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Based on observation, interview and record review the facility's Chief Executive Officer (CEO) failed to manage the operation of the facility to ensure that:
-All patients received a telephone number and name of an entity they could file a complaint and/or grievance with;
-All intended staff received the required education on contraband identification and seizure since the survey of 10/04/12, during which problems with contraband (items patients were not supposed to have because of their potential harmful properties) were found. The facility census was 66.

Findings included:

1. Review of the facility policy, "Patients' Rights and Responsibilities Policy" last revised 09/2012 showed that prior to the provision of services, all patients will be provided with a written statement of the facility's Patient Rights. This information will be reviewed verbally and a signed copy of the patient rights shall evidence acknowledgement of the receipt of this document. The list of rights included the right to file a complaint with the State Department of Health (sic) regarding a concern about patient abuse, neglect, misappropriation of patient property in the facility, or other unresolved complaint.

2. Review of the patient rights form in a patient admission packet showed no contact telephone number for filing a complaint with the Department of Health and Senior Services (DHSS).

3. Review of the signed patient rights forms in the medical records of Patients #4, #5, #9, #10, #12, #13, #14, #48, and #49 showed no contact telephone number to file a complaint with the DHSS.

4. During an interview on 12/12/12 at 1:35 PM, Patient #49 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #49 had no name of an entity to report to, or telephone number.

5. During an interview on 12/12/12 at 1:40 PM, Patient #13 stated that she was not aware of who to contact if she needed to file a complaint/grievance. Patient #13 had no name of an entity to report to, or telephone number.

6. Record review of the facility policy titled, "Control of Contraband," revised 11/12, showed the facility will make all reasonable efforts to provide a safe environment for patients and staff of the center by establishing and maintaining a consistent process for identifying, securing and preventing potentially dangerous or harmful contraband items from reaching the inpatient units;

7. During an interview on 12/11/12 at approximately 2:20 PM, Patient #22 (Adolescent Unit), stated that a contraband check was not conducted upon his admission on 12/08/12.

8. Record review of the "Belongings List and Contraband Assessment" forms showed eight (Patients #1, #21, #16, #17, #19, #4, #5, and #22) of twelve patients without the admission contraband assessment portion of the forms completed on the adolescent unit.

9. During an interview on 12/12/12 at 9:14 AM, the CNO stated that the education of staff related to contraband had not been completed as of this date, but would be with the annual skills fair/competencies during the week of 12/17/12.

10. Review of education documentation dated 12/12/12, revealed that 14% of staff intended to receive the contraband re-inservicing information had not yet received it.

11. During an interview on 12/12/12 at 3:34 PM, the CEO stated that he had relied upon the CNO to ensure issues since the prior survey were indeed corrected. The CEO stated that he was completely unaware that the education piece had not been met. The CEO stated that he would have thought it would have been required of all staff prior to return to work status, rather than wait until the week of 12/17/12.



31633




31891

Based on observation, interview, and record review, the facility failed to provide the Department of Health and Senior Services telephone number for filing a complaint to 11 patients (#4, #5, #9, #10, #12, #13, #14, #22, #33, #48, and #49) of 12 patients reviewed and failed to include the telephone number on two posted patient rights signs. These failures had the potential to affect all patients admitted to the facility. The facility census was 66.

Findings included:

1. Review of the facility policy, "Patients' Rights and Responsibilities Policy" last revised 09/2012 (September 2012) showed these directives for facility staff: Prior to the provision of services, all patients will be provided with a written statement of the facility's Patient Rights. This information will be reviewed verbally and a signed copy of the patient rights shall evidence acknowledgement of the receipt of this document. The list of rights included the right to file a complaint with the State Department of Health (sic) regarding a concern about patient abuse, neglect, misappropriation of patient property in the facility, or other unresolved complaint.

2. Review of the Patients' Rights form in a patient admission packet showed no contact telephone number for filing a complaint with the Department of Health and Senior Services.

3. Review of the signed Patients' Rights forms in the medical records of Patients #4, #5, #9, #10, #12, #13, #14, #48, and #49 showed no contact telephone number to file a complaint with the Department of Health and Senior Services.

4. During an interview on 12/12/12 at 1:40 PM, Patient #13 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #13 had no name of an entity to report to, or telephone number.

5. During an interview on 12/12/12 at 2:25 PM, Patient #22 stated that no rights, complaint process, or Department of Health and Senior Services phone number was reviewed or given to him upon admission.

