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Based on record review and interview the facility failed to ensure all patients sign and acknowledge their patient rights for one patient (#59) of three records reviewed for patient rights on the child/adolescent unit. The facility census was 86.

Finding included:

Review of current Patient #59's medical record showed the patient entered the facility 1/27/10 due to violent and aggressive behavior. The medical record showed no document of patient rights located in the record.

Review of the facility booklet, "Welcome to the Adolescent Program" showed a page of patient rights and patient responsibilities. The bottom of the second page has an area to acknowledge the patient received a copy of their rights and responsibilities and that these were explained to the patient. There are signature lines for the patient, parent or authorized representative and for a facility witness.

During an interview on 1/29/10 at 2:10 PM the nurse manager of the unit Staff P said that patients are given the "Welcome to the Adolescent Program" booklet, which contains their rights. Staff P acknowledged Patient #59's medical record shows no evidence staff explained his/her rights to the patient and/or parent or authorized representative.

Based on policy review and record review, the facility failed to ensure one patient (#48) of three patients reviewed who received electroconvulsive therapy received information and signed the informed consent form before receiving electroconvulsive therapy. The facility census was 86.

Findings included:

Review of the facility policy 603.311.85, "Electroconvulsive Therapy (ECT)", revised 05/09 gave direction for informed consent, in part: - To provide informed consent, the patient or guardian must be competent to understand the following in simple language:
- The nature and seriousness of the disorder
- The probable course that is likely with or without the ECT (without providing guarantees)
- A description of the procedure
- The nature, degree, duration and probability of significant risks and/or side effects and/or adverse effects. Special attention will be paid to post-treatment confusion and memory dysfunction
-A description of reasonable treatment alternatives, and why ECT is being recommended
- The right of the patient to accept or refuse ECT, the right to revoke his/her consent at any time, and acknowledgment that the consent is for a specified maximum period of time
-The name of the physician who will perform the procedure
- The attending physician will explain the information necessary to meet the requirements of Informed Consent

Review of current outpatient Patient #48's medical record showed a form titled, "Electroconvulsive Therapy (ECT) Consent Form: Continuation/Maintenance" dated 7/22/09. Although Patient #48 consented to the procedure as indicated by the patient's signature, the consent documents, "I, the undersigned, do hereby decree the patient to be competent to sign for this consent. I have also discussed the risk and benefits of ECT with the patient." However, although there was a place below that statement for the physician to sign, there was no physician signature on the consent form.

Since electroconvulsive therapy is one form of treatment conducted on patients with a psychiatric diagnosis, absence of a physician's signature does not ensure that the patient was competent to make such a decision regarding this treatment.

Based on observation, interview and record review, the facility failed to provide a safe environment for 18 of 18 patients on the child/adolescent unit by allowing non-suicide - resistant shower knobs in 18 patient rooms, one hall access shower room and one seclusion room shower. The configuration of these water control knobs creates a hazard for all 18 patients. In addition, the facility failed to ensure the safety of all patients on the Adult and Senior Units by not preventing patient access to belts and shoestrings, objects that a patient with thoughts of suicide could acquire and use to try to stangle or hang themself. The facility census was 86.

Findings included:

1. Observation on 1/29/10 on the child/adolescent unit showed regular shower water knobs located in the bathrooms of all 18 patient rooms, in a shower located in the hall way of the seclusion/restraint room, and an additional shower located in the hallway across from the nurses' station. The water knob controls protrude from the wall approximately 2-1/2-inches which would allow something to be looped over the knob.

Observation showed that all 18 patient rooms are unlocked and patients have access to their rooms and bathrooms without constant monitoring by staff.

During an interview on 1/29/10 at 2:25 PM, the child/adolescent nurse manager Staff P said that patients are allowed to go to their rooms if not in groups or working with staff. Staff P said staff does not monitor patients during showers. Although said the facility plans to remodel the patient showers on this unit, no time frame has been announced. Staff P said the facility does admit suicidal patients to the unit at times but that none of the current 18 patients on the unit are on suicide precautions. Staff P said all 18 patients are checked by the staff every 15 minutes. Staff P said if any patients are actively suicidal a staff member is assigned to them on a 1:1 basis.

During an interview on 1/29/10 at 2:30 PM the Director of Plant Operations and Safety Staff Y said that the facility identified the shower water knobs as a risk during a assessment for risk sometime in 2008. Staff Y said the adult unit showers were torn out and replaced with showers which meet behavioral unit safety standards several years ago. Staff Y said that the facility hopes to replace the shower water knobs on the child/adolescent unit with knobs that meet behavioral unit safety standards sometime within the first quarter of this year. Staff Y provided a copy of an e-mail dated 12/04/09 from an outside vendor with a picture of a suicide resistant retrofit shower knob. Staff Y said that he/she hopes to retrofit all 20 showers on the child/adolescent unit with these knobs.

During an interview on 1/29/10 at 4:30 PM the Chief Nursing Officer Staff A and the Chief Executive Officer Staff EE said that the existing showers on the adult unit and the senior adult unit were replaced a couple of years ago because it was determined those areas were the high risk areas. Staff A and Staff EE said the 20 shower water knobs on the child/adolescent unit will be replaced with safety knobs as soon as the knobs can be obtained.

Review of the history and physicals for the 18 patients on the child/adolescent unit showed six patients (#24, #25, #26, #27, #28 and #29) admitted with suicidal ideations.

- Review of the history and physical dated 1/24/10 of Patient #24 showed the patient entered the facility on 1/23/10 expressing suicidal thoughts.
- Review of the history and physical dated 1/21/10 of Patient #25 showed the patient entered the facility on 1/20/10 following the patient's reported attempt to jump out of a third story window. The patient also made statements to the effect that he/she should be dead.
- Review of the history and physical dated 1/24/10 of Patient #26 showed the patient entered the facility on 1/24/10 because of suicidal ideations.
- Review of the history and physical dated 1/25/10 of Patient #27 showed the patient entered the facility on 1/24/10 expressing a desire to do bodily harm to him/herself.
- Review of the history and physical dated 1/27/10 of Patient #28 showed the patient entered the facility on 1/26/10 due to ongoing arguments with his/her mother and he/she threatened to kill him/herself.
- Review of the history and physical dated 1/26/10 of Patient #29 showed the patient entered the facility on 1/25/10 because of his/her expressed desire to do bodily harm to him/herself. The patient wrote a letter to his/her dad stating that he/she is going to hang him/herself.


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2. Record review of the facilities policy Contraband/Sharps POLICY#: 603.350.85 in part states the following information:

POLICY:
It shall be the policy of Research Psychiatric Center to provide a safe and hazard free environment for our patients. For the protection of all {patients, visitors, and staff), potentially dangerous items will be removed from the patient at the time of admission.
3. Because of the hazards of falls, shoelaces will not be removed unless ordered by the physician, or unless the patient is assessed actively suicidal.
-ADULT CONTRABAND LIST in part have the following items listed:
Rope, chain, other corded items, large, heavy jewelry

Nevertheless, observation on 1/28/10 at 9:10 AM revealed a patient standing across from the nursing station with a leather belt with metal buckle securing his jeans. Observation on 1/28/10 at 9:10 AM revealed many of the 31 adult patients with shoe strings in their shoes.


The following patients were identified by the social worker as wearing belts on the Adult unit:

-Record review of Patient #34's medical chart revealed the patient was admitted to the facility on 1/21/10 with chief complaint of suicidal ideations.
History of present illness: He stopped his insulin (a medication given for diabetes) and Acu-Cheks (a device used to check a patients blood sugar) about 2 weeks ago presuming that this will ultimately result in his death secondary to medical neglect.

-Record review of Patient #35's medical chart revealed the patient was admitted to the facility on 1/15/10 for worsening depression.
Past medical history: Multiple psychiatric admissions, major depressive disorder, bipolar disorder, suicide attempt by overdose.

-Record review of Patient #36's medical chart revealed the patient was admitted to the facility on 1/25/10 with the chief complaint of suicidal ideations.
History of Present Illness: The patient was brought to the facility after having jumped in front of a car to commit suicide.

