HospitalInspections.org

Based on contract reviews, medical staff roster review, call schedule review, and staff interview, the hospital's governing body failed to ensure telemedicine services (Virtual Hospitalist) were furnished to hospital patients via written agreement that specified the distant-site telemedicine entity (DSE) was a contractor of services to the hospital and as such, in accordance with §485.635(c)(4)(ii), furnished the contracted services in a manner that enabled the hospital to comply with all applicable conditions of participation for contracted services for 1 of 3 telemedicine service contracts reviewed (Contract #1).

The findings include:

Review on 06/04/2015 at 0945 of Contract #1, revealed "Addendum to Professional Services Agreement" made and entered into as of 09/30/2014, by and between (Hospital A) Physician Network, Inc. and (DSE #1) Physicians Network, Inc., revealed "...Effective as of October 1, 2014, (DSE #1) will provide the following providers for the provision of hospitalist services..." Review of the written agreement failed to reveal any available documentation that specified DSE #1 was a distant-site telemedicine entity and was a contractor of "Virtual Hospitalist" telemedicine services to Hospital A.

Review on 06/05/2015 of a medical staff roster dated 06/05/2015 for Hospital A, revealed "Virtual (telemedicine) Hospitalist" with four (4) medical doctors listed as active medical staff.

Review on 06/05/2015 of the "May 2015 Physician Call Schedule" for Hospital A, revealed "Virtual Care Hospitalist pager....please enter the following numbers to indicate which department the physician needs to call back:....**If response is not received within 15 minutes, call....and ask to be connected to....Virtual Care Hospitalist**..."

Interview on 06/04/2015 at 1041 and 1537, respectively, with Chief Executive Officer (CEO) #1 revealed, the hospital provided three (3) telemedicine services, "Virtual Hospitalist" and "Virtual Radiology" and "Telepsychiatry." Interview revealed there was not a "separate virtual agreement" for the hospitalist providing telemedicine services to the hospital. Interview revealed the professional services agreement (PSA) was "all inclusive." Interview revealed the PSA did not contain any language specific to the provision of telemedicine services by the hospitalist. Interview revealed the virtual hospitalist are credentialed and granted privileges by the hospital. Interview revealed the contract was with (DSE #1). Interview revealed "I was unhappy with the language of the contract." Interview verified the findings.

Based on observations as referenced in the Life Safety Report of Survey completed June 02, 2015, the hospital staff failed to develop and maintain the physical plant and environment in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to ensure the hospital's physical facilities were constructed, arranged, and maintained in a manner to ensure access to and the safety of patients.

~cross refer to 485.623(b)(1) - Maintenance, Standard Tag - C0221.

2. The hospital staff failed to ensure all essential mechanical, electrical, and patient care equipment was maintained in a manner to ensure safe operating conditions.

~cross refer to 485.623(b)(1) - Maintenance, Standard Tag - C0222.

3. The hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 485.623(d)(1) - Life Safety from Fire. NFPA, Standard Tag - C0231.

Based on observations as referenced in the Life Safety Report of Survey completed June 02, 2015, the hospital staff failed to ensure the hospital's physical facilities were constructed, arranged, and maintained in a manner to ensure access to and the safety of patients.

The findings include:

Building 01
1. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The exit discharge path is obstructed by wood pallets and other impediments at loading dock area near room 609.

This deficiency affected three of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

2. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There is an exposed bulb light fixture above storage items in biohazard room - located in ER (Emergency Room) area.

b. There is less than three feet clearance maintained in front of electrical panels - located in ICU (Intensive Care Unit) equipment room.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0147.

Based on observations as referenced in the Life Safety Report of Survey completed June 02, 2015, the hospital staff failed to ensure all essential mechanical, electrical, and patient care equipment was maintained in a manner to ensure safe operating conditions.

The findings included:

Building 02
1. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The essential electrical system failed to restore power in not greater than ten seconds during loss of normal power to the Life Safety Branch transfer switch. The system required sixteen seconds to restore power during test.

b. The generator annunciator panel failed to read generator supplying load during test of the essential electrical system as stated in item #1.

c. There is no task lighting with unitary equipment at access panels to the emergency generator - the lighting must be connected to the essential electrical system in accordance with NFPA 99 and NFPA 70.

This deficiency potentially affected all smoke compartments and resident use areas.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0106.

Based on observations as referenced in the Life Safety Report of Survey completed June 02, 2015, the hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings included:

Building 01
1. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. The fire door to the clean linen storage room is tied in the open position - fire door must be self-closing and latching without manual intervention. Room of reference is located off exit corridor leading to loading dock.

b. There is a wedge under fire door to environmental housekeeping room - room is located off hallway leading to kitchen.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

2. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is an incomplete electromagnetic locking system used on access door between outpatient surgery office and intensive care unit. The lock is not equipped with switching arrangements, and complete building sprinkler or detection system as described in section 7-2.1.6 of NFPA 101; 2000 Life Safety Code.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

3. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

a. There is no exit directional sign for corridor exit sign located near dining room area - existing sign directs occupants toward dining room and not toward exit discharge near loading dock.

b. There is no exit directional sign for exit discharge serving the ER entrance waiting area - existing sign is not equipped with chevron directing occupants to appropriate exit.

This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

4. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is no smoke detector provided not greater than five feet from smoke barrier located near room 706.

This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0051.

Building 02
5. Based on observations, on 06/02/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are oxygen cylinders stored less than five feet from combustible storage in future elevator shaft storage room. Room is identified as room 1215.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

Based on current hospital Medical Staff Bylaws review, physicians education summary review, credential file (CF) reviews, Medical Staff letter review, and staff interviews, the hospital's governing body failed to ensure all individual practitioners were appointed, reappointed, or granted privileges to the Medical Staff in accordance with established Medical Staff criteria for 8 of 13 Medical Staff credential files reviewed (CF #1, CF #2, CF #3, CF #4, CF #5, CF #6, CF #7, and CF #8).

The findings included:

Review on 06/02/2015 of the hospital's current "Medical Staff Bylaws" revised July 26, 2011, approved by the hospital's Chairman, Board of Trustees and Chief of Staff, revealed "Article 2 Qualifications, Conditions, and Responsibilities 2.A.1. Threshold Eligibility Criteria." Further review revealed, "To be eligible to apply for initial appointment, reappointment, or clinical privileges, the applicant must, as applicable: ...Demonstrates successful completion of education of EMTALA (Emergency Medical Treatment and Labor Act) requirements and Infection Control practices each 2 years prior to re-appointment...".

1. Review on 06/05/2015 of credential file #1 for Physician Assistant (Medical Staff Member [MSM] #1) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 11/03/2014 for the term of 10/30/2014 through 10/30/2016. Review revealed the letter was signed by the CEO #1.

2. Review on 06/05/2015 of credential file #2 for Certified Registered Nurse Anesthetists (MSM #2) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for appointment to the Medical Staff. Review revealed a Letter of Appointment to the Medical Staff dated 01/30/2015 for the term of 01/30/2015 through 04/30/2017. Review revealed the letter was signed by CEO #1.

