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Based on policy review, document review and interview the facility failed to provide the patients with the contact information for lodging a grievance with the State agency, resulting in the potential for patients to lack the knowledge to file a complaint or grievance with the State agency. Findings include:

On 8/7/2012 at approximately 1600 during review of the policy titled "Grievance Policy" under the section titled "Purpose" in the second paragraph it it stated "The hospital informs the patient and/or the patient's representative of the internal grievance process, including whom to contact to file a grievance (complaint). As part of its notification of patient rights, the hospital provides the patient or the patient's representative a phone number and address for lodging a grievance with the State agency."

On 8/7/12 at approximately 1100 during document review of the patient information binder that is stored at the patient bedside, it was revealed that the information lacked the phone number and address for lodging a grievance with the State agency.

On 8/8/2012 at approximately 0845 during an interview with staff I, it was confirmed that the required contact information was not in the patient information binder. Staff I also confirmed at this time that the patient is not provided with the required contact information for the State agency.

Based on medical record review and interview the facility failed to gain consent for treatment in 1 of 30 patients (#12) resulting in the potential to treat a patient without the right to refuse treatment. Findings include:

On 8/6/2012 at approximately 1500 during medical record review of patient #12 it was revealed consent for treatment was not obtain on 8/2/2012 stating "patient unable to sign due to condition". The patient's face sheet had contact information for the medical guardian of patient #12 and also contained advance directives with the medical guardian listed. An interview with staff I confirmed the patient did indeed have a medical guardian and consent from the medical guardian had not been obtained.

Based on medical record review and interview the facility failed to document restraint use in the patient's plan of care in 1 out of 1 restrained patients reviewed (#30). Findings include:

On 8/8/2012 at approximately 0900 during review of patient #30's medical record it was revealed that restraints were being used, however, not reflected on the plan of care (POC).

On 8/8/2012 at approximately 0915 the above finding was confirmed with staff I who stated "Yes, I agree it should have been documented in the POC.

Based on medical record review, interview and policy review, the facility failed to:
1. Develop care plans for four (Patient #s 1, 2, 3 and 4) of seven medical records reviewed
2. Develop interventions for care planning for 13 (Patient #s 5, 6, 12, 17, 20, 21, 22, 23, 27, 28, 29 and 30) of 14 medical records reviewed
3. Document indication for and response to pain medication for six (Patient #s 17, 20, 22, 23, 27 and 28) of eight medical records reviewed, resulting in the potential failure to achieve optimal patient outcomes. Findings include:


On 8/6/12 at approximately 1450 during open record review for Patient #17 revealed a document titled "Patient Plan of Care/Progress Record General Medical", which contained a highlighted section titled "Body System of "Pain Control". The document also revealed that under "Assessment Pain (list)" was blank and the outcomes were listed as "understands pain control plan and absence of discomfort". Dates, nurse signature lines and codes were left blank. Individualized interventions to help the patient achieve the stated goal were not listed. The patient was medicated for pain with "Ibuprofen 200 mg TID prn PO pain "8/5/12 at 1830, with no supporting documentation for the need for nor the patient response to the medication. These findings were confirmed by Staff F, on 8/6/12 at approximately 1455, who indicated that "the patient is here for respite care and is being cared for by Hospice of Lenawee".

On 8/6/12 at approximately 1640 during open record review for Patient #20 revealed a document titled "Patient Plan of Care/Progress Record General Medical", which contained a highlighted section titled "Body System of "Pain Control". The document also revealed that under "Assessment Pain (list)" was blank and the outcomes were listed as "understands pain control plan and absence of discomfort". Dates and codes were left blank. The patient was medicated with "Demerol 25 mg slow IVP q 4 hrs PRN pain" on 8/5/12 at 0445, 1845 and 2310. The "Pain Assessment Tool for that date lists Pain Level Assessments at 0800 "denies". 1505 "denies", 2125 denies, and 2300 a pain level assessment of 8, for which the IV pain medication was administered. The patient assessment after the 2310 IV medication has been administered was listed as "sleeping". Individualized interventions to help the patient achieve the stated goal were not listed. This was confirmed by Staff F, on 8/6/12 at approximately 1655.

