HospitalInspections.org

Washington Township Division

Based on observation and interview, it was determined the facility failed to ensure that privacy requirements are met.

Findings include:

Reference: Facility policy titled, "Patient Privacy and Confidentiality" states, " ...every patient has the right to visual and auditory privacy... the patient is provided with a private environment during medical treatment ... "

1. During a tour of off-site facility, The Center for Advance Wound Care and Hyperbaric Oxygen Therapy at Washington Township, on 1/14/15, two patients wearing "johnny coats," were observed side by side receiving treatment in the hyperbaric chambers. Patient #W10, a female patient was in hyperbaric chamber #1 and Patient #W11, a male patient, was in hyperbaric chamber #2.

2. The privacy curtain between Patient #W10 and Patient #W11 was not drawn to give each patient privacy.

3. Staff #W10 and #W52 confirmed the above findings.

Washington Township

Based on review of three quality projects and staff interview, it was determined that the facility failed to complete all interventions as outlined in their project plan, and aggregate the data of all interventions.

Findings include:

1. On 1/15/15, three (3) quality projects were reviewed in the presence of Staff #W1, #W31, #W32, and #W33. A COPD [chronic obstructive pulmonary disease] project initiative, to reduce the re-admissions of patients with COPD, was reviewed. One of the interventions outlined in the project was to complete a follow up telephone call to the patients on discharge day #2, #5, #7, #15, and #30. There was no documented evidence that the data collected for this intervention was aggregated and analyzed to ensure completion of the follow up discharge phone calls as outlined in the project plan.

2. The above was reviewed with and confirmed by Staff #W1.

Cherry Hill Division

Based on document review and staff interview, it was determined that the facility's performance improvement activities failed to aggregate and evaluate the collected data from the preventive actions implemented for all adverse events.

Findings include:

On 1/14/15, three Root Cause Analysis' (RCAs) were reviewed for Performance Improvement (PI) in the presence of Staff #C44. RCA #1 indicated that a needs assessment of patients would be completed bi-weekly for physical therapy consults by the nurse manager of a patient care unit. The facility could not provide documented evidence that this intervention was completed, the data was aggregated, or the data was being reported to a quality committee.

Cherry Hill Division

Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to implement its policy for enteral tube feedings.

Findings include:

Reference: Facility Policy NO: E-4, titled 'Enteral Feedings and Medications via Feeding Tube, Administration of' states, POLICY: It is the policy of the --[facility name]-- to administer enteral feedings and medications via feeding tubes safely, in accordance with the following protocol and procedure. ... SUMMARY OF NURSING ACTIONS: ... Continuous Ready-to-Feed System Change [1st bullet] Tubing ("spike set") - Every 24 hours. ... Change Feeding supplies (flush syringes, water containers, tubing cap, etc.) Every 24 hours ... PROCEDURE: Section 5. Continuous Feeding using the Ready-to-Feed (CLOSED) System ... STEPS ... 2. Label feeding formula container, flush bag and spike set tubing with the patient's name, date/time/nurse's initials, name of feeding formula, ordered rate and expiration date/time, as per label requirements. ... KEY POINTS [2nd box] spike set (tubing) must be changed every 24 hours."

1. On 1/13/15 at 10:30 AM, Unit T-2, a Medical-Surgical Telemetry Unit was toured in the presence of Staff #C14. The following was observed:

a. Patient #C6 was observed in Room #215-1 with Glucerna Tube Feeding via a spike set bottle. A Kangaroo Flush bag for water was also connected to the feeding system.

(i) The Glucerna Tube Feeding bottle did not have a label indicating the patient's name, date/time/nurse's initials, name of feeding formula, ordered rate and expiration date/time. The label on the tubing did not have the date or time indicated. Without indication of the date and time the tube feeding set was initiated, it could not be determined if the feeding was changed every 24 hours, as per policy above.

(ii) The Kangaroo Flush bag was dated and timed "1/11 0030." The flush bag was beyond its 24 hour expiration, as per policy.

(iii) A irrigation set [fluid/water bottle and bulb syringe] on the patient's bedside table was dated "1/11." The irrigation set was beyond its 24 hour expiration, as per policy.

b. Patient #C7 was observed in Room #204-2 with a Jevity Tube Feeding via a spike set bottle. A Kangaroo Flush bag for water was also connected to the feeding system.

(i) The Jevity Tube Feeding bottle did not have a label indicating the patient's name, date/time/nurse's initials, name of feeding formula, ordered rate and expiration date/time. The label on the tubing did not have the date or time indicated. Without indication of the date and time the tube feeding set was initiated, it could not be determined if the feeding was changed every 24 hours, as per policy above.

(ii) There was no date or time indicated on the flush bag or the tubing. Without indication of the date and time the flush bag was initiated, it could not be determined if the bag was within its 24 hour expiration.

2. The above was reviewed with and confirmed by Staff #C14.


34120



Cherry Hill Division

B. Based on medical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to implement its policy for patients that present with risk of harm to themselves or others.

Findings include:

Reference: Facility policy titled "Therapeutic Sitter (1:1) Observation" states, "Definition 1. Therapeutic Sitter: Continuous 1:1 monitoring by a qualified staff member for a patient who presents an imminent or actual threat of harm to themselves and/or others. The patient remains within direct visualization and continuous supervision at all times. Order Requirement 1. Implementing a Therapeutic Sitter requires a physician order by the Licensed Independent Practitioner (LIP)... 3. In an emergent situation, the assigned nurse may initiate a Therapeutic Sitter for continuous observation of a patient in order to maintain safety for the patient and/or others until a formal evaluation can be conducted. The assigned nurse must notify the LIP immediately and obtain a physicians order. Documentation Requirements 1. The The Therapeutic Sitter is responsible for documenting on the Patient Observation Checklist every 15 minutes. ... Procedure 1. The LIP, in collaboration with the RN staff assigned to the patient, determines imminent or actual threat of harm by the patient to themselves and/or others. The behavior(s) may be identified through the following mechanisms: a. Current clinical and/or behavioral assessment b. Medical History c. Patient, staff, and/or family interview d. Current diagnoses e. Current or historical patterns of behavior. 2. When the LIP identifies the need to for 1:1 monitoring, he or she will enter a physician order for Therapeutic Sitter (1:1) in the Clinical Information System (CIS). ... Special Considerations for the Patient Requiring Continuous Monitoring. ... 3. The Therapeutic Sitter must remain with the patient regardless of visitor(s). ... 4. The assigned RN must check the patient's environment and personal belongings for items that could potentially be harmful at the following intervals: a. Upon initiation of 1:1 observation..."

