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Based on observations, review of the facility policy and procedure, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, review of previous survey Plan of Correction, and interviews with staff it was determined the facility Governing Body failed to ensure:

1. The facility implemented an environmental safety risk assessment strategy to include a ligature risk assessment and mitigation plan.

2. A safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit.

3. The staff on the Geri-Psych unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies.

4. The facility corrected / addressed all ligature risk points in the Geri-Psych unit following the recertification survey on 1/11/18, the resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018.

5. Patient food and medication refrigerators were maintained at the appropriate temperature daily.

6. A PCA (patient care assistant) was in attendance in the day room on the Geri-Psych Unit at all times when patients were in the day room as directed by facility policy.

7. Patient weights were obtained and documented twice per week as ordered by the physician.

8. The nutritional status of patients were reassessed as appropriate.

9. A dietitian consult was obtained for a patient not eating and experienced weight loss.

10. The physician's ordered diet was provided.

11. The nursing staff assessed and documented patients skin status/injuries and implemented preventive interventions.

12. The nursing staff documented the specific treatment modalities they provided.

13. The nursing staff provided and documented interventions to manage behaviors prior to administering prn (as needed) medications.

14. Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible as directed per facility policy.

15. The nursing staff followed the facility policy for admixtures prepared outside the pharmacy.

16. The nursing staff followed the facility policy and CDC hand hygiene guidelines during medication preparation and administration.

17. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy.

18. Each patient admitted to the Geri-Psych Unit had a psychiatric evaluation completed within 60 hours of admission.

19. Psychosocial admission assessments were completed within 3 treatments days of admission.

20. Dietary staff provided food in a consistency the patient could consume.

21. The dietitian provided diet education / counseling for a patient on a special diet that was not eating / drinking.

22. The dietitian initiated a calorie count as directed per policy for a patient consuming less than 50% of meals.

Findings include:

Refer to A 115, A 144 A 385, A 392, A 405, A 431, A 449, and A 630.

Based on observations, review of the facility policy and procedure, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), review of previous survey Plan of Correction, and interviews with staff it was determined the facility failed to:

1. Implement an environmental safety risk assessment strategy to include ligature risk assessment and mitigation plan.

2. Ensure a safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit.

3. Ensure staff on the Geri-Psych unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies.

4. Correct / address all ligature risk points in the Geri-Psych unit following the recertification survey on 1/11/18, the resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018.

5. Ensure food and medication refrigerators were maintained at the appropriate temperature daily.

6. Ensure a PCA (patient care assistant) was in attendance in the day room at all times when patients were in the day room as directed by facility policy.

These deficient practices had the potential to affect all patients admitted to the Geri-Psych Unit at this facility.

Findings include:

Refer to A 144

Based on review of facility policies, medical records (MR), Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, and interviews with staff it was determined the nursing staff failed to:

1. Obtain weights and document twice per week as ordered for patients admitted to the Geri-Psych (Geriatric Psychiatry) Unit.

2. Reassess the nutritional status of a patient that was not eating / drinking.

3. Obtain a dietitian consult for a patient not eating and with weight loss.

4. Ensure the physician ordered diet was provided.

5. Assess and document patient's skin status/injuries and implement preventive interventions.

6. Document specific treatment modalities provided.

7. Provide and document interventions to manage behaviors prior to administering prn (as needed) medications.

8. Ensure Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible.

9. Follow the facility policy for admixtures prepared outside the pharmacy.

10. Follow the facility policy and CDC hand hygiene guidelines during medication preparation and administration.

Findings include:

Refer to A 392 and A 405

Based on review of facility policies and procedures, medical records (MR), and staff interviews it was determined the facility failed to ensure:

1. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy.

2. Each patient admitted to the Geri-Psych (Geriatric Psychiatry) Unit had a psychiatric evaluation completed within 60 hours of admission.

3. Admission evaluations were completed with 3 days of admission.

Refer to A 449

Based on facility tour observations, review of the policies and procedures, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), review of the previous survey Plan of Correction, and interviews with staff it was determined the facility failed to:

1. Implement an environmental safety risk assessment strategy to include a ligature risk assessment and mitigation plan.

2. Ensure a safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit.

3. Ensure staff on the Geri-Psych Unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies.

4. Correct / address all ligature risk points following the recertification survey on 1/11/18, resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018.

5. Ensure food and medication refrigerators were maintained at the appropriate temperature daily.

6. Ensure a PCA (patient care assistant) was in attendance in the day room at all times when patients were in the day room as directed by facility policy.

These deficient practices did affect Patient Identifier (PI) # 4 and PI # 3 and had
the potential to affect all patients admitted to the Geri-Psych Unit at this facility.

Findings include:

Policy: Unit Safety Checks
Revised: 2/2/18

Purpose:

To ensure a safe patient environment and the safety of each patient on the unit.

