orientation to sitter request form
-Handoff to sitter, when indicated
Responsible Party: ED Director, Chief Nursing Officer
Measurement: 100% of ED Nurses, as evidenced by sign-in sheet
Implementation Date: 2/18/2020 COMPLETED 2.20.2020

ED Provider Education:
-Level of orders/what they mean
-Psych [psychiatric] order set
-Communication on safety plan of care with nursing team
-Provider to provider handoff for transition of care
-Reevaluating level of observation
Responsible Party: Chief Medical Officer
Measurement: 100% of ED Providers, as evidenced by sign-in sheet
Implementation Date: 2/18/2020 COMPLETED 2.20.2020

Sitter Education:
-Handoff from nurse of level of care and reason for monitoring
-How to document 1:1 observation, line of sight observation, q15 [every 15] minute observation
Responsible Party: Director of Staffing
Measurement: 100% of Patient Safety Attendants, as evidenced by sign-in sheet
Implementation Date: 2/18/2020 COMPLETED 2.20.2020

*Level of precaution orders will print to ED Desk Tech
Responsible Party Director of Advanced Clinical
Measurement: Escalated to IT [information technology] for immediate implementation
Implementation Date: 2/18/2020 at 1725 (5:25 p.m.) COMPLETED 2.20.2020

Monitoring Plan:
-ED Charge Nurse to review all Behavioral Health patients
-ED Charge Nurse to call Chief Operating Officer (COO) when patients with suicidal or homicidal ideation are registered
-COO to ensure that:
*Level of observation is ordered
*Sitter has been requested and obtained, if indicated/ordered
-ED Charge Nurse to review ED BH patients every four hours (Meditech report)
Responsible Party: Chief Operating Officer
Measurement: 100% review of patients with positive SI/HI [suicidal ideation/homicidal ideation] screening
Implementation Date: 2/18/2020 COMPLETED 2.20.2020

Sitters can be responsible for no more than four patients with q15 minute observations (an order for 1:1 monitoring requires one sitter for one patient
Responsible Party: Chief Nursing Officer
Measurement: 100% review of appropriate sitter assignment, as evidenced by ED Charge Nurse Monitoring Log
Implementation Date: 2/18/2020 COMPLETED 2.20.2020

The Plan of Removal was reviewed by the survey team and accepted at 4:45 p.m. on 2/20/2020, the IMMEDIATE JEOPARDY was abated during the survey, and findings now cited at the Condition of Participation level. Please see citation 0144 for further detailed information regarding the observations and concerns identified related to patient safety interventions.
Based on observations, staff interviews, and facility document reviews, it was determined the facility staff failed to ensure that Patient Safety policies related to patients experiencing suicidal and homicidal ideations were followed

The findings include:

On 02/18/2020 at 12:50 p.m., the surveyor spoke with the family member of Patient #17. During the conversation, the family member relayed concerns that Patient #17 had been in the ED for six (6) days waiting for bed placement in a psychiatric facility, and that for the first thirty-six hours (36) of the stay, the patient had been on a stretcher in the hallway when the complainant observed that there were unoccupied ED rooms. At the time of the interview, Patient #17 was in an ED room, where the complainant stated Patient #17 had been moved on 2/14/2020 at around 9:00 p.m.

After speaking with the complainant, the surveyor interviewed Staff Member (SM) #14, ED Manager, and SM #15, ED Director at 1:00 p.m. on 2/18/2020. The surveyor inquired as to the number of ED beds, and SM #14 told the surveyor that there were twenty-six (26) ED rooms, and one (1) stretcher outside every room, for a total of approximately twenty (20) additional "hallway beds". SM #15 added that room #13 was used as the facility's behavioral health room, but that all behavioral health (BH) patients go in the hallway on a stretcher after they are wanded, placed in paper scrubs, and personal belongings are searched for contraband. SM #15 told the surveyor that BH patients are placed in the hallway "across the board" so that staff will recognize which patients are BH.

