HospitalInspections.org

Based on review of hospital polices, medical record reviews, observations during tours, code cart checklist reviews, manufacturer's users guide review, and staff interviews, the nursing staff failed to: A) follow physician's orders for obtaining urine drug screens (UDS) in a timely manner for 3 of 6 patients (#32, #29, #41) reviewed with orders for UDS; B) label urine specimens per policy for 1 of 1 refrigerated urine specimens observed (#40); C) follow policy and procedures to ensure plant operations was promptly notified of the malfunctioning of an Automated External Defibrillator (AED) stored on the emergency code cart located in the out-patient Partial Hospitalization Program (PHP) building.

The findings include:

A. Review on 09/20/2012 of current hospital policy "NURSING STANDARDS OF CARE" (Policy Number: NSNS09) revealed "POLICY It is the policy that all patients admitted to (Name of Hospital) will have their nursing care delivered in accordance with established standards of care and practice. It is also policy that these standards be written, objective and used in the measurement of quality care..."

Review on 09/20/2012 of current hospital policy "LABORATORY SERVICES" (Policy Number: NS94) revealed "POLICY It is the policy of (Hospital Name) to provide laboratory services through contractual agreements. Specimens will be collected by (Hospital Name) staff..."

1. Open record review on 09/19/2012 for Patient #32 revealed a 33 year-old female admitted to 1 West (Adult/Detox), on 09/16/2012, with a diagnosis of Major Depression. Record review revealed a physician's telephone order, dated 9/16/2012 at 2030, for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect; patient refusal to collect; and of a UDS specimen collection. Review of reported lab results revealed no UDS reports for Patient #32 as of 09/19/2012.

Observations during tour on 09/20/2012 at 1045 of 1 West (Adult/Detox), revealed a Lab Log Book, Laboratory Orders and Collection Record (black notebook binder). Review of the log revealed Patient #32 had orders for UDS transcribed on 9/17/2012. Further review revealed under the column heading labeled "Date drawn" was blank. Review of the log book revealed a "Refusal" section. Review of the refusal section revealed no documentation that Patient #32 refused specimen collection for the UDS ordered on 9/16/2012 at 2030.

Interview with Patient #32 on 09/20/2012 at 1015 revealed the patient believed she was still experiencing Detox symptoms. Patient stated, "I'm still having withdrawals, I feel like I'm not being treated, they have stopped my Detox...I'm coming off more than Oxycodone..." Interview revealed the patient provided a urine specimen prior to interview on 09/20/2012 at approximately 1000.

Interview with the 1 West charge nurse on 09/20/2012 at 1000 revealed nursing staff or the unit secretary prepares requisition forms for ordered labs and places a specimen cup with the patient's name and biohazard bag onto the nursing station desk. Interview revealed nursing staff verbally communicated labs still needing collection during shift reports and the presence of the specimen cup on the desk was a visual reminder lab specimens were needed for ordered labs.

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #32 ordered on 09/16/2012 at 2030 was not collected until 09/20/12 at 1000 (UDS collected 105 hours, 30 minutes following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

2. Open record review on 09/19/2012 for Patient #29 revealed a 35 year-old male admitted on 09/17/2012 at 1558 with an admitting diagnosis of "Psychotic Disorder." Record review revealed a physician's telephone order, dated 9/17/2012 at 1840 for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect, of patient refusal to collect, and of a UDS specimen collection. Review of reported lab results revealed no UDS reports for patient #29 as of 09/19/2012.

Observations during tour on 09/19/2012 at 1400 of 1 East Adults, treatment room specimen refrigerator, revealed a urine specimen for Patient #29 awaiting collection by the contracted lab service courier.

Interview on 09/19/2012 at 1415 with medical staff revealed UDS labs should be collected on "the same day as ordered, within 24 hours is best."

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #29, ordered on 09/17/2012 at 1840, was not collected by the contracted lab service courier until 09/19/12 at 1400 (43 hours, 20 minutes. following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

3. Open record review on 09/20/2012 for Patient #41 revealed a 45 year-old female admitted on 09/16/12 at 0217 with a diagnosis of BPAD (Bipolar Affective Disorder). Record review revealed a physician's telephone order, dated 09/16/2012 at 0150 for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect, of patient refusal to collect, and of a UDS specimen collection. Review of the contracted lab service's form reporting the results of UDS revealed "Date of Collection Time: 09/17/2012 at 1131 (33 hours, 41 minutes following order)."