1. In 3 out of 3 medical records reviewed, the following was revealed:

2. Medical Record #C30 revealed that on 11/15/14 at 18:18, the patient was brought to the Emergency Department (ED) with the complaint: "Harm to himself and others."

a. The patient eloped after registration and was brought back to the ED by the police.

b. Nursing documentation at 19:28 states, "patient was escorted to Room #6 by hospital security ... "

c. There was no indication that a qualified 1:1 staff member was initiated by nursing staff or that the LIP was immediately notified to obtain an order.

(i) Staff #C51 confirmed that security personnel is not considered "qualified staff" for 1:1 patient safety observation purposes.

d. At 19:59, ED physician documentation states, "History of Present Illness,"... "pt [patient] threatened to kill the female staff and to kill the Drs taking care of him. ... pt yelling and agitated. ..."

(i) There was no documented evidence that the assigned RN checked the patient's environment and personal belongings for items that could potentially be harmful.

e. On 11/16/14 at 07:30, nursing documentation revealed, "Psych/Social: ... PT. WITH PERIODS OF AGITATION-YELLING."

(i) At 11:35 AM, "Nursing Notes: pt. in room doorway, yelling at group home leader, redirected to stretcher for safety and aware of care plan."

(ii) There was no physician's order for a 1:1 or documentation that the "Patient Observation Checklist" was completed every 15 minutes, as required.

3. Medical Record #C32 revealed that the patient was brought to the ED by the police and his/her mother on 11/21/14 at 01:00 with the complaint: "Pt sts [states] Crisis Suicidal."

a. Triage Notes at 01:00 state, "+HI (homicidal ideation) towards uncle Pt states her uncle touched her leg so she kicked him in the face. Mom reports uncle was trying to get pt to take his/her medication. Pt became agitated ..."

(i) There was no indication that a qualified 1:1 staff member was initiated or that the LIP was immediately notified to obtain a physicians order.

b. At 01:07, nursing documentation states, "Nursing Procedure: Nursing Notes: Pt changed into green scrubs by security" . . .

(i) Staff #C50 verified that patients are changed into scrubs as a precaution if the staff perceives the patient is a risk for eloping. Belongings are also to be checked to ensure the patient did not bring in anything with them that may be harmful.

(ii) There was no evidence that the assigned RN checked the patient's personal belongings for items that could potentially be harmful.

c. At 01:21, Physician documentation states, "History of Present Illness: "... pt states that he/she wants to thoughts [sic] of wanting to hurt self a little and hurt his/her uncle a little. no specific plan. . ." At 01:22 AM, in "Psychiatric: ... Judgement poor, ...Suicidal ideation present, Homicidal ideation present."

(i) There was no physician's order for a 1:1 or documentation that the "Patient Observation Checklist" was completed every 15 minutes, as required.

4. Medical Record #C33 revealed that the patient arrived to the ED on 11/5/14 at 11:15 with the complaint: "Suicidal."

a. Documentation revealed the following in the Triage Notes, "11:15 AM ... pt admits to SI [suicidal ideation] with no plan..."

(i) There was no indication that a qualified 1:1 staff member was initiated and remained with the patient, or that the LIP was immediately notified to obtain an order.

b. At 17:40, "Nursing Procedure: Admission - Belongings: Belongings remain with patient, Valuables remain with patient."

(i) There was no evidence that the assigned RN checked the patient's personal belongings for items that could potentially be harmful.

5. The above findings were confirmed by Staff #C46 and Staff #C50.

Washington Township

Based on medical record review, review of documentation, review of policies and procedures, and staff interview, it was determined that the facility failed to ensure that all nursing treatments and times are documented.

Findings include:

Reference: Facility policy titled: "Nursing Documentation, The (facility name) believes that patient documentation must reflect care rendered. The documentation system promotes an interdisciplinary approach, integrating care across the continuum. Purpose: To ensure consistent documentation of patient care. General Charting Requirements ...5. The date and time must be documented for each entry using military time."

1. Review of the facility form, "Nursing Assistant Report Sheet," Staff W#42 explained and confirmed in the column titled, "Q2h turn," the "Yes," indicates which patients have orders to be turned at least every 2 hours. Staff W#42 stated that he/she does not keep a documented record of the times the patients have been turned or positions of the patients when turned.

2. Review of 2 out of 2 medical records, nursing failed to document the time and specifics of care rendered, throughout the 12 hours shifts.

3. Medical Record #W25 contained an order dated 1/13/15 at 14:50, "Turn Patient Every 2 Hours, for Pressure Ulcer Prevention."

a. Nursing documentation of care provided from 1/13/15 to 1/15/15, was as follows:

(i) On 1/13/15 at 20:40, "Turns Self, Position aids, Turn at least every 2 hours ..."

(ii) On 1/14/15 at 08:45, "Turns Self, Position aids, Turn at least every 2 hours." In section, "Braden" states, "Mobility: Very Limited, ..."

(iii) On 1/14/15 at 20:20, "Turns Self."

(iv) 1/15/15 at 08:46, "Turn at least every 2 hours."

4. Medical Record #W26 contained an order dated 1/8/15 at 23:28, "Turn Patient Every 2 Hours, for Pressure Ulcer Prevention."

a. Nursing documentation of care provided from 1/9/15 to 1/13/15, was as follows:

(i) On 1/9/15 at 09:22 and 20:00, "Turn at least every 2 hours."

(ii) On 1/10/15 at 07:52 and at 20:04, "Turn at least every 2 hours."

(iii) On 1/11/15 at 08:15, "Mobility: Very Limited, Preventative Measures: Turn Right, Turn-Left ..."

(iv) On 1/11/15 at 20:10 and on 1/12/15 at 08:00, "Turn at least every 2 hours."

(v) On 1/12/15 at 19:57, "Mobility: Very Limited, ...Turn Right, Turn-Left, Turns self, ..."

(vi) On 1/13/15 at 08:00 and 20:00, "Turn at least every 2 hours."

5. Staff #W38 and Staff #W39 stated that the nurses' documentation, 'Turn at least every 2 hours' is used as a general note to indicate that the patients were turned every 2 hours during a 12 hour shift.

6. There was no evidence in the above medical records to identify the specific time or how the patients were positioned throughout the shifts, that would be needed for the next 2 hours, when care is due.

7. The above findings were confirmed by Staff #W38 and #W39.

Stratford Division

Based on observation and staff interview, it was determined that the facility failed to ensure that contrast agents are used in accordance with manufacturer labeling.

Findings include:

Reference: Manufacturer's package insert for Omnipaque-350 500ml Pharmacy Bulk Package (NDC # 0407-1414-98) states, "...DIRECTIONS FOR PROPER USE OF OMNIPAQUE PHARMACY BULK PACKAGE...a. The transfer of Omnipaque (Iohexol Injection) from the Pharmacy Bulk Package is restricted to a suitable work area, such as a laminar flow hood."

