HospitalInspections.org

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on January 27, 2020. Further details are outlined in that Division of Life Safety Survey Report.

Based on review of facility policy, facility documentation and staff (EMP) interview, it was determined the facility failed to perform filter changes to the outpatient rehabilitation pool monthly as per manufacturer's instructions in two of 13 months reviewed and the facility failed to perform preventive maintenance on ice machines as per facility policy for ten of 24 scheduled maintenance events.

Findings include:

1) Review of the facility policy "EOC: Utility Management- Management Plan," last reviewed/revised January 16, 2020, revealed " ... Implementation: ... Responsibility- The Utilities Management Plan is directed by the Maintenance Department in conjunction with all Hospital departments and is monitored by the Safety Committee ... Written documentation of all equipment maintenance and operations procedures is provided to the Maintenance Department and filed in the Maintenance Department. ... Preventative maintenance procedures and frequencies are set-up on a computer generated preventative maintenance program based on manufacturer's recommendations, regulatory requirements, risk assessment of unscheduled downtime and where applicable, past experience ... Reduction for potential of organizational acquired illness, Managing pathogenic biological agents in cooling towers, domestic hot water and other aerosolizing water systems Process includes: ... Preventative Maintenance Programs (i.e. Hot Water Storage Tanks, Ice Machines) ... Monitoring: Incident Commander and/or Safety Officers and/or Director of Maintenance. ..."

Review of the facility policy "Rehabilitation Pool Cleaning and Chemical Monitoring," last reviewed/revised June 9, 2019, revealed "Purpose: To maintain patient safety by providing a clean aquatic setting for rehabilitation and exercise purposes in the 5,000 gallon aquatic therapy pool .... Implementation: ... Filters will be inspected, cleaned and changed when necessary by the Maintenance Services staff ..."

Review on January 30, 2020, of documentation of the pool manufacturer's instructions for use revealed "Pool Operating System ... Filter Changing ... Change or clean the filter at least once a month or any time the filter pressure increases 3 pounds over the normal reading."

Review of the electronic system of work orders with EMP7 on January 30, 2020, at 1:15 PM revealed no documentation of pool filter changes in January 2019 and February 2019.

Interview with EMP7 on January 30, 2020, at 1:15 PM confirmed there was no documentation of monthly pool filter changes in January 2019 and February 2019.

2) Review of facility policy "EOC: Utility- Ice Machine Cleaning and Sanitizing," last reviewed/ revised October 30, 2019, revealed: "Purpose: The intent of this policy is to minimize the growth of pathogens in ice machines/ice dispensers. Implementation: The following procedures will be performed on a semi-annual basis: 1. Remove all ice from the storage bin. 2. Follow ice machine cleaning and sanitizing procedure located on the inside cover of the ice machine. 3. Clean, inspect and sanitize the ice bin for machines with an ice bin. 4. Replace and clean water filter. 5. Clean ice machine air filter. 6. Clean outside of ice machine. Monitoring: Director of Maintenance & Engineering or designee; Maintenance log book."

Review of the maintenance department ice machine preventative maintenance documentation with EMP7 on January 30, 2020, at approximately 10:45 AM revealed there was no documentation for the cleaning, sanitization, and filter changes of the ice machines for the following: in the first half of 2018 and last half of 2019 for the cafeteria; the first half of 2018 for the snack bar; the first half of 2018 and last half of 2019 in maternity/OB; the first half of 2018 and last half of 2019 in the emergency department; the entire year for 2018 in MS(med/surg) 3; and the first half of 2018 in MS4.

Interview with EMP7 on January 30, 2020, at approximately 10:45 AM, confirmed there was no documentation for the ice machine cleaning, sanitization, and filter changes as listed above.

Based on review of facility policies and documents, observation and staff interview (EMP), it was determined the facility failed to ensure proper storage of food in three (October 2109, November 2019 and December 2019) of three months reviewed; failed to ensure expiration date labeling of five of five bags of frozen food items; failed to ensure food safety in two (October 2019 and November 2019) of three months reviewed and failed to ensure proper cleaning and sanitation of food preparation and serving equipment in three (November 2019, December 2019 and January 2020) of three months reviewed.

Findings include:

Review on January 29, 2020, of facility policy "General Requirements-Food Supply and Storage," last reviewed November 27, 2019, revealed "Purpose: To ensure that the proper food and non-food supplies will be purchased and stored under sanitary, safe, and secure conditions as required to meet federal, state and local laws "...Food storage: ... All open foods will be labeled with an open date using the appropriate label. Foods without a manufacturer's expiration date will also be dated with a use by date. All foods with a manufacturer's expiration date will use the manufacturer's expiration date or be labeled with a shorter date based on hospital policy ... Refrigerator and Freezer Temperature Logs: Hospitality Services staff will check all refrigerator temperatures daily...All temperatures must be recorded on the Refrigerator Temperature Log attached to each refrigerator..."

