HospitalInspections.org

Based on review of the Governing Board (GB) minutes, and interviews the GB failed to

A. protect the patients from the unnecessary use of restraint and seclusion for falls, document and log patient holds to administer psychotropic medications, and follow physician orders in 3(#12, 10, and 21.) of 20 (#1-20) charts reviewed. The governing body failed to provide a safe setting for care and treatment of psychiatric patients in 1 of 1 patient care unit.


Refer to Tags A0144 and A0154


B. provide a safe environment for all patient's, staff, and visitors. Insure the outpatient treatment center was safe from fire disaster in 1 of 1 out patient treatment locations, and
failed to follow its policy for sanitary disposal of garbage in 2 of 2 dumpster's observed.

Refer to Tags A0701, A0709, and A0713


C. include infection control risks in 4 (dietary, housekeeping/garbage collection, outpatient, and nursing) of 8 departments ( laundry, laboratory, radiology, Emergency Services) represented in the Quality Assessment and Process Improvement for the facility.

refer to Tags A0756

Based on medical record review and interviews the facility failed to protect the patients from the unnecessary use of restraint and seclusion for falls, document and log patient holds to administer psychotropic medications, and follow physician orders for levels of monitoring in 3(#12, 10, and 21.) of 20 (#1-20) charts reviewed.

Refer to tags A0144 and A0154

Based on observation, interview and document review the facility:

A 701
Failed to provide a safe environment for all patient's, staff and visitors.


A 709
Failed to insure the outpatient treatment center was safe from fire disaster in 1 of 1 out patient treatment locations.


A 713
Failed to follow its policy for sanitary disposal of garbage in 2 of 2 dumpsters observed.

Based on observation interview and document review the facility failed to include infection control risks in 4 (dietary, housekeeping/garbage collection, outpatient, and nursing) of 8 departments ( laudry, laboratory, radiology, Emergency Services) represented in the Quality Assessment and Process Improvement for the facility.

Refer to A 0756

Based on medical record review and interviews the facility failed to protect the patients from the unnecessary use of restraint and seclusion for falls, document and log patient holds to administer psychotropic medications, and follow physician orders in 3(#12, 10, and 21) of 20 (#1-20) charts reviewed.

