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Based on observation and interviews, the facility failed to ensure each patient's privacy relative to name and treatments is maintained on 1 of 12 patient care units of the Winter Park Hospital. (Inpatient Orthopedic Rehabilitation)

The findings include:

During an observation on the Inpatient Orthopedic Rehabilitation unit on 10/26/11 at about 12:45 p.m., a locator board in the hallway and visual to patients, staff, and visitors was noted to list patient last names, room numbers, and treatments (therapies, group therapy).

During an interview with the unit manager (staff LL, RN), she stated the locator board has always been in the hallway so patients can know what their schedule was for the day. A review of the policy and procedure for "Visual Privacy for Patient Information" (010.022-1) revealed "Clinical data, diagnostic testing results, treatment or procedures shall not be displayed on locator boards. When any clinical information is maintained outside/near the patient's room, at the nurses station or in any public area, it shall be turned toward the wall, turned over, or covered in a manner that will provide visual privacy."

Based on observation, record review and interview, the facility failed to assure a registered nurse assessed the care for each patient upon admission and when appropriate on an ongoing basis for 2 patient (#169 & 176).

Finding:

Celebration Campus:

1. Review of record #169: 63 F, admitted on 10/24/2011 with a diagnosis of abdominal pain; reflected Dilaudid, a medication used for pain control, 1 milligram (mg.) intravenous (IV) was administered on 10/24/2011 at 9:10 a.m. and on 10/25/2011 at 7:15 a.m. and 4:30 p.m. The record failed to document assessment of pain prior to any of the administration times. There was also lack of documentation post administration on the doses administered on 10/25/2011. Interview on 10/26/2011 at 2:25 p.m. with the Nurse Manager of the Medical Telemetry unit confirmed the lack of documentation of the pain assessment.

2. Review of record #176: 29 M, admitted 10/21/2011 with diagnosis of nausea and vomiting, reflected Dilaudid 1 mg. IV was administered on 10/24/2011 at 12:55 p.m., 5:35 p.m., and 10 p.m. The record failed to reflect documentation of the effect of the medication following administration. Interview with director of the intensive care unit (ICU) on 10/27/2011 at 11:30 a.m. confirmed the lack of documentation of the pain assessment.

Based on interview and record review, the facility failed to develop a treatment plan for the patient for 9 of 205 sampled patients (#67, 86, 137, 141, 142, 143, 144, 151 & 152).

Findings:

1. Review of the records for patient #86 revealed an incomplete Interdisciplinary Plan of Care Summary (IPOC). This is a 2 paged document and only the second page contained any information. The document did not contain the names and titles of the staff who contributed. The goals were not specifically stated and no evidence of input other than nursing was found. No educational needs for this patient were indicated. An interview with supervisory staff #YYY on 10/27/11 around 10:15 a.m. confirmed that there was no further information available concerning the IPOC.


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Orlando Campus
2. During record review for patient #67 on 10/24/11 at about 2 p.m., documentation revealed the patient was admitted on 10/24/11 for abdominal/pelvic swelling resulting in an exploratory laparotomy to excise a pelvic mass with anastomosis, a type of surgery to connect pieces of tissue. She was transferred to the 9th floor at about 6:15 p.m. Her Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. Her initial Admission Plan (IPOC) and subsequent "Reassessment Plans" were not completed, including date and time, at the time of record review on 10/24/11 at about 2 p.m. The goals were checked with no documented plan to meet the goals.

During an interview with the registered nurses (RNs) responsible for her care, they all agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.
Winter Park Campus
3. During record review for patient #137 on 10/25/11 at about 10 a.m., documentation revealed the patient was admitted on 10/25/11. His Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. His Reassessment Plan of Care (IPOC) for 10/24/11 was not completed, including date and time, at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RN responsible for his care, he agreed that the documentation needed to be signed and dated when the entries were made. He also stated the IPOC should have been accurately completed on admission and then every 12 hours.

4. During record review for patient #141 on 10/25/11 at about 10:45 a.m., documentation revealed the patient was admitted on 10/25/11 for a fractured right hip after a fall. Her Assessment Plan of Care (IPOC), during downtime for 10/25/11 was not completed (including date and time) except for pain until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RN responsible for her care, she agreed the IPOC should have been accurately completed on admission and then every 12 hours.

5. During record review for patient #143 on 10/25/11 at about 11 a.m., documentation revealed the patient was admitted on 10/24/11 with a diagnoses of cellulitis. His Resident Care/Graphic Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for 10/24/11 and subsequent reassessment IPOCs were not completed (including date and time) at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RNs responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

6. During record review for patient #144 on 10/25/11 at about 11:30 a.m., documentation revealed the patient was admitted on 10/25/11 with a diagnosis of chest pain. Her Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. Her Assessment Plan of Care (IPOC) for 10/25/11 was not completed, including date and time, at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RNs responsible for her care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

7. During record review for patient #151 on 10/25/11 at about 1 p.m., documentation revealed the patient was admitted on 10/24/11 for chest pain and gastrointestinal bleeding. His Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for downtime on 10/25/11 was not completed, including date and time, until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RNs responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

8. During record review for patient #152 on 10/25/11 at about 10 a.m., documentation revealed the patient was admitted on 10/24/11 for chest pain. His Patient Care/Graphic Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for downtime on 10/25/11 was not completed, including date and time, until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RNs responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

9. During record review for patient #142 on 10/26/11 at about 10:45 a.m., documentation revealed the patient was admitted 10/26/11 for a left total hip replacement due to osteoarthritis from steroid therapy for Lupus.

A review of the policy and procedure for guidelines for medical record entries (700.719) revealed " Nursing and ancillary staff authentication must contain the following: 1. Authentication - May use of the following: first initial/last name - must be recognizable, signature - must use full name, or initials - must include reference to full printed name, 2. Date, and 3. Time. "

During a dressing change for the surgical site at about 10:50 a.m. the incision line was noted to be clean and intact with 12 staples in place. The nurse was observed removing the old dressing using gloves and placing them in a red bag. She cleaned her hands and applied new gloves. She then cleaned the incision with hydrogen peroxide and coated the area with betadine. She then applied petroleum gauze, a dry gauze dressing, and covered the area with an ABD dressing and paper tape. She disposed of the soiled dressing materials in the proper container and washed her hands. Clinical documentation for physician orders written for post-operative care 10/26/11 showed the only order for dressing changes was "Change dressing daily beginning Post Op Day 1. Use minimal amount of tape using transverse strips. Loosen tape as necessary. " A review of the patient's Interdisciplinary Plan of Care (IPOC) showed no specific plan of care for dressing changes.

During an interview with the nurse providing care on 10/27/11 at about 11 a.m. she stated the dressing is always changed on day post op in the manner for this physician."

