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Based on observation, interview, record review, and policy review, the facility failed to:
- Ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to provide an environment aimed at preventing looping and hanging hazards;
-Provide a safe environment when waste containers lined with plastic bags were accessible to suicidal patients;
-Provide a safe environment when plastic bags were stored in an unlocked cabinet and were accessible to suicidal patients;
-Provide a safe environment when staff did not confiscate clothing contraband according to their facility policy, which allowed patients with suicidal tendencies to have access to items which could be used to loop over environmental hazards;
-Ensure staff documented the actual time of patient observations when ordered every 15-minutes;

Based on interviews with management the admission criteria requires the patient to be severely depressed, acutely suicidal (SI) or homicidal (HI). All patients are either SI, HI, or both.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

The facility census was 53.

Based on observation and interview, the facility failed to provide the correct phone number for patients to file a complaint with the State. The facility census was 53.

Findings included:

1. Record review of the facility's form titled "Your Opinion Matters," dated 03/06/07, showed the following:

-If you have a complaint or grievance with the services being provided you may contact Missouri State Licensure Complaint line at 573-751-6303 (correct phone number).

However, observation on 08/16/11 at 9:58 AM showed the facility posted a patient rights sign in the 4 South hallway with phone numbers for patients to contact the State office in case of complaint. The phone number listed was incorrect (573-751-0293, and should have been 573-751-6303).

During a phone call and interview on 08/16/11 at 11:23 AM, to the person answering the phone at the number the facility had listed, the department reached was the Professional Registration department, not a number to file a general patient complaint.

During an interview on 08/17/11 at 9:10 AM, Staff E, Registered Nurse Manager of 4 South, stated that he/she was not aware the phone number was wrong, but would have it corrected.


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2. During an interview on 08/16/11 at 2:35 PM, Staff R, Nurse Manager 2 South, called the phone number the facility had listed on patient rights to file a complaint. The department reached was the Professional Registration department, not a number to file a patient complaint. Staff R stated that he/she did not know the number was incorrect and had not tried to call the phone number prior to today.

Based on observation, interview and policy review, the facility failed to provide personal privacy for patients while doing physical assessments. This had the potential to affect all patients on unit 2 South with a census of 19 and unit 4 South with a census of 16. The facility census was 53.

Findings included:

1. Review of the facility's undated policy titled "Conditions of Admission/Admission Consent," provided by the Chief Nursing Officer, showed the patient and/or their legal guardian have the following rights:

-To every consideration of privacy concerning my medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. Those not directly involved in my care must have my permission to be present.

2. Observation on 08/16/11 at 9:19 AM showed Staff G, Registered Nurse (RN), called a minimum of three patients by name to a chair in the common area of the 4 South unit and listened to the patient's lungs, did a pupil check of the eye, took the blood pressure, pulse and temperature. The common area was filled with patients, and other staff, within hearing and visual distance of these assessments.

During a concurrent interview, Staff E, RN Manager of the 4 South unit, stated that RN G was doing the daily assessment on each of the patients.


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3. Observation on unit 2 South on 08/15/11 at 3:15 PM showed paperwork for physician's orders for two patients sitting on the nurse's desk and viewable to anyone behind the nurse's station. Staff U, RN, called a patient into the nurse's station, had the patient sit in a chair at the nursing desk where other patient records were located and then listened to the patient's lungs, did a pupil check and took the patient's blood pressure, pulse and temperature.

There were other staff members in the nurse's station and other patients within hearing distance of this assessment.

During an interview on 08/15/11 at 3:17 PM, Staff R, RN Nurse Manager of unit 2 South, stated that Staff U did an assessment of the patient in the nurse's station and did not provide for the patient's privacy or the confidentiality of the other patient's medical records located on the nurse's desk and in the nurse's station.

Based on observation, interview, record review and recognized standards of practice, the hospital failed to:

-Ensure patients are provided care in a safe setting in 28 of 28 patient rooms when the hospital failed to provide an environment aimed at preventing looping and hanging hazards;
-Provide a safe environment for all patients on unit 2 South with a unit census of 19 when waste containers lined with plastic bags were accessible to suicidal patients;
-Provide a safe environment for all patients on unit 3 South with a census of 18 when plastic bags were stored in an unlocked cabinet accessible to suicidal patients and;
-Provide a safe environment when staff did not confiscate clothing contraband according to their facility policy, which allowed patients with suicidal tendencies to have access to items which could be used to loop over environmental hazards.

Based on interviews with management the admission criteria requires the patient to be severely depressed, acutely suicidal (SI) or homicidal (HI). All patients are either SI, HI, or both.

This had the potential to affect 53 of 53 patients. The facility census was 53.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with the Joint Commission patient safety goals as well as the current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

The Joint Commission (TJC) is a United States-based not-for-profit organization. The Joint Commission accredits over 19,000 health care organizations and programs in the United States. This hospital is accredited and deemed by TJC.

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA, TJC and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
-Use doors with piano hinges or other hardware that reduces the risk of the hardware being used as an anchor. Use anti-ligature doors for non-corridor doors (e.g. bathrooms, stalls, showers);
- Plumbing enclosed in a tamper-resistant enclosure to prevent access by patients. Plumbing fixtures should be enclosed to minimize risks. All supply and waste plumbing should be concealed and inaccessible with tamper resistant fasteners;
- Faucets and spouts in sinks and showers should be an institutional type. There should be no handheld shower devices and no temperature adjusting devices with in the showers (unless recessed). Shower heads should be institutional type. Institutional faucets will not provide an anchor point for hanging.