SM #15 went on to tell the surveyor that generally length of stay in a hallway bed could be two (2) to three (3) days, but added that pediatric patients are usually given a room, "because they usually stay the longest". SM #15 told the surveyor that "we usually put a sitter with patients with suicidal ideation (SI)", and that the hallway beds are "as safe and secure as they can be". SM #15 told the surveyor that there were three (3)rooms in which behavioral health assessments were conducted via tele-psych, and that patients were moved from the hall into one of the 3 rooms, then moved back into the hallway after the BH assessment has been conducted.

The surveyor asked SM #27, an ED Registered Nurse (RN) on duty at the time of the ED visit, which patients were BH who also had suicide precautions ordered. SM #27 told the surveyor that Patient #10 was currently on suicide precautions. The surveyor observed Patient #10 walk down the hallway unaccompanied, and get onto a stretcher. SM #27 responded that suicide precautions were ordered, but a sitter was not available. The surveyor asked SM #27 to pull up Patient #10's physician orders, and noted that on 2/17/2020 at 5:54 p.m. there was a physician order for one to one (1:1) sitter, which was acknowledged by a nurse on 2/18/2020 at 2:18 a.m. When asked if Patient #10 had been monitored by a 1:1 sitter after the order was written, SM #27 said "No", and that some providers don't know the difference between 1:1 and suicide precautions. "we [nurses] reach out every day for sitters, we just don't have enough. We always ask for sitters".

Another SM who was standing in the area of the conversation said that there was only one (1) sitter in the ED, and that person was sitting with four (4) BH patients "around the corner" in the red subwait area.
One (1) patient (Patient #17) did not have a diagnosis of suicidal or homicidal ideations (SI/HI), and was in attendance of family members in ED room 13.

At 1:15 p.m. the surveyor went to the red subwait area just outside of ED room 13 and interviewed SM #28 who was monitoring 4 patients sitting in recliner chairs at the end of the hall where a television was on the wall, just outside of ED room #13. The surveyor inquired as to the patients in the chairs and for what reason they were being monitored. SM #28 said "I don't know why they are being watched, nobody told me. I am just doing every 15 minute checks". The surveyor reviewed the "Patient Monitoring Record" on which SM #28 was documenting every 15 minute checks for Patients #11, 12, 13, and 14. The document reviews revealed that for four (4) of four (4) of the patients being monitored, the records lacked evidence of what type of safety precautions were ordered for the patient (suicide precautions, standard (every 15 minute), line of sight, or 1:1).

The surveyor inquired as to the status of Patient #18, who was wearing blue paper scrubs and lying on a stretcher in the hallway of the ED. Patient #18 had an order written 2/18/2020 for a 1:1 sitter. SM #27 told the surveyor that facility staff had "contracted with the family for 1:1 sitter". An abbreviated review of the electronic health record (EHR) with SM #27 while in the ED revealed a physician order for a 1:1 sitter for Patient #18; however, a sitter was not present and conducting every 15 minute checks.

On 2/18/2020 the surveyor found seven (7) behavioral health (BH) patients awaiting disposition in the ED (Patients #10, 11, 12, 13, 14, 17, and 18).

Two (2) of seven (7) patients (Patients #11 and 13) were in the ED for detox (detoxification (detox) is a period of medical treatment, usually including counseling, during which a person is helped to overcome physical and psychological dependence on alcohol or drugs), and were not diagnosed as having SI/HI. Patients #11 and 13 did not have a physician order for safety monitoring; however, the surveyor was advised as a nursing measure, they were being monitored every 15 minutes by a Safety Attendant.

Three (3) of seven (7) patients had been diagnosed with suicidal ideations (SI), and had a physician order for a one to one (1:1) sitter (Patients #10, 14, and 18). The surveyor observed, and Staff Member (SM) #27 confirmed, that there was no 1:1 sitter in attendance of Patients #10, 14, and 18. Patients #10 and 18 were lying in the hallway on stretchers dressed in blue paper scrubs.