Review of patient #12's chart revealed that she was a 91 year old female admitted on 3/6/2014. Review of the psychiatric evaluation dated 3/10/2014, staff #4 documented, " was sent to us due to increasing confusion, hallucinations, and agitation. The patient was agitated and combative at the nursing home. Patient made suicidal statements at the nursing home. The patient presents to the hospital with a urinary tract infection. Diagnostic impression: Axis I Delirium secondary to general medical condition, due to urinary tract infection. Rule out dementia, Alzheimer's type, with behavioral disturbances.
Review of the physician orders for admission on 3/7/14 revealed the patient was put on a level one monitoring level. Review of Policy and procedure " Patient Monitoring and Precautions Policy #: 6O51 " defined the 3 monitoring levels;
" A. Level I: constant monitoring within 6 feet distance (arms reach). No more than two level I patients are assigned to an individual technician to monitor.
B. Level II: constant monitoring within 20 feet distance, line of sight.
C. Level Ill: close monitoring every 15 minutes. Within a distance of 40 feet or less. "
Review of patient #12's chart revealed a physicians' order for level I monitoring. The sheet had the definition of a level one, two, and three monitoring system and columns. The columns listed where date, time, level, precaution orders/level of justification, MD signature, and RN signature.
Patient #12 was placed on a level one for "falls" from 3/14-3/18/2014. The definition on the "Physician order for monitoring" of a level one is as follows:
" LEVEL 1- patient is an extreme danger to themselves or others and requires 1:1 constant monitoring within arm's reach while awake, and from doorway of patient's room while asleep. Patient is never more than six feet away from the staff while awake at all times. Patient is accompanied by staff at all times including bathing, showering, shaving, and toileting. Order must be reviewed and changed or renewed by MD every 24 hours.
An interview with staff # 20 confirmed that she had 2 patients that she was watching on a 1:1. Staff #20 confirmed most of the patients she has on 1:1 are confused or high fall risks. Staff #20 confirmed two patients on a 1:1 was difficult. If one patient needed to go to the bathroom she would not be able to go right away until another employee could monitor the second patient. Staff #20 confirmed that the patients are awakened early in the mornings and brought to the quiet room. The quiet room had recliners and Geri chairs all along the walls. The patients stay in the quiet room unless they are in group or seeing the physician. The patients on 1:1s are not taken to their rooms to rest. If they need to rest they are laid back into the recliners or geri chairs. The patients are put back to bed after the 7:00 PM shift comes on. Staff#20 also confirmed that if a patient needed to be secluded or restrained it was always in the patients' room.
An interview was conducted on 3/18/2014 with staff #1. Staff #1 revealed she was aware that the definition of a 1:1 means 1 employee to 1 patient. However, most of the MHTs have 2 patients to care for. Staff #1 stated, "The mental health technicians (MHT) have to be aware that the patients are at a high fall risk. The patients are placed on 1:1s so the MHT will stay with the patients and be more observant. They don't get paid very much. If we don't put them on 1:1s then we ended up having too many falls."
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they do not fall. A patient had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. The patient struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed. Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #12's chart revealed two "Now Order for Involuntary Emergency Administration of Psychoactive Medication" order forms. Patient #12 was administered Haldol 1 mg IM x 1 dose now on 3/8/14 at 8:05 PM and 3/13/14 at 10:30 PM for aggressive behavior.
Staff #1 was questioned on 3/18/14 about restraints. Staff #1 stated we don't do those here. Staff #1 denied any behavioral restraints were used. Staff #1 stated, "We do use chemical restraint as a last intervention. " Review of the restraint log was blank. Staff #1 confirmed that she did not enter chemical restraints in the restraint log.
Interview with staff #3 reported there had been patient holds for chemical restraints. Staff #3 stated, "to be honest we have not written the holds because we cannot get the doctors up here to do the face to face."
Review of patient #21's chart revealed the patient was an 86 year old male admitted to the facility on 3/7/14 for Dementia, Alzheimer's type, with behavioral disturbances.
Patient #21's chart revealed an admission order on 3/7/14. An order was written to place patient #21 on a Level 2 monitoring level (close observation within eyesight at all times.) Patient #21 was changed to a Level 1 (constant monitoring within 6 feet while awake, and at doorway when asleep.) Review of the Physician Order for Monitoring check sheet had the date as 3/12/14, level 1 for falls, aggression, aspirations, staff #4's initials, and an RN's signature. The order does not have an end time, date, what behaviors caused the level increase, and what behaviors patient #21 needs to exhibit to be removed from the 1:1.
Patient #21 was found in a geri chair laid back in the quiet room on 3/18/14 at 2:00pm. Staff #20 was in the room with the patient as his 1:1 along with 4 other patients. Patient #21 requested from the surveyor to help him. Patient #21 requested help to go to bed. Patient #21 made several attempts to get out of the chair but was unable to sit up.
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they would not fall. Patient #21 had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. Patient #21 struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed.
Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #21's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient is up in a geri chair or recliner without the ability to move freely on his own.
3/6/14- admitted at 5:15 PM- to bed at 9:15 PM for a total of 4 hours in a chair.
3/7/14 up to chair at 5:45 AM- to bed at 8:45 PM. Patient back up to chair at 11:00 PM for a total of 15 hours in a chair.
3/8/14 -11:00pm on (3/7). Patient back to room at 8:30 PM for a total of 21.5 hours in a chair.
3/9/14- up at 6:00 AM- to bed at 6:00 PM for a total of 12 hours in a chair.
3/10/14- up at 2:45 AM- to bed at 8:30 PM for a total of 18.5 hours in a chair.
3/11/14 up at 6:15 AM- to bed at 8:15 PM for a total of 14 hours in a chair.
3/12/14 up at 6:30 AM- to bed at 8:45 PM for a total of 14.25 hours in a chair.
Staff #20 and #26 confirmed that this would be a normal day for the patients. If the patients were tired they could sleep in the chairs.

