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Based on observation, interview, and document review, it was determined the Hospital failed to ensure proper supervision of food service to ensure safe food was available for patient consumption. This potentially affected an average of 52 patients per day.

As a result the Condition of Participation 42 CFR 482.28, Food and Dietetic Service was not met.

Finding includes:

1. The Hospital failed to ensure breakfast food temperatures were monitored as required. See deficiency at A 620.

A. Based on observation, document review, and interview, it was determined for 2 of 2 (Pt. #'s 8 and 9) clinical records reviewed of "high fall risk patients", the Hospital failed to ensure proper identification.

Findings include:

1. On 1/10/17 between 9:45 AM and 10:35 AM, an observational tour of the Hospital's patient care unit (North Section, Rooms 131 to 150) was conducted. During the tour a "yellow strip" used to identify high risk patients, was not seen displayed outside the door of Pt.'s # 8 and 9.

2. On 1/10/17 at approximately 10:25 AM, the Hospital's Fall Precaution Protocol (undated) was reviewed and indicated, "...Greater than 45 Morse Fall Assessment Score: High Risk... 4. Place identifier of high fall risk in patient room..."

3. On 1/10/17 at approximately 10:15 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 71 year old female admitted on 12/31/16 with diagnoses of back pain, vertebroplasty (injection of bone cement into a fractured vertebra). Pt. #8's clinical record contained documentation of a nursing fall risk assessment dated 1/3/17, that indicated that Pt. #8 had a Morse Fall Risk Score of 60.

4. On 1/10/17 at approximately 10:30 AM, the clinical record of Pt. #9 was reviewed. Pt. #9 was a 68 year old female admitted on 1/4/17 with diagnoses of stroke, left hemiplegia. Pt #9's clinical record contained a nursing fall risk assessment dated 1/4/17 that indicated that Pt. #9 had a Morse Fall Risk Score of 55.

5. During an interview on 1/10/17 at approximately 10:30 AM, findings were discussed with E #2 (Hospital Educator). E #2 stated that when patient's are identified as high fall risk, a "yellow slider" is placed outside the patient's door. E #2 added that staff have been educated to look at patient's Morse Fall Risk Score when providing patient care.

6. During the interview on 1/10/17 at approximately 10:30 AM, E #3 (licensed practical nurse assigned to Pt. #8) was also interviewed. E #3 stated that Pt. #8 was not a high risk for falls and commented, "a report is given if a patient has been identified as high risk for falls." E #3 stated that, "I don't look at the Morse Fall Risk Score."

7. On 1/10/17 at approximately 1:00 PM, the Hospital's policy titled, "Facility Fall Prevention Program" (effective 7/23/01) was reviewed and indicated, "...C.1. When a patient is identified as high risk for fall... 2. Yellow strip will be placed outside the door to identify patients as high risk."

B. Based on document review and interview it was determined for 1 of 4 (Pt. #8) patients with an order for blood glucose monitoring, the Hospital failed to ensure physicians' order was followed as written.

Findings include:

1. On 1/10/17 at approximately 10:15 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 71 year old female admitted on 12/31/16 with diagnoses of back pain and vertebroplasty. Pt #8's clinical record contained a physician's order dated 12/31/16 at 8:52 PM that included, "Blood Glucose Monitoring... q AM (every morning)." Pt #8's clinical record lacked documentation of blood glucose monitoring on 1/1/17, 1/3/17, and 1/7/17.

2. During an interview on 1/10/17 at approximately 10:20 AM, the Hospital Educator (E #2) stated she could not find the blood glucose monitoring results on the said dates [01/1/17, 01/3/17, 01/7/17] and stated it should have been done as ordered.

Based on document review, and interview, it was determined for 5 of 6 ( Pts' #2, 3, 8, 6 and 9) clinical records reviewed of patients in isolation, the Hospital failed to ensure the interdisciplinary plan of care (IPOC) was complete to include isolation precautions.