Procedure:

A. The charge RN (Registered Nurse) will walk the entire unit at some time during their shift, preferable near the beginning.

B. The inspection will include all the areas of the unit.

C. The worksheet will be brought along to note any deficiencies and/or contraband found on the unit. The worksheet will include reminders such as doors secured, seclusion room and hallways clear, patient rooms clean and in order, presence of any nonessential furniture, bed alarms working properly, electrical cords on beds shortened/secured to bed frames, and the like.

D. Any contraband, to include but not limited to: sharps, cans, wire hangers, lighters, cords, bottles, personal items except for patient clothing or bed linens, perfume, makeup, plastic bags, medicines including over the counter medications, found in patient areas will be removed immediately, labeled, put in patient locker, and noted on worksheet.

E. Any other deficiencies, such as: housekeeping issues, maintenance problems, or needed supplies must also be noted on the log sheet.

F. The RN will complete work orders for repairs needed and report deficiencies to the Director as necessary.

Policy: Observation Status/Special Precautions
Revised: 9/7/16

Purpose:

To divine observational/special precautions monitoring and circumstances under which they are utilized to maintain the safety of each patient.

V. Special Precautions
A. Fall Precaution: All Senior Care patients are considered at high risk for falls. (Reference NSA 25.1)
a. Observe every fifteen minutes
g. PCA in day room when patients are present

1. A tour of the facility was conducted 10/30/18 at 12:45 PM with Employee Identifier (EI) # 2, Director of Patient Care Services.

During the tour of the Geri-Psych Unit (GPU) the surveyor observed open safety bars in the patient bathrooms and showers, exposed plumbing at the sinks/toilets and round door knobs on the closet doors.

EI # 2 was asked why the ligature points in the patient rooms had not been corrected and the answer was "it is in process". When asked what that means, the answer was "I'm not sure without checking with the unit Director".

The initial tour continued with EI # 2 to the day room which served as the Group Therapy room, Activities room, dining room and patient leisure room.

The day room had 2 tables with chairs, a kitchen area with a sink, cabinets, and refrigerator. There were storage cabinets along the wall beside the refrigerator with various games and papers. In an unlocked drawer the surveyor observed a long cell phone charger which could be used as a ligature.

There were 2 temperature logs on the patient refrigerator door dated October 2018.

Review of the Patient Food Refrigerator Log dated October 2018 revealed no temperature check documented on 10/9/18, 10/18/18, 10/21/18, and 10/24/18.

Review of the second log titled Temperature Charts Senior Care, revealed no temperature check documented on 10/10/18, 10/24/18, and 10/29/18.

The surveyor asked to see the medication room and was taken to a closet at the nursing station. The nurse on duty unlocked the closet which revealed a medication cart backed into the closet and a shelf above the medication cart with a small refrigerator. The shelf beside the medication refrigerator contained a clear plastic bag with shoes and an envelope labeled with a patient's name and the contents. The nurse on duty was asked if this was a current patient and the answer was no. There was no explanation why shoes and patient belongings were in the medication closet.

There was no hand washing sink in the vicinity of the medication closet and no disinfectant hand gel was observed at the nurses desk.

EI # 2 was asked where the nurses performed hand washing prior to medication preparation. EI # 2 stated in the staff bathroom which was located directly behind the nurses desk.

The tour on 10/30/18 concluded at 2:10 PM to be resumed when the unit Director would be available.

2. A second tour of the GPU was conducted on 10/31/18 at 9:20 AM with EI # 1, Director of Geri-Psych with the following findings:

Patient Room 233 A & B: multiple ligature points including the bed with open rails, round door knobs, exposed plumbing, open safety bars, door latch plate with crossbar in opening, and a walk in shower (open to the room with a curtain) with wet paper in the drain. The room had only 1 closet.

To access the second closet, as well as the toilet and sink for room 233, the patient goes through a connecting door to an ante room outside of the seclusion room. In the ante room was a closet with a round door knob, a door leading into the bathroom which had exposed plumbing to the toilet and sink, a door leading to the seclusion room, and a door leading to the unit hallway. The anteroom, with all 4 doors closed, was a rectangular enclosure which could not be seen from any area outside the enclosed space, posing a patient safety risk.

Patient rooms 234, 235 and 236 had multiple ligature points including the bed with open rails, round door knobs, exposed plumbing and open safety bars.

Patient Rooms 237, 238, and 239 had multiple ligature points including the bed with open rails, round door knobs, exposed plumbing, shower faucet, open safety bars and door latch with a solid bar in the plate at both the bathroom door and the door to the hallway.

During the tour, EI # 1 stated she did not know what happened because she knew all the door latch plates had been replaced with latch plates without the bar across the center.

