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Based on observation, staff interview and document review the hospital failed to ensure that it met State regulatory requirements. The hospital had failed to ensure that there were complete and accurate plans as well as safe, adequate equipment and supplies to support dietetic services during emergency and disaster conditions. By not having such there was the potential for inability to support the internal start-up plan for foodservice, contamination and confusion during implementation.

Findings:

The hospital did not meet regulatory requirements for-

Title 22, CCR, Section 70273. Dietetic Service General Requirements. (a) (5)-
(a) The dietetic service shall ....
(5) When food is provided by an outside service, all applicable requirements herein set forth shall be met. The hospital shall maintain adequate space, equipment and staple food supplies to provide patient food service in emergencies.

Title 22. CCR, Section 70741. Disaster and Mass Casualty Program. (b) (1)-
b) The program shall cover disasters occurring in the community and widespread disasters. It shall provide for at least the following:
1) Availability of adequate basic utilities and supplies, including gas, water, food and essential medical and supportive materials.

1. On 4/26/10 between 11:10 a.m. and 11:40 a.m. review of the emergency and disaster plans revealed that while the hospital had evidence that the contracted outsource for foodservice had a contingency plan for an alternative site for food production, there was limited start-up capacity within the hospital kitchen in the event of sudden, unexpected protracted discontinuation of the outsource and their support materials (e.g. carts and wares).

a. There were limited dishwashing capabilities as there was no dishmachine and only a two-compartment sink for a three-step (washing, rinsing and sanitizing) manual process. Also, the two compartment sink had limited counter space and there was no designated shelving to ensure effective interim storage for air drying.

b. Although there was plan for use of frozen meals and adequate storage for such in the event of prolonged disruption, there were limited surfaces for meal set-ups and no evidence that these surfaces had been factored in the plan.

c. There was no ice machine in the kitchen and no plan for the availability of ice from a sanitary source within the kitchen premises. Although there was a dispenser for ice at a nearby (Northwest Unit) nursing station, there was no reference to how, in the event of freezer malfunction how perishable items, including potentially hazardous (non-acidic, protein containing) foods could be maintained and free of potential cross-contamination.

Later, between 2:15 p.m. and 2:20 p.m. while in an administrative conference room, Hospital Representative 1 and Dietitian 1 stated that the layout and equipment of the kitchen had been in place prior to their employment. Hospital Representative 1 and Dietitian 1 stated that to their knowledge, the hospital had long-term reliance upon the contracted foodservice outsource resulting in: limited dishwashing; constricted space for meal set-ups; and uncertain use and volume of ice to help maintain frozen foods in the event of freezer failure as well as for other purposes. Also, upon review of the emergency and disaster plans as well as the contract with the cafeteria service, Hospital Representative 1 and Dietitian 1 stated that pertaining to start-up capacity --specific to dishwashing, meal set-ups and ice usage would need review and updating.

2. On 4/27/10 between 2:20 p.m. and 2:40 p.m. while in an administrative conference room review of the contract with the cafeteria service with Hospital Representative 1 and Dietitian 1 revealed that there was a lack of specificity regarding the type and amount of equipment for storage, preparation, distribution and service which could be readily accessed there during an emergency or disaster and if there were sufficient non-disposable meal service and distribution items to continue beyond a short-term disruption of meal service to substitute, augment or add to what was currently available in the dietetic service department which was not property of the contracted outsource. At 2:40 p.m. Hospital Representative 1 stated that "review" of the emergency and disaster plans was "needed" to ensure an intact system for continuity of service for patient meal service.

Based on observation, record review, and interview, for 4 of 43 sampled patients (Patients 17, 45, 46, and 47 ), the facility failed to use a consistent and accurate method to track intake of tube feedings, which could lead to the inaccurate evaluation of fluid balance.

Findings:

1. Patient 17 was admitted to the facility's critical care unit on 4/18/10 with diagnoses that included gastrointestinal bleeding and alcohol abuse.