Findings include:

1. The clinical record of Pt. #2 was reviewed on 1/10/17. Pt. #2 was a 76 year old male admitted on 1/6/17 with a diagnosis of CVA (cerebral vascular accident - stroke). A physician's order dated 1/6/17 at 3:25 PM included, "contact isolation for c-diff (clostridium difficile - bacteria in the colon)." As of 1/10/17, the plan of care dated 1/6/17 at 3:01 PM failed to include the c-diff or isolation.

2. The clinical record of Pt. #3 was reviewed on 1/10/17. Pt. #3 was a 67 year old male admitted on 12/15/16 with a diagnosis of spinal cord injury. Pt #3's clinical record contained a physician's order dated 12/15/16 at 11:03 PM included, "Contact precautions - MRSA (methicillin-resistant staphylococcus aureous - infection)." The plan of care dated 12/15/16 and the plan of care updates (12/26/16, 1/1/17 and 1/9/17) did not include the MRSA or isolation.

3. On 1/10/17 at approximately 10:15 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 71 year old female admitted on 12/31/16 with diagnoses of back pain and vertebroplasty (injection of bone cement into a fractured vertebra). Pt. #8's clinical record contained a physician's order dated 12/31/16 at 7:50 PM that indicated, "Patient Isolation...Contact Precaution, Reason: MRSA...VRE..." As of 1/11/17, the care plan dated 1/10/17 at 7:43 AM lacked documentation (and has not been updated) to include the above problem (isolation).

4. The clinical record for E #6 was reviewed on 1/10/17 at approximately 10:30 AM. Pt. #6 was 72 year old male admitted on 1/7/17 with a diagnosis of brain abscess. The clinical record included a physician order dated 1/7/17 at 6:31 PM, for contact precaution for history of MRSA (Methycillin Resistant Staphylococcus Aureus). The IPOC did not address the isolation order/precaution.

5. On 1/10/17 at approximately 10:30 AM, the clinical record of Pt. #9 was reviewed. Pt. #9 was a 68 year old female admitted on 1/4/17 with diagnoses of stroke and left hemiplegia [paralysis]. Pt. #9's clinical record included a physician order dated 1/06/17 at 1:13 PM that indicated, "Patient Isolation... Contact Precaution, Reason: MRSA..." As of 1/11/17, the care plan dated 1/09/17 at 3:44 AM lacked documentation (and has not been updated) to include the above problem (isolation).

6. Hospital policy titled "Interdisciplinary Plan of Care" (rev. 10/15) was reviewed on 1/10/17 at approximately 12:30 PM required, "It is the policy...that each patient admitted will have IPOCs (Interdisciplinary Plan of Care). The interdisciplinary Team will complete the IPOC following patient assessment...Long term goals are identified by the IDT (Interdisciplinary Team) for each problem area...Short Term goals will be recorded upon development of the IPOC and when new goals are determined...The plan must include anticipated interventions..."

7. On 1/10/17 at approximately 10:30 AM and 12:50 PM, the findings were discussed with the Hospital Educator (E #2), who acknowledged the IPOCs lacked the inclusion of isolation precautions and they should have been included.

8. During an interview on 1/10/17 at approximately 10:30 AM, the Infection Control/Employee Health nurse (E#1) stated, "The isolation is not included in the plan of care and should be".

Based on document review and interview, it was determined the Hospital failed to ensure the medical records were completed as required by the Hospital Policy.

Findings include:

1. On 1/11/17 at approximately 11:00 AM, the Hospital's policy titled, "Discharge Audit of Medical Records & Notification to Physicians and Clinical Staff Regarding Incomplete and Delinquent Records' (effective 7/23/01) was reviewed and indicated, "...Policy...Records of discharged patients are to be completed within a timeframe not to exceed thirty (30) days following discharge... Delinquent Record: Discharged records 30 days or more post discharge..."

2. On 1/11/17 at approximately 10:45 AM, the Health Information Supervisor (E #5) provided an attestation letter that included, "As of today, January 11, 2017... (the Hospital) has five medical records that are delinquent..."

3. On 1/11/17 at approximately 10:00 AM, E # 5 stated that the medical record should be complete within 30 days after discharge.

Based on observation, document review and interview, it was determined that the Hospital failed to ensure food temperatures were monitored as required. This potentially affected all patients receiving meals from the Hospital's kitchen, an average of 52 per day.

