HospitalInspections.org

Based on document review and interview, the Director of Dietary Services failed to supervise on-duty personnel (SP-4, Dietary staff member) for possible intoxication.

Findings include:

1) Policy titled, "HR015-Substance-Free Workplace," last revised, 01/2024, signed by SP-9, read under paragraph titled, "Policy" on page one of five, "...employees are required to report to work in an appropriate mental and physical condition so they may perform their jobs in a satisfactory manner...It is the Company's policy to conduct drug testing on all prospective and current employees for purposes of pre-employment screening, post-accident investigation, random testing, and reasonable suspicion testing..." Under paragraph titled, "Reasonable Suspicion" on page three of five, read, "...A member of management may request a drug test when there is a documented 'reasonable suspicion' that an employee is impaired or incapable of performing assigned duties as shown by factors including: Observable phenomena, such as physical symptoms or manifestations of being under the influence of a drug or alcohol at work; Abnormal conduct or erratic behavior at work; A significant deterioration in work performance...We require two (2) or more individuals (at least one person at a supervisory level) to observe and document these types of 'reasonable suspicion' behaviors...The evidence of reasonable suspicion will be presented to Human Resources who will conduct any investigation deemed necessary before sending the employee to be tested..."

2) Review of three of three witness statements indicated the following:

a) Statement #1, documented and signed by SP-3 (Behavioral Health Aide) on March 30, 2025 at 10:40 am, read "I found SP-4 (Dietary Staff Member) looking lost in the hall and peering through windows. I asked what she/he was looking for and she/he said Ibuprofen. She/he said she/he had some in her/his car and when I asked where her/his car was parked, she/he said she/he didn't know. I walked with her/him back to the kitchen where SP-6 (Head Cook) was. SP-6 and I asked if she/he was okay and she/he stated yes. I told her/him she/he didn't look well and then SP-6 offered her/him the option of going home if she/he wasn't' feeling well. She/he stated she/he had been throwing up on her/his way in to work. I asked if she/he would be okay to drive and she/he said yes but then said she/he was given a ride here. I asked if she/he wanted me to call her/him a transportation company and she/he said 'no I can drive.' Throughout entire interaction she/he appeared very disoriented and confused with delayed responses." This statement was also signed on 3/30/25 by SP-5 (Director of Risk Management).

b) Statement #2, documented and signed by SP-7 (House Supervisor) on 3/30/25 at 7:45 am, read "Writer received a message...telling me to check on the dietary aid. Writer went to cafeteria where tech stated that they were concerned that she/he was either under the influence or something was really wrong with her/him. Writer went in to talk with aid and she/he was trying to unlock one of the doors in the kitchen and could not get the key in the door knob. Writer asked her/him if she/he was ok and she/he offered me some food. I explained that I was there checking on her/him and that I did not want any food but thank you. She/he again asked if I wanted something to eat. Writer again told her/him no that I was just checking in to see if they needed anything this morning. She/he said 'Can I get you a muffin or something else to eat' Writer told her/him no. During conversation she/he was slurring her/his words and appeared unsteady and kept leaning on her/his elbows on the prep area." This statement was also signed on 3/30/25 by SP-5 (Director of Risk Management).

c) Statement #3, documented and signed by SP-5 (Director of Risk Management) on 3/30/25 at 11:00 am, read "SP-7 spoke to writer about concerns w/dietary staff 'SP-4.' SP-7 stated staff thought SP-4 intoxicated. Writer asked how they know that. SP-7 reported staff stated she/he was belligerent and either appeared to be intoxicated or 'very ill.' ...SP-7 stated "...SP-4 kept repeating herself/himself and not making sense..." "...Writer went to dietary. SP-4 was stuttering her/his words and her/his speech was pressure delayed. She/he asked who I was and gave her/him my name and title. She/he introduced herself/himself to me and fumbled with her/his name badge..."

3) In interview on 3/30/25 at 9:40 am with SP-3 (Health Aide), indicated the following:

(i) SP-3 confirmed they authored Statement #1 above and signed/dated the document (as indicated above) and confirmed the findings.

(ii) SP-3 also stated, "I am a behavioral health tech and have been here two and a half years. SP-4 is one of the cooks. I was notified by our house supervisor, SP-7, and let me know SP-4 appeared to be intoxicated and belligerent with the adolescent patients and that she/he was trying to contact the dietary manager, SP-2, and the Director of Risk, SP5."

4) In interview on 3/30/25 at 10:10 am with SP-7 (House Supervisor), indicated the following:

(i) SP-7 confirmed they authored Statement #1 above and signed/dated the document (as indicated above) and confirmed the findings.

(ii) SP-7 also stated, "I am the house supervisor, RN (Registered Nurse), and I was the house supervisor on March 30, 2025. I have been here for almost 2 years... I went down to the cafeteria and saw her/him messing with the condiments counter and asked her/him if she/he was ok, she/he said she/he was fine. I could not smell anything on her/his breath, but she/he had an unsteady gait when walking around the cafeteria area...I saw SP-6 come in to work and I explained the staff member's behavior and she/he said, she/he couldn't smell anything on her/him. I filled out a witness statement and gave it to SP-5 that same day."

5) In interview on 3/30/25 at 10:39 am with SP-5 (Director of Risk), indicated the following:

(i) SP-5 confirmed she authored, signed, and dated a copy of the written statement that was given to the surveyor on 5/13/25 and that she/he still agreed with everything she/he documented.

(ii) SP-5 also stated, "I am the Director of Risk and have been here for 20 months. SP-7 approached me and said, they had some concerns about an employee in the dietary area, named SP-4. SP-7 and SP-3 indicated, they thought she/he was under the influence of alcohol and I asked them how they came to that suspicion, SP-3 indicated, she/he was slurring her/his words and had short memory recall...I went down to dietary and spoke to SP-4, around 10:30-11:00 am...Shehe slurred her/his words a little bit...I then called the Director of Human Resources (SP-8) and let them know the staffs' concerns and what I had observed..."

6) In interview on 3/30/25 at 10:59 am with SP-8 (HR Manager), indicated the following: "I am the Director of HR and have been here for 1 yr. I received a phone call from SP-5 in the afternoon who told me, that SP-4 wasn't answering questions properly...I told her/him to get witness statements. I was off that day and didn't receive the witness statements until the next day."

7) In interview on 3/30/25 at various different interview times (see above); SP-3, SP-7, SP-5, and SP-8 all indicated through written or verbal statements that SP-4 was not in a competent state of mind and they failed to follow company policy.