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Based on medical record review and staff interview, the facility failed to ensure that record entried for one (1) of two (2) records reviewed, Patient #1,were timed by the person responsible for providing or evaluating the services provided.

Findings Include:

Record review for Patient #1 revealed that the admission orders written by the attending physician included the date written but no time.

During an interview with the Director of Nurses (DON) on 2/17/16 at 1:25 p.m. she was informed concerning the regulation on timing of physician orders. The DON stated that this set of orders was written by the physician at the nursing home before the patient was admitted to the hospital and that most all orders are signed in the computer.

Based on observation and staff interview, the facility failed to ensure their hazardous waste was stored properly.

Findings Include:

On 2/16/16 at 1:15 p.m. observation revealed that the facility was storing Hazardous Waste in the hallway of the Nursing Unit where patient rooms are located. It was noted that the top of the can could be easily opened. The can on the left side of the rack in the hallway had a red bag in the can that was labeled Hazardous Waste. The Registered Nurse on the nursing unit stated, "When needle boxes are full they are closed well then placed in this can in the hallway until picked up. The top of the container can be easily opened."

Review of the facility's undated policy "Handling and Storage of Regulated Waste" revealed, "#3: Keep containers in a secure location at all times except during transport or use. It is the supervisor's responsibility to designate appropriate central storage locations for regulated waste containers. Do not leave them unattended when they are in locations accessible to the general public. Employees who generate or collect regulated waste shall place it into the central storage location awaiting pick up... #5: Location of biohazard trash cans in the facility are kept in Radiology Department, Lab, Laundry, and a storage area secured on the West Wing of the hospital."

During an interview on 2/17/15 at 1:25 p.m. the storage of Hazardous Waste was discussed with the Director of Nurses. She made no additional comments.

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Based on observation, staff interview, policy review, document review and manufacturer's instructions review, the facility failed to identify and correct poor infection practices and failed to ensure preventive infection control measures are followed.


Findings Include:

1) Review of the facility's temperature logs for the hydrocollator revealed only two temperatures were recorded. One on 1/11/16 and another on 2/16/16. Review of the operation manual for the hydro collator revealed the recommended temperature of the water should be checked with a thermometer after every adjustment, before using the HotPacs. The tank should also be drained and cleaned systematically, at a minimum every two (2) weeks. There was no documented evidence of temperature checks or cleaning of the paraffin unit. Review of the operation manual of the paraffin unit revealed the temperature is to be tested prior to use. The unit should be cleaned when significant discoloration or yellowing of the paraffin is noticed, or when excessive sediment is observed in the tank.


During an interview on 2/16/16 at 12:30 p.m. the Rehabilitation Technician stated, "We do not keep logs on cleaning the hydrocollator and paraffin. I do clean them once a week." The Rehabilitation Technician confirmed they have only two (2) documented temperatures and cleaning on the hydrocollator and none on the paraffin unit.


On 2/18/16 at 10:00 a.m. an interview with the Physical Therapist revealed, "We are suppose to keep logs on the cleaning and temperatures of the hydrocollator and paraffin but we have not. Howeve,r we have started to keep daily logs of the temperatures and cleaning. The paraffin has not been use in over a year. The hydro collator is used just about every day."


Review of the facility's "Equipment Maintenance" policy (revised 3/1/12) revealed, "...appropriate inspection and maintenance of all equipment to ensure the safety of patients, personnel, and the public. A current record is kept of all electrical equipment safety inspections, calibrations and repairs."


2) Observation on 2/16/16 at 1:15 p.m. revealed that the facility's soiled linen was stored in a covered hamper in the hallway, instead of behind closed doors. Observation also revealed that the facility's Soiled Utility Room door had a keyless entry. In an interview with the Registered Nurse (RN) working on the hall revealed that the linen was not bagged at the bedside. Staff takes the soiled linen down the hallway by hand and disposes of it in the container labeled 'Soiled Linen' and it remains in the hallway for an indefinite period of time until picked up by Laundry personnel.

On 2/17/16 at 1:25 p.m. these findings were presented to the Director of Nurses. She provided no additional information.


3) Observation on 2/18/16 at 10:30 a.m revealed a housekeeping employee spraying a bedside table with Lysol foam spray. She sprayed the foam onto the table and immediately wiped the foam off. When the housekeeping employee was asked about this procedure, she stated that she sprays the Lysol on the surface and then wipes the spray off with a cloth. She stated that she does not leave the spray on any length of time unless the surface is sticky.


Review of the facility's "Environmental Control" policy (revised and approved on January 6, 2016) revealed, "Cleaning, Disinfecting and Sterilizing Patient-Care Equipment #10. All disinfectant solutions shall be labeled and followed according to the manufactures instructions."


Review of the Manufactures Instructions on the can of Lysol Foam Spray revealed:
1. To Sanitize pre-clean surface. Spray surface until covered with foam, leave on thirty (30) seconds before wiping.
2. To Disinfect pre-clean surface. Leave on for ten (10) minutes before wiping.