EI # 1 was asked what had been done since the follow up survey in February 2018 to address the ligature risks. EI # 1 stated "it's a process". When asked if there was any documentation of the process and what progress had been made EI # 1 stated she had no documentation.

The tour on 10/31/18 continued to the laundry closet which revealed a stackable washer/dryer combination and 3 shelves beside the laundry unit for supplies. The washer was dirty under the lid, there was dust on top of the dryer and on the 3 storage shelves.

The Conference Room across from the nurses station which was used as the staff break room, team conference room, patient/family education room and storage room revealed: a table and chairs, TV, books and videos, a coffee maker and staff refrigerator, 2 portable vital sign monitors, 2 IV (intravenous) pumps, 2 walkers, 1 standing walker, 1 wheelchair, 1 O2 (oxygen) concentrator, 1 portable O2 tank, a covered linen cart and a metal cabinet with medical supplies.

The patient equipment was not tagged in any way to indicate it was clean and ready for patient use. Inside the metal cabinet was an Apex Heating pad with a PM (preventive maintenance) date of 7/2015. The O2 concentrator did not have a PM sticker. EI #1 stated it belonged in RT (respiratory therapy) and they just had not picked it up yet. The surveyor asked who had used the O2 concentrator and the answer was "I don't know without researching."

Also in the Conference Room was a locked closet containing the patient's personal items. On the top shelf was a space labeled "nail polish" and a plastic bath basin filled with various open and partially used bottles of lotions, shampoos, body butter and mouthwash. EI # 1 was asked if the patients used these items. EI # 1 hesitated and went to get the charge nurse who stated she did not know if the patients used the items. The charge nurse placed all the items in the trash.

Also in the closet for patient belongings on the top shelf was a plastic bag which contained a watch and the bag was labeled with a patient's name and dated 1/27/16 (not a current patient). EI # 1 did not know why the patient watch was still there.
There was also a white Styrofoam cup, unlabeled, which contained about 1 inch depth of a blue gel-like substance. EI # 1 was asked what the substance was and she did not know. EI # 1 discarded the cup with the blue gel like substance.

The nurses station housed one camera monitor with a view of the day room. EI # 1 was asked what areas of the unit had video cameras and if they recorded. The surveyor was informed only the day room and the conference room had cameras and there was no recording. There were no cameras in the hallway. The staff at the nurses station were unable to view the hallway leading to the day room. EI # 6, Registered Nurse, was sitting at the nurses station. EI # 6 was asked if someone was assigned to watch the monitor at all times and the answer was no.

Review of the unit Environmental Safety Check Log on 10/31/18 revealed the form had no check/observation/reminder to assess for ligature risks. The form was updated 2/2/18. EI # 1 was asked what was updated on the form in February 2018. EI # 1 stated the section for unessential furniture, specifically, only 1 chair in a private room and 2 in a semi-private room was added to the form. EI # 1 verified a check for ligature risks was not on the Environmental Safety Check Log form.

EI # 1 stated the environmental rounds were completed once per shift by the PCA (patient care assistant) and the nurse reviews and signs off on them. EI # 1 was asked what ligature risks training and education had been provided to the staff since the recertification survey in January 2018. EI # 1 stated all staff had a class on ligature risks by Inspirien, an outside company. The surveyor requested copies of the training material.

The surveyor reviewed the 4 refrigerator logs for the GPU with EI # 1 on 10/31/18 at 11:00 AM. EI # 1 verified the temperature was not documented each day as required. EI # 1 further clarified the second log in the Day Room was for the freezer but the log failed to identify that as the location.

The floors in the patient rooms all had stains and scuff marks, the showers all had dirty tiles and grout, and on 10/31/18 the shower drain in room 233 still had the same wet paper that was observed during the tour on 10/30/18. There was dust on shelves and cabinets.

EI # 1 was asked how the cleanliness of the unit was maintained. EI # 1 stated housekeeping cleaned once a day and there was a cleaning schedule assigned to the staff for certain things to be cleaned at certain times.

3. Review of the Event/Occurrence Log on 11/1/18 at 11:55 AM revealed PI # 4 sustained a fall in the day room on 7/20/18 at 7:12 AM.

Review of the documentation provided by the facility revealed PI # 4 was admitted to the GPU 7/9/18 with diagnoses including Dementia with Behavior Disturbances. Fall Precautions were ordered for PI # 4 at admission.

The documentation by the nurse on the Event report dated 7/20/18 at 7:12 AM revealed "heard noise from day room - looked at monitor - pt (patient) had fallen in day area. Pt assessed, pt was on floor on (his/her) bottom with back against wall on far end of room by cabinets. Assisted off floor back in w/c (wheelchair). Asked pt was (he/she) ok, stated I was getting up."

An interview was conducted on 11/1/18 at 4:20 PM with EI # 1 to review the patient fall event. EI # 1 stated she was making rounds with the doctor and heard a noise from the day room. When she entered the day room the patient had fallen out of the wheelchair and was on the floor.