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2. Observation of 4 South unit with census of 16 inpatients on 08/15/11 at 2:30 PM through 08/17/11 at 1:00 PM showed nine patient rooms (Rooms 420, 422, 424, 425, 426, 427, 428, 429 and 430). Each patient room contained a private bathroom with a shower, hand washing sink and toilet, all with conventional plumbing fixtures. Observations of each patient room showed the following:
-Hand-made plastic Lexan (a brand of thermoplastic) grill covers affixed to ventilation duct openings in ceilings and walls of each bedroom and private bathroom. Each cover was perforated with hand-drilled holes that ranged in size from one-half inch diameter up to five-eight's inch in diameter which provided a potential looping hazard for a sheet or cord to be passed through the holes and tied off.
-Single control operated mixing faucets extended five and one-half inches above the top of the sink and counter top in each private bathroom, and hand wash sink outside of a locked staff bathroom provided potential looping hazards.
-Exposed plumbing and flush valve mechanism behind each bathroom toilet extended 26 inches above the toilet base and six inches from the wall behind the toilet and provided a potential ligature hazard.
-Large plastic toilet paper dispenser in each bathroom measured 46 inches above the floor and protruded six inches from the bathroom wall provided a potential looping hazard.
-Handle of each shower control valve in patient bathrooms measured two and three-quarters inches long provided a potential tie-off point for looping and ligature hazard.
-Metal frames and attached shower doors with opaque Lexan plastic panel inserts provided a potential hanging or looping hazard. The sharp edges at the top of the shower door frame were not finished and provided a potential slicing hazard to patients.
-Conventional door knobs on entrance doors and all bathroom doors 40 inches above the floor presented looping hazard and do not afford maximum protection to at risk patients behind a closed door and out of staffs line of vision.
-Conventional hospital hinges on entrance and bathroom doors measured seven inches high by one inch wide opening between the door frame and the hinge provided a potential hanging or looping hazard with the door opened or closed.
-Vent control knobs on existing wall radiators in patient bedrooms and common areas were 26 inches above the floor and provided a potential hanging or looping hazard to patients regardless of whether the knob was removed from the stem or not.
-Metal access doors located in bathroom ceilings and patient bedrooms were secured with common Phillips head screws (type of cross-head screw) which were not tamper resistant.
-Plastic covers used in all rooms and areas on blind junction boxes, light switches and duplex electrical outlets were breakable and could be used by a patient to cut themselves or others.
-Single staff bathroom located behind the nurse's station and out of direct line of sight was locked, however the corridor-accessible, conventional hand washing sink fixture in the anteroom, steel paper towel holder screwed to the wall and door knob to locked tub/bathroom remained exposed and provided potential looping or ligature hazards to those patients not directly supervised.
-Room 429: large metal access door and frame in the ceiling air conditioning unit were separated 1/16th inch opening along the sides, between the frame and door which created a looping or hanging hazard as a cord or sheet could be placed across a corner of the door.
-Sink top and cabinet in the bathroom of Room 428 pulled away from the wall exposed a ? inch open crack and possible access to plumbing.
-Room 427: lock cylinder hanging out of its housing in a ceiling panel, created a potential hanging hazard if a cord or wire were wrapped around the lock or tied to the lock, it could support a substantial weight before breaking. Common Phillips head screws used to secure top of box beds; metal brackets and Phillips head screws used to repair a cracked light lens in the bathroom. Phillips head and flat head screws and metal brackets are hardware that are easily undone with a pocket knife, paperclip, or coin and present a significant hazard to the occupant and do not assure protection of the occupant from self harm.
-Room 425: ceiling panel above the window bed had a gap the size of a pencil lead (1/16th inch), and the lock cylinder hanging out of its housing showed signs it had been tampered with; plastic light cover pulled away 1/16th of an inch from the wall and mounting attachments. Gaps between hardware and lock cylinders provide potential looping points to pass a cord or wire through the edge or around the cylinder's crown.
-Room 426: a six by six Lexan vent in the bathroom was separated from the ceiling 1/16th of an inch, providing a potential looping hazard for thin cord or wire. In the bathroom ceiling, a large access panel to air conditioning had a missing lock cylinder, which left a half inch diameter hole. The panel was secured with common Phillips head screws that could be easily undone with a pocket knife, coin or paperclip present a significant hazard to the occupant and do not assure protection of the occupant from self harm.
-Room 417: time out/seclusion room door to corridor was out of adjustment and did not close securely into the frame. The solid core door only opened inward, a potential risk for barricading, and hung on three conventional hinges with a seven inch gap at the top of the door which posed a potential ligature risk where a knotted cord or wire could be looped over and tied off..
-Room 416: shower door and frame had been pulled loose from the mounting on the wall next to the sink, which caused the door to hang crooked and not operate smoothly. The unsecured metal door and frame were aluminum with unfinished top edges, and no longer firmly attached to the wall, it not only created an additional looping hazard, but potentially could be worked loose, broken or further disassembled and the exposed rough/sharp edges used as a cutting weapon to injure at risk patients.

During interviews on 08/15/11 at 2:30 PM through 08/17/11 at 1:00 PM, Staff V, Director of Plant Operations stated that all the rooms used to have suspended ceilings, but after the decision to become a psychiatric facility and conversion to monolithic (one piece) ceilings, it became much more difficult to access all plumbing and electricity. This included the air conditioning units that were located in patient rooms. He/she stated that the ventilation openings were covered with conventional metal vent/grill covers, however, they were viewed as a potential ligature or hanging risk and replaced with perforated Lexan covers manufactured on site by maintenance workers. He/she stated that they were currently using tamper proof screws in projects and repairs and would eventually be replacing all the Phillips head screws with Torex or other type of screws that discouraged tampering. He/she stated that the loose shower door frame in room 416 was one of the things that happened when they removed the portion of the frame that supported the top of the shower door because it was identified as a potential hanging risk.

3. Observation of 3 South unit with census of 18 inpatients on 08/16/11 at 10:10 AM through 08/17/11 at 1:00 PM, showed 10 patient rooms (Rooms 320, 322, 324, 325, 326, 327, 328, 329, 330 and 331). Each patient room contained a private bathroom with a shower, hand washing sink and toilet, all with conventional plumbing fixtures. Observations of each patient room showed the following:
-Hand-made plastic Lexan grill covers affixed to ventilation duct openings in ceilings and walls of each bedroom and private bathroom. Each cover was perforated with hand-drilled holes that ranged in size from one half inch diameter up to five eight's inch in diameter, which provided a potential looping hazard for a sheet or cord to be passed through the holes and tied off.
-Single control operated mixing faucets extended five and one half inches above the top of the sink and counter top in each private bathroom, and hand wash sink outside of a locked staff bathroom provided potential looping hazards.
-Exposed plumbing and flush valve mechanism behind each bathroom toilet extended 26 inches above the toilet base and six inches from the wall behind the toilet and provided a potential ligature hazard.
-Large plastic toilet paper dispenser in each bathroom measured 46 inches above the floor and protruded six inches from the bathroom wall provided a potential looping hazard.
-Handle of each shower control valve in patient bathrooms measured two and three-quarters inches long provided a potential tie-off point for looping and ligature hazard.
-Metal frames in shower doors with opaque Lexan plastic panel inserts (excepting rooms 325, 327 and 329, where shower doors and frame had been removed and replaced with a curtain) provided a potential hanging or looping hazard. The sharp edges at the top of the shower door frame were not finished and provided a potential slicing hazard to patients.
-Conventional door knobs (except for Room 320) on entrance doors and all bathroom doors 40 inches above the floor created potential looping hazards for at risk patients behind a closed door or out of staffs direct line of vision.
-Conventional hospital hinges on entrance and bathroom doors, (except for Room 320) on bathroom doors, measured seven inches high by one inch wide opening between the door frame and the hinge that provided a potential hanging or looping hazard with the door opened or closed.
-Vent control knobs on existing wall radiators in patient bedrooms and common areas were 26 inches above the floor and provided a potential hanging or looping hazard to patients; regardless of whether the knob was removed from the stem.
-Metal access doors located in bathroom ceilings and patient bedrooms were secured with common Phillips head screws which were not tamper resistant.
-Plastic covers used in all rooms and areas on blind junction boxes, light switches and duplex electrical outlets were breakable and could be used by a patient to cut themselves or others.
- Single staff bathroom located behind the nurse's station and out of direct line of sight was locked, however the corridor-accessible, conventional hand washing sink fixture in the anteroom, steel paper towel holder screwed to the wall and door knob to locked tub/bathroom remained exposed and provided potential looping or ligature hazards to those patients not directly supervised.
-Room 324-had a shower curtain on flexible break-away rod, however, the shower curtain was heavy vinyl and posed a potential hazard of suffocation.
-Room 331-Lexan plastic mirror in one inch thick wood frame above sink mounted with six flat head screws could potentially be removed and misused by a patient intent on self harm or as a potential weapon to destroy property or injure others.
-Room 323-(group kitchen) damaged wall register with baseboard cover absent, and unsecured control access doors, exposed pipe connections and control stub (knob removed) that provided a potential hazard to patients not closely supervised. A cord or wire could be attached to the exposed hardware or knotted through a corner of the metal register, and passed over the back of a chair to create a potential hanging or strangulation hazard. A 48 inch long television cable and electrical cord of the same length provided a ligature opportunity for patients who may be intent on self harm such as strangulation or aggression toward others.

Observation on 08/15/11 at 2:15 PM in the day room of 3 South Unit, showed a roll of approximately ten, large clear plastic bags and five large red plastic biohazard bags stored in an unlocked cabinet. These bags present suffocation/choking hazard for suicidal patients.