On 8/6/12 at approximately 1630 during open record review for Patient #21 revealed a document titled "Patient Plan of Care/Progress Record General Medical", which contained a non-highlighted section titled "Body System of "Pain Control". The document also revealed that under "Assessment Pain (list)" was blank and the outcomes were listed as "understands pain control plan and absence of discomfort". Dates and codes were left blank. Individualized interventions to help the patient achieve the stated goal were not listed. This was confirmed by Staff F, on 8/6/12 at approximately 1640, "they should have highlighted the problems from the problem list that were applicable to this patient".

On 8/7/12 at approximately 1000 during closed record review for Patient #22 revealed a document titled "Patient Plan of Care/Progress Record General Medical", which contained a single individualized section titled "Pathology PX". The document also revealed that under "Assessment Pain (list)" was blank and the outcomes were listed as "understands pain control plan and absence of discomfort". Dates and codes were left blank. Individualized interventions to help the patient achieve the stated goals were not listed. This was confirmed by Staff I, on 8/7/12 at approximately 1110, who indicated that "the staff are not individualizing these care plans". When asked where documentation of nursing interventions to help the patient achieve the stated goals, Staff I responded, "there is none".
On 5/23/12 at 1035 the patient was medicated with "Vicodin 5-500 1-2 tabs oral PRN every 6 hours as needed for pain". On undated document at 0515 and 2215 the patient was medicated with "Vicodin 5-500 1-2 tabs oral PRN every 6 hours as needed for pain". On 5/21/12 at 1000, 1441, and 1930 the patient was medicated with "Vicodin 5-500 1-2 tabs oral PRN every 6 hours as needed for pain". On 5/22/12 at 1520 the patient was medicated with "Vicodin 5-500 1-2 tabs oral PRN every 6 hours as needed for pain". A document titled Pain Assessment Tool was completed for this patient with three entries on 5/22/12 with Pain Level Assessments at 1430 "denies, 5/22/12 with Pain Level Assessments at 2210 "4 neck", and 5/23/12 with Pain Level Assessments at 0730 "denies". No other documentation was found indicating the need for pain medication nor the effect of pain medication administered. This was confirmed by Staff I on 8/7/12 at 0910, who indicated that "nurses are not using the tools they have available".

On 8/7/12 at approximately 1030 during closed record review for Patient #23 revealed a document titled "Patient Plan of Care/Progress Record General Post-op", which contained a single individualized section titled "Pain Control". The document also revealed that under outcomes goals were listed as "pain control with IV/IM meds and understands pain control plan". Individualized interventions to help the patient achieve the stated goals were not listed. This was confirmed by Staff I, on 8/7/12 at approximately 1120, who indicated that "the staff are not individualizing these care plans". When asked where documentation of nursing interventions to help the patient achieve the stated goals, Staff I responded, "there is none".
On 4/12/12 at 0950, 1515 and 2118 the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". On 4/13/12 at 0130, 0820, 1115, 1950, and 2215 the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". On 4/14/12 at 0230, 0530, 0900, 1445, and 1740 the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". On 4/15/12 at "15, 20 and 24" the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". On 4/16/12 at 0350, 1045, 1515 and 21030 the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". On 4/17/12 at 0300, 0445 and 0930 the patient was medicated with "morphine 4-7 mg IV q 3 hrs PRN as needed for pain". A document titled Pain Assessment Tool was completed for this patient with inconsistent entries from 4/12/12 through 4/17/12 with Pain Level Assessments ranging from 1-6, however not matching when the patient was administered pain medication. No other documentation was found indicating the need for pain medication nor the effect of pain medication administered. This was confirmed by Staff I on 8/7/12 at 0910, who indicated that "nurses are not using the tools they have available".