6. During an interview on 12/12/12 at 2:30 PM, Patient #33 stated that no rights, complaint process, or Department of Health and Senior Services phone number was reviewed or given to him upon admission.

7. During an interview on 12/12/12 at 1:35 PM, Patient #49 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #49 had no name of an entity to report to, or telephone number.

8. Observation on 12/10/12 at 1:45 PM showed no contact telephone number for filing a complaint with the Department of Health and Senior Services on the Patients' Rights posted on the wall of Hallway B in the Senior Adult Unit.

9. Observation on 12/11/12 at approximately 10:30 AM showed no contact telephone number or information for filing a complaint with the Department of Health and Senior Services on a wall posting behind the Adolescent Unit nursing station.




12450




31891

Based on observation, interview, and record review the facility failed to:
-Complete accurate and comprehensive admission contraband assessments for eight patients (#16, #17, #19, #1, #21, #4, #5, and #22) of twelve patients on the adolescent unit and for one patient (#6) of fifteen patients on the Intensive Treatment Unit (ITU-utilized to treat the more acutely ill, behavior problem patients).
-Take action to prevent Patient #4 from acquiring a lighter, a pack of cigarettes, and an unknown pill;
-Complete accurate and comprehensive interventions according to the mandatory education process initiated on 10/10/12 for control of contraband;
-Identify old and potential newly-acquired contraband, and add those items to inventory lists for three of 38 patients reviewed (Patients #13, #51, and #52).
-Assess and document size, description, and take photos of a reddened skin issue on one of one patient identified with skin issues (Patient #13); and
-Assess and document goals and interventions to prevent skin irritation related to poor hygiene of one patient identified with skin issues (Patient
#13).

These failures had the potential to affect all patients, and could potentially lead to harm of the patients admitted to the facility. The facility census was 66.

Findings included:

1. Record review of the facility policy titled, "Control of Contraband", revised 11/12, showed the following direction:
- [The facility] will make all reasonable efforts to provide a safe environment for patients and staff of the center by establishing and maintaining a consistent process for identifying, securing and preventing potentially dangerous or harmful contraband items from reaching the inpatient units;
- To accomplish control of contraband and to assure a safe, therapeutic environment, certain items will not be allowed into any patient areas under any circumstances;
- Restricted items include, but are not limited to; electronics, chemicals, corded items, glass, fire hazards/weapons, and personal items;
- Restricted personal items included razors & sharp metal objects, mirrors, items with cords, prescription & over the counter medications, shaving lotion, and nail polish remover, to name a few;
- Patients who present for a medical screening exam (pre-admission assessment) will be asked to place their personal items into a locked container, to remain in their presence until their disposition to the next level of treatment. Patients refusing to cooperate with the search will remain with staff until an inspection takes place. Security may be called to assist for patients resistant to the search;
- A second check for contraband items will take place during the nursing assessment on the inpatient unit;
- To prevent inadvertent entry of contraband items that cannot be detected through electronic wands, patients with an acute history of suicidal ideation, gesture or attempt shall, upon admission to their nursing unit, be required to put on a patient gown, (while maintaining privacy with a screen) and have all clothing searched before allowing the patient to wear these items within the unit environment.

2. Record review of the facility mandatory education titled, "Control of Contraband" with an effective date of 10/10/12 showed the following requirements for direct care staff:
- Upon admission to the unit, patient belongings will be placed in a secure place until they can be searched. All clothing items will be checked for strings and cords and removed before returning to patient;
- The patient will be placed in a paper gown without underwear until he/she can be searched. Privacy will be maintained but safety is the first priority;
- As soon as possible after admission, patient belongings will be searched and documented on a medical record form (Belongings List and Contraband Assessment);

3. Record review of the contraband assessment portion of the "Belongings List and Contraband Assessment" form included the following:
- Wanded for metal;
- Checked for contraband;
- Placed in gown;
- Photo and description of injury.

Record review on 12/11/12 of the admission "Belongings List and Contraband Assessment" forms showed staff failed to complete the contraband assessment portion for eight patients (#1, #21, #16, #17, #19, #4, #5, and #22) out of twelve patients reviewed on the adolescent unit.

4. Record review of the last documented suicide risk scores dated 12/11/12 for the eight patients on the adolescent unit without the contraband assessment showed Patient #1 with a score of 6 (high risk), Patient #21 with a score of 4 (moderate risk), Patients #16, #17, and #19 with a score of 2 (low risk), Patients #4 and #5 with a score of 1 (low risk), and Patient #2 with a score of zero (low risk).