Record review on 4/29/10 showed a doctor's order written on 4/20/10 for the patient to have nothing by mouth except for nasogastric tube feedings (NGT - tube inserted through the nose and into the stomach for hydration and nutrition) which was Nutren 1.0 to run continuously with a starting rate of 20 milliliters/hour and if well tolerated, advance formula volume by 10 milliliters/hour and to advance formula rate every 4 hours.

During an observation of Patient 17 on 4/29/10 at 9:52 AM, the NGT feeding was being infused by an automatic pump that was delivering Nutren 1.0 at 85 milliliters/hour. The total volume infused of Nutren 1.0 was digitally displayed on the electric pump and showed that 9,994 milliliters was infused into the patient.

In an interview on 4/29/10 at 9:52 AM, the licensed staff stated that the total fluid volume infused of NGT feeds were generally not zeroed until the digital display reached its maximum of 10,000 milliliters. In other words, the pump's digital display was not cleared per shift or every eight hours to truly obtain the actual total volume that was given to the patient. Additionally, the licensed staff stated the pump would be placed on hold during medication administrations, turning, or transferring to a chair and would not take into account the volume that was not infused during those temporary interruptions because the electronic charting showed the patient was still receiving the ordered amount per hour which was 85 milliliters/hour for Patient 17. For procedures that required longer discontinuations such as CT scans or X-rays, a doctor's order was required and the fluid amount not infused would be accounted for.

The facility's policy and procedure titled, "Feeding Tube", number PP.06.02, revised/reviewed on 10/09 did not indicate to clear the electronic pump every shift or account for temporary interruptions or discontinuations such as medication administrations or patient activities.

The facility's standard of care titled, "Basic Unit Standards, Critical Care", number SOC.02.01, revised/reviewed 01/23/07, page 3 of 5, number 20 of "A. The patient's biophysical needs are assessed and addressed", stated: " I & O and fluid balance is monitored and evaluated every shift".

Not accounting for the temporary discontinuations of the NGT feedings does not reflect the actual nutrition and fluids that was administered to the patient every shift. This nursing practice placed the patient at risk for further decline in medical condition for not providing the patient the required nutritional and hydration needs.

2. Patient 45 was admitted to the facility's critical care unit on 4/14/10 with diagnoses that included pleural effusion (disorder characterized by swelling of subcutaneous tissue caused by obstruction of lymphatic vessels and resulting edema of lymph fluid) that required thoracic (chest) surgery and intervention.

Record review on 4/29/10 showed a doctor's order written on 4/26/10 to start tube feedings with Peptamen at 50 milliliters/hour continuous.

During an observation of Patient 45 on 4/29/10 at 10:30 AM, the tube feeding was being infused by an electronic pump that was delivering Peptamen at 50 milliliters/hour. The total volume of Peptamen was digitally displayed on the electric pump and showed 7,938 milliliters was infused into the patient.

In an interview on 4/29/10 at 10:30 AM, the licensed staff that took care of Patient 45 stated the digital display for the feeding on the electric pump was not cleared every shift but only when the machine reached its maximum capacity. Also, the licensed staff stated the temporary interruptions to stop the feeds such as medication administrations and patient activities were not accounted for in the hourly fluid intake documentation.

The facility staffs' failure to monitor and document interruptions in administering the ordered amount of nutrition and fluids placed the patients at risk for inadequate fluid intake that may cause further decline in the patients' medical condition.







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3. On 4/30/10 patients receiving tube feedings were randomly chosen from nursing unit 4-South and nursing unit Central, and their nurses were interviewed to find out how they calculated total shift intake.

Patient 46 was on nursing unit 4-South. Record review on 4/30/10 found Patient 46 was admitted to the facility on 4/22/10 with diagnoses including myocardial infarction and pneumonia. Patient 46 had a gastric tube. On 4/22/10, the physician ordered measurement of intake and output every shift.

During observation of Patient 46 mid-morning on 4/30/10, while accompanied by the registered nurse providing care for him, the tube feeding was infusing via pump that displayed the total amount of tube feeding infused.

