Holly Hill Mental Health Services was cited by the Centers for Medicare and Medicaid Services (CMS) for deficiencies with the supervision of its nursing care. CMS found that the facility failed to ensure that its nursing staff followed physician’s orders for obtaining urine drug screenings (UDS) from three patients in a timely manner. An interview with the nursing administration revealed that routine UDS should be collected within 24 hours following the order, but one patient’s UDS was not collected by the lab service until more than 43 hours after the initial order. The interview further revealed that “current policy does not clearly define time frames for “routine” and “stat” labs from time of order to time of actual collection by nursing staff” and that “procedures vary from unit to unit.”
CMS also found that the facility failed to follow policy and procedures to ensure that its plant operations department was immediately notified of malfunctioning equipment. CMS surveyors observed that there was a malfunctioning Automated External Defibrillator (AED)/AED battery stored on the emergency code cart in the outpatient partial hospitalization (PHP) building. The CMS surveyor later found that the AED was the only one available for use in the entire outpatient PHP building and that “If an AED was needed for an emergency, one would have to be brought over to the PHP building from the main hospital across the street.”
CMS also cited the facility for deficiencies with the competency of its dietary staff. CMS found that the “hospital’s dietary staff failed to carry out their respective duties in a competent manner” and as a result, failed to ensure food safety and sanitation. For example, the facility failed to ensure that foods were stored in a safe and sanitary manner in the refrigerator and kitchenware/cookware was sanitized and stored in a sanitary manner.
As a result of CMS’ findings, the facility had to submit a plan of correction to address its cited deficiencies and deficient practices.