-Record review of Patient #37's medical chart revealed the patient was admitted to the facility on 1/12/10 with chief complaint of suicidal ideation.
History of Present Illness: This is a 51-year old male who presents to Research Psychiatric Center with a complaint of suicidal ideations. He states his symptoms have become so severe that last night he tried to kill himself by putting vodka in his CPAP (Continuous positive airway pressure) machine (a machine used to assist a patient to breathe more easily during sleep).

-Record review of Patient #59's medical chart revealed the patient was admitted to the facility on 1/26/10 with chief complaint of psychosis.
History of Present Illness: He has had associated audio and visual hallucinations. This has been occurring over the last several weeks.

-Sixteen patients on the Adult unit were identified of having suicidal ideations (Patients #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58)


During an interview on 1/28/10 at 9:20 AM, Unit Manager H stated patients on the Adult Unit were allowed to have belts after having an assessment for Suicidal Ideations. When asked about the risk to other patients he/she relied the patients would be watched and if a belt was found on floor or something like that the staff would take the belt away. He/she stated the patients can't keep their pants up. Unit Manager H stated no patients on the unit were under suicide precautions.

During an interview on 1/28/10 at 4:20 p.m. Physician L stated the belts and shoelaces were not considered contraband and were not on the list of contraband items. He/she stated the belts and shoestrings were needed to maintain patient dignity and make them feel as normal as possible.

However, during an interview on 1/29/10 at 2:35 PM, the nurse manager for the child/adolescent unit Staff P said that the patients on this unit are not allowed to have belts or shoe strings. Staff P said that other units allow patients to have these articles but the patients on this unit are more impulsive and he/she decided these articles were a risk to patients.

Based on interview and record review, the hospital:

- failed to develop and implement effective policies and procedures to screen staff for past history of abuse in six (Staff E, R, S, T, U, V) of ten personnel files reviewed,
- failed to develop and implement policies to identify and monitor patient care interactions to protect patients and
- failed to protect patients from abuse during investigation of allegations of abuse.

The facility census was 86 patients.

Findings included:

1. Record review of the facility policy and procedure titled "Reporting and Initial Actions Related to Patient Abuse", reviewed 08/09, directed in part the following:
-Abuse, neglect or exploitation was prohibited and was grounds for disciplinary action up to and including termination.
-Upon receipt of an allegation of suspected abuse and/or neglect, it is the responsibility of the Nurse Manager or House Supervisor, to within two hours of receipt of the information, initiate the investigation, notify the Risk Manager or the Patient Advocate and the re-assign or place the staff suspected on administrative leave.
-Sexual abuse was defined as any physical or emotional acts of abuse or exploitation of a sexual nature toward any adult admitted to the facility. (The policy does not address the Child and Adolescent Unit with eighteen current admissions, male and females, aged six years through eighteen years.)
-The Nurse Manager/House Supervisor will take immediate action to protect the patient.
-The Nurse Manager/House Supervisor has authority to temporarily re-assign the suspected staff to non-patient care pending resolution or place the staff on administrative leave and for protection of the patient the decision on the suspected employees status must be made within two hours of the receipt of the allegation.

Record review of the facility policy and procedure titled "Mistreatment, Neglect and Abuse of Patients", reviewed 08/09, in part directed the following:
-Therapeutic, safe and respectful care will be provided to all patients.
-Abuse was defined as any intentional act by which serious injury by physical injury was inflicted or sexual abuse of a patient.
-Abuse was also defined as any intentional act by which injury other than serious physical injury was inflicted upon a patient.
-Abuse was also defined as use of verbal or other communication to degrade a patient.
-Neglect was defined as failure of the caretaker to maintain reasonable care and treatment of an individual to the extent the individual's health and emotional well-being was injured.
-Treat all patients in a way that indicates respect for individual human rights and dignity.
-All new employees received, as a part of orientation, training as pertains to appropriate conduct and that relates to this policy.

Record review of the facility policy and procedure, titled "Background Investigations", effective 11/01/09 directed the following:
-The policy was to ensure a standard requirement and process for obtaining and evaluating background information on candidates for employment.
-The policy directed staff to not allow any candidate for employment to start or provide services until a satisfactory background investigation had been obtained.
-A qualified candidate will be offered employment contingent upon completing an authorization for the procurement of a background investigation. The report must be received by the facility prior to the candidates first day of employment.

Record review of the facility policy and procedure titled "Criminal Record Background Checks-Missouri Requirements", dated 01/25/10, directed the following:
-The facility does not knowingly hire a person for a position that has contact with patients if the person has been convicted or pled guilty or no contest to certain crimes in this state of other states.
-Specific crimes as defined under this state's laws included assault, elder abuse, rape, attempted rape, sodomy, statutory sodomy, child molestation and sexual abuse.
-The facility would not hire a person listed on the Department of Social Services Employee Disqualification List (EDL, actually maintain by the Department of Health and Senior Services, DHSS).
-The policy directed a person convicted of patient or child abuse or failing to report abuse or neglect in a mental health facility may not hold any position in a psychiatric facility. There may be crimes other than those listed in the policy for which conviction will result in disqualification for, or termination of, employment.
-The state Criminal Records Check will be requested from the state in which the individual will primarily be working. (The facility neglected to include a request from the state of current residence or state where the applicant was most recently living and/or employed.)
-Human Resources (HR) staff was directed to review the Missouri Department of Social Services (erroneous, as the EDL is maintained by the DHSS) EDL quarterly for current employee names.
-Not to hire persons convicted, pled guilty or no contest to specific crimes. (But the procedure failed to direct staff to check for those public records in neighboring states.)
-Failed to direct HR to check current status of professional licensure of licensed, credentialed professional applicants (nurses, therapists, dietitians) in this and other states where the individual may have held licensure.

2. Record review of a facility list of most recently terminated staff dated six months prior through 01/10 revealed a Physical Therapist (PT) terminated for misconduct in 11/09.

Record review of the personnel file of the recently terminated PT, Staff FF, revealed the following:
-The PT had been hired on 12/03/07.
-An annual performance appraisal dated 05/16/08 with ratings of "more than acceptable" and "much more than acceptable" in competencies listed as code of conduct, care management, builds customer loyalty, decision making, time management, adaptability, stress tolerance, conflict management, energy, safety intervention, communication and impact (attire, demeanor, tone of voice) and patient education/health promotion.
-A patient complaint regarding inappropriate touching (insertion of fingers, between legs, inside underwear by a patient of the opposite sex) during a physical therapy treatment session conducted in a patient room on 06/16/08. The House Supervisor received the complaint on 06/16/08 at 6:00 PM, but neither the patient nor other patients were protected from the alleged perpatrator during investigation since the therapist was not relieved of duty or re-assigned. The therapist was interviewed on 06/18/08 by the Chief Nursing Officer (CNO) and the Patient Advocate. During the interview, the PT denied inappropriate contact with the patient, was asked about any other allegations and stated there were two others allegations in a neighboring state that were found unsubstantiated. The resolution for the patient complaint (called unsubstantiated by the facility investigation) was to direct the PT to have a staff witness present during any physical therapy sessions.
-The position description/position summary, last revised 01/24/09, directed the incumbent to provide care to pediatric/child, adolescent, adult and geriatric patients and did not note any restrictions on provision of therapy such as maintain a second staff witness during therapy sessions.
-The PT again received an annual performance appraisal dated 06/19/09 with ratings of "more than acceptable" and "much more than acceptable" in the same competencies as listed the previous year.
-A Counseling Report, a written warning, dated 08/05/09, was given by the supervisor to the therapist for failure to produce outcome. It included multiple staff complaints regarding the therapist not seen providing therapy as ordered to patients, but entering medical record chart notes that therapy was provided. An alert and oriented patient complained that therapy was not provided and a second patient's request for assistive devices not responded to by the therapist. This Counseling Report also referenced a previous offense dated 07/06/08 during which the therapist charted provision of therapy, but had not treated the patient.
-Another patient complaint received by staff 10/29/09 again regarding inappropriate touching (patient with knee problems was inappropriately touched on bare chest/nipples) during a therapy session on 10/26/09 and was made to feel uncomfortable by verbal requests (to get on all fours and crawl on the bed) from the therapist on 10/28/09. During interview on 10/30/09, the PT became hostile towards the supervisor, denied the allegation, was reminded of the restriction to maintain another staff present during therapy session and was then placed on administrative leave (supervisor took name badge and keys from the therapist) more than twenty-four hours after receipt of the complaint.
-A copy of a Division of Professional Registration, from the state Division of Professional Registration, dated 11/04/09, showing the PT's state license was currently under disciplinary status called "reprimand" as of 09/29/08 due to "state board found cause to discipline the licensee because the physical therapy license in a neighboring state (the state where the PT resided) was censured for altering patient charts. The License was Publicly Reprimanded.
-The hospital terminated the PT on 11/11/09.