EI # 1 was asked if there was a PCA or staff member in the day room at the time of the fall and the answer was no. EI # 1 was asked if patients are to be supervised when in the day room and the answer was yes.

EI # 1 was asked what follow up was completed to prevent falls in the future and EI # 1 stated she talked to the staff about not leaving patients alone in the day room. When asked for documentation EI # 1 provided a one page Unit Meeting agenda dated August 2018. Item # 3 on the agenda was "Pt Observation Status A. Dayarea". There was no specific documentation regarding what was discussed and there was no sign in sheet of who was in attendance at the meeting.

Further review of the Event/Occurrence Log revealed PI # 3 was in the day room and was pushed by another patient sustaining a head injury with multiple skull fractures and bleeding in the brain. Review of the MR revealed PI # 3 was examined and treated in the ER and subsequently transferred out for further care.

An interview with EI # 1 on 11/1/18 at 4:30 PM confirmed the above findings. Additionally, EI # 1 confirmed there was no video recording of the events in the day room.

An interview was conducted 11/1/18 at 1:45 PM with EI # 3, PCA Geri-Psych. EI # 3 was asked "What are the environmental rounds and why are they done?" EI # 3 stated "Done for safety purposes- check the bed alarm, check all lights, shower clean, beds locked, 2 chairs for semi-private and 1 for private, no contraband, doors are locked at all times... Checks are one time per shift by PCA and nurse".

EI # 3 was asked "What is a ligature risk? What training have you had on identifying ligature risks?" EI # 3 stated "I have no idea what it is"

An interview was conducted 11/1/18 at 2:20 PM with EI # 4, PCA Geri-Psych. EI # 4 was asked "What are the environmental rounds and why are they done?" EI # 4 stated "Alarms, check for cords...gloves left in room...bed down low, nothing in room. Check at the beginning and ending of shift. One PCA going off and another one coming on."

EI # 4 was asked "What is a ligature risk? What training have you had on identifying ligature risks?" EI # 4 replied "I don't know".

An interview was conducted 11/1/18 at 4:30 PM with EI # 1. EI # 1 was asked what changes have you made in your unit since attending the class on Ligature Risks in March 2018? EI # 1 stated she had talked to the staff about contraband and about suicide precautions. "Is this documented in any way?" The answer was "No." EI # 1 was asked "What changes in process have you made on your unit to be ligature free?" EI # 1 stated "We talked about the plumbing in bathrooms, hand rails in the bathrooms and door hinges in our Safety Meeting." The surveyor requested the Safety Meeting documentation and none was provided.

An interview was conducted on 11/2/18 at 10:00 AM with EI # 7, Director of Plant Operations. EI # 7 was asked for documentation of the "process" for addressing the ligature risk points in the Geri-Psych Unit and none was provided. EI # 7 stated "it's in my head".

EI # 7 showed the surveyor information pages printed from the internet 11/1/18 on various products such as psychiatric compliant safety rails and plumbing enclosures for the bathrooms. The surveyor asked if anything had been ordered and the answer was no.

There was no documentation provided to show the facility had taken action to mitigate the ligature risks identified on the Geri-Psych Unit.

Based on review of facility policy, medical records (MR), and interviews with staff it was determined the nursing staff failed to:

1. Obtain weights and document twice per week as ordered for patients admitted to the Geri-Psych (Geriatric Psychiatry) Unit.

2.Reassess the nutritional status of a patient that was not eating / drinking.

3. Obtain a dietitian consult for a patient not eating and with weight loss.

4. Ensure the physician ordered diet was provided.

5. Assess and document patient's skin status/injuries and implement preventive interventions.

6. Document specific treatment modalities provided.

7. Provide and document interventions to manage behaviors prior to administering prn (as needed) medications.

This affected 3 of 4 MRs reviewed including PI # 1, # 2, # 3, and had the potential to negatively affect all patients admitted to the Geri-Psych Unit.

Findings include:

Policy: Assessment/Reassessment
Revised: 09/17

Each inpatient has an initial physical, psychological, and social assessment. The initial assessment is done by the independent licensed practitioner and by an RN (Registered Nurse) in those areas that nursing care is provided...

Screening for Nutritional Status

Nutritional status is a part of the initial nursing assessment. The attending Dietary Department is notified when the patient fails the nutritional screen and the Dietitian will screen the patient and notify the attending M.D. (Medical Doctor) of a consult order if needed.

Reassessment

Reassessment is done to determine the patient's response to the treatment outlines in the plan. In other words, has the patient made the progress needed to obtain the goals outlined in the plan for the patient?

Periodic reassessment is done at pre-established timeframes:
Medical Staff - At least every 24 hours
Nursing - At least every 24 hours

1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 at 8:50 PM with diagnoses including Dementia with Behavioral Disturbances, and was discharged on 10/12/18.

