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Based on observation, interview, and record review, on April 4-7, 2017, the governing body failed to provide effective oversight to ensure that patients recieved care in a safe environment.


1.The facility did not ensure that each patient receive treatment in a safe setting as evidenced by the presence of multiple ligature risks. These identical ligature risks were previously cited on March 8, 2017 and had not been removed.


2. The facility was not constructed and maintained to guarantee the safety and well-being of each patient as evidenced by the presence of multiple ligature risks. The identified practices continue to present a likelihood of Immediate Jeopardy to the 32 current patients and all potential patients with behavioral problems on the adult and adolescent units.


Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive treatment in a safe setting as evidenced by all patients placed on units with known multiple ligature risks present that were easily accessible for self-harm.


This deficient practice posed a likelihood of serious harm or death for current and potential patients with suicidal ideation on the adult and adolescent units.


Refer to 482.13(c)(2) - [A-0144]

Based on observation, interview, and record review, on April 4-7, 2017, the facility failed to ensure the rights of each patient to receive treatment in a safe setting. Eleven (11) of 33 patients (Patients #1, #2, #3, #10, #11, #15, #16, #18, #28, #32, #33) were placed in rooms with known multiple ligature risks present and easily accessible for use to harm self or others. These eleven (11) patients were on suicide precautions.


This deficient practice posed a likelihood of serious harm or death for current and potential patients with suicidal ideation on the adult and adolescent units.


Refer to 482.13(c)(2) - [A-0144]

Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive care in a safe setting on 2 of 2 patient care units (Unit 1-adult and Unit 2-child/adolescent). The facility failed to:


(1) remove multiple known ligature risks that jeopardized the safety of 11 patients on Suicide Precautions (SP) that included bathroom faucets, push/pull door handles, and architechtural grade butt door hinges potentially usable for ligature during self-harm,


(2) ensure that a patient diagnosed with Disorganized Schizophrenia on suicide precautions was prevented access to a glass light bulb and electrical wiring,


(3) ensure unoccupied patient bedrooms were locked when unoccupied,


(4) ensure that a personal hygiene item requiring poison control intervention in case of ingestion was inaccessible to patients,


(5) ensure that a piece of plastic that can be used for self-harm was not accessible to patients,


(6) implement an effective system to prevent patients on SP from accessing cutlery pthat can be used for to harm self or others,


(7) make certain newly admitted patient on SP did not have personal clothing item potentially that can be used for self-harm.



Findings included:


(1) Ligature Risks:


Observation on 04-04 17 at 2: 30 p.m. revealed the following:


Unit 1 (adults) :


Observation of all 19 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt hinges [the identical risks were previously cited on 03-08-17 survey].


Record review of facility "Patient Census," dated 04-04-17 revealed the Unit 1 census was 28 patients; two(2) were on Suicide Precautions (Patient # 15, #16).


Patient # 15:

Record review of the medical record of Patient # 15 revealed he was admitted on 04-02-17 with a diagnosis of "Schizophrenia superimposed on a mildly intellectually disabled state". Physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 15 was admitted to room 123-B where there are ligature risks easily accessible for self harm.


Patient # 16:

Record review of the medical record of Patient # 16 revealed she was admitted on 04-02-17 with diagnoses of bipolar disorder and polysubstance abuse. Admission orders dated 04-04-17, read: ...suicide precautions.." Patient # 16 was admitted to room 108-B where there are ligature risks easily accessible for self harm.



Observation on 04-04 17 at 2: 30 p.m. revealed the following:


Unit 2 ( adolescents/children) :


Observation of all 11 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the identical risks were previously cited on 03-08-17 survey].


Record review of facility "Patient Census", dated 04-04-17 revealed the Unit 2 census was 12 patients; three (3) were on Suicide Precautions (Patient # 1, # 2, # 10).


Patient # 1:

Record review of the medical record of Patient # 1 revealed she was admitted on 04-03-17 with a diagnosis of major depressive disorder with suicidal ideation. Physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 1 was admitted to room 204-A where there are ligature risks easily accessible for self harm.


Patient # 2

Record review of medical record of Patient # 2 revealed he was admitted on 03-17-17 with diagnoses of bipolar disorder and suicidal ideation. Observation on 04-04-17 of unit "bedboard" [whiteboard] and record review of "Precaution Sheets", dated 04-04-17 revealed Patient # 2 was on suicide precautions. Patient # 2 was admitted to room 205 where there are ligature risks easily accessible for self harm.