One patient (Patient #12) was admitted to the ED with SI/HI, and a behavioral health assessment documented on 2/18/2020 that Patient #12 was "Agitated, rocking back and forth, combative, homicidal with delusions of grandeur, having auditory hallucinations, and at high risk for suicide and homicide". The nursing suicide assessment of Patient #12 evidenced that the patient was at high risk for suicide, and that the patient was also homicidal. Nursing Documented further that safety precautions and safe environment were implemented, but did not specify what safety precautions were initiated. There was no physician order for safety precautions.

Patient #12 was being monitored every 15 minutes by a safety attendant in the "red subwait" area of the ED, along with three (3) other BH patients (Patients #11, 13, and 14). Patients # 11, 12, 13 and 14 were sitting in recliner chairs at the end of a hall watching television while SM #28, a Patient Care Attendant (PCA), who was functioning in the capacity of a Safety Attendant, was documenting every 15 minute safety checks on the four aforementioned patients.

The surveyor asked for the facility's policy for monitoring patients with suicidal and/or homicidal behaviors in the ED, and was given a policy titled "Suicide Screening and Prevention: Non-Behavioral Health, NPSG.11.606.00.0. The policy was last revised 7/2011, and documented an Expiration of 6/2018. A review of the policy revealed the following information, in part:

"...The scope of this plan begins prior to admission to the hospital and continues through the patient's discharge...A. The Registered Nurse will screen all patients presenting for admission for risk of suicidality as outlined in this plan...C. If the patient is determined to be of suicide risk, the results of this screening will be clearly communicated to the treatment team in the treatment area immediately...B. Screening and Reassessment; 1. Suicide Risk Screening and Assessment...b. The Emergency Department (ED) Registered Nurses will screen patients admitted to the ED with a primary focus/complaint of a behavioral issue(s) and/or if the RN has any clinical concerns for any patients presenting with risk for self harm. c. Any patient cared for in the ED or inpatient care areas of the hospital that has a "yes" answer to any of the suicide risk screening questions will be identified as patients that are at risk for suicide. Any patient that responds yes to any of the interview questions on the suicide risk screening will be placed on suicide precautions and the RN will assign patient observation monitoring immediately and a LIP [licensed independent practitioner] order will be generated in order to gain further suicide risk assessment by a qualified mental health professional (QMHP) or assigned LIP and determine an ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be documented and implemented to ensure the environment and patient will be safe...C. Heightened observations-Patients who are screened and assessed to be at risk for suicidality will be placed on patient observation and monitoring as assigned by the RN and reassess {sic} after the QMHP or assigned LIP assessment is completed. The patient may be placed on every 15 minute monitoring (Standard observations), continuous or visual or line of sight observation or a one to one (1:1) observation status as outlined in the Level of Observation definitions below (Use monitoring Documentation form for all levels of observation) and as determined by the treatment team and LIP order. 1. Level 1: Standard Observation- Monitor and observe minimally every 15 minutes. Staff visually observes the patient at least every 15 minutes, verifies their well-being, and ensures that they are safe both physically and mentally. Staff ensures the right patient is in the right bed and if the patient is sleeping, ensuring that they are breathing and in no distress...2. Level 2: Line of Sight Observation-Line of sight at all times monitoring and observation. Continuous Visual Observations means that at no time is the patient out of the visual contact of a staff member. Staff shall ensue safety when the patient is in the restroom, shower, or changing clothes. Staff shall attempt to maintain the patient's privacy as much as possible, however the safety of the patient must be the main consideration. Staff can be outside the open door but the patient must be in site...3. Level 3- 1:1 monitoring and observation. The patient is NEVER to be out of arms reach of the assigned and dedicated staff member. The patient will be in seclusion, restraint or emergency use of medications, actively attempting to harm self or others, hallucinations which have the potential to result in harm to self or others, demonstrated dangerous and unpredictable behavior, patient failed on line of sight and is unsafe at a lower level of care...D. Suicide Precautions...2. Suicide precautions are to be clearly indicated on the assignment sheet and patient specific rounds sheets and communicated during every transition of care (change of shift, breaks, and lunches) through thorough hand-off communication...".
The aforementioned policy also included instruction that 1:1 observation would be supported at the time of reassessment for patients who had attempted suicide in the past 48 hours, had displayed self injurious behaviors in the last "8/12 (shift specific) hours", verbalized SI with a plan to harm self, is having command hallucinations to harm self, verbalized hopelessness, or had experienced traumatic loss or a disrupted support system in the last 24 hours.