During an interview on 08/15/11 at 2:20 PM Staff R, nurse manager, stated that he/she understood how the bags could be a suicide risk and the cabinet should be locked.

Observation on 08/15/11 at 2:40 PM in room 326 (3 South Unit) revealed a pair of mid rise hiking shoes with shoestrings on patient bed. Patient rooms are kept unlocked. These shoestrings present a strangulation risk for suicidal patients.

During an interview on 08/15/11 at 2:45 PM Staff C, Risk/Performance Improvement Manager, stated that patients are allowed to keep their shoes with shoe strings after the first 24 hours of admission. Staff C did not understand the risk of shoestrings for patients on suicide precautions.

During an interview on 08/17/11 at 11:40 AM Staff W RN, stated that all patients on this unit (3 South) are on suicide, elopement and aggression precautions.

4. Observation of 2 South unit with census of 19 inpatients on 08/16/11 at 2:00 PM through 08/17/11 at 1:00 PM, showed nine patient rooms (Rooms 222, 223, 224, 225, 226, 227, 282, 229 and 230). Each patient room contained a conventional private toilet and hand washing sink. Observations of each patient room showed the following:
-Hand-made plastic Lexan grill covers affixed to ventilation duct openings in ceilings and walls of each bedroom and private bathroom. Each cover was perforated with hand-drilled holes that ranged in size from one half inch diameter up to five eight's inch in diameter, which provided a potential looping hazard for a sheet or cord to be passed through the holes and tied off.
-Single control operated mixing faucets extended five and one half inches above the top of the sink and counter top in each private toilet room provided potential looping hazards.
-Exposed plumbing and flush valve mechanism behind each bathroom toilet extended 26 inches above the toilet base and six inches from the wall behind the toilet and provided a potential ligature hazard.
-Large plastic toilet paper dispenser in each bathroom measured 46 inches above the floor and protruded six inches from the bathroom wall provided a potential looping hazard.
-Handle of each shower control valve in patient bathrooms measured two and three-quarters inches long provided a potential tie-off point for looping and ligature hazard.
-Conventional door knobs on entrance doors and all bathroom doors 40 inches above the floor exposed a potential looping hazard to at risk patients behind a closed door and out of staffs direct line of vision..
-Conventional hospital hinges on entrance and bathroom doors measured seven inches high by one inch wide opening between the door frame and the hinge provided a potential hanging or looping hazard with the door opened or closed.
-Vent control knobs on existing wall radiators in patient bedrooms and common areas were 26 inches above the floor provided a potential hanging or looping hazard to patients; regardless of whether the knob was removed from the stem.
-Metal inspection and access doors located in bathroom ceilings and patient bedrooms were secured with common Phillips head screws which were not tamper resistant.
-Large plastic protective covers installed over thermostats in patient rooms measured nine inches high, seven inches wide and three and one half inches deep, and six feet above the floor, a potential ligature and hanging risk to patients at risk for suicide.
-Room 227-unsecured and unprotected water pipe in the south east corner of the room was wrapped in loosely fitting insulation. The one inch gap between the wall and the pipe exposed a potential tie-off point for a patient intent on self harm, suicide or harm to others.
- Observation on 08/15/11 at 2:50 PM showed plastic bag liners in three large 20 gallon waste containers located in the corridor, nurses's station and in the group room. These presented a potential risk of suffocation to patients at risk for suicide or harm to others. Staff informed of the potential risk on 08/15/11; however the plastic bags remained in the waste containers and accessible to patients on 08/16/11 at 1:40 PM and 08/17/11 at 9:00 AM.

5. During an interview on 08/16/11 at 11:00 AM, Staff A, Director of Nursing, stated that a risk assessment of potential hazards to patients throughout the facility was completed by the facility in March 2011. Review of the risk assessment dated 03/11 showed risks evaluated in each patient room and common areas, and rated on a 1-5 scale, with one (1) being the lowest and five (5) being the highest, or most extreme hazard to patients at risk for self harm. Staff A stated that the facility has a three year plan to make all patient rooms suicide resistant but will make two rooms on each of the three units suicide resistant by the end of 2011.

Document review of the facility's, facility-wide assessment showed among the highest risks (category 5) identified were; door hinges, door knobs, shower doors, shower rods, and sink faucets, toilet pipes, toilets, drop (suspended tile) ceilings, sprinkler heads in halls, HVAC vents with Lexan plastic covers, light covers and wardrobe closets, and door closing devices with arm exposed on the wrong side of the door.





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6. Record review of the facility's policy titled "Observation of Patient/Residents During Bathroom and Shower Periods," dated 04/04/11, showed the staff were to communicate with a patient in the bathroom/shower every two to three minutes. If the patient did not respond, the door would be opened to ensure safety. Staff was to ensure doors were closed and locked at the conclusion of bathroom/showers.

7. During an interview on 08/16/11 at 9:05 AM, Staff E, Registered Nurse (RN) Manager of 4 South, stated that the admission criteria requires the patient to be severely depressed, acutely suicidal (SI) or homicidal (HI), so all patients are either SI, HI, or both. RN E stated that patient rooms were checked for contraband one time daily, upon admission, and when visitors bring things in to the facility. RN E stated that all patients are on 15-minute checks for safety. RN E stated that all bathroom doors were kept locked and the patients were allowed in by staff. The staff stay nearby and check on the patient after two to three minutes. If no answer, the staff member is to unlock the bathroom door and go in. Patient room doors were left open, allowing any patient access to items in the room.

8. During an interview on 08/16/11 at 2:00 PM, Staff E stated that the 15-minute rounds form was pre-printed with the time (every 15-minutes) and the staff document, with a code, where the patient was at the 15-minute mark. However, review of the form found that staff failed to document location of the patient in real time. Staff E stated that the contraband rounds were completed each day, but at no specific time. These rounds were documented as done, but not specific as to items/areas checked and actual result of the check.

9. Record review of the facility's undated policy titled, "Clothing List-4 South," (surveyor requested the contraband list) provided by the RN E on 08/16/11, showed the following:
-No spaghetti strap shirts/undershirts;
-No drawstrings longer than 6-inches, unsecured.

However, record review of the facility's policy titled "Contraband, Search for and Disposition of" revised 06/24/10 showed the intent of the policy is to maintain a safe and therapeutic environment for patients, visitors and staff. The policy showed the definition of contraband to be items in the possession of patients/residents that are not allowed in patient/resident care areas. Contraband items include those things which can be used to harm self, others or damage property. Examples of contraband items which are confiscated due to suffocation/asphyxiation/hanging/strangling are:
-Scarves
-Window blind cords
-Drawstrings from clothing/bags, long, heavy-duty shoe/boot laces
-Straps from purses/luggage
-Personal appliances (blow dryers, curling irons, anything with an electrical cord that isn't removable)
-Plastic bags
-Aerosol cans/products
-Belts

The policy showed shoes with strings may be worn as long as the patient/resident is not trying to use the strings to harm self or others and may be allowed under staff supervision only (facility editing).

10. Observation of the 4 South unit on 08/16/11 at approximately 9:25 AM, showed the following:
-Rooms were semi-private (two beds), a total of 20 beds.
-Three patients wore tennis shoes with shoe strings (considered a choking/hanging hazard);

11. Record review of Patient #1's (room #416) psychiatric evaluation, dated 08/10/11, showed the patient was admitted on 08/09/11 with a diagnosis of major depressive disorder, severe. The patient was violent to self and others and made suicidal statements, "Mother makes me suicidal," and, "I asked God to take me off the world." The patient had carved the word "Fat" into the skin of his/her right hip.