Review of patient #10's chart revealed the patient was an 83 year old male admitted on 3/7/14 with a diagnosis of Major Depressive Disorder. Review of Patient #10's admission physician orders revealed that the patient was placed on a level 1 monitoring level (constant monitoring within 6 feet while awake, and at doorway when asleep) for falls. Nurse's notes dated 3/7/14 at 7:00 PM states, "will continue to monitor on level 2 precautions." There was no order or nursing documentation that the physician was notified and the precaution levels were lowered.
Review of patient #10's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient was up in a geri chair or recliner without the ability to move freely on his own. Surveyor observed patient #10 in a geri chair and the patient was leaned back. The patient demonstrated that he was not able to get out of the chair on his own.
3/8/14 up to chair at 12:30 AM- to bed at 8:15 PM for a total of 20.45 hours.
3/9/14 up to chair at 6:15 AM- to bed at 6:15 PM for a total of 12 hours.
3/10/14 up to chair at 6:15 AM- to bed at 9:00 PM for a total of 15 hrs.
3/11/14 up to chair at 6:15 AM- to bed at 8:30 PM for a total of 14 hours.
3/12/14 up to chair at 6:15 AM- to bed at 9:45 PM for a total of 17 hours.

On 3/11/2014 during the morning tour of the inpatient treatment unit the following was observed:

Twenty (20) bed room doors were observed with three (3) hinges. The hinges located at the top, middle and bottom of the door with space between provided a potential for ligature risk.

Twenty-two (22) beds located within the patient bed rooms had a 4 foot electrical cord that was plugged into the electrical outlet in the wall. This provided a potential ligature risk.

Twenty-two (22) windows were observed with "Venetian" type blinds. The blinds had draw strings on the left side of the blinds that provided a potential ligature risk.

Each patient bed room had a bathroom with a shower. The shower curtain was suspended on a spring loaded tension rod. The shower rod was easily removed and could be used as a weapon by a patient.

A ground level seclusion room was noted to have a window with a crank handle. The crank handle had been removed. The window was not closed securely and the ground was visible from the window. The window moved when pressure was pushed against it and could have been pushed out. The above observations were confirmed by staff #3.

On 3/12/2014 in the afternoon interview with staff #1 confirmed the beds on the inpatient psychiatric treatment unit were electrically powered beds. She also revealed the patient beds were moved from the obstetrical unit to the inpatient psychiatrics treatment unit because they were a higher quality bed. Each electric cord was supposed to be secured with a zip tie to a length of 16 inches to eliminate the ligature risk, however as beds had been moved the zip ties had been broken and no staff had recognized the danger and reported the cords to maintenance.

Based on record review and interviews the facility failed to protect the patients from the unnecessary use of restraint and seclusion for falls, document and log patient holds to administer psychotropic medications, and follow physician orders in 3(#12, 10, and 21) of 20 (#1-20) charts reviewed.