Based on observation, record review and interview, the facility failed to assure drugs and biological's were administered in accordance with the orders of the practitioner or practitioners responsible for four patients (#47, 83, 200 & 201).

Findings:

Orlando Campus

1. Review of patient record #47: admitted 10/22/2011 with diagnosis of lower GI (large intestines) bleed, reflected order for sliding scale Insulin was written on 10/22/2011 at 10:55 p.m.; the order included HumaLOG (a type of insulin used to treat diabetes) subcutaneous; 2 units for blood glucose (BG) of 150 -200 and 3 units for BG of 201 -250.

The Medication Administration Record (MAR) for 10/24/2011 at 12 p.m., 5 p.m. and 9 p.m. reflected the patient refused the injection. The Diabetes Flow Sheet for 10/24/2011 documented Blood Glucose (BG) of 200 at 1 p.m., 218 at 6 p.m., and BG 184 at 9:30 p.m. but failed to reflect the administration of insulin at any of these times. There was no documentation that the physician was notified the patient refused between 11:35 a.m. and 10/25/2011 on 10/24/2011.

Interview with Staff X, registered nurse at 1:15 p.m. on 10/25/2011 confirmed the medication was not given and that the record did not reflect the physician was notified.


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Kissimmee Campus:

2. On 10/26/11 at 2:15 p.m., during a medication pass observation for patient #201 with his medication nurse (ZZZ), the nurse gave the patient a subcutaneous (sc) injection of 5 units of Humulin HR, a type of insulin used to treat diabetes, 100 units/milliliter (ml).

In an interview with the patient at this time, he stated he had eaten lunch at about 12 p.m., 2 hours earlier. The nurse stated that the patient's blood sugar had been 310 prior to lunch and that she was late in giving him the sliding scale insulin (dosage depends on the patient's blood sugar levels).

Review of patient #201's medical record revealed that he had been admitted to the hospital on 10/25/11 with diagnoses with included insulin dependent diabetes and a left lower leg cellulitis. Review of the paper medication record dated 10/26/11 revealed an order dated 10/25/11 for the patient to get blood sugar checks before each meal and at bedtime. Humulin HR 100 units/ml. was to be given to the patient per a sliding scale order depending upon the patient's blood sugar level.

On 1026/11 at about 3:15 p.m. during an interview with patient #201's nurse, she stated that the reason for giving the sliding scale insulin so late was due to the electronic medical record being down and that it took her longer than expected to put her patient's medications on paper documents in order to know what to give.

2. Review of patient #200's hard copy physician orders dated 10/26/11 at 11:30 a.m. revealed an order for sc Lovenox, a medication used to thin blood, 40 milligrams (mg.) to be given to the patient every 24 hours. On 10/27/11, review of the paper medication records and the electronic medication records revealed that the patient had not received the infection of Lovenox. Continued review of the electronic medication record (MAR) revealed that the hospital pharmacy had entered the new order on the MAR but had not scheduled it to be given. The hospital's electronic medical record program had gone down on 10/24/11 and was in the process of being repaired between 10/24/11 and 10/26/11.

Review of patient #200's medical record revealed that he had been admitted to the facility on 10/19/11 with diagnoses which included lower back fractures and pneumonia. The patient had been assessed to be at moderate risk for deep vein thrombosis (DVT).

On 10/27/11 at 11 a.m., during an interview with the hospital's director of nurses, she validated that the patient had not received the Lovenox injection, that it had not been scheduled to be given, and that the patient was at moderate risk for DVT.


17432


Florida Hospital East Campus

3. Review of the records for patient #83 revealed that on 10/26/11 the patient had sliding scale insulin ordered with physician orders to medicate the patient with regular insulin if the blood sugar was above 121 mg. per deciliter (mg./dl). The checks of the blood sugar were ordered for every 4 hours when the patient was given nothing by mouth (NPO) or with meals and at bedtime when receiving food. On 10/26/11, the patient's blood sugar was checked at 7:30 a.m., 11:45 a.m., and 5 p.m. The results were 183 mg/dl, 183 mg./dl, and 150 mg./dl, respectively. The nurse indicated that no insulin was given with any of these readings. The notes further indicate that the patient was NPO during that time. The nurse did not state any reason for withholding the insulin that was ordered or for not checking the blood sugar every 4 hours. In an telephone interview with the nurse around 10 a.m. on 10/27/11, the nurse stated that the spouse of the patient stated that s/he did not agree to the administration of insulin while the patient was not receiving food. There was no record of the nurse contacting the physician to report this information.

Based on observation, record review, and interview, the facility failed to ensure orders for biologicals, including dressing changes were documented and signed by a practitioner who is authorized to write orders by hospital policy and in accordance with State law, and who is responsible for the care of the patient as specified under §482.12(c) for 1 patient observed during wound care for a surgical incision on the orthopedic unit at the Winter Park campus (#142).

The findings include:

During record review for patient #142 on 10/26/11 at about 10:45 a.m., documentation revealed the patient was admitted 10/26/11 for a left total hip replacement due to osteoarthritis from steroid therapy for Lupus. During a dressing change for the surgical site at about 10:50 a.m. the incision line was noted to be clean and intact with 12 staples in place. The nurse was observed removing the old dressing using gloves and placing them in a red bag. She cleaned her hands and applied new gloves. She then cleaned the incision with hydrogen peroxide and coated the area with betadine. She then applied petroleum gauze, a dry gauze dressing, and covered the area with an ABD dressing and paper tape. She disposed of the soiled dressing materials in the proper container and washed her hands. Clinical documentation for physician orders written for post-operative care 10/26/11 showed the only order for dressing changes was "Change dressing daily beginning Post Op Day 1. Use minimal amount of tape using transverse strips. Loosen tape as necessary." A review of the patient's Interdisciplinary Plan of Care (IPOC) showed no specific plan of care for dressing changes.

During an interview with the nurse providing care on 10/27/11 at about 11 a.m., she stated the dressing is always changed on day post op in the manner for this physician." Further interview with the assistant nurse manager and the RN educator for the unit at about 11 a.m., they confirmed that the patient had no order for the dressing change as observed but this was the way this physician always does dressing changes one day post operatively from a total hip replacement. When questioned about a written protocol for this dressing change, both nurses stated there was no written protocol; a protocol for "Dry and Moist-to-Dry Dressing" from Mosby's Nursing Skills was presented. The observed dressing change was not part of the protocol from Mosby's Nursing Skills. When questioned about educating new nurses on this protocol, the nurses stated they learn by observation and this was the way it was done.

Based on record reviews and interviews, the facility failed to maintain medical records for for each patient which were accurately written and promptly completed when the computer charting system was down for 9 of 205 sampled patients (#67, 79, 137, 140, 141,143, 144, 151 & 152).

