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Based on observation, interview and record review, the facility failed to ensure the door was locked to the nurses' station resulting in the potential for an unsafe environment and potential for negative outcomes for all patients receiving care on the unit. Findings include:

During the initial tour of the facility, on 07/21/25 at 1037, the nurses' station door on 5 South unit was observed unlocked. Patients were observed walking the hallway while the door was unlocked. Nurses' station area had easily accessible office supplies, telephone, computers and equipment cords, and a heavy-duty metal paper punch.

On 07/22/25 at 0958, during tour of the 5 South unit, nurses' station door was observed unlocked. Registered nurse, Staff O, was present in the area and was interviewed regarding safety on the unit. Staff O was asked if the door to nurses' station needs to be locked. She stated "yes". Mental health technician was observed on the unit making safety rounds.

On 07/22/25 at 1020 Chief Compliance Officer, Staff A, was interviewed regarding the unlocked door. Staff A confirmed that the door has to be locked.

Facility policy "Precautions and Level of Monitoring" dated 5/10/21 and revised 8/12/24 was reviewed and revealed:
"IV. The MHT (mental health technician) will:
N. Identify and report any findings while conducting observation rounds:
2. Ensure doors that are to be locked are, in fact, locked".

Based on interview and record review, the facility failed to establish an individualized plan of care for 2 (P-16, P-18) of 20 patients reviewed, resulting in the potential for unmet care needs and negative outcomes for these patients. Findings include:

P-16: This 18-year-old female was admitted to the facility on 1/3/25 with diagnoses of brief psychotic disorder, rule out schizoaffective disorder, bipolar type, intellectual and developmental disabilities, and attention deficit hyperactivity disorder. Admission was petitioned by P-16's mother, who is also her guardian.

During record review on 7/22/25, it was noted that the initial psychological evaluation dated 1/4/25, stated, "intelligence is below average based on history, grammar, and speech." The master treatment plan dated 1/3/25 included three problems: aggression, altered thought process, and potential for fall resulting injury which was added on 1/14/25. The treatment plan failed to include intellectual and developmental disabilities or any barriers that could potentially impact learning, understanding, or care.

This finding was reviewed and acknowledged by the Director of Nursing (Staff F) during an interview on 7/22/25 at 1200.


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On 7/22/2025 at 1345, P-18's medical record was reviewed with Director of Quality Staff H. P-18 was admitted on 2/27/2025 for schizoaffective disorder and had a past medical history that included "Significant for sleep apnea, type 2 diabetes, hypertension, hyperlipidemia, and asthma."

On 2/27/2025, P-18's Master Treatment plan included ten listed problems including diabetes mellitus and asthma/COPD (chronic obstructive pulmonary disease).

On 2/27/2025, P-18 had individual treatment plans developed for diabetes with a target date on 3/13/25 and asthma with a target date of 3/13/25.

On 3/7/2025, P-18's individual plan of service progress summary had 4 identified problems (Altered thought process, Danger to self, Borderline Personality Traits, and Ineffective Coping) and there was no documentation or updates for P-18's diabetes and asthma problems.

On 7/23/2025 at 1145, P-18's medical record was reviewed with Nurse Staff O and Staff O confirmed that the individual plan of service progress summary on 3/7/25 should have included information on diabetes and asthma.

The facility's policy titled Individualized Treatment Plan dated 12/18/2024 stated, "Based on the psychiatric evaluation and the Nursing Assessment, the Nurse initiates the ITP (individual treatment plan) by listing identified problems, strengths, and weaknesses. The problem list is developed from intake information, the medical/physical History and Physical, the Nursing Assessment, an initial interview with the patient and/or family, and any other assessments already completed."

The policy also revealed "ITPs will be reviewed and revised at least every seven (7) days and as needed in response to assessments conducted the multidisciplinary team and changes in a patient's condition. Record progress or lack of progress for each short term goal. Determine the extent to which the interventions were implemented and the extent to which the goals were accomplished. Discuss any modifications that should be made to the interventions or goals and give a narrative statement describing progress or response to the treatment intervention in the lines provided."

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of 1 of 2 medication refrigerators observed and failed to ensure the digital thermometers for recording the temperatures for the medication refrigerators and medication freezer were within the due dates for calibration for 3 of 3 thermometers observed resulting in the increased likelihood of negative consequences for all patients. Findings include:

On 7/21/2025 at 1000 during a tour of the main pharmacy, two digital thermometers for recording medication refrigerator and freezer temperatures were observed to be past their listed calibration due dates. The thermometer connected to the medication refrigerator had a due date 7/13/2025 and the thermometer connected to the medication freezer had a due date of 2/5/03. Director of Pharmacy Staff G confirmed the findings at the time of discovery.

On 7/21/2025 at 1010, during an inspection of the medication refrigerator in the main pharmacy, a black substance was observed along the inside rubber lining on top of the medication refrigerator door. Staff G was queried what was that substance, and they revealed it looks like "mold" and confirmed the findings at the time of discovery.

On 7/21/2025 at 1045, during a tour of the 5 North medication room, the digital thermometer connected to the medication refrigerator was observed to have a calibration due date July 20, 2020. Staff G confirmed the findings at the time of discovery.

According to the facility's policy "Medication Management," dated 1/13/2025, "Medications are stored under necessary conditions to ensure stability and in the most ready-to-administer forms available, when feasible, Temperature readings must be taken daily or twice a day if vaccines are stored at the location." The policy also revealed that "All medication storage areas are inspected periodically to ensure proper medication storage as per Department of Pharmacy policy."