When concurrently interviewed mid-morning on 4/30/10, Patient 46 registered nurse said the feeding pump total was cleared by the night shift, and she was able to take the infused amount shown on the pump for Patient 46 intake total for that shift.

4. Patient 47 was on nursing unit Central. Record review on 4/30/10 found Patient 47 was admitted to the hospital on 4/28/10 with diagnoses including pancreatic fistula. Patient 47 had a nasogastric feeding tube placed 4/28/10. On 4/28/10, the physician ordered measurement of intake and output every eight hours.

During observation of Patient 47 mid-morning on 4/30/10, while accompanied by the registered nurse providing care for Patient 47, the tube feeding was infusing via pump. The pump in use was the same kind of pump that was in use on 4-South, and displayed the total feeding that had infused.

When concurrently interviewed mid-morning on 4/30/10, Patient 47's registered nurse said she calculated the eight hour intake total for Patient 47 by multiplying the number of hours the feeding ran by the milliliters each hour the pump was set to infuse. To adjust the total feeding intake amount for brief periods when the feeding pump was turned off, Patient 47's registered nurse deducted the amount that should have infused during the time the pump was off from the total amount that should have infused for eight hours. Patient 47's registered nurse was not sure when the feeding pump total was cleared.

The method used to calculate total feeding intake by the registered nurse on nursing unit Central was different from the method employed by the registered nurse on nursing unit 4-South, even though the same type of feeding pump was in use.

Based on closed record review and staff interview, the facility failed to ensure that the conditions of admission forms contained documentation of advance directive information was provided to each patient who did not have an advance directive in 4 of 9 records reviewed.

Findings:

On 4/29/2010 beginning at 0930, closed record review revealed that 4 of 9 closed medical records reviewed lacked documentation of advance directive information that was provided to the patients who did not have an advance directive. The "Hospital Conditions of Admission Inpatient/Outpatient Services" forms contained a statement "Does the patient have an advance directive ___Yes ____No?
If no, advance directive brochure provided by _________(name)." In 4 of 9 closed medical records reviewed, the line that states that the person was given a brochure was blank. Susequent interview with Staff Member #1 verified that each conditions of admission form should contain the name of the employee that provided the brochure to the patient. (Patients #20, #22, #24, #25).

Based on medical record and document reviews A 467
as well as staff interview the hospital failed to ensure that all nutrition care orders, nursing notes and accurate information needed for the assessment of nutritional needs had been available for monitoring of intake (Patient 17). Also, there was the potential that nursing admission screens would not capture information pertinent to assistive feeding equipment.

Findings:

1. Patient 17 was an adult male admitted 4/18/10 with alcohol abuse and a GI (gastro-intestinal) bleed who was in the ICU (Intensive Care Unit), mechanically ventilated and tube fed. Further, according to available information in the automated record, Patient 17 had a medical history and nutritionally significant diagnoses e.g. hypertension, hepatic failure, acute respiratory failure and moderate protein-calorie malnutrition. During the duration of stay, this five feet ten inch patient went from an admission weight of 73.1 kg (160.8 lbs) with substantial weight changes in the interim, e.g. 4/23/10-79 kg (173.8 lbs) and 4/24-82.4 kg (181.28 lbs) with subsequent diuresis such that weight on 4/28/10 was 73.9 kg (162.58 lbs).

On 4/28/10 and 4/29/10 during reviews of both the Quality Assurance systems and Patient 17 ' s care there was concern as to the accuracy of the recording of the Nutren 1.0 enteral formula infusions as nursing staff had carried forth the the physician-prescribed 4/21/10 goal rate of 85 cc ' s per hour routinely on an hourly basis without having relied upon the pump information. Of related concern was this on-going recording without questioning why there had not been downtime for checking residuals, turning, administering medications and other daily interventions which per Nurse X would account for a downtime of one hour from the presumed continuous tube feeding within 24 hours.

