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Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure that all applicants at the time of reappointment completed a new privilege set for seven seven out of 16 credential files reviewed (CF3, CF4, CF5, CF6, CF10, CF12, CF14).

Findings include:

Review on September 26, 2019, of facility policy, "Medical Staff Privileging," reviewed April 30, 2018, revealed "Policy: It is the policy of Wayne Memorial Hospital to ensure that medical staff clinical privileges consistently reflect the applicant's education, training, experience, demonstrated competence and judgement, references and other relevant information. ...Procedure: ...II. Procedure for Reappointment A. At the time of reappointment, all applicants are required to complete a new privilege set. They are evaluated based on his continued qualifications and competence to exercise the clinical privileges requested. ..."

Review on September 26, 2019, of CF3 revealed a reappointment to the Medical Staff was granted from August 28, 2019, until August 27, 2021. At the time of reappointment, CF3 did not complete a new privilege set.

Review on September 26, 2019, of CF4 revealed a reappointment to the Medical Staff was granted from May 1, 2019 to April 30, 2021. At the time of reappointment, CF4 did not complete a new privilege set.

Review on September 26, 2019, of CF5 revealed a reappointment to the Medical Staff was granted from August 28, 2019 to August 27, 2021. At the time of reappointment, CF5 did not complete a new privilege set.

Review on September 26, 2019, of CF6 revealed a reappointment to the Medical Staff was granted from May 28, 2019 until May 28, 2020. At the time of reappointment, CF6 did not complete a new privilege set.

Review on September 26, 2019, of CF10 revealed a reappointment to the Medical Staff was granted from May 15, 2018 until May 15, 2019. At the time of reappointment, CF10 did not complete a new privilege set.

Review on September 26, 2019, of CF12 revealed a reappointment to the Medical Staff was granted from December 7, 2018 to December 6, 2020. At the time of reappointment, CF12 did not complete a new privilege set.

Review on September 26, 2019, of CF14 revealed a reappointment to the Medical Staff was granted from June 27, 2018 to June 27, 2020. At the time of reappointment, CF14 did not complete a new privilege set.

Interview on September 26, 2019, at approximately 2:15 PM with EMP18 confirmed CF3, CF4, CF5, CF6, CF10, CF12, CF14 did not complete a new privilege set at the time of reappointment.

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure a restraint order for a 13-year-old child was limited to two (2) hours for one of one applicable medical records reviewed (MR52).

Findings include:

Review on September 27, 2019, of facility policy "Restraints," revised March 2019, revealed "Purpose: Restraint is the use of a physical or chemical measure for the purpose of limiting the activity and/or controlling the behavior of an individual who poses an immediate or potential danger to self or others. Policy: ...Each order for physical restraint or seclusion for behavior management is limited to 4 hours for adults; 2 hours for children and adolescents 9 to 17; or 1 hour for patients under 9. ... "

Review on September 27, 2019, of MR52 revealed a 13-year-old who was brought to the Emergency Department (ED) on September 22, 2019 for suicidal thoughts and aggressive behavior.

Continued review of MR52 revealed a restraint order dated September 22, 2019 for soft wrist restraints and soft ankle restraints. Time Frame: May utilize for 4 hours. Documentation revealed MR52 was placed in restraints at 12:00 PM and restraints were removed at 15:00 PM.

Interview on September 27, 2019, with EMP17 confirmed MR52 was brought to the ED on September 22, 2019 for suicidal thoughts and aggressive behavior. EMP17 confirmed a restraint order dated September 22, 2019, for soft wrist and soft ankle restraints. EMP17 confirmed time frame was for 4 hours. EMP17 confirmed MR52 was placed in restraints at 12:00 PM and restraints were removed at 15:00 PM.

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure that code carts were inspected daily as per established nursing policy for 17 times in a two month period.