Observation on 08/16/11 at approximately 9:25 AM, showed the following:
-A spaghetti strap shirt, plus a sports bra, in a bedside cabinet in room #416, which could be used as a hanging device.
-The bathroom door was open (unlocked) in room #416 (Patient #1). The facility failed to keep the bathroom door locked, allowing the patient access to unsafe bathroom plumbing.

Observation on 08/16/11 at 1:20 PM, in room #416, showed forbidden items mentioned above, spaghetti strap top, and one pair of tennis shoes with shoestrings remained in Patient #1's bedside cabinet.

12. During an interview on 08/16/11 at 2:00 PM, Staff R, Nurse Manger stated that all patients on the unit (2 South) are on suicide precautions.

13. Observation in room #427, on 08/16/11 at 1:17 PM, showed one pair of pajama bottoms/shorts with an unattached drawstring in the waist. The drawstring was approximately 24-inches long (considered a choking/hanging hazard). Don't have diagnosis, but all patients on this unit are on suicide precautions per interview in #12 above.

14. Observation in room #428, on 08/16/11 at 1:19 PM, showed one pair of black slinky shorts with an unattached drawstring in the waist. The drawstring was approximately 24-inches long. According to interview with the Nurse Manager all patients on this unit are on suicide precautions.

15. Observation in room #222 on 08/17/11 at 3:40 PM showed a locked cubicle door located above open shelving. Protruding from under the bottom of the door was a drawstring. On pulling the drawstring, it pulled completely out of the locked cubicle and was approximately 36-inches long. Also observed in the room was a pair of tennis shoes with shoestrings located near bed two. The patients in room #222 are on suicide precautions.

16. Observation in rooms #224, 226, 228 and 229 on 08/17/11 from 3:45 PM until 4:00 PM showed a pair of tennis shoes with shoestrings located on the floor in each room. The patients in these rooms were admitted on suicide precautions.

17. During an interview on 08/17/11 at 9:05 AM, Staff J, Behavioral Health Technician (BHT) stated that he/she can open three bathroom doors at a time on the 2 South unit for patients to go to the bathroom. He/she stated that one patient may go into the room and use the bathroom with the bathroom door shut, but the door to the room remains cracked open. Staff J stated that the other patient assigned to that room sits on the floor in the hallway until it is their turn to use the bathroom. Staff J stated that with three patients in three different bathrooms at the same time, he/she checks on those patients every two to three minutes. Staff J stated that he/she does not document those observations. Observation showed Staff J does not wear a watch and Staff J stated that he/she just knows how often to check on the three patients in the bathrooms and stated that he/she is also observing the three patients assigned to those three rooms who are sitting in the hallway waiting for their turn to use the bathroom.

18. During an interview on 08/17/11 at 1:20 PM, Staff K, RN, stated that BHT's check on patients while in the bathroom every five minutes (not the two to three minutes as dictated in the policy).

19. Record review of the facility's policy titled, "Observation and Patient Monitoring," revised 05/24/11, showed One-to-One (1:1) is the highest level of observation and dictated staff stay within an arm's length of the patient, and keep the patient in view at all times.

20. Record review of a facility-provided list of all patients in restraints/seclusions from 12/10-8/14/11, showed the following:

- Patient #5 was admitted on 03/14/11 with diagnoses of bipolar disorder and polysubstance abuse. Patient #5 also had a history of cutting behaviors. Record review of patient #5's treatment plan, dated 03/14/11, showed the patient would receive 1:1 every shift and as necessary.

Record review of a Sentinel Event report, dated 03/15/11, timed 5:51 PM, showed the patient entered the shower/bathroom. Staff failed to check on the patient for approximately 5 minutes. When the BHT did check on the patient, the patient did not answer. Rather than entering immediately (BHT had a key), the BHT waited for the RN to come and unlock the door. The patient had wrapped a sports bra over the shower control and his/her neck, and was hanging/sitting on the shower floor. The patient's neck was reddened.

The facility failed to provide the 1:1 monitoring and/or failed to keep the patient in view at all times.

- Patient #14 was admitted on 12/06/10 with a diagnosis of major depression. The patient had threatened to kill him/herself with a pillowcase or shoestrings.

Record review of the patient's History and Physical, dated 12/07/10, showed the patient wanted to hang him/herself.

Record review of physician's orders dated 12/09/10, showed an order for the patient #14 to be on 1:1 while awake. This order continued through 12/14/10 at 8:20 AM. Record review of the patient's treatment plan, dated 12/06/10, dictated staff provide 1:1 twice daily and as necessary (contrary to physician's orders).

Record review of a post restraint/seclusion code critique form, dated 12/10/10, timed 8:06 AM, showed patient #14 became agitated and wrapped his/her shirt around his/her neck and attempted to choke him/herself.

Record review of post restraint/seclusion debriefing form, dated 12/14/10, timed 8:12 AM, showed patient #14 had become agitated and wrapped his/her sweater around his/her neck, and made statements of self-harm, "I just want to kill myself." Even though the patient was on 1:1, staff allowed the patient to wrap a shirt and sweater around his/her neck.

- Record review showed Patient #12 entered the facility 05/14/11 with a diagnosis of intermittent explosive disorder and oppositional defiant disorder. Review of the history and physical showed on admission the patient was threatening, kicking and biting at staff, took off his/her shirt, tied it around his/her neck requiring the shirt to be cut from the patient's neck.

Review of the physician's admission orders showed an order for the patient to be on 15 minute checks by the staff.

Record review of a post restraint/seclusion code critique form, dated 05/22/11, showed the patient placed a chair on the bed and attempted to hang his/herself by hanging a sheet from the ceiling vent and wrapping the sheet around his/her neck.

21. During an interview on 08/17/11 at 1:20 PM, Staff K stated that BHT's were to monitor the patients every 15-minutes, and every five minutes while in the bathroom (contrary to policy). Staff K stated he/she watched the BHT's from afar, but had no specific documentation as to how or when he/she monitored all BHT's for assurance this monitoring actually gets done.

22. During an interview on 08/17/11 at 1:25 PM, Staff E, Manager 4 South, stated that there was no specific documentation of monitoring the RN's or BHT's to assure patient monitoring is completed as ordered. Staff E stated that he/she monitored the round sheets and addressed issues as they come up.

23. During an interview on 08/17/11 at 10:00 AM, Staff R, Manager 2 South, stated that the unit admitted only suicidal patients. Staff R stated that the patients are between the ages of four years and fourteen years old. Staff R stated that when patients are transitioning between groups and other activities they are allowed to use the toilets in their rooms, but only one patient can be in the room at a time. The other patient sits in a spot in the hallway outside of their room while waiting to use the bathroom. Staff R stated, "Bathrooms are the number one spot to kill themselves [patients]." Staff R stated that staff is assigned to monitor three rooms during those transition periods. He/she stated that staff checked on the patients in the bathrooms every two to three minutes while the patients are in the bathrooms.

Staff R stated that he/she randomly observed staff during those transition times making sure they check patients every two to three minutes. Staff R stated that he/she also has the ability to watch video recordings of staff monitoring patients during those transition times but also does this on a random basis and does not document when or what staff he/she monitored. Staff R stated, "I don't document what staff I've monitored and I don't keep a list to make sure I monitor every s

Based on observations, interviews and record reviews, while the hospital employed a full-time director of food and dietetic services, the facility failed to allow a sufficient number of hours for this individual to manage the department. The census was 53 patients.