1. On 1/16/15 at 10:30 AM, one Omnipaque-350 500ml (milliliter) bottle was found spiked and hanging on an IV pole in the CT Room labeled "1/16/15 4:30 PM."

a. The manufacturer's label on the Omnipaque-350 500ml bottle states, "Pharmacy Bulk Package-Not for Direct Infusion...Multi-Dose Bottle...If fluid transfer cannot be completed without delay, discard the container no later than 8 hours after initial puncture."

b. Upon interview, Staff #S95 stated that the bottle was entered at 8:30 AM that morning and would be used throughout the day in the CT Room with a beyond-use time of 8 hours.

c. The use of a Pharmacy Bulk Package for multiple doses in the CT Room is not in accordance with manufacturer guidelines.

A. Based on observation and policy review, it was determined that the facility failed to implement policies and procedures to ensure that expired medications are not available for patient use.

Findings include:

Reference: Facility policy titled "Expired and Recalled Medication" states, "... Expired or recalled medication will be returned to the pharmacy for return to the manufacturer or destruction."

Stratford Division

1. On 1/13/15 at 10:45 AM, during a tour of the Operating Room (OR) Suite, the following expired medications were found:

a. One Succinylcholine 200mg (milligram)/10ml (milliliter) manufactured pre-filled syringe, expired 12/28/14, in OR #3.

b. One Atropine 0.4mg/ml manufactured pre-filled syringe, expired 12/18/14, in OR #3.

c. Four Amiodarone 150mg/3ml vials, expired 4/14, in the malignant hyperthermia cart.

d. Four Furosemide 40mg/4ml vials, expired 5/1/14, in the malignant hyperthermia cart.

e. One Intralipid 20% 250ml bag, expired 9/14, in the anesthesia block cart.

f. These findings were confirmed by Staff #S9, Staff #S19, and Staff #S21.

Washington Township

2. On 1/15/15 at 10:45 AM, during a tour of the OR Suite, the following expired medications were found in the Anesthesia Room refrigerator:

a. Two boxes of Fluzone influenza virus vaccine, expired 6/30/13.

b. One Diltiazem 50mg/10ml vial, expired 8/1/13.

c. One Nimbex 200mg/20ml vial, expired 10/1/14.

d. These findings were confirmed by Staff #W6, Staff #W21, Staff #W22 and Staff #W23.


Washington Campus

B. Based on observation and staff interview, it was determined that the facility failed to develop and implement policies and procedures addressing the preparation and labeling requirements with intravenous solutions.

Findings include:

1. On 1/15/15 at 10:45 AM, during a tour of the OR Suite, three pre-spiked 0.9% Sodium Chloride intravenous bags (IV) were found in the Anesthesia Room.

a. One IV bag was labeled "start: 1/15 6am...discard: 1/16 6am."

b. One IV bag was not labeled and had no indication of when the bag was prepared.

c. One IV bag was labeled "start: 1/15 7am...discard: 1/15 2pm."

d. Upon interview, Staff #W6 stated that the bags were prepared that morning. Staff #W6 could not explain why one IV bag did not have a label and the discrepancy of the beyond-use times written on the other two bags.

e. Upon request, Staff #W23 could not provide a policy outlining the facility's expectations with labeling a pre-spiked IV bag and determining the beyond-use time once entered.

f. These findings were confirmed by Staff #W6, Staff #W21, Staff #W22 and Staff #W23.

A. Based on staff interview, document review and observations, it was determined that the facility failed to ensure that the General Manager of Food and Nutrition Services is responsible for the daily management of the dietary service.

Findings include:

Reference #1: The General Manager of Food and Nutrition Services job description states, "Directs daily food service operations in order to provide quality products. Maintains and implements sanitary and food safety conditions and training to adhere to auditing procedures and statutory regulations."

Reference #2: The Floor Supplies policy and procedure states, "Patient refrigerators are randomly monitored by dietitians and clinical nutrition manager or other manager or food services employee as assigned for compliance with guidelines and proper food storage...Temperatures of patient refrigerators are monitored via the hospitals Temp Trak system."

Reference #3: The Temp Trak Temperature Monitoring System policy and procedure states, "Refrigerators will be monitored for the prescribed temperature range set below:...Patient Food Refrigerators 32ºF to 40ºF... Dietary Food Refrigerators 32ºF - 40ºF... All alerts will be answered by Boiler Plant Operator or other as designated by the Hospital Facilities Director. Follow-up alert will be conducted by the Hospital Facilities department personnel or the user department. Such follow-up will be ensuring the door to the refrigerator is closed or the refrigerator box temperature is adjusted properly. If there is no clear cause of alarm a Hospital facilities mechanic will respond to investigate the cause of the alarm."

Reference #4: N.J.A.C. 8:24-3.5(f) 2 states, "potentially hazardous food shall be maintained at refrigeration temperatures." "N.J.A.C. 8:24-1.5 Definitions, Refrigeration temperatures defined as 41ºF or less... "

Cherry Hill Division

1. On 1/13/15 at 11:15 AM, in the presence of Staff #C12 and Staff #C13, the patient refrigerator on Unit T-1/Same Day Surgery contained skim milk at 43ºF and 2% milk at 42.5ºF. The milk was not maintained at 41ºF or less as stated in facility policy, Reference #3 and State Sanitation Code, N.J.A.C. 8:24, Reference #4.

a. On 1/13/15 at 11:15 AM, during an interview, Staff #C12 and Staff #C13 did not know the prescribed Temp Trak Temperature range settings for monitoring patient refrigerators.

b. On 1/13/15 at 2:30 PM, during an interview, Staff #C5 stated that the patient refrigerators on the units are maintained with the Temp Trak Temperature setting at 36ºF - 46ºF.

(i) Upon review of the Temp Trak Temperature Monitoring System policy and procedure, Staff #C1 and Staff #C5 acknowledged that the facility failed to set and monitor the patient refrigerators at the required 32ºF to 40ºF temperature settings as stated in Reference #3.

c. On 1/13/15, Staff #C12 and Staff #C13 could not provide evidence that the patient refrigerators were randomly monitored by food and nutrition services staff for compliance with guidelines and proper food storage, as stated in Reference #2.

d. Upon review of the local Department of Health inspection, dated 9/6/14, the report identified non-compliance with N.J.A.C. 8:24-3.5(f) 2 "Milk in various units throughout hospital measured 42ºF - 46ºF. Units' ambient air temperatures measured 42ºF - 48ºF. Units must be corrected in 48 hours."

(i) On 1/13/15, the facility failed to provide documentation of a corrective action plan implemented for the above-identified deficient practice. Staff #C1 stated that dairy products are not stored in the refrigerators and that a plan to replace the refrigerators is in place.