Interview on 09/20/12 at 11:15 with the 1 East charge nurse revealed the 1 East Unit staff placed lab requisition slips into a clear slotted wall shelf in the nurses' station. Interview revealed nursing staff communicated labs still needing collection during shift reports and presence of requisition slips in slot as a visual reminder labs specimens were needed for ordered labs.

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #41, ordered on 09/16/2012 at 0150, was collected by contracted lab service courier on 09/17/12 at 1131 (33 hours, 41 minutes following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

B. Review on 09/20/2012 of current hospital policy "LABORATORY SERVICES" (Policy Number: NS94) revealed "...PROCEDURE... Routine Specimens 1. Specimens are stored in the specimen refrigerator on each unit. 2. Label with name, identification number, date and the time specimen was obtained and initial..."

Open record review for Patient #40 on 09/20/12 revealed a 20 year-old male admitted on 09/19/12 at 2044 with an admitting diagnosis of "Mood DO (Disorder) NOS (Not Otherwise Specified)." Record review revealed a physician's telephone order, dated 09/19/2012 at 2225, for a "UDS (Urine Drug Screen)." Review of nursing notes revealed no documentation of date or time a urine specimen was obtained.

Observations during tour on 09/20/2012 at 1045 of 1 West (Adult/Detox), treatment room, specimen refrigerator, revealed a urine specimen for Patient #40, sealed in a biohazard bag with a contracted lab service's 2 part requisition form in the front slip of the biohazard bag. Review of the requisition form revealed no date or time of collection documented on the form and no staff initials signed on form. Review of the urine specimen cup revealed a patient label in place but no documentation of date or time of specimen collection and no staff initials. Observations during tour of 1 West, nursing station, revealed a Lab Log Book. Review of the Lab Log Book revealed an order for a UDS for Patient #40 listed on the log. Further review revealed under the column heading for date drawn, was blank.

Interview with administrative staff during review of the lab requisition form and specimen cup (09/20/2012 at 1045) for Patient #40 confirmed neither requisition form nor specimen cup were labeled with date and time of collection or staff initial.

Interview on 09/20/12 at 1400 with nursing administration revealed patient specimens should be labeled with date and time of collection and staff initials per hospital policy.



25936

C.) Review of current hospital policy "Medical Equipment Management Plan" Policy Number: EC.01.01.01-7 (reviewed 03/12/2012) revealed "...Emergency Procedures Written procedures are followed when medical equipment fails. These procedures include emergency clinical intervention and the location and use of backup medical equipment. In addition, Nursing Staff and all Direct Care Staff should notify the Director of Plant Operations via the hospital work order system Facility Dude of any equipment problems. Work Orders can be flagged as emergency and will be responded to immediately. ..."

Observation during tour on 09/19/2012 at 1040 of the out-patient PHP building located across the street from the main hospital revealed an exam room on the first floor. Observation within the exam room revealed an emergency code cart being stored. Observation revealed an AED stored ontop of the code cart. Observation revealed a solid red "X" displayed in the AED's status indicator window. Observation revealed when the AED's case was opened the battery to the AED was not installed. Upon installation of the battery by the PHP staff nurse on-duty, observation revealed a flashing red "X" accompanied by a chirping sound. Interview with the PHP staff nurse during the observation revealed the AED was the only AED available for use in the out-patient PHP building. Interview revealed the battery to the AED had been removed due to the chirping sounds. Interview revealed the PHP staff nurse on duty Monday, 09/17/2012 had identified the AED as having a malfunctioning battery and documented it on the daily code cart check list. Interview revealed the battery had not been replaced as of 09/19/2012 (2 Days Later). Interview revealed if an AED was needed for an emergency, one would have to brought over to the PHP building from the main hospital across the street.

Review on 09/19/2012 of the Code Cart Checklist for the PHP building revealed the following documented for the AED by PHP nursing staff:
1. 09/17/2012: "...c) Blinking Status Hourglass Indicator" with a "0" hand written in the box; and "...d) Battery Removal/Self System Check" with "Need New" hand written in the box.
2. 09/18/2012: "...c) Blinking Status Hourglass Indicator" with "0" hand written in the box; and "...d) Battery Removal/Self System Check" with an arrow drawn from the box on 09/17/2012 to the box under 09/18/2012.
3. 09/19/2012: "...c) Blinking Status Hourglass Indicator" with "0" hand written in the box and "...d) Battery Removal/Self System Check" with "0" hand written in the box.