Findings include:

Review on September 24, 2019, of facility policy, "Code Carts-Checking," revised June 12, 2018, revealed "Policy: It is the policy of Wayne Memorial Hospital to maintain the integrity of the code carts. ...Procedure: A. Code Carts are inspected daily by department personnel for lock integrity in departments that are open 24 hours. All other department code carts are inspected daily by department personnel when the department is open. B. Inspection of the crash cart is documented on the Crash Cart Check form/department checklist. ..."

Review on September 24, 2019, of the daily code cart check on the fourth floor nursing unit for the month of July 2019 and August 2019, revealed that the code cart was not checked six times in July 2019 and 10 times in August 2019.

Interview on September 24, 2019, at approximately 2:00 PM confirmed the code cart was not checked daily as per policy six times in July 2019 and 10 times in August 2019.

Based on review of facility policy, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure informed consent forms were properly executed on nine out of 52 medical records (MR1, MR16, MR18, MR20, MR29, MR30, MR32, MR33 and MR46).

Findings include:

Review on September 27, 2019 of facility policy, "Consent - Informed, Hospital Treatment & Minors," last review April 16, 2018, revealed "Policy: It is the policy of Wayne Memorial Hospital that the Informed Consent of the patient or the patient's authorized representative is obtained prior to the start of any procedure or treatment as set forth in this policy, or both as defined by Pennsylvania Statute or Federal Laws. Further, the patient's authorization for general hospital treatment is to be obtained at the time of admission to the hospital, same day surgery, outpatient or emergency room, except in a medical emergency. ... Informed Consent - Consent is informed if the patient has been given a description of a procedure and the risks and alternatives that a reasonably prudent patient would require to make an informed decision as to that procedure. ... Procedure: I. Authorization for Hospital Treatment: A signed authorization form (Attachment - B) will be obtained by Registration personnel from all patients who are capable of consent, or from an authorized representative at the time of admission to the hospital, including Emergency, Same Day Surgery or Outpatient admission, except in a medical emergency when the patient or authorized representative is unable to provide authorization. ... II. Informed Consent: 1. Procedures Requiring Consent: The physician who is to perform the procedure (See Attachment A) must obtain the Informed Consent of the patient or the patient's authorized representative prior to conducting the following procedures: a. surgery, including the related administration of anesthesia; ... d. insertion of surgical device; ...2. Informed consent Form Requirements: A properly executed informed consent form contains at least the following: ... g. Signature of patient or authorized representative; h. Date and time consent is obtained; ... k. Name/signature of person (i.e. practitioner) who explained the procedure to the patient or authorized representative. 3. Physician Responsibility: Obtaining the informed consent is the sole responsibility of the physician. ... c. The physician should also sign, date and time the form prior to the performance of the procedure. ..."

Review on September 25, 2019 of MR1, revealed a consent for treatment was obtained on September 11, 2019. The consent form had no documentation of the time of the consent and no signature of a witness.

Interview with EMP17 on September 25, 2019, at approximately 9:35 AM, confirmed MR1's consent for treatment dated September 11, 2019, had no documentation of the time of the consent and no signature of a witness.

Review on September 24, 2019 of MR16 revealed an informed consent for a surgical procedure on May 2, 2019, had no documentation of the patient's initials, name of patient and no time of the patient's, the witness and the physician's signatures. Further review revealed an informed consent for a surgical procedure on May 7, 2019, had no documentation of the patient's initials, the date, the patient's name and no time of the physician's signature. Further review revealed an informed consent for a surgical procedure on May 9, 2019, had no documentation of the patient's initials, the date and the date and time of the physician's signature. Review of an informed consent for a surgical procedure on May 21, 2019, revealed no documentation of the patient's initials, the date, the date and time of the witness signature and the date, time and signature of the physician. Review of an informed consent for administration of anesthesia on May 2, 2019, revealed no documentation of the time of the witness's signature. Review of a facility transfer form dated May 26, 2019, revealed no documentation of the time of the transfer, the patient's signature, the date of the consent and the time the accepting physician was notified.