Based upon observation, record review and interview, the facility failed to maintain chilled water piping, proper exhaust ventilation and air pressure relationships and clean ceiling tiles resulting in potential failure of the chilled water system and spread of infectious agents. Findings include:

1. At 1054 on 7/21/25 during a tour of the power plant, it was observed that the chilled water supply line was leaking, with the leak being directed right into a drain on the floor that was overflowing and not draining at the speed the water was being supplied from the leak. The chilled water return line was also leaking from the pump assembly onto the floor. Staff E was asked what the situation with the chilled water piping was and they explained that the supply line pump failed in February of this year and the return line was now being used temporarily as the supply line. The replacement part was in the power plant ready to be installed for a week or so at the time of the observation, but they have not been able to replace the part without shutting the hospital down. When Staff E was asked when the return line started leaking they said recently, but they were not concerned that that leak was a serious risk of failure for the chilled water system and were not anticipating on fixing it until October when the next anticipated hospital shut down was.

2. At 1201 on 7/21/25 during a tour of the 5th floor north wing of the hospital, it was observed that the soiled utility room did not have a negative air pressure relationship with the respect to the corridor after performing the tissue test at the base of the door. Staff E was asked if there was an issue with the exhaust fan serving this room and they stated they weren't aware of an issue. A tissue was also placed on the vent where the exhaust should be pulling air from the room and it was not exhausting at all at the vent. Record review showed that there were no exhaust fans out of operation and they all were working properly on the last preventative maintainance check, around 7/1/25.

3. At 1006 on 7/22/25 during a tour of the 4th floor south wing of the hospital, it was observed that soiled utility room 475 did not have a negative air pressure relationship with respect to the corridor while performing the tissue test at the base of the door. Staff E was asked when this fan was not operating correctly and they stated that they were not aware that this was not working correctly.

4. At 1015 on 7/22/25 during a tour of the 4th floor south wing of the hospital, 4 stained ceiling tiles were observed in the dining room 461 and storage room adjacent to the dining room. Staff E was asked why the ceiling tiles were stained and they stated that their boiler recently failed which caused excessive humidity to condensate in the HVAC system in the hospital and was dripping water down on the ceiling tiles.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in proper working order, resulting in the potential for the backflow of contaminates into equipment. This deficient practice had the potential to affect all patients in the facility. Findings include:

On 7/22/25 at 9:30 AM, the ice machine drain lines were observed to extend down below the flood level rim of the floor drain. When queried at that time, Consultant Registered Dietitian Staff BB provided no explanation.

According to the Food & Drug Administration (FDA) 2022 Model Food Code section 5-202.13 Backflow Prevention, Air Gap, "An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonfood EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch)."

According to the Food & Drug Administration (FDA) 2022 Model Food Code, Section 5-402.11 Backflow Prevention, "(A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed."

On 7/22/25 at 11:30 AM, the following pieces of kitchen equipment were observed with "Out of Order" signs: The dish machine, Traulsen reach-in cooler #2, #14 and #15. When queried at that time, Consultant Registered Dietitian Staff BB stated the plan was to repair the equipment, but that they are waiting on funding.

According to the Food & Drug Administration (FDA) 2022 Model Food Code section 6-501.114 Maintaining Premises, Unnecessary Items and Litter, "The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used;".

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all patients that consume food from the kitchen. Findings include:

On 7/22/25 at 10:00 AM, the Consultant Registered Dietitian (RD) Staff BB was queried regarding the lunch menu for the current day. Staff BB stated that Dietary Manager (DM) Staff CC was currently at the store purchasing the food items to be served for that day's lunch meal.

On 7/22/25 at 11:00 AM, DM Staff CC was observed entering the kitchen, carrying numerous grocery bags. DM Staff CC was observed placing the bags on the food preparation table. DM Staff CC then donned an apron, and began preparing the food items for lunch service, without first performing hand washing.

On 7/22/25 at 11:25 AM, when queried, Consultant RD Staff BB confirmed that staff should be washing their hands upon entering the kitchen.

Record review of standard of practice in the 2022 FDA Food Code noted: "Section 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles P and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P (E) After handling soiled equipment or utensils; P (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw food and working with ready-to-eat food; P (H) Before donning gloves for working with food; P and (I) After engaging in other activities that contaminate the hands."

On 7/22/25 at 11:15 AM, DM Staff CC was observed slicing zucchini to be served for the lunch meal. When finished, DM Staff CC rinsed the knife under running water at the food prep sink, dipped the knife blade in the sanitizer bucket (which also contained a wiping cloth), and placed the knife back into the knife rack.

On 7/22/25 at 11:25 AM, DM Staff CC was queried about the washing of the knife used to cut the zucchini. DM confirmed that the knife was rinsed in the sanitizer bucket and then put away.

Record review of standard of practice in the 2022 FDA Food Code noted: "Section 4-303.11 Cleaning Agents and Sanitizers, Availability (A) Cleaning agents that are used to clean EQUIPMENT and UTENSILS as specified under Part 4-6, shall be provided and available for use during all hours of operation. P"

Record review of standard of practice in the 2022 FDA Food Code noted: "Section 4-501.17 Warewashing Equipment, Cleaning Agents. When used for WAREWASHING, the wash compartment of a sink, mechanical warewasher, or wash receptacle of alternative manual WAREWASHING EQUIPMENT as specified in 4-301.12(C), shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. Pf"