Review on 09/20/2012 of the manufacturer's user's guide for the AED (Heartstart FR2+ Defibrillator) copyright 2003 revealed on page 4-11 a status indicator of "Solid red X" with a meaning of "The battery is completely depleted or a self-test failure occurred." Further review revealed a status indicator of "Flashing red X accompanied by a chirping sound" with a meaning of "The self-test error has occurred or the battery is low or depleted."

Interview on 09/19/2012 at 1314 with the Director of the PHP program revealed the PHP staff nurse who performed the AED check on 09/17/2012 called an accounting department staff member on 09/17/2012 and requested a new battery for the AED be ordered. Interview revealed the accounting department is responsible for ordering supplies such as the AED battery. Interview revealed the PHP staff nurse did not notify the Director of Plant Operations or submit a workorder. Interview revealed the accounting department staff member did not call the Director of Plant Operations to notify him of the need to replace the AED and/or the battery. Interview revealed the PHP staff nurse on-duty on 09/17/2012 should have contacted the Director of Plant Operations and completed a work order.

Interview on 09/19/2012 at 1520 with the Director of Plant Operations revealed he was first notified of the need for an AED replacement battery today (09/19/2012). Interview revealed no work order had been entered into "Facility Dude" (hospital's computerized internal workorder system) for the AED battery replacement. Interview revealed AED batteries have to be ordered by the purchasing department. Interview revealed the new battery ordered for the AED has not arrived as of today. Interview revealed the hospital does have spare AED batteries. Interview revealed the battery in the AED has already been replaced. Interview revealed a spare battery was used from another code cart in-house. Interview revealed if he had been notified of the need to replace the AED battery on the PHP code cart on Monday 09/17/2012, "the battery could have been installed within 10 minutes of notification." Interview revealed if a piece of equipment is malfunctioning the staff are to notify plant operations and submit a work order. Interview confirmed the nursing staff failed to follow the hospital's policy.

Based on policy and procedure reviews, observations during tour, and staff interviews the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure: foods were stored in a safe and sanitary manner in the refrigerator; kitchenware/cookware was sanitized and stored in a safe and sanitary manner; sweeping was not performed during food preparation and cooking; documentation of daily chemical sanitizer strip testing and temperature checks of the triple-compartment sink; and chemical cleaning agents were stored in a safe manner within the main kitchen.

The findings include:

Review of current hospital policy "Infection Control Dietary" effective 06/05/2009, revealed "...SERVICE STANDARDS: ...Ware washing procedures ensure sanitized serviceware and prevent re-contamination. ...FOOD PREPARATION * The objective of infection control in food preparation is to use techniques to prevent the spread of disease and infection, while maintaining a high quality product output. Equipment: *All Kitchen ware and food contact surfaces used in the preparation and/or serving of food and drink are cleaned and sanitized before use and cleaned after each meal preparation. ...*After cleaning and until use, all food contact surfaces of equipment and utensils are handled and stored so as to prevent contamination. ...CLEANING: The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas. ...*Cleaning supplies are stored separate from food items and paper supplies. ...EQUIPMENT/ENVIRONMENT: ...*For pots, pans, mixer blades....*Items are washed in hot water and detergent until all debris is removed... DISHWASHING: ...*Dishes are allowed to air dry before stacking them in service area or clean dish storage area. Dishes are not to be stored when wet. Dishes are never towel dried. ..."

Review of current hospital policy "POTS & PANS CLEANING" effective 01/2007 (last reviewed 10/2011) revealed "POLICY: All cooking vessels and utensils washed manually shall be properly cleaned and sanitized after each use. PROCEDURE: ...3. A three-compartment sink is to be used to wash items manually. ...6. The third sink is filled with at least 75 (degree) water to which a sanitizer is added. ...7. Chemical strips shall always be available to test for adequate sanitizing strength in the third sink. The color codes indicated on the strip container must be verified prior to submersion into the third solution (sanitizer). The PPM (parts per million) must be....or per chemical manufacturer's instructions. ...10. Prior to the washing of items, all items are scraped of food particles and soaked as necessary to loosen baked on debris. ...13. Following sanitizing, items are placed on an adjacent drain board (or in a dishrack) to allow for thorough air-drying. ...14. Items must be completely dry before returning to storage. ..."