The findings include:

Orlando Campus
1. During record review for patient #67 on 10/24/11 at about 2 p.m., documentation revealed the patient was admitted on 10/24/11 for abdominal/pelvic swelling resulting in an exploratory laparotomy to excise a pelvic mass with anastomosis, a surgery to connect tissue. She was transferred to the 9th floor at about 6:15 p.m. Her Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. Her initial Admission Plan (IPOC) and subsequent "Reassessment Plans" were not completed, including date and time, at the time of record review on 10/24/11 at about 2 p.m. The goals were checked with no documented plan to meet the goals.

During an interview with the registered nurses (RNs) responsible for her care, they all agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

Winter Park Campus
2. During record review for patient #137 on 10/25/11 at about 10 a.m., documentation revealed the patient was admitted on 10/25/11. His Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. His Reassessment Plan of Care (IPOC) for 10/24/11 was not completed, including date and time, at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RN responsible for his care, he agreed that the documentation needed to be signed and dated when the entries were made. He also stated the IPOC should have been accurately completed on admission and then every 12 hours.

3. During record review for patient #140 on 10/25/11 at about 10:30 a.m., documentation revealed the patient was admitted on 10/24/11 for cholecystitis, removal of the gallbladder. His Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form on 10/24/11 on the day shift.

During an interview with the RN responsible for his care, she agreed that the documentation needed to be signed and dated when the entries were made.

4. During record review for patient #141 on 10/25/11 at about 10:45 a.m., documentation revealed the patient was admitted on 10/25/11 for a fractured right hip after a fall. Her Assessment Plan of Care (IPOC), during downtime for 10/25/11 was not completed, including date and time, except for pain until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RN responsible for her care, she agreed the IPOC should have been accurately completed on admission and then every 12 hours.

5. During record review for patient #143 on 10/25/11 at about 11 a.m., documentation revealed the patient was admitted on 10/24/11 with a diagnoses of cellulitis. His Resident Care/Graphic Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for 10/24/11 and subsequent reassessment IPOCs were not completed, including date and time, at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RNs responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

6. During record review for patient #144 on 10/25/11 at about 11:30 a.m., documentation revealed the patient was admitted on 10/25/11 with a diagnosis of chest pain. Her Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. Her Assessment Plan of Care (IPOC) for 10/25/11 was not completed, including date and time, at the time of record review. The goals were checked with no documented plan to meet the goals.

During an interview with the RNs responsible for her care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

7. During record review for patient #151 on 10/25/11 at about 1 p.m., documentation revealed the patient was admitted on 10/24/11 for chest pain and gastrointestinal bleeding. His Graphic/Resident Care Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for downtime on 10/25/11 was not completed, including date and time, until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RN responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

8. During record review for patient #152 on 10/25/11 at about 10 a.m., documentation revealed the patient was admitted on 10/24/11 for chest pain. His Patient Care/Graphic Flowsheet was not signed or dated by the nurse completing the form. His Assessment Plan of Care (IPOC) for downtime on 10/25/11 was not completed, including date and time, until 10/26/11 at 8:30 a.m. when the computer system restarted.

During an interview with the RNs responsible for his care, they agreed that the documentation needed to be signed and dated when the entries were made. They also stated the IPOC should have been accurately completed on admission and then every 12 hours.

A review of the policy and procedure for guidelines for medical record entries (700.719) revealed "Nursing and ancillary staff authentication must contain the following: 1. Authentication - May use of the following: first initial/last name - must be recognizable, signature - must use full name, or initials - must include reference to full printed name, 2. Date, and 3. Time."


17432


9. Review of the records for patient #79 revealed that the medication administration record used during the computer down time on 10/25/11 did not have times of the medication administration for the evening shift. The nurse indicated that medications were administrated by initialing but did not include the time of administration. In an interview with the supervisory staff #YYY on 10/27/11 around 2 p.m., she stated that the recently trained nurses did not have the experience with charting on paper that the older nurses have.

Based on observation, interview and record review, the facility failed to store, prepare, serve and distribute food under sanitary conditions, described as follows: Multi-use eating ware, food preparation, serving equipment and utensils were not being properly sanitized; the facility failed to ensure dietary staff members were appropriately educated in ware washing sanitation to prevent the potential of causing food borne illness trained in the dish machine operation; and the facility failed to ensure managerial oversight to ensure that multi-use eating ware and equipment was sanitized. The hospital uses multi-use eating ware for patients with contagious/ infectious diseases.
Hospital patients are considered a highly susceptible population because they are more likely than other people in the general population to experience foodborne disease because they are older adults and/or immuno-compromised. Foodborne illness from microorganisms, such as Norovirus, Hepatitis A virus, Shigella spp., enterohemorrhagic or shiga toxin-producing Escherichia Coli, and/or Salmonella Typhi (all types of contagious organisms) may have serious medical consequences in hospital patients. The hospital uses multi-use eating ware for patients with contagious infectious diseases. Therefore, the hospital ' s failure to properly wash and sanitize the patient ' s multi-use eatingware has a potential to spread microorganisms from healthcare related infectious diseases.
The severity and cumulative effect of the systemic practices resulted in widespread Immediate Jeopardy (IJ), to the health of 1067 patients, plus staff and visitors at the South campus due to the high potential for food borne illness These practices resulted in the hospital's failure to have consistently provided maintenance, a monitoring program,and staff education of the dishwashing machines.
The IJ was removed on 10/26/11. The condition of participation for Food and Dietetic Services remains out of compliance.

Findings included:

1. During an observation 10/24/11 at approximately 10:35 a.m., the dish room for the ground floor patient service (GFPS) kitchen revealed the dishwashing machine wash temperature at 110°F (Farenheit), rinse temperature was 120°F; chlorine sanitizer concentration was at 50 ppm (parts per million). During an interview at the time of the observation with the food service director and patient services area senior manager on the Florida hospital South campus as well as the safety and sanitation specialist regarding the water pressure (PSI) requirements for the dishwashing machine, it was identified that they were not aware that the machine had a pressure gauge or what the correct pressures should be. At that time, the director, manager and sanitation specialist confirmed that the minimum wash temperature should be 120°F.
Further interview at that time revealed that the GFPS kitchen dish machine was temporarily installed on 9/13/11 at the site of the regular dish machine due to the remodeling of the patient food service system. The regular dish machine was a high temperature machine. The temporary machine was a low temperature, chemical sanitizing unit which was relocated again on 10/13/11 out of the patient kitchen.