Findings included:

1. Review of job descriptions found that each employee except the Certified Dietary Manager (who was the director of the department) and the Registered Dietitian (RD) were cooks. However, during an interview on 08/16/11 at 9:45 AM, Staff I, the CDM, stated that all the staff other than himself/herself and the RD were not cooks as the job descriptions reflected. He/she stated that he/she planned to update them so that they accurately reflected the duties the workers performed, but stated that he/she had not had time to do so due to him/her working in production at least four days per week for the last six months.

See also the deficiency at A621 regarding the lack of an organization chart that accurately reflected the management of the department and the job description of the dietitian that did not accurately describe his/her responsibilities.

2. Record review of dietary department policies and procedures showed the department did not have a policy and procedure regarding in-service education to dietary employees and maintenance of the those records.

During an interview on 08/15/11 at 2:45 PM, Staff I, stated that she/he had not provided in-service training education to his/her personnel nor had Staff H due to shortage of personnel and him/her having to work as the cook and/or other positions in the department, which restricted him/her from performing assigned duties. See the deficiency at A701 regardling the lack of cleanliness in the dietary department.

3. See the deficiency at A628 regarding the hospital's failure to implement a system to plan and follow written menus and serve foods to meet the nutritional needs of the patients or as modified by the physician's order.

Based on observations, staff interviews, and review of the hospital's organization chart for the dietary department and the Registered Dietitian's (RD) job descriptions, the facility failed to ensure both accurately reflected the operation of the department and/or the actual current responsibilities of the RD. The facility also failed to ensure nutritional needs were met for one (Patient #2) of 53 patients. The communication system the facility had in place failed. The facility's census was 53.

Findings included:

1. Record review of the facility's undated "Job Description" for the Registered Dietitian, provided by the Certified Dietary Manager (CDM), showed the following direction:
-Assess patients within 72 hours of physician's order.
-Writes and conducts initial progress notes.
-Communicates specialized dietary information/requirements to the medical staff, nursing staff, and Nutrition Service Staff.
-Review menus on a weekly basis.
-Consults with Nutrition Services Manager regarding ideas for improving menu selections.
-Modify diets individually to meet patients' needs.
-Gives approval to finalized menus.
-Communicate weekly with Dietitian Assistant.
-Co-signs Dietitian Assistant's progress notes.

2. Record review of Patient #2's current medical record showed the patient entered the facility on 08/12/11 with a diagnosis including PICA (a medical disorder characterized by an appetite for substances largely non-nutritive, such as dirt, feces, chalk, etc.). A review of the nutritional assessment completed by Staff H, Registered Dietitian (RD) on 08/13/11 showed he/she made no recommendations regarding the patient's nutritional status other than, "Monitor eating, encourage only food." Staff H did not specify how patient's eating should be monitored.


Record review of Patient #2's medical record also showed on 08/14/11 staff gave Patient #2 a piece of chalk and he/she ate the chalk.

During an interview on 08/17/11 at 10:40 AM, Staff H stated that he/she completed a consult on Patient #2 on the evening of Tuesday 08/16/11. Staff H stated that when he/she completed the nutritional assessment, but he/she did not meet with the patient nor his/her parents. Staff H stated, "I don't need to talk with the patient/parents when I do an assessment, just when I do a consult. I don't educate staff unless they ask questions or express a need for education."

3. Review of the facility's menu options for the week of 08/14/11 through 08/20/11 showed the following:
- Three of the seven days contained two milk and/or substitute per day and the other 11 days contained only one milk and/or milk substitute per day. Neither of the seven days contained three milk and/or substitutes per day.
-The meals lacked the minimum of at least 1-2 cups (2 servings) of fruits and 2-3 cups (3 servings) of vegetables per day.
-The menus lacked adequate (at least 6 servings) whole grain and increased (20-25 grams) fiber foods.
-Menu items contained foods high in saturated fat, trans fat, cholesterol, salt (sodium), and added sugars such as:
Super Bun, Biscuits and Gravy, Funnel Cake w/Powdered Sugar and Honey Bun four of seven possible breakfasts;
Tater Tot Casserole, Au Gratin Casserole, Tuna Casserole, Ravioli, Pepperoni Pizza, Hot Dog, Corn Dog, Biscuit and Gravy served seven of 14 possible meals; and
Cookies and Cakes served nine of 14 possible meals.

Review of the menus on 08/16/11 at 9:45 AM showed they were most likely deficient in the following nutrients because the menu contained little or no food sources of the following nutrients:
Vitamin A
-Sources of Vitamin A foods are orange vegetables such as carrots, sweet potatoes, pumpkin; dark leafy green vegetables such as spinach, broccoli, collards, turnip greens; orange fruits such as mango, cantaloupe, peaches, apricots, etc; and tomatoes.
Vitamin C
-Cirtus fruits and juices, strawberries and cantaloupe; broccoli, peppers, cabbage and tomatoes; leafy greens such as romaine lettuce, turnip greens, broccoli and spinach.
Folate
-Cooked dry beans, peas and peanuts; oranges and orange juice; and dark-green leafy vegetables like spinach, broccoli and mustard greens and romaine lettuce.
Potassium
-Baked white or sweet potato, cooked greens (such as spinach) and winter (orange) squash; bananas, dried fruits such as apricots and prunes and orange juice; and cooked dried beans (such as baked beans) and lentils.

Eating sources of Vitamin A, C, Folate and Potassium may help protect the body against many chronic diseases such as coronary heart disease, stroke and certain types of cancer.

4. Observations of the kitchen on 08/18/11 between 9:03 AM and 12:45 PM showed the following:
-The inside top of the ice machine had a build-up of mold and the mold had a build-up of condensation over it, which could cause the mold to drip onto the clean ice used for human consumption. The outside of the ice machine contained a black air filters covered with dirt and grease debris.
-The area around the ice machine was very dirty with trash and dirt, an old window blind and an old rack used in a refrigerator.
-Stone blocks supported the ice machine and the floor area under the stone blocks contained a build-up of lime, trash, dirt, and debris.
-The kitchen had three portable fans throughout the kitchen. Each fan had dirt, grease and debris covering the outside and blades of the fans. One fan in the food preparation area faced the toaster and when on, blew towards the toaster when on, causing the dirt, grease and debris to possibly contaminate the food items. Another dirty fan in the pots and pans area faced the mixer, which could possibly contaminate foods while mixing them. The third dirty fan in the cooks' area faced the stovetop, which could possibly blow dirty particles onto the food and causing them to possibly become contaminated.
-The soda fountain pipes in the toaster area contained dirt, grease and debris covering them.
-The ceiling vents in the kitchen that ran the length of the kitchen had chipped paint that ran over the food production area, it contained mold in some areas of the vent and other areas of the vent it contained dirt, grease and debris.
-The ceiling had missing tiles (which left holes in some areas of the ceiling) in the area behind the vent in the "Emergency eye wash area."
-The ceiling tiles throughout the kitchen contained stains, dirt, grease and debris.
-Dirt, grease and debris covered the electrical socket on the wall by the window in the
ice machine area.
-Opened trash containers by the dessert preparation and clean pots and pans areas.
-Dried food, mold, grease and debris covered the back splash behind the dish machine.
-Dried baked-on foods covered the bottom of the grill.
-Grease, dirt and debris covered the cords, pluming and pipes on the back of the convection ovens.

5. Observations and interviews between 08/15/11 at 2:15 PM and 08/18/11 at 11:30 AM showed Staff H, RD, did not provide any interaction, supervision of oversight to Staff I, CDM, and his/her staff of the dietary department.