Review of current hospital policy "PERSONNEL & INFECTION CONTROL - PI.3 IC.4" effective 01/2007 (last reviewed 10/2011) revealed "ESSENTIAL: 3. ...c. Use only clean utensils in preparing, cooking and serving food. ...k. All food containers are kept covered during cleaning of floors. ...SANITATION AND SAFETY POLICIES: ..."...8. Procedures for washing and sanitizing dishes, glassware, silverware and patient trays are developed, posted and followed. Dish machine washing and rinsing temperatures are recorded daily. All utensils and trays are allowed to air dry; toweling of these utensils is not permitted. ...9. Procedures for washing, rinsing, and sanitizing pots, pans and other cooking utensils are developed, posted and followed. A chemical sanitizer is used in the final rinse of the pot and pan washing and is used as a final disinfectant at the end of the work day. Pots and pans are stored properly and in an orderly manner. "

Review of current hospital policy "FOOD STORAGE - TX.4.3, TX.4.4, IC.4" effective 01/07 (last reviewed 2011) revealed "PURPOSE: To hold food products in a safe and efficient manner. ...Action: ...5. Food is stored in a separate area from chemical non-food supplies. ..."

Review of current hospital policy "SAFETY PRACTICES AND PRECAUTIONS - TX.4.4, EC.1.4, EC.2.1, EC.2.2, IC.4" effective 01/07 (last reviewed 2011) revealed "...2. Receiving and Storage ...B. Potentially hazardous materials (cleaning compounds, etc.) are stored apart from food, and properly labeled. ..."

Observations during tour of the hospital's main kitchen and dining room on 09/20/2012 from 1000 to 1130 revealed the following:

1. In the main kitchen refrigeration area:
Observation at 1015 inside of the walk-in (cooler) refrigerator, revealed frozen turkeys stored in a white cardboard box on the lower shelf of a storage rack. Observation failed to reveal a leak-proof container used to collect and contain juices from leakage. Further observation revealed two rolls of ground meat product being stored on top of a white cardboard box on the shelf above the turkeys. Observation revealed red colored fluid inside the clear packaging of the meat product. Observation failed to reveal a leak-proof container used to collect and contain juices from leakage. Interview with the dietary manager during the observation revealed the turkeys had been placed in the refrigerator to thaw for use on 09/21/2012. Interview revealed the ground meat product had been placed into the refrigerator fresh and not frozen. Interview confirmed a leak-proof container was not used under the meat products and turkey to collect and contain juices from leakage. Interview revealed current dietary policies do not address the use of a leak-proof container to collect and contain juices from fresh and/or thawing meats. Interview confirmed the white cardboard boxes were not leak proof.

2. In the main dining room and kitchen storage areas:
a. Observation at 1007 in the main dining room revealed a serving counter with a coffee machine, ice machine, and soda fountain being stored. Observation revealed adjacent to the beverage machines were stacked trays containing plastic beverage cups. Observation of five (5) of five (5) sampled beverage cups revealed visible clear liquid on the inner and outer surfaces of the beverage cups. Interview with the dietary manager during the observation revealed the beverage cups were available for patient, visitor, and staff use. Interview confirmed the presence of clear liquid on the inner and outer surfaces of the sampled cups. Interview revealed the beverage cups should have been completely dry before being stacked for use. Interview revealed the beverage cups should not have been stacked wet.

b. Observation at 1042 in the main kitchen revealed a dry metal storage rack located adjacent to the triple-compartment sink used to store clean dry pots/pan. Observation of two (2) of six (6) sampled metal pans, of which two were stacked one within the other, revealed visible clear liquids on the inner and outer surface of the pans. Interview with the dietary manager during the observation revealed the metal storage rack was used to store pots/pans that had been cleaned, sanitized, and completely air dried. Interview confirmed the presence of the clear liquid on two of the metal pans sampled. Interview revealed pots/pans should be allowed to completely air dry before being placed on the dry storage rack. Interview confirmed pots/pans should not be place on the dry storage rack wet.