On 10/24/11 at approximately 2:30 p.m. the facility provided copies of the manufacturer specifications for the single tank low temperature dish machine and conveyor belt high temperature dish machine.
Review of the manufacturer specifications for the GFPS kitchen dishwashing machine showed the following: "CMA single tank dishwasher -44L: Operating temperature: Wash 140-150° F, Final Rinse 140- 150°F. Summary of specifications: Model 44L low energy chemical sanitizing conveyor dishwasher meets NSF, UL, and CUL sanitation and construction standards without the use of a Booster Heater. Final rinse pressure 20(+-5) PSI."

Review of the 2009 Federal Food and Drug Administration Food code chapter 4-501.110 for Mechanical washing Equipment, Wash Solution Temperature read as follows: "(B) The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49°C (120°F)."


2. Observation of the Welch cafeteria dish room on 10/24/11 at approximately 11:30 a.m. revealed patient equipment and trays being washed through the high temperature dish machine, a dishwashing machine that uses a minimum of 180°F of hot water to sanitize. The wash temperature was 125°F and the final rinse temperature was 130°F. The water pressure was 58 PSI, which was the maximum readable pressure on the gauge. A list of equipment for the patient meal services being washed in the Welch cafeteria dish room included black patient trays, pink tray covers for use of the long term acute care hospital and the psychiatric behavioral center, patient food production steam table insert pans, sheet pans, hotel pans, and utensils used for serving the patient meals.

The dish machine was washing and sanitizing approximately 3000 patient trays and the equipment used to serve the patient meals since 9/13/11. This placed an increased load on the dish machine.

Interview with dishwasher in the Welch cafeteria dish room at the time of the observation verified that he was not aware that temperatures were below the minimum required wash and rinse temperatures. He used a thermal strip (heat sensitive strip) to check the rinse temperature. The strip did not change color to verify that the rinse temperature was at least 160°F.

A bucket of concentrated chlorine sanitizer was observed under the machine with a feed line attached to the machine. There were no chemical test strips available to test the concentration of the chlorine based sanitizer. The staff member was not aware that there was a difference between thermal strips used to measure a minimum temperature and the chemical test strips that measure the concentration of sanitizer. The administrative director, Orlando campus director and cafeteria supervisor confirmed that they were not aware that the dish machine was not functioning properly and that chlorine sanitizer strips were not available. When a test strip was requested to check the chlorine concentration, none were present in the dish room or readily accessible. The thermometer gauges on the dish machine specified the minimum wash temperature of 145°F and rinse temperatures of 180°F.

The facility had no written documentation of the sanitizer concentration to monitor that the dishes were being sanitized according to the FDA 2009 Food code requirements.

On 10/24/11 at approximately 2:30 p.m., the facility provided copies of the manufacturer specifications for the single tank low temperature dish machine and conveyor belt high temperature dish machine.

Review of the manufacturer specifications for the Welch Cafeteria dish machine showed the following: "Champion upright 29" Conveyor dishwashing machine. (Welch Cafeteria). Specification: Temperature F Wash (min) 150° F, Power rinse (min) 160° F, Auxiliary Rinse (min) 165° F, Final Rinse (min) 180° F. Plumbing notes: Because of the variation in house-supplied water pressure regulating valve (PRV) is needed (water PRV is standard). Steam PRV ' s may be required for pressure higher than 30 PSI."

The hospital maintains hot water temperatures at 110°F for patient safety. There is not an independent hot water system for the patient food service dishmachine to meet minimum standards.

Review of the soap company's warewash service reports document the following visits:
9/22/11 1 p.m., wash temp. 140°F, rinse temp. 110°F, chlorine 75 ppm. Inspected dishmachine- good function. Checked water and chemical lines for leaks checked for clogs. *adjusted sanitizer up to reach 75 ppm, good now.
10/10/11 install day - no operation results of dishmachine.
10/24 at 3:55 p.m., received a call that the dishmachine was not reaching temp of 120°F wash. Sending specifications for dishmachine via fax.
These were the only reports available during survey.

Review of the policies for Nutritional Services (NS) - Environment of Care Title Safety & Sanitation Standards. Policy number 210.900-1: "Policy - The NS Department follows the State of Florida chapter 64E-11, Florida Administration Code for Food Service as the minimum standard throughout all patient, retail and service production . . . areas. In addition, NS promotes and monitors compliance with sanitation standards through a department inspection program, conducted by the NS Safety\Sanitarian who provides food safety and sanitation education and makes recommendation regarding change in cleaning products or techniques. NS participates in the FH Environment of Care committee. Purpose to ensure the provision of safe foods. Procedure: unannounced inspections of NS kitchens, storerooms. Arrives unannounced at NS location. Requests supervisory staff to accompany him on the inspection tour. Provides education for staff during tours. Completes NS safety and sanitation report comments."

Further review of job descriptions revealed the following: "Jobs Title: Food service manager-principle duties and job responsibilities included Sanitation\Safety- Demonstrates and teaches the standards and principals of quality service, cleanliness, sanitation, safety and human relationships. Performs daily inspections of work area. . . . Job Title: NS supervisor General summary: Responsible for overseeing all services to patients and customers, as well as . . . .to assure outstanding quality, service and sanitation . . . ." Principle duties and job responsibilities included "Maintains satisfactory safety & Sanitation inspection scores; demonstrates and teaches the standards and principles of quality, service, cleanliness, sanitation and safety. Performs daily inspections of work area ... Collaborates with Engineering and Environment Services to ensure timely resolution of issues."

Review of the Florida Administrative Code Chapter 64E-11.006 Equipment and Utensils - effective 7/14/2003. This is the Florida food hygiene code. (As of July 1,2010 this code no longer applies to Hospitals.) (b) Mechanical - Cleaning and sanitizing may be done by spray type or immersion dishwashing or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. These machines and devices shall be properly installed and maintained in good repair. Machines and devices shall be operated in accordance with the manufacturer's instructions and specifications, which must be attached to the machine. Utensils and equipment placed in the machine shall be exposed to all dishwashing cycles. Automatic detergent dispensers, wetting agent dispensers, and liquid sanitizer injectors, if any, shall be properly installed and maintained. All dishwashing machines shall be thoroughly cleaned at least once a day, or more when necessary, to maintain them in a satisfactory operating condition."

Interview with the Manager of training and development on 10/27/11 at 10:30 a.m., identified that cafeteria staff have weekly meetings, included on the agenda is sanitation. There was nothing specifically documented related to proper functioning of the dish machine. There was no documentation of in-services related to Safety and Sanitation.

There was no documentation for training of the transition from the high temperature dish machine to the temporary low temperature dish machine on 9/13/11 or any day until 10/24/11.

She confirmed that there was not a record of notification of when the transition to chemical sanitizer occurred for the Welch dining room related to the low temperatures of the dish machine. There was no work order written that documented that the dish machine was not working properly. She also reconfirmed that there were no sanitizer strips present in the Welch dish room to test the sanitizer concentration. She provided a copy of the last all staff in-service "NS Safety and Sanitation Standards Review" which was completed on 9/10/2010.