1) Review on January 29, 2020, of the facility's "Cooler Temperature Chart" for October 2019, November 2019 and December 2019, revealed 21 incidents in October 2019, 14 incidents in November 2019 and seven incidents in December 2019, when no daily temperatures were recorded.

Interview with EMP4 on January 31, 2020, at approximately 9:00 AM, confirmed cooler temperatures were not documented for 21 incidents in October 2019, 14 incidents in November 2019 and seven incidents in December 2019.

2) Observed on January 29, 2020, at approximately 10:45 AM, during a tour of the walk-in freezer in dietary, a bag of frozen meatballs, a bag of frozen shrimp, a frozen pork roast and two bags of frozen pepperoni. None of the items were marked with an expiration date.

Interview with EMP4 on January 29, 2020, at approximately 10:45 AM, confirmed the items had been removed from boxes and staff had failed to record the expiration dates on the items.

3) Review on January 29, 2020, of facility policy "Food Temperature," last reviewed November 12, 2018, revealed "Purpose: To ensure that tray line food temperatures are served according to established guidelines...Implementation: The temperature of food items on tray line shall be taken and recorded before the start of serving..."

Review on January 29, 2020, of the facility's "Trayline [sic] Steam Table Temperature Log" and "Milk Temperature Log" for October 2019, November 2019 and December 2019, revealed 27 meals in November 2019 with no food temperatures recorded and 24 meals in October 2019 and one meal in December 2019, with no milk temperatures recorded.

Interview with EMP4 on January 31, 2020, at approximately 9:00 AM, confirmed 27 meals in November 2019 had no food temperatures recorded and 24 meals in October 2019 and one meal in December 2019, had no milk temperature recorded.

4) Review on January 29, 2020, of facility policy "Dishwasher Temperature Logs," last reviewed January 7, 2019, revealed, "Purpose: To ensure that all dishes and flatware are washed and sanitized at the proper temperatures, the temperatures must be checked at every meal...Employee: During each meal, record wash, rinse and final rinse temperatures on the "Record of Dishwashing Temperature" form. During each meal runs a Dishwasher Temperature strip to check the internal washing temperatures are accurate in reaching a minimum of 160 degrees F..."

Review on January 29, 2020, of the facility's "Record of Dishwashing Temperatures" for October 2019, November 2019 and December 2019, revealed 17 meals in October 2019, 13 meals in November and seven meal in December with no wash, rinse, final rinse temperatures and no temperature strip results recorded.

Review on January 29, 2020, of the facility's "Sanitizer Concentration Log" for October 2019, November 2019 and December 2019, revealed seven meals in October 2019, two meals in November 2019 and three meals in December 2019 with no documentation of sanitizer concentration.

Interview on January 31, 2020, at approximately 9:10 AM, confirmed 17 meals in October 2019, 13 meals in November 2019 and seven meals in December 2019, had no wash, rinse, final rinse temperatures and no temperature strip results recorded. EMP4 further confirmed seven meals in October 2019, two meals in November 2019 and three meals in December 2019, had no documentation of sanitizer concentration.

Interview with EMP4 on January 29, 2020, at approximately 11:00 AM, confirmed sanitizer concentration in the dishwashing sink was to be checked and recorded each meal.

Request for a facility policy regarding cleaning of food preparation equipment in the kitchen was made on January 29, 2020 and January 30, 2020. No policy was provided.

Review on January 29, 2020, of facility documentation revealed the facility had developed lists with daily and weekly cleaning responsibilities for 16 job positions along with a "Daily Checkout" form for staff to initial prior to the end of their shift indicating completion of their responsibilities. Further review revealed the cleaning responsibilities included tasks such as daily cleaning of the microwaves, the steam tables on the tray lines, cook tables, mixers, food carts, the grill and fryer and weekly responsibilities including cleaning of the floor mixer, deep cleaning of all coffee pots, cleaning of the dish machine and sweeping and mopping of all coolers.

Review on January 31, 2020, of the facility's "Daily Checkout" for November 2019, December 2019 and January 2020, revealed multiple cleaning tasks on each month's log that were not initialed to document completion of the tasks. The number of cleaning tasks with no documentation of completion included 117 of 448 tasks in November 2019, 125 of 448 tasks in December 2019 and 76 of 336 tasks in January 2020.