5. Review of medical record for Patient #4 on 12/10/12 showed:
- Patient admitted on 12/02/12 after she told her aunt she wanted to die;
- Patient had a history of cutting and had fresh scratches on her left arm;
- Progress documentation dated 12/03/12 noted the patient with a pack of cigarettes and lighter on the day shift and the patient's aunt found a pill in her pocket..

6. During an interview on 12/11/12 at approximately 1:00 PM, Staff R, Registered Nurse (RN), stated that contraband checks are completed upon admission, environmental rounds are completed twice per day, staff on evenings conducts contraband searches after visitation, she did not know how cigarettes and lighter got in, and she did not know that a pill was found on patient.

7. During an interview on 12/11/12 at approximately 11:00 AM, Staff W, Mental Health Technician (MHT), stated that she was aware Patient #4 was found with a lighter and cigarettes and still does not know how it happened. She further stated that she, as an experienced MHT, conducts training for new staff including procedures for contraband checks, belongings inventory, and documentation requirements.

8. During an interview on 12/11/12 at approximately 2:20 PM, Patient #22 (Adolescent Unit), stated that a contraband check was not conducted upon his admission on 12/08/12 and he did not change into a gown or pajamas.

9. During an interview on 12/12/12 at 9:35 AM, Staff Q, Adolescent Unit Director, stated that:
- Belongings are secured and checked upon admission for contraband;
- Patients receive a contraband search in examination room;
- Patients at low to high risk of suicide are searched in a paper gown with underwear removed;
- By report, two MHT staff conducted Patient #4's admission contraband assessment and that she did not remove her underwear during the search;
- He did not understand how cigarettes and a lighter were not found during search; and
- He was unable to submit evidence of an admission contraband search from the patient's medical record.

10. During an interview on 12/12/12 at approximately 2:00 PM, Staff F (RN) and Charge Nurse on the Adolescent Unit, stated that:
- During a contraband assessment, the patient is required to change into paper scrubs after removing clothes and underwear;
- The requirement was included in mandatory training on Control of Contraband; and
- She does not understand why some staff do not want to have underwear removed when a patient stands behind a screen to change for privacy.

11. During an interview on 12/11/12 at approximately 1:30 PM, Staff R, RN stated that if contraband is found, the nurse is to contact the physician, determine the level of monitoring, search room clothes, document on an incident report and notify the Director.

The findings noted above show that policies, procedures and interventions do not provide patients on the adolescent unit with consistent and effective supervision and contraband searches,thereby placing them at potential risk of acquiring harmful objects (contraband).

12. Review of the Adult and Intensive Treatment Units' suicidal risk assessment documentation dated 12/10/12, showed sixteen of thirty-eight patients with a suicidal risk score of "3-6", or a moderate-high risk for suicidal tendencies.

13. Review of Patient #6's History and Physical (H&P) dated 12/07/12, showed the patient was admitted to the ITU on that date with a diagnosis of schizoaffective disorder, bipolar type (a condition whereby the patient hears voices, and has manic [high-energy] days and depressed days).

Review of the patient's suicidal risk score dated 12/10/12, showed the patient was rated as being a moderate risk for suicide with a score of "3."

Review of the patient's Physician's orders dated 12/07/10, showed the patient was to be monitored by staff every 15-minutes.

14. Observation and concurrent interview on 12/10/12 at 1:50 PM showed Patient #6 had a purple/plumb colored top lying on her bed with four fabric ties sewn to the side seam at the waistband. Each tie was approximately 12-15-inches long (probably used to tie a bow at the waist). These long ties could have been removed from the top and utilized as a hanging/looping hazard. Staff Y, Quality RN, stated that the patient should not have this top with ties. Staff Y stated that the top should have been removed by staff either in the inspection process during admission and/or upon discovery during environmental rounds completed each shift.

Even though this top was found in the patient's room, review of the patient's List of Personal Possessions, undated, showed no such top in her possession and review of the Environmental Rounds documentation dated 12/10/12, not timed, showed no such top with ties.

15. During an interview on 12/11/12 at 3:06 PM, Staff SS, MHT, stated that he admitted Patient #6 and never saw a top with long ties on it. Staff SS stated that if the top was brought in by family after the admission process, it should have been inventoried by staff and removed from the patient because it was considered contraband, or a hazard to this patient and all others at risk.

Staff failed to search the patient and/or room in a thorough manner in order to protect all patients from potential harm related to contraband.