A review of facility policy titled "Plan of Care for Patients / Teaching Documentation" reviewed 9/2011 revealed "...The RN selects one appropriate Patient Plan of Care...pull the Plan of Care that is the primary problem being dealt with on this admission...the RN takes the Patient Plan of Care to the bedside and uses the pre-printed material to review each body system to identify the presence of abnormalities...indicate an abnormal finding by highlighting the preprinted finding with an approved highlighted pen ...The RN must identify an appropriate patient individualized outcome for each body system in which there were abnormal finding noted by accepting the preprinted statements as written, editing/revising the statements or entering entirely different, specific outcomes"...Evaluating Progress. Each shift, the RN is responsible for assessing each patients progress and documenting patient education. Your daily signature on the Patient Plan of Care indicated your monitoring and evaluating the patients plan of care..."






29314

On 8/6/2012 at approximately 1100 during medical record review for patient #1 on the Labor and Delivery Unit, it was revealed that a POC had not been developed. This finding was confirmed with staff C at approximately 1100 on 8/6/2012.

On 8/6/2012 at approximately 1115 during medical record review for patient #2 on the Labor and Delivery Unit, it was revealed that a POC had not been developed. This finding was confirmed with staff C at approximately 1115 on 8/6/2012.

On 8/6/2012 at approximately 1130 during medical record review for patient #3 on the Labor and Delivery Unit, it was revealed that a POC had not been developed. This finding was confirmed with staff C at approximately 1130 on 8/6/2012.

On 8/6/2012 at approximately 1215 during medical record review for patient #4 on the Critical Care Unit, it was revealed that a POC had not been developed. This finding was confirmed with staff C at approximately 1215 on 8/6/2012.

On 8/6/12 at approximately 1215 during medical record review for Patient #5, it was revealed in the document titled "Patient Plan of Care/Progress Record", individualized interventions to assist the patient in achieving the stated goals were not documented. This finding was confirmed with staff C at approximately 1215 on 8/6/2012 who stated "We need to document our interventions, I don't see any here."

On 8/6/12 at approximately 1220 during medical record review for Patient #6, it was revealed in the document titled "Patient Plan of Care/Progress Record", individualized interventions to assist the patient in achieving the stated goals were not documented. This finding was confirmed with staff C at approximately 1220 on 8/6/2012.

On 8/7/12 at approximately 1315 during medical record review for Patient #30, it was revealed in the document titled "Patient Plan of Care/Progress Record", individualized interventions to assist the patient in achieving the stated goals were not documented. This finding was confirmed with staff I at approximately 1315 on 8/7/2012.



29955

On 8/7/2012 at approximately 1000 during medical record review it was revealed the facility failed to ensure all medication administration was documented on the "pain assessment tool" and that interventions that were documented were reassessed according to the intervention. Intravenous medication intervention is to be reassessed within 15 minutes of administration, Intramuscular medication injection is to be reassessed within 30 minutes of administration, and pain medication received orally is to be reassessed within in one hour of administration.

Review of patient #27's medical record failed to have 14 medication administrations listed and failed to have 11 of 16 medication administrations for pain to have a reassessment after intervention.

Review of patient #28's medical record failed to have 2 of 2 medication administrations for pain to have a reassessment after intervention.

An interview with staff I confirmed the findings on 8/7/2012 at approximately 1400.

On 8/7/2012 at approximately 1330 during medical record review it was revealed patients #27, #28, and #29 failed to have a nursing care plan that listed interventions implemented to address nursing plan of care. An interview with staff I confirmed the findings.

Based on medical record review, interview and policy review the facility failed to ensure all telephone orders are authenticated by physicians for two (#17) of six charts reviewed, resulting in the potential for medical errors and patient harm. Findings include:

On 8/6/12 at approximately 1450 during a record review for Patient #17 revealed a telephoned physician order dated 8/3/12
which was not authenticated by the ordering physician. A document titled Admission Orders- Adult were completed by the RN, however were not authenticated by the time of the chart review on 8/6/12. This was confirmed by Staff F who responded, "this is a patient admitted for respite care only, I am not sure the physician needs to admit him".