On 2/19/2020 at 5:10 p.m. SM #2, Vice President (VP) of Quality advised surveyors that a new Suicide Screening and Prevention Policy had been in progress for about six (6) weeks, but it was not approved until 2/14/2020 at approximately 4:30 p.m. SM #2 also said that corporate put Meditech changes for the new policy through and was available for staff to use on 2/18/2020.
Based on observations, staff interview, and review of facility documents, it was determined that facility staff failed to ensure that their policy and procedure for self administration of patient's home medications was followed for one (1) patient (Patient #19).

Findings included:

On 2/13/2020 at 3:00 p.m. the surveyor observed two (2) bottles of eye drops on the bedside table in the room of Patient #19. One (1) bottle was over-the-counter lubricant eye drops, and the other was a prescription bottle of eye drops used to treat chronic dry eyes. The surveyor interviewed a family member present in the room with Patient #19 who told the surveyor that when Patient #19 was admitted the eye drops were not available for the patient to use, so he and another family member have been administering the eye drops since Patient #19's admission to the hospital.

The surveyor asked the Unit Manager, Staff Member (SM) #29 to review Patient #19's electronic medication administration record (eMAR) in order to determine whether the medications had been ordered by the physician, and whether the record included an order for self-administration of the eye drops. SM #29 told the surveyor that Patient #19 had been an inpatient for three (3) days. The eMAR lacked evidence of an order for either of the eye drops sitting on the bedside table in Patient #19's room. SM #29 advised the surveyor that there is a procedure for patient's who use their own home medications when they are unavailable from the hospital pharmacy, and that the medications should have been sent to the pharmacy to be verified and bar coded.

The surveyor reviewed the facility's policy entitled "Patient's Personal Medications", last revised 3/2018, with an expiration of 3/2021. The policy review revealed the following information, in part:
"...Procedure: When a Patient brings personal medications to the hospital at the time of admission, one of three scenarios:
1. The medication is identified by the nurse for medication reconciliation, and then sent home with a family member or caregiver within 24 hours after admission.
2. A physician writes an order for the patient to be administered their own home medications. If the patient is going to take medication(s) brought in from home during his/her stay, a pharmacist must identify these medications.
a. A prescriber may order the patient may use his/her home medication(s) under any of the following conditions:
i. The pharmacy and Therapeutics Committee classifies the medication as non-formulary and no suitable formulary option is acceptable to the prescribing licensed independent practitioner.
ii. The pharmacy cannot obtain the formulary medication.
iii. The medication is supplied to the patient as an investigational drug (refer to investigational study drugs portion of the Medication Administration Policy).
iv. The medication is in an unopened multiple dose container such as eye drips {sic}, topical creams, inhalers, etc.
v. The patient is classified as an out-patient or 23-hour hold patient..."

The surveyor also reviewed the facility's policy entitled "Medication Administration", last revised 8/2015, expiration: 7/2021, which revealed, in part: "...E. Patient Personal Medication/Self Administration of Medications
1. Patients own medications will be handled according to the Patient Own Medication policy and procedure.
2. To allow self-administration of medications by patients, a written order must appear in the medical record. Self administration is permissible where patient participation is essential for patient teaching purposes, such as rehabilitation, the use of metered dose inhalers, teaching the patient to self-administer insulin injections or investigational agents. Patients who will be self-administering drugs (or family members who might administer drugs to inpatients) should receive training about the medication, including the nature of the medication, how to administer it, expected effects, potential adverse effects and reporting side effects. Prior to ordering the drug, the provider must deem the patient or family member competent to administer the drug. The nurse should document patient self-administration in the e-MAR.