16. Review of Patient #51's H&P dated 12/04/12, showed the patient was admitted to the Adult unit on 12/03/12 with a diagnosis of suicidal ideations and attempt by hanging.

Review of the patient's suicidal risk score dated 12/10/12, showed the patient was a low risk (0-2) with a score of "1." Her roommate had a score of "2."

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had contraband in her room (Mentholatum ointment, a topical pain relieving rub). This ointment could be inappropriately consumed or applied.

17. Review of Patient #52's H & P dated 12/05/12, showed the patient was admitted to the Adult unit on 12/04/12 with a diagnosis of bipolar disorder.

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had a wire-bound notebook and a dress with strings. The wire from the notebook could be used by the patient to injury herself. The strings could be utilized for a potential looping hazard.

18. Review of Patient #53's H&P dated 12/06/12, showed the patient was admitted to the Adult unit on 12/05/12 with a diagnosis of suicidal ideations and a history of suicide attempt by overdose.

Review of the Adult Environmental rounds documentation dated 12/11/12 showed the patient had a glass bottle in her room. This bottle could potentially be used as a cutting weapon.

19. Review of Patient #13's H & P dated 12/01/12, showed the patient was admitted to the Adult unit on 11/30/12 with a diagnosis of schizoaffective disorder.

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had shoes with strings. These strings could be utilized for a potential looping hazard.

20. Record review of the "Control of Contraband" mandatory education, dated effective 10/10/12 showed the following requirements:
-Staff will complete an admission checklist (form required to be completed on every patient as an audit/review tool and is not part of the medical record) and turn into the team RN.
-The admission checklist includes: a) belongings removed upon admission to unit, b) patient placed in paper gown and searched, c) clothing searched for contraband and strings/cords removed before returning to patient, d) patient belongings searched and logged on valuables checklist, e) valuables and medications locked in appropriate safes, f) requirement to complete on every patient admitted, g) Signature authentication by Mental Health Technician (MHT) conducting the search, and h) signature authentication by the team RN.
-The team RN will review to make sure the checklist is complete and turn into the Director. The Director or designee will randomly check staff for completeness of contraband checks weekly and will document on the audit form.

21. Following request on 12/12/12 for audit information on control of contraband, Staff F (Adolescent unit RN), Staff Q (Adolescent unit Director) and Staff A (Chief Nursing Officer) did not submit any completed audit forms for review. Therefore, the facility failed to show completed admission checklists on every patient.

22. Review of a facility policy titled, Skin Assessment for Bruising, Pressure Ulcers and other Skin Markings, revised 06/12," showed the following:
-The Registered Nurse (RN) completed the Plan for Nursing Care, including;
-Specific nursing interventions for psychological, psychosocial, and environmental factors;
-The Plan is specific, individualized and goal oriented.
-The Plan will be based on the patients' strengths, liabilities, and patient care needs;
-Team members will develop quantifiable short-term and long-term goals for which specific interventions are developed;
-The Plan will be evaluated and revised every 48-hours;
-Skin assessment will be completed via the Braden (a tool used to assess risk for skin breakdown) on admission and daily thereafter if the Braden score is less than or equal to "16;"
-Photos are taken bi-weekly of identified sites;
-The physician is notified of a change in skin condition, and the abnormal skin area is documented with general skin appearance (color, warmth, integrity) and identifying characteristics (bruises, skin tears, stitches, etc.);
-Wounds should be measured in centimeters (cm) with a detailed description in the daily nursing assessment.

23. Review of Patient #13's Psychiatric Report dated 12/01/12, showed the patient was admitted to the Adult unit on 11/30/12 with a diagnosis of schizoaffective disorder. The patient also had a history of obstructive sleep apnea, was morbidly obese (486 pounds) with poor hygiene and had a bad odor.

Review of Patient #13's Braden scale score on admission showed a score of "14," or at risk. A Braden scale is used to predict the risk of skin breakdown.

Review of the patient's medical record showed no description, size or photos of the patient's redness/yeast areas.

Review of a physician's note dated 12/09/12, showed the patient had redness to areas on backs of arms, axilla (underarms), buttocks and inner thighs. The patient had limited mobility and had to be encouraged to be more mobile to prevent breakdown and also had to be encouraged to perform hygiene.

Review of nurses' and social workers' notes showed the following:
-On 12/01/12 the patient's grooming was poor;
-On 12/03/12 the patient had poor hygiene and had skin breakdown between abdominal folds where skin touches, smells horrible, appearance disheveled with strong body odor;
-On 12/04/12 the patient had a history of not bathing and was reported to authorities for self-neglect;
-On 12/06/12 the patient's activities of daily living were poor.