3. Review on 06/05/2015 of credential file #3 for Physician (MSM #3) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 01/30/2015 for the term of 01/30/2015 through 01/30/2017. Review revealed the letter was signed by CEO #1.

4. Review on 06/05/2015 of the credential file #4 for Dentist (MSM #4) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for granting of privileges to the Medical Staff. Review revealed a Letter granting temporary privileges in Dentistry dated 04/13/2015 for a term not to exceed 120 days from the effective date. Review revealed the letter was signed by CEO #1.

5. Review on 06/05/2015 of credential file #5 for Physician (MSM #5) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 01/30/2015 for the term of 01/30/2015 through 01/30/2017. Review revealed the letter was signed by CEO #1.

6. Review on 06/05/2015 of credential file #6 for Physician (MSM #6) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 04/28/2014 for the term of 04/28/2014 through 04/28/2016. Review revealed the letter was signed by CEO #1.

7. Review on 06/05/2015 of credential file #7 for Physician (MSM #7) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 04/28/2014 for the term of 04/28/2014 through 04/28/2016. Review revealed the letter was signed by CEO #1.

8. Review on 06/05/2015 of credential file #8 for Physician (MSM #8) failed to reveal any available documentation of completion of the EMTALA or Infection Control education required by the Medical Staff Bylaws for reappointment to the Medical Staff. Review revealed a Letter of Reappointment to the Medical Staff dated 04/28/2014 for the term of 04/28/2014 through 04/28/2016. Review revealed the letter was signed by CEO #1.

In brief, credential file reviews revealed 8 of 13 individual practitioners did not have any available documentation of completion of EMTALA or Infection Control education as required in the hospital's current Medical Staff Bylaws for appointment, reappointment or granting of privileges. Review revealed individual practitioners were appointed or reappointed or granted privileges after the last revision and approval of the hospital's Medical Staff Bylaws (July 26, 2011) and received a Letter of Appointment or Reappointment or Granting of temporary privileges to the Medical Staff, signed by the hospital's CEO.

Interview on 06/03/2015 at 0830 with Compliance Officer #1, revealed EMTALA and Infection Control education is required for appointment and/or reappointment every two (2) years. Interview revealed "I'll be honest with you, the list (individual practitioners who have completed EMTALA & Infection Control education) is not going to be very long. We put the training out there but they just don't do it. I've told them it's required but they don't do it".

Review on 06/03/2015 of a "Physician Education" summary for May 2014 through June 1, 2015, revealed the names of 24 individual practitioners that had completed the EMTALA and Infection Control practices education required by the hospital's Medical Staff Bylaws (12 in 2014 and 12 in 2015).

Interview on 06/03/2015 at 1330 with Medical Records Manager #1, revealed she also coordinates the credentialing for the hospital's medical staff. Interview revealed the hospital has "approximately 90-100" medical staff members. Interview revealed, "Right now we don't have a clear process" for ensuring all training requirements outlined in the Medical Staff Bylaws are present prior to appointment or reappointment. Interview revealed, "We are lacking verification from (Human Resource Manager #1)." Interview revealed, "We are attempting status reviews of education requirements every six (6) months." Interview revealed a "letter is sent to (Physician A) every six (6) months" identifying medical staff who are lacking the required training(s). Interview revealed, "approximately 60 have been sent out so far. We've known for a while we have a problem with compliance issues." Interview revealed the credentialing process is completed in three (3) steps. (Physician A) reviews the application and approves it, the application is then brought before the Medical Staff and Medical Executive Committee Chairman, the application is reviewed and either approved or denied, and it is then forwarded to the hospital's CEO for final approval or denial. Further interview revealed a process was implemented November 2014, which included having a letter reminding Medical Staff members of the the importance of completing the "physician course" education.

Review on 06/05/2015 of a letter to "All Members of the Medical Board" provided by Medical Records Manager #1 revealed, "In order to maintain our compliance with Joint Commission and other regulations regarding education....XYZ Hospital Medical Staff members will complete the education during the initial credentialing process and every two years during the re-credentialing process....The course includes EMTALA, HIPAA Privacy and Security....Infection Control....Once you have completed the course....will forward your attestation to our Medical Staff office for placement in your physician credentials file. The assignment needs to be completed within one month of this notification...".

Interview on 06/05/2015 at 1535 with CEO #1, revealed "I am fairly involved in it (credentialing). I usually review every file of everyone." Interview revealed (Physician B) receives and reviews the application then forwards it to (Physician C) who also reviews and then forwards it to the hospital's CEO for final review and approval/denial. Interview revealed, "I was not aware, that's something that I missed (EMTALA and Infection Control education requirements). They should have everything done, ready to go. I actually go through every application, it didn't slap me in the face." Interview revealed Medical Staff seeking reappointment/appointment without the required training(s) should not have been reappointed/appointed and granted privileges. Interview revealed "No, we should've ensured they got it done and then credentialed them. As I shared earlier, we need to review our Bylaws more frequently." Interview revealed the governing body failed to ensure individual practitioners were appointed and/or reappointed or granted temporary privileges in accordance with established Medical Staff Bylaws criteria.

Based on Medical Staff Bylaws, Rules and Regulations review, policy review, medical record reviews, and staff interviews the hospital's physician failed to ensure a completed admission history and physical (H&P) was performed on a patient after admission to the hospital for 1 of 2 Behavioral Health Unit (BHU) patients sampled (Patient #13).

The findings included:

Review on 06/05/2015 of current Medical Staff Bylaws, Rules and Regulations, revised July 26, 2011, revealed "...Section III. Medical Records ...Article II. Rules and Regulations (Page 7) ...D. History and Physical (H&P): An adequate history and physical examination shall be completed and recorded within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. If the history and physical is dictated, an admission progress note indicating the reason for admission and a plan for evaluation and treatment must be recorded on the chart within twenty-four (24) hours after admission of the patient. The history and physical shall be consistent with normally accepted professional standards, Joint Commission, State and Federal laws and Conditions of Participation for Medicare and Medicaid requirements. If a history and physical has been completed by the attending Physician/Oral Surgeon within thirty (30) days prior to admission, a signed, dated and timed, durable , legible copy of this report may be used in the patient's medical record provided there has been no subsequent change as noted in an update to the history and physical that is singe,d dated and timed within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery or the changes have been recorded in an updated note to the history and physical that is signed, dated and times within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. ..."

Review on 06/05/2015 of current Psychiatry policy "Medical History and Physical" policy number: 08-0069, reviewed 02/2014, revealed "I. POLICY: A medical history and physical will be completed by the assigned psychiatrist within 24 hours of admission unless one has been completed by a physician of this hospital within 30 days. A medical doctor will be consulted for acute medical problems. ..."

Open medical record review on 06/04/2015 for Patient #13 revealed a 76 year old female admitted to the BHU on 05/29/2015 for Major Depressive Disorder, severe, with recurrent psychosis. Review of a "History And Physical Examination" form dated 05/29/2015, revealed the form was blank. Review revealed "See (Hospital) name H&P" hand written on the form and signed by Psychiatrist #1. Further medical record review failed to reveal any available documentation of an admissions H&P conducted after admission to the BHU for Patient #13.

