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Based on observation, record review and interviews, the facility failed to ensure a clean and sanitary environment for the kitchen.
The findings were:
Observations on 2/26/14 at 9:35 a.m. during the tour of the facility kitchen revealed:
1. The rubber seal around the oven door was eroded and falling apart. There was also dust under the oven door.
2. There was grease and rust on top of the oven.
3. The vent hood area was dusty.
4. The wall by the oven/stove area was stained and dirty.
5. The plastic lid the flour bin was cracked.
6. The can opener was rusty.
Record review of the facilities policies and procedures (P and P) revealed:
The P and P for Sanitation and Safety, last reviewed 2/99 stated " The dietary department supervisor and the consultant are responsible for supervising sanitation and housekeeping procedures within the dietary department.
The P and P for Storage, last reviewed 2/99 stated " Dry staples are stored in tightly sealed plastic containers. "
The P and P for Care of Walls in the Dietary Department, last reviewed 9-9-94, stated " Walls that become heavily soiled must be washed. Walls should be checked and spot cleaned every Wednesday as scheduling permits. Walls must be kept clean and free of dust, moisture, grease, grime and mildew. "
The P and P for Cleaning of the Hood and Hood Filters, last reviewed 9-9-94 stated " Hoods may become a sanitary hazard if they are not kept clean because the drip from the hood may fall onto food and contaminate it. "
The P and P for Range Oven, last reviewed 9-9-94 stated the oven is to be cleaned daily.
The P and P titled Bench Can Opener, last reviewed 9-9-94 stated the can opener is to be cleaned daily.
Interview on 2/26/14 at 9:56 a.m. with the facility staff (S#12) confirmed the findings.

1. Based on an inspection, review of policies and procedures, and staff interviews Jackson Healthcare Center failed to adhere to nationally recognized standards of practice.
The findings included:
a. An inspection of the emergency department conducted with staff member # on 2/25/14 at 2:25 p.m. revealed multiple dose vials of novolin insulin and sensorcaine in the refrigerator with labels that did not include the initials of the person who opened them or an expiration date.
b. Following her review of the findings the department manager acknowledged the medications labels and the policy and procedure regarding labeling multiple dose vials did not meet current recognized standards of practice.

Based on record reviews and interviews with facility staff, the facility failed to ensure that it's Quality Assurance Performance Improvement Program included all hospital services that were directly provided or contracted by the hospital.

Findings included:

Record review of a hospital policy entitled Performance Improvement Plan Subject: Quality Assessment/Performance Improvement Function, last revised 12/21/2009, revealed but was not limited to: "This plan is an on-going program that will show measurable improvement in indicators for which there is evidence that they will improve health outcomes and identify and reduce medical errors. To this end, the hospital will assess all areas of hospital services and operations. Based on this information the hospital will prioritize the improvement activities that most directly affect patient safety and clinical outcomes. The hospital's cadre of department managers is on the "front line" of the delivery of health services. As such, this group is individually and collectively able to immediately identify opportunities for performance improvement projects. The hospital has built responsibility for identifying quality improvement tactics into the job responsibility of its department heads."

Record review of Performance Meeting Minutes, held monthly from 09/13/13 to 02/14/14, revealed no discussion of quality indicators for the Outpatient Mental Health Program, the laboratory department, the dietary department, the respiratory therapy department (inpatient and outpatient), and contracted Emergency Room Physicians.

Interview on 02/25/14 in the afternoon with the Program Director (Staff #4) of the contracted outpatient geriatric mental health services program revealed that she used quality indicators within the program to evaluate the effectiveness of the program but these quality indicators were not a part of a hospital wide Quality Assurance Performance Improvement Program. Staff # 4 was not listed as part of the Performance Improvement Committee.

Interview on 02/26/14 at 11:40 AM with the Director of the Laboratory (Staff #8) in the laboratory services department revealed she was not aware of a quality assessment plan or a quality assessment team with established identified quality indicators. Staff #8 explained the laboratory department had their own quality control for their equipment that is kept within their department. Staff #8 confirmed it was not integrated into a hospital-wide team unless there was an adverse event.

Interview on 02/26/14 at 1:0 PM with the facility Dietitian (Staff #12) revealed that she has worked as a full-time employee of the facility for 5 months and was providing contracted services prior to then. She indicated that she utilizes checking temperatures and limited patient satisfaction surveys as quality indicators within the Dietary Department but this information is not shared outside of the dietary department. Staff #12 confirmed she is not part of the Performance Improvement Team.

Interview on 02/26/14 at 1:10 PM with the Respiratory Services Manager (Staff #11) in the respiratory services department revealed he was not aware of a hospital wide Quality Assurance Performance Improvement Plan that include quality indicators for his department.

Interview on 02/26/14 with the Director of the Emergency Department (Staff #5) revealed the Emergency Department physician services were contracted. She stated the facility Performance Improvement team does not do an evaluation on the services of these physicians unless a root cause analysis is required to an adverse event.

Interview on 02/16/14 at 1:30 PM with Staff #10, who served as Director of Quality and was Chairman of the Performance Improvement Committee, revealed she could not provide a hospital-wide Quality Assurance Performance Improvement Plan with established quality indicators for each department approved by the administrator, medical staff and governing body. She confirmed that not all department heads report to the Performance Improvement Committee. She confirmed that she does not use the hospital policy entitled Performance Improvement Plan Subject: Quality Assessment/Performance Improvement Function, last revised 12/21/2009, as a guide for establishing a Quality Assurance Performance Improvement Plan.