Record review of the personnel file of the recently terminated PT, Staff FF, also revealed a copy of a Consent Order filed 12/13/04 in the state where Staff FF resided which directed the following:
-PT waived rights to a hearing.
-PT inappropriately touched two patients and inappropriately questioned one patient about nipples during treatment.
-In lieu of formal proceeding, Staff FF voluntarily entered into the Consent Order and agreed to limitations on the physical therapy license including that he/she shall not practice physical therapy unless chaperoned in the room at all times, meet with the Board regarding boundaries, have ten percent of medical records of treated patients reviewed by a Board approved PT, and pay a stated fine.
-The Consent Order was deemed a public record and reported to the National Practitioner Databank and other reporting entities requiring disclosures of the Consent Order.

Record review of the personnel file of the recently terminated PT, Staff FF also revealed a copy of a Final Order filed 10/24/07 in the state where Staff FF resided which directed the following:
-The PT satisfied the requirement of chaperoned patient therapy.
-The PT altered patient medical records in an attempt to deceive the Physical Therapist who was reviewing medical record entries and billed for services not provided.
-The PT's license was cancelled (in state of residence) after the proceeding began so, limitation, suspension or revocation served no purpose.

During an interview on 01/28/10 at 9:30 AM Director of Human Resources, Staff F stated the following:
-Had been supervised by the nurse manager of the Senior Unit.
-PT, Staff FF, worked part time on Monday, Wednesday, Friday during day shift for about six hours a week.
-The PT, Staff FF worked primarily on Senior Unit and sometimes on the Adult Unit and was never on the Child/Adolescent Unit.

During an interview on 01/28/10 at 10:00 AM the Clinical Nurse Specialist for the Senior Unit, Staff G stated the following:
-She had been employed in the facility for eight to nine years.
-She was the supervisor for the PT, Staff FF.
-The PT, Staff FF, worked Monday, Wednesday, Friday on the Senior Unit.
-Therapy was provided out in the hallways for gait, safe ambulation and use of assistive devices.
-Normally the PT would take a second staff into a room of a patient.
-PT Staff FF would intermittently provide therapy on the Adult Unit.
-While on the Adult Unit, Staff FF would still be expected to follow the same "second staff person" rule as on the Senior Unit.
-Staff FF always followed the second staff person rule on the Senior Unit. However, according to feedback from staff on the Adult Unit, did not always follow the second staff person rule on that unit.
-She knew of two occasions when PT, Staff FF, had not followed the second staff person rule.
-Did not know if the facility had a written policy and procedure outlining the second staff person rule.
-She had discussed the second staff person rule with Staff FF prior to the complaint lodged on 10/29/09.
-She found no reason for the PT to touch the chest of a patient who had knee problems.
-Did not feel any patients in the Senior Unit had been victimized (and not reported or recalled an encounter) by the PT.
-Felt the PT had not every been on the Child/Adolescent Unit because staff on that unit would have commented on the presence of a PT there.
-Protective safeguards for patients that were now in place included 15-minute checks, nursing staff to be aware of who was with patients and the second person rule. However, these interventions were not new or revised due to the termination of the PT.
-Felt the PT was never in the building after hours or unless scheduled because the staff would have reported that to her.
-Her first step after receipt of an accusation would be to keep the accused staff off the unit and discuss the incident with the person then, after a second accusation would put the person on leave of absence. (This action is in contradiction to the facility policy.)

During an interview on 01/19/10 at 8:40 AM the Nurse Manager of the Adult Unit, Staff H, stated the following:
-She had been the Adult Unit Manager since 2003.
-She reported an incident of inappropriate touching of a patient by a PT to the supervisor of the PT, Clinical Nurse Specialist, Staff G, and to the Human Resources Manager, Staff F.
-Nurse Manager Staff H stated a staff person on the pay roll could enter the facility.
-Would expect therapy staff would provide treatment in the open.
-Did not think there was a formal facility policy directing parameters for staff performing physical contact/examination of patients.

During an interview on 01/29/10 at 11:20 AM the Chief Nursing Officer (CNO) Staff A stated the following:
-The Manager/Supervisor for PT, Staff FF, had been off ill so the time sequence may not have been followed.
-The PT, Staff FF, could have entered the building during the facility investigation of the complaint because there was no re-assignment.
-The facility did not have a written policy and procedure for a second staff person rule.


4. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks and periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (the quarterly updated EDLs are available on the Missouri Department of Health and Senior Services website).

- Record review of Staff E's personnel file revealed Staff E had been employed in the facility since 12/15/03 and had not had EDL verification at the time of hire.
- Record review of Staff R's personnel file revealed Staff R had been employed in the facility since 04/18/94 and had not had verification EDL verification at the time of hire.
- Record review of Staff S's personnel file revealed Staff S had been employed in the facility since 04/05/04 and had not had EDL verification at the time of hire.
- Record review of Staff T's personnel file revealed Staff T had been employed in the facility since 11/11/96 and had not had EDL verification at the time of hire.
- Record review of contracted Staff U's personnel file revealed Staff U had been employed in the facility since 09/15/05 and had not had EDL verification at the time of hire.
- Record review of contracted Staff V's personnel file revealed Staff V had been employed in the facility since 12/02/08 and had not had EDL verification at the time of hire.

During an interview on 01/29/10 at 1:50 PM the Director of Human Resources Staff F stated staff names and social security numbers were compared quarterly against the EDL. However, six of ten of the personnel records did not have proof of EDL verification on hire in their personnel files.

Refer to State Licensure Complaint MO 57989

Based on observation, interview and record review, the facility failed to ensure the registered nurse evaluated the nursing care for each patient to ensure nursing staff follow the hospital's policy for skin assessment of patients and documentation of a surgical incision for one of one (Patient #2) on the Adult Unit. The facility census was 86.

Findings included:

1. Record review of the facility's policy titled "Skin Assessment for Bruising, Pressure Ulcers and Other Skin Markings" POLICY#: 912.139.96 in part states the following:
PURPOSE: This policy is to describe the process and documentation format for wound and skin assessment and to accomplish the following
2. Identify patients with positive findings of skin integrity.
POLICY: Skin Assessment
On admission, a Registered Nurse will evaluate the skin integument for integrity and appearance. The frequency of the skin assessment will be as follows:
3. Pictures taken of identified site bi-weekly and PRN;
Wound Assessment - Wounds identified during initial assessment well (sic) be evaluated and documented in detail utilizing the Skin Integrity Management Flow Sheet. Identifying characteristics such as site, orientation, date first observed, etc. Indicate location of wound on figure. Document date site, size, stage, depth, drainage, odor, color, if culture was sent, treatment ordered and wound dressing information, and response to treatment, date physician was notified, and nurses signature will be documented.
The frequency of the comprehensive wound assessment will be as follows:1) admission; 2) daily nursing physical assessment; 3) pictures taken of the site be-weekly and PRN daily as indicated; 4) assessment performed in chart per dressing change ordered by physician.


However, record review of Patient #2's medical chart revealed the patient was admitted to the facility on 1/18/10 for psychosis (a loss of contact with reality), mania (a state of abnormally elevated or irritable mood, arousal and/or energy) and confusion.

Record review of the E-Sig Psych Report dated 1/19/10 in part revealed the following information:
-The patient was admitted to another hospital and delivered a baby by C-Section (Caesarian section: a surgical procedure in which incisions are made through the mother's abdomen and uterus to deliver a baby) on 1/7/10. She was noted to be disorganized and unstable in her moods on the unit and there was concern about her safety and the safety of the baby. The patient was transferred to this hospital on 1/18/10 with medications that included Augmentin for a wound infection.