Interview on 06/04/2015 at 1415 with Nurse Manager #1 during medical record reviews, revealed she was the BHU nurse manager. Interview revealed Psychiatrist #1 used the emergency department physician's documentation as the admission H&P for Patient #13. Interview revealed there was no other available documentation in the medical record of an H&P obtained after admission for the patient.

Interview on 06/05/2015 at 1234 with Chief Nursing Officer #1 revealed the admission H&P should be completed after admission to an inpatient unit by the attending physician. Interview revealed the H&P should be a full H&P with review of systems, psychosocial and physical examination elements. Interview revealed an H&P does not include the outpatient emergency department physician's evaluation. Interview revealed the medical-staff bylaws specify the admission H&P is to be conducted after admission.

Based on current policy and procedure reviews, medical staff roster review, and staff interview, the hospital failed to develop hospital policies with the advice of members of the hospital's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff; and failed to conduct annual policy reviews for 1 of 1 anesthesia department's policies.

The findings revealed:

1. Review on 06/04/2015 of the facility's current policy "Policy Development/Review Guideline", policy number: 00-0000, effective 02/01/2015, revealed "I. PURPOSE To provide guidelines and a standard template to (hospital name) personnel for the development, revision and review of all organizational policies and clinical practice guidelines. The leadership of (hospital name) will ensure that all organizational policies/clinical practice guidelines will be reviewed every three years (to be in compliance with the Joint Commission Requirements). To facilitate this decision, all departments will be asked to review and/or revise their policies and include a new formatted header before the end of 2015. ...III. PROCEDURE A. By the end of 2015, all departments will have reviewed their policies or clinical practice guidelines to ensure that all have been reviewed in the last 3 year period. ... C. If the policy/guideline has to be reviewed/approved by the medical director for the service or a standing committee, input should be sought during the review cycle. D. The department manager will sign all policies/guidelines as the reviewer and include the medical director name as appropriate. E. Once the policy is in its final stage, the policy/guideline will be submitted to the HR/Patient Care Administrative Assistant to apply the template and any missing guidelines. If the administrative assistant is not utilized, and the department manger accepts the responsibility for the updating process, the department manager will ensure these guidelines are followed. F. the administrative assistant will then forward completed policies/guidelines to the appropriate VP (Vice-President) or CEO for final authorization G. Only authorized personnel may review or revise policies." Policy review failed to reveal any available documention requiring the hospital's policies to be reviewed at least annually by an advisory group that included at least one physician (MD or DO), and one or more Physician Assistants (PA), Nurse Practitioners (NP), and Clinical Nurse Specialist (CNS) per regulatory requirements.

Review on 06/05/2015 of the medical staff roster for Hospital A provided by Medical Staff Credentialing Staff #1, revealed the hospital's medical (active, courtesy, consulting) staff included 103 physicians, 4 NPs, 5 PAs, and 0 CNS.

Interview on 06/03/2015 at 1353 with Chief Nursing Officer #1 revealed she helped develop the "Policy Development/Review Guidelines" policy. Interview revealed she works with the department managers and physicians to develop area specific policies. Interview revealed all patient care policies come to the CNO for final approval. Interview revealed the practice is to review policies every three years. Interview revealed the goal is to have all hospital policies reviewed and updated by the end of 2015, then continue every three years. Interview revealed the policies are currently reviewed by individuals, but not as a collective group or an advisory group that includes at least one MD or DO, and one or more PA, NP, and CNS. Interview revealed no available documentation that provides evidence that an advisory group has conducted its annual reviews and made recommendations concerning patient care policies. Interview revealed the hospital does have nurse practitioners and physician assistants on staff. Interview revealed the current policy requiring review every three years was approved in February of 2015. Interview revealed she was unaware of the Condition of Participation requirements to have patient care policies reviewed annually by an advisory group that included at least one MD or DO, and one or more PA, NP, and CNS.


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2. Review on 06/05/2015 of the anesthesia department's policy and procedure manual revealed a policy and procedure review signature page located inside the manual cover. Review of the signature page revealed the last documented policy and procedure review was performed by anesthesia staff in 2012.

Interview on 06/05/2015 at 1245 with Chief Nursing Officer #1 revealed the anesthesia department policy and procedure manual was last reviewed in 2012. Interview revealed no available documentation of reviews since 2012. Interview confirmed the findings.

Based on hospital policy and procedure reviews, preventative maintenance documentation review, dish machine log reviews, observations during tour, and staff interviews, the hospital's dietary staff failed to follow recognized dietary practices, policies and procedures, to ensure the safe delivery of dietary services to patients and maintain the kitchen facilities, supplies and equipment at an acceptable level to prevent potential cross contamination of food products prepared for and served to patients, visitors, and staff for 1 of 1 Dietary Department toured.

The findings include:

A) Review on 06/05/2015 of hospital policy "Food and Supply Storage Procedures" revised 01/09, revealed "Procedures: ...*do not sell products in retail areas or place on patient trays/resident plates past the date on the product ...*Do not use products in recipes past the "use-by date...".

Review on 06/05/2015 of hospital policy "Food and Supply Storage Procedures" revised 01/09, revealed "...Dry Storage: ...*Date and rotate items; first in, first out (FIFO). Remove from storage any items for which the expiration date has expired ...Frozen Storage: ...*Discard food past the use-by date. Discard unused portions of prepared recipes not utilized within 2 days, including day of preparation ...Discard unused portions of all other potentially hazardous foods, such as milk, cheese....within 4 days, including day of opening ...Cover, label, and date unused portions completing all sections on the (contract vendor name) orange label...".

Review on 06/05/2015 of hospital "Food Storage Chart" revealed, "...*Expiration dates printed by the manufacturer's apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1 ...*Dry Storage ...Bread and Rolls - if not dated by the manufacturer, add a stick with an expiration date of 4 days from deliver (including day of delivery....30 days Oil; 6 months, or the manufacturer's expiration date, if sooner Cereal, Honey, Cake, brownie and pancake mixes...".

1. Observations during tour of the hospital's main kitchen on 06/04/2015 at 0935 onward, revealed the following:

In the dry storage areas:
a. Observation in the dry storage room revealed, 1 case (24 cartons) Nutren 1.0 Complete Liquid Nutrition with an expiration date of 04/2015 (35 days expired); 1 case (18 cartons) Nutren 1.0 Complete Liquid Nutrition with an expiration date of 05/2015 (4 days expired); Diabetisource AC nutritional supplement 2 cases (24 cans per case) with an expiration date of 05/2015 (4 days expired). Observation of the nutritional supplements revealed cases were not rotated "first in, first out (FIFO)" per hospital policy. Cases stamped with an expiration date of 05/2015 were stacked in front of those with an expiration date of 04/2015. Observation revealed 1 opened gallon jug of Worcestershire with a "best by" date of 05/20/2014. Observation revealed opened bread, oil, syrup, cereal, cake mix, brownie mix, pancake mix, pumpkin spice baking mix, ketchup, and horseradish with no sticker indicating date of opening per hospital policy. Further observation revealed 1 open pint jug of honey that was solidified with no label or opened date indicated.