Findings include:

1. On 1/11/17 at approximately 11:30 AM an observational tour of the Hospital's dietary department was conducted. During the tour the Service Line Log for 2017 were reviewed. The log indicated food was to be heated to a temperature of 165 degrees or above. The log contained sheets monitoring temperatures for lunch and dinner meals but did not include temperature monitoring sheets for breakfast meals.

2. Hospital policy entitled, "Food Handling and Preparation," (review/revision date 5/16) required, "Policy: All foods shall be handled and prepared in such a manner to ensure their safety and quality by adhering to standards and procedures outlined below...Procedure: A. Maintain all potentially hazardous foods at specific safe temperatures. These include but not limited to eggs, dressing and perishables, especially raw meats...c. Foods are cooked at the correct temperatures according to recipes or HACCP (Hazard Analysis-Critical Control Point) guidelines."

3. E #6 stated during an interview on 1/11/17 at approximately 12:00 PM, that the cooks monitor the temperatures, but the breakfast meal is not being monitored.

4. On 1/11/17 at approximately 12:05 PM, the morning Cook (E #7) was interviewed. E #7 stated that he has not monitored the breakfast temperatures for 5 to 6 years. He stated that it is a waste of time because the food will get cold.

5. The Hospital's HACCP manual (revised July 2000), was reviewed on 1/12/17 at approximately 9:00 AM. The manual required the temperature of all cooked food items to be at least 165 degrees.

6. E #7 stated, during an interview on 1/12/17 at approximately 9:05 AM, that the Hospital follows the HACCP guidelines.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on January 10 - 11, 2017, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. Only standard level deficiencies were observed during the survey walk-through.
See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that for 1 of 2 (South) crash carts, the Hospital failed to ensure routine daily checks were performed to ensure proper functioning of the equipment as required. This potentially affected approximately 54 patients (average daily census) in the Hospital.

Findings include:

1. The Hospital policy titled, "Response Cart Inspection (reviewed 2/15). The policy required, "RN's will be assigned to check the Code response cart and AED (automated external defibrillator) monitor on a daily schedule during the night shift and record the results on the response cart check sheet".

2. An observational tour of the Hospital was conducted on 1/10/17 at 10:00 AM. The "First Response Cart South Station" log was reviewed from 12/1/16 to present. The log lacked documentation of daily checks on the following days: 12/2/16; 12/5/16; 12/15/16; 12/22/16; 12/23; 12/28/16; 1/3/17; and 1/9/17.

3. During an interview on 1/10/17 at approximately 10:30 AM, the Infection Control/Employee Health Nurse (E#1) stated, "The first response cart should be checked everyday and documented".

Based on document review and interview, it was determined for 1 of 2 (Pt. #24 ) clinical records reviewed of patients discharged to home with home care services, the Hospital failed to ensure patient was provided with a list of available home care agencies.

Findings include:

1. On 1/12/17 at approximately 1:30 PM, the Hospital policy titled, "Home Health Referral List" (reviewed 4/16 ) was reviewed and indicated, "...Policy: Patient referred for Home Health Services are provided a list of licensed Home Health Agencies that service the area in which the patient resides, and provides services that meet patient needs."

2. Hospital document entitled, "Home Health Patient Choice List," (dated 4/11) required, "...This is your choice. Attached is a list of providers in the area who have requested to be on this list...You may select a provider from this list or any other provider you desire...After discussing my choices with my Case Manager, I choose the following Home Health Agency as my preferred home health provider..." The form required both the signature of the patient and Case Manager.

3. On 1/12/17 at approximately 10:00 AM, the clinical record of Pt. #24 was reviewed. Pt. #24 was an 83 year old male patient with the diagnosis of left above the knee amputation. Pt. #24 was discharged on 11/4/16 with home care services. Pt #24's clinical record lacked a signed copy of the "Home Health Patient Choice List" indicating Pt #24 was provided with a list of home care agencies.

4. During an interview on 1/12/17 at approximately 11:00 AM, the Director of Case Management (E #8) stated the documentation (Home Health Patient Choice List) could not be found.