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Based on review of documentation and interview, it was determined that the facility did not follow its own policy in regard to complaint resolution.

Findings were:

Facility policy entitled "Patient Grievance Procedure" stated in part, "The Patient Advocate will attempt to respond in writing to all grievances within 7 calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within 30 calendar days of receipt of the grievance.

a) The written communication includes a statement of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of completion, and the Patient Advocate contact information. If the grievance could potentially result in legal action, the Patient Advocate reviews the written response prior to mailing the notice to the patient. Physician peer review proceedings and employee and physician disciplinary actions are confidential; therefore, these outcomes are not communicated to the complainant.
b) In these cases, the written response will explain that the concern has been addressed by the appropriate committee or department through its internal policies and procedures. Whether or not a grievance is filed by the patient or by another individual on his/her behalf, written response is made directly to the patient.

The grievance and problem resolution/follow up should be documented. This documentation shall include:
· Date complaint received
· Name of person voicing a grievance/how to contact
· Patient name
· Nature of complaint
· Pertinent investigational information
· Resolution of grievance/follow up
· Signature of Patient Advocate
· Date complaint resolved."

Review of "Patient Communication Forms" dated 11/01/13 through 2/15/14 revealed 75 of approximately 145 patient complaint forms with no documented follow up with the patient or patient representative. No issues were identified with forms from 2/15/14 to the date of survey (4/23/14).

In an interview with the Patient Advocate and the Chief Executive Officer on 4/23/14, the lack of documented response to written patient grievances was acknowledged. It was also confirmed that staff members were not following facility policy and procedure in regard to the grievance procedure.








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Based on observation, interview and review of documentation the facility did not always ensure the safety of its patients.

Findings were:

Tour of the facility on 4/22/14 revealed Patient # 21 lying in his room at midday utilizing his C-Pap machine. When asked where he stored the machine while not in use, the patient replied that he kept the machine on the shelf in his room. He said that he had no access to a locked cabinet.

On the adolescent unit, exposed electrical cords with attached power strips were noted dangling from the TV cabinet. A broken electrical outlet was also observed.

In an interview with the Chief Executive Officer on 4/22/14, it was acknowledged that the C-Pap machine, with its cords and tubing, presented a danger to the psychiatric population as did the electrical cords, broken electrical outlet and power strip. On 4/23/14, the CEO told the survey team that Patient # 1's private C-Pap machine had been cleaned and was now stored in the nurses' station.

Based on review of documentation, medical records and interview, it was determined that the facility failed to complete all of its medical records within specified time limits.

Findings were:

Facility policy entitled "Medical Staff Rules and Regulations" stated in part "Verbal orders are strongly discouraged. The responsible practitioner/ or practitioner familiar with the case shall authenticate such orders within 48 hours. A telephone admission order must be authenticated by the issuing physician along with the written or dictated admit note within 24 hours. Orders for Restraint/Seclusion and admission order must be authenticated within 24 hours."

Facility policy entitled "Completion of the Medical Record" stated in part "A completed medical record is one that contains the following:

a) All documentation and orders, including telephone/verbal orders, are signed, timed and dated by the issuing practitioner. Telephone/verbal orders may be signed, timed and dated by a designated practitioner signing for an order the on call practitioner wrote;
b) History and Physical examination signed, timed and dated;
c) Psychiatric Evaluation (should be dictated);
d) Consultations (if applicable) signed, timed and dated;
e) Discharge Summary (should be dictated)
1. A medical record is considered deficient if any of the above is not completed by the time of discharge, or by individual policy, if applicable
2. A medical record is considered delinquent if any of the above is not completed within 30 days from the time of discharge.
3. Practitioners will be notified weekly of all deficiencies and delinquencies."

Facility policy entitled "Documentation Procedure/Error Correction/Authorized Personnel" stated in part,

· "Medical Record entries must be completed in a timely manner.
· Telephone/verbal orders must follow read back procedures. All medical record entries must be signed, dated and timed by the author. Telephone/verbal orders must follow read back procedures and be signed within forty eight (48) hours or twenty four (24) hours for admit orders.
· Never pre or postdate entries
· If an entry is made in the hard copy medical record retrospectively, it must reflect the date and time the entry is actually made. Note the reason for late entry and sign with a full signature."

Patient # 1 was discharged on 3/12/14. The following documents were unsigned 40 days after discharge:

· The Discharge Summary
· The History and Physical
· Physician Order dated 3/9/14 for Seclusion or Therapeutic Hold
· Physician Order dated 3/9/14 for emergency medications
· Physician Order dated 3/9/14 for transfer to ER for " medical clearance. "
· Physician Admission Orders dated 3/9/14

Patient # 3 was discharged 4/11/14. The following item was not cosigned:

· "Observation Form" dated 4/11/14 was not cosigned by the 7-3 or the 3-11 RNs.