Interview with EMP17 on September 26, 2019, at 2:45 PM confirmed MR16 had an informed consent for a surgical procedure on May 2, 2019, with no documentation of the patient's initials, name of patient and no time of signature of patient, witness and physician. EMP17 confirmed an informed consent for a surgical procedure on May 7, 2019, had no documentation of the patient's initials, the date, the patient's name and the time of the physician's signature. EMP17 confirmed an informed consent for a surgical procedure on May 9, 2019, had no documentation of the patient's initials, the date and the date and time of the physician's signature. EMP17 confirmed an informed consent for a surgical procedure on May 21, 2019, revealed no documentation of the patient's initials, the date, the date and time of the witness signature and the date, time and signature of the physician. EMP17 confirmed an informed consent for administration of anesthesia on May 2, 2019, had no documentation of the time of the witness's signature. EMP17 confirmed a facility transfer form dated May 26, 2019, had no documentation of the time of the transfer, the patient's signature, the date of the consent and the time the accepting physician was notified.

Review on September 25, 2019, of MR18 revealed an informed consent for a surgical procedure on May 8, 2019, with no documentation of the provider's name and no time and date of the patient's signature. Further review revealed an informed consent for administration of anesthesia on May 8, 2019, with no documentation of the patient's initials.

Interview with EMP 17 on September 26, 2019, at 3:00 PM, confirmed MR18 contained an informed consent for a surgical procedure on May 8, 2019, with no documentation of the provider's name and no time and date of the patient's signature. EMP17 confirmed an informed consent for administration of anesthesia on May 8, 2019, had no documentation of the patient's initials.

Review on September 26, 2019 of MR20 revealed a facility transfer form on March 2, 2019, with no documentation of the time the accepting physician was notified.

Interview with EMP17 on September 26, 2019, at 3:05 PM, confirmed MR20 had a facility transfer form dated March 2, 2019, with no documentation of the time the accepting physician was notified.

Review on September 25, 2019, of MR29 revealed an informed consent for a surgical procedure on February 19, 2019, with no documentation of the patient's initials, the date, the name of physician, the date and time of the patient's signature and the time of the physician's signature. Further review of MR29 revealed an informed consent for administration of anesthesia on February 19, 2019, with no documentation of the patient's initials, no patient name and no time of witness signature.

Interview with EMP17 on September 26, 2019, at 3:10 PM, confirmed MR29 with an informed consent to surgical procedure on February 19, 2019, with no documentation of the patient's initials, the date, the name of physician, the date and time of patient's signature and the time of the physician's signature. Further interview with EMP17 confirmed an informed consent for administration of anesthesia on February 19, 2019, did not have documentation of the patient's initials, the patient's name or the time of the witness's signature.

Review on September 26, 2019, of MR30 revealed an informed consent for a surgical procedure dated February 19, 2019, with no documentation of the date of the surgical procedure or date and time of the patient's signature. Further review revealed an informed consent for administration of anesthesia on February 19, 2019, with no documentation of the patient's initials.

Interview with EMP17 on September 26, 2019, at 3:15 PM, confirmed MR30 had an informed consent for a surgical procedure on February 19, 2019, with no documentation of the date of the surgical procedure or the date and time of the patient's signature. Further interview with EMP17 confirmed an informed consent for administration of anesthesia on February 19, 2019, did not have documentation of the patient's initials.

Review on September 26, 2019 of MR32 revealed a consent for treatment on September 10, 2019. Documentation noted the patient was five years-old. This consent for treatment did not have the relationship of the authorized representative. Futher review revealed an informed consent for a surgical procedure on September 19, 2019, had no documentation of the authorized representative's initials, the date of the procedure, the date and time when the authorized representative signed the consent This surgical consent did not have the date, time and signature of a witness or the date and time the physician signed the consent.