On 8/7/12 at approximately 1000 during a closed record review for Patient # 22 revealed three telephoned physician orders dated 5/20/12 at 2300, 5/21/12 at 0905 and 5/22/12 at 1040, which were not authenticated by the ordering physician. This was confirmed by Staff I on 8/8/12 at 0930.

On 8/8/12 at approximately 0930 during a policy review of facility policy titled " Authentication Standards for Medical Record Entries including Physician Orders" revised 4/1/12 revealed that"....Verbal Orders/Phone Orders on Inpatients, Verbal orders on inpatients must be authenticated with a handwritten or electronically signed signature within 48 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient..".

Based on medical record review, interview and document review the facility failed to ensure a history and physical was completed on one of six patients (Patient #17) resulting in the potential for medical errors and patient harm. Findings include:

On 8/6/12 at approximately 1450 during open record review for Patient #17 revealed a document titled "History and Physical" that was blank. A review of the progress notes revealed that the physician had not been in to evaluate the patient since admission. Interview with Staff F on 8/6/12 at 1455 confirmed that the physician had not been in to evaluate the patient since the day of admission on 8/3/12. Staff F indicated that "the patient is admitted for respite care only".

On 8/8/12 at approximately 1300 during a review of facility policy titled "Contract For Hospice Inpatient, Respite and Outpatient Services" dated 8/1/2009 revealed "...Responsibilities of Hospice shall be to require that all orders of a medical nature made by the Hospice Patient's Attending Physician shall be made in accordance with the normal Medical Center procedures utilized for patient service orders. Assure daily review of the patient's documented care to assure compliance with the established plan of care by either the Hospice Medical Director or the attending physician...The Hospice shall furnish to the Medical Center, prior to or at the time of the patient's admission a copy of the patient's plan of care and medical history....".

Based on document review and interview the facility failed to ensure medical records were completed within 30 days for 8% of records or 175 records resulting in the potential for medical errors and patient harm. Findings include:

On 8/6/12 at approximately 1400 during interview with Staff G when asked how many medical records are incomplete beyond 30 days, Staff G replied that " we have vastly improved our delinquent medical records process " . A document titled " Promedica Bixby/Herrick Hospitals Delinquency Rate 2011-2012 " revealed that quarterly averages of delinquent medical records beyond 30 days, for 3rd and 4 th quarters for 2011 were 51% and 16% respectively. Medical record delinquency for the 1st and 2nd quarters for 2012 were recorded as 5% and 8% respectively with July 2012 delinquent medical records beyond 30 days recorded as " 175 " . This was confirmed by Staff G on 8/6/12 at 1450.

Based on medical record review and interview the facility failed to adjust the dose of acetaminophen for 1 of 1 patients (#27) with the diagnosis of hepatitis C and cirrhosis resulting in the potential for harm. Findings include:

On 8/8/2012 at approximately 1300 during medical record review it was revealed the pharmacy failed to recognize a prescribed dose for acetaminophen was potentially harmful to patient #27. Listed on the patient's allergy sheet was acetaminophen as the result of liver damage (confirmed hepatitis C and cirrhosis). An as needed tylenol extra strength was listed for availability with a maximum dose of 4000 milligrams of all acetaminophen per day for patient #27. When querried about the dosage and allergy listing staff I contacted the pharmacy to confirm the patient's profile had been reviewed by a pharmacist. Staff I confirmed the pharmacist had reviewed the patient's allergies and chart.