(ii) On 1/13/15, the facility provided for review, the Temp Trak Temperature Monitoring logs dated, 1/6/15 -1/13/15, for patient refrigerators on units T1, T2, and T3. Three of three patient refrigerators were set at 36ºF - 46ºF, not 32ºF to 40ºF as stated in Reference #3.

(iii) On 1/14/15, the facility provided for review, the Temp Trak Temperature Monitoring logs for the date range of 1/13/15 -1/14/15 for patient refrigerators on units T1, T2, T3, T4, CCU(North), and ER(New). The patient refrigerators on units T1, T3, T4 and CCU (North)measured 41.5ºF - 52ºF, not the required 32ºF to 40ºF, as stated in Reference #3.

Stratford Division

1. On 1/14/15 at 11:15 AM, in the presence of Staff #S32 and Staff #S33, the 4th floor Family Lounge refrigerator contained Half-and-Half pods with a temperature of 45ºF. The Half-and-Half was not maintained at 41ºF or less as stated in the facility policy, Reference #3.

a. On 1/14/15, Staff #S32 and Staff #S33, could not provide evidence that the patient refrigerators were randomly monitored by food and nutrition services staff for compliance with guidelines and proper food storage, as stated in Reference #2.

b. Staff #S32 and Staff #S33 stated that the temperature for this refrigerator is monitored by the facility Temp Trak Temperature Monitoring System.

(i) Staff #S5 provided for review, the Temp Trak Temperature Monitoring logs for date range of 1/1/15 -1/14/15 for the refrigerator located in the 4th floor Family Waiting Room. The refrigerator log indicated that for four (4) out of thirteen (13) days (1/10/15, 1/11/15, 1/12/15 and 1/13/15), the refrigerator temperatures were out of range, 41.2º- 46.9ºF. The facility alert log indicated that for two (2) out of the four (4) days (1/10/15 and 1/11/15), action was not taken to correct the alert. The facility mechanic failed to investigate the cause of the alarm as stated in the facility Temp Trak Temperature Monitoring System policy and procedure, Reference #3.

Based on observation and staff interview, it was determined the facility failed to ensure that the environment is maintained in a manner that the safety and well-being of patients is assured.

Findings include:

Cherry Hill Division

1. On 1/12/15, in the presence of Staff #C6, wall damage or unpainted joint compound, which would preclude cleaning, was observed in the following areas:

a. The Same Day Stay Nurses Lounge, at 9:30 AM.

b. The first floor bathroom, opposite Patient Room #106, at 9:45 AM .

c. The Sub Sterile Room between Operating Room #2 and Operating Room #3, at 1:15 PM.

d. Treatment Room #1 and Treatment Room #2 in the Emergency Department, at 2:45 PM.

2. On 1/12/15 at approximately 10:00 AM, in the presence of Staff #C6, rust stained equipment racks and patient treatment chairs were found in the Dialysis Unit.

3. On 1/12/15 at approximately 11:00 AM, in the presence of Staff #C6, visibly dusty air vent supply registers were found in the following areas:

a. The third floor hallway, opposite the Nurse's Station.

b. The Endoscopy Suite Anteroom.

4. On 1/12/15 at approximately 11:45 AM, in the presence of Staff #C6, open seams which would prevent thorough cleaning were found on the monolithic floor surface in Operating Room #3.

5. These findings were confirmed by Staff #C6.

Washington Township

1. On 1/13/15 at approximately 10:45 AM, in the presence of Staff #W75, two exterior roof access doors, located on the third floor in Pavilion E, had a visible air-gap to the outside which would possibly allow the entrance of insects or vermin.

2. This finding was confirmed by Staff #W75

Stratford Campus

1. On 1/14/15, in the presence of Staff #S94, dusty air vent registers were found in the following areas:

a. The Operating Room Utility Room, at 1:15 PM.

b. The physician scrub sink area located in the Operating Room Hallway, at 1:30 PM.

c. Same Day Stay bathroom, at 2:00 PM.

2. These findings were confirmed by Staff #S94.






33557

Washington Township - Surgical Center

1. On 1/15/15 at 10:05 AM, in the presence of Staff #W10 and Staff #W29, the carpet in the Waiting Room was stained.

2. On 1/15/15 at 10:10 AM, in the presence of Staff #W10 and Staff #W29, the carpet in the Waiting Room was torn near the windows.

a The rip in the carpet was parallel to the windows and ran the entire length of the windows.

3. On 1/15/15 at 12:00 PM, in the presence of Staff #W10 and Staff # W29, the back wall of Operating Room #4 was cracked and chipped.

Stratford Division - Family Health Services

1. On 1/13/15 at 10:30 AM, in the presence of Staff #S5 and Staff #S13, the wall was chipped and cracked near the Registration Counter.

2. On 1/13/15 at 10:45 AM, in the presence of Staff #S5 and Staff #S13, the gypsum board wall was torn near the door in Exam Room #6.

3. On 1/13/15 at 10:50 AM, in the presence of Staff #S5 and Staff #S13, the wall around both rear exit door's were cracked and chipped.

A. Based on observation and interview, it was determined that the facility failed to ensure that a safe and sanitary environment is maintained for patients, staff and the general public.

Findings include:

Stratford Division

1. During a tour of the Surgical Suite, Intensive Care Unit (ICU), Telemetry, 4 West, 2 East, and the Radiology Department on 1/13/15, 1/14/15, and 1/15/15, in the company of Staff #S2, Staff #S18, Staff #S19, Staff #S20, Staff #S89, Staff #S90, and Staff #S91, the following was observed:

a. The floors throughout the units had dirt build up along the edges.

b. In the ICU hallway, there was dust accumulation on the floor.

c. In the Fluoroscopy Room, a white residue was noted around the faucet and the spigot of the handwashing sink.

d. In the CT Room, within the Radiology Department, dust and a spackled area was noted on the wall.

(i) The cabinet doors and the base of the portable table had white stains.

e. Outside of the X-ray Room, tape was on top of the fire alarm box.











26599

Kennedy Family Health Center at Somerdale Square at Stratford

1. During a tour on 1/13/15, the following was observed:

a. The corners of the mattress on the exam bed in the OB Corridor were torn.

b. The corners of the mattress on the exam bed in Exam Room #2 were torn.

c. The corners of the mattress on the exam bed in Exam Room #4 were torn.

d. The corners of the mattress on the exam bed in the Exam Room #6 were torn.

2. These findings were confirmed by Staff #S10 and Staff #S12.


Kennedy Physical Therapy at Washington Township

1. During a tour on 1/13/15, the following was observed:

a. Three (3) treatment exam tables contained debris in the folds on the mattress pads.

b. Ten (10) hot pad covers hanging on the wall, were dirty.

(i) Upon request of a log to review of how often the hot pad covers were cleaned, Staff #W63 stated that the there was no log to document when the hot pad covers were washed.