Further, discussion revealed that there had been the reliance upon this data by registered dietitians in assessing actual calories, fluid and protein provided via tube feeding as well as determining the goal rate without having factored downtime. Further, on 4/29/10 at 2:55 p.m. Dietitian 1 stated that the accuracy of setting the goal rate based on physician orders which had been written without total hours and without having looked at downtime had not been discussed " in committee " and that these items " never been a quality project " .

On 4/29/10 at 4:10 p.m. while in an administrative conference room, Consulting, Administrative Nurse 1 stated that the recording was in question and of concern as nursing staff should not have carried forth the data unless it had been reflective of actual infusion and that it could be questionable not only in terms of reliability in terms of nutrition care, but safe nursing services as the data suggested that perhaps nursing staff had not been turning off the pump when needed for interventions. Additionally, Consulting/Administrative Nurse 1 stated that there also need to be a review of the way physicians wrote tube feeding orders as there had been inattention to total hours for continuous feeding to ensure accuracy in goal rate and total volume.

2. On 4/29/10 between 4:08 p.m. and 4:13 p.m. Therapist Supervisor 1 and Therapist 1 stated that the admission nursing screens did not have a field to complete which was specific for the needs of patients requiring assistive feeding devices. At 4:10 p.m. Therapist 1 stated that there had not been an alert system developed to ensure that patients requiring such devices had needs met. Further, as of 4:13 p.m. both Therapist Supervisor 1 and Therapist 1 stated that there was neither equipment " in the department " nor a policy and procedure for procurement, maintenance, cleaning and sanitizing.

The hospital failed to properly store irrigation solutions when the solutions were not dated in the operating room warmers which resulted in an unknown storage status of three 3000ml bags of irrigation solution.

Findings:

On 04/29/10 at 2:55 PM there were two 30000 ml bags of sterile water irrigation solutions in warmer 1 that were not dated. It was also observed that warmer 2 had a bag of 3000ml normal saline that was not dated.

During an interview on 04/29/10 at 2:55 PM Director 1 stated the warmed irrigation solutions should be dated because they are not usable if warmed greater then 72 hours. If the solutions are warmed for long periods of time the plastic may seep into the solution. He also stated that the person stocking the irrigation solutions forgot to date the solution and he did not know if the solutions where usable. He said he would discard the solutions.

Based on observation, interview, and record review, the hospital pharmacy failed to provide patient safety in controling and distributing medications to patients in accordance with applicable standards of practice when:

1. The hospital failed to administer Advair for two patients out of four patients that were on long acting-beta agonists which resulted in Patient 1 not being administered Advair 6.5 days out of 17 days, and Patient 2 was not administered Advair 3 days out of 10 days.

2. The hospital failed to account for medications when non-controlled drug discrepancies were not accounted for which could indicate medication errors that a patient received an extra dose, missed a dose, or was administered the wrong medication.

Findings:

1. On 04/26/10 at 2:40 PM the nursing station medication storage area had an Advair inhaler for Patient 1 that had additional doses that were not administered based on the dispense date and the quantity indicated on the Advair inhaler. The Advair had been dispensed on 04/20/10 which would have lasted for 7 days. The remaining doses indicated there were 3.5 days remaining.

A review of the clinical record indicated that Patient 1 was a 63 years old with a medical history of chronic respiratory failure, chronic obstructive pulmonary disease (COPD - chronic lung disease), pneumonia, and bronchitis. He had an order for Advair 500-50mcg 1 puff twice daily for COPD.

A review of Patient 1's medication administration record (MAR) indicated that Advair was administered to the patient by the licensed nurse for 17 days from 04/09/10 through 04/26/10.

A review of Patient 1's dispense record indicated that two Advair inhalers were dispensed on 04/09/10 and the other on 04/20/10. The two dispensed Advair inhalers indicated that 14 days of medication was available since 04/09/10.