Review of the hospital's organizational chart for the dietary department, presented on 08/16/11 at 09:30 AM by Staff A, Director of Nursing (DON), showed a revision date of 08/15/11. It showed Staff H to have direct supervision and oversight over the dietary department and to provide supervision over Staff I.

6. Interviews revealed the following:

-During an interview on 08/15/11 at 2:45 PM, Staff I, stated that Staff H did not provide supervision and oversight to the dietary department. Staff I stated that he/she planned the weekly regular menus and sent them to Staff H to review and make necessary changes/recommendations. He/she stated Staff H individualized special diets and took care of clinical nutrition, but had no involvement with the food service operation and management.

- During an interview on 08/15/11 between 1:45 PM and 3:30 PM, in two different conversations, both Staff A and Staff I stated that Staff H worked part time during the evening, usually after 4:00 PM and on some Mondays. Staff A stated Staff H worked about 20 hours per week at the facility (which included caring for acute care and non-acute care patients' nutritional needs).

- During an interview on 08/16/11 at 4:00 PM, Staff H stated that she/he worked in the evenings after 4:00 PM and some Mondays, Wednesdays and Fridays or Tuesdays, Thursdays or Saturdays for about three hours each visit and he/she provided services to the facility some Mondays during the day for about six hours. Also, in addition to spending time assessing patients' nutritional status in the acute hospital, he/she shared that time assessing the nutritional status of the patients in the non-acute part of the hospital (an area of the facility where Federal regulations do not have to be met). Staff H also stated that he/she did not have any oversight duties of the dietary department. His/her main duties consisted of assessing the nutritional status of patients and making recommendations to the physicians concerning patients' nutritional status. He/she stated that most of his/her communication with the physicians involved communicating with them in a communication notebook.

- During an interview on 08/17/11 at 10:35 AM, Staff H stated that she/he received a copy of his/her job description, but it did not contain anything in it that made him/her responsible for supervising and providing oversight to the dietary department's staff. He/she also stated that the facility's administrative staff never told him/her that she/he also had responsibility for the overall dietary department. He/she did not know when the facility held team conference meetings (which included discussing patients' with nutrition needs). He/she stated that he/she never attended a team conference at the facility nor had she/he provided dietary counseling to patients' family and/or caretaker.

Based on interviews and policy and other document reviews, the facility failed to implement a system to plan and follow written menus and serve foods to meet the nutritional needs of the patients (as determined by the Recommended Dietary Allowances (RDA) of the Food and Nutrition Board of the National Council, National Academy of Sciences) or as modified by the physician's order. The facility also failed to provide a variety of adequate substitutes for one (Patient #4) of 53 patients. The facility census was 53.

Findings included:

1. Record review of the facility's Policy #4.4.1, Patient Care Manual, Section #4.4, Treatment of the Patient Dietetic Care, titled "Provision of Meals," dated 08/26/10 provided by the Certified Dietary Manager(CDM), showed the following direction:
-Nutrition meals will be provided to each patient and in compliance with DOH (Department of Health) guidelines.
-Purpose is to provide each patient with a nutritionally sound diet as prescribed by their physician.
-Nursing staff should provide a diet list with the patient's name and diet order to the Nutrition Department by 6:00 AM.
-Nursing should communicate all diet order changes and discontinuations via phone.
-Nursing Supervisor/Unit Staff/Intake should call kitchen to request a meal for any newly admitted patients when needed. When kitchen staff is gone for the day, notify Nursing Supervisor of need for sack lunch.
-Nursing Supervisor should obtain a sack lunch from dietary when kitchen staff is gone for the day.
-Unit Dining - Nursing staff should:
Supervise distribution of individual served meals.
-Cafeteria Dining - Nursing staff should...Supervise patients while in the cafeteria; including patients on special diets (see policy and procedure #4.4.5, Modified Diets).
-Provide three meals and two substantial evening meal snacks for distribution to the units and cafeteria at the designated time.
-Use diet list with patient name. Ask unit staff's assistance to identify patients on special diets.

2. Record review of the facility's Policy #4.4.5, Patient Care Manual, Section #4.4, Treatment of the Patient, titled "Modified Diets," dated 08/26/10 provided by the Certified Dietary Manager (CDM) showed the following direction:
-Modified diets will be provided as ordered by the physician and noted on the diet sheet.
-Purpose is to accommodate the special dietary needs of patients.
-Nursing Unit Staff should provide to the kitchen at 6:00 AM daily, a diet list that shows each patient's name, their diet order, and food allergies.
-Nursing Unit Staff should call kitchen staff with updates to the diet list as needed throughout the day.
-Kitchen staff should review diet list daily and prepare meals accordingly.
-Unit Dining - Unit staff should obtain the modified diet(s) with the food cart at the back door of the kitchen at the scheduled hours.
Unit Staff should verify modified diets by checking patients' name and diet order, and distribute meals to patients accordingly.
-Cafeteria Dining - Nursing Unit Staff should:
Identify patients on modified diet(s) by checking the modified diet list, and send those patients to the front of the line.
Kitchen Staff should provide each patient the modified diet indicated on the diet list.

3. Based on the "United Stated Department of Agriculture (USDA) Dietary Guidelines for Americans 2010 and American Heart Association's Dietary Guidelines for Americans, 2010," the recommended guidelines for children (two years) to adolescents (18 years) are as follows:
-Eat foods low in saturated fat, trans fat, cholesterol, salt (sodium), and added sugars. Keep total fat intake between 25 to 35 percent of calories for children and adolescents four to 18 years of age, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts and vegetable oils.
-Choose a variety of foods to get enough carbohydrates, protein and other nutrients.
-Serve whole-grain/high-fiber breads and cereals rather than refined grain products. Recommended grain intake ranges from two oz/day for a one-year-old to seven oz./day for a 14-18-year-old boy.
-Serve a variety of fruits and vegetables daily, while limiting juice intake. Children's recommended fruit intake ranges from one cup/day, between ages one and three, to two cups for a 14-18-year-old boy. Recommended vegetable intake ranges from ? cup a day at age one, to three cups for a 14-18-year-old boy.
-Introduce and regularly serve fish as an entree.
-Serve fat-free and low-fat dairy foods. From ages one-eight, children need two cups of milk or its equivalent each day. Children ages 9-18 need three cups.
-Estimated calories needed by children range from 900/day for a one-year-old to 1,800 for a 14-18-year-old girl and 2,200 for a 14-18-year-old boy.