The facility provided the dishwasher temperature logs submitted for review for the low temperature dish machine. Eleven out of 41 report logs were received from 9/13 to 10/24/11. The logs were dated 9/23, 24, 10/16, 17, 19, 20, 21, 22, 23 and 24/2011. There were no reports available from 9/13/11- 9/22/11 and 9/25/11-10/16/11. The 10/17/11 and 10/23/11 logs did not contain any documentation. The logs had documentation once per day. There was no written documentation of the sanitizer concentrations.

Interview with the lead dishwasher on 10/24/11 at approximately 11:45 a.m. confirmed that he checked the sanitizer concentration then taped the test strip to the log. When the test strip dried, the color of the concentration level was no longer visible.

The temperature of the dish machine wash water below 120°F was as follows:
9/24/11 - 8:05 a.m. - 118°F.
10/18/11- 8:10 a.m. - 118°F,
10/22/11 - (no time) 110°F,
10/23/11 had no documentation, and 10/24/11 at 8:30 a.m. 112°F.


Review of the facility Safety and Sanitation Standards from the Nutritional Services (NS) - Environment of Care policy #210.099 - 1 effective 9/29/2011 did not have any standards present or guidance to address the temporary low temperature dish machine requirements.

In an interview on 10/25/11 at 3 p.m., with the director of infection control, he stated that contagious diseases and infections did not require use of disposable plates and utensils since the dish machine appropriately sanitized to prevent the potential spread. He stated that reports of infections are medical and culture based. There had been no increase in the past 6 months of food borne pathogens such as Shigella or Salmonella.

Review of the Infection control policy- #500.100-1, effective 10/29/2010- Policy:
"The guidelines contain two tiers of precautions ... in the first and most important tier ... Standard precautions .... The second tier are precautions designed only for care of specific patients. These additional "Transmission- Based Precautions" are used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Patients are to remain on precautions until the infection has been treated appropriately or has been ruled out .... Page 2 of policy and procedures Action F. Patients on transmission based precautions will use the usual regular dietary tray from nutritional Services, special precautions are not required.
On page 5-6 Fundamentals of Isolation Precautions: E. Dishes glasses and cups and eating utensils. No special precautions are needed for dishes, glasses and cups or eating utensils. Regular dishes may be used for patients on isolation precautions. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses and cups, and eating utensils."

There was no standard or guidance present in the policy for the implementation of other safety or sanitary guidelines for dishes, glasses and cups and eating utensils if the dish machine was not functioning correctly.

Based on observation and interview, the facility failed to ensure that nutritional needs were met in accordance with recognized dietary practices in the form of covering food products within a refrigerator.

Findings:

Altamonte Springs Campus

During a tour of the kitchen on 10/26/11 at approximately 10:10 AM, a food refrigerator, termed a "back-up refrigerator" was examined. Inside, eleven uncovered pizzas were observed.

During an interview of the Director of Dietary Services on 10/26/11 at the above time, he confirmed that the pizzas should have been covered.

During an interview of the Accreditation Team Manager on 10/27/11 at approximately 5:48 PM, she confirmed the preceding.

Based on observation and interview, the facility failed to ensure that the hospital environment in the Central Processing and Operating Rooms were maintained in manner that the safety and well-being of patients with respect to exposure to potential sources of infection was assured.

Findings:

Altamonte Springs Campus

During a tour of the Decontamination Room within Central Processing on 10/26/11 at approximately 1:38 PM, a pipe was observed protruding from the wall beneath the manual cleaning sink. There was an unsealed gap between the pipe and the wall proper of approximately one inch on all sides of the pipe. This opening had the potential of introducing disease organisms into the room from the subsurface of the wall, which was part of the building's superstructure. The preceding observation was confirmed during an interview of the Director of Surgical Services at the above stated time.

During a tour of Operating Room #4 on 10/26/11 at approximately 2:05 PM, while no patient was present, a sound speaker was observed in the ceiling. The speaker's flange was not flush with the ceiling and exhibited an approximately one-half inch gap between itself and the ceiling proper on all sides. This opening had the potential of introducing disease organisms into the room from the subsurface of the ceiling, which was part of the building's superstructure. The immediately preceding observation was confirmed during an interview of the Director of Surgical Services at the above stated time.

Facility policy 630.038-1 read, "It is the policy of Florida Hospital to maintain hospital grounds and external property and equipment in a safe and efficient manner to reduce risks to patients, visitors, and employees."

During an interview of the Accreditation Team Manager on 10/27/11 at approximately 5:48 PM, she confirmed the preceding.

Based on observation, staff interview, and record review, the hospital's failed to maintain dishwashing machine equipment to ensure that it sanitized patient's eatingware and food service equipment and utensils.
The severity and cumulative effect of the systemic practices resulted in widespread Immediate Jeopardy (IJ) to the health of 1067 patients, plus staff and visitors at the South campus due to the high potential for food borne illness. Hospital patients are considered a highly susceptible population because they are more likely than other people in the general population to experience foodborne disease because they are older adults and/or immunocompromised. Foodborne illness from microorganisms, such as Norovirus, Hepatitis A virus, Shigella spp., enterohemorrhagic or shiga toxin-producing Escherichia Coli, and/or Salmonella Typhi (all contagious organisms) may have serious medical consequences in hospital patients. The hospital uses multi-use eating ware for patients with contagious infectious diseases. Therefore, the hospital's failure to properly wash and sanitize the patients' multi-use eatingware has a potential to spread microorganisms from healthcare related infectious diseases.

The IJ was removed on 10/26/11. The standard for facility maintenance remains out of compliance.

Findings Include:


1. During an observation 10/24/11 at approximately 10:35 a.m., the dish room for the ground floor patient service (GFPS) kitchen revealed the dishwashing machine wash temperature at 110°F (Farenheit), rinse temperature was 120°F; chlorine sanitizer concentration was at 50 ppm (parts per million). During an interview at the time of the observation with the food service director and patient services area senior manager on the Florida hospital South campus as well as the safety and sanitation specialist regarding the water pressure (PSI) requirements for the dishwashing machine, they identified that they were not aware that the machine had a pressure gauge or what the correct pressures should be. At that time, the director, manager and sanitation specialist confirmed that the minimum wash temperature should be 120°F.

Further interview at that time revealed that the GFPS kitchen dish machine was temporarily installed on 9/13/11 at the site of the regular dish machine due to the remodeling of the patient food service system. The regular dish machine was a high temperature machine. The temporary machine was a low temperature, chemical sanitizing unit which was relocated again on 10/13/11 out of the patient kitchen.