On 04/26/10 the MAR and the dispense record indicated that the nurses documented that they administered 17 days of Advair but only 14 days of Advair was available. It was also observed that 3.5 days remained on 04/26/10. This indicated that there were 6.5 days of medication supply that was not administered to Patient 1.

2. review of the clinical record indicated Patient 2 was a 71 years old with a medical history of shortness of breath, pulmonary edema, and respiratory distress. She had an order for Advair 500-50 mcg 1 puff twice a day for obstructive lung disease.

A review of Patient 2's MAR indicated that Patient 2 started the Advair on 04/16/10 and the nurse documented that it was administered daily for 10 days until 04/26/10.

A review of Patient 2's dispense record indicated that one Advair was dispensed on 04/16/10. This indicated that 7 days of medication was available from 04/16/10.

On 04/26/10 Patient 2's MAR and dispense record indicated that the nurses documented that they administered 10 days of Advair but only 7 days of Advair was available. This indicated that there were 3 days of medication that was not administered to Patient 2.

In an interview on 04/27/10 at 11:09 am the Pharmacy Supervisor stated that the nurses were not correctly administering the Advair and that the patients did not always get the medication.

During a group interview on 04/29/10 at 9:35 am with the Director of Pharmacy (DOP) and Pharmacy Supervisor collectively stated and acknowledged that Advair was used in more severely asthmatic and COPD patients. The missing doses of Advair could severely exacerbate symptoms and could be fatal.

In an interview on 04/27/10 at 2:00 PM, the DOP stated that the Discrepancy Summary Reports were reviewed daily. She said the Discrepancy Summary Reports are reports that indicate missing or extra doses found in the Pyxis machines throughout the hospital. She also said that the pharmacist did not routinely review the majority of the discrepancies.

In a group interview on 04/28/10 at 9:45 am with Pharmacist 1, DOP, and Pharmacy Supervisor, Pharmacist 1 stated and acknowledged that the reported missing and excess doses could indicate that a patient received too much medications (extra doses), not enough medications (missing doses), and/or wrong medication. They acknowledged that missing and excess doses could be medication errors.

A review of the Discrepancy Summary Report dated 04/26/10 indicated a list of medications that had been missing or excess doses within the Pyxis machines through out the hospital. There was a total of 1,074 missing and excess doses of 64 different types of medications.

During a group interview on 04/29/10 at 9:53 am, the DOP and Pharmacy Supervisor both stated, after the Department identified unaccounted missing and excess medications, that a two day full audit on 04/26/10 and 04/27/10 of the Discrepancy Summary Report revealed two systems issues. The Pharmacy Supervisor said that the bar scanning was not correctly scanning when nurses were to administer medications. The DOP said she had identified issues with the nurses incorrectly wasting medication. They both acknowledged that it would be beneficial to fully review the Discrepancy Summary Report on a daily basis.

Based on observation, staff interview and document review the hospital failed to ensure that: there had been interim daily monitoring of foods originating from a contracted outsource for foodservice: reliable reference for safe food temperatures; diligent surveillance for the operability of the refrigerators; and an intact system to preclude the introduction of communicable disease (TB). By not having such systems there was the potential for undetected development of foodborne illness and transmission of disease.

Findings:

1. On 4/26/10 between 11:50 a.m. and 1:10 p.m. while conducting the inspection of the kitchen there was evidence of dietetic service staff management and staff inattention. This included the failure to: readily locate the complete temperature tracking records used at both the outsource and at the hospital in the past 30 days; the use of signs on ten refrigerators (eight of which were for hospital patient food storage and two of which were for cafe patronage) which incorrectly stated that the danger zone for the development of foodborne illness was 41 degrees F to 100 degrees F (rather than 41-135 degrees F per the 2009 Food Code); and the failure to know the significance of digital displays on two refrigerators which were neither defrosting nor displaying temperatures, but were instead displaying letters signifying need for attention due to malfunction and/or need for checking.