Interview during tour with Dietary Manager #1 at 1015 revealed routine practice is to place products with upcoming expiration dates in front of those with later dates. Interview revealed all open products should be labeled and dated when opened. Further interview revealed the dietary staff was unable to determine when the last carton of Nutren 1.0 was dispensed for patient use and when the Worcestershire or solidified honey were opened or how long they had been on the dry storage shelves. Interview revealed the dietary staff failed to follow the hospital's policies and verified the observation findings.

In refrigeration storage areas:
b. Observation inside the cold food preparation refrigerator revealed 1 open gallon tub of chicken salad one-quarter empty with no label or date when opened and 1 open gallon tub of pimento cheese one-half empty with no label or date when opened. Observation of the hot food preparation Herreck refrigerator revealed a black substance (mold/mildew appearance) around the seal of the door. Further observation revealed three (3) liquid saturated handtowels in the bottom left corner of the unit used to soak up condensation. Observation revealed four (4) cheese slices with green mold on the corner edges wrapped in plastic wrap with no label or date opened. Observation of the Walk-in Dairy Refrigerator revealed Ricotta cheese in a metal container covered with plastic wrap stored on shelving directly under the cooling unit. Observation revealed condensation, approximately 15-30 milliliters, standing on top of the plastic wrap.

Interview during tour with Dietary Manager #1 at 1115 revealed the black substance around the hot food preparation refrigerator door was "mold" due to "condensation." Interview revealed, "I have to get that seal replaced." Interview revealed, "It's on the list (Herreck refrigerator)" to be replaced. Interview revealed issues related to condensation and mold have been ongoing. Interview revealed food products placed into refrigerators and freezers are to be dated and labeled. Interview revealed foods should not be stored in a manner to allow condensation buildup on it while in the refrigerator. Interview verified the observation findings.

B) Review of hospital policy "Disposable Glove Use" revised 07/07 revealed "Procedures ...*Hands must be washed or hand sanitizer used before putting on disposable gloves ...*Disposable gloves must be changed....and when moving from one task to another ...*Hands must be washed or hand sanitizer used after removing disposable gloves...".

1. Observations during tour of the hospital's main kitchen on 06/04/2015 at 0935 onward, revealed the following:

In the food preparation/serving areas:
Observation at 1030 revealed Dietary Staff #1 in the cold food preparation area leave the food preparation area with gloves on, walked to the dairy cooler, opened the door with gloved hands, removed a bag of shredded cheese, returned to the food preparation area, opened the bag of cheese, and placed same gloved hand into bag. Observation revealed Dietary Staff #1 failed to don clean gloves when handling the cheese. Observation at 1115 revealed Dietary Staff #2 working on the patient serving line place a gloved hand onto lasagna to stabilize it on the spatula then transfer to the patient's/resident's plate. Further observation revealed Dietary Staff #2 left the work station, opened the warmer door, obtained a baked potato and returned to the serving line to prepare the next meal tray. Observation revealed the dietary staff member failed to don clean gloves "when moving from one task to another." Observation revealed dietary staff did not wash or use hand sanitizer "before putting on disposable gloves" or "after removing disposable gloves" as defined in hospital policy.

Interview during tour with Dietary Manager #1 at 1115 revealed it is the expectation that all staff preparing food who leave the work area are to remove their gloves and wash their hands prior to donning new gloves. Interview revealed that if food is touched with gloved hand while working on the serving line, the expectation is that the employee will change their gloves if the employee leaves the work station and returns. Interview revealed the staff failed to follow hospital policies and verified the observation findings.

C) Review on 06/05/2015 of hospital policy "Required Cleaning and Sanitation" revised 07/07 revealed "Policies: ...Nonfood Contact Surfaces: Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris...".

Review of hospital policy "Equipment Inspection Program" issued 05/95 revealed "Policy: To ensure that all equipment is in safe operating condition, an equipment inspecting program is followed....Procedures: ...*Visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use....Identify repairs needed. Monitor completion of repairs...".

Review of hospital policy "Storage of Pots, Dishes, Flatware, Utensils" revised 01/09 revealed "Procedures ...*Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in self-draining position. Do not stack or store when wet...".

Review of the "Routine Preventative Maintenance Service Detail Report - Warewashing" dated 05/11/2105 completed by a Ecolab Representative, revealed "...*Readings....Temperature Gauge Checked - OK....Thermostat Checked - OK....Final Rinse Temp 180 deg. (degrees) F (Fahrenheit) Wash Temp 160 deg. F."

Review of the "Dish Machine pH Test Log" revealed a label attached for the chlorine test strips used to measure pH levels to ensure sanitation levels are maintained. Review revealed "Chlorine Test Papers ...*Note: ...Keep vial closed when not in use ...Exp (expiration) 01/14" (over 16 months expired).

1. Observations during tour of the hospital's main kitchen on 06/05/2015 at 1035, onward revealed the following:

In refrigeration storage areas:
a. Observation inside of the Walk-in Combination Refrigerator/Freezer revealed excessive (thick layer) dust buildup on the ceiling of the freezer compartment in front of the cooling unit. Observation revealed an excessive (thick layer) dust buildup on the ceiling of the refrigerator compartment in front of the cooling unit.

Interview during tour with Dietary Manager #1 at 1100 revealed there should not be a dust build-up on the ceiling of the walk-in combination refrigerator/freezer. Interview revealed the dietary staff are to clean the ceilings every week. Interview revealed food products placed into refrigerators and freezers are to be dated and labeled. Interview revealed it had "probably been six (6) months" since the refrigerator/freezer unit(s) had been serviced. Interview revealed the dietary staff failed to follow the hospitals's policies and verified the observation findings.

In the cooking areas:
b. Observation of the food steamer in the hot food preparation area revealed the steamer was located adjacent to the food preparation/thawing sink. Observation revealed the steamer was in operation. Observation revealed dense steam rising from the steamer and traveling up the back wall. Observation revealed heavy condensation collecting on the wall and ceiling. Observation revealed the steamer drained into an open floor drain located in between the sink and steamer. Observation revealed dense steam rising from the open floor drain. Observation revealed dietary staff thawing fish in a metal bowl under running water in the sink. Observation revealed the dietary staff turned the water off and removed the bowl of fish from the sink. Observation revealed dense steam began rising up out of sink's drain. Observation revealed the sink and steamer drained into the same open floor drain and steam from the steamer was backflowing from the floor drain into the sink. Further observation revealed the HVAC return air grilles located above the hot food food preparation/thawing sink and steamer were covered with excessive (thick layer) dust build up.

Interview during tour with Dietary Manager #1 at 1100, revealed the steamer was new and had been installed approximately 6 months ago. Interview revealed he had not noticed the steam backflowing into the food preparation/thawing sink. Interview revealed hospital maintenance staff are responsible for cleaning the return air grilles. Interview revealed he does not know when they were last cleaned. Interview verified the observation findings.