(ii) Upon request for a policy of how often the hot pad covers should be cleaned, Staff #W63 was unable to provide one.

2. This finding was confirmed by Staff #W10.



33557

yWashington Township - Surgical Center

On 1/15/15 at 10:05 AM, in the presence of Staff #W10 and Staff #W29, rust was present on the frame of the operating table in Operating Room #4 and Operating Room #7.

Washington Township

1. On 1/16/15, during a tour of the Emergency Department, the following was observed:

a. The three (3) cushion couch in the Pediatric Waiting Room had multiple tears on all the cushions.

b. The stretcher in Room #5 had a hole on the left-side at the head of the mattress.

2. The above was confirmed by Staff #W66.





33800



Cherry Hill Division

B. Based on observation, review of documents, and staff interview conducted on 1/13/15, it was determined that the facility failed to ensure that it provides and maintains adequate facilities and personal protective equipment for the safe handling of formaldehyde.

Findings include:

Reference #1: OSHA 29 CFR 1910.1030 (d) (3) (i) states, "Provision. When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection ..."

Reference #2: Fischer Scientific 10% Neutral Buffered Formalin Material Safety Data Sheet (MSDS) that states, "...Handling
Use only under a chemical fume hood. Wear personal protective equipment. Do not breathe vapors or spray mist. Avoid contact with skin eyes and clothing."

1. During a tour of the Operating Room (OR) Specimen Room at 1:40 PM, a large dispensing container of Formalin (10% formaldehyde) was observed on top of a storage cabinet.

2. Staff #C4 stated that OR personnel would bring the specimen in a container into this room then fill the container with Formalin from the large dispenser.

3. A copy of the OSHA standards and guidelines for safe handling of formaldehyde was not available in the Specimen Room.

4. There were no faceshield or goggles to protect the personnel handling specimens from Formalin exposure in the OR Specimen Room.

5. There was no chemical fume hood to protect personnel handling specimens from harmful Formalin fumes in the OR Specimen Room.

a. The facility failed to follow manufacturer's instructions for safe handling of Formalin.

6. These findings were confirmed by Staff #C2, Staff #C4, and Staff #C6.

Cherry Hill Division

A. Based on staff interview, observations and review of documents, it was determined that the facility failed to ensure that the infection control officer identifies and develops corrective action plan for patient refrigerators not maintaining the required temperatures.

Findings include:

Reference #1: The Temp Trak Temperature Monitoring System policy and procedure states, "Refrigerators will be monitored for the prescribed temperature range set below:...Patient Food Refrigerators 32ºF to 40ºF...Dietary Food Refrigerators 32ºF - 40ºF...All alerts will be answered by Boiler Plant Operator or other as designated by the Hospital Facilities Director. Follow-up alert will be conducted by the Hospital Facilities department personnel or the user department. Such follow-up will be ensuring the door to the refrigerator is closed or the refrigerator box temperature is adjusted properly. If there is no clear cause of alarm a Hospital facilities mechanic will respond to investigate the cause of the alarm."

Reference #2: N.J.A.C. 8:24-3.5(f) 2 states, "potentially hazardous food shall be maintained at refrigeration temperatures." "N.J.A.C. 8:24-1.5 Definitions, Refrigeration temperatures defined as 41ºF or less... "

1. On 1/13/15 at 11:15 AM in the presence of Staff #C12 and Staff #C13, the patient refrigerator on Unit T-1/Same Day Surgery contained skim milk at 43ºF and 2% milk at 42.5ºF. The milk was not maintained at 41ºF or less, as stated in facility policy Reference #1 and State Sanitation Code, N.J.A.C. 8:24, Reference #2.

a. On 1/13/15 at 11:15 AM, during an interview, Staff #C12 and Staff #C13 did not know the prescribed Temp Trak Temperature range settings for the monitoring of patient refrigerators.

b. On 1/13/15 at 2:30 PM, during an interview, Staff #C5 stated that the patient refrigerators on the units are maintained with a Temp Trak Temperature setting of 36ºF - 46ºF.

c. Upon review of the Temp Trak Temperature Monitoring System policy and procedure, Staff #C1 and Staff #C5 acknowledged that the facility failed to set and monitor the patient refrigerators at the required 32ºF to 40ºF temperature settings, Reference #1.

d. On 1/13/15, Staff #C12 and Staff #C13, provided for review, the local Department of Health inspection, dated 9/6/14. The report indicated a "Conditional" evaluation and non-compliance with N.J.A.C. 8:24-3.5(f)2 "Milk in various units throughout hospital measured 42ºF - 46ºF. Units' ambient air temperatures measured 42ºF - 48ºF. Units must be corrected in 48 hours."

(i) On 1/13/15, the facility failed to provide documentation of a corrective action plan for the above-identified deficient practice. Staff #C1 stated that dairy products are not stored in the refrigerators and that a plan to replace the refrigerators is in place.

(ii) On 1/13/15, the facility provided for review the Temp Trak Temperature Monitoring logs dated 1/6/15 -1/13/15, for patient refrigerators on units T1, T2, and T3. Three of three patient refrigerators were set at 36ºF - 46ºF, not 32ºF to 40ºF, as stated in Reference #1.

(iii) On 1/14/15, the facility provided for review, the Temp Trak Temperature Monitoring logs for the date range of 1/13/15 -1/14/15 for patient refrigerators on units T1, T2, T3, T4, CCU(North), and ER(New). The patient refrigerators on units T1, T3, T4, and CCU (North), measured 41.5ºF - 52ºF and not the required 32ºF to 40ºF, as stated in Reference #1.

e. During review of the Infection Control Committee Meeting Minutes, dated November 21, 2014, the Food and Nutrition section for inspection noted that Camden County - inspected the Cherry Hill Campus. The report failed to identify the general evaluation received on 9/6/14 as "Conditional" and failed to document an action plan for the required corrections.

(i) For example, the facility Temp Trak Temperature Monitoring System policy and procedure was not reviewed and monitored for compliance. The patient refrigerators were set at 36ºF - 46ºF, not 32ºF to 40ºF, as stated in Reference #1. This error in setting, resulted in maintaining dairy products and patient food items at a potentially dangerous temperature range for an extended period.




13896

B. Based on observation, document review, and staff interview, it was determined that the facility failed to ensure that its policy for handwashing is implemented.

Findings include:

Reference: Facility policy titled, "Hand Hygiene" states, " ... All associates, physicians, students, contracted workers, and volunteers must cleanse their hands: ...
2. Before and after touching a patient
3. After touching patient surroundings or belongings
4. Before clean aseptic procedures
5. After contact with any blood or body fluids
6. Before donning and after removing gloves ..."


