HospitalInspections.org

41697

Based on observations, document reviews, and interviews, the hospital failed to ensure that the temperature was maintained, within the identified range, in a walk-in freezer for 1 of 1 freezers.

Findings:

The hospital's "Storage Temperature" policy and procedure, indicated that "Temperatures of food storage areas are monitored, and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Frozen Storage: min -10°F [degrees Fahrenheit] max 0°F."

The temperature log sheet, for the walk-in freezer, indicated "freezers should not exceed 0°F. Report deviant temperatures to Food Services Supervisor immediately." The temperatures were recorded, on the log sheet, as follows:

- On 9/1/19, 5°F in the AM and 7°F in the PM;
- On 9/2/19, 4°F in the AM and 7°F in the PM;
- On 9/3/19, 4°F in the AM and 6°F in the PM;
- On 9/5/19, 3°F in the AM and 5°F in the PM;
- On 9/6/19, 4°F in the AM and 5°F in the PM;
- On 9/7/19, 4°F in the AM and 4°F in the PM;
- On 9/8/19, 4°F in the AM and 4°F in the PM;
- On 9/9/19, 5°F in the AM and 4°F in the PM;
- On 9/10/19, 4°F in the AM and 6°F in the PM;
- On 9/11/19, 3°F in the AM and 5°F in the PM; and
- On 9/12/19. 5°F in the AM.


On 8/12/19 at 2:10 PM, the Director of Food Services confirmed that the temperatures were recorded out of range. When asked what the process was when temperatures were outside of the recommended range, the Director of Food Services replied, "We report them to maintenance."

There were no maintenance logs, related to elevated walk-in freezer temperatures, were provided to the surveyor.

Based on observations, record reviews, and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to reporting freezer temperatures outside identified ranges, removing expired food from storage, restraint training and documentation, written resolution of grievances, personnel performance evaluations, and medical record content.

Findings:

The Governing body is responsible to ensure hospital policies are implemented and monitored. Based on observations, document reviews, and interviews, the Governing Body has failed to ensure the hospital's policies were implemented and monitored as evidenced by the following:

1. The hospital's "Storage Temperatures" policy and procedure, in relation to reporting and documentation of any action taken for temperatures outside the range identified in the policy, was not implemented. Please see Tag C-0226 for details.

2. The hospital's "Food and Supply Storage" policy and procedure indicated, the following: "Remove from storage any items for which the expiration date has expired."

On 8/12/2019 at approximately 2:10 PM, seven expired cans of Campbell's Healthy Request Chicken Noodle Soup was observed in the dry goods storage area. This finding was immediately confirmed with the Director of Food Services.

3. The hospital's policy titled, "Restraints, Standard of Care for the Use of Restraints" stated, "CRH [Calais Regional Hospital] staff members who assess, apply and monitor patients for restraint shall receive training."

On 8/13/19, the list of providers who can assess, apply, and monitor patients for restraint was reviewed. There was no documentation that 1 of the 10 providers (Provider #5) reviewed had received restraint training.

On 8/13/19 at 9:20 AM, the Credentialing Coordinator confirmed this finding.

4. The hospital's policy titled, "Complaints, Concerns and Grievance Policy" stated, "A. Hospital/Clinic Complaints 1.3 Process for review...Inform the complainant that when the investigation is complete, they will receive a written response that outlines the steps taken on their behalf to investigate the complaint, the results of the complaint process and the date of completion."

On 8/13/19, five grievances were reviewed. There was no documentation that Patient #1G, #3G, #4G, and #5G had received a written response that outlined the steps taken on their behalf to investigate the complaint, the results of the complaint process, and the date of completion.

On 8/13/19, at 8:55 AM and again at 9:40 AM, the Nursing Administrative Assistant confirmed these findings.

5. The hospital's "Personnel Performance Evaluations" policy and procedure indicated, "Procedure: 1. Agency's performance evaluation is continuous and includes input from each employee's direct supervisor, from Agency's staff identified as appropriate by Agency's Administrator and from each employee. 2. Formal documentation is performed [...] 2. Annually within thirty (30) days prior to the employee's date of hire

A record review was conducted of personnel files. Employee #1's annual periodic evaluation was due 12/17/18, as of 8/12/19 it was not completed.

On 8/13/19 at 8:30 AM, the Vice President of Quality confirmed this finding.

6. A review of the hospital's "Obtaining General Consent at Time of Registration" policy, dated 11/2018, indicated "If the patient is unable to give consent hospital staff must: Make an attempt to obtain consent from another party related to the patient."

Patient #3's "Consent to Treatment" form indicated the patient was unable to sign and there was no documentation indicating the legal representative or related party was contacted.

On 8/14/19 at 12:30 PM, the Patient Access Coordinator confirmed this finding.


Based on the above findings, the Governing Body has failed to ensure current policies were implemented.

Based on record review and interview, the hospital failed to ensure that a patient's record contained a consent for treatment for 1 of 20 patients reviewed (Patient #3).

Finding:

A review of the hospital's "Obtaining General Consent at Time of Registration" policy, dated 11/2018, indicated "If the patient is unable to give consent hospital staff must: Make an attempt to obtain consent from another party related to the patient."

Patient #3's "Consent to Treatment" form indicated the patient was unable to sign and there was no documentation indicating the legal representative or related party was contacted.

On 8/14/19 at 12:30 PM, the Patient Access Coordinator confirmed this finding.

Based on document reviews and interview, the hospital failed to ensure that all patients were discharged in the company of a responsible adult for 1 of 5 surgical patients (Patient #29).

Finding:

On 8/14/19 at 9:00 AM, surgical records were reviewed with the Clinical Information Technology person. Patient #29's medical record did not contain any documentation that the patient left the surgical suite with a responsible adult.

This finding was confirmed at the time of the record reviews.