In cookware/dishware dry storage areas:
c. Observation revealed multiple pots and pans being stored face up. Observation revealed 2 of 7 metal pans sampled had dried food particles noted on interior surfaces. Observation revealed 4 of 4 metal mixing bowls stored face up. Observation revealed 4 of 5 plastic beverage glasses sampled were stacked with clear liquid on the interior surfaces, and 2 of 10 metal serving/storage containers sampled were stacked with clear liquid on interior surfaces. Observation revealed sticky residue build-up on pot lids stored on the bottom storage rack ready-for-use. Observation revealed sticky liquid residue build-up on tray holding, ready-for-use.

Interview during tour with Dietary Manager #1 at 1110, revealed the stored cookware and dishware was clean and available for use by staff. Interview revealed cleaned items should not have residual dried food particles stuck on their surfaces after being cleaned and sanitized. Interview revealed there should be no sticky residue. Interview revealed cookware and dishware should no be stored face up or stacked wet. Interview verified the observation findings.

In dish machine area:
d. Observation of the dish machine revealed the wash cycle temperature gauge and the rinse cycle temperature gauge covers were missing and the inside mechanics were exposed to outside elements. Observation revealed both the wash temperature and high temperature rinse gauges registered during a test cycle. Observation revealed a reading of 154 degrees Fahrenheit during the wash cycle and 158 degrees Fahrenheit during the rinse cycle. Observation revealed at the end of the test cycle, staff tested the final rinse water with pH test strips for the efficacy of the chemical sanitizer. Observation revealed the concentration of chemical sanitizer was within range to sanitize items. Further observation revealed the pH test strips used to measure the chlorine levels (chemical sanitizer) in the dish machine had an expiration date of "01/14" (greater than 15 months expired) and the pH test strip container was not sealed per manufacturer's recommendations.

Interview during tour with Dietary Manager #1 at 1120 revealed according to facility engineering, due to the location of the kitchen a booster heater is required to boost the amount of steam required to raise water temperatures in the dish machine to over 180 degrees. Interview revealed the reason for using a "chemical wash" is because acceptable water temperatures cannot be accomplished despite the use of a booster heater. Interview revealed the dietary staff use a low temperature wash with a chemical sanitizer. Further interview revealed he was not aware the two gauge covers were broken "until just now" and he was not sure if the recorded readings had been accurate. Interview revealed that even with the booster heater, a temperature of 180 degrees Fahrenheit during the final rinse as documented on the Preventive Maintenance report by the contract vendor would not be possible. Interview revealed the accuracy of both gauges was in question. Interview revealed the pH tests strips were used to measure chlorine levels for the low temperature dish machine to ensure sanitization. Interview verified the test strips had expired in 2014. Interview revealed he "had no answer" addressing whether the tests were still good. Interview revealed, "All I know is what the Health Department told me. If it turns colors, they're good." Interview revealed staff most likely ran out of test strips and went to the office and requested more, and were handed the expired strips "without looking at them." Interview verified the observaiton findings.

Based upon contract files list (CFL) review and staff interview, the hospital's staff failed to maintain a list of all services furnished under arrangements or agreements that described the nature and scope of the services provided to include at a minimum: The service(s) being offered; The individual(s) or entity providing the service(s); Whether the services are offered on-site or off-site; Whether there is any limit on the volume or frequency of the services provided; and When the service(s) are available, for 1 of 1 contract files list reviewed (CFL #1).

The findings revealed:

Review on 06/03/2015 at 1130 of the "(name) Hospital Contract Files (Admin Office)" list, dated 12/24/2013, provided by Vice President #1 revealed an 18 page(s) typed list. Review revealed a column titled "Contract Name" with a total of ~450 contract names listed. Review revealed a column titled "Expiration Date" with a total of ~197 (197 out of 450) expiration dates listed (i.e. by MM/YY, MM/DD/YY, Automatic, Open ended, Yearly, Indefinite, Continuous, Perpetual, or Mutual Consent). Review revealed no available documentation of one or more of the following information:
·The service(s) being offered;
·The individual(s) or entity providing the service(s);
·Whether the services are offered on-site or off-site;
·Whether there is any limit on the volume or frequency of the services provided; and
·When the service(s) are available.
Further review revealed no available documentation the list was updated each time a contracted service was added or removed.

Interview on 06/03/2015 at 1415 with Vice President #1 and Chief Nursing Officer #1, revealed the hospital's chief executive officer's administrative assistant maintains the hospital's contract files and list in her office. Interview revealed there was not a standardized process or time frame for reviewing contracts. Interview revealed the hospital staff conducts periodic audits by departments to make sure services are being provided per the contracts. Interview revealed contracts are reviewed by the Department Managers. Interview revealed if there are no issues identified, then the contracts are not relayed to the governing body; except for those contracts that are required to be reviewed by the governing body. Interview revealed the current contract files list only documents the contract name and expiration date. Interview revealed they were unaware of the documentation requirements required by the Conditions of Participation to be included on the list. Interview confirmed the findings.

Based on contract files list review, hospital policy and procedure reviews, preventative maintenance documentation review, dish machine log reviews, observations during tour, and staff interviews, the hospital's Governing Body failed to ensure the hospital's contracted dietary services followed recognized dietary practices, policies and procedures, to ensure the safe delivery of dietary services to patients and maintain the kitchen facilities, supplies and equipment at an acceptable level to prevent potential cross contamination of food products prepared for and served to patients, visitors, and staff in order to comply with all applicable Medicare Conditions of Participation for 1 of 1 contracted services (Dietary).

The findings include:

A) Review on 06/05/2015 of hospital policy "Food and Supply Storage Procedures" revised 01/09, revealed "Procedures: ...*do not sell products in retail areas or place on patient trays/resident plates past the date on the product ...*Do not use products in recipes past the "use-by date...".

Review on 06/05/2015 of hospital policy "Food and Supply Storage Procedures" revised 01/09, revealed "...Dry Storage: ...*Date and rotate items; first in, first out (FIFO). Remove from storage any items for which the expiration date has expired ...Frozen Storage: ...*Discard food past the use-by date. Discard unused portions of prepared recipes not utilized within 2 days, including day of preparation ...Discard unused portions of all other potentially hazardous foods, such as milk, cheese....within 4 days, including day of opening ...Cover, label, and date unused portions completing all sections on the (contract vendor name) orange label...".

Review on 06/05/2015 of hospital "Food Storage Chart" revealed, "...*Expiration dates printed by the manufacturer's apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1 ...*Dry Storage ...Bread and Rolls - if not dated by the manufacturer, add a stick with an expiration date of 4 days from deliver (including day of delivery....30 days Oil; 6 months, or the manufacturer's expiration date, if sooner Cereal, Honey, Cake, brownie and pancake mixes...".