4. Review of the facility's menu for the week of 08/14/11 through 08/20/11 showed the following:
Day 1 - Sunday
Breakfast: Super Bun, Cereal, Yogurt and Fruit.
Lunch: Tuna Casserole, Cauliflower and Cake.
Dinner: Chicken Nuggets w/Sweet & Sour Sauce, Mixed Vegetables, Ranch Potatoes and Cookie.
DAy 2 - Monday
Breakfast: Omlet, Cereal, Yogurt and Pears.
Lunch: Pork Roast, Mashed Potatoes w/Pork Gravy, Corn and Cookie.
Dinner: Ravioli, Garlic Bread Stick, Italian Beans and Pudding.
Day 3 - Tuesday
Breakfast: Biscuit & Gravy, Egg Patty and Yogurt.
Lunch: Salisbury Steak, Oven Fried Potatoes, Vegetable Blend and Sherbert.
Dinner: Hot Dog on Bun, Potato Chips, Cauliflower and Cookie.
Day 4 - Wednesday
Breakfast: Scrambled Eggs, Oatmeal and Yogurt.
Lunch: Chicken Alfredo, Garlic Breadstick, Carrots and Peanut Butter Bar.
Dinner: Corn Dog, Fries, Corn and Cake.
Day 5 - Thursday
Breakfast: Funnel Cake w/Powdered Sugar, Peaches and Yogurt.
Lunch: Au Gratin Casserole, Cauliflower and Cookie.
Dinner: Tomato Soup, Grilled Cheese Sandwich, Carrot Stix & Ranch Dressing and Cake.
Day 6 - Friday
Breakfast: Pancakes, Egg Patty and Yogurt.
Lunch: Chicken Fried Rice, Egg Roll, Broccoli and Chocolate Cake w/Peanut Butter Icing.
Dinner: Biscuit and Gravy, Scrambled Eggs and Ice Cream.
Day 7 - Saturday
Breakfast: Honey Bun, Yogurt, Banana and Cereal.
Lunch: Tater Tot Casserole, Crackers, Green Beans and Chocolate Pudding.
Dinner: Pepperoni Pizza, French Fries, Pears and Cake

- Three of the seven days contained two milk and/or substitute per day and the other 11 days contained only one milk and/or milk substitute per day. Neither of the seven days contained three milk and/or substitutes per day.
-The meals lacked the minimum of at least 1-2 cups (2 servings) of fruits and 2-3 cups (3 servings) of vegetables per day.
-The menus lacked adequate (at least 6 servings) whole grain and increased (20-25 grams) fiber foods.
-Menu items contained foods high in saturated fat, trans fat, cholesterol, salt (sodium), and added sugars such as:
Super Bun, Biscuits and Gravy, Funnel Cake w/Powdered Sugar and Honey Bun four of seven possible breakfasts;
Tater Tot Casserole, Au Gratin Casserole, Tuna Casserole, Ravioli, Pepperoni Pizza, Hot Dog, Corn Dog, Biscuit and Gravy served seven of 14 possible meals; and
Cookies and Cakes served nine of 14 possible meals.

Review of the menus on 08/16/11 at 9:45 AM showed they were most likely deficient in the following nutrients because the menu contained little or no food sources of the following nutrients:
Vitamin A
-Sources of Vitamin A foods are orange vegetables such as carrots, sweet potatoes, pumpkin; dark leafy green vegetables such as spinach, broccoli, collards, turnip greens; orange fruits such as mango, cantaloupe, peaches, apricots, etc; and tomatoes.
Vitamin C
-Cirtus fruits and juices, strawberries and cantaloupe; broccoli, peppers, cabbage and tomatoes; leafy greens such as romaine lettuce, turnip greens, broccoli and spinach.
Folate
-Cooked dry beans, peas and peanuts; oranges and orange juice; and dark-green leafy vegetables like spinach, broccoli and mustard greens and romaine lettuce.
Potassium
-Baked white or sweet potato, cooked greens (such as spinach) and winter (orange) squash; bananas, dried fruits such as apricots and prunes and orange juice; and cooked dried beans (such as baked beans) and lentils.

Eating sources of Vitamin A, C, Folate and Potassium may help protect the body against many chronic diseases such as coronary heart disease, stroke and certain types of cancer.

5. During an interview on 08/16/11 at 9:43 AM, Staff I, the CDM stated that the facility did not have a policy and procedure for the dietitian to review the nutrient content (calories, grams of protein, carbohydrate, and fat, International Units of vitamins or milligrams of minerals) for the regular diet or any therapeutic diets ordered for patients.

(A therapeutic or modified diet is one where either a nutrient is limited or increased, such as a low sodium or high protein diet, or the consistency of the food is changed, such as a mechanical diet that requires ground meat).

Staff I stated that Staff H, Registered Dietitian (RD) did not have a way to determine the nutritional adequacy of the menus to ensure they met the nutritional needs of patients, and the facility did not use any particular standard when planning menus for the patients. Staff I stated that he/she did not use any specific guidelines or references when planning pateints' menus. He/she stated that he/she visited patients during meal hours and planned the regular diet menus by incorporating foods on the menu that the patients liked. He/she stated that the facility had a six week regular menu cycle (i.e., the menu was planned for six weeks then repeats), but he/she changed the items on the menu often. He/she stated that Staff H planned the modified diets when the physician ordered one for a patient. (This tracking system is needed to ensure that a food substitution would be the same or provide similar nutrients and calories as the food not served.)

During an interview on 08/17/11 at 10:35 AM, Staff H stated that he/she did not evaluate the menus for nutritional adequacy and he/she did not have a system to ensure each patient received foods and beverages that were at or near a nutritionally adequate diet.

6. Record review of the 2 South, 3 South and 4 South Units diet sheets showed that Patient #4 received a Vegetarian Diet. The record showed the patient received a Peanut Butter Sandwich or Peanut Butter as a meat substitute for 11 of 14 possible meals. The choices given lacked a variety of substitutes available for patients.

During an interview on 08/18/11 at 9:45 AM, Staff I stated the facility generally offered patients Peanut Butter or whatever they may have on hand when they refused food served. Staff I stated that nursing staff should identify what modified diet a patients should receive when they come through the serving line, but staff did not always do that.

7. Observations at meals between 08/16/11 at 11:00 AM and 8/17/11 at 12:30 PM showed patients came through the cafeteria serving line and selected any quantity and/or combination of foods without staff assistance or guidelines or a template to promote food selections that would meet the daily recommended intake required by the guidelines listed in example 3.

The dietary server asked patients what they wanted from the serving line and staff placed those items on the patients' trays.

Observation showed that except for breakfast each day, the regular menu did not include milk. However a cooler in the dining room contained milk. Nevertheless, the patients selected another beverage rather than milk. The patients ranged in age from three years to 16 years old.

During an interview on 08/18/11 between 11:30 AM and 12:30 PM, Staff I stated that patients could select milk if they wished to, but most wanted another beverage during the lunch and dinner meals. He/she stated the patients usually selected milk during the breakfast meal when they have cereal.

Staff I stated that the policies and procedures he/she provided for review were all the policies and procedures the facility had. Review of the policies and procedures presented did not include one encouraged patients to choose milk nor did they include a policy and procedure regarding the frequency of milk offered to the patients.

Based on observation, interviews and policy review, the facility failed to ensure the current Diet Manual, approved for use in the hospital, was readily available and accessible to all medical and nursing personnel following facility policy. The facility census was 53. If not readily available, staff may provide a patient with food or beverages not allowed by the physician ordered diet.

Findings included:

1. Record review of the facility's Policy #4.4.2, Patient Care Manual, Section #4.4, Treatment of the Patient, (4) Dietetic Care, titled "Diet Manual, Approved," dated 04/15/10, provided by Staff I, Certified Dietary Manager(CDM), showed the following direction:
-A current diet manual is annually approved by the medical staff and is made available to all staff.
-The Registered Dietitian (RD) should provide a copy of the approved diet manual in the kitchen for the Nutrition Department Staff, in the Employees Lounge where all employees may access it, and to the Medical Doctor.
-Nutrition Staff refer to the diet manual for diet order interpretation as needed.
-Medical Staff order diets based on assessed need.
-All Staff refer to the approved diet manual should a question arise concerning diet orders.

2. Observation on 08/16/11 at 10:00 AM showed the facility had a current hard copy of the approved diet manual in the Dietary Department. Staff I, Certified Dietary Manager, stated that he/she found a copy of the diet manual in the nursing lounge and brought it to the dietary department. He/she did not know if a copy of the diet manual was available at each of the Nursing Care Stations nor did he/she know if the Medical Staff had access to a copy.