Observation on 1/28/10 at 9:47 AM of Licensed Practical Nurse (LPN) J entered the patient's room to change the dressing on the abdominal incision. LPN J did not follow the policy of wound care documentation of measuring the wound or taking pictures.

Record review of the patient's medical chart revealed:
- no documentation in the nurses notes of surgical wound care of the C-Section incision.
- no documentation of skin assessment or wound assessment or documentation utilizing the Skin Integrity Management Flow Sheet as described in the facilities policy.

During an interview on 1/27/10 at 2:30 PM, the Unit Manager H stated he/she was unable to find the documentation of the surgical incision wound care in the daily nursing notes to the C-Section surgical incision.

During an interview on 1/27/10 at 2:45 PM, the Family Nurse Practitoner stated he/she changed the surgical incision daily and documented in her notes. He/she stated she did not do the wound care on 1/26/10 and did not know who would have done it on that day.

Based on record review and interview, the facility failed to identify and/or update the nursing plan of care for each patient to include pertinent, individualized problems and/or interventions for one (Patient # 2) of three records reviewed. The facility census was 86.

Findings included:

Record review of Patient #2's medical chart revealed the patient was admitted to the facility on 1/18/10 for psychosis (a loss of contact with reality), mania (a state of abnormally elevated or irritable mood, arousal and/or energy) and confusion.

Record review of the E-Sig Psych Report dated 1/19/10 in part revealed the following information:
-The patient was admitted to naother hospital and delivered a baby by C-Section (Caesarian section: a surgical procedure in which incisions are made through the mother's abdomen and uterus to deliver a baby) on 1/7/10. She was noted to be disorganized and unstable in her moods on the unit and there was concern about her safety and the safety of the baby. The patient was transferred to this hospital on 1/18/10 with medications that included Augmentin for a wound infection

Record review of the patient's plan of care and MASTER PROBLEM LIST Initiated Date: 1/19/10 revealed in part the following information:
-Specific Problem Description - 6. C-Section Incision
-Multidisciplinary Treatment Plan
Problem: Recent C-Section as evidenced by: per H&P (History and Physical) dated 1/18/10

However, neither short term or long term objectives included wound care any place in the care plan.

During an interview on 1/27/10 at 2:30 PM, the Unit Manager H stated he/she was unable to find the documentation of the surgical incision wound care in the treatment plan and no documentation by the staff in the daily nursing notes for wound care to the surgical incision.

During an interview on 1/27/10 at 2:45 PM, the Family Nurse Practioner (FNP) stated he/she changed the surgical incision daily and documented in her notes and he/she did not do the wound care on 1/26/10 and did not know who would have done it on that day.

However, record review of the "Multidisciplinary Treatment Plan" Policy#: 794.111.85 revised 3/09 in part revealed the following :
POLICY:
1. Each patient will have an individualized comprehensive treatment plan, which is based on the patient's strengths, liabilities, patient care needs, and priorities.
PROCEDURE:
2. The R.N. ( Registered Nurse) assigned to the patient on the following shift assures that:
A. All identified patient problems are documented; and
B. Each identified problem has a designed plan of care based on current information.
4. The Admitting or Co-Case Nurse (R.N.) ensures that:
A. Treatment Plan is evaluated and revised every 48 hours;
C. Care is accomplished based on patient care priorities and needs.
5. The Charge Nurse/Social Worker ensures that the team:
B. Meets on a regular basis to evaluate and revise the treatment plan every 48 hours, or more often, as appropriate, throughout the patient's hospital stay.

Based on interview and record review, the facility failed to ensure that all medical records entries were dated, timed and authenticated by the person providing the service or evaluation in eight (Patient #1,#3,#31,#33, #23, #19, #28 and #59) of 24 medical records reviewed for dated, timed and authenticated entries. The facility census was 86 patients.

Findings included:

1. Record review of the facility "Medical Staff Bylaws and Rules and Regulations", dated 08/08, directed in part, the following:
-Section C Medical Records - (7) Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability.
-Section C Medical Records - (10) All entries in the medical record are legible, dated, timed, authenticated recorded in black ink, typewritten, or recorded electronically.
-Section D General Conduct of Care - (2) A Practitioners routine orders, shall be reproduced in detail on the order sheet of the patient's medical record, dated and signed by the Practitioner.

During an interview on 01/27/10 at 3:19 PM the Director of Health Information Management (HIM), Staff E stated all physician's orders in patient medical records should be dated, timed and authenticated.


2. Record review of current Patient #23's admission history and physical revealed staff admitted the patient on 01/20/10 with diagnoses including depression with suicidal ideation.

Record review of the patient's physician's orders revealed the following:
-Overprinted Post ECT (electroconvulsive therapy) orders dated 01/27/10 with an untimed authentication.
-An authenticated, but untimed order for Tylenol and an anti-nausea medication dated 01/27/10.
-Overprinted Post ECT orders dated 01/29/10 with an untimed authentication.
-An authenticated, untimed order for Tylenol dated 01/29/10.

3. Record review of closed Patient #19's admission history and physical revealed staff admitted the patient on 12/12/09 with diagnoses including depression with suicide attempt, migraine headaches, tobacco dependence and seasonal allergies.

Record review revealed:
- the patient's consult for medical management included an untimed, authenticated note on an overprinted form dated 12/13/09.
- the patient's psychiatry progress notes revealed an untimed, authenticated note dated 12/14/09.

During an interview on 01/29/10 at 3:11 PM the Director of HIM, Staff E reviewed the patient's medical management note and the psychiatry progress note and stated the physicians failed to time the notes as required.


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4. Record review of current Patient # 1's medical chart revealed the patient was admitted to the facility on 1/25/10 for Major Depressive Disorder.

Record review of the medical chart revealed the following information:
-The DVT/PE Prophylaxis Screening Tool noted on 1/25/10 was not dated or timed by the physician.

5. Record review of current Patient #3's medical chart revealed the patient was admitted to the facility on 1/20/10 for abnormal labs. The patient has a history of Schizophrenia (a mental disorder that makes it difficult to tell the difference between real and unreal experiences, to think logically), Multiple Sclerosis (a disease which affects the brain and spinal cord), Diabetes Mellitus (a disease marked by high levels of sugar in the blood) (a type 2.

Record review of the Physicians Orders revealed the following orders were not either not signed/dated or timed by the physician:
-Physician Orders Sliding Scale Insulin Protocol (Revised 4/25/08) dated 1/21/10 was not timed by the physician.

6. Record review of current Patient #31's medical chart revealed the patient was admitted to the facility on 12/20/09 for bipolar disorder (a mental disorder which involves periods of excitability [mania] and with periods of depression).

Record review of the medical chart of the patient revealed the following information:
-A document titled Electroconvulsive Treatment (ECT) (a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect) dated 12/30/09 at 11:54 AM revealed the verbal order was not signed, dated or timed by the physician.
not dated by the physician.
-The Physician's Orders Medication Reconciliation Order dated 12/21/09 pages 1 and 2 were not timed by the physician.
-The Recovery Room Record dated 1/15/10 at 9:21 AM was not dated or timed by the physician.
-The Senior Adult Preprinted Orders noted 12/20/09 was not dated or timed by the physician.
-The Physician's Orders dated 12/27/09 Fe Sol (Iron) 325 BID; CBC (unreadable); In computer for 2 wks T.O. [telephone order] was not signed.
-A document titled ECT dated 12/30/09 at 11:54 AM revealed the verbal order was not signed, dated or timed by the physician.
-The Physician's Orders Medication Reconciliation Order dated 12/21/09 pages 1 and 2 were not timed by the physician.
-The Post-ECT Orders on 1/11/10, 1/13/10, 1/15/10, 1/18/10, 1/20/10, 1/27/10,1/29/10 were not timed by the physician.
-The Behavioral Health Progress Notes dated 12/23/09, 12/28/09, 12/29/09, 01/06/2010, 1/9/10 were not dated by the physician.

7. Record review of current Patient #33's medical chart revealed the patient was admitted to the facility on 1/21/10 for altered mental status/delirium sudden severe confusion.