On 10/24/11 at approximately 2:30 p.m., the facility provided copies of the manufacturer specifications for the single tank low temperature dish machine and conveyor belt high temperature dish machine. Review of the manufacturer specifications for the Ground Floor Patient Services Kitchen dishwashing machine showed the following: "CMA single tank dishwasher - 44L - Operating temperature: Wash 140-150° F, Final Rinse 140- 150°F. Summary of specifications: Model 44L low energy chemical sanitizing conveyor dishwasher meets NSF, UL, and CUL sanitation and construction standards without the use of a Booster Heater. Final rinse pressure 20(+-5) PSI."

2. Observation of the Welch cafeteria dish room on 10/24/11 at approximately 11:30 a.m., revealed patient equipment and trays being washed through the high temperature dish machine, a dishwashing machine that uses a minimum of 180°F of hot water to sanitize. The wash temperature was 125°F and the final rinse temperature was 130°F. The water pressure was 58 PSI, which was the maximum readable pressure on the gauge. A list of equipment for the patient meal services being washed in the Welch cafeteria dish room included black patient trays, pink tray covers for use of the long term acute care hospital and the psychiatric behavioral center, patient food production steam table insert pans, sheet pans, hotel pans, and utensils used for serving the patient meals. The dish machine was washing and sanitizing approximately 3000 patient trays and the equipment used to serve the patient meals since 9/13/11. This placed an increased load on the dish machine.

Interview with dishwasher in the Welch cafeteria dish room at the time of the observation verified that he was not aware that temperatures were below the minimum required wash and rinse temperatures. He used a thermal strip (heat sensitive strip) to check the rinse temperature. The strip did not change color to verify that the rinse temperature was at least 160°F.

A bucket of concentrated chlorine sanitizer was observed under the machine with a feed line attached to the machine. There were no chemical test strips available to test the concentration of the chlorine based sanitizer. The staff member was not aware that there was a difference between thermal strips used to measure a minimum temperature and the chemical test strips that measure the concentration of sanitizer. The Administrative director, Orlando campus director and cafeteria supervisor confirmed that they were not aware that the dish machine was not functioning properly and that chlorine sanitizer strips were not available. When a test strip was requested to check the chlorine concentration, none were present in the dish room or readily accessible. The thermometer gauges on the dish machine specified the minimum wash temperature of 145°F and rinse temperatures of 180°F.

The facility had no written documentation of the sanitizer concentration to monitor that the dishes were being sanitized according to the FDA 2009 Food code requirements.

On 10/24/11 at approximately 2:30 p.m. the facility provided copies of the manufacturer specifications for the single tank low temperature dish machine and conveyor belt high temperature dish machine.

Review of the manufacturer specifications for the Welch Cafeteria dish machine showed the following: "Champion upright 29" Conveyor dishwashing machine. (Welch Cafeteria); Specification: Temperature F Wash (min) 150°F, Power rinse (min) 160°F, Auxiliary Rinse (min) 165°F, Final Rinse (min) 180°F. Plumbing notes: Because of the variation in house-supplied water pressure regulating valve (PRV) is needed (water PRV is standard). Steam PRVs may be required for pressure higher than 30 PSI."

The hospital maintains hot water temperatures at 110°F for patient safety. There is not an independent hot water system for the patient food service dishmachine to meet minimum standards.
Review of the 2009 Federal Food and Drug Administration Food code - Chapter 4-501.110 for Mechanical washing Equipment, Wash Solution Temperature read as follows:
"(B) The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49°C (120°F).
4-204.115 Warewashing Machines, Temperature Measuring Devices. A WAREWASHING machine shall be equipped with a TEMPERATURE MEASURING DEVICE that indicates the temperature of the water: (A) In each wash and rinse tank; and (B) As the water enters the hot water SANITIZING final rinse manifold or in the chemical SANITIZING solution tank.
4-204.118 Warewashing Machines, Flow Pressure Device. (A) WAREWASHING machines that provide a fresh hot water SANITIZING rinse shall be equipped with a pressure gauge or similar device such as a transducer that measures and displays the water pressure in the supply line immediately before entering the WAREWASHING machine.
4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature.
(A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than:
(4) For a multitank, conveyor, multi-temperature machine, 60°C (150°F).
4-502.11 Good Repair and Calibration.
(A) UTENSILS shall be maintained in a state of repair or condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded.
(B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy.
(C) Ambient air temperature, water pressure, and water TEMPERATURE MEASURING DEVICES shall be maintained in good repair and be accurate within the intended range of use.

In an interview on 10/25/11 at approximately 9 a.m. with the food service director (FSD), he stated that the dishwashing machines were still down. The contractors and chemical company were servicing the machines. The owner of the soap/chemical supplier stated that the low temperature dish machine for the patient kitchen was installed when the new food production area was modified. This dishwashing machine was installed in the old dishwashing room area on 9/13/11. On 10/13/11, the machine was moved to temporary area. Further interview with FSD and the contractors completing the installation identified that they were not aware of the water temperature requirements or that the CMA(brand) single tank dishmachine had a feature with a booster heater that heats the water when water temperatures does not reach minimum temperatures.

The hospital maintains hot water temperatures at 110°F for patient safety. There is not an independent hot water system for the food service dishmachines to meet minimum temperature. The contractor was not aware that the machine would have required a booster heater to increase the water temperatures to acceptable levels.

Review of the manufacturer specifications read, "CMA single tank dishwasher -44L - (Ground Floor Patient Services Kitchen). Operating temperature: Wash 140-150° F, Final Rinse 140- 150°F. Summary of specifications: Model 44L low energy chemical sanitizing conveyor dishwasher meets NSF, UL, and CUL sanitation and construction standards without the use of a Booster Heater.

Champion upright 29 "Conveyor dishwashing machine. (Welch Cafeteria)"; Specification: Temperature F Wash (min) 150°F, Power rinse (min) 160°F, Auxiliary Rinse (min) 165°F, Final Rinse (min) 180°F. Plumbing notes Because of the variation in house-supplied water pressure regulating valve (PRV) is needed (water PRV is standard). Steam PRVs may be required for pressure higher than 30 PSI."


Interview with a maintenance staff member in the Welch cafeteria dishwasher room on 10/25/11 at approximately 9:30 a.m. revealed that he did not know what the water pressure gauge should have been 20 PSI (acceptable range 15-30 PSI) or that the dishwasher was not functioning correctly until the surveyor identified the condition on 10/24/11.

