HospitalInspections.org

Based on observation, record review, and staff interview the CAH (Critical Access Hospital failed to maintain a clean and sanitary environment in the Dietary Department.

Failure to maintain a clean and sanitary environment in the Dietary Department could potentially result in an outbreak of food borne illness.

An observation on 04/27/10 at 9:00 AM, revealed the following:
1. Carbon build-up present on the grill back splash of the stove and on the
side back splash of the burner surface.
2. Carbon build-up present on the stainless steel cooking surface of the
stove ' s broiler.
3. Four ? sheet pans with carbon build-up present on the cooking surface.
4. The range hood with a greasy brown lint build-up present on the surface.
Presence of carbon build-up renders the surfaces unable to be sanitized.

A review of the policy/procedure manual for dietary revealed a policy titled, " Dietary Infection Control Policy " , dated 01/19/10 that stated in part ... " Purpose: Maintain an environment free from harmful bacteria by applying hygienic principles in the receiving, storage, preparation and serving of food " . The CAH lacked a policy/procedure for the cleaning of the range hood.

An interview on 04/27/10 at 9:00 AM, with the Dietary Manager acknowledged the carbon build-up on the various surfaces. The Dietary Manager implied that the maintenance department cleans the range hood twice a year.

Based on policy review, document review, and staff interviews, the Critical Access Hospital
Administrative staff failed to ensure the Activity Coordinator developed and documented activity goals in the care plan for 5 of 5 open (#1, 2, 3, 4, and 5) and 4 of 5 closed skilled records reviewed (#6, 7, 8, and 9). The hospital reported a census of five patients.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient has the potential to impede the physical and psychological well being of each patient.

Findings include:

1. Review of Central Community Hospital (CCH) Skilled Nursing Care Policy titled "Activity Program" approved 9/15/09 stated " CCH will provide an ongoing program of activities appropriate to the needs and interests of the patient, that encourage self care, resumption of normal activities, and maintenance of an optimal level of psycho-social functioning while considering the well being of each patient. The Activity Program will be created within the context of the assessment; it will be multifaceted; and it will reflect individual needs."

2. Review of Central Community Hospital (CCH) Skilled Nursing Care Policy titled "Comprehensive Assessment" approved 9/15/09 stated " CCH will conduct, initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each swing bed patients capability to perform daily life functions and significant impairments in functional capacity. The results of the assessment are used to develop, review, and revise the comprehensive plan and to provide the appropriate care and services for each patient. The information in the assessment enable facility staff to plan care that allows the patient to reach his/her highest practicable level of physical, mental, and psychosocial functioning. The assessment includes: ... Activity pursuit ... Documentation of summary information regarding additional assessments performed. CCH must develop a comprehensive plan of care for each patient admitted to Swing Bed. This includes objectives and timetables to meet a patient's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must be developed within 7 days of completion of the admission assessment."

3. Review of the open medical record for Patient #1, admitted to the skilled unit on 4/10/10, revealed the activity assessment completed on 4/10/10 at 9:42 AM. Review of the chart also revealed the Comprehensive Care Plan initiated on 4/15/10 and reviewed on 4/16/10, 4/17/10, 4/18/10, 4/19/10, and 4/27/10 revealed no activity goal.

4. Review of the open medical record for Patient #2, admitted to the skilled unit on 3/26/10, revealed the activity assessment completed on 3/27/10 at 11:31 AM. Review of the chart also revealed the Comprehensive Care Plan initiated on 4/20/10 and reviewed on 4/21/10, 4/22/10, 4/23/10, 4/22/10, and 4/27/10 revealed no activity goal.

5. Review of the open medical record for Patient #3, admitted to the skilled unit on 4/5/10, revealed the activity assessment completed on 4/7/10 at 11:33 AM. Review of the chart also revealed the Comprehensive Care Plan initiated on 4/5/10 and reviewed on 4/8/10, 4/10/10, 4/11/10, 4/15/10, 4/19/10, 4/20/10, 4/22/10, 4/23/10, 4/24/10, 4/26/10, and 4/27/10 revealed no activity goal.

6. Review of the open medical record for Patient #4, admitted to the skilled unit on 4/23/10, revealed the activity assessment completed on 4/24/10 at 9:23 AM. Review of the chart also revealed the Comprehensive Care Plan initiated on 4/23/10 and reviewed on 4/24/10, and 4/26/10 revealed no activity goal.

7. Review of the open medical record for Patient #5, admitted to the skilled unit on 4/12/10, revealed the activity assessment completed on 4/14/10 at 7:55 AM. Review of the chart also revealed the Care Plan initiated on 4/13/10 and reviewed on 4/15/10, 4/17/10, 4/18/10, 4/19/10, 4/21/10, 4/22/10, 4/23/10, 4/24/10, and 4/26/10 revealed no activity goal.

8. Review of the closed medical record for Patient #6, admitted to the skilled unit on 2/11/10 and discharged on 2/15/10, revealed the activity assessment completed on 2/14/10 at 7:45 PM. Review of the chart also revealed the Care Plan initiated on 2/13/10 and reviewed on 2/14/10 and 2/15/10 revealed no activity goal.

9. Review of the closed medical record for Patient #7, admitted to the skilled unit on 1/20/10 and discharged on 2/6/10, revealed the activity assessment completed on 1/22/10 at 11:48 AM. Review of the chart also revealed the Care Plan initiated on 1/20/10 and reviewed on 1/21/10 and 1/23/10, 1/24/10, 1/27/10, 1/29/10, 1/30/10, 2/2/10, 2/3/10, 2/4/10, and 2/5/10 revealed no activity goal.

10. Review of the closed medical record for Patient #8, admitted to the skilled unit on 12/26/09 and discharged on 1/7/10, revealed the activity assessment completed on 12/26/09 at 2:18 PM. Review of the chart also revealed the Care Plan initiated on 12/22/09 and reviewed on 12/23/09, and 12/24/09, 12/25/09, 12/26/09, 12/27/09, 12/28/09, 12/29/09, 12/31/09, 1/1/10, 1/2/10, 1/3/10, 1/5/10, 2/2/10, 1/6/10, and 1/7/10 revealed no activity goal.

11. Review of the closed medical record for Patient #9, admitted to the skilled unit on 10/29/09 and discharged on 11/11/09, revealed the activity assessment completed on 10/29/09 at 9:51 PM. Review of the chart also revealed the Care Plan initiated on 10/31/09 and reviewed on 11/1/09, 11/2/09, 11/4/09, 11/5/09, 11/6/09, 11/7/09, 11/8/09, 11/9/09, and 11/10/09 revealed no activity goal.

12. During an interview on 4/26/10 at 3:00 PM, the Director of ED, Utilization, and Discharge Planning stated " The Acclivity Coordinator does not put goals on the Comprehensive Care Plan but attends Care Conferences when able."

12. During an interview on 4/26/10 at 3:15 PM the Activity Coordinator stated "He/She does not address activity goals on the patient's care plans but does chart on the nursing progress notes any activities the patient's do."