Review of a Consult Note dated 12/02/12, showed the patient had moist skin with redness and a yeasty odor under the skin folds of the abdomen, near the groin.

Review of physician's orders dated 12/09/12, the physician ordered Desitin (zinc oxide) ointment to be applied to the reddened area, twice daily until healed.

24. During an interview on 12/11/12 at 1:00 PM, Staff D, Registered Dietitian, stated that Patient #13 had mobility and hygiene issues which lead to the skin breakdown.

25. Observation and concurrent interview on 12/11/12 at 9:08 AM, showed Patient #13 walking down the hallway emitting a very discernible body odor. Staff TT, RN, confirmed the patient typically had an odor, had just finished a shower, and generally resisted showering/hygiene. The patient had a large area of redness under the large folds of her abdomen, measuring approximately 15-inches across by six-inches wide.

26. During an interview on 12/11/12 at 1:52 PM, Staff Y, Quality RN, stated that she did not believe staff were required to document size/description, and take photos of a redness/yeast area (as stated in policy), just staged pressure sores.

27. During an interview on 12/12/12 at 9:14 AM, Staff A, Chief Nursing Officer, stated that there was no facility policy addressing a redness/yeast area. Staff A stated it was a nursing judgment if a skin issue worsened, with report to the physician, oncoming nurse, and documentation reflecting the change. However, Staff A could not specifically relate how the nurses would track condition from one shift to the next without the description, size, etc. documented in the record. Staff A stated that depression typically lead to poor hygiene, and poor hygiene could lead to skin issues. If hygiene improved, the skin condition would also improve. Staff A stated that quality monitoring of skin assessment/documentation was not typically an issue on the Adult/ITU, just the senior unit.

28. During an interview on 12/12/12 at 1:47 PM, Patient #13 stated that the redness/yeast area would come and go, and itched.

29. Review of facility quality monitoring documentation, for the third quarter of 2012, showed no performance indicator for skin assessment and documentation on the Adult/ITU.




12450

Based on observation, interview and record review the facility failed to develop/maintain a comprehensive, individualized care plan, with a problem, goal and specific interventions for two of eight care plans reviewed (Patients #4 and #13). This failure could potentially lead to improper identification and provision of care needs. The facility census was 66.

Findings included:

1. Review of facility policies titled, "Treatment Plan, revised 08/12; and Multidisciplinary Treatment Plan, revised 11/12 showed the following:
-The Registered Nurse (RN) completed the Plan for Nursing Care, including;
-Specific nursing interventions for psychological, psychosocial, and environmental factors,
-The Plan is specific, individualized and goal oriented;
-The Plan will be based on the patients' strengths, liabilities, patient care needs;
-Team members will develop quantifiable short-term and long-term goals for which specific interventions are developed;
-The Plan will be evaluated and revised every 48-hours.

2. Review of Patient #13's Psychiatric Report dated 12/01/12, showed the patient was admitted to the Adult unit on 11/30/12 with a diagnosis of schizoaffective disorder. The patient also had a history of obstructive sleep apnea, was morbidly obese (486 pounds) with poor hygiene and had a bad body odor.

Review of a physician's note dated 12/09/12, showed the patient had to be encouraged to perform hygiene.

Review of nurses' and social workers' notes showed the following:
-On 12/01/12 the patient had sleep apnea and grooming was poor;
-On 12/03/12 the patient had poor hygiene, smelled horrible, appearance was disheveled with strong body odor;
-On 12/04/12 the patient had a history of not bathing and was reported to authorities for self-neglect;
-On 12/06/12 the patient's activities of daily living were poor.

Review of a physician Consult Note dated 12/02/12, showed the patient utilized a CPAP (continuous positive airway pressure used to assist in breathing) machine in her home related to the sleep apnea.

Review of physician's orders dated 12/06/12 showed the patient required oxygen at two liters per nasal cannula (tubing) at bedtime and during naps.

3. Observation and concurrent interview on 12/11/12 at 9:08 AM, showed Patient #13 walking down the hallway emitting a very discernible body odor. Staff TT, RN, confirmed the patient typically had an odor, and generally resisted showering/hygiene.

4. During an interview on 12/11/12 at 11:03 AM, Staff X, RN, stated that Patient #13 had Chronic Obstructive Pulmonary Disease related to her weight which compromised her breathing.