Review of patient #12's chart revealed that she was a 91 year old female admitted on 3/6/2014. Review of the psychiatric evaluation dated 3/10/2014, staff #4 documented, " was sent to us due to increasing confusion, hallucinations, and agitation. The patient was agitated and combative at the nursing home. Patient made suicidal statements at the nursing home. The patient presents to the hospital with a urinary tract infection. Diagnostic impression: Axis I Delirium secondary to general medical condition, due to urinary tract infection. Rule out dementia, Alzheimer's type, with behavioral disturbances.
Review of the physician orders for admission on 3/7/14 revealed the patient was put on a level one monitoring level. Review of Policy and procedure "Patient Monitoring and Precautions Policy #: 6O51" defined the 3 monitoring levels:
"A. Level I: constant monitoring within 6 feet distance (arms reach). No more than two level I patients are assigned to an individual technician to monitor.
B. Level II: constant monitoring within 20 feet distance, line of sight.
C. Level Ill: close monitoring every 15 minutes. Within a distance of 40 feet or less."
Review of patient #12's chart revealed a physicians' order for level I monitoring. The sheet had the definition of a level one, two, and three monitoring system and columns. The columns listed where date, time, level, precaution orders/level of justification, MD signature, and RN signature.
Patient #12 was placed on a level one for "falls" from 3/14-3/18/2014. The definition on the "Physician order for monitoring" of a level one is as follows:
"LEVEL 1- patient is an extreme danger to themselves or others and requires 1:1 constant monitoring within arm's reach while awake, and from doorway of patient's room while asleep. Patient is never more than six feet away from the staff while awake at all times. Patient is accompanied by staff at all times including bathing, showering, shaving, and toileting. Order must be reviewed and changed or renewed by MD every 24 hours.
An interview with staff # 20 confirmed that she had 2 patients that she was watching on a 1:1. Staff #20 confirmed most of the patients she has on 1:1 are confused or high fall risks. Staff #20 confirmed two patients on a 1:1 was difficult. If one patient needed to go to the bathroom she would not be able to go right away until another employee could monitor the second patient. Staff #20 confirmed that the patients are awakened early in the mornings and brought to the quiet room. The quiet room had recliners and Geri chairs all along the walls. The patients stay in the quiet room unless they are in group or seeing the physician. The patients on 1:1s are not taken to their rooms to rest. If they need to rest they are laid back into the recliners or geri chairs. The patients are put back to bed after the 7:00 PM shift comes on. Staff#20 also confirmed that if a patient needed to be secluded or restrained it was always in the patients' room.
An interview was conducted on 3/18/2014 with staff #1. Staff #1 revealed she was aware that the definition of a 1:1 means 1 employee to 1 patient. However, most of the MHTs have 2 patients to care for. Staff #1 stated, "The mental health technicians (MHT) have to be aware that the patients are at a high fall risk. The patients are placed on 1:1s so the MHT will stay with the patients and be more observant. They don't get paid very much. If we don't put them on 1:1s then we ended up having too many falls."
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they do not fall. A patient had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. The patient struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed. Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #12's chart revealed two "Now Order for Involuntary Emergency Administration of Psychoactive Medication" order forms. Patient #12 was administered Haldol 1 mg IM x 1 dose now on 3/8/14 at 8:05 PM and 3/13/14 at 10:30 PM for aggressive behavior.
Staff #1 was questioned on 3/18/14 about restraints. Staff #1 stated we don't do those here. Staff #1 denied any behavioral restraints were used. Staff #1 stated, "We do use chemical restraint as a last intervention. " Review of the restraint log was blank. Staff #1 confirmed that she did not enter chemical restraints in the restraint log.
Interview with staff #3 reported there had been patient holds for chemical restraints. Staff #3 stated, "to be honest we have not written the holds because we cannot get the doctors up here to do the face to face."
Review of patient #21's chart revealed the patient was an 86 year old male admitted to the facility on 3/7/14 for Dementia, Alzheimer's type, with behavioral disturbances.
Patient #21's chart revealed an admission order on 3/7/14. An order was written to place patient #21 on a Level 2 monitoring level (close observation within eyesight at all times.) Patient #21 was changed to a Level 1 (constant monitoring within 6 feet while awake, and at doorway when asleep.) Review of the Physician Order for Monitoring check sheet had the date as 3/12/14, level 1 for falls, aggression, aspirations, staff #4's initials, and an RN's signature. The order does not have an end time, date, what behaviors caused the level increase, and what behaviors patient #21 needs to exhibit to be removed from the 1:1.
Patient #21 was found in a geri chair laid back in the quiet room on 3/18/14 at 2:00pm. Staff #20 was in the room with the patient as his 1:1 along with 4 other patients. Patient #21 requested from the surveyor to help him. Patient #21 requested help to go to bed. Patient #21 made several attempts to get out of the chair but was unable to sit up.
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they would not fall. Patient #21 had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. Patient #21 struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed.
Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #21's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient is up in a geri chair or recliner without the ability to move freely on his own.
3/6/14- admitted at 5:15 PM- to bed at 9:15 PM for a total of 4 hours in a chair.
3/7/14 up to chair at 5:45 AM- to bed at 8:45 PM. Patient back up to chair at 11:00 PM for a total of 15 hours in a chair.
3/8/14 -11:00pm on (3/7). Patient back to room at 8:30 PM for a total of 21.5 hours in a chair.
3/9/14- up at 6:00 AM- to bed at 6:00 PM for a total of 12 hours in a chair.
3/10/14- up at 2:45 AM- to bed at 8:30 PM for a total of 18.5 hours in a chair.
3/11/14 up at 6:15 AM- to bed at 8:15 PM for a total of 14 hours in a chair.
3/12/14 up at 6:30 AM- to bed at 8:45 PM for a total of 14.25 hours in a chair.
Staff #20 and #26 confirmed that this would be a normal day for the patients. If the patients were tired they could sleep in the chairs.