1. Observations during tour of the hospital's main kitchen on 06/04/2015 at 0935 onward, revealed the following:

In the dry storage areas:
a. Observation in the dry storage room revealed, 1 case (24 cartons) Nutren 1.0 Complete Liquid Nutrition with an expiration date of 04/2015 (35 days expired); 1 case (18 cartons) Nutren 1.0 Complete Liquid Nutrition with an expiration date of 05/2015 (4 days expired); Diabetisource AC nutritional supplement 2 cases (24 cans per case) with an expiration date of 05/2015 (4 days expired). Observation of the nutritional supplements revealed cases were not rotated "first in, first out (FIFO)" per hospital policy. Cases stamped with an expiration date of 05/2015 were stacked in front of those with an expiration date of 04/2015. Observation revealed 1 opened gallon jug of Worcestershire with a "best by" date of 05/20/2014. Observation revealed opened bread, oil, syrup, cereal, cake mix, brownie mix, pancake mix, pumpkin spice baking mix, ketchup, and horseradish with no sticker indicating date of opening per hospital policy. Further observation revealed 1 open pint jug of honey that was solidified with no label or opened date indicated.

Interview during tour with Dietary Manager #1 at 1015 revealed routine practice is to place products with upcoming expiration dates in front of those with later dates. Interview revealed all open products should be labeled and dated when opened. Further interview revealed the dietary staff was unable to determine when the last carton of Nutren 1.0 was dispensed for patient use and when the Worcestershire or solidified honey were opened or how long they had been on the dry storage shelves. Interview revealed the dietary staff failed to follow the hospital's policies and verified the observation findings.

In refrigeration storage areas:
b. Observation inside the cold food preparation refrigerator revealed 1 open gallon tub of chicken salad one-quarter empty with no label or date when opened and 1 open gallon tub of pimento cheese one-half empty with no label or date when opened. Observation of the hot food preparation Herreck refrigerator revealed a black substance (mold/mildew appearance) around the seal of the door. Further observation revealed three (3) liquid saturated handtowels in the bottom left corner of the unit used to soak up condensation. Observation revealed four (4) cheese slices with green mold on the corner edges wrapped in plastic wrap with no label or date opened. Observation of the Walk-in Dairy Refrigerator revealed Ricotta cheese in a metal container covered with plastic wrap stored on shelving directly under the cooling unit. Observation revealed condensation, approximately 15-30 milliliters, standing on top of the plastic wrap.

Interview during tour with Dietary Manager #1 at 1115 revealed the black substance around the hot food preparation refrigerator door was "mold" due to "condensation." Interview revealed, "I have to get that seal replaced." Interview revealed, "It's on the list (Herreck refrigerator)" to be replaced. Interview revealed issues related to condensation and mold have been ongoing. Interview revealed food products placed into refrigerators and freezers are to be dated and labeled. Interview revealed foods should not be stored in a manner to allow condensation buildup on it while in the refrigerator. Interview verified the observation findings.

B) Review of hospital policy "Disposable Glove Use" revised 07/07 revealed "Procedures ...*Hands must be washed or hand sanitizer used before putting on disposable gloves ...*Disposable gloves must be changed....and when moving from one task to another ...*Hands must be washed or hand sanitizer used after removing disposable gloves...".

1. Observations during tour of the hospital's main kitchen on 06/04/2015 at 0935 onward, revealed the following:

In the food preparation/serving areas:
Observation at 1030 revealed Dietary Staff #1 in the cold food preparation area leave the food preparation area with gloves on, walked to the dairy cooler, opened the door with gloved hands, removed a bag of shredded cheese, returned to the food preparation area, opened the bag of cheese, and placed same gloved hand into bag. Observation revealed Dietary Staff #1 failed to don clean gloves when handling the cheese. Observation at 1115 revealed Dietary Staff #2 working on the patient serving line place a gloved hand onto lasagna to stabilize it on the spatula then transfer to the patient's/resident's plate. Further observation revealed Dietary Staff #2 left the work station, opened the warmer door, obtained a baked potato and returned to the serving line to prepare the next meal tray. Observation revealed the dietary staff member failed to don clean gloves "when moving from one task to another." Observation revealed dietary staff did not wash or use hand sanitizer "before putting on disposable gloves" or "after removing disposable gloves" as defined in hospital policy.

Interview during tour with Dietary Manager #1 at 1115 revealed it is the expectation that all staff preparing food who leave the work area are to remove their gloves and wash their hands prior to donning new gloves. Interview revealed that if food is touched with gloved hand while working on the serving line, the expectation is that the employee will change their gloves if the employee leaves the work station and returns. Interview revealed the staff failed to follow hospital policies and verified the observation findings.

C) Review on 06/05/2015 of hospital policy "Required Cleaning and Sanitation" revised 07/07 revealed "Policies: ...Nonfood Contact Surfaces: Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris...".

Review of hospital policy "Equipment Inspection Program" issued 05/95 revealed "Policy: To ensure that all equipment is in safe operating condition, an equipment inspecting program is followed....Procedures: ...*Visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use....Identify repairs needed. Monitor completion of repairs...".

Review of hospital policy "Storage of Pots, Dishes, Flatware, Utensils" revised 01/09 revealed "Procedures ...*Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in self-draining position. Do not stack or store when wet...".

Review of the "Routine Preventative Maintenance Service Detail Report - Warewashing" dated 05/11/2105 completed by a Ecolab Representative, revealed "...*Readings....Temperature Gauge Checked - OK....Thermostat Checked - OK....Final Rinse Temp 180 deg. (degrees) F (Fahrenheit) Wash Temp 160 deg. F."

Review of the "Dish Machine pH Test Log" revealed a label attached for the chlorine test strips used to measure pH levels to ensure sanitation levels are maintained. Review revealed "Chlorine Test Papers ...*Note: ...Keep vial closed when not in use ...Exp (expiration) 01/14" (over 16 months expired).

1. Observations during tour of the hospital's main kitchen on 06/05/2015 at 1035, onward revealed the following:

In refrigeration storage areas:
a. Observation inside of the Walk-in Combination Refrigerator/Freezer revealed excessive (thick layer) dust buildup on the ceiling of the freezer compartment in front of the cooling unit. Observation revealed an excessive (thick layer) dust buildup on the ceiling of the refrigerator compartment in front of the cooling unit.

Interview during tour with Dietary Manager #1 at 1100 revealed there should not be a dust build-up on the ceiling of the walk-in combination refrigerator/freezer. Interview revealed the dietary staff are to clean the ceilings every week. Interview revealed food products placed into refrigerators and freezers are to be dated and labeled. Interview revealed it had "probably been six (6) months" since the refrigerator/freezer unit(s) had been serviced. Interview revealed the dietary staff failed to follow the hospitals's policies and verified the observation findings.

In the cooking areas:
b. Observation of the food steamer in the hot food preparation area revealed the steamer was located adjacent to the food preparation/thawing sink. Observation revealed the steamer was in operation. Observation revealed dense steam rising from the steamer and traveling up the back wall. Observation revealed heavy condensation collecting on the wall and ceiling. Observation revealed the steamer drained into an open floor drain located in between the sink and steamer. Observation revealed dense steam rising from the open floor drain. Observation revealed dietary staff thawing fish in a metal bowl under running in the sink. Observation revealed the dietary staff turned the water off and removed the bowl of fish from the sink. Observation revealed dense steam began rising up out of sink's drain. Observation revealed the sink and steamer drained into the same open floor drain and steam from the steamer was backflowing from the floor drain into the sink. Further observation revealed the HVAC return air grilles located above the hot food food preparation/thawing sink and steamer were covered with excessive (thick layer) dust build up.