5. During an interview on 12/12/12 at 9:14 AM, Staff A, Chief Nursing Officer, stated that depression typically leads to poor hygiene. Staff A stated that she did not feel like oxygen use and poor hygiene was something that needed to be added to the treatment plan for this patient because they were not new problems.

6. During an interview on 12/12/12 at 1:47 PM, Patient #13 stated that she gets short-of-breath with exertion and required oxygen at night and during naps. Patient #13 stated that the oxygen helped a lot.

7. Review of the patient's Treatment Plan dated 12/01/12 showed staff failed to address the patient's lack of hygiene, history of and current odors. There was only one intervention, "Assist with performance of basic living." A problem of altered skin integrity (the patient had developed a yeasty rash under her abdominal folds as a result of poor hygiene) showed an intervention to keep the patient clean and dry. Staff also failed to address the patient's need for oxygen at bedtime and during naps in the treatment plan.

8. Review of Patient #4's medical record on 12/12/12 showed:
- Patient admitted on 12/02/12 at 9:19 PM after she told her aunt she wanted to die; had a history of cutting and had fresh scratches on her left arm; and reported that her mother died of a heart attack three months ago;
- Progress documentation dated 12/03/12 noted the patient had a pack of cigarettes and lighter (contraband) on the day shift, the patient's aunt found a pill in the patient's pocket; and the patient displayed secretive behaviors;
- A Physician's order dated 12/04/12 at 9:45 PM for close observation (patient to remain within eyesight of staff);
- A Physician's order dated 12/07/12 at 7:10 PM for unit restriction (patient to remain on unit) and 1:1 supervision (one staff is assigned to supervise one patient at all times);
- The Physician re-ordered 1:1 supervision and unit restriction on 12/08/12 at 11:00 AM, until the patient was discharged.

9. Review of Patient #4's treatment care plan dated 12/02/12 showed:
-No comprehensive treatment/care plan to address 1:1 supervision, unit restriction, and/or contraband interventions.

10. During an interview on 12/12/12 at approximately 9:00 AM, Staff Q (Adolescent Unit Director) stated that Patient #4 had been on 1:1 and close observation; however, these interventions were not included in treatment plans.



31891

Based on interview and record review, the facility failed to establish a Utilization Review Committee staffed by practitioners that included at least two doctors of medicine or osteopathy and failed to maintain records of utilization review functions. These failures had the potential to impact the appropriateness and clinical necessity of admissions, continued stays, and support services for all patients admitted to the facility. The facility census was 66.

Findings included:

1. Review of a list of Utilization Review Committee members showed that there was only one physician on the list.

2. Review of the facility's Utilization Management Plan, dated 2012, showed direction for facility staff to maintain records that include minutes of any committees where decisions regarding a patient's length of stay or utilization of services were made and reference the cases reviewed, problems identified, recommendations, subsequent actions, evaluation of the effectiveness of actions taken, disposition of cases, and broader recommendations for improving utilization of hospital services.

3. Review of "UM (Utilization Management) Staff Committee Meeting" minutes, dated 11/28/2012 and provided as documentation of utilization review functions, showed that no physician was present and there were no specific case files reviewed.

4. During an interview on 12/12/2012 at 3:30 PM, Staff DD, Director of Therapeutic Services, stated that:
-Her responsibilities included direction of utilization review activities performed by the case managers daily in collaboration with physicians;
-She was unable to provide records of those activities for surveyor review; and
-The "UM Staff Committee Meeting" on 11/28/2012 was the only utilization review committee meeting held in 2012.

Based on observation, interview and record review the facility failed to ensure food stored in the Dietary department was maintained in a sanitary manner to protect against spoilage and/cross contamination that could cause food borne illness. The facility census was 66.

Findings included:

1. Review of the facility's Food and Nutrition (F&N) department's policy titled "Sanitation and Infection Control" issued 05/95 showed direction for staff to conduct monthly sanitation inspections in the facility kitchen using a form called the Sanitation Checklist.

2. Review of the facility's F&N department's Sanitation Checklist showed direction for staff to check storage areas and ensure scoops were not stored in bulk food bins.

3. Review of the U. S. Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed direction in Chapter 3-304.12 "In-use utensils, between use-storage" food preparation and dispensing utensils shall be stored with their handles above the top of the food in the container.

4. Observation on 12/10/12 at 2:55 PM in the cook's area showed staff stored a scoop with the handle in direct contact with the surface of the food in a bulk sugar bin.