c. Observation at 1053 in the main kitchen revealed a large metal "Jones-Zylon" dish storage rack containing plastic serving trays and tray covers for patient meals. Observation of six (6) trays and six (6) tray lids selected revealed three (3) of six (6) trays had visible dry food particles on the inner surface of the trays. Further observation revealed three (3) of six (6) trays and/or tray lids had visible clear liquids on the inner and/or outer surfaces. Observation of the dish storage rack revealed visible pooled clear liquids on the storage shelves where trays and/or tray lids were being stored. Interview with the dietary manager during the observation revealed the dish storage rack is used to store patient serving trays and tray lids. Interview revealed the patient trays and tray lids are ready for patient use. Interview revealed patient trays and tray lids are placed on the dish storage rack wet after being washed in the dish machine and allowed to air dry on the same rack before use. Interview revealed separate racks are not used to allow for air drying and then dry storage. Interview confirmed the presence of the dried food particles on the sampled patient trays. Interview revealed the dietary staff should have inspected the trays to make sure no food particles were present before being placed on the dish storage rack. Interview confirmed the presence of the clear liquids on the inner/outer surface of the patient trays and/or lids sampled. Interview revealed the patient trays/lids should have been allowed to completely air dry before use. Interview confirmed the presence of visible clear liquids pooled on the dish storage rack shelves. Interview revealed pots/pans/utensils are stored wet and allowed to completely air dry on one rack. Once dried the pots and pans are placed onto a separate dry storage rack. Interview revealed no evidence based reason for two separate standards for air drying and storage of pots/pans/utensils versus patient trays and tray lids. Interview revealed "this has always been the process."

3. In the main kitchen food preparation and cooking areas:
a. Observation at 1030 revealed dietary staff member #1 (DSM #1) sweeping the floor in the dry storage room. Observation revealed DSM #1 exited the dry storage room with a broom and dust pan in hand. Observation revealed DSM #1 walked from the dry storage room into the vegetable preparation area and emptied the dust pan (using a repeated up/down shaking motion) over the trash bin located directly in-front of and less than 6 inches from the vegetable prep sink/table. Observation revealed, simultaneously, DSM #2 was standing adjacent to the trash bin and directly in-front of the vegetable sink/table cutting-up lettuce and placing the lettuce into a large uncovered clear plastic container on the vegetable table. Observation revealed the container was located directly in-front of the trash bin. Observation revealed DSM #2 was using the trash bin to discard unused pieces of lettuce during preparation. Observation confirmed DSM #1 emptied the dust pan while food was uncovered and being prepared. Interview with the dietary manager during the observation confirmed DSM #1 should not have emptied the dust pan into the trash bin while food was uncovered and being prepared by DSM #2 in the vegetable preparation area. Interview confirmed sweeping should not occur during food preparation.

b. Observation at 1038 revealed dietary staff member #3 (DSM #3) sweeping the floor in the cooking area adjacent to the soup vat and stoves. Observation revealed food being cooked in the soup vat (appeared to be noodles). Observation reveled the soup vat lid was not closed and the food was uncovered. Interview with the dietary manager during the observation confirmed DSM #3 should not have been sweeping while food was uncovered and being cooked in the cooking area. Interview confirmed sweeping should not occur during food preparation and cooking.

4. In the triple-compartment sink area:
Observation at 1040 of the triple-compartment sink revealed the dietary staff used water requiring a minimal temperature and a chemical sanitizer solution requiring a minimal parts per million concentration (PPM) to sanitize pots/pans/utensils. A request was made to review the monitoring log used by dietary staff to record daily temperatures and sanitizing solution (PPM) concentrations in order to ensure proper sanitization. Interview with the dietary manager during the observation revealed the dietary staff did not document the temperatures or PPM concentrations test performed. Interview revealed a monitoring log was not maintained. Interview revealed the staff check the temperatures and PPM concentrations daily. Interview revealed the dietary manager observes the staff perform the tests each morning. Interview revealed the dietary manger works Monday thru Friday and every third weekend. Interview revealed on days when the dietary manger is off work or absent from work, there is no process in place to ensure staff performed the temperature and PPM tests as required nor to track when temperatures and PPM concentrations test were not acceptable or not performed.

5. In the dish machine room:
Observation at 1104 revealed a bottle of chemical cleaning agent (Clorox) being stored on the same shelf as clean kitchenware/cookware used for preparing and serving food. Interview during the observation with the dietary manager revealed the chemical cleaning agent should have been stored in the janitorial closet and not on the shelf with the clean kitchenware/cookware.