Stratford Division

1. On 1/13/15 at 11:30 AM, during a tour of the Same Day Stay Unit, Staff #S29 was in Room #253 wearing gloves and attending to the patient's intravenous access. Staff #S29 then removed his/her gloves, proceeded to do other tasks within the room, exited the patient room and continued to do other tasks without sanitizing/decontaminating his/her hands.

2. The above was confirmed by Staff #S20.

Cherry Hill Division

1. On 1/13/15 at 2:05 PM in the Operating Room (OR) Soiled Utility Room, Staff #C33 removed his/her soiled gloves without sanitizing his/her hands.

a. This finding was confirmed by Staff #C3 and Staff #C4.

Washington Township

1. On 1/14/15 at 11:50 AM, in the Central Processing Department (CPD), Staff #W59 removed his/her soiled gloves without cleansing his/her hands.

2. At 11:55 AM, Staff #W56 removed his/her soiled gloves without cleansing his/her hands.

3. These findings were confirmed by Staff #W2 and Staff #W51.

Stratford Division

1. On 1/15/15 at 11:15 AM, in the Same Day Surgery (SDS), in the presence of Staff #S2 and Staff #S82, Staff #S71 donned a pair of gloves without sanitizing his/her hands before performing a glucose check on Patient #S23. He/She then removed his/her soiled gloves without sanitizing his/her hands. The glucose check was found unsuccessful and at 11:20 AM, Staff #S73 performed another glucose check on the same patient. He/She then removed his/her soiled gloves and donned another pair of gloves without sanitizing his/her hands.

a. These findings were confirmed by Staff #S2 and Staff #S82.

2. On 1/15/15 at 11:54 AM, in the Post Anesthesia Care Unit (PACU), Staff #S74 touched Patient #S26, then proceeded to touch the stretcher and other furniture's multiple times without sanitizing his/her hands.

a. This finding was confirmed by Staff #S18 and Staff #S20.










33800


F. Based on observation, document review and staff interviews, it was determined that the facility failed to ensure that its instrument reprocessing practice is in conformance with the manufacturer's recommendation for use.

Findings include:

Reference #1: Facility policy titled, 'Event-Related Sterility' states, "Hospital processed sterile items packaged or wrapped in disposable wraps, ... will have an indefinite shelf life, as long as the integrity of the packaging is not compromised ..."

Reference #2: AAMI (Association for the Advancement of Medical Instrumentation) "Sterilization in Health Care Facilities, 2014 edition" ST 79 section 7.2.2 states, "Manufacturers' written IFU...The written IFU of the device manufacturer should always be followed."

Cherry Hill Division

1. On 1/13/15 at 11:40 AM, Staff #C4 stated that "the facility follows APIC [Association for Professionals in Infection Control and Epidemiology], AAMI [Association for the Advancement of Medical Instrumentation], CDC [Centers for Disease Control and Prevention], AORN [Association of periOperative Registered Nurses], and OSHA [Occupational Safety and Health Standards] guidelines."

2. At 12:00 PM, facility processed sterile items were wrapped with blue disposable nonwoven wrappers and did not contain expiration dates on their labels.

a. Staff #C28, in the presence of Staff #C3 and Staff #C4 stated that the facility policy follows "event-related sterilization" and all instruments are considered sterile indefinitely.

b. At 2:05 PM, Staff #C28 stated that the facility uses Kimberly-Clark and Medline disposable nonwoven wrappers.

c. The manufacturer's instructions for use (IFUs) for the Kimberly-Clark and Medline disposable nonwoven wrappers were requested.

(i) The facility was unable to provide the requested IFUs.

(ii) The facility failed to ensure that manufacturer's IFUs were available.

3. On 1/16/15, during an interview at the Stratford Division, Staff #C28 stated that the Kimberly-Clark manufacturer's IFU indicates up to one year of shelf life and the Medline manufacturer's IFU indicates up to two years of shelf life.

4. The facility failed to ensure that processed sterile items wrapped in Kimberly-Clark and Medline wrappers, were labeled with expiration dates, in accordance with the manufacturer's IFUs.

5. These findings were confirmed by Staff #C4 and Staff #C28.

Washington Township

1. On 1/14/15, facility processed sterile items were wrapped with blue disposable nonwoven wrappers and did not contain expiration dates on their labels.

a. Staff #W50 and Staff #W56, in the presence of Staff #W2, Staff #W49 and Staff #W51 stated that the facility policy is "event-related sterilization," and all instruments are considered sterile indefinitely.

b. At 11:55 AM, Staff #W56 stated that the facility uses Kimberly-Clark and Medline disposable nonwoven wrappers.

c. The manufacturer's instructions for use (IFUs) for the Kimberly-Clark and Medline disposable nonwoven wrappers were requested.

(i) The facility was unable to provide the requested IFUs.

(ii) The facility failed to ensure that manufacturer's IFUs were available.

2. On 1/16/15, during an interview at the Stratford division, Staff #W50 stated that the Kimberly-Clark wrapper manufacturer's IFU indicates up to one year of shelf life and the Medline wrapper manufacturer's IFU indicates up to two years of shelf life.

3. The facility failed to ensure that processed sterile items wrapped in Kimberly-Clark and Medline wrappers were labeled with expiration dates, in accordance with the manufacturer's IFU.

4. These findings were confirmed by Staff #W50 and Staff #W51.

Stratford Division

1. On 1/15/15, hospital processed sterile items were wrapped with blue disposable nonwoven wrappers and did not contain an expiration date on their labels.

a. At 10:50 AM, Staff #S69 and Staff #S70, in the presence of Staff #S2, Staff #S20 and Staff #S82 stated that the facility policy is "event-related sterilization" and all instruments are considered sterile indefinitely.

b. Staff #S69 and Staff #S84 stated that the facility uses Kimberly-Clark and Medline disposable nonwoven wrappers.

c. The manufacturer's instructions for use (IFUs) for the Kimberly-Clark and Medline disposable nonwoven wrappers were requested.

(i) The facility was unable to provide the requested IFUs.

(ii) The facility failed to ensure that manufacturer's IFUs were available.

2. On 1/16/15, during an interview, Staff #S84 stated that the Kimberly-Clark manufacturer's IFU indicates up to one year of shelf life and the Medline manufacturer's IFU indicates up to two years of shelf life.

3. The facility failed to ensure that processed sterile items wrapped in Kimberly-Clark and Medline wrappers are labeled with expiration dates, in accordance with the manufacturer's IFU.

4. These findings were confirmed by Staff #S82 and Staff #S84.


G. Based on observation, document review and staff interview, it was determined that the facility failed to ensure that soiled instruments are transported according to facility policy and AAMI (Association for the Advancement of Medical Instrumentation). AAMI is the nationally recognized Infection Control guideline the facility has selected for its Instrument Reprocessing.