Patient # 10:

Record review of the medical record of Patient # 10 revealed he was admitted on 04-03-17 with a diagnosis of mood disorder/mood swings depressive disorder with suicidal ideation. Admission physician order, dated 04/04/17 read : "... suicide precautions..." Patient # 10 was admitted to room 221-B where there are ligature risks easily accessible for self harm.




Multiple observations were done on 04-05-17 & 04-06-17 between 8:00 a.m. and 2:00 p.m. on Unit 1 and Unit 2 revealed the following:


04-05-17:

Unit 1: three (3) patients were on suicide precautions ( Patients # 11, #15, 16)


Unit 2: four(4) patients were on suicide precautions ( Patients # 1, #2,# 3)


04-06-17:


Unit 1: two(2) patients were on suicide precautions ( Patients # 28, # 18)


Unit 2: five(5) patients were on suicide precautions ( Patients # 1, #2, #3,# # 32, #33)


Record review of the medical records for Patients 1, 2, 3, 11,15,16,18,28,32,33 revealed physician orders for suicide precautions on April 5 & 6, 2017.




Observation on 04-07-17 between 9 a.m. and 11 a.m. revealed the following:


Unit 1 (adults) :


Observation of all 13 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the same risks were previously cited on 03-08-17 survey].


Record review of facility "Patient Census," dated 04-07-17 revealed the Unit 1 census was 20 patients; two(2) were on Suicide Precautions (Patient # 15, #28). Record review of medical records for both patients revealed current physician orders for suicide precautions.


Unit 2 (adolescents/children) :


Observation of all 10 occupied patient rooms revealed the following ligature risks in each room: bathroom faucets, push/pull door handles, and architechtural grade butt door hinges [the same risks were previously cited on 03-08-17 survey].


Record review of facility "Patient Census", dated 04-07-17 revealed the Unit 2 census was 12 patients; two(2) whom were currently on Suicide Precautions (Patient # 2, #33). Record review of medical records for both patients revealed current physician orders for suicide precautions.



During the interview on 04-07-17 at 11:10 a.m. with Chief Executive Officer (CEO) #1, he provided the following information in regards to the ligature risks (previously cited on 03-08-17 survey) :


Faucets: waiting for a "prefab faucet shroud" to be developed. "This was supposed to be ready on 04-03-17 but the machine broke; should be ready by 04-10-17. We will test this to make sure it works before we order it. After it is ordered, it will be 4 to 5 weeks to be delivered and 1 week to install in all the patient rooms." CEO # 1 went on to say "the back up plan" was to order all new sinks which would be a 3 to 6 week delivery time; 2 to 3 week installation.


Door hinges: ordered on 03-24-17; delivery expected in 2 to 3 weeks; 2 week installation time.


Door handles: ordered on 03-23-17; up to 4 week delivery time; less than 1 week to install.


When asked how facility verified in-room checks (of patient's on SP) on the night shift, CEO # 1 went on to say the facility did not presently have closed circuit TV video (CCTV) surveillance cameras. He said the CCTV cameras were placed in the coming year's capital budget. No other measures were put in place in the interim.



During the interview on 04-06-17 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2, she stated in addition to the staff training , Registered Nurse (RN) rounds were increased from every 3 hours to every hour. She went on to say these rounds included RN verification that SP was correctly documented on unit bedboard, nursing notes, observation sheets, and treatment plans. CNO # 1 did not include actual patient observation by the RNs during the rounds. CNO #1 went on to say that RNs reviewed the patients for need for 1:1 monitoring, especially for those at high risk.


Record review of facility "Precaution Sheets", dated April 4, 5, 6, 7, 2017 failed to reveal any patients had been monitored 1:1 on any shift at any time. This was verified by interviews with charge nurses on both units on same dates.



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During an interview on 4/5/2017 at 7:45 am on the Adult Psychiatric Unit with Staff # 16 Charge Nurse, he stated when there are patients in their rooms the doors are kept opened and there was staff assigned to the hall to monitor the patients in their rooms. He stated, the staff is always on the hallway to ensure they are aware of the patients' locations. When the patients are not in their rooms the doors were locked with keys kept by staff.