Interview with EMP17 on September 26, 2019, at 3:20 PM, confirmed MR32 had a consent for treatment on September 10, 2019. EMP17 confirmed the patient was five years-old. EMP17 confirmed the consent for treatment did not have the relationship of the authorized representative. EMP17 confirmed an informed consent for a surgical procedure on September 19, 2019, did not have documentation of the authorized representative's initials, the date of the procedure, the date and time when the authorized representative signed, the date, time and signature of the witness, or the date and time the physician signed the surgical consent.

Review on September 26, 2019 of MR33 revealed a consent for treatment on September 19, 2019. Documentation noted the patient was 11 years-old. Review of the consent for treatment revealed no documentation of the authorized representative's signature. Further review revealed an informed consent for a surgical procedure on September 19, 2019, had no documentation of the authorized representative and no date of the procedure.

Interview with EMP17 on September 26, 2019, at 3:25 PM, confirmed MR33 had a consent for treatment on September 19, 2019. EMP17 confirmed the patient was 11 years-old. EMP17 confirmed there was no documentation of the authorized representative's signature on the consent for treatment. EMP17 confirmed an informed consent to surgical procedure on September 19, 2019, did not have the authorized representative initials or the date of the procedure.

Review on September 27, 2019 of MR46 revealed a consent for administration of anesthesia on September 24, 2019, with no documentation of the date and time of the patient's signature.

Interview with EMP20 on September 27, 2019, at 11:00 AM, confirmed MR46's consent for administration of anesthesia on September 24, 2019, did not have the date and time of the patient's signature.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure medical records were completed 30 days following discharge for two of 19 credential files reviewed (CF 2 and CF5) and for 13 of 13 physicians reviewed with greater than 30 day delinquent medical records (OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OTH7, OTH8, OTH9, OTH10, OTH11, OTH12 and OTH13).

Findings include:

Review on September 26, 2019, of the facility's "Medical Staff Rules and Regulations" last revised June 20, 2018, revealed "... Medical Records ... 11) Completion of Medical Records a) The Centers for Medicare and Medicaid Services (CMS) require chart completion within thirty days of discharge. however, providers should electronically complete all available medical records on a weekly basis. b) Providers will receive notification of all charts assigned to them on a weekly basis. A chart will be considered delinquent in the following situations: i) Unsigned entries greater than 30 days from date deficiency identified ii) Incomplete entries greater than 30 days from date deficiency identified iii) History and Physical greater than 24 hours post admission order iv) Operative Reports greater than 24 hours post procedure v) Discharge Summaries greater than 15 days form date deficiency identified ..."

Review on September 25, 2019, of the facility provided "Incomplete Records List by Provider and Reason" identified by EMP5 as the medical record delinquent report dated Wednesday, September 25, 2019. This medical record delinquent report revealed tracking of delinquent medical records from June 25, 2019, to August 26, 2019. The log contained the part of the medical record not completed, the name of the physician, the patient's name and medical record number, and the patient's discharge date. EMP5 revealed a delinquent medical record was one that was not closed within 30 days after the patient was discharged. Per the Unresolved Deficiencies by Responsibility report, physicians (CF and OTH) who had delinquent medical records as of September 25, 2019, were as follows:

CF2 had 13 medical records not completed ranging from July 22, 2019, to August 22, 2019.
CF5 had one medical record not completed from August 21, 2019.

OTH1 had two medical records not completed ranging from August 12, 2019 to August 16, 2019.
OTH2 had two medical records not completed ranging from July 30, 2019, to August 24, 2019.
OTH3 had one medical record not completed from August 25, 2019.
OTH4 had three medical records not completed ranging from July 10, 2019, to August 21, 2019.
OTH5 had nine medical records not completed ranging from July 15, 2019, to August 5, 2019.
OTH6 had three medical records not completed ranging from July 9, 2019, to August 13, 2019.
OTH7 had seven medical records not completed ranging from July 6, 2019, to August 22, 2019.
OTH8 had one medical record not completed from July 29, 2019.
OTH9 had three medical records not completed ranging from August 20, 2019, to August 23, 2019.
OTH10 had three medical records not completed ranging from June 25, 2019, to July 9, 2019.
OTH11 had one medical record not completed from July 18, 2019.
OTH12 had 10 medical records not completed ranging from July 19, 2019, to July 24, 2019.
OTH13 had four medical records not completed ranging from June 27, 2019, to August 9, 2019.