5. During an interview on 12/10/12 at 2:55 PM, Staff B, Director of Food and Nutrition stated the scoop should not be stored in the bulk sugar bin in direct contact with the sugar.

6. Observation on 12/10/12 at 3:00 PM in the cook's area showed staff stored an opened, partially full one gallon container of soy sauce and a ten ounce bottle of soy sauce both unrefrigerated on a shelf under a cook's preparation table. Further observation showed both containers of soy sauce had manufacturer's labels with directions to "refrigerate after opening".

7. During an interview on 12/10/12 at 3:00 PM Staff B stated he was unaware that soy sauce had to be refrigerated after opening as directed on the manufacturer's labels.

Based on interview and record review the facility failed to follow their infection control policy regarding Tuberculosis (TB-a contagious respiratory disease) testing for two of seventeen employees reviewed. This has the potential to affect all employees and patients if an outbreak would occur. The facility census was 66.

Findings included:

1. Review of a facility policy titled, "New Employee and Annual TB Screening and Testing," revised 06/12, showed the following:
-Baseline TB screening will be performed on all new hires, using the two-step method;
-Then, all employees will need to complete an annual TB health assessment form;
-If an employee has been exposed to TB a screening will be completed with a follow-up screen in three months.

Review of a facility policy titled, "Infection Control Guidelines for the Nursing Department," revised 06/12, showed the following:
-Nursing personnel will review at least annually and comply with the standards set forth for the TB control plan;
-There will be monitoring tools to evaluate whether personnel are complying with stated infection control policies.

3. Review of the Tuberculosis Infection Surveillance Plan, dated October 2011, showed that to reduce the risk for transmitting TB, employees shall be screened and protected from health hazards associated with TB.

4. During an interview on 12/12/12, Staff G, Infection Control Registered Nurse, confirmed the above process and policies.

5. Review of employee records on 12/12/12, showed Staff B, Director of Dietary, had no documentation of TB screening, or the annual risk health assessment since 07/04. Staff MM, Physical Therapy, had no documentation of TB screening, or the annual risk health assessment since hire on 07/12/10.

6. During an interview on 12/12/12 at 2:55 PM, Staff NN, Director of Human Relations (HR), confirmed the failure to have TB screening evidence in the above personnel files.

7. During an interview on 12/12/12 at 3:06 PM, Staff A, Chief Nursing Officer, confirmed there was no additional evidence of TB screening for the above two employees. Staff A stated that HR utilizes an employee roster to track annual TB screenings, and was not sure how these two got missed.

Based on observation interview and record review the facility failed to ensure Food and Nutrition (F&N) staff used appropriate food handling techniques to prevent cross contamination through:
-Failure to perform appropriate hand hygiene before applying clean and after removing soiled disposable gloves;
-Failure to ensure the Director of Dietary used effective hand hygiene after licking his finger tips to turn pages in manuals, policy books and other department documents and before touching equipment and surfaces in the food production and service areas;
-Failure to use effective hair restraints and effective beard restraints; and
-Failure to ensure patient meals were served at appropriate temperatures to protect against bacterial growth that may cause food borne illness.

The facility census was 66.

Findings included:

1. During an interview on 12/10/12 at 1:45 PM Staff B, Director of Food and Nutrition (F&N) stated the facility infection control practitioner did not approve or have any input on the department's food sanitation policies and procedures.

2. Review of the U. S. Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction:
-In Chapter 2-301.14 When to wash. Food employees shall clean their hands.
-In Chapter 2-301.14 (A) After touching bare human body parts (such as mouth, lips, tongue) other than clean hands and clean, exposed portions of arms.
-In Chapter 2-301.14 (H) Before donning gloves for working with food.
-In Chapter 2-301.14 (I) After engaging in other activities that contaminate the hands.
-In Chapter 3 304.15 Gloves, Use Limitation (A) Gloves shall be used for only one task such as ready to eat foods or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

3. Review of the facility's policy titled "Hand washing (HACCP, Hazard Analysis Critical Control Point, a preventative approach to food safety through identification of possible food safety hazards and methods to control those to eliminate or reduce the risk of food borne illness) dated March, 2006 showed the following direction:
-All employees associated with the handling of food shall wash hands.
-Hands shall be washed at the following times: before putting on gloves; after any other activity that may contaminate the hands.
-Procedures included: All food handlers should use sinks designated for hand washing

Review of the facility's policy titled "Personal Hygiene," effective March, 2010 showed the following direction:
-Purpose: To prevent the spread of food borne illness.
-Hand washing: Employees must wash hands before beginning/returning to work or when necessary.
-Hand washing: Wash hands frequently.
-To prevent cross contamination and the transmission of disease-carrying organisms, plastic gloves will be worn.
-Disposable gloves must be changed with each activity or whenever gloves become torn or contaminated.
-Other guidelines to further prevent the spread of illness: Hands also must be washed after scratching heads, touching hair, sneezing, blowing nose and other acts of personal nature.