Concerns were discussed with SM's #1 and 2 at the time of the observation, and again on 2/21/2020 at 2:15 p.m. with administration and department directors at the exit conference.
Based on observations, interview and document review, it was determined the facility failed to meet this condition based on the scope and severity of infection control deficiencies.

See Tag A-0749
Based on observations, interview, and document review, it was determined facility and contracted staff failed to ensure that facility policies and procedures, as well as policies and procedures of contracted vendors and their staff, were followed in order to prevent cross contamination and spread of communicable infections.

Findings included:

On 2/13/2020 at 9:50 a.m., while making observations of a medication pass on 5 East, the surveyor observed Staff Member #30 remove a pair of scissors and an alcohol prep pad from their uniform top, open the prep pad, wipe the blades of the scissors before cutting a pill in half through the packaging, put the scissors back in their pocket, place the medication into a pill cup and administer it to the patient.

On 2/13/2020 at approximately 9:55 a.m., while walking with the surveyor to the medication room to get medications for a patient in room 511, a nurse asked SM #30 if they knew where the pill crusher was located. SM #30 responded that the pill crusher was in room 501. On the way to room 511 to observe medication administration, the surveyor observed the nurse walk from the direction of room 501 with a small clear baggie of what appeared to be crushed medication. After observation of the medication pass in room 511, at approximately 10:25 a.m., the surveyor walked to room 501 and observed a "Silent Night" pill crusher setting on the counter to the right of the door upon entering room 501. SM #5 advised the surveyor that "typically staff take the pill crusher with them and use a wipe to clean it on the way out of the room".

On 2/13/2020 between 10:00 a.m. and 10:20 a.m., the surveyor accompanied SM #30 into room 511 to observe administration of medications. The patient in room 511 was on Contact Isolation Precautions as evidenced by the green contact isolation sign at the doorway; SM #30 confirmed to the surveyor that the patient was on Contact Isolation precautions due to a Methacillin-resistant Staphylococcus aureus (MRSA) infection. Both the surveyor and SM #30 sanitized hands and donned appropriate personal protective equipment (PPE) prior to entering the room. After touching the patient with gloved hands in attempts to scan the arm band prior to the administration of medications, SM #30 pushed the PPE gown to the side and reached into their uniform pocket, retrieving a pair of scissors and some alcohol prep pads. SM #30 then cut the wrist band from the patient's arm, replaced it with one provided by staff outside the room, wiped the scissor blades with an alcohol prep pad, and put them back into the pocket of their uniform top. While administering medications to the patient, a physician, SM #31 entered room 511 without donning PPE. After seeing SM #30 and the surveyor wearing PPE, SM #31 asked if the patient was on isolation precautions, to which we both responded "Yes". SM #31 did not don PPE, took a stethoscope from around their neck, and, after auscultating the patient's chest, placed the stethoscope back around his/her neck and left the room. SM #31 neither cleaned and disinfected the stethoscope nor washed or sanitized their hands prior to exiting the room and walking down the hall.

The surveyor asked for and was given the facility's policy entitled "Guidelines for Isolation Precautions", last revised 1/2020, expiration 1/2023. A review of the policy revealed, in part, the following information:
"...C. Contact isolation Precautions (Green Door Sign)- Contact Precautions are designed to reduce the risk of transmission of epidemiologially important microorganisms by direct- or indirect-contact...Contact Precautions apply to specified patients known or suspected to be infected or colonized (presence of microorganism in nor on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct- or indirect-contact...2. Gloves and Hand Hygiene-In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate) when entering the room...Remove gloves before leaving the patient's environment perform hand hygiene immediately with an antimicrobial agent or a waterless antiseptic agent...wear a gown (a clean, non-sterile gown is adequate) when entering the room...When possible, dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient..."