Based on policy and procedure reviews, observations during tour, and staff interviews the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure: foods were stored in a safe and sanitary manner in the refrigerator; kitchenware/cookware was sanitized and stored in a safe and sanitary manner; sweeping was not performed during food preparation and cooking; documentation of daily chemical sanitizer strip testing and temperature checks of the triple-compartment sink; and chemical cleaning agents were stored in a safe manner within the main kitchen.

The findings include:

Review of current hospital policy "Infection Control Dietary" effective 06/05/2009, revealed "...SERVICE STANDARDS: ...Ware washing procedures ensure sanitized serviceware and prevent re-contamination. ...FOOD PREPARATION * The objective of infection control in food preparation is to use techniques to prevent the spread of disease and infection, while maintaining a high quality product output. Equipment: *All Kitchen ware and food contact surfaces used in the preparation and/or serving of food and drink are cleaned and sanitized before use and cleaned after each meal preparation. ...*After cleaning and until use, all food contact surfaces of equipment and utensils are handled and stored so as to prevent contamination. ...CLEANING: The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas. ...*Cleaning supplies are stored separate from food items and paper supplies. ...EQUIPMENT/ENVIRONMENT: ...*For pots, pans, mixer blades....*Items are washed in hot water and detergent until all debris is removed... DISHWASHING: ...*Dishes are allowed to air dry before stacking them in service area or clean dish storage area. Dishes are not to be stored when wet. Dishes are never towel dried. ..."

Review of current hospital policy "POTS & PANS CLEANING" effective 01/2007 (last reviewed 10/2011) revealed "POLICY: All cooking vessels and utensils washed manually shall be properly cleaned and sanitized after each use. PROCEDURE: ...3. A three-compartment sink is to be used to wash items manually. ...6. The third sink is filled with at least 75 (degree) water to which a sanitizer is added. ...7. Chemical strips shall always be available to test for adequate sanitizing strength in the third sink. The color codes indicated on the strip container must be verified prior to submersion into the third solution (sanitizer). The PPM (parts per million) must be....or per chemical manufacturer's instructions. ...10. Prior to the washing of items, all items are scraped of food particles and soaked as necessary to loosen baked on debris. ...13. Following sanitizing, items are placed on an adjacent drain board (or in a dishrack) to allow for thorough air-drying. ...14. Items must be completely dry before returning to storage. ..."

Review of current hospital policy "PERSONNEL & INFECTION CONTROL - PI.3 IC.4" effective 01/2007 (last reviewed 10/2011) revealed "ESSENTIAL: 3. ...c. Use only clean utensils in preparing, cooking and serving food. ...k. All food containers are kept covered during cleaning of floors. ...SANITATION AND SAFETY POLICIES: ..."...8. Procedures for washing and sanitizing dishes, glassware, silverware and patient trays are developed, posted and followed. Dish machine washing and rinsing temperatures are recorded daily. All utensils and trays are allowed to air dry; toweling of these utensils is not permitted. ...9. Procedures for washing, rinsing, and sanitizing pots, pans and other cooking utensils are developed, posted and followed. A chemical sanitizer is used in the final rinse of the pot and pan washing and is used as a final disinfectant at the end of the work day. Pots and pans are stored properly and in an orderly manner. "

Review of current hospital policy "FOOD STORAGE - TX.4.3, TX.4.4, IC.4" effective 01/07 (last reviewed 2011) revealed "PURPOSE: To hold food products in a safe and efficient manner. ...Action: ...5. Food is stored in a separate area from chemical non-food supplies. ..."

Review of current hospital policy "SAFETY PRACTICES AND PRECAUTIONS - TX.4.4, EC.1.4, EC.2.1, EC.2.2, IC.4" effective 01/07 (last reviewed 2011) revealed "...2. Receiving and Storage ...B. Potentially hazardous materials (cleaning compounds, etc.) are stored apart from food, and properly labeled. ..."

Observations during tour of the hospital's main kitchen and dining room on 09/20/2012 from 1000 to 1130 revealed the following:

1. In the main kitchen refrigeration area:
Observation at 1015 inside of the walk-in (cooler) refrigerator, revealed frozen turkeys stored in a white cardboard box on the lower shelf of a storage rack. Observation failed to reveal a leak-proof container used to collect and contain juices from leakage. Further observation revealed two rolls of ground meat product being stored on top of a white cardboard box on the shelf above the turkeys. Observation revealed red colored fluid inside the clear packaging of the meat product. Observation failed to reveal a leak-proof container used to collect and contain juices from leakage. Interview with the dietary manager during the observation revealed the turkeys had been placed in the refrigerator to thaw for use on 09/21/2012. Interview revealed the ground meat product had been placed into the refrigerator fresh and not frozen. Interview confirmed a leak-proof container was not used under the meat products and turkey to collect and contain juices from leakage. Interview revealed current dietary policies do not address the use of a leak-proof container to collect and contain juices from fresh and/or thawing meats. Interview confirmed the white cardboard boxes were not leak proof.