Interview with EMP5 on September 26, 2019, at approximately 12:45 PM confirmed CF2, CF5, OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OTH7, OTH8, OTH9, OTH10, OTH11, OTH12 and OTH13 had medical records that were not completed within 30 days of the patients' discharge date.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to maintain an accurate controlled substance inventory of Schedule 4 drugs in the hospital pharmacy.

Findings include:

A request was made of EMP10 on September 24, 2019, for a facility policy, procedure or guideline for pharmacy staff to follow regarding the receipt, storage, monitoring and destruction of expired Schedule 4 controlled substance inventory. None was provided.

Review on September 24, 2019, of the pharmacy's Schedule 4 inventory log revealed documentation there was an opened 10 milliliter (ml) vial of Lorazepam (Ativan - a medication used to treat anxiety disorders). There was no documentation on the Schedule 4 inventory log indicating the amount of Lorazepam in the vial and there was no vial of Lorazepam in the controlled substance inventory of Schedule 4 drug storage container.

Interview with EMP10 on September 24, 2019, at the time of the observation confirmed the pharmacy Schedule 4 inventory log contained documentation there was an opened 10 ml vial of Lorazepam; there was no documentation on the Schedule 4 inventory log indicating the amount of Lorazepam in the vial and there was no vial of Lorazepam in the controlled substance inventory of Scheduled 4 drug storage container.

Review on September 24, 2019, of the pharmacy's Schedule 4 storage container revealed three 2 milligram (mg) tablets of Diazepam (Valium - a medication used to treat anxiety). There was no documentation on the on the Schedule 4 inventory log indicating these Valium tablets were recorded.

Interview with EMP10 on September 24, 2019, at the time of the observation confirmed the Schedule 4 storage container had three 2 mg tablets of Diazepam and there was no documentation on the on the Schedule 4 inventory log indicating these Valium tablets were recorded.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure the Rehabilitation patient care unit was free of dirt, dust and dried food debris; the dietary department was free of dirt, dust and dried food debris; the facility failed to ensure staff working in the dietary department had all hair restrained by hair restraints; the facility failed to complete cool down temperatures for left over foods and the facility failed to ensure the areas on the loading dock area where food and hospital supplies are delivered was free of dirt, dust and debris.

Findings include:

1) Review on September 24, 20190, of the facility's "Environmental Services Purpose and Function/Mission" policy, last reviewed May 2019, revealed "The Environmental Services mission is to effectively and efficiently maintain an acceptable level of cleanliness and an improved environment for Wayne Memorial Hospital. We are a department which provides a service to others."

Review on September 24, 2019, of the facility's "Housekeeping Daily Log" no review date, revealed "... Check & Light Clean all empty rooms."

Review on September 24, 2019, of the facility's "Patient room Discharge cleaning" policy, last reviewed August 2019, revealed "Purpose: To provide clean antiseptic patient room when a patient is discharged or transferred. ... Procedure: ... 4. Wash and wipe with clean germicidal solutions High-Touch surfaces: Bed Rails, Tray Table, IV Poles, Call Bells, Telephone, Furniture, Door knobs, Light Switch, Grab Bars, Toilet Flush and sink. ..."

Observation on September 24, 2019, revealed an accumulation of dust and sticky areas on the overbed tables and on the bedside tables in patient rooms 380, 381, 384 and 385.

Interview with EMP3 and EMP4 on September 24, 2019, at the time of the observations confirmed the accumulation of dust and sticky areas on the overbed tables and on the bedside tables in patient rooms 380, 381, 384 and 385. EMP3 revealed these patient rooms were considered clean and ready for patient admission.