The surveyor also reviewed the facility policy entitled "Hand Hygiene, IC.05.1105.0.0" Last revised 7/2019, expiration 7/2022. The hand hygiene policy stated, in part to perform hand hygiene "...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...D. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. *Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another...".

A tour of the facility's kitchen was conducted, and observations were made on 2/12/2020 and 2/13/2020.
On 2/12/2020 at 11:15 a.m. the surveyor, accompanied by SM #10, an employee of the contracted services provider for the facility's kitchen, entered the walk in freezer, and the surveyor noted loose particles of food lying on the floor of the walk in unit, containers of french fries, diced chicken, frozen Lo mein noodles, ground turkey burgers, egg patties, biscuits, and sausage links, all of which were open and exposed, and none of which were labeled with an open date. SM #10 told the surveyor "I have never dated an open container of frozen food". The surveyor also noted a box sitting on the floor of the walk in freezer which was packed with loaves of bread and french fries, and when the surveyor inquired as to why the box of food items were setting in the floor, SM #10 stated "They are just odds and ends stuff that the stock guy is going to throw away".

In the "pot storage area" the surveyor observed "clean" muffin pans with crumbs on the sides of them, and food debris in the floor under the storage racks. The surveyor observed an open/undated container of basil pesto (with the top off) setting on a cart which contained slices of pizza being prepped for meals.

At 11:45 a.m., the surveyor asked staff to check the chemical concentration in the sanitation bucket in the cold prep area; the chemical test strip registered "0". The surveyor was told by SM #9, Operations Manager for the contracted food services vendor, that the facility used Quaternary Ammonia (QUAT) in the sanitation buckets, and that the solution is premixed when it goes into the sanitation bucket. Food sanitation buckets are used for routine cleaning and sanitizing of food contact surfaces and equipment necessary to prevent the growth of bacteria, and should be tested regularly to ensure that they maintain the proper strength of sanitizer for food contact surfaces. Buckets should register between 200-400 ppm (parts per million), and should be changed every two (2) to four (4) hours, or more often, as needed to keep the buckets clean, and the chemical sanitizer effective.

In the cold prep area, the surveyor observed a staff member's personal drink in a styrofoam cup setting on the food prep area with food supplies.

At 11:50 a.m. on 2/12/2020, in a refrigerator used to store items for use in "Jazzman's cafe", the surveyor observed already prepared bacon which had an expiration date of 1/18/2020, open coleslaw in a pan with an expiration date of 1/15/2020, prepared Caeser salad was not labeled with an expiration date, and boiled eggs had two (2) expiration date stickers (1/18/2020 and 2/17/2020).

SM #9 stated "Whoever labeled these things probably forgot to change the stamp date to February, I know these things haven't been in here this long".

At 12:05 p.m. on 2/12/2020 the surveyor asked to review the temperature log for the hot prep food area. The log lacked documentation for the first temperature reading of the day, during the breakfast meal. SM #11, cook stated "Looks like it didn't get done. It's usually done about 10:30 a.m. when it's [food] is up on the line, whoever is on the line should be doing that". The surveyor also noted that there were no temperatures documented for the cold prep area as of 12:05 p.m. on 2/12/2020.

On 2/13/2020 At 10:55 a.m., the surveyor asked staff to check the mixture in random sanitation buckets in the kitchen area to ensure that the chemical concentration was at least 200 ppm (parts per million)
The sanitation bucket at the tray line measured 100 ppm, the sanitation bucket in the cold prep area showed a test strip that was orange in color, indicating the sanitizer was less than 200 ppm.

At 10:55 a.m. on 2/13/2020 the surveyor observed metal food containers which had been run through the facility's dishwasher, being stored on a shelf while wet (wet nesting). Wet nesting is the practice of placing two recently washed items together in a nested fashion, which prevents proper airflow, and can lead to bacterial growth.