Also, in one of the two malfunctioning refrigerators, there was additional compromise for safe ambient air temperature as dietetic service staff had stored lunch trays compactly (i.e. with less than two inches of circulating air space) and there had been frequent door opening for patient lunch set-up and distribution Alone, in part and/or together, this had resulted in foods being above 41 degrees F., the maximum for safe chilling of potentially hazardous (non-acidic, protein-containing) foods and if left undetected could have resulted in subsequent delivery of foods containing significant micro-organismal growth and toxin development.

At 12:38 p.m. when brought to the attention of Dietitian 1 and then at 12:58 p.m. to Engineer 1 and Engineer 2, discussion ensued regarding potentially unsafe service, need to check the significance of the varying displays within references pertaining to safe operability of equipment and trouble-shooting such that by 1:10 p.m. Dietitian 1 determined the need for the discard of not only the foods above 41 degrees F within the same refrigeration during the timeframe in question, but other foods which had not been probed as well. Further, Dietitian 1 determined upon consultation with Engineer 1 and Engineer 2 that following remediation there would be a minimum of at least 48 hours of verifiable operability and surveillance before foods could be stocked under this refrigeration.

2. On 4/28/10 between 11 a.m. and 12:05 p.m. while in an administrative conference
room, independent review of the personnel and health records of five dietetic service staff with Human Resource Staff 1 and Employee Health Staff 1, revealed that one long-term employee, Dietetic Service Staff 1 had been allowed to return to work on 3/30/10-having been on a preceding leave for " a few weeks " per Dietitian 1 without having had her annual TB screen completed as the last had been completed on 3/19/09. As such, per report of Employee Health Staff 1, Dietetic Service Staff 1 was notified of the need for such testing during the survey.

Upon review with Employee Health Staff 1 at 12:05 p.m. there was no policy on return to work standards (e.g. when an employee had been on an extended leave) and as of conclusion of the survey on 4/30/10 no additional documentation presented as to the role of Dietitian 1 (who had responsibility for management of the department) in assuring that dietetic service staff had timely testing and that systems were in place to ensure that dietetic service staff who may have had exposure to communicable disease during leave, were free from illness and potential for transmission.

Based on observation and staff interview the hospital failed to ensure that the hospital environment had been maintained in a manner to ensure the well-being and safety of patients. By not having ensured safe, sanitary environment and space for the storage and procurement of emergency/disaster potable water and support materials, there was the potential for cross-contamination and transmission of disease.

Finding:

1. On 4/26/10 between 11:12 a.m. and 11:29 a.m. inspection of the outdoor premises where emergency/disaster supplies were stored revealed potential for contamination. These included:

a. At the site of the tank containing 5,000 gallons of potable water there were two uncovered faucet spigots which had cobwebs and one which had a soiled cap (plug) with a thick cobweb.

b. At the shed containing support materials there was an insect comb (hive) at least three inches in diameter and the upper right juncture of the doorframe. Additionally, there was a strong musky odor and a cardboard box containing rope with a brown stain of at least five inches in diameter.

At 11:29 a.m. Engineer 3, Safety Officer 1, Emergency Preparation Officer 1 and Dietitian 1 concluded that there needed to be protective measures for the potable water tank so as to prevent transmission of disease by vectors as well as environmental contamination. Also, Safety Officer 1 added there was a need to determine the source of the musky odor and to check the imperviousness of the shed to water as it contained support materials (e.g. coolers and containers for water) needed during emergency/disaster conditions.

Based on observation and staff interview the hospital failed to ensure that equipment in the dietetic service department was reliable and safe. By not having accurate thermometers and malfunctioning refrigerators, there was potential for undetected conditions leading to the development of foodborne illness as well as the potential short-fall in storage space during regular, emergency and/or disaster conditions.