Review of patient #10's chart revealed the patient was an 83 year old male admitted on 3/7/14 with a diagnosis of Major Depressive Disorder. Review of Patient #10's admission physician orders revealed that the patient was placed on a level 1 monitoring level (constant monitoring within 6 feet while awake, and at doorway when asleep) for falls. Nurse's notes dated 3/7/14 at 7:00 PM states, "will continue to monitor on level 2 precautions." There was no order or nursing documentation that the physician was notified and the precaution levels were lowered.
Review of patient #10's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient was up in a geri chair or recliner without the ability to move freely on his own. Surveyor observed patient #10 in a geri chair and the patient was leaned back. The patient demonstrated that he was not able to get out of the chair on his own.
3/8/14 up to chair at 12:30 AM- to bed at 8:15 PM for a total of 20.45 hours.
3/9/14 up to chair at 6:15 AM- to bed at 6:15 PM for a total of 12 hours.
3/10/14 up to chair at 6:15 AM- to bed at 9:00 PM for a total of 15 hrs.
3/11/14 up to chair at 6:15 AM- to bed at 8:30 PM for a total of 14 hours.
3/12/14 up to chair at 6:15 AM- to bed at 9:45 PM for a total of 17 hours.

Based on record review and interview the facility failed to ensure the documentation per the Registered Nurse (RN) on the patient Admission Assessment was complete. Citing 7 of 30 patient medical records reviewed. (Patients #1, 3, 4, 6, 8, 9, and 18).

Findings include:
Review of patient medical records on 3/18/2014 and 3/19/2014 revealed the following:

1. Patient medical record #1- no documentation of nutritional assessment on RN Admission Assessment found.
2. Patient medical record #3- no documentation of nutritional assessment on RN Admission Assessment found.
3. Patient medical record #4- no documentation of nutritional assessment on RN Admission Assessment found.
5. Patient medical record #6- no documentation of nutritional assessment on RN Admission Assessment found.
6. Patient medical record #8- no documentation of nutritional assessment on RN Admission Assessment found.
7. Patient medical record #9- no documentation of nutritional assessment on RN Admission Assessment found.
10. Patient medical record #18- no documentation of nutritional assessment on RN Admission Assessment found.

Interview with staff #1 on 3/19/2014 at 11:45 in the conference room confirmed the findings.

Based on record review and interview the facility failed to ensure the patients admitted for care received a nutritional assessment by Registered Nurse (RN) and/or Registered Dietitian. Citing 10 of 30 patient medical record reviewed.(Patient's #1, 3, 4, 5, 6, 8, 9, 14, 15, and 18).

Findings include:
Review of patient medical records on 3/18/2014 and 3/19/2014 in the conference room revealed the following:
1. Patient medical record #1- no documentation of nutritional assessment on RN Admission Assessment found.
2. Patient medical record #3- no documentation of nutritional assessment on RN Admission Assessment found.
3. Patient medical record #4- no documentation of nutritional assessment on RN Admission Assessment found.
4. Patient medical record #5- Documentation on Admission Assessment per RN revealed high risk condition and need for nutritional assessment by dietitian. No documentation of Dietitian referral found.
5. Patient medical record #6- no documentation of nutritional assessment on RN Admission Assessment found.
6. Patient medical record #8- no documentation of nutritional assessment on RN Admission Assessment found.
7. Patient medical record #9- no documentation of nutritional assessment on RN Admission Assessment found.
8. Patient medical record #14- Dietary consult ordered on 2/25/2014 per physician. No documentation of dietary consult per dietitian found.
9. Patient medical record #15- Dietary consult ordered on 2/26/2014 per physician. No documentation that referral was sent to dietitian found.
10. Patient medical record #18- no documentation of nutritional assessment on RN Admission Assessment found.

Review of Policy and Procedure Manual on 3/18/2014 revealed to following:
Policy #2- Nutritional Screening Date of Origin: 12/20/2007 Revision: 6/11/2008
Administrative Approval: 6/11/2008
Policy: All patients who are admitted will be screened for nutritional risks within 72 hours.
Procedure: The dietitian screens all patients admitted within 72 hours to determine if the patient is at any nutritional risks.
Intervention is taken as deemed necessary based on accepted dietetic practices.

Interview with staff #1 and #12 confirmed the findings on 3/18/2014 at 1:00 pm.

Based on observation, interview and document review the facility failed to provide a safe well maintained environment for all patient's, staff and visitors.

On 3/11/2014 at 9:30 AM while touring the main campus the following observations were made:

The basement level dining room was observed with green linoleum that was split in several location exposing 1-2 inches of the surface below. These areas of split floor were lifted up creating a tripping hazard.