Interview during tour with Dietary Manager #1 at 1100, revealed the steamer was new and had been installed approximately 6 months ago. Interview revealed he had not noticed the steam backflowing into the food preparation/thawing sink. Interview revealed hospital maintenance staff are responsible for cleaning the return air grilles. Interview revealed he does not know when they were last cleaned. Interview verified the observation findings.

In cookware/dishware dry storage areas:
c. Observation revealed multiple pots and pans being stored face up. Observation revealed 2 of 7 metal pans sampled had dried food particles noted on interior surfaces. Observation revealed 4 of 4 metal mixing bowls stored face up. Observation revealed 4 of 5 plastic beverage glasses sampled were stacked with clear liquid on the interior surfaces, and 2 of 10 metal serving/storage containers sampled were stacked with clear liquid on interior surfaces. Observation revealed sticky residue build-up on pot lids stored on the bottom storage rack ready-for-use. Observation revealed sticky liquid residue build-up on tray holding, ready-for-use.

Interview during tour with Dietary Manager #1 at 1110, revealed the stored cookware and dishware was clean and available for use by staff. Interview revealed cleaned items should not have residual dried food particles stuck on their surfaces after being cleaned and sanitized. Interview revealed there should be no sticky residue. Interview revealed cookware and dishware should no be stored face up or stacked wet. Interview verified the observation findings.

In dish machine area:
d. Observation of the dish machine revealed the wash cycle temperature gauge and the rinse cycle temperature gauge covers were missing and the inside mechanics were exposed to outside elements. Observation revealed both the wash temperature and high temperature rinse gauges registered during a test cycle. Observation revealed a reading of 154 degrees Fahrenheit during the wash cycle and 158 degrees Fahrenheit during the rinse cycle. Observation revealed at the end of the test cycle, staff tested the final rinse water with pH test strips for the efficacy of the chemical sanitizer. Observation revealed the concentration of chemical sanitizer was within range to sanitize items. Further observation revealed the pH test strips used to measure the chlorine levels (chemical sanitizer) in the dish machine had an expiration date of "01/14" (greater than 15 months expired) and the pH test strip container was not sealed per manufacturer's recommendations.

Interview during tour with Dietary Manager #1 at 1120 revealed according to facility engineering, due to the location of the kitchen a booster heater is required to boost the amount of steam required to raise water temperatures in the dish machine to over 180 degrees. Interview revealed the reason for using a "chemical wash" is because acceptable water temperatures cannot be accomplished despite the use of a booster heater. Interview revealed the dietary staff use a low temperature wash with a chemical sanitizer. Further interview revealed he was not aware the two gauge covers were broken "until just now" and he was not sure if the recorded readings had been accurate. Interview revealed that even with the booster heater, a temperature of 180 degrees Fahrenheit during the final rinse as documented on the Preventive Maintenance report by the contract vendor would not be possible. Interview revealed the accuracy of both gauges was in question. Interview revealed the pH tests strips were used to measure chlorine levels for the low temperature dish machine to ensure sanitization. Interview verified the test strips had expired in 2014. Interview revealed he "had no answer" addressing whether the tests were still good. Interview revealed, "All I know is what the Health Department told me. If it turns colors, they're good." Interview revealed staff most likely ran out of test strips and went to the office and requested more, and were handed the expired strips "without looking at them." Interview verified the observaiton findings.

Based on current hospital policy and procedure review, medical record reviews, and staff interviews, the hospital's nursing staff failed to monitor vital signs per policy for 1 of 3 patient's who received a blood transfusion. (Patient #8)

The findings included:

Review on 06/04/2015 of the hospital's "Blood Product Transfusion: Administration and Monitoring" policy revealed "...During this time, the RN (Registered Nurse) will monitor the patient frequently: vital signs (HR [hear rate], RR [respiratory rate], BP [blood pressure], TEMP [temperature]) every 15 minutes X4. If the vital signs are unchanged and no symptoms of reaction are noted, the LPN (Licensed Practical Nurse) may monitor the transfusion. Repeat vital signs every 30 minutes X2, then every (1) hour, then every (4) hours after the transfusion is completed. Staff will record the vital signs with the frequency as described on the Supplemental Vital Sign Record... The vital signs will coincide with the start of the blood time..."

Closed medical record review on 06/04/2015 for Patient #8 revealed the patient was admitted on 01/16/2015 for a surgical procedure. Review revealed the patient received 1 unit of packed red blood cells (PRBCs) on 01/16/2015. Review revealed the blood transfusion was started at 0851 and stopped at 1125. Review revealed vital signs were obtained at 0900, 0915, and 0945. Review failed to reveal any available documentation vital signs were obtained at 0930 (every 15 minutes times 4 sets per policy). Further review revealed no available documentation of the subsequent vitals signs obtained every 30 minutes times 2 sets at 1015 and 1045 as required per policy.

Interview on 06/05/2015 at 1030 with Nurse Manager #2, revealed she was the Medical-Surgical floor's Nurse Manager. Interview revealed the expectation during blood transfusions is for the nursing staff to monitor vital signs "every 15 minutes X4 then every 30 minutes X2 and every hour until complete." Interview revealed Patient #8's blood transfusion documentation was missing 1 of 4 initial vital signs (0930 set) and both of the subsequent 30 minute vital signs (1015 and 1045 set). Interview revealed there was a "supplemental vital sign record" nurses were expected to use during blood transfusions. Interview revealed "they are not expected to document on both the supplemental vital sign record and the EMR (electronic medical record)." Further interview revealed, the paper documentation is scanned into the patient's EMR. Interview revealed Patient #8's supplemental vital sign record did not get scanned into the EMR and she was unable to locate the paper copy.

Based on policy review, medical record review, and administrative staff interview, the hospital failed to ensure a multidisciplinary care plan including measurable objectives and timetables for completion was initiated for 4 of 4 Swing Bed patients (#15, #10, #11 and #12).

The findings include:

Review of current hospital policy "Interdisciplinary Care Plan Team" reviewed/revised 04/2013, revealed "The coordination of treatment by the members of an interdisciplinary team identify the specific needs for the patient, establish achievable goals, set target dates and maintain documentation of progress in an organized and dynamic plan of care."

1. Open medical record review for Patient #15 revealed a Swing Bed admission on 06/02/2015 for aftercare following a fall that resulted in a left leg fracture and left wrist fracture. Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Review of the plans of care revealed each discipline had a separate plan of care. Review of the PT and OT plans of care revealed the plans were continued from the patient's acute care hospital stay. Review of the nursing and OT plans of care revealed there was no timetables for completion of objectives.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that included measurable objectives and timetables for completion that would be based on a comprehensive assessment. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed when a patient has moved to Swing Bed status the PT plan of care is continued from acute care. The interview revealed there is not a new assessment conducted unless there was a change in patient condition. The interview revealed the plan of care included PT services only. Interview verified the medical record findings.