According to Staff (# 16), patients were "eyeballed" every fifteen (15) minutes and the observation was documented on the rounding sheet. Staff (#16) stated patients on Suicide Precaution are monitored more closely. However, Staff (#16) was not able to describe what "more closely" meant or show where the "more closely" monitoring was documented for patients on suicide precautions.



( 2) Light fixture risk:


Observations in Room 123 on 04/05/17 at approximately 11:30 a.m. reflected a loose light fixture above the sink.


Employee #5 acknowledged the potential for hiding contraband and access by patients to a light bulb and electric wiring at that time.


The Patient Census dated 04/05/17 reflected Patient #15 was assigned to Room 123.


Patient #15's Psychiatric Evaluation dated 04/01/17 at 2354 reflected Patient #15 had a history of Schizophrenia. The patient was intellectually disabled. He was admitted with increasingly bizarre behavior, was noted to be hallucinating and stated he "would rather die."


Patient #15's Psychiatric Admission Orders dated 04/02/17 reflected the patient was on suicide precautions and on fifteen-minute observational checks.


Employees #2 and #17 were interviewed regarding the loose fixture on 04/05/17 at approximately 12:05 p.m. Employee #17 stated, "I would not be surprised if the patient did it."




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(3) Unlocked patient rooms with identified ligature risks : [120, 126, 204, 210, 222, & soiled utility room]


Observation on 4/4/17 at 3:25 p.m. of facility's child and adolescent unit hallways, accompanied by Registered Nurse (RN)#5, revealed an empty patient's room, #204. The door was closed but unlocked, allowing anyone to enter. RN #5 stated the room door should have been locked.


Observation on 04/04/17 at 12:30 p.m. of facility's child and adolescent hallways, accompanied by RN#5, revealed an empty patient's room, # 210. The door was closed but unlocked, allowing anyone to enter. RN #5 stated that the room door should have been locked.


Observation on 4/7/17 at 9:50 a.m. of facility child and adolescent unit hallways, accompanied by RN # 4, revealed an empty patient's room, # 222. The door was closed but unlocked, allowing anyone to enter. RN #4 stated that the room door should have been locked.


Observation on 4/5/17 at 11:00 a.m. of facility child and adolescent unit hallways , accompanied by Mental Health Tech (MHT) Staff # 8, revealed an unlocked door to the "Soiled Utility Room", allowing anyone to enter. Inside this Soiled Utility room the following items were observed: a sharp metal dust pan, a broom, two (2) large approximately 25 gallon sinks, two (2) large plastic bag trash can liners, a sprinkler head, regular door hinges, large air vents protruding down from ceiling, and a wheelchair with removable leg rests. MHT Staff #8 stated that this door should have been locked.



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Observations on 04/07/17 at 9:31 a.m. revealed that Rooms 126 and 120 were unlocked. No patient was observed in the room at that time. Personnel #8 acknowledged at that time that he should have locked Room #126. Room 126 was observed unlocked again approximately three hours later, on 04/04/17 at 12:20 p.m. without a patient's presence in the room.


Observation on 04-07-17 at 9:58 a.m. of Unit 2 patient "bedboard" [posted white board] revealed Patient # 18 was currently placed in room # 126 and was on Suicide Precautions. Record review of Patient # 18's physician order, dated 04-07-17 revealed SP had been in the room at that time. Personnel #8 acknowledged at that time that he should have locked Room #126. Room discontinued at 2:00 a.m. The white board had not been updated.


Record review of facility's policy titled "Locks on Patient Room Doors", dated 4/2017, read: "Purpose: to help in establishing a safe environment for patients and to mitigate ligature risks in patient rooms...Procedure:...Vacant unoccupied rooms will be locked...occupied patient rooms will be locked when the patients are in scheduled activities or not in their rooms.."


(4) Hazardous items

Observations on 04/04/17 at 2:40 p.m. on the hospital's adult unit Room 125, Bed A, had a bottle with lotion that stated to keep the content "out of reach of children." Bed B's night stand had a bottle labeled as antiperspirant that noted to "call poison control in case of ingestion."


Review of facility policy titled:" Search and Contraband", undated , read: "...Prohibited items-possessions that may create a safety risk for self or others:...toxic or hazardous liquids, materials, or aerosols..."


(5) Hazardous item


A piece of black plastic material potentially dangerous when ingested or inhaled was observed in the bathroom of Room 126 on 04/04/17 at approximately 2:25 p.m. Personnel #13 acknowledged the item and removed it.