At 11:00 a.m. on 2/13/2020, the surveyor observed a food services staff member who was working with food while wearing gloves in the "catering " area move from food preparation to the walk in refrigerator, enter the refrigerator, pick up shredded cheese and return to the catering area, pick up labels and a pen, wrote on the bag of cheese, and resumed preparing food, all while wearing the same gloves. The same staff member then went to the small refrigerator near the catering area, got something from the refrigerator, and started working with the food, again without washing or sanitizing hands, or changing gloves.

On 2/13/2020 at 11:00 a.m., the surveyor held a discussion with SM #10, General Manager of dietary services for the contracted company, related to observations over the past two (2) days. SM #10 agreed with the surveyor that "the freezers and refrigerators have not been swept out this week", and there was food on the floors. SM #10 also told the surveyor that "if an employee goes from working with food to touching a direct surface, they need to wash their hands and change gloves". SM #10 told the surveyor that they perform monthly food safety audits, and provided the surveyor with a copy of the audit performed 1/15/2020.

The surveyor asked SM #10 for the contracted food vendors policies and procedures related to infection control, hand hygiene and glove use, labeling of foods, testing of sanitation bucket chemicals, employee training requirements. The surveyor was given copy of a document entitled "Operational Standard: SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION" Food Safety (HACP)", effective 10/1/14, of review 6/12/19, and included the following information, in part: "...All food items are to be properly labeled, dated, covered and stored using first-in, first-out rotation; Food Services personnel will routinely inspect all cold food storage units for food items not meeting quality standards f any standard stipulated in this policy...Food Services will maintain clean, sanitary and safe food storage areas and equipment; Food Service personnel will handle/store all food items according to related HACCP [Hazard analysis and critical control points] guidelines and infection control policies and procedures...Food Service personnel are trained in the process of handling potentially hazardous foods to include: personal hygiene, hand hygiene & glove use, thermometer calibration, proper cooking methods, proper temperature documentation, and proper sanitation...Food temperatures of potentially hazardous foods are monitored during cooking to ensure adequate minimum internal cooking temperatures per HACCP guidelines as identified in department HACCP Food Safety Program...Temperature records are maintained for each service location where potentially hazardous food is served. Foods found to be outside the acceptable range are immediately removed from service and rapidly chilled, reheated or discarded as indicated...Food Services personnel will receive skill-based HACCP training appropriate for their level of responsibility. Competency will be assessed based on observation of job performance...".

The surveyor reviewed the contractors HACCP employee training information for new employee and annual training, which included the following in part: Food Safety Information: "...Clean, rinse and sanitize all food contact surfaces between each use or at regular intervals..." A document "When to Wash Hands", which guides employees to always wash hands thoroughly after going to the restroom, before beginning work or when returning from breaks, after handling raw meat, poultry, seafood, and produce, before working with ready-to-eat foods, before handling different types of food, after touching hair, face, nose, or other body part, after coughing, sneezing, or blowing nose, after cleaning, after handling chemicals, after handling dirty equipment, after handling trash or other contaminated objects.

SM #17, Director of Infection (IP) on 2/20/2020 at approximately 10:00 a.m. in order to discuss concerns related to observations of infection control practices throughout the facility during the survey process. SM #17 shared infection control meeting minutes, infection control policies and procedures, and the facility's 2019 infection prevention annual evaluation. SM #17 also told the surveyor that quarterly rounds are conducted in the facility's kitchen, and any noted issues would be addressed.

SM #17 described the facility's "Secret Shopper" program to monitor for proper hand hygiene throughout the facility. Unit Managers gather and provide data to IP, information is then shared with the facility's quality program.
The surveyor discussed observations related to a physician entering an isolation room without donning proper PPE, and SM #17 said that leadership staff accompanying the surveyor at the time of the observation spoke with the clinician at the time of the incident, and that the incident had been referred for peer review. A discussion was also held related to clinical staff having supplies in their uniform pockets, and SM #17 said "uniforms are not for storage of supplies".

Concerns were discussed with the facility's Quality, Infection Prevention, Nursing, and Contracted Kitchen staff throughout the survey as described above; concerns were again discussed with administrative staff and department directors on 2/21/2020 at 2:15 p.m. at the exit conference.