Admission orders included activity as tolerated; cardiac low sodium diet, fall precaution high; special observation 1:1 (one to one) x (for) 48 hours; weight on admission and twice weekly and record; therapeutic programs - activity therapy, nsg (nursing) education, and group therapy five days per week for each program.

Review of the MR revealed the patient's weight on admission (9/3/18) was 167 pounds.

Subsequent weights were recorded as follows:
9/27/18 - 159 (8 pound loss since admission)
10/1/18 - 156 (11 pound loss since admission)
10/4/18 - 158 (9 pound loss since admission)
10/11/18 - 152 (15 pound loss since admission)

The staff failed to obtain and record weights twice a week as ordered.

Review of the nursing documentation revealed the following:
9/4/18 at 8:30 PM - not tolerating diet well, refusing to eat at this time
9/5/18 at 9:49 AM - not tolerating diet well, sedated
9/6/18 at 10:14 AM - not tolerating diet well, sedated, lethargic
9/7/18 at 8:22 PM - not tolerating diet well, sedated, lethargic, weakness, refused to eat or drink
9/8/18 at 8:13 PM - tolerating diet well, requires feeding, eating some, needs encouragement, sedated, lethargic, weakness, completely dependent for all ADL's (activities of daily living), unable to ambulate at this time
9/9/18 at 8:03 AM - tolerating diet well, requires feeding, eating some, needs encouragement, confused, resistant to ADL care.

Review of the nursing documentation from 9/10/18 - 10/10/18 revealed the patient's intake varied from 0 % to 100% and the diet provided and documented varied from Regular, to 2 Gram Sodium, 4 Gram Sodium, 1 Gram Sodium to 1800 ADA (Americal Diabetes Association) Diabetic Diet documented on 10/8/18 at 2:59 PM.

The nursing staff failed to assess PI # 1's nutritional needs, intake, weight, and diet order to ensure PI # 1's needs were met and the physician ordered diet was provided,

Further review of the MR and physician's orders revealed PI # 1 required IV (intravenous) fluids for treatment of dehydration on 9/11/18, 9/12/18, and 9/20/18.

A reassessment of the patient's nutritional status was not completed and a dietitian consult was not obtained.

Record review revealed PI # 1 received prn medications (Haldol and Lorazepam) for agitation at the following times and there was no documentation of non-pharmacological interventions provided to manage the behaviors/symptoms prior to administering the prn:

9/4/18 at 11:45 AM: Haldol 2 mg (milligram) and Lorazepam 0.5 mg IM (intramuscular injection)
9/5/18 at 8:50 AM: Haldol 5 mg and Lorazepam 0.5 mg IM
9/6/18 at 12:09 AM: Haldol 2 mg and Lorazepam 0.5 mg IM

An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier (EI) # 1, Director Geri-Psych, who confirmed the above findings.

2. PI # 2 was admitted to the facility Geri-Psych Unit on 10/18/18 with diagnoses including Bipolar Affective Disorder. PI # 2 was a current patient in the Geri-Psych Unit.

Review of the admission orders dated 10/18/18 included diet 1800 ADA (American Diabetes Association) and obtain weight on admission and twice weekly and record.

The surveyor requested all the weights for PI # 2 was was provided a weight documented on 10/22/18 of 176 and a weight obtained on 10/30/18 of 185. There was no admission weight documented.

The nursing staff failed to obtain and document a weight twice weekly as ordered.

An interview was conducted on 11/2/18 at 11:00 AM with EI # 1 who confirmed the above findings.

3. PI # 3 was admitted to the facility geri-psych unit on 9/6/18 with diagnoses including Dementia, Hallucinations and Delusions. PI # 3 was discharged on 9/24/18.

Review of the admission documentation revealed the patient's weight on admission was 170 pounds with orders to obtain weights twice weekly and record.

There were no further weights recorded in the medical record.

Review of the MR record revealed documentation on 9/12/18 at 6:23 PM by the RN: Modality Start Time -11:00 End Time - 11:30
Modality Type: Group Therapy
There was no documentation what specific Group Therapy was provided or topic discussed by the RN and how it applied to PI # 3.

Review of the RN documentation dated 9/13/18 at 8:48 PM revealed PI # 3 had Bruise/Hematoma to bilateral hands/arms and Abrasions to the left wrist. There was no documentation how/when the bruise/hematoma and abrasion occurred nor interventions put into place for prevention.

Review of the RN documentation dated 9/14/18 at 11:50 AM revealed:
Modality Start Time -11:00 End Time - 11:40
Modality Type: Group Therapy
There was no documentation what specific Group Therapy was provided or topic discussed by the RN.