Record review revealed the following orders were either not signed, dated or timed by the physician:
-Fall Prevention Protocol dated 1/21/10 with no date or time of physician's signature.
-Medication Reconciliation Order dated 1/21/10 pages 1 through 3 with no date or time of physician's signature..
DVT/PE (Deep Vein Thrombosis [blood clot in the legs] (Pulmonary Embolism) [the clots break off from the vein and travel through the heart to the pulmonary arteries] Prophylaxis (to prevent) Screening Tool date 1/21/10 no date or time of physician's signature.
-Telephone orders taken on 1/22/10 at 9:00 PM for Egg Crate Mattress to bed with no date or time of physician's signature.
-Telephone orders taken on 1/26/10 at 1:00 PM for No Smoking with no date or time of physician's signature.
-Behavioral Health Progress Notes dated 1/23/10, 1/24/10, 1/25/10, 1/26/10, 1/27/10 and 1/28/10 with no time of physician's signature.

During an interview on 1/28/10 at 9:20 AM Unit Manager H stated she did not see times and dates authenticated by the physician.


19957

8. Record review of current Patient #28's admission history and physical showed the patient entered the facility 1/26/10 with suicidal ideations.

Review of the patient's physician's orders showed the following:
- An authenticated, untimed order dated 1/27/10 for Benzal Peroxide Gel 5% apply to skin q HS (every night)
- An authenticated, untimed order dated 1/27/10 for an X-Ray R (right) knee portable [sic]

9. Record review of current Patient #59's admission history and physical showed the patient entered the facility 1/27/10 for violent and aggressive behavior.

Review of the physician's orders showed the following authenticated, untimed orders dated 1/28/10 for:
- Serum Lipid Panel (a group of tests ordered together to determine risk of coronary heart disease)
- HGB A1C (hemoglobin blood test to measure how blood sugars run over several months at a time)
- One touch (a meter used to monitor blood sugar levels) before lunch and 2 hrs (two hours) after lunch today only.

Based on record review and interview, the facility failed to have a system in place that ensured physician's verbal and telephone orders were dated, timed and authenticated within forty-eight hours as directed by facility policy for 13 (Patient #1, #3, #20, #21, #22, #23, #15, #17, #19, #31, #33, #52 and #58) of 24 patient medical records reviewed for dated, timed and/or authenticated verbal/telephone orders. The facility census was 86 patients.

Findings included:

1. Record review of the facility "Medical Staff Bylaws and Rules and Regulations", dated 08/08, directed in part, the following:
-Section C Medical Records - (10) All entries in the medical record are legible, dated, timed, authenticated recorded in black ink, typewritten, or recorded electronically.
-Section D General Conduct of Care - (1) All orders dictated over the telephone shall be dictated by the Practitioner. The responsible Practitioners shall authenticate such order within forty-eight hours.

During an interview on 01/27/10 at 3:40 PM the Director of Health Information Management (HIM) Staff E stated all physician's verbal orders in patients medical records should be dated, timed and authenticated within 24-hours (not 48 as the policy stated).

2. Record review of patient medical records, conducted during the survey 1/27-29/10 revealed the following:

a. Record review of current Patient #20's admission history and physical revealed staff admitted the patient on 01/21/10 for bipolar disorder.
Record review of the patient's physician's orders revealed the following:
-Overprinted telephone (verbal) admission orders dated 01/21/10 with an undated, untimed authentication.
-A verbal order for Tylenol dated 01/24/10 with an undated, untimed authentication.

During an interview on 01/29/10 at 3:14 PM the Director of HIM Staff E reviewed the patient's physician's orders and stated staff physicians failed to date and time their authentications.

b.. Record review of current Patient #21's admission history and physical revealed staff admitted the patient on 01/14/10 for diagnoses including dementia with agitation.

Record review of the patient's physician's orders revealed the following:
-A telephone order for a dressing to a skin tear on the left forearm dated 01/26/10 with an untimed, undated authentication.
-A verbal order for clarification of a Depakote order dated 01/27/10 with an untimed, undated authentication.

During an interview on 01/29/10 at 3:24 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated staff physicians failed to date and time their authentications.

c. Record review of current Patient #22's admission history and physical revealed staff admitted the patient on 01/26/10 for diagnoses including psychosis, contusion, right wrist pain and tobacco abuse.

Record review of the patient's physician's orders revealed the following:
-Overprinted telephone (verbal) orders for admission dated 01/26/10 with a dated but, untimed authentication.
-A telephone order directing staff to obtain an x-ray of the right wrist dated 01/26/10 with an untimed, undated authentication.
-An unauthenticated telephone order for a CT of the head without contrast dated 01/27/10.

During an interview on 01/29/10 at 3:20 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated staff physician's failed to date, time and authenticate verbal/telephone orders as required.

d. Record review of current Patient #23's admission history and physical revealed staff admitted the patient on 01/20/10 with diagnoses including depression with suicidal ideation.

Record review of the patient's physician's orders revealed the following:
-A telephone order dated 01/20/10 for Clonidine for a blood pressure greater than a specific measurement with an undated, untimed authentication.
-A telephone order on an overprinted Home Medications physician's order form dated 01/21/10 with an untimed authentication.
-A telephone order dated 01/26/10 directing the patient was medically cleared for electroconvulsive therapy treatments with an untimed, undated authentication.
-A telephone order dated 01/26/10 directing staff to obtain an EKG (electrocardiogram) and x-ray then call the physician with an undated, untimed authentication.

During an interview on 01/29/10 at 3:22 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated staff physician's failed to date and time authentications of verbal/telephone orders as required.

e. Record review of closed Patient #15's admission history and physical revealed staff admitted the patient on 11/30/09 with diagnoses including dementia with agitation, degenerative joint disease, high blood pressure, anorexia/bulimia, gastroesophageal reflux disease, chronic allergies, breast cancer and hypoxemia.

Record review of the patient's physician's orders revealed the following:
-A telephone order to maintain the patient's oxygen level at a specific percentage, an order for the patient to be designated as do not resuscitate, obtain a chest x-ray dated 11/30/09 with an undated, untimed authentication.
-A telephone order to transport the patient to the Emergency Room of a local hospital dated 12/02/09 with an undated, untimed authentication.
-A telephone order for an antibiotic, video swallow study, breathing treatments and chest x-rays dated 12/03/09 with an undated, untimed authentication.
-A telephone order to continue an antibiotic for another week, obtain a chest x-ray and provide breathing treatments dated 12/07/09 with an undated, untimed authentication.
-A telephone order to discontinue antibiotics dated 12/08/09 with an undated, untimed authentication.
-A telephone order for anti-nausea medication dated 12/10/09 with an undated, untimed authentication.
During an interview on 01/29/10 at 3:05 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated staff physician's failed to date and time authentications of verbal/telephone orders as required.

f. Record review of closed Patient #17's admission history and physical revealed staff admitted the patient on 12/28/.09 with diagnoses including mood disorder.

Record review of the patient's physician's orders revealed a telephone order recorded on an overprinted admission form with an undated, untimed authentication.

During an interview on 01/29/10 at 3:10 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated the staff physician failed to date and time the authentication as required.

g. Record review of closed Patient #19's admission history and physical revealed staff admitted the patient on 12/12/09 with diagnoses including depression with suicide attempt, migraine headaches, tobacco dependence and seasonal allergies.

Record review of the patient's physician's orders revealed the following:
-A telephone order to admit the patient dated 12/12/09 with an undated, untimed authentication.
-A telephone order to admit the patient dated 12/12/09, recorded on an overprinted form with an undated, untimed authentication.
-A verbal order for methicillin resistant staph aureus screening culture dated 12/13/09 with an undated, untimed authentication.

During an interview on 01/29/10 at 3:11 PM the Director of HIM, Staff E reviewed the patient's physician's orders and stated the physician failed to date and time authentications of verbal/telephone orders as required.