4. Observations on 12/10/12 from 1:45 PM through 2:46 PM showed Staff B, Director, licked his fingers while turning multiple pages in the department policy manual, department training records, facility menus, nutrient analysis of the menus and quality assessment/performance improvements documents and failed to perform hand hygiene to remove saliva from his hands before touching multiple surfaces in the dry food storeroom, in the walk-in refrigerator, before touching a bulk sugar bin, door handles and multiple other surfaces in the kitchen.

5. Observation on 12/11/12 at 10:48 AM in the patient meal tray assembly area showed Staff Z, Diet Aide reapplied her hair restraint, failed to perform hand hygiene, applied gloves then, returned to patient meal tray assembly.

During an interview on 12/11/12 at 10:49 AM Staff Z stated she had not performed hand hygiene after touching her hair and applying gloves.

6. Observation on 12/11/12 at 11:05 AM on the Intensive Treatment Unit (ITU) dining area showed Staff Z applied gloves without performing hand hygiene.

During an interview on 12/11/12 at 11:05 AM Staff Z stated she knew she should perform hand hygiene however there was no sink in the ITU dining area so, she could not perform hand hygiene.

7. Observation on 12/11/12 at 11:05 AM in the ITU showed Staff B rubbed his hand across his mouth then without performing hand hygiene handled patient meal trays.

8. Record review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 2-402 Food handlers should wear effective hair restraints including beard restraints to keep hair from exposed foods, clean equipment and utensils.

9. Review of the facility's policy titled "Personal Hygiene", effective March, 2010 showed the following direction:
-Policy: Associates will practice good personal hygiene habits at all times while on duty.
-Purpose: To prevent the spread of food borne illness.
-Guidelines: Dress Code: Associates wear approved hair restraints, including beard guards.

10. Observation on 12/11/12 at 10:48 AM in the patient meal tray assembly area showed Staff Z, Diet Aide, placed portioned foods on each patient meal tray and failed to cover two to three inches of hair on each side of her head with an effective hair restraint.

11. During an interview on 12/11/12 at 10:48 AM Staff D, Lead Dietitian stated Staff Z failed to wear an effective hair restraint.

12. Observation on 12/11/12 at 10:55 AM showed Staff AA, Diet Aide in the cold food area (where other staff portioned uncovered cream pies) without a beard cover over facial hair.

During an interview on 12/11/12 at 10:55 AM Staff AA stated he had never been told by F&N supervisory staff to wear a beard cover over facial hair.

13. Observation on 12/11/12 at 10:58 AM showed Staff BB, Diet Aide carried a stack of cleaned trays from the dish washing room to the cafeteria area and failed to wear a beard cover over facial hair

During an interview on 12/11/12 at 10:58 AM Staff BB stated no one in the F&N department had told him to wear a beard cover over facial hair.

14. Review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 3-501 Foods should be maintained at a temperature less than 41 degrees Fahrenheit or above 135 degrees Fahrenheit to decrease growth of bacteria that could cause food borne illness.

15. Review of an undated form titled "Food and Nutrition Services Test Tray Evaluation," provided during the survey by Staff C, Dietitian showed the following permissible temperature ranges for foods served on a test tray:
-Hot entrees should be served at greater than 140 degrees Fahrenheit.
-Vegetable should be served at greater than 140 degrees Fahrenheit.
-Dessert should be served at lesser than 40 degrees Fahrenheit.

16. Observation on 12/11/12 at 11:17 AM showed staff served a test meal tray with foods at the following temperatures:
-Roast pork at 114 degrees Fahrenheit.
-Spinach at 118 degrees Fahrenheit.
-Canned pineapple at 51.1 degrees Fahrenheit.

17. During an interview on 12/11/12 at 11:17 AM the Staff C, Dietitian stated the following:
-The roast pork and the spinach should be served at 135 degrees Fahrenheit and it was not.
-The canned pineapple should be served at or below 40 degrees Fahrenheit and it was not.
-The roast pork and the spinach need to be warmer.