Record review of a blank facility "Environmental Services Daily Routine Quality Checklist" read: "...TASK: Clean shower stall..remove ...all debris.."


(6) Accessibility of cutlery


During the interview in the facility kitchen on 04-06-17 at 10:45 a.m. with Assistant Dietary Director # 37, she stated the facility used Styrofoam and plastic products because they have "many patients at risk to harm themselves". She went on to say patients on Suicide Precautions (SP) were not given any cutlery, salt, or ice.


Dietary Director # 37 said, 'Nursing gives us the Diet Logs every day and it will indicate if a patient is on suicide precautions. We prepare the patient tray based on that".


Review of the "Adult Diet Sheet"; "Adolescent Diet Log"; and the Children Unit Diet Log" , all 3 dated 04-06-17 failed to indicate any patient on any unit was on SP. Assistant Dietary Director # 37 said "according to the logs, no patients are on SP today."


Observation on 04-06-17 at 11:15 a.m. on the Children's hall activity room revealed six (6) patients eating lunch. Further observation revealed after the children finished eating, they disposed of the trash from their trays into a large paper bag located on the floor by the wall. Patient # 32 was observed disposing of his trash which included plastic cutlery. At the time Patient # 32 placed his trash into the paper bag, Mental Health Tech (MT) # 7 had his back to this patient. No other staff was observing this patient.


Further observation revealed Patient # 32 could have easily hidden the cutlery on his person with no staff noticing.


Record review of facility "Precaution Sheet, Unit 2: Children", dated 04-06-17 ( 7A-7P) revealed Patient #32 was on Suicide Precautions.


(7) Personal clothing: ligature risk


Observation of room # 206 on 04-07-17 9:30 a.m. revealed a plastic basket that contained clothing. Within the basket a girl's tank-top style shirt with thin "spagetti straps" was observed . RN # 6 stated Patient # 33 had been newly-admitted to this room. She went on to say this patient was on Suicide precautions (SP). RN # 6 said the patient should not have a shirt with straps like this as they posed a risk. She removed the shirt from the room.


Review of facility policy titled "Organization Ethics and Compliance", revised 5-18-16, read: "...Treatment of Patients:...The well-being and safety of patients should be the focus of all employees...Safe Patient Care: Safe environment safe care is essential to the well-being and recovery of psychiatric patients.....the hospital will promote a safety culture based on appropriate policies, systems,and equipment..."

Based on record review, observation, and interview, the hospital's nursing staff failed to supervise and evaluate the nursing care for two of two patients (Patients #15, #20) according to the patients' needs.


1)Although Patient #15 had a 50 pound reported weight loss during the two months prior to his hospital admission, nursing failed to verify the patient's reported weight on admission and to obtain a dietary consult for the patient who was under-weight and refused at least three meals at the time of survey,


2)Although Patient #20 had been noted to be losing weight during his partial hospitalization treatment, nursing did not weigh the patient for two and one half months.


Findings included:


1) On 04/05/17 at 11:15 a.m., Patient #15 was observed in the adult unit's dining room. Patient #15 was very slender. He refused his lunch meal. Personnel #12 reported the patient did not eat breakfast.


On 04/05/17 at 1635, Patient #15 was observed eating only his dinner roll and refused to eat the rest of the meal.


Hospital Intake Assessment dated 04/01/17 at 11: 24 a.m. reflected Patient #15 had lost 50 pounds during the two months prior to his admission.


Vital Signs Flow Sheet dated 04/06/17 reflected the patient weighed 131 pounds.


Personnel #20 was interviewed by telephone on 04/06/17 at 9: 11 a.m. and denied that the Patient #15 was weighed during the hospital intake process because the patient was "non- responsive."


On 04/06/17 at 4:00 p.m. Personnel #5 stated a dietary consult was ordered at that time.


Personnel #2 acknowledged that Patient #15's reported weight on admission had not been verified through hospital personnel.


According to the National Institute of Health, Patient #15 had a body mass index of 17.8 and was under-weight. (https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm)



2) Patient #20's Psychiatric Progress Notes dated 04/05/17 reflected that nursing reported the patient's "ongoing weight loss."


During an interview on 04/06/17 at 11:55 a.m., Personnel #24 stated the physician saw Patient #20 the day prior to the interview and noted the patient's weight loss. Personnel #24 denied weighing the patient at that time and stated the last time that the patient was weighed was on 01/18/17.