Patient # 4 was discharged on 3/31/14. The following items were not signed within 48 hours:

· Physician Verbal Order dated 3/13/14 for emergency medications
· Physician Verbal Order dated 3/13/14 for Seclusion or Therapeutic Hold

Patient # 8 was discharged on 4/8/14. The following items were not signed in a timely manner:

· Physician Verbal Order dated 3/31/14 for medications
· "Observation Form" dated 3/31/14 not cosigned by 7-3 or 3-11 RNs.

Patient # 9 was discharged on 4/21/14. The following items were not signed in a timely manner:

· Psychiatric Evaluation was not dated and timed by the physician
· "Observation Form" dated 4/11/14 was not cosigned by 7-3 or 3-11 RNs.
· Medication Consent form dated 4/8/14 was not cosigned by a physician.

Patient # 10 was discharged on 4/21/14. The following items were not signed in a timely manner:

· Physician Verbal Order dated 4/17/14 for emergency medications.
· History and Physical not signed, timed or dated
· "Observation Form" dated 4/21/14 not cosigned by 7-3 or 3-11 RNs.

Patient # 13 was discharged on 4/15/14. The following items were not signed within 48 hours:

· Physician Verbal Order dated 4/7/14 for Elopement Precautions
· Physician Verbal Order dated 3/29/14 for Medication
· Physician Verbal Order dated 3/26/14 for Unit Restriction
· Physician Verbal Order dated 3/12/14 for Medication

Patient # 16 was discharged 3/11/14. The following items were not signed in a timely manner:

· Physician Discharge Summary dated 3/11/14 was not signed, dated or timed
· Psychiatric Progress Note dated 3/7/14 was not signed, dated or timed
· Medication Consent dated 3/4/14 was not signed by the Physician until 3/13/14

Patient # 19 was discharged on 2/28/14. The following item was not signed within 48 hours:

· Physician Verbal Order dated 2/26/14

In an interview with the Chief Executive Officer on 4/23/14, the above delinquent medical records were confirmed.

Based on observation, review of documentation and interviews with facility staff, the facility failed to properly store medications as the medication refrigerator in the partial hospitalization unit had not had the temperature checked consistently. This was not in accordance with facility policy and could have potentially resulted in patients receiving ineffective or unsafe medication due to improper storage.

The findings were:

The facility policy entitled "Medication Storage" #PH.39 dated 1/14 reflected in part "Medications requiring refrigeration will be stored in a refrigerator, which will be maintained by the medication nurse at a temperature of between 36 and 46 degrees Fahrenheit. The temperature of each refrigerator on each nursing unit will be recorded by nursing personnel on a daily basis on a log sheet which shall be maintained on the nursing unit."

During a tour of the partial hospitalization unit on the afternoon of 4/22/14, the temperature log for the medication refrigerator in the nursing room was observed to not have temperatures recorded for the following dates: 3/17-20/14; 3/24-27/14; and 3/31/14. There was no temperature log for April 2014. The refrigerator contained two vials of insulin which required refrigeration.

In an interview with the unit nurse, staff #4 on the afternoon of 4/22/14 in the nursing room, staff #4 was asked if there was a temperature log for April 2014. After checking, staff #4 stated none could be found. When shown the log for March 2014, staff #4 agreed the missed temperature recordings noted above were on days the unit was open and should have been done.

Based on observation, review of documents and interviews with facility staff, the facility failed to make outdated drugs unavailable for patient use as an expired vial of insulin was found in the partial hospitalization unit medication refrigerator available for use in patient care. This was not consistent with facility policy and could have potentially resulted in patients receiving ineffective or unsafe medication.

The findings were:

The facility policy entitled "Expiration Dates" #PH.41 dated 3/13 reflected in part "9. Expiration dates of medications will be checked during the routine medication area inspections, and all medications scheduled to expire that month for before the next inspection will be removed."

During a tour of the partial hospitalization unit on the afternoon of 4/22/14, the medication refrigerator in the nursing room was observed to contain a vial of Humulin R insulin, 100 units/ml, with a prescription label for patient #22. The prescription label reflected "discard after 1/5/14."

In an interview with the unit nurse, staff #4 on the afternoon of 4/22/14 in the nursing room, staff #4 agreed the vial of insulin for patient #22 was expired and should have been discarded.

Based on observation and interview, it was determined that the facility failed to demonstrate effective monitoring of the facility's dietary and patient care areas for a safe and sanitary environment for it's staff and patients, as correctable potential infection control issues were identified.