Further review of patient #27's labs indicated an elevated Alanine aminotransferase (ALT) lab value 71 with a normal range indicated 0-40 U/L and an elevated aspartate aminotransferase (AST) lab value 52 with a normal range of 0-41 U/L, which reflects abnormal liver function and could justify review to determine if a lower prescribed daily maximum dose of acetaminophen was indicated. Failure to acknowledge the patient's listed allergy and lab values posed potential for patient harm and revealed a lack of a system to identify high risk medications for a patient with hepatic impairment.

Based on observation, interview, and policy review the facility failed to ensure narcotics were locked and secured resulting in the potential for drug diversion.

On 08/07/2012 at approximately 1055 during tour of the surgical post operative area it was revealed one carpujet of .25 ml of Demerol 100mg/ml and one carpujet of .50 ml of Demerol 75mg/ml was unsecured in an open drawer.

On 08/07/2012 at approximately 1100 an interview occurred with staff M. When queried about the narcotics in an unlocked area staff M stated the patients had been moved to the phase two area of the post operative area and kept in the drawer in case there was a need for additional medication. When asked about the drawer being unlocked staff M responded "it is not necessary to keep the drawer locked because there is someone at the nearby desk area almost all of the time". When asked if a patient code in the phase two post op area were to occur would there be someone at the desk staff M responded "probably not:"

Based on observation, interview and policy and procedure review the facility failed to ensure that outdated and unusable drugs and biologicals were not available for patient use. Findings include:
During the observational tour on 8/7/12 at approximately 1110 the following medications were found to be unusable:
Operating Room #1
1. One 20 ml vial of ondansetron was open with no open or expiration date.
Operating Room #3
1. One 20 ml vial of Zofran was open with no open or expiration date.
Operating Room #4 Anesthesia Cart
1. One 5 milliliter (ml) vial of glycopyrrolate was open with no open or expiration date.
2. One 20 ml vial of ondansetron was open with no open or expiration date.
Malignant Hyperthermia Cart
1. One 500 ml, 20% Mannitol intravenous infusion bag of fluid expired 8/1/12
The above findings were confirmed by staff L and M.
During policy and procedure review on 8/7/12 at approximately 1500 it was found in the policy titled, "Multiple Dose Vials", states, "Multiple dose vials may be used for 28 days after opening. Multiple dose vials should be dated with the date opened or discarded after a single use".


29955

On 8/6/2012 at approximately 1100 during the initial tour of the emergency room (ER) department it was revealed medications that were outdated were stored and available for use in the ER department refrigerator. The following medications were identified as outdated or stored incorrectly and available for patient use:

1. Cephalexin 250/5 in suspension form dated 7/6/2012 with an outdate of 7/20/2012.
2. Amoxicillin 250/5 in suspension form dated 7/22/2012 with an outdate of 8/5/2012.
3. Azithromycin 200/5 in suspension form dated 8/1/2012 labeled "DO NOT REFRIGERATE".

An interview with staff E confirmed the findings.

The facility failed to provide and maintain a safe environment for patients and staff as evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 7, 2012 for Life Safety Code.

Based on observation, interview and policy and procedure review the facility failed to ensure that supplies were maintained at an acceptable level of safety and quality. Findings include:
During the observational tour on 8/6/12 during the hours of 1100-1200 the following items were found to be expired and available for patient use:
Emergency Department Crash Cart #1:
1. Two packages of pediatric electrode pads that expired 12/11
2. Two packages of EKG electrode pads that expired 1/11 and 6/12
3. Two packages of pediatric electrode pads that expired 7/12
4. One Carbon Dioxide (CO2) detector that expired 4/12
Emergency Department Crash Cart #2
1. One package of pediatric electrode pads that expired 7/12
2. One package of EKG electrode pads that expired 6/12
3. One Carbon Dioxide (CO2) detector that expired 7/30/10
Emergency Department Stock Room:
1. One bottle of Anaerobic specimen collector that expired on 7/31/12
2. One bottle of Aerobic specimen collector that expired on 6/30/12
3. One bottle of pediatric Anaerobic specimen collector that expired on 8/31/11
4. One STAR swab that expired 11/13/11
5. Twenty-four microtainer blood collection tubes that expired 7/12
The above findings were confirmed by staff E and H.
During observations on 8/7/12 during the hours of 1045-1200 the following items were found to be expired and available for patient use:
Post Anesthesia Care Unit (PACU)-Airway box
1. Three tongue depressors that expired 8/22/11
2. One size 2.0 Endotracheal (ET) Tube that expired 6/09
3. One size 2.5 ET tube that expired 2/09
4. One size 3.0 ET tube that expired 6/09
5. One size 3.5 ET tube that expired 9/09
5. One size 5.0 ET tube and one size 5.5 ET tube that expired 7/11