Based on record review, observation, and interview, the hospital failed to keep current a nursing care plan according to hospital policy for one of one patient (Patient #15) whose fear of receiving poison in his hospital food was not addressed by the treatment team.


Findings included:


Patient #15's Psychiatric Evaluation dated 04/01/17 at 11:54 p.m. , unsigned as of 04/05/17 at 3:15 p.m., reflected the patient's admitting diagnoses that included Disorganized Schizophrenia and Mild Intellectual Disability. Prior to his hospital admission, Patient #15 had decreased his food intake and lost 50 pounds.


On 04/05/17 at 11:15 a.m. Patient #15 was observed in the adult unit's dining room. He refused his lunch meal. On 04/05/17 at 4:35 p.m., Patient #15 was observed eating only his plastic wrapped dinner roll and refused to eat the rest of the meal.


On 04/07/17 at 1:45 p.m., Patient #15 stated through an interpreter that he thought his food was "poisoned" and staff put medicine in his food. Patient #15 stated he would "die soon."


Patient #15's Multidisciplinary Treatment Plan dated 04/05/17 did not address the patient's statements regarding hos food had 'poison" or staff adding medicine to it.


Personnel #5 denied on 04/06/17 at 2:00 p.m. that Patient #15's treatment plan addressed the patient's fear.


Clinical Services Policy # 608, undated, reflected the hospital policy to "provide documentation ...of the care and treatment ...that is planned and provided ..."

Based on observation and interview, the hospital failed to ensure that the facility and equipment were maintained to ensure an acceptable level of safety and quality.


Findings included:


Observation on 04/04/17 at 2:20 p.m. revealed a fist-sized hole in the wall of the hallway leading from the main entrance to the adult patient unit.


A small cove in the hallway identified by Personnel #13 as space formerly occupied by washer and dryer was observed on 04/04/17 at 2:20 p.m. with water dripping from the space above the missing ceiling tile. Wet towels covered the floor.


Observations on 04/07/17 at 9:26 a.m. revealed water dripping again through the ceiling into a trash barrel. Two wet towels were on the floor at that time.


Observation on the hospital's adult unit Quiet/Activity Room on 04/04/17 at 2:55 p.m. revealed the paint on at least two walls was scraped off. Personnel #3 and/or Personnel #13 acknowledged the findings at that time.


Two stained ceiling tiles were observed in the hospital's clean utility room and in the hallway in front of Room 123 on 04/05/17 at 11:40 a.m.


Observations in the hospital's Partial Hospitalization Program on 04/06/17 at 12:25 p.m. revealed a central supply room with multiple brown spots, trash, and two bugs on the floor. A floor tile was missing. Personnel #23 stated on 04/06/17 at 12:30 p.m. that the room had not been checked.


Observations in the hospital's Central Supply room on 04/06/17 at 2:20 p.m. revealed a rough cement floor without covering. Two light bulbs were burnt out. A rectangle hole sized approximately 15 centimeter times 10 centimeter was cut out of the wall's sheet rock and gave view onto the wood frame. Three walkers identified by Personnel #5 as "used" were leaning against two pair of wrapped crutches. Personnel #5 stated, the crutches were new and acknowledged that used and clean equipment were in close proximity. Three large ceiling tiles were missing and gave view to pipes in the floor above. A large piece of plastic was dangling down from the ceiling.


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Observation on 04-06-17 at 11:30 a.m. on the of children's unit revealed three large holes in the hall's walls in-between patient rooms on the children's unit. There was one hole next to patient room 205 approximately 6" x 3" with a 3"-5'' depth (6 inches x 3 inches with approximately 3-5 inch depth). Further observation revealed another hole in the wall of approximately the same dimensions as the first aforementioned hole. This second hole was located between patient rooms 205 and 206. A third smaller hole also in the corridor hallway walls, approximately 2" x 4" with approximately a 2"-3" depth (2 inches by 4 inches with approximately a 2-3 inch depth) was also located between patient rooms 205 and 205.


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Observation on the adult unit on 4/5/2017 at 9:15 am in the bath room shared by rooms 121 and 122 revealed an area of peeling ceiling plaster over the hand sink low enough for a patient to reach up and pull the peelings off. This material could be ingested by a patient. The rooms were occupied by patients.