2. Closed medical record review for Patient #10 revealed a Swing Bed admission on 05/30/2015 for aftercare following a left knee arthroplasty (replacement) on 05/27/2015. Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Review of the plans of care revealed each discipline had a separate plan of care. Review of the PT and OT plans of care revealed the plans were continued from the patient's acute care hospital stay. Review of the nursing and OT plans of care revealed there was no timetables for completion of objectives.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that included measurable objectives and timetables for completion that would be based on a comprehensive assessment. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed when a patient has moved to Swing Bed status the PT plan of care is continued from acute care. The interview revealed there is not a new assessment conducted unless there was a change in patient condition. The interview revealed the plan of care included PT services only. Interview verified the medical record findings.

3. Closed medical record review for Patient #11 revealed a Swing Bed admission on 04/27/2015 for aftercare following bilateral knee arthroplasty (replacement). Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Review of the plans of care revealed each discipline had a separate plan of care. Review of the PT and OT plans of care revealed the plans were continued from the patient's acute care hospital stay. Review of the nursing and OT plans of care revealed there was no timetables for completion of objectives.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that included measurable objectives and timetables for completion that would be based on a comprehensive assessment. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed when a patient has moved to Swing Bed status the PT plan of care is continued from acute care. The interview revealed there is not a new assessment conducted unless there was a change in patient condition. The interview revealed the plan of care included PT services only. Interview verified the medical record findings.

4. Closed medical record review for Patient #12 revealed a Swing Bed admission on 04/17/2015 for continued care for acute renal failure and heart failure. Continued review revealed the patient received physical therapy (PT), nursing, case management, and palliative care services. Review of the plans of care revealed each discipline had a separate plan of care. Review of the PT plan of care revealed the plan was continued from the patient's acute care hospital stay. Review of the nursing plan of care revealed there was no timetable for completion of objectives.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that included measurable objectives and timetables for completion that would be based on a comprehensive assessment. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed when a patient has moved to Swing Bed status the PT plan of care is continued from acute care. The interview revealed there is not a new assessment conducted unless there was a change in patient condition. The interview revealed the plan of care included PT services only. Interview verified the medical record findings.

Based on policy review, medical record review, and administrative staff interviews, the hospital failed to ensure a multidisciplinary team of qualified persons periodically reviewed the plan of care for 4 of 4 Swing Bed patients (#15, #10, #11 and #12).

The findings include:

Review of current hospital policy "Interdisciplinary Care Plan Team" reviewed/revised 04/2013, revealed "The coordination of treatment by the members of an interdisciplinary team identify the specific needs for the patient, establish achievable goals, set target dates and maintain documentation of progress in an organized and dynamic plan of care. . . 1. The Interdisciplinary Team will conduct care-planning daily except Saturday and Sunday. . . The multidisciplinary team will review patient data, identify problems, concerns and needs and address these issues. . . "

1. Open medical record review for Patient #15 revealed a Swing Bed admission on 06/02/2015 for aftercare following a fall that resulted in a left leg fracture and left wrist fracture. Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Continued review of the medical record revealed no evidence the plans of care had been reviewed and update by an interdisciplinary team.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that is reviewed and updated as needed. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed all Swing Bed patients are discussed Monday through Friday at 1030. The interview revealed the discussion is not documented in the patient record. Interview verified the medical record findings.

Interview with Nursing Supervisor #1 on 06/04/2015 at 1420 revealed a representative from the the following services nursing, chaplain, PT, OT, dietician, pharmacy, respiratory therapy, case management, and a hospitalist meet daily Monday through Friday at 1030 to discuss each Swing Bed patient. The interview revealed the discussion is not documented in the medical record. There was no evidence produced during the survey of the interdisciplinary team review of the plans of care. Interview verified the medical record findings.

2. Closed medical record review for Patient #10 revealed a Swing Bed admission on 05/30/2015 for aftercare following a left knee arthroplasty (replacement) on 05/27/2015. Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Continued review of the medical record revealed no evidence the plans of care had been reviewed and update by an interdisciplinary team.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that is reviewed and updated as needed. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed all Swing Bed patients are discussed Monday through Friday at 1030. The interview revealed the discussion is not documented in the patient record. Interview verified the medical record findings.

Interview with Nursing Supervisor #1 on 06/04/2015 at 1420 revealed a representative from the the following services nursing, chaplain, PT, OT, dietician, pharmacy, respiratory therapy, case management, and a hospitalist meet daily Monday through Friday at 1030 to discuss each Swing Bed patient. The interview revealed the discussion is not documented in the medical record. There was no evidence produced during the survey of the interdisciplinary team review of the plans of care. Interview verified the medical record findings.

3. Closed medical record review for Patient #11 revealed a Swing Bed admission on 04/27/2015 for aftercare following bilateral knee arthroplasty (replacement). Continued review revealed the patient received physical therapy (PT), occupational therapy (OT), case management and nursing services. Continued review of the medical record revealed no evidence the plans of care had been reviewed and update by an interdisciplinary team.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that is reviewed and updated as needed. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed all Swing Bed patients are discussed Monday through Friday at 1030. The interview revealed the discussion is not documented in the patient record. Interview verified the medical record findings.

Interview with Nursing Supervisor #1 on 06/04/2015 at 1420 revealed a representative from the the following services nursing, chaplain, PT, OT, dietician, pharmacy, respiratory therapy, case management, and a hospitalist meet daily Monday through Friday at 1030 to discuss each Swing Bed patient. The interview revealed the discussion is not documented in the medical record. There was no evidence produced during the survey of the interdisciplinary team review of the plans of care. Interview verified the medical record findings.

4. Closed medical record review for Patient #12 revealed a Swing Bed admission on 04/17/2015 for continued care for acute renal failure and heart failure. Continued review revealed the patient received physical therapy (PT), nursing, case management, and palliative care services. Continued review of the medical record revealed no evidence the plans of care had been reviewed and update by an interdisciplinary team.

Interview with Chief Nursing Officer #1 on 06/05/2015 at 1315 revealed Swing Bed patients should have an interdisciplinary plan of care that is reviewed and updated as needed. Interview verified the medical record findings.

Interview with Physical Therapy Director #1 on 06/04/2015 at 1500 revealed all Swing Bed patients are discussed Monday through Friday at 1030. The interview revealed the discussion is not documented in the patient record. Interview verified the medical record findings.

Interview with Nursing Supervisor #1 on 06/04/2015 at 1420 revealed a representative from the the following services nursing, chaplain, PT, OT, dietician, pharmacy, respiratory therapy, case management, and a hospitalist meet daily Monday through Friday at 1030 to discuss each Swing Bed patient. The interview revealed the discussion is not documented in the medical record. There was no evidence produced during the survey of the interdisciplinary team review of the plans of care. Interview verified the medical record findings.