Findings include:-

Reference #1: Facility document titled, "Transportation of Instruments From Other Kennedy Facilities" states, "Soiled instruments that are to be sent to the Kennedy Memorial Hospital Central Processing Departments for reprocessing ... will be transported in a 'biohazard bag' (for regulated Medical Waste) contained within an impervious red container to prevent cross-contamination of other items or persons."

Reference #2: AAMI (Association for the Advancement of Medical Instrumentation) ST79 2014 edition section 6.4 states, "Contaminated items should be contained during their transport from the point of use to the decontamination area. ... Containers, devices, or carts must be marked with a biohazard label or other means of identifying contaminated contents..."

Cherry Hill Division

1. On 1/13/15 at 11:40 AM, Staff #C4 stated that "the facility follows APIC [Association for Professionals in Infection Control and Epidemiology], AAMI [Association for the Advancement of Medical Instrumentation], CDC [Centers for Disease Control and Prevention], AORN [Association of periOperative Registered Nurses], and OSHA [Occupational Safety and Health Standards] guidelines."

2. During a tour of the Operating Room (OR) on 1/13/15 at 12:15 PM, Staff #C3 stated that soiled instruments are transported to the Central Processing Department (CPD) by covering the soiled surgical table and instruments with a table cover.

3. At 2:05 PM, at the end a surgical procedure, Staff #C33 piled soiled orthopedic instruments on the surgical table and placed a basin full of red-tinged fluid on top of the soiled instruments.

a. The table was covered by folding the edges of the soiled table cover over the instruments.

b. Staff #C33 stated, "I leave them (soiled instruments) on the table and let CPD take care of it."

4. The facility failed to transport soiled instruments within a biohazard-labeled and impervious container to prevent cross-contamination of other items or persons.

5. This finding was confirmed by Staff #C2, Staff #C4 and Staff #C28.

Washington Township

1. During a tour of the OR on 1/14/15, Staff #W12 stated that the soiled instruments are transported to the Central Processing Department (CPD) through a case cart.

2. At the end a surgical procedure in OR #9 on 1/14/15 at 11:10 AM, soiled instruments were placed inside a case cart and brought to the Soiled Utility Room.

a. The case cart failed to have a biohazard label.

3. The facility failed to transport soiled instruments within a biohazard-labeled case cart to prevent cross-contamination of other items or persons.

4. This finding was confirmed by Staff #W2, Staff #W12, Staff #W49 Staff #W50 and Staff #W51.

Stratford Division

1. During a tour of the OR on 1/15/15 at 10:50 AM, Staff #S69 and Staff #S70 stated that soiled instruments are transported to the Central Processing Department (CPD) in a dirty case cart.

a. Soiled instruments were brought into the Soiled Utility Room and placed inside a dirty case cart after a procedure. The dirty case cart contained multiple instruments.

b. Staff #S69 stated that once filled, the dirty case cart is brought to the CPD.

c. The dirty case cart failed to have a biohazard label.

2. The facility failed to transport its soiled instruments within a biohazard-labeled case cart to prevent cross-contamination of other items or persons.

4. This finding was confirmed by Staff #S20, Staff #S69, Staff #S70, and Staff #S82.

H. Based on observation and staff interviews conducted on 1/13/15, 1/15/15 and 1/16/15, it was determined that the facility failed to ensure that its Infection Control program conforms with the nationally recognized Infection Control guidelines it has selected.

Findings include:

Reference: AAMI (Association for the Advancement of Medical Instrumentation) ST 79 section 3.3.6.4 states, "Except for exhaust fans on ventilation systems and properly installed and operated fume control hoods, neither fixed nor portable fans should be permitted in any area of Central Service."

1. On 1/13/15 at 11:40 AM, during an interview at the Cherry Hill division, Staff #S82 stated, "the facility follows APIC [Association for Professionals in Infection Control and Epidemiology], AAMI [Association for the Advancement of Medical Instrumentation], CDC [Centers for Disease Control and Prevention], AORN [Association of periOperative Registered Nurses], and OSHA [Occupational Safety and Health Standards] guidelines."

2. On 1/15/15 at 2:05 PM, a free-standing air conditioning unit was observed in the Endoscopy Decontamination Room.

a. This finding was confirmed by Staff #S20, Staff #S79, and Staff #S82.

3. On 1/16/15 at 10:10 AM, in the presence of Staff #S18, Staff #S69, and Staff #S82, a free-standing Movin Cool Classic Plus 14 air conditioning unit was observed in the CPD (Central Processing Department) Decontamination Room.

a. Staff #S-85 stated, "It gets too hot in here without the A/C."

4. The facility failed to conform with AAMI guidelines, as indicated in the above Reference.



















26599

Kennedy Family Health Center at Somerdale Square at Stratford

C. Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that infection control practices that adhere to nationally recognized infection control guidelines are implemented for the protection of patients and facility personnel.

Findings include:

Reference #1: Facility policy titled "Packaging and Wrapping Procedures" states, " ... The prime function of package containing a sterile medical item is to ensure that the sterility of the contents is maintained up to the time the package is intentionally opened and that provisions are made for contents to be removed without contamination."

Reference #2: AAMI ST 79 section 8.9.2 on 'Storage facilities' states, "Sterile items should be stored in a manner that reduces the potential for contamination... The items should be positioned so that packaging is not crushed, bent, compressed or punctured and so that their sterility is not otherwise compromised."

1. During a tour of the Clean Utility Room on 1/13/15, the following was observed:

a. Fourteen (14) Bandex Foley Catheters were held together with a rubber band; the packaging was crushed, yellowed and peeling.

b. Multiple instruments in sterile packing were placed in drawers and bins that were to tight, causing the sterile packaging to bend, crush and fold.

2. These findings were confirmed by Staff #S10, Staff #S12 and Staff #S15.

Kennedy Family Health Center at Somerdale Square at Stratford

D. Based on observation and staff interview, it was determined that the facility failed to ensure that an infection control policy was developed for presoaking non-disposable surgical instruments prior to placement in a transport container, that adhere to nationally recognized infection control guidelines.

Findings include:

Reference: AAMI ST 40 section 5.4 on 'Handling, collection, and transport of items previously used in patient care' states, "Soil should be removed ... personnel should avoid splashing water and thereby contaminating attire, the area near the sink,... A disposable brush moistened with water (not saline) should be used to wipe gross soil from instruments... . Items should be kept moist to prevent soil from drying on device surfaces ... . Items can be kept moist in the transport container by adding a moist towel or a foam, spray... to prevent the formation of biofilms, definitive cleaning should occur as soon as possible."

1. During a tour of the Soiled Utility Room on 1/13/15, the following was observed:

a. Used surgical instruments were directly in the sink, under the faucet, not placed in a container.