3. During an interview on 08/16/11 at 2:20 PM, Staff F, Registered Nurse (RN) on 4 South stated that he/she had not seen a diet manual on the Unit.

4. During an interview on 08/17/11 at 11:10 AM, Staff H, Registered Dietitian (RD) stated that he/she knew a copy of the diet manual should be in the staff's lounge, but he/she did not know if the Medical Staff had one accessible and available.

5. During an interview on 08/18/11 at 9:53 AM, Staff R, RN 2 South stated that he/she did not believe the Nursing Station had a copy of the Diet Manual. He/she looked in the possible places where the manual would be and confirmed the Unit did not have a copy.

6. During an interview on 08/18/11 at 10:12 AM, Staff S, RN 2 South stated that the Nursing Station did not have a copy of the Diet Manual that he/she was aware of.

Based on observation, interview and policy review, the facility failed to maintain walls and floors in a condition that presented a clean, maintained environment to all 53 hospital patients (16 patients on 4 South, 18 patients on 3 South and 19 patients on 2 South). The facility failed to implement a system to maintain the cleanliness of the kitchen to provide for the well-being of patients. This practice could affect all patients, staff and visitors who consomed food. The facility census was 53.

Findings included:

1. Observation of 4 South nursing unit with a census of 16 inpatients on 08/15/11 at 2:30 PM through 08/17/11 at 1:00 PM showed nine patient rooms (Rooms 420, 422, 424, 425, 426, 427, 428, 429, and 430) with the following:
-Large accumulation of gray fuzz and lint in the holes of perforated Lexan plastic vent covers in bathrooms and bedrooms.
-Black and pink deposits of what appeared to be mold up to two-inches high in the grout, and on tile surfaces of shower stall corners and around the perimeter of the shower floor, including the shower door frame and threshold.
- Brown water stains on the shower floors.
-Fingerprints, soil marks and peeling paint on ceiling inspection doors in bathrooms and bedrooms.
-Door frames of entrance doors, bathroom doors, and window sills showed contrasting former colors of paint and trim.
-Unsealed gaps between the floor and drywall in the seclusion room where the cove base had been removed for safety.

2. Observation of 3 South nursing unit with a census of 18 inpatients on 08/16/11 at 10:10 AM through 08/17/11 at 1:00 PM showed 10 patient rooms (Rooms 320, 322 324, 325, 326, 327, 328, 329, 330, and 331) with the following:
-Large accumulation of gray fuzz and lint in the holes of perforated Lexan plastic vent covers in bathrooms and bedrooms.
-Black and pink deposits of what appeared to be mold up to two-inches high (and as high as approximately six inches in the shower of Room 324) in the grout and on tile surfaces of shower stall corners, and around the perimeter of the shower floor, including the shower door frame and threshold.
-Brown water stains on the shower floors.
-Fingerprints, soil marks and peeling paint on ceiling inspection doors in bathrooms and bedrooms.
-Door frames of entrance doors, bathroom doors, and window sills showed contrasting former colors of paint and trim.
-Rusted base on all bathroom door frames from long-term exposure to water.
-Unsealed gaps between the floor and drywall in the seclusion room.

3. Observation of 2 South unit with census of 19 inpatients on 08/16/11 at 2:00 PM through 08/17/11 at 1:00 PM showed nine patient rooms (Rooms 222, 223, 224, 225, 226, 227, 282 229 and 230) with the following:
-Accumulations of gray fuzz and lint in the holes of perforated Lexan plastic vent covers in bathrooms and bedrooms.
-Fingerprints, soil marks and peeling paint on ceiling inspection doors in bathrooms and bedrooms.
-Door frames of entrance doors, bathroom doors, and window sills showed contrasting former colors of paint and trim.
-Rusted base on one or both sides of bathroom door frames from long-term exposure to water.
-Wall register in Room 224 was covered with fire resistant panel (FRP), attached with fender washers and screws.
-Unsealed gaps between the floor and drywall in the seclusion room.
-Lexan viewing window and reflective mirror in seclusion room were badly scratched and potentially hampered staff surveillance capability.
-Wall damage in seclusion room with green "chalk board" paint had been touched up with darker green acrylic or enamel spray. Toxicity of either paint could not be verified by Staff V, Director of Plant Operations, due to age of the paint.

4. During an interview on 08/16/11 at 4:00 PM, Staff V stated that the paint on the walls of the South seclusion room was at least 15 years old and he/she did not have any information on the product's origin. He/She stated that he/she recalled when they put it on it really smelled until it dried. He/She stated that the material covering the wall radiator in room 224 was installed because the patient kept urinating into the register. He/She stated the ceramic tile with mortar based grout used in most of the patient bathrooms (excluding the common bathrooms on 2 South) was original material, a dark brown color. He/She stated that he/she felt the surfaces were difficult to keep clean, especially around the toilets and in the showers.

5. During an interview on 08/16/11, at 9:00 AM, Staff X, housekeeper, stated he/she used a variety of cleaning products in his/her duties, but used a cleaning product HDQ C-2 (brand of disinfectant cleaner) for just about everything. He/She stated that it was a sanitizing cleaner that cleaned and disinfected surfaces such as ceilings, walls, doors and door facings. He/She stated that he/she used a wire brush in the showers and a stiff fiber brush around the perimeter of the shower floor. He/She stated that there are five full-time housekeepers altogether and they work seven days a week on day and evening shifts.

6. Record review of the facility's policy titled, "Environment of Care Housekeeping Policy No. 7.10.15", last revision dated 03/01/10, showed housekeeping staff are assigned the responsibility of cleaning patient/resident's bed, closet and room. Housekeeping Duties work sheets showed housekeepers do high and low dusting of furnishings twice a week and vents, window sills and other items three times a week. Dusting of vents is not included on the checklist titled, "Daily Unit Duties".


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7. Observations of the kitchen on 08/18/11 between 9:03 AM and 12:45 PM showed the following:
-The inside top of the ice machine had a build-up of what appeared to be mold and the mold had a build-up of condensation over it, which could cause the mold to drip onto the clean ice used for human consumption.
-The floor area around the ice machine was very dirty with trash, lime and dirt, an old window blind and an old rack used in a refrigerator.
-The three portable fans throughout the kitchen had dirt, grease and debris covering the outside and blades of the fans. The fans had the possibility of blowing the dirty debris onto foods and food contact surfaces.
-The soda fountain pipes in the toaster area contained dirt, grease and debris.
-The ceiling vents in the kitchen that ran the length of the kitchen over the food production area had chipped paint. It contained what appeared to be mold in some areas of the vent and other areas of the vent contained dirt, grease and debris.
-The ceiling had missing tiles (which left holes in some areas of the ceiling) in the area behind the vent in the "Emergency eye wash area".
-The ceiling tiles throughout the kitchen contained stains, dirt, grease and debris.
-Dirt, grease and debris covered the electrical socket on the wall by the window in the ice machine area.
-Trash containers by the dessert preparation and clean pots and pans areas were uncovered, potentially exposing refuse to pests.
-Dried food, mold, grease and debris covered the back splash behind the dish machine.
-Dried baked-on foods covered the bottom of the grill.
-Grease, dirt and debris covered the cords, pluming and pipes on the back of the convection ovens.

8. During an interview on 08/18/11 between 9:28 AM and 9:40 AM, Staff I, Certified Dietary Manager (CDM) stated that he/she wanted the kitchen cleaner, but a shortage of personnel resulted in the CDM working in the kitchen at least four days of the work week cooking and/or filling other positions. This restricted him/her from performing his/her assigned duties as a dietary manager.