Also in the basement level was the dietary department. The entire kitchen area had a tiled floor. The floor tiles had been painted. The paint was not intact and could be seen peeling from the high traffic areas of the kitchen. Observed in the kitchen was wooden shelving with white paint. The shelf surfaces exhibited broken areas of the paint and tears in the wood surface that rendered then unable to be sanitized. Observed at the back of the stove was coiled tubing for the gas lines. These were covered with a thick greasy substance and the immediate area smelled of natural gas. Beneath a cloth cover, an old floor mounted metal stand type mixer was observed. Removal of the cover revealed the mixers metal surface was peeling away leaving the mixer unable to be sanitized.
Also in the dry goods pantry, two (2) working motors which were the cooling mechanism for the freezers and refrigerators were observed covered with a dark sticky substance. There was approximately six (6) feet separating the motors from the shelves. The shelves held paper goods, cleaning supplies and canned goods.

The Central Purchasing department was observed to not have a protective ceiling above the supplies. Supplies stored in this area were patient use items that were clean and packaged to be sanitized until opened. The ceiling was observed to be open to the air conditioning ducts and all supplies were exposed to the sprayed on ceiling insulation. The floor in the central purchasing supply area was bare concrete with no sealant. Cracks were visible in the floor. Supplies entered the storage area via a three (3) bay loading/unloading dock. Staff #15 confirmed that when the supplies were delivered, the bay doors were opened and unloaded from the trucks, exposing all centrally stored supplies to the outside dust and wind. The loading docks were separated from the supplies only by the bay doors.

During the tour of the facility's second floor, the second floor was observed to be empty of patients and staff. However, the floor contained the patient Emergency Treatment room. The nurses station had a crash cart and the patient rooms had beds. The employee break room was observed with a functioning refrigerator which needed cleaning. The surface of the floor was dusty and did not appear as though housekeeping had entered the floor.

During the tour of the outside portion of the grounds two (2) dumpsters were observed with loose garbage and white bags of trash behind the dumpster's, lining the concrete walls the two dumpster's sat against. This posed a hazard to attract varmints, rodents and increased the unsanitary conditions.

During a tour of the off campus outpatient treatment center, the carpet was observed to be heavily soiled with dark black areas which could not be cleaned of the stains. The walls were chipped at the corners and a fist size hole was observed in the bathroom wall. The walls themselves were scratched, discolored and streaked with black, 3 feet high. Six to eight (6-8), 2 x 4 inch pieces of carpet was observed removed from a carpeted treatment room. The concrete was exposed. Staff #18 confirmed a wall had been removed and the holes in the carpet had been left exposing the concrete.

Based on observation, interview and document review the facility failed to insure 1 of 2 outpatient treatment centers and 2 of 3 buses were safe from fire hazards.

On 3/12/2014 at 9:00 AM a tour of the off campus outpatient treatment center revealed the following: The building was not equipped with an inside sprinkler system. When questioned regarding the frequency of fire drills, staff #18 replied "The Maintenance Director had them."

On 3/12/2014 at 1:00 PM the fire drills supplied by the Maintenance Director were reviewed and revealed no fire drills were identified for the past 12 months for the off campus outpatient treatment center.

On 3/12/2014 at 10:30 AM a tour of facility buses was conducted. Three (3) buses were on campus, two (2) were observed with fire extinguishers that were not secured. Both fire extinguishers were visible on the floor behind the drivers seat. Upon closer inspection neither fire extinguisher had a safety inspection tag.

On 3/12/2014 at 11:30 AM staff #1 confirmed the Maintenance Director was responsible to keep the fire extinguishers current on safety checks. He was also responsible to keep the fire extinguisher secured in such a fashion as not to be rolling around on the floor.

Based on observation, interview and document review the facility failed to follow its policy for sanitary disposal of garbage in 2 of 2 dumpsters observed.

On 3/11/2014 during the morning tour of the outside grounds, two (2) dumpsters were observed with loose garbage and bags of trash around the dumpsters, lining the concrete walls the two dumpsters sat against. One of the dumpsters did not have a lid to secure trash from blowing out or keep varmints from rummaging through the garbage. This posed a hazard to attract varmints, rodents and increased the risk of unsanitary conditions.

On 3/11/2014 at 11:30 AM an interview with the Maintenance Director confirmed the staff had tossed sacked garbage at the dumpsters. Some of the bags were broken allowing loose trash and bagged trash to be trapped behind the dumpster's. He also confirmed the lid was not present on one of the dumpsters.

On 3/11/2014 in the conference room the policy for collection and disposal of facility trash was reviewed and revealed the housekeeping staff was responsible to collect the trash during their shift and deposit the trash in the dumpsters.