Observation on September 24, 2019, revealed an accumulation of dust on the window sills in patient rooms 380, 381, 383, 384 and 385 measuring the size of approximately a dime on each window sill.

Interview with EMP3 and EMP4 on September 24, 2019, at the time of the observations confirmed the accumulation of dust on the window sills in patient rooms 380, 381, 383, 384 and 385 measuring the size of approximately a dime on each window sill. EMP3 revealed these patient rooms were considered clean and ready for patient admission.

Observation on September 24, 2019, of patient room 383 revealed a suction canister hanging from the wall behind the bed.

Interview with EMP3 on September 24, 2019, at the time of the observation confirmed the suction canister hanging for the wall behind the bed. EMP3 revealed this suction canister was considered dirty and was not removed from the room after the patient was discharged. EMP3 revealed this patient room was considered clean and ready for patient admission.

Observation on September 24, 2019, of patient room 384 revealed a water pitcher and glass on the bedside table and a suction canister hanging from the wall behind the bed.

Interview with EMP3 on September 24, 2019, at the time of the observation confirmed the water pitcher and glass on the bedside table and a suction canister hanging from the wall behind the bed. EMP3 revealed the water pitcher and glass on the bedside table and the suction canister were considered dirty and were not removed from the room after the patient was discharged. EMP3 revealed this patient room was considered clean and ready for patient admission.

Observation on September 24, 2019, of patient room 385 revealed a trash bag taped and hanging from the overbed table.

Interview with EMP3 on September 24, 2019, at the time of the observation confirmed the trash bag taped and hanging from the overbed table. EMP3 revealed the trash bag taped and hanging from the overbed table contained trash and it was not removed from the room after the patient was discharged. EMP3 revealed this patient room was considered clean and ready for patient admission.

Observation on September 24, 2019, of patient room 384 and 387 revealed light gray dust measuring approximately a quarter in size when gathered together on the ceiling near the ceiling vents.

Interview with EMP3 on September 24, 2019, at the time of the observation confirmed the light gray dust measuring approximately a quarter in size when gathered together on the ceiling near the ceiling vents. EMP3 revealed this patient room was considered clean and ready for patient admission.

2) Review on September 24, 2019, of the "Food Service Manager" job description, revised December 2004, revealed "Primary Purpose Of The Position: Assumes responsibility for overall food production and service to patients, staff, and guests. This responsibility encompasses employees in food production, i.e. cooks, dietary aides and other support staff within the department. ..."

Review on September 25, 2019, of the facility's "Cleaning Schedule Procedures" policy, last reviewed August 2019, revealed "The following areas are to be cleaned according to the posted list of days indicated. After cleaning each area your initials will indicate completion of each area. Wall washing Begin at the pot sinks area and continue around the kitchen until all of the walls are clean using a multi-surface cleaner. Second day, Begin [sic] at the serving area and continue around by the coffee maker area until all walls are clean. ... Convection Ovens ... Wipe the exterior of the ovens especially the top. ... Sweep & Mop Floor Sweep entire kitchen floor including the walk-in refrigerator, pantry and under the serving area. Be sure to move any equipment that is on wheels and sweep thoroughly in corners. ..."

Observation on September 25, 2019, at approximately 11:20 AM, of the steam oven revealed an accumulation of dirt, dust and dried food debris under the oven and behind the wheels measuring approximately one-quarter cup when gathered together.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the accumulation of dirt, dust and dried food debris under the steam oven and behind the wheels measuring approximately one-quarter cup when gathered together.

Observation on September 25, 2019, at approximately 11:20 AM of the floor under the soup pots and the wall behind the soup pots revealed an accumulation of dirt, dust and dried food debris.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the floor under the soup pots and the wall behind the soup pots had an accumulation of dirt, dust and dried food debris.