Interview with the director of maintenance on 10/25/11 at approximately 5:30 p.m. revealed that the hospital maintenance did have a staff member that checked on the dishwashing machines. He was not aware prior to the surveyor's observations that the GFPS mechanical dishwasher did not have sufficient hot water temperatures to meet minimum standards. He was not aware that the Welch cafeteria was not maintaining minimum standards for high temperature mechanical dishwashers or that the pressure gauge for the final rinse sanitizing was not functioning correctly. He stated that the equipment was maintained by a contracted service. He confirmed that the maintenance department did not provide oversight of the equipment.

Based on observation, staff interview and record review, the hospital's infection control program did not address the prevention of foodborne illness, including contaminated equipment. The hospital failed to sanitize patients' eatingware and food service equipment and utensils due to dish machine not operating properly, as evidenced by:
· The dish machine did not achieve the minimum wash and rinse temperatures and/or chemical concentration to sanitize dishes
· There was a lack of testing equipment to monitor the chemical concentration of the sanitizing solution of the dish machine
· There was a lack of monitoring of the chemical sanitizer to ensure that solution was effectively sanitizing.
The hospital uses multi-use eating ware for patients with contagious/infectious diseases. The hospital ' s failure to properly wash and sanitize the patient ' s multi-use eating ware has the potential to spread organisms from healthcare related infectious diseases.
Hospital patients are considered a highly susceptible population because they are more likely than other people in the general population to experience foodborne disease because they are older adults and/or immunocompromised. Foodborne illness from microorganisms, such as Norovirus, Hepatitis A virus, Shigella spp., enterohemorrhagic or shiga toxin-producing Escherichia Coli, and/or Salmonella Typhi may have serious medical consequences in hospital patients. The hospital uses multi-use eating ware for patients with contagious infectious diseases. Therefore, the hospital's failure to properly wash and sanitize the patients' multi-use eatingware has a potential to spread microorganisms from healthcare related infectious diseases.
The severity and cumulative effect of the systemic practices resulted in widespread Immediate Jeopardy (IJ) to the health of 1067 patients, plus staff and visitors at the Orlando campus due to the high potential for food borne illness
The IJ was removed on 10/26/11. The Condition of Participation for Infection Control Services remains out of compliance.

Findings include:
The Hospital is responsible for providing and maintaining a sanitary environment to avoid sources and transmission of infections and communicable diseases. The infection prevention and control program must have appropriate monitoring of renovation and construction activities ensuring the maintenance of a sanitary environ

1. Patient Food Service Kitchen: Observation of the dish room for the ground floor patient service (GFPS) kitchen on 10/24/11 at approximately 10:35 a.m. revealed a low temperature single tank dish machine. The wash temperature at 110°F (Farenheit), rinse temperature was 120°F; chlorine sanitizer concentration was at 50 ppm (parts per million).

During an interview, at the time of the observation, with the food service director and patient services area senior manager on the Florida hospital South campus as well as the safety and sanitation specialist regarding the water pressure (PSI) requirements for the dishwashing machine identified that they were not aware that the machine had a pressure gauge or what the correct pressures should be. At that time, the director, manager and sanitation specialist confirmed that the minimum wash temperature should be 120°F.
Further interview at that time revealed that the GFPS kitchen dish machine was temporarily installed on 9/13/11 at the site of the regular dish machine due to the remodeling of the patient food service system. The regular dish machine was a high temperature machine. The temporary machine was a low temperature, chemical sanitizing unit which was relocated again on 10/13/11 out of the patient kitchen. Since it was a single tank machine, the food pans for the steam table and utensils were being sent to the cafeteria dish room to be cleaned.

2. Observation of the Welch cafeteria dish room on 10/24/11 at approximately 11:30 a.m. revealed patient equipment and trays being washed through the high temperature dish machine (a dishwashing machine that uses a minimum of 180°F of hot water to sanitize). The wash temperature was 125°F and the final rinse temperature was 130°F. The water pressure was 58 PSI, which was the maximum readable pressure on the gauge. A list of equipment for the patient meal services being washed in the Welch cafeteria dish room included black patient trays, pink tray covers for use of the long term acute care hospital and the psychiatric behavioral center, patient food production steam table insert pans, sheet pans, hotel pans, and utensils used for serving the patient meals.

The dish machine was washing and sanitizing approximately 3000 patient trays and the equipment used to serve the patient meals since 9/13/11. This placed an increased load on the dish machine.

Interview with dishwasher in the Welch cafeteria dish room at the time of the observation verified that he was not aware that temperatures were below the minimum required wash and rinse temperatures. He used a thermal strip, heat sensitive strip, to check the rinse temperature. The strip did not change color to verify that the rinse temperature was at least 160°F.

A bucket of concentrated chlorine sanitizer was observed under the machine with a feed line attached to the machine. There were no chemical test strips available to test the concentration of the chlorine based sanitizer. The staff member was not aware that there was a difference between thermal strips used to measure a minimum temperature and the chemical test strips that measure the concentration of sanitizer. The administrative director, Orlando campus director and cafeteria supervisor confirmed that they were not aware that the dish machine was not functioning properly and that chlorine sanitizer strips were not available. When a test strip was requested to check the chlorine concentration, none were present in the dish room or readily accessible. The thermometer gauges on the dish machine specified the minimum wash temperature of 145°F and rinse temperatures of 180°F.

The facility had no written documentation of the monitoring the sanitizer concentration to verify that the dishes were being sanitized according to the FDA 2009 Food code requirements.

Review of the Florida Administrative Code Chapter 64E-11.006 Equipment and Utensils- effective 7/14/2003. This is the Florida food hygiene code. (As of July 1, 2010 this code no longer applies to Hospitals): "(b) Mechanical - Cleaning and sanitizing may be done by spray type or immersion dishwashing or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. These machines and devices shall be properly installed and maintained in good repair. Machines and devices shall be operated in accordance with the manufacturer's instructions and specifications, which must be attached to the machine. Utensils and equipment placed in the machine shall be exposed to all dishwashing cycles. Automatic detergent dispensers, wetting agent dispensers, and liquid sanitizer injectors, if any, shall be properly installed and maintained. All dishwashing machines shall be thoroughly cleaned at least once a day, or more when necessary, to maintain them in a satisfactory operating condition."

Review of the Infection control policy- #500.100-1, effective 10/29/2010- Policy:
"The guidelines contain two tiers of precautions ... in the first and most important tier ... Standard precautions .... The second tier are precautions designed only for care of specific patients. These additional "Transmission- Based Precautions" are used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Patients are to remain on precautions until the infection has been treated appropriately or has been ruled out ....
Page 2 of policy and procedures. Action F. Patients on transmission based precautions will use the usual regular dietary tray from nutritional Services, special precautions are not required.
On page 5-6 Fundamentals of Isolation Precautions:
E. Dishes glasses and cups and eating utensils.
No special precautions are needed for dishes, glasses and cups or eating utensils. Regular dishes may be used for patients on isolation precautions. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses and cups, and eating utensils."