Findings were:

The facility failed to monitor the following areas to mitigate potential infection control issues:

Tour of the kitchen/dining room on 4/22/14 revealed the following:

· In the dining room a cabinet had sawdust and insect bait present where cup lids were being stored. Brown sticky stains were observed to the interior to the cabinet door.
· The door frame leading into the kitchen was rusted and abraded
· The tile surrounding the drain in the dishwashing room was missing and the concrete underneath was abraded.
· Approximately 20 metal pans were stacked with moistures present between the pans. This moisture could provide a medium for bacterial growth.
· 2 muffin tins had what appeared to be food debris present.
· The lip to the ice machine was dirty with what appeared to be dirt/food accumulation
· 3 bags of open pasta unlabeled as to date opened were found in the walk in pantry
· A tray of 12 uncovered and unlabeled Jello desserts were found in the walk in cooler.
· Open and unlabeled bottles and jars of mayonnaise, oils, and juices were noted in the walk in cooler. An open container of cottage cheese was observed in the area with no date indicating when it was opened. Two jugs of salad dressing were observed with a sticky substance on the outside of the containers.
· A tray of uncovered and unlabeled ground beef was noted in the walk in freezer. The Kitchen Manager stated, "I put that meat into the freezer this morning. After it freezes, I will individually wrap and label it."
· The floor of the staff restroom was dirty with peeled paint. The door to the restroom was dirty with an accumulation of a greasy, brown substance marking where the door had been pushed open by employees.
· The vent above the clean sink was covered with dust which permeated the surrounding ceiling. This vent was situated above a sink where a large pot of pasta was cooling, potentially blowing dust onto the patients' lunch.
· A plastic pitcher containing four "clean" knives was observed to have visible dust and debris in the bottom.
· The serving line floors were dirty, with an accumulation of black colored substance under the steam tables.
· Steam table lids were visibly dirty.
· The cooler storing milk had a leak which resulted in a pool of water. This created a fall risk for staff. This also presented a risk for mold and bacterial growth.
· Food splatters were noted on the ceiling.
· An electrical outlet was observed to have visible debris and dust present.
· The light switch cover the dining room was observed to de discolored with dark smudged around the switch.
· The trash can located beside the hand washing sink was inoperable by foot pedal requiring staff touch the trash can lid to dispose of paper towels after hand drying.
· Dried food spills were observed on the floor on the patient side of the serving line.
· One drain under the serving line was dirty, with an accumulation of dust, hair and an unknown green substance.
· Insects were visible in the light fixture in the dining room.
· The hand sanitizer dispenser was empty when checked.

Tour of the kitchen and dining room area on 4/23/14 revealed the issues noted above had been repaired and/or corrected.

Tour of the adult medication room on 4/22/14 revealed the following:

· The floor was dirty with paper scraps and one broken tile.
· Stained ceiling tiles
· Observed under the sink were a plastic container, a scoop, a large bottle of Dr. Pepper and a puddle of dried brown liquid.
· A yogurt was found in the medication refrigerator which was labeled that food was not to be stored in the refrigerator.

Tour of the adult unit on 4/22/14 revealed the following:

· A "Patient Snack" refrigerator log for April 2014 stated "Note: for temp above 45 F or below 36 F Maintenance must be notified." On the following dates refrigerator temperatures were above 45 degrees Fahrenheit with no documented notification of Maintenance: 4/11, 4/12, 4/13, and 4/19.

Tour of the adolescent medication room on 4/22/14 revealed the following:

· Paint was observed to be flaking off the ceiling above the mediation carts. Tape was also observed on the ceiling above the medication cart.

Tour of the Adolescent Unit on 4/22/14 revealed the following:

· 2 vents were dust covered with noted dust accumulated in the "popcorn ceiling" surrounding the vents.
· In room # 246 a 6 X 6 inch hole was observed in the wall.
· Several ceiling tiles near the nursing station had water damage.

Throughout the units, duct tape and paper tape demarcation were observed on the floor. Tape cannot be clean effectively. Throughout the facility insects were observed in light fixtures.

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility policy entitled "Exposure Control Plan" stated "Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, the type of surface to be cleaned, type of soil present, and tasks and procedures being performed in that area. All contaminated work surfaces are decontaminated after completion of procedures, immediately or as soon as feasible after any spill of blood or other potentially infectious materials, and at the end of the work shift."

Facility policy entitled, "Food Storage" stated in part, "All containers of food properly re-sealed after portions are removed and the container dated."

· "Work and floor surfaces will be kept clean and free of clutter and defects
· Pots and pans will be scrubbed with stiff brushes or non-metal scouring pads
· Vents in range hoods are intact and cleaned regularly
· Floors are to be kept dry, free of grease, flour or other loose objects. Spills are to be wiped up immediately and a wet floor sign posted."

Tour of the facility on 4/22/14 with the Chief Executive Officer confirmed the above infection control deficits.