Review of the RN documentation dated 9/18/18 at 7:55 AM revealed PI # 3 had Bruise/Hematoma to bilateral hands and Abrasions to the right elbow and left wrist. There was no documentation how/when the bruise/hematoma and abrasion occurred nor interventions put into place for prevention.

An interview conducted on 11/1/18 at 4:55 PM with EI # 1 confirmed the above findings.

Based on facility policies and procedures, Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, observations, and interviews with staff it was determined the facility failed to ensure:

1. Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible.

2. The nursing staff followed the facility policy for admixtures prepared outside the pharmacy.

3. Staff followed the facility policy and CDC hand hygiene guidelines during medication preparation and administration.

This affected 1 of 1 observation of IV medication preparation and administration for an unsampled patient and 1of 1 observation of medication administration for Patient Identifier (PI) # 2. This deficient practice had the potential to affect all patients served by the facility.

Findings include:

Policy: Admixtures and Sterile Products Prepared Outside the Pharmacy
Date: 3/06

Purpose:

To enhance patient safety by:
A. Minimizing admixture of sterile medications outside the pharmacy
B. Employing safeguards when admixture must occur outside the pharmacy.

Policy:

A. Intravenous admixtures or other sterile medications requiring admixture are prepared by the pharmacy except in emergencies or when not feasible.

D. Safeguards will be in place whenever sterile medications or IV admixtures are prepared outside the pharmacy. These safeguards include the following:
1. Preparation is permitted only by an RN (Registered Nurse) or LIP (Licensed Independent Practitioner).
2. A second licensed employee must check the product.
3. Only standard concentrations and standard admixture procedures are used.
4. Appropriate techniques are used to avoid contamination during preparation.
5. The product is labeled appropriately.

Procedure:

A. Before preparation, the RN or LIP will refer to an admixture preparation reference and refer to the Standard IV Drip Concentration cabinet in Meditech.

B. The medication and supplies needed will be obtained.

C. The product will be prepared using clean technique on the top of a clean, uncluttered medication cart. If no medication cart is present, preparation will occur on a clean, uncluttered countertop.

D. The supplies and medications used in preparation will be saved of rechecking by a second licensed staff member.

E. The product will be labeled with the following information...

F. A second licensed staff member will check the accuracy of the preparation.

Policy: Hand Hygiene
Revised: 09/17

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections.

Statement of Policy:
It is the policy of PCMC (Picken's County Medical Center) as recommended by the CDC that health care workers wash their hands with either a non-antimicrobial soap (plain soap) and water or an antimicrobial soap and water when their hands are visibly dirty or contaminated with proteinaceous material or are visible soiled with blood or other body fluids. If hands are not visibly soiled an alcohol-based hand rub can be used.

3. If hands are not visibly soiled, use an alcohol-based handrub (ABHR) for routinely decontamination hands in the following situations:

Before direct contact with patients

After direct contact with a patient's skin

When moving from a contaminated body site to a clean body site during patient care

After contact with inanimate objects in the immediate vicinity of the patient

After removing gloves

Centers for Disease Control and Prevention

Hand Hygiene in Healthcare Settings

Practicing hand hygiene is a simple yet effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 25 hospital patients has at least one healthcare-associated infection.

1. Employee Identifier (EI) # 8, RN, was observed on 10/30/18 at 3:30 PM preparing and administering an IV antibiotic for an unsampled patient.

EI # 8 verified the order, Zithromax 500 mg (milligrams) in 250 ml (milliliters) of normal saline every 24 hours IV.

EI # 8 then entered the medication room, obtained the medication vial from the med dispensing drawer without first washing her hands (there was a handwashing sink in the medication room) and placed the vial on a counter top surface work space without first clearing / cleaning a work space. EI # 8 then left the medication room to go to the supply room to obtain the bag of normal saline and returned to the medication room.

EI # 8 donned gloves without first performing hand hygiene. EI # 8 then reached into the pocket of her scrub top with the clean gloves on, thereby contaminating the clean gloves, and retrieved 2 alcohol prep pads and placed them on the work space thus contaminating the work space. EI # 8 then opened a drawer and withdrew a prefilled saline syringe, removed the wrapping, obtained a needle, opened and attached the needle to the saline syringe and placed it on the counter top. Then EI # 8 opened an alcohol prep, wiped the rubber septum of the medication vial, inserted the needle and injected the saline into the vial, left the needle and syringe in place while shaking the medication vial to mix, then withdrew the medication into the saline syringe, opened a second alcohol prep pad, wiped the injection port of the and normal saline bag, and injected the mixture into the bag without first changing the needle.

EI # 8 then discarded the needle into the sharps container, completed the label and applied the label to the IV bag, removed gloves and exited the medication room without performing hand hygiene after glove removal.