Finding:

On 4/26/10 between 12:12 p.m. and 12:58 p.m. while conducting the kitchen inspection there were two malfunctioning reach-in refrigerators and three internal thermometers registering inaccurate temperatures, one of which was in one of the malfunctioning refrigerators.

a. In a reach-in refrigerator which had a gauge registering "def" (defrost) and cooked pot roast at 39-41 degrees F, there was a dislodged center tube at an angle which Dietitian 1 stated "looks like thirty- eight <38 degrees F>". In another reach-in refrigerator which had a gauge registering "def" and milk at 38.1 degrees F, there was an internal thermometer registering between 40-42 degrees F, yet the exact temperature could not be determined by Dietitian 1 as there had been a separation in the tubing.

b. In one of the two malfunctioning refrigerators, while the gauge registered 36.4 degrees F --less than one minute before a set of letters displayed showing malfunction, i.e. "CAL SER" probed foods --e.g. soup-unlabeled as to type, omelet, ham and cheese sandwich were at 49.2 degrees F, 50.1 degrees F and 50.3 degrees F respectively and were above the maximum temperature for the safe chilled storage of potentially hazardous (non-acidic, protein-containing) foods, 41 degrees F. The temperatures were of concern as Dietitian 1 stated that the foods with elevated temperatures had been stored there for "possibly two or three hours". A further complication was that this refrigerator had an internal thermometer registering 28 degrees F (four degrees below the freezing temperature of water, 32 degrees F) and in question as reference to it was not only unreliable, but of concern as potentially hazardous foods were not at the safe storage temperature of no more than 41 degrees F.

At 12:58 p.m. upon conferring with Engineer 1 and Engineer 2, Dietitian 1 stated that in addition to further checking of food temperatures and discard of potentially unsafe foods, there was the need to check, repair and replace equipment and to have increased surveillance of the reliability of the thermometers and safe operability of the refrigerators.

Based on observation and staff interview the hospital failed to ensure that there was on-going, knowledgeable surveillance of the refrigerators in the dietetic service department to prevent the growth of micro-organisms and the development of toxins. By not having sufficient surveillance there was the potential for unsafe foodservice leading to foodborne illness.

Based on record review and interview, the facility failed to ensure annual skin tests to determine whether tuberculosis exposure had occurred for 1 of 10 sampled nursing employees, which could lead to manifestation of tuberculosis (TB) in that employee, and the exposure of patients and other hospital employees to tuberculosis.

Finding:

1. On 4/26/10 between 12:12 p.m. and 12:58 p.m. while conducting the kitchen inspection there were two malfunctioning reach-in refrigerators. While both contained potentially hazardous (non-acidic, protein containing) foods, one required immediate attention as potentially hazardous foods were above the maximum for safe chilling. Soup (which was unlabeled as to type was at 49.2 degrees F, omelet at 50.1 degrees F and a ham and cheese sandwich was at 50.3 degrees F.

At 12:58 p.m. after discussion with Engineer 1 and Engineer 2 and determination that the foods in the second unit may have been elevated for " two to three hours " with remaining uncertainty as to prior temperatures of the foods, Dietitian 1 stated that discard of the foods was to be done " now" and that the refrigeration needed to be checked and out of service until temperature could be maintained at 41 degrees F or below. Further, Dietitian 1 admitted that in general, there was a need to review the nature of the digital displays on refrigerators when not registering temperature and defrost with dietetic service staff and to enhance the current surveillance system for monitoring as there was do documented evidence presented to show that there had been on-going surveillance of the refrigerators and freezers so as to identify potential equipment failure.


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2. During record review of ten employee health files on 4/28/10, while assisted by a Facility Staff Person, one registered nurse had no recorded annual skin test for TB in her employee file.

When concurrently interviewed, the Facility Staff Person said she thought the registered nurse had been on a health leave and that was why the annual skin test for TB was missed.

Review of the facility's human resources policy and procedure (P&P) entitled, "Health Screenings," found under 6.1, "... Employee Health Services will review the employee's file to make sure health screening requirements are up to date and will follow up with the employee if necessary." Under 6.1.3, the P&P read, "TB screening ... may involve a two-step process, if indicated;" and under 8.1, "All employees in HCW (health care workers) positions... must complete an annual (or periodic) TB screening."