2. In the main dining room and kitchen storage areas:
a. Observation at 1007 in the main dining room revealed a serving counter with a coffee machine, ice machine, and soda fountain being stored. Observation revealed adjacent to the beverage machines were stacked trays containing plastic beverage cups. Observation of five (5) of five (5) sampled beverage cups revealed visible clear liquid on the inner and outer surfaces of the beverage cups. Interview with the dietary manager during the observation revealed the beverage cups were available for patient, visitor, and staff use. Interview confirmed the presence of clear liquid on the inner and outer surfaces of the sampled cups. Interview revealed the beverage cups should have been completely dry before being stacked for use. Interview revealed the beverage cups should not have been stacked wet.

b. Observation at 1042 in the main kitchen revealed a dry metal storage rack located adjacent to the triple-compartment sink used to store clean dry pots/pan. Observation of two (2) of six (6) sampled metal pans, of which two were stacked one within the other, revealed visible clear liquids on the inner and outer surface of the pans. Interview with the dietary manager during the observation revealed the metal storage rack was used to store pots/pans that had been cleaned, sanitized, and completely air dried. Interview confirmed the presence of the clear liquid on two of the metal pans sampled. Interview revealed pots/pans should be allowed to completely air dry before being placed on the dry storage rack. Interview confirmed pots/pans should not be place on the dry storage rack wet.

c. Observation at 1053 in the main kitchen revealed a large metal "Jones-Zylon" dish storage rack containing plastic serving trays and tray covers for patient meals. Observation of six (6) trays and six (6) tray lids selected revealed three (3) of six (6) trays had visible dry food particles on the inner surface of the trays. Further observation revealed three (3) of six (6) trays and/or tray lids had visible clear liquids on the inner and/or outer surfaces. Observation of the dish storage rack revealed visible pooled clear liquids on the storage shelves where trays and/or tray lids were being stored. Interview with the dietary manager

Based on review of hospital polices, medical record reviews, observations during tours, code cart checklist reviews, manufacturer's users guide review, and staff interviews, the nursing staff failed to: A) follow physician's orders for obtaining urine drug screens (UDS) in a timely manner for 3 of 6 patients (#32, #29, #41) reviewed with orders for UDS; B) label urine specimens per policy for 1 of 1 refrigerated urine specimens observed (#40); C) follow policy and procedures to ensure plant operations was promptly notified of the malfunctioning of an Automated External Defibrillator (AED) stored on the emergency code cart located in the out-patient Partial Hospitalization Program (PHP) building.

The findings include:

A. Review on 09/20/2012 of current hospital policy "NURSING STANDARDS OF CARE" (Policy Number: NSNS09) revealed "POLICY It is the policy that all patients admitted to (Name of Hospital) will have their nursing care delivered in accordance with established standards of care and practice. It is also policy that these standards be written, objective and used in the measurement of quality care..."

Review on 09/20/2012 of current hospital policy "LABORATORY SERVICES" (Policy Number: NS94) revealed "POLICY It is the policy of (Hospital Name) to provide laboratory services through contractual agreements. Specimens will be collected by (Hospital Name) staff..."

1. Open record review on 09/19/2012 for Patient #32 revealed a 33 year-old female admitted to 1 West (Adult/Detox), on 09/16/2012, with a diagnosis of Major Depression. Record review revealed a physician's telephone order, dated 9/16/2012 at 2030, for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect; patient refusal to collect; and of a UDS specimen collection. Review of reported lab results revealed no UDS reports for Patient #32 as of 09/19/2012.

Observations during tour on 09/20/2012 at 1045 of 1 West (Adult/Detox), revealed a Lab Log Book, Laboratory Orders and Collection Record (black notebook binder). Review of the log revealed Patient #32 had orders for UDS transcribed on 9/17/2012. Further review revealed under the column heading labeled "Date drawn" was blank. Review of the log book revealed a "Refusal" section. Review of the refusal section revealed no documentation that Patient #32 refused specimen collection for the UDS ordered on 9/16/2012 at 2030.