19957

h. Record review of current outpatient Patient #52's admission history showed the physician scheduled the patient for outpatient electroconvulsive therapy (ECT). Review of the physician's order dated 1/25/10 included the following medication telephone order:
Vicodin 5/500 mg one (1) p.o. q 6 hours prn for headache
Phenergan 25 mg one (1) p.o. q 6 hours prn for nausea
The order is not signed, dated or timed by the physician.

i. Record review of current outpatient Patient 58#'s admission history showed the physician scheduled the patient for outpatient electroconvulsive therapy (ECT) on 1/27/10.
Review of the physician's orders showed a telephone order dated 1/27/10 for:
Zofran 4 mg p.o. (by mouth) q (every) six (6) hours prn (as needed) for (sic) nausea
Oxycodone one (1) 20 mg q 8 hours prn
The order is not signed, dated or timed by the physician.


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j. Record review of current Patient # 1's medical chart revealed the patient was admitted to the facility on 1/25/10 for Major Depressive Disorder.

Record review of the Physician's Orders revealed the following information:
-The Physician's Order taken verbally dated 1/25/09 at 7:40 PM. was not dated or timed by the physician. This order was noted on 1/26/10.
-The Medication Reconciliation Order taken as a telephone order on 1/25/10 was not dated or timed by the physician.

k. Record review of current Patient #3's medical chart revealed the patient was admitted to the facility on 1/2/10 with schizophrenia ( a disorder that makes it difficult to tell the difference between real and unreal experiences, to think logically), Multiple Sclerosis (a disease which affects the brain and spinal cord), Diabetes Mellitus (a disease marked by high levels of sugar in the blood) (a type 2.

Record review of the Physicians Orders revealed the following orders were not either not signed/dated or timed by the physician:
-Verbal order taken on 1/21/10 at 11:00 AM for Clozapine ( a drug used to treat mental disorders) 300 mg PO (by mouth) 12:00 PM. today only was not timed by the physician
-Physician Orders Sliding Scale Insulin Protocol (Revised 4/25/08) dated 1/21/10 was not timed by the physician.
-Telephone order taken on 1/20/10 at 6:00 PM for DC above order; give Clozaril ( a drug used to treat mental disorders) 300 mg (milligrams) BID ( two times a day )with no signature, date or time of physician.
-Telephone order taken on 1/20/10 at 6:00 PM for DC above order; give Clozaril ( a drug used to treat mental disorders) 300 mg (milligrams) BID ( two times a day )with no signature, date or time of physician.
-Telephone order taken 1/21/10 at 8:10 AM for Stat (immediately) check CBC Complete Blood Count) with Differential ( the types of white blood cells present) and weekly thereafter was not signed, dated or timed by the physician.

l. Record review of current Patient #31's medical chart revealed the patient was admitted to the facility on 12/20/09 for bipolar disorder (a mental disorder which involves periods of excitability [mania] and with periods of depression).

Record review of the medical chart of the patient revealed the following information:
-A document titled Electroconvulsive Treatment (ECT) ( a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect) dated 12/30/09 at 11:54 AM revealed the verbal order was not signed, dated or timed by the physician.
not dated by the physician.

m. Record review of current Patient #33's medical chart revealed the patient was admitted to the facility on 1/21/10 for altered mental status/delirium sudden severe confusion).

Record review revealed the following orders were either not signed, dated or timed by the physician:
-Medication Reconciliation Order dated 1/21/10 pg 1 through 3 with no date or time of physician's signature..
-Telephone orders taken on 1/22/10 at 9:00 PM for Egg Crate Mattress to bed with no date or time of physician's signature.
-Telephone orders taken on 1/26/10 at 1:00 PM for No Smoking with no date or time of physician's signature.
-Telephone order taken on 1/26/10 at 3:40 PM for Change Seroquel ( a medication to treat schizophrenia and bipolar disorder) to 50 mg PO TID ( three times a day) and 150 mg PO q (every) HS (at night).

Based on policy review, record review, and interview, the facility failed to promptly identify and investigate three missing doses of a controlled medication/substance. The facility census was 86.

Findings included:

Review of facility policy 733.10.3.03 "Controlled Substance Monitoring" showed in part:
-The purpose is to establish monitoring processes relating to ordering, receiving, storing, dispensing and administering of controlled substances and document such activities.
- The Director of Pharmacy will be responsible for insuring that the monitoring described in this policy is performed, results are collected, and that data is presented quarterly to the Ethics & Compliance Committee. The departmental manager shall immediately investigate any discrepancies identified in ordering, receiving, administering, or reconciling the inventory of controlled substances. Similarly, the departmental manager shall investigate any situation that indicates a breach in product integrity or a failure to follow appropriate policies related to controlled substances.

However, record review of an Acudose -RX (an automated dispensing medication cart) open discrepancy report showed an event start date of 12/23/09 and an event end date of 12/24/09. The report showed the primary delivery site as the adult unit. The report showed a discrepancy of three Oxycodone/APAP 5-325 milligram (mg) tablets (Oxycodone/APAP products are narcotics and are classified as Schedule II controlled substances). The report showed a beginning count on 12/24/09 of 21 Oxycodone 5-325 mg tabs. An employee removed one tablet from the Acudose machine. The ending count should have been 20 tablets but the actual count showed 17 tablets with a discrepancy of three tablets.

During an interview on 1/28/10 at approximately 11:00 AM the Director of Pharmacy Staff C said the Acudose machine was not functioning correctly around 12/20/09 through 12/24/09. The Director said he/she attributed the discrepancy of the Oxycodone to the malfunctioning machine and did not audit any patient records during this time frame to determine if there was any medication missing.

On 1/29/10 the Director Staff C provided an audit of the use of Oxycodone/APAP. The Director said he/she compared the medication administration records with the patients whose physicians had ordered Oxycodone during the time frame of 12/20/09 through 12/24/09. Through this audit the Director accounted for two missing doses of Oxycodone and determined the Oxycodone discrepancy is one tablet. The Director was unable to account for the one missing dose. The facility investigated and audited this discrepancy approximately 34 days after the discrepancy occurred.

Based on interview and record review, the facility:

- failed to implement effective policies and procedures to provide comprehensive nutrition assessment and nutrition care to patients after they were identified at nutritional risk for two (Patient #21, #23) of four patients reviewed for nutritional care;
- failed to write or have a system in place for patients on therapeutic menus not routinely ordered by the physician for patients (this included at the time of the survey patients on a low potassium diet, no concentrated sweet (NCS), and low salt/2.5 to 4.0 grams diet) for food service staff to use as guidance when serving patient meals and
- failed to maintain a complete nutrient analysis of current menus to monitor and ensure the nutritional needs of all patients and specifically children and adolescents were met.

The facility census was 86 patients.

Findings included:

1. During an interview on 01/27/10 at 2:10 PM the substitute Director of Dietary Staff B was asked to provide the facility policy on nutrition screening and assessment of patients and a list of all the patients with their current diet orders.

Record review of the facility policy and procedure titled "Nutrition Screening and Assessment/Reassessment", dated 06/09, and not provided until 01/29/10 directed the following:

-Nursing staff completed a nutrition screening for patients within twenty-four hours of admission.
-A positive screen generated from the admission data base results in a referral to the dietitian.
-The dietitian will respond to the referral within forty-eight hours and determine nutritional risk.
-Patients who were identified with unintentional weight loss, less than fifty percent of usual intake for greater than five days, actual or potential malnutrition, prolonged chewing or swallowing difficulties, tube feeding or use of supplements, high risk pregnancy (no parameters provided), vomiting or diarrhea for greater than five days,
Kidney failure, pressure ulcers, chemical dependency, eating disorders, HIV/AIDS (Human immunodeficiency virus, a virus that causes acquired immunodeficiency syndrome), cancer, severe trauma-multiple, head, abdominal or chest trauma, gunshot wound, parenteral nutrition (intravenous nutrition when the gastrointestinal tract is nonfunctional), liver failure or malnutrition were identified as being at high nutritional risk. However, patients with these diagnoses were determined as being able to wait up to 48-hours for nutrition assessment by the registered dietitian.
-Patients who were identified with no food by mouth for more than three days, pancreatitis (inflammation of the pancreas), gestational diabetes (a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy) or new diagnosis of diabetes, small bowel obstruction (a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion), Crohn's disease (inflammatory bowel disease), ulcerative colitis (chronic inflammation of the digestive tract, characterized by abdominal pain and diarrhea), being on the geriatric unit, being a geriatric patient after surgery, an organ transplant recipient or donor of an organ, diagnosis of new kidney disease, or congestive heart disease were identified as only moderate risk and able to wait up to three days before the dietitian was to provide nutritional assessment.
-Patients with dehydration and all others not identified as being at nutritional risk were called low risk and could wait up to five days after admission for a nutrition assessment by the dietitian.