There was no standard or guidance present in the policy for the implementation of other safety or sanitary guidelines for dishes, glasses and cups and eating utensils if the dish machine was not functioning correctly.

An interview was conducted on 10/25/11 at 3 p.m. with the director of infection Control. He stated that contagious diseases and infections did not require use of disposable plates and utensils since the dish machine appropriately sanitizes to prevent the potential spread. He stated that reports of infections are medical and culture based. There had been no increase in the past 6 months of food borne pathogens such as Shigella or Salmonella. He was not aware of the changes from the high temperature to low temperature dishwashing machine during the renovation of the kitchen. He stated that he did not establish any changes in precautions or monitoring of the dishware sanitation.

Based on observation, interview and a review of facility documentation, the facility failed to ensure the implementation of policies governing control of infections in the form of removing sterile items which have expired dates from circulation.

Findings:

Altamonte Springs Campus

During a tour of Central Processing on 10/26/11 at approximately 1:54 PM on 10/26/11, sixteen shielded IV (intravenous) catheters with the following labeling were observed stored upon a shelf: 18 GA 1.16 IN 1.3 X 30 mm. All of these items had expiration dates of June, 2011.

A review of facility policy 510.100-1, "Storage of Medical Supplies" was performed. It read, "Expiration dates must be used when medication or dated materials are contained. The expiration date on the package comes the expiration date of the medication or product."

During an interview of the Director of Surgical Services at the above time, he confirmed the above observation. During an interview of the Risk Manager on 10/27/11 at approximately 2 PM, she confirmed all of the preceding.

Based on observation, interview, and record review, the facility failed to ensure staff followed policy practices related to hand washing and glove use when changing wound dressings for 2 of 4 patients (#3 & 16) and one patient (#198) during a medication observation.

Finding included:

Orlando campus:
1. During a wound dressing change observation on 10/25/2011 at 12 p.m. registered nurse (RN) staff was observed to change the dressing on patient #3's right knee and left thigh. The RN donned gloves, cleansed the right knee area (the dressing was already removed), removed the gloves, donned new gloves, and then applied a dressing to the right knee wound area. The RN then removed the gloves, applied new gloves, cleansed the left thigh area, removed the gloves, applied new gloves, and applied a dressing to the left thigh area. No hand hygiene was observed between glove changes and no hand hygiene was observed between wound sites. During the dressing change the RN nurse educator was present for the observation.

During an interview on 10/15/2011 at 12:20 p.m., RN nurse educator confirmed the RN staff changing patient #3 ' s dressing did not perform hand hygiene per hospital policy. The nurse educator said the hospital policy is to do hand hygiene, either foam or wash hands between each glove change.

During an interview on 10/27/2011 at 1:50 p.m. the Executive Director and Assistant Director for Infectious Prevention both confirmed nursing staff should be either using hand gel or washing hands between glove changes. The Assistant Director also said there is not enough manpower at this time to monitor staff practices related to dressing changes and hand/glove hygiene.

Review of the policy-Infection Control-Hand Hygiene, dated as effective 07/23/2010, states in policy: "When to Wash Your Hands-3. Before putting on and taking off gloves."


20257


Orlando Campus:

2. On 10/24/11 from 3:50 p.m. - 4:15 p.m., a sternal wound care observation for patient #16 with the patient's nurse #QQQ revealed that the patient was on contact isolation precautions for Methylcillin Resistant Staphylococcus Aureus (MRSA) in the wound. During the wound care, observation revealed that the nurse removed her dirty gloves, but did not wash her hands or use hand antiseptic gel after cleansing the wound and applying the Bactroban antibiotic salve and clean dressing. The wound had a moderate amount of tannish yellow drainage.

On 10/24/11 at 4:15 p.m., nurse #QQQ validated the above findings. She stated that it was the hospital's infection control expectations that she should have either washed her hands or used the antiseptic gel after cleaning the wound prior to providing the clean treatment. She stated that she had changed her gloves, but forgot to clean her hands.

Review of patient #16's medical record revealed that the resident had been admitted to the hospital on 10/19/11 with diagnoses which included an open sternal wound that was infected with MRSA. The patient had daily wound care treatment orders. The patient was receiving an intravenous antibiotic, Cefitime 1 gram, every 12 hours for the sternal wound infection.

Kissimmee Campus:

3. On 10/27/11 at about 9:40 a.m., observation of the medication nurse #TTT for patient #198 revealed that she used a hand antiseptic at the entrance of the medication room, then used her pen, picked up her clipboard, then got the patient's anti-hypertensive medication, 2 tablets of Lisinopril 10 milligrams (mg.) each, out of the medication cart. She then cut one of the two 10 (mg.) tablets in half, then picked up the half tablet with her bare hands, and placed it into a medicine cup. The nurse took the cup to the patient's room and gave him the medication. At 10:10 a.m., nurse #TTT then applied Brimondine 0.2% eyedrops into patient #198's eyes. She held the patient's upped and lower eyelids open with her bare hands and applied the eyedrops into his eyes. She did not wear gloves.

On 10/27/11 at about 1:15 p.m., during an interview with the hospital's infection control preventionist director, she validated that gloves needed to be used when working with mucous membranes such as eyes. She also stated that hands needed to be cleansed immediately prior to holding a patient's pill with bare hands.

Review of the hospital's Infection Prevention Precautions validated this according to their Standard Precautions protocol.

Based on record review and interview, the facility failed to credential three registered nurse first assistants (RNFAs) through the medical staff credentialing process prior to allowing their services assisting with patient surgical procedures in the operating rooms (staff #GGG, HHH & III).
Findings included:
The facility has three RNFAs recorded as providing services at the facility.
During an interview on 10/26/2011 at 10:30 a.m., the vice president of accreditation said the hospital no longer credentials RNFAs through the medical staff office. The RNFAs are now process through the human resources department. This changed occurred with the last accreditation survey.
During an interview on 10/26/2011 at 12:50 p.m., the director of the medical staff office said the bylaws for the policy for Allied Health Professional were changed on 8/10/2010, moving the process from credentialing through the Medical Staff Office to the Human Resources Office/department.
Review of the Bylaw change 571-2010 Policy on Allied Health Professionals dated as approved by the Board of Directors 08/10/2010 showed RNFA as struck through to be removed on that date.
Review of the three RNFA worked days, the last 30 days, showed RNFA staff #GGG last worked on 10/28/2011, RNFA staff #HHH last worked on 10/19/2011, and RNFA staff #III last worked on 10/24/2011.
Review of the Medical Staff Bylaws dated 07/2011 showed no requirement for RNFA to be credentialed by the medical staff.