HospitalInspections.org

Based on document review, staff interview and observation it was determined the Human Resources (HR) Director of Dietetic Services failed to ensure all freezers were monitored to maintain temperatures within recommended ranges. This deficient practice was identified on two (2) of two (2) freezers located in the kitchen area. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of Dietetic Services was conducted on 11/27/17 at 10:50 a.m. It was observed the "freezer log" was incomplete for two (2) of two (2) freezers located in the kitchen area. Freezer #1 log, location #13, had not been checked to monitor temperatures from 11/1/17 to 11/27/17. Freezer #2 log, location #8, had not been checked to monitor temperatures from 11/1/17 to 11/2/17, 11/7/17 to 11/10/17, 11/13/17 to 11/18/17 and 11/20/17 to 11/24/17.

2. A review of the policy and procedure titled "Cold Storage Temperatures" revealed it states, in part: "Temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies."

3. An interview was conducted with the HR Director of Dietetic Services on 11/29/17 at 12:30 p.m.. She concurred the policy for monitoring the temperatures of freezers was not followed.

Based on observation, staff interview and document review it was determined the hospital failed to ensure patient supplies and food were kept separated from cleaning supplies in four (4) of six (6) patient care units toured. This failure has the potential for all patient supplies and food to be contaminated by cleaning chemicals that can cause harm to all patients who use food and supplies provided by the hospital.

Findings include:

1. A tour of the hospital was conducted on 11/27/17 from 12:45 p.m. through 4:15 p.m. with the Vice President of Quality and Safety. The following units each contain a clean utility room stocked with patient supplies, food and chemicals: Orthopedics Unit, Intensive Care Unit, Pediatric Unit and Progressive Care Unit. Observation of these units revealed there was no separation of food, supplies and chemicals.

2. An interview conducted during the tour with the Vice President of Quality and Safety revealed the hospital does not have a policy on the separation of supplies, food and chemicals and he stated, "This is not acceptable".

3. A review of the hospital infection control program revealed the hospital follows the Centers for Disease Control (CDC) guidelines. A review of the CDC guidelines titled "Guidelines for Environmental Infection Control in Health-Care Facilities" revealed it stated, in part: "A mixture of caustic, nutritional, and patient care supplies in the same area creates an unsanitary environment which has the potential to negatively impacts all patients."

4. An interview was conducted on 11/27/17 at 4:30 p.m. with the Vice President of Quality and Safety and he concurred with the above findings.

Based on document review and staff interview it was determined the hospital failed to ensure the Operating Room (OR) Register was completed in its entirety. This deficient practice was identified in the October and November 2017 OR registers. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the OR Registers for October and November 2017 revealed the age of patients is not indicated on the registers.

2. An interview with the Vice President of Quality and Safety on 11/28/17 at 12:30 p.m. revealed the hospital does not have a policy for the OR Register.

3. An interview was conducted with the Assistant Director of Nursing/Surgical Department on 11/28/17 at 12:40 p.m. She concurred the age of the patient is not indicated on the OR Registers.