Operating Room #1 Anesthesia Cart
1. Nine open suction/yankeurs open on the machine with two connected to tubing open and out of their package

Operating Room #3 Anesthesia Cart
1. Two size 7.0 ET tubes open and placed back in the drawer with sterile items
2. One size 7.5 ET tube open and placed back in the drawer with sterile items
3. Six Tegaderm patches that expired 7/12
4. Six Tegaderm patches that expired 3/12

Operating Room #4 Anesthesia Cart
1. One tourniquet that expired 2/15/11
2. Three size 7.0 ET tubes that were opened and placed back in the drawer with sterile items
3. One size 8.0 ET tube that was open and placed back in the drawer with sterile items

Operating Room Supply Hallway
1. One unpackaged suction extension tubing in the drawer

Operating Room Pediatric Cart
1. Four 20 gauge intravenous (IV) catheters that expired 5/12
2. One 22 gauge IV catheter that expired 11/11
3. One 4.0 ET tube opened and placed back in the drawer with sterile items

The above findings were confirmed by staff L and M

During policy and procedure review on 8/7/12 at approximately 1500 it was found in the policy titled, "Stock Rotation", states, "All stock items will be rotated to prevent deterioration or expiration. Oldest items will be used first".



29774

Based on observation and interview the facility failed to ensure an acceptable level of safety and quality for expired patient care supplies and torn upholstered surfaces, resulting in the potential for patient harm. Findings include:

On 8/6/12 at approximately 1130 during a tour of Palmer 3 clean supply room found three (3) trochar thoracic catheters with a manufacturers expiration date of 6/2011. Two (2) additional trochar thoracic catheters had yellowed labels that were torn. Interview with Staff F on 8/6/12 at approximately 1132 confirmed the presence of the expired and yellowed chest tube catheters. When asked whether these would be used on a patient Staff F replied "I would hope not".

On 8/6/12 at between approximately 1100 and 1200 during a tour of the Palmer 2 unit found upholstery tears in the recliners in rooms 350, and 346. This was confirmed by Staff F on 8/6/12 at approximately 1155.




02902

Based on observation, the patient care supply storage area and two defibrillators were not properly maintained or configured to promote an acceptable level of safety, as evidenced by:
1. It was observed at 09:58 A.M. on August 7, 2012 that no finished ceiling was provided where patient care supplies were being stored (outside of shipping containers) in central stores. As found dirt and debris from exposed/uncleanable pipes, conduits, and light fixtures could fall unto and contaminate patient care supplies.
2. It was observed at 13:43 P.M. on August 7, 2012 that the defibrillator serving the 2nd floor Palmer medical/surgical inpatient nursing unit was not served by an emergency powered electrical convenience receptacle so as to always be fully charged and available for use.
3. It was observed at 13:51 P.M. on August 7, 2012 that the defibrillator serving the 3rd floor Palmer medical/surgical inpatient nursing unit was not served by an emergency powered electrical convenience receptacle so as to always be fully charged and available for use.

Based on observation, measurement and interview, it was determined that the facility failed to provide proper illumination in a diagnostic imaging area. Findings include:

Inadequate lighting was provided to promote proper and effective hand washing by staff assigned to interact with patients, other hospital staff and the public. As observed at 10:55 A.M. on August 7, 2012 the level of artificial illumination provided at the hand washing sink in x-ray room #1 was measured at 2 footcandles versus the recognized standard of 30 footcandles as derived from the Illuminating Engineering Society.
These findings were confirmed by the Maintenance Director during the observation.