Based on observation, interview and document review the facility failed to include infection control risks in 4 (dietary, housekeeping/garbage collection, outpatient, and nursing) of 8 departments ( laundry, laboratory, radiology, Emergency Services) represented in the Quality Assessment and Process Improvement for the facility.

On 3/11/2014 at 2:00 PM the Infection Control program was reviewed and revealed, findings of environmental rounds were not incorporated into the Quality Assessment Process Improvement (QAPI) portion of the program and not identified as infection control risks. A review of the data by department revealed:

The sanitation issues of the dietary department were not addressed in the QAPI. In 3/11/2014 interview with the Dietary Supervisor confirmed environmental rounds were being completed and the findings were being submitted to the QAPI committee. Observations of the tour of the kitchen revealed the following:
The dish washer was rated as a warm temperature sanitation machine. The sanitation liquid was rated for hot temperature sanitation. The storage rack used to hang utensils ( large spoons, ladles, whisks etc) had visible rust on it. The rack was empty of utensils awaiting repainting and the utensils were stacked in a bin rather than hung from the rack. The bin was not covered. Metal baking pans were observed with heavy carbon build up making them improbable to sanitize. The freezer was observed with 6-7 shipping boxes containing frozen foods stored on wire racks next to un boxed frozen foods. Plumbing fixtures beneath the sinks were visibly dirty. The stainless steel carts had porous surfaces indicating their age and making them unlikely for sanitation. All the legs of the stainless steel prep tables were damaged. The filter of the ice machine was white with lint and dust. The surface of wooden shelves were identified with dust, visible stains and chipped paint making them not easily sanitized. The mechanical area where the freezer and refrigerator motors were located was open to the surrounding storage of dry goods (paper goods, cleaning supplies and can goods) for the hospital. The gas oven was observed with a build up of a thick greasy substance and lint on the metal coils. The floor tiles were stained at the wall base around the entire perimeter of the floor.

The sanitation issues of the garbage collection and storage areas were not addressed in the QAPI. They revealed the following:

On 3/11/2014 during the tour of the outside grounds, two (2) dumpster's were observed with loose garbage and white bags of trash which was trapped behind the dumpster's, lining the concrete walls the two dumpster's sat against. One of the dumpster's did not have a lid to secure trash from blowing out or keep varmints from rummaging through the garbage. This posed a hazard to attract varmints, rodents and increased the unsanitary conditions.

On 3/11/2014 at 11:30 AM an interview with the Maintenance Director confirmed the staff had tossed sacked garbage at the dumpster's. Some of the bags were broken allowing loose trash and bagged trash to be trapped behind the dumpsters.

On 3/11/2014 in the conference room the policy for collection and disposal of facility trash was reviewed and revealed the housekeeping staff was responsible to collect the trash during their shift and deposit the trash in the dumpsters.

The sanitation issues of the Outpatient Treatment (OpT) center was not addressed in the facility QAPI program. The observations from the tour of the OpT Center revealed the following:

During a tour of the off campus outpatient treatment center, the carpet was observed to be heavily soiled with dark black spots which could not be cleaned of the stains. The walls were chipped at the corners and a fist size hole was observed in the bathroom wall. The walls themselves were scratched, discolored and streaked with black, three (30 feet high. Six to eight (6-8), 2 x 4 inch pieces of carpet was observed removed from a carpeted treatment room. The concrete was exposed. Staff #18 confirmed a wall had been removed for space and the holes in the carpet had been left exposing the concrete. The patient meals were catered to the facility and the patient ate there meals in one of the heavily stained carpeted areas. Staff #18 confirmed the patient's drinks were prepared in the in the kitchen area. The kitchen was very small, visible stains were present on the refrigerator and cabinet doors. Observed in the refrigerator was a plastic pitcher having visible stains, which contained a brown liquid. There was no date on the container to identify the age of the liquid.

On 3/13/2014 in the afternoon, during a tour of the inpatient unit, the common shower area was observed to have a plastic box of hygiene items resting on the counter. Staff #13 confirmed the items were used to meet hygiene needs after showers. The single use items included, tooth paste, roll on deodorant and mouth wash. These small containers were not identified by patient. They were not separated used or unused. There was no method identified to determine if one or more patients had used the single use containers. By weight alone some bottles were lighter than others. Staff #13 confirmed she could not tell which had been used and which had not been used by a patient.