2. Upon interview, Staff #S13 stated that he/she places the used surgical instruments in the sink, sprays them with an enzymatic, leaves it on for 5-10 minutes, brushes the instruments with a surgical scrub hand/nail brush and then places the instruments in a transport container. When questioned by the surveyor how long the instruments were in the sink, she/he stated since yesterday. Furthermore, Staff #S13 stated that the facility had no policy on how long the enzymatic can stay on the instruments, what kind of brush/sponge should be used in cleaning the instruments or that they should not be put directly in the sink.




E. Based on observation and staff interview, it was determined that the facility failed to ensure that a sanitary environment is provided for the safety of patients and personnel.

Findings include:

Kennedy Physical Therapy at Washington Township

1. During a tour on 1/14/15, two (2) stacks of Styrofoam drinking cups were placed directly on the water fountain, inches away from the drinking spout.

2. Staff #W10 and Staff #W63, confirmed this finding.

Washington Township

1. At 10:30 AM, in the presence of Staff #W2 and Staff #W49, the vinyl flooring in the elevator was lifting.

a. The surface beneath the lifted vinyl flooring is uncleanable.

2. At 10:55 AM, in the OR hallway across from the control desk, a 'Trumpf Orbiter' patient moving device contained a thick layer of dust.

3. These findings were confirmed by Staff #W2 and Staff #W49.

4. At 10:58 AM, in the Post Anesthesia Care Unit (PACU), in the presence of
Staff #W12, Staff #W18 and Staff #W49, the Pedigo Endovascular Standby Cart contained tape residue on the surface of its door.

5. These findings were confirmed by Staff #W12, Staff #W18 and Staff #W49.

Stratford Division

1. On 1/15/15 at 12:05 PM, in the presence of Staff #S18 and Staff #S20, Staff #S75 and Staff #S76 were cleaning OR #3 after a surgical procedure.

a. Staff #S75 cleaned the anesthesia table and equipment without adequately disinfecting the blood pressure cuff and pulse oximeter sensors.

b. Staff #S76 poured an amount of Ecolab Neutral Disinfectant (ammonium-based quaternary) solution and mixed it with bleach solution on the floor prior to mopping.

(i) Mixing ammonia and bleach may produce toxic and explosive fumes.

c. These findings were confirmed by Staff #S18 and Staff #S20.

2. On 1/15/15 at 2:15 PM, in the presence of Staff #S18, Staff #S20, Staff #S79 and Staff #S82, the following was observed in the Endoscopy Decontamination Room:

a. The base of an IV pole was soiled with dirt and stained with white residue.

b. Brown stains were on the floor near the air conditioning unit.

c. The vent tubes on a free standing air conditioning unit, was held together with surgical tape.

(i) The surgical tape is not a cleanable surface.

d. The air vents louvers contained a thick layer of dust.

e. These findings were confirmed by Staff #S18, Staff #S20, Staff #S79 and
Staff #S82.

3. The walls in OR #6 contained sticky residue and peeled paint.

a. The above findings were confirmed by Staff #S2 and Staff #S82.

4. On 1/16/15 at 9:05 AM, in the presence of Staff #S18, Staff #S20 and Staff #S82, Staff #S80 was observed preparing for a surgical procedure in OR #3.

a. Staff #S80 stated, "This is the second case in this room."

b. Reddish residue was observed at the base of the OR table while Staff #S80 was opening sterile items onto the sterile field.

c. OR #3 was not adequately cleaned and disinfected prior to the preparation of the sterile field.

d. This finding was confirmed by Staff #S18, Staff #S20, Staff #S80 and Staff #S82.

5. On 1/16/15 at 9:55 AM, in Central Processing Department (CPD) Prep and Pack area, the floors in front of sterilizer #1 and sterilizer #3 were gouged, scratched, and soiled with black residue and stains.

a. This was confirmed by Staff #S18, Staff #S69, Staff #S82 and Staff #S84.

6. On 1/16/15 at 10:10 AM, in the presence of Staff #S18, Staff #S69 and
Staff #S82, a free standing 'Movin Cool Classic Plus 14' air conditioning unit in the CPD Decontamination Room contained a thick layer of dust.

a. This finding was confirmed by Staff #S18, Staff #S69, and Staff #S82.

Stratford Campus

Based on a review of 2 medical records, facility policies and procedures, and staff interview, it was determined that the facility failed to have one clear policy regarding organ donation.

Findings include:

Reference #1: Facility Policy #A122, "Anatomical Donations and Organ Donation after Cardiac Death and after Brain Death" (10 pages) last reviewed/revised January 2013. This policy was originally approved on July 7, 1989 and reviewed/revised August 2008, October 2010, and January 2013.

Reference #2 Facility Policy #A122, "Organ Donation" (6 pages) last reviewed/revised August 2008. This policy was originally approved on July 7, 1989 and reviewed/revised August 2008.

1. Reference #1 states that at the time of death or determination of imminent death of a patient, the nursing supervisor or other designee, will contact the Gift of Life Donor Program (GLDP).

a. The policy does not indicate what documentation the nursing supervisor is required to complete regarding this process.

2. Reference #2 states that at the time of death or determination of imminent death of a patient, the nursing supervisor or other designee, will contact the Gift of Life Donor Program (GLDP) with the knowledge of.

a. This policy states that the individual that contacts the GLDP will provide them, and document on section 1 of the 'Certificate of Referral/Request of Anatomical Donations,' the following information: Patient's name, Patient's identifier (medical record number), Patient's age, Patient's cause of death, Any available past medical history, and Date and time of first brain death exam (if done) or time of death with regard to tissue.

b. Neither of these policies accurately reflect the current practice at this facility.

3. Medical Record #S18 contained an electronic version of the Certificate of Referral/Request of Anatomical Donations, instead of the form contained in Reference #2.

(i) The form did not include any past medical history, or a notation that none was available.

(ii) The form was not signed by the individual who completed it.

4. Medical Record #S19 contained an electronic version of the Certificate of Referral/Request of Anatomical Donations, instead of the form contained in Reference #2.

(i) The form did not include any past medical history, or a notation that none was available.

(ii) The form was not signed by the individual who completed it.

5. These findings were confirmed by Staff #S5.

6. The Electronic version of the Certificate of Referral/Request of Anatomical Donations contained a statement, "In compliance with Kennedy Health System Organ/Tissue Protocol (#B-6), this form must be completed on all deaths and included as part of the patient's permanent medical record."

a. When Staff #S5 was asked to provide a copy of Protocol #B-6, he/she was unable to locate it. It was determined that this protocol did not exist.

7. The two policies (#A122), referenced above, for the same procedure, but with different content, and the reference to a protocol that is not available, are a possible source of confusion and could lead to the procedure not being done properly.