Interview with EMP4 on January 31, 2020, at approximately 9:15 AM, confirmed 117 of 448 cleaning tasks in November 2019, 125 of 448 cleaning tasks in December 2019 and 76 of 336 cleaning tasks in January 2020, lacked documentation the tasks were completed.

Based on review of facility policy and credential files (CF) and staff (EMP) interview, it was determined the governing body failed to ensure the credentialing policy regarding the granting of temporary clinical privileges was followed for three of five credential files (CF18 and CF20).

Findings:

Review on January 28, 2020, of the facility's "Credentials Policy," last reviewed September 20, 2019, revealed "... 4. Article 4 4.1 Clinical Privileges ... A. 4.1.2. Temporary Clinical Privileges: a. Temporary privileges may be granted by the President and Senior Executive, upon recommendation of the Chief of Staff, to:...2. Non-applicants, when there is an important patient care, treatment, or service need, including the following: i. the care of a specific patient; ii. when necessary to prevent a lack of services in a needed specialty area; iii. proctoring; or iv. when serving as a locum tenens for a member of the Medical Staff...c. The grant of temporary privileges will not exceed 120 days. d. For non-applicants, who are granted temporary locum tenens privileges, the individual may exercise locum tenens privileges for a maximum of 120 days, consecutive or not, anytime during the 24-month period following the grant of privileged..."

Review on January 28, 2020, of a facility provided spreadsheet documenting the number of days the practitioner provided medical coverage revealed CF18 was initially granted temporary privileges for 120 days on January 2, 2019. Further review revealed CF18 provided medical coverage for 224 days from January 2, 2019, through January 28, 2020.

Review on January 28, 2020, of a facility provided spreadsheet documenting the number of days the practitioner provided medical coverage revealed CF20 was initially granted temporary privileges for 120 days effective March 18, 2019. Further review revealed CF20 provided medical coverage for 216 days from March 18, 2019, through January 28, 2020.

Interview with EMP1 on January 28, 2020, at approximately 10:00 AM, confirmed CF18 provided coverage for 224 days from January 2, 2019, through January 28, 2020 and CF20 provided coverage for 216 days from March 18, 2019, through January 28, 2020.

Based on review of facility documents, medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure informed consents for minors contained the relationship the signer had with the patient in two out of four minor medical records (MR5 and MR37) and failed to ensure an informed consent for a minor contained the date and time signed for one out of four minor medical records (MR37).

Findings include:

Review on January 31, 2020, of facility policy "Informed Consent Policy," last reviewed June 12, 2019, revealed "Purpose To support the patient's right to participate in healthcare decision making, including granting or withholding informed consent .... Informed Consent - Consent is informed if the patient, or, if the patient is incompetent, the patient's health care agent or health care representative has been given at a minimum the following information: a description of the procedure or treatment the benefits and the risks associated with the procedure any alternatives to the procedure and any risk associated with the alternatives the risks of refusing the procedure or treatment the physician performing the surgical intervention ... Minor: For purposes of this Policy, a minor means an individual under the age of eighteen (18) years ... Who May Give Informed Consent The following individuals may give effective informed consent: a competent, adult patient ... If the patient is a minor, one or both parents can consent for the minor patient ... Documentation of Informed Consent ... The patient or, if the patient is incompetent, the patient's healthcare agent or healthcare representative, is to sign and date the form at the conclusion of the informed consent discussion in the presence of the physician ... All blanks are to be completed prior to the signature ...."

Review on January 31, 2020, of MR5, revealed MR5 was an eleven-year-old patient. MR5's consent for treatment dated January 3, 2020, revealed no documentation of the relationship the person signing the form had with the patient.

Interview with EMP3, on January 31, 2020, at 1:15 PM, confirmed MR5 ' s consent for treatment dated January 3, 2020, was without documentation of the relationship the person signing the form had with the patient. EMP3 confirmed the relationship is to be documented on the consent form.

Review on January 27, 2020, of MR37, revealed MR37 was a seven-year-old patient. MR37's consent for treatment dated January 20, 2020, revealed no documentation of date and time when signed. Continued review revealed no documentation of the relationship the person signing the form had with the patient.

Interview with EMP9, on January 27, 2020, at 11:50 AM, confirmed MR37 ' s consent for treatment had no documentation of the date and time when signed and no documentation of the relationship the person signing the form had with the patient. EMP9 confirmed the forms are to have the date and time, and relationship documented, where appropriate, when the forms are signed.