Observation on September 25, 2019, at approximately 11:25 AM revealed an accumulation of dark brown grease on the handle and the exterior sides of the tilt skillet.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the accumulation of dark brown grease on the handle and the exterior sides of the tilt skillet.

Observation on September 25, 2019, at approximately 11:30 AM revealed an accumulation of dark brown grease and dried food on the handle of the slicer.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the accumulation of dark brown grease and dried food on the handle of the slicer.

Observation on September 25, 2019, at approximately 11:35 AM revealed an accumulation of dark brown grease and dried food on the top surface and all the outer sides of the French fryer.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the accumulation of dark brown grease and dried food on the top surface and all the outer sides of the French fryer. EMP6 revealed the French fryer was not on a cleaning schedule and there was no policy, procedure or guideline instructing dietary staff on the cleaning or the frequency of cleaning of the French fryer.

Observation on September 25, 2019, at approximately 11:40 AM revealed an accumulation of dirt, dust and dried food debris under the convection oven and behind the legs measuring approximately one-quarter cup when gathered together.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the observation confirmed the accumulation of dirt, dust and dried food debris under the convection oven and behind the legs measuring approximately one-quarter cup when gathered together.

Observation on September 25, 2019, at approximately 11:40 AM revealed a cook's skillet with an accumulation of tan grease in the catch drawer.

Interview with EMP6 on September 25, 2019, at the time of the observation confirmed the accumulation of tan grease in the catch drawer of the cook's skillet. EMP6 revealed the cook ' s skillet is not used by dietary staff.

Observation on September 25, 2019, at approximately 11:45 AM revealed a stand-up floor mixer with an accumulation of dirt dust and dried food debris on the stand and in the mixer.

Interview with EMP6 on September 25, 2019, at the time of the observation confirmed the accumulation of dirt dust and dried food debris on the stand and in the mixer.

3) Review on September 25, 2019, of the facility's "Department of Nutrition and Food Services Dress Code" policy, last reviewed September 2019, revealed " Policy: A standardized dress code for the department will provide for uniformity in appearance and personal standards for employees. Procedure: ... Clean hats or hair nets must be worn when entering department (to keep hair away from your face, hands and food). Hair restraints are located at every entrance. When in the prep or serving area line of the kitchen, all hair must be covered with a hair restraint. ... These policies apply to both men and women. ..."

Observation of EMP9, EMP11, EMP12, EMP13 on September 25, 2019, at approximately 11:15 AM revealed these employees working in the dietary department preparing patient trays and preparing food for patient consumption without all hair restrained in the hairnet.

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the confirmed EMP9, EMP11, EMP12, EMP13 were working in the dietary department preparing patient trays and preparing food for patient consumption without all hair restrained in the hairnet.

Observation of EMP15 and EMP16 on September 25, 2019, at approximately 11:45 AM revealed these dietary employees in the dietary department preparing and serving food. These employees did not have all hair restrained

Interview with EMP6 and EMP7 on September 25, 2019, at the time of the confirmed EMP15 and EMP16 were working in the dietary department preparing patient trays and preparing food for patient consumption without all hair restrained in the hairnet.

4) A request was made of EMP8 on September 26, 2019 for a facility policy, procedure of guideline for facility staff to follow regarding completing cool down temperatures on leftover food on the tray line. None was provided.

Interview with EMP6 on September 25, 2019, at approximately 11:00 AM revealed the facility does have leftover food items at the end of the serving time and these foods are then pureed for future patient consumption. EMP6 revealed the facility does not complete or document cool down temperatures on left overs to ensure foods to ensure these foods are out of the danger zone for bacteria growth.

5) A request was made of EMP8 on September 26, 2019 for a facility policy, procedure of guideline for facility staff to follow regarding cleaning of the loading dock area where food and hospital supplies are delivered. None was provided.

Observation on September 26, 2019, of the facility's loading dock area revealed spider webs, dead bugs, cocoons and dry leaves on the overhang extending from the building, the overhead door, the opening of the overhead door opening and on the ceiling.