EI # 8 went into a room to obtain the COW (computer on wheels), rolled the COW to the patient room, then went to the supply room for IV tubing, returned, performed hand hygiene outside of the room, pushed the COW into the room and made several attempts to scan the medication and the patient's arm band. EI # 8 then applied gloves, tried to scan the armband several more times unsuccessfully. EI # 8 removed the gloves, did not perform hand hygiene, then went to the nursing station to obtain a new armband, returned, donned gloves without first performing hand hygiene, scanned the armband, opened the IV tubing, spiked the bag, and primed the tubing.

EI # 8 then reached into her uniform pocket with gloved hand (thus contaminating the glove) for alcohol prep, opened the prep, wiped the IV connection and proceeded to connect the IV medication and reprogram the IV pump.

The IV mixture was not verified by a second licensed employee as directed per the facility policy.

EI # 8 failed to prepare and administer IV medication in a manner to prevent contamination and promote patient safety as directed per policy.

An interview conducted on 11/2/18 at 11:00 AM with EI # 2, Director of Patient Care Services, confirmed the above findings.

2. An observation was conducted on 10/31/18 at 9:00 AM with EI # 9, RN, to observe medication administration.

EI # 9 verified the orders for PI # 2 at the request of the surveyor. EI # 9 then unlocked the medication (med) closet, rolled the med cart to the patient day room where the Geri-Psych patients were engaged in activities. EI # 9 verified PI # 2 by checking the patient's armband then asked PI # 2 to leave the table and sit in a chair beside the med cart. EI # 9 reviewed the medications with PI # 2, opened all the oral medications and placed in med cup, performed hand hygiene and administered the medications. EI # 9 failed to perform hand hygiene prior to preparing oral medications.

EI # 9 donned gloves, removed a Nicoderm patch from the patient's right deltoid and discarded, reached into her uniform pocket with a dirty gloved hand to retrieve a pen and labeled the new Nicoderm patch. EI # 9 then applied the new Nicoderm patch to the patient's left deltoid with the same gloves. EI # 9 failed to change gloves and perform hand hygiene after removing the used patch and before preparing and applying the new, clean patch.

An interview conducted on 11/2/18 at 11:15 AM with EI # 2, Director of Patient Care Services, confirmed the above findings.

Based on review of facility policies and procedures, medical records (MR), and staff interviews it was determined the facility failed to ensure:

1. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy.

2. Each patient admitted to the Geri-Psych (Geriatric Psychiatry) Unit had a psychiatric evaluation completed within 60 hours of admission.

3. Admission evaluations were completed within 3 days of admission.

This affected 3 of 4 MRs reveiwed including Patient Identifier (PI) # 1, # 2, # 3 and had the potential to affect all patients admitted to the Geri-Psych Unit at this facility.

Findings Include:

Policy: Multidisciplinary Treatment Planning
Reviewed: 9/22/16

Purpose:
A. To provide individualized care responsive to patient specific needs...

Policy:
A. Each patient shall have a written individualized treatment plan based on the patient's presenting problems, physical health, emotional and behavioral status, and strengths and weaknesses...

B. The plan of care is supervised by the attending psychiatrist. The admitting physician shall formulate a preliminary treatment plan no later than three (3) treatment days following the date of admission...

F. The Multidisciplinary Treatment Plan shall be completed by the third (3rd) day of treatment...

Policy: Psychiatric Evaluation
Revised: 8/22/18

Purpose:
To ensure that the physical and psychiatric needs of the patient are assessed by a psychiatrist.

Policy:
A. The psychiatric evaluation is completed and on the patient's chart within sixty (60) hours of admission.

1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 8:50 PM with diagnoses including Dementia with Behavioral Disturbances.

Review of the MR revealed a progress note (PN) by the social worker (MSW) dated 9/6/18 Modality Type - Group Therapy which included a plan to continue group therapy participation pending treatment plan development scheduled for 9/7/18 (4 days after admission).

Further review of the MR revealed the Psychosocial Assessment was completed 9/7/18 (Friday), 4 days after admission.

Review of the MR revealed the Multidisciplinary Treatment Plan was completed on 9/7/18 which was not within 3 treatment days as directed by the facility policy.

An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier (EI) # 1, Director of Geri-Psych. EI # 1 was asked why the MSW waited until Friday (9/7/18) to complete the initial assessment for PI # 1 who was admitted on Monday (9/3/18)? The answer was "he (MSW) was off." The surveyor asked why the assessment was not completed on Thursday (9/6/18) the date the patient attended Group Therapy conducted by the MSW. The answer was "I'm not sure." EI # 1 was asked if there was another social worker available to provide care when EI # 5, Social Worker Geri-Psych, was off and the answer was "no".

EI # 1 confirmed the psychosocial assessment was completed 4 days after admission and not within 3 treatment days as directed by facility policy.

2. PI # 2 was admitted to the facility geri-psych unit on 10/18/18 with diagnoses including Bipolar Affective Disorder.

Review of the MR revealed the initial psychiatric evaluation was completed on 10/22/18 and was not completed within 60 hours of admission.