Interview with Patient #32 on 09/20/2012 at 1015 revealed the patient believed she was still experiencing Detox symptoms. Patient stated, "I'm still having withdrawals, I feel like I'm not being treated, they have stopped my Detox...I'm coming off more than Oxycodone..." Interview revealed the patient provided a urine specimen prior to interview on 09/20/2012 at approximately 1000.

Interview with the 1 West charge nurse on 09/20/2012 at 1000 revealed nursing staff or the unit secretary prepares requisition forms for ordered labs and places a specimen cup with the patient's name and biohazard bag onto the nursing station desk. Interview revealed nursing staff verbally communicated labs still needing collection during shift reports and the presence of the specimen cup on the desk was a visual reminder lab specimens were needed for ordered labs.

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #32 ordered on 09/16/2012 at 2030 was not collected until 09/20/12 at 1000 (UDS collected 105 hours, 30 minutes following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

2. Open record review on 09/19/2012 for Patient #29 revealed a 35 year-old male admitted on 09/17/2012 at 1558 with an admitting diagnosis of "Psychotic Disorder." Record review revealed a physician's telephone order, dated 9/17/2012 at 1840 for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect, of patient refusal to collect, and of a UDS specimen collection. Review of reported lab results revealed no UDS reports for patient #29 as of 09/19/2012.

Observations during tour on 09/19/2012 at 1400 of 1 East Adults, treatment room specimen refrigerator, revealed a urine specimen for Patient #29 awaiting collection by the contracted lab service courier.

Interview on 09/19/2012 at 1415 with medical staff revealed UDS labs should be collected on "the same day as ordered, within 24 hours is best."

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #29, ordered on 09/17/2012 at 1840, was not collected by the contracted lab service courier until 09/19/12 at 1400 (43 hours, 20 minutes. following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

3. Open record review on 09/20/2012 for Patient #41 revealed a 45 year-old female admitted on 09/16/12 at 0217 with a diagnosis of BPAD (Bipolar Affective Disorder). Record review revealed a physician's telephone order, dated 09/16/2012 at 0150 for a UDS (Urine Drug Screen). Review of nursing notes revealed no documentation: of attempts to collect, of patient refusal to collect, and of a UDS specimen collection. Review of the contracted lab service's form reporting the results of UDS revealed "Date of Collection Time: 09/17/2012 at 1131 (33 hours, 41 minutes following order)."

Interview on 09/20/12 at 11:15 with the 1 East charge nurse revealed the 1 East Unit staff placed lab requisition slips into a clear slotted wall shelf in the nurses' station. Interview revealed nursing staff communicated labs still needing collection during shift reports and presence of requisition slips in slot as a visual reminder labs specimens were needed for ordered labs.

Interview on 09/20/12 at 1400 with nursing administration revealed routine UDS should be collected within 24 hours following order. Interview confirmed UDS for Patient #41, ordered on 09/16/2012 at 0150, was collected by contracted lab service courier on 09/17/12 at 1131 (33 hours, 41 minutes following order). Interview revealed current policy does not clearly define time frames for "routine" and "stat" labs from time of order to time of actual collection by nursing staff. Interview revealed procedures varied from unit to unit. Interview revealed nursing administration had identified patient refusals as a factor delaying performance of blood sugar monitoring and were beginning to tract patient lab refusals.

B. Review on 09/20/2012 of current hospital policy "LABORATORY SERVICES" (Policy Number: NS94) revealed "...PROCEDURE... Routine Specimens 1. Specimens are stored in the specimen refrigerator on each unit. 2. Label with name, identification number, date and the time specimen was obtained and initial..."

Open record review for Patient #40 on 09/20/12 revealed a 20 year-old male admitted on 09/19/12 at 2044 with an admitting diagnosis of "Mood DO (Disorder) NOS (Not Otherwise Specified)." Record review revealed a physician's telephone order, dated 09/19/2012 at 2225, for a "UDS (Urine Drug Screen)." Review of nursing notes revealed no documentation of date or time a urine specimen was obtained.

Observations during tour on 09/20/2012 at 1045 of 1 West (Adult/Detox), treatment room, specimen refrigerator, revealed a urine specimen for Patient #40, sealed in a biohazard bag wi