Interview with EMP8 on September 26,2 019, at the time of the observation confirmed the facility's loading dock area had spider webs, dead bugs, cocoons and dry leaves on the overhang extending from the building, the overhead door, the opening of the overhead door opening and on the ceiling. EMP8 confirmed this is the entrance where food and hospital supplies are delivered.

Based on review of facility policy, observation and staff (EMP) interview, it was determined the facility failed to ensure proper attire in the Operating Room during a procedure.

Findings include:

Review on September 27, 2019 of facility policy, "Subject: Dress Code Department: General Nursing," last reviewed/revised March 2018, revealed "Purpose: All staff are expected to be professionally attired at all times. ... Operating Room/PACU/Cardiac Cath Lab: ... Jewelry, except a plain wedding band, should not be worn. ... Jewelry: The following jewelry is acceptable to be worn: ... small post earrings (to provide safety to the employee) if the ears are pierced (exception is in the Operating Room, where none are to be worn. ... ."

Observation of a procedure on MR26, in an Operating Room, on September 25, 2019, at 11:10 AM, revealed, OTH14, with yellow colored dangle earrings, approximately ¼ inch in length, showing out from under the cap on both ears.

Interview with EMP19, on September 25, 2019, at 11:10 AM, confirmed OTH14 with yellow colored dangle earrings, approximately ¼ inch in length, showing out from under the cap on both ears during a procedure in an Operating Room.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to document activities were offered to swing bed program patients and the facility failed to document the swing bed patients' refusal of the activity for three of six swing bed patient medical records reviewed (MR40, MR41 and MR42).

Findings include:

A request was made on September 27, 2019, of EMP1 and EMP17 for a facility policy, procedure or guideline for staff to follow addressing the documentation of activities offered to swing bed program patients and the swing bed patient's acceptance or refusal of the activity. None was provided.

Interview with EMP1 on September 27, 2019, at approximately 1:00 PM revealed it is the facility's expectation that activities offered and provided to the swing bed patient be documented in the patient's medical record by the staff person performing that activity.

Review of MR40 on September 27, 2019, revealed the facility assessed this swing bed patient's activity interest in magazines. There was no documentation in MR40 indicating the facility offered this patient magazines or that MR40 refused to accept magazines during the stay in swing bed.

Interview with EMP17 on September 27, 2019, at approximately 10:00 AM confirmed MR40 was a swing bed patient. EMP17 confirmed MR40's activity interest included magazines and there was no documentation indicating the facility offered this patient magazines or that MR40 refused to accept magazines during the stay in swing bed.

Review of MR41 on September 27, 2019, revealed the facility assessed this swing bed patient's activity interest to include magazines, the daily paper and word puzzles. There was no documentation in MR41 indicating the facility offered this patient magazines, the daily paper and word puzzles or that MR41 refused to accept magazines, the daily paper and word puzzles during the stay in swing bed.

Interview with EMP17 on September 27, 2019, at approximately 10:15 AM confirmed MR41 was a swing bed patient. EMP17 confirmed MR41's activity interest included magazines, the daily paper and word puzzles. EMP1 confirmed there was no documentation indicating the facility offered this patient magazines, the daily paper and word puzzles or that MR41 refused to accept magazines, the daily paper and word puzzles during the stay in swing bed.

Review of MR42 on September 27, 2019, revealed the facility assessed this swing bed patient's activity interest to include books, magazines and the daily paper. There was no documentation in MR42 indicating the facility offered this patient books, magazines and the daily paper or that MR42 refused to accept books, magazines and the daily paper during the stay in swing bed.

Interview with EMP17 on September 27, 2019, at approximately 10:30 AM confirmed MR42 was a swing bed patient. EMP17 confirmed MR42's activity interest included books, magazines and the daily paper. EMP17 confirmed there was no documentation indicating the facility offered this patient books, magazines and the daily paper or that MR42 refused to accept books, magazines and the daily paper during the stay in swing bed.