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Observation in the facility kitchen on 04-06-17 at 10:30 a.m. revealed a large six(6) burner industrial gas stove top. The stove top was approximately 3 feet in height from the floor. The pilot lights on all six burners were lit and appeared to be approximately 3 inches in height. Heat was felt coming off the appliance as surveyor walked by the stove top.


When asked at the time of observation, Dietary Director # 37 said she did consider this a safety hazard. She said "I was reaching over on the stove top one day and caught my shirt on fire." Dietary Director # 37 went on to say she had brought this to the attention to the contracted company she worked for "but this is the way they like it."

Based on observation, interview, and record review, the hospital failed to develop an effective system for identifying and controlling potential infections.


Patient accessible furniture and equipment were in need of repair and cleaning,


Patient belongings / clothing were stored directly on the floor,


Washing machine was not cleaned after each use,


Clean linen was not stored in a manner to prevent contamination,


Staff failed to sanitize their hands prior to donning gloves.


Findings included:


Observation on the hospital's adult unit's Quiet/Activity Room identified by Personnel #13 on 04/04/17 at 2:55 p.m. as patient care area reflected two chairs with ripped padding which would make it difficult to adequately clean and sanitize. The paint on at least two walls was scraped off. The wood veneer table top was broken in two places leaving it difficult to clean.


A large black bug was observed in Room 120 on 04/05/17 at 12:10 p.m. across the room. Personnel #17 stated it was a spider and removed it.


Observations on 04/05/17 at 11:40 a.m. in the hospital's adult unit clean utility room reflected one oversized and one regular sized wheel-chair covered with plastic. Employee #5 stated those wheel-chairs were clean. Both wheel-chairs were observed with dusty and grimy wheels. Employee #5 acknowledged the observations at that time and stated they needed to be cleaned.


Review of undated Hospital Policy titled "Hospital Equipment Cleaning" reflected that "equipment used routinely during the day shall be cleansed after each use per national healthcare regulatory standards ...examples of these are wheel-chairs."


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Observation during initial tour on 04-04-17 between 2:30 p.m. and 3:30 p.m. revealed the following infection control issues on Unit 2 (adolescent and children's hallways):


Patient belongings room:


a. Floor was dirty with multiple areas of dark grime and stains,

b. (3) large 30 gallon plastic bags overflowing with clothing were placed directly on the floor,

c. Two (2) wire shelving units that contained various patient items: no plastic/impermeable barrier noted on the bottom shelf of either shelving unit.


Interview with Chief Nursing Officer (CNO) # 2 at the time of observation, she stated the floor should be cleaned and the clothing bags should all be labeled and not be stored on the floor. CNO went on to say she thought all the wire shelving units had plastic barriers on the bottom; "these must have been missed."


Patient laundry room:


Observation of the washing machine revealed a thick film that covered most of the inside of the washer. Interview with CNO # 2 at the time of observation, she said the washer was used to wash the patients' clothing and it should be cleaned after every use by the techs.


Record review of facility policy titled" Cleaning of Patient Washers and Dryers, undated, read: "...3. The hospital staff will spray the drum with disinfectant solution and allow to air dry following each use...Housekeeping will disinfect the machine daily.."


Clean linen storage room:


Observation of a large wire cart that contained stacks of linen revealed a wadded up towel and a plastic "golf club" mixed in with the "clean linen". Further observation revealed no plastic/impermeable barrier noted on the bottom shelf of the storage cart.


Interview with CNO # 2 at the time of observation, she stated the bottom shelf should have a plastic barrier on the bottom. She acknowledged the linen could become contaminated when the floor was mopped.


Review of facility policy titled" Handling of Clean and Soiled Linen", undated , read: "Clean Linen shall be handled, transported and stored by methods that prevents contamination and ensures cleanliness.."


Hand Hygiene:


Observation on 04-06-17 at 11: 00 a.m. revealed Mental Health Techs(MHT) # 8 and MHT# 9 preparing to serve lunch trays on the children's hallway. Both MHTs failed to sanitize their hands prior to donning gloves and serving lunch to the patients.


Interview on 04-07-17 at 1:00 p.m. with Registered Nurse (RN) # 4, she stated hand hygiene should be performed before and after donning gloves.


Record review of facility policy titled " Hand Hygiene",undated, read: "...Indication For Hand Washing and Hand Antisepis: Hands should be sanitized using the hospital approved waterless antiseptic agent in the following situations:...upon entering the work area...before eating or handling food..."