During an interview on 01/28/10 at 8:45 AM the facility Director of Pharmacy Staff C stated that the facility provided no parenteral nutrition (intravenous nutrition) to patients even though this was listed in the facility policy/procedure.

a. Record review of current Patient #21's admission history and physical revealed staff admitted the patient on 01/14/10 with diagnoses including dementia with agitation, high blood pressure, high blood cholesterol, osteoporosis and degenerative joint disease.

Further review of the patient's admission history and physical revealed the physician assessed that the patient was thin, weighed 124 pounds at a height of 61 inches, had fair to poor dentition with most teeth missing, and planned to order a commercially-prepared nutritional supplemental beverage.

Record review of the patient's nutrition note dated 01/15/10 revealed the dietitian assessed the following:
-The patient was assessed because of the expected length of the admission (but not due to assessment of possible nutritional problems, such as the high blood pressure, high blood cholesterol, osteoporosis, missing teeth, or low weight).
-The diet served was regular (not mechanical soft or pureed that may be needed for poor dentition).
-The patient's reported oral intake was 72% consumed at meals {not evaluation of the amount and type of foods served, a standard of practice for dietitians}.
-The height and weight were assessed as within normal limits {even though the physician assessed the patient as thin}.
-The dietitian assessed there were no nutritional concerns, planned to continue the current regular diet and follow-up as needed.

b. Record review of current Patient #23's admission history and physical revealed staff admitted the patient on 01/20/10 with diagnoses including high blood pressure, low blood potassium {a mineral found in foods}, constipation, degenerative joint disease, degenerative disc disease {spinal bone}, history of bowel surgery with removal of part of the colon, and history of breast cancer with lumpectomy.

Further record review of the patient's admission history and physical revealed the elderly patient was admitted to the geriatric unit and reported a thirty pound weight loss in the last six months, had been taking a colon cleanser for constipation, and the physician planned to replenish the patient's potassium stores found to be low on analysis of blood samples.

Record review of the patient's nutrition notes dated 01/21/10 revealed the dietitian assessed the following:
-The nutrition assessment was done due to the estimated length of hospital stay and not due to evaluation of possible nutritional concerns or admission to the geriatric unit, a criteria included in the hospital policy.
-The patient had poor oral intake prior to admission to the facility.
-The diet ordered was regular.
-Assessed the patient was over weight for height.
-The dietitian failed to assess the need for increased fluids or fiber for constipation, failed to assess the possible need for increased calories and protein due to past history of cancer and weight loss, failed to assess the potential need for high potassium foods in the diet until blood factors returned to normal, and failed to assess the need for diet counseling.

c. During an interview on 01/29/10 at 10:40 AM dietitian Staff W stated the following:
-She fills in for dietitian Staff U occasionally.
-When she does fill in, the steps she takes to screen patient's for nutritional problems are to review the diet listing and look for the patient's diagnoses (although the diet list does not have diagnosis of each patient), the diet ordered and admission date.
-When asked if she reviewed the nurse admission assessment which contains nurses review of systems including gastrointestinal, oral and past medical problems, the Staff W stated she would never review or look at the nurse admission assessment for possible nutrition or diet related problems.

2. Record review of the list of current inpatients with their diet orders was provided on 01/29/10 revealed orders for one patient who required a low potassium (a mineral found in foods that may be restricted in kidney disease) diet, an order for one patient who required a No Concentrated Sweets (NCS) diet (restriction of sugars that may be required for a diabetic person), and one order for a patient who required a low salt-2.5 to 4.0 gram diet (salt contains sodium which may be restricted for cardiac, kidney or liver problems).

However, record review of a copy of the current menus, requested on 01/27/10 and provided on 01/29/10, revealed the menus were dated 06/04 and staff failed to include menus for the following:
-No listing of amount and types of foods that could be used by staff to serve a patient ordered to be on a low potassium diet.
-No listing of amounts and types of foods that could be used by staff to serve a patient ordered to be on a No Concentrated Sweets or NCS diet.
-No listing of amounts and types of foods that could be used by staff to serve a patient
ordered to be on a low salt-2.5 to 4.0 gram diet.

Further review of these menus revealed the following:
-Only partial menus planned for Monday supper.
-No menus planned for Tuesday supper.
-Conflicting menus planned for Wednesday lunch (different foods listed on the same meal).
-No menus planned for Wednesday supper.
-No menus planned for Thursday supper.
-No menus planned for Friday supper.
-No menus planned for Saturday supper.

3. Record review of the facility menu nutrient analysis, requested on 01/27/10 and provided on 01/29/10, revealed the menus were dated for use on 06/01/08 through 06/07/08 and did not match the copy of menus provided during the survey and reported to currently be served to patients.

Further review of the facility menu's nutrient analysis revealed the following:
-The foods were listed in three small meals and three snacks that did not match the current meal serve of three meals per day.
-Some of the foods listed were low in calories (diet jelly, fat free salad dressing, diet syrup, sugar free pudding), a limitation not needed for patients on a regular diet.
-No special alterations were noted for children who require additional calcium (according to the recommended dietary allowances, a standard of nutritional reference).
-No additional alterations were noted for adolescents who usually require additional calories and protein.
-No calculation of the calcium content of the menus was found (for children and post menopausal women patients).

Record review of the diet list, provided during the survey revealed two patients below the age of eight years and sixteen pre-teen and teenagers were served the standard regular diet without supplementation or age-related alterations in the food served.

Based on observation, interview and record review, the facility failed to ensure a current therapeutic diet manual was available to all medical and nursing staff. The facility census was 86 patients.

Findings included:

During an interview on 01/27/10 at 2:00 PM the substitute Director of Dietary Staff B and Dietary Supervisor/Cook Staff D stated the facility used the "Manual of Clinical Nutrition Management", kept in the administrator's office and in the diet office of the kitchen - the only two locations where the diet manual was kept. However:

- During an interview on 01/29/10 at 10:20 AM Mental Health Technician (MHT) Staff Z stated he/she did not know of a diet manual maintained on the Child and Adolescent Unit.

- During an interview on 01/29/10 at 10:21 AM the Child and Adolescent Unit Charge Nurse Staff X stated he/she was unaware of a diet manual maintained on the Child and Adolescent Unit.

- During an interview on 01/29/10 at 10:47 AM MHT, Staff CC stated he/she had been employed in the facility for the last ten or fifteen years and was unaware of a diet manual maintained on the Adult Unit.

- During an interview on 01/29/10 at 11:16 AM the Clinic Nurse Specialist, Senior Adult Unit, Staff G stated the following:
-He/she was not aware of a diet manual on the unit.
-After searching book shelving in an office area, found a Missouri Diet Manual, 7th edition dated 1991 and stated there was not more recent copies of any diet manual on the unit.

- Observation on 01/29/10 at 11:16 AM revealed staff on the Senior Adult Unit maintained a copy of the Missouri Diet Manual, 7th edition, dated 1991.

Based on observation, interview and record review, the facility failed to maintain kitchen and refrigeration equipment in a clean sanitary manner to store foods safely and failed to store foods used in patient food service to protect against cross-contamination that could cause food borne illness. Hospitalized patients with acute medical conditions are more vulnerable to food borne illness. The facility census was 86 patients.

Findings included:

1. Record review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 "Food Code" directed in part, the following:
-Chapter 3-305.11 Food shall be stored to protect against contamination, in a clean, dry location, not exposed to splash, dust or other contaminants, at least six inches off the floor.
-Chapter 3-305.12 Food shall not be stored under sources of contamination.
-Chapter 4-601 Equipment, food contact surfaces, non food contact surfaces and utensils shall be clean to sight and touch.