Based on observation, interview and policy and procedure review the facility failed to ensure that the infection control officer developed a system for identifying potential infections and communicable diseases of patients and personnel. Findings include:
During observation of the Emergency Department on 8/6/12 at approximately 1110 it was found that the pre-registration area, where patients are seen had a soda bottle and coffee cup on the sink.
Staff E and H confirmed these findings
During policy and procedure review on 8/7/12 at approximately 1500 it was found in the policy titled, "Exposure Control Plan", states under C, #12, "In areas where occupational exposure may occur, there will be no applying of cosmetics, eating, drinking, or handling contact lenses".


29774

Based on observation, interview and policy review the facility failed to monitor and provide a clean and sanitary environment for all patients served by the facility resulting in the risk for transmission of infectious agents among patients and staff. Findings include:
On 8/6/12 at approximately 1125 during unit tour found storage of clean patient care supplies immediately around the hand hygiene sink in the " old medication room " risking spray and splatter contamination. This was confirmed by Staff F on 8/6/12 at approximately 1125, who stated " we could find someplace else to store those items " .
On 8/6/12 at approximately 1125 during unit tour found in the " old medication room " a patient nutrition refrigerator with accumulated grime, dried food and juice and ice accumulated in the freezer section beyond 1 inch. This was confirmed by Staff F on 8/6/12 at approximately 1125, who stated " it looks like it needs defrosting " . When asked who was responsible for monitoring the nutrition refrigerators Staff F replied " I am not sure " .
On 8/6/12 at approximately 1130 during unit tour found in the soiled utility room, clutter of (2) waste receptacles, (2) soiled linen bins and a food tray cart arranged so that access to the hopper sink and the hand hygiene sink were obstructed and also the presence of a strong fecal odor. In the clean storage room, which was a converted patient room, found much clutter with wall-shelved storage in addition to two free standing wire storage units, a clean linen cart and a wheelchair- accessible scale. This was confirmed by Staff F on 8/6/12 at approximately 1130. When asked how housekeeping can clean the floor in the soiled and clean storage rooms with the clutter, Staff F replied " it would be difficult " . Staff F was asked how often the scale was used and cleaned, to which she replied, " I think the scale is cleaned weekly " .
On 8/6/12 at approximately 1145 during unit tour found in the medication area, two blood glucose testing machines, one of the machines had visible blood spatter. This was confirmed by Staff F on 8/6/12 at approximately 1145. When asked how often the machines are cleaned, Staff F replied " after each use " .
On 8/8/12 at approximately 1330 a review of facility policy titled " Cleaning/Disinfecting Frequencies of Patient Care Equipment (non-critical) " dated 6/2/11 revealed " ...Items that must be cleaned at a designated frequency as determined by the IP&C are noted with an asterisk on the chart * ...Glucometer- between patients ...any item soiled with blood or body fluid is cleaned between patients ... " .



29955

On 8/6/2012 during the initial tour of the emergency room department it was revealed the patient medication refrigerator was dirty and had an accumulation of water in the back bottom of the refrigerator. Further findings included a dirty patient food refrigerator and coffee rings on the cabinets in the triage area. Staff E confirmed the findings and stated dietary was responsible for the patient food refrigerator, pharmacy was responsible for the medication refrigerator, and housekeeping was responsible for keeping services clean.

Tour of the soiled utility area revealed patient care items located on the shelving. Found in the soiled utility area were one bottle of normal saline for irrigation (250 ml) and one bottle of providine/iodine (100 ml). Findings were also confirmed by staff E.

On 8/7/2012 during a tour of the pre-surgical area it was revealed the refrigerator in the pre-operative area had an accumulation of ice and was in need of defrosting. Staff L confirmed the findings.