Further review of the MR revealed the Multidisciplinary Treatment Plan was completed on 10/23/18 which was not within 3 treatment days and the psychosocial assessment was completed on 10/31/18, 13 days after admission.

An interview was conducted on 11/2/18 at 11:00 AM with EI # 1 who confirmed the initial psychiatric evaluation, psychosocial assessment, and the treatment plan as not completed timely as directed by the facility policy.

3. PI # 3 was admitted to the facility geri-psych unit on 9/6/18 with diagnoses including Dementia, Hallucinations and Delusions.

Review of the MR revealed the psychosocial assessment and the treatment plan was completed on 9/10/18, 4 days after admission and not within 3 treatment days as directed per the facility policy.

An interview was conducted on 11/1/18 at 4:55 PM with EI # 1 who confirmed the above findings.

Based on review of facility policies, medical records (MR), and interviews with staff it was determined the facility dietary staff failed to:

1. Provide a diet consistency the patient could could consume.

2. Provide diet education / counseling for a patient on a special diet that was not eating / drinking.

3. Initiate a calorie count as directed per policy for a patient consuming less than 50%.

4. Ensure the physician ordered diet was provided.

This affected 1 of 4 MRs reviewed including Patient Identifier # 1 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy: Medical Nutrition Therapy Protocol
Revised: 09/11

Purpose:

To facilitate timely patient nutrition care management and to provide an efficient and effective process to initiate Medical Nutrition Therapy.

Protocol:

Dietitian may initiate the following:

2) If on assessment the patient is found to be experiencing difficulty chewing, change diet to Soft, Mechanical Soft, or Pureed Diet.
3) If patient or patient's family requests diet education on physician ordered diet, provide education.
4) If on assessment, the patient is found to have average intake less than 50 %, initiate a calorie count to further assess and make appropriate recommendations.

Policy: Medical Nutrition Therapy - Nutrition Counseling
Revised: 09/11

Purpose:

To provide nutrition education for patients on modified diets or with specific nutrition needs.

Procedure:

A. Nutrition counseling will be provided by a Clinical Dietitian when ordered by a physician or referred by nursing or other heath care personnel ("unordered consults"). Family members or significant others will be included as appropriate.

1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 at 2050 (8:50 PM) with diagnoses including Dementia with Behavioral Disturbances and discharged on 10/12/18.

Admission orders included activity as tolerated and cardiac low sodium diet.

Review of the MR revealed the patient's weight on admission (9/3/18) was 167 pounds.

Subsequent weights were recorded as follows:
9/27/18 - 159 (8 pound loss since admission)
10/1/18 - 156 (11 pound loss since admission)
10/4/18 - 158 (9 pound loss since admission)
10/11/18 - 152 (15 pound loss since admission)

Review of the nursing documentation revealed the following:
9/4/18 at 8:30 PM - not tolerating diet well, refusing to eat at this time
9/5/18 at 9:49 AM - not tolerating diet well, sedated
9/6/18 at 10:14 AM - not tolerating diet well, sedated, lethargic
9/7/18 at 8:22 PM - not tolerating diet well, sedated, lethargic, weakness, refused to eat or drink
9/8/18 at 8:13 PM - tolerating diet well, requires feeding, eating some, needs encouragement, sedated, lethargic, weakness, completely dependent for all ADL's (activities of daily living), unable to ambulate at this time
9/9/18 at 8:03 AM - tolerating diet well, requires feeding, eating some, needs encouragement, confused, resistant to ADL care.

Review of the nursing documentation from 9/10/18 - 10/10/18 revealed the patient's intake varied from 0 % to 100% (less than 50 % on average) and the diet provided and documented varied from Regular, to 2 Gram Sodium, 4 Gram Sodium, 1 Gram Sodium, Regular No Added Salt, to 1800 ADA (American Diabetes Association) Diabetic Diet documented on 10/8/18 at 2:59 PM.

The ordered cardiac 2 gram low sodium diet was not provided consistently.

The surveyor asked Employee Identifier (EI) # 1, Director Geri-Psych, what interventions were done to address the PI # 1's poor oral intake and was a dietitian consult done.

The surveyor was provided a Nutrition Note dated 10/5/18 by the dietitian as follows: "pt visited per phone call with pt's son. Spoke with (spouse) last week for food preferences. Pt po (oral) intake erratic from 0-100 % of meals eaten. Pt still combative at times. Wt=159 # stable since 9/27. Continue chopped meats and Boost at each meal."

There was no documentation the Clinical Dietitian provided education regarding the ordered modified / special diet.

There was no further documentation by the dietitian provided. PI # 1 was discharged 10/12/18 with a 15 pound weight loss since admission.

An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier # 1, Director Geri-Psych, who confirmed the above findings.