2. Observation on 01/27/10 beginning at 2:20 PM in the facility kitchen revealed the following:

In the dry food storeroom:
- a heavily soiled floor with individual portion control condiment packets spilled on floor.
- an eleven-pound container of chocolate fudge icing stored on a soiled shelf with a cracked and soiled lid incompletely covering the contents, allowing dust and debris to potentially gather on the surface of the food.
- an opened two-pound, eight-ounce container of dry roasted peanuts labeled opened 10/28/09 and discard by 11/31/09 (there are only thirty days in November) stored on a soiled shelf.

In the walk-in refrigerator:
- a partial forty-pound case of apples stored on a heavily soiled floor.
- partial containers of foods on stainless steel shelving coated with black, fuzzy mold so thick that when touched, a black, greasy smudge coated fingers.
- an opened five-pound bag of Feta cheese labeled to be discarded on 01/17/10, but still present ten days late.
-In the walk-in refrigerator staff stored two cases of eggs in the shell near individual cartons of milk used on patient tray service.

In the walk-in freezer:
- food and ice littered the floor.
- a frozen loaf of bread on the floor, labeled to discard by 01/10/10.

During an interview on 01/27/10 Supervisor/Cook, Staff D stated the following:
-The floors of the walk-in refrigerator should be swept and mopped daily.
-Staff had failed to sweep and mop the walk-in refrigerator floor daily.
-The floor of the walk-in freezer should be swept daily.
-Staff failed to sweep the walk-in freezer floor daily.
-The stainless steel shelving in the walk-in refrigerator was heavily soiled with black mold - the shelving should be cleaned daily.
-Staff failed to clean the shelving in the walk-in refrigerator as required.

Observation on 01/27/10 at 2:24 PM revealed staff failed to clean and maintain the interior surfaces and shelving in a thaw box (used to thaw frozen foods).

3. Observation on 01/28/10 at 11:10 AM revealed staff failed to maintain broken ceramic wall tiles on the wall near two carbon dioxide tanks chained loosely to the wall with the chain draped across one collar of one tank in a manner that would not prevent the tank from falling to the ground if pushed, a safety hazard.

Further observation on 01/28/10 at 11:10 AM revealed the two carbon dioxide tanks were stored on a heavily soiled floor with a dried red-browned elliptical shaped soil mark under the tanks.

4. Observation 01/28/10 from 11:15 AM through 11:45 AM of refrigeration equipment on the units revealed the following:
-No thermometer in the freezer compartment of the senior unit, child/adolescent unit, and adult unit, making it impossible to check for adequate food storage temperatures.

During an interview on 01/28/10 at 11:35 AM the Regional Clinical Dietitian Staff N stated staff failed to ensure a thermometer was place in the freezer compartment of the refrigerators of the senior unit, the child/adolescent unit and the adult unit to ensure the temperature of the compartment was adequate for safe frozen food storage.

5. During an interview on 01/28/10 at 1:25 PM the Infection Control Nurse stated the following:
-She reviewed the dietary policies and procedures as part of a group in the Safety and Infection Control Committee meetings.
-She had input into the dietary policies and procedures only if she had concerns.
-She had no input of into the cleaning of dietary department food contact surfaces.
-She had no input into methods of food storage.

Based on observation, interview and record review, facility infection control staff failed to ensure nursing staff followed the hand washing policy. Furthermore, infection control staff in conjunction with facility dietary staff failed to develop policies and procedures to ensure foods served to patients were protected against cross-contamination to prevent food borne illness and staff failed to ensure foods on patient meal trays were served at appropriate temperatures to prevent growth of bacteria that may cause food borne illness. The facility census was 86 patients.

Findings included:

1. Record review of the facility policy "Hand Washing" # 603.4.06.05 revised 05/09 stated in part the following:

PROCEDURE:
3. Hands should be washed for nursing staff:
a. Before and after patient contact
b. After contact with a source of microorganisms (e.g. body fluids, inanimate objects likely to be contaminated).

2. Record review of current Patient #2's medical record revealed the patient was admitted to the facility on 1/18/10 for psychosis (a loss of contact with reality), mania (a state of abnormally elevated or irritable mood, arousal and/or energy) and confusion.

Record review of the E-Sig Psych Report dated 1/19/10 in part revealed the following information:
-The patient was admitted to another hospital and delivered a baby by C-Section (Caesarian section: a surgical procedure in which incisions are made through the mother's abdomen and uterus to deliver a baby) on January 7, 2010. She was noted to be disorganized and unstable in her moods on the unit and there was concern about her safety and the safety of the baby. The patient was transferred to [this hospital] on 1/18/10.
-Medications: 6. Augmentin for a wound infection

Observation on 1/28/10 at 9:47 AM found Licensed Practical Nurse (LPN) Staff J entered the patient's room to change the dressing on the abdominal incision. LPN J did not wash his/her hands with soap and water or hand sanitizer when entering the room that would remove any bacteria on the hands that could have been acquired from other patients or objects. LPN J donned non-sterile gloves and removed the dressing from the patient's wound which he/she then placed on the towel draped over the legs of the patient. He/she then cleansed the wound and placed gauze over the wound. LPN J removed her gloves and then gathered up the towel with the dirty dressing and walked down the hall with the towel and dirty dressing and placed them in a bin in the dirty utility room. LPN J did not wash his/her hands with soap and water or use a hand sanitizer when leaving the patient's room.

During an interview on 1/29/10 at 10:03 AM, Family Nurse Practitioner Staff I stated washing your hands should be done if having patient contact, when you enter a room and when leaving a room. If there is no patient contact hand washing is not necessary.

During an interview on 1/28/10 at 1:25 PM the Infection Control Officer Staff DD stated she would not expect the nurse to change her gloves and wash her hands between removing the soiled dressing and applying the new dressing because it was not a sterile dressing (although bacteria on the soiled dressing could, then, be tranmitted to the new, clean dressing). Staff DD stated staff should wash their hands when entering or leaving a room.


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3. Record review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 "Food Code" (considered a reference for the standard of practice for food service) directed in part the following;
-Chapter 2-402 Food handlers should wear effective hair restraints including beard restraints to keep hair from exposed foods, clean equipment and utensils.
-Chapter 3-501 Foods should be maintained at a temperature less than 41 degrees Fahrenheit or above 135 degrees Fahrenheit.

During an interview on 01/27/10 at 2:10 PM the substitute Director of Dietary, Staff B, stated the facility had a policy and procedure for personal hygiene and dress code for food service staff. Record review of the facility policy and procedure provided to the surveyor was titled "Uniforms", dated 03/06, that directed dietary staff to wear clean, neat uniforms and refer to the facility employee handbook for specifics on uniform policy.

Observations on 01/28/10 at 11:16 AM in the facility dish washing area revealed Diet Aide Staff AA and Diet Aide Staff BB failed to wear effective hair restraints over facial hair.

During an interview on 01/28/10 at approximately 3:00 PM, the Director of Dietary Staff V was asked to provide the surveyor with a copy of the facility employee handbook for specifics regarding the uniform policy. However, as of exit date and time, facility staff had provided no facility employee handbook regarding specifics of uniform policy to review for directives on hair restraint that may be different than found in the "Food Code".

4. Observation on 01/28/10 from 11:05 AM through 11:22 AM revealed staff served a test meal tray with foods at the following temperatures:
-Hamburger patty at 117.5 degrees Fahrenheit.
-Diet gelatin served at 54 degrees Fahrenheit.

During an interview on 01/28/10 at 11:22 AM the Director of Dietary, Staff V stated the following:
-He felt the hamburger patty should be served at 140 degrees Fahrenheit or above (inconsistent with current the "Food Code" authoritative reference).
-He felt the diet gelatin should be served at 40 degrees Fahrenheit or below.

5. During an interview on 01/28/10 at 1:25 PM the Infection Control Officer, Staff DD, stated the following:
-She was a registered nurse.
-She was working on becoming a member of the Association of Professionals in Infection Control (APIC).
-She reviewed the dietary policies and procedures as part of a group in the Safety and Infection Control Committee meetings.
-She had input into the dietary policies and procedures only if she had concerns.
-She does hand washing in-services for the dietary staff.
-She was aware the dietary staff had to wear hair covers on the head but was not aware of the requirement for effective hair restraint over facial hair.
-She had no input of into the cleaning of dietary department food contact surfaces.
-She had no input into methods of food storage.