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Based on observation interview and record review the hospital failed to ensure that 1 (#6) of 2 patients observed wearing mittens of a total sample of 40 patients were free from physical restraints.

Findings:

During observation of medication administration on 6/4/13 at 9:35 AM for Patient #6 it was observed that the patient was on a ventilator per endotrachea tube. She also had bilateral mittens which were secured to the bed frame. Her eyes were closed and she was calm as we entered the room. As the nurse explained the medication administration process she opened her eyes and was alert and cooperative. She received her medications through a nasogastric tube.

Interview with the nurse on 6/4/13 at 9:40 AM she stated that mittens are not considered a restraint therefore no physician's order is necessary. Review of the nursing notes with the nurse and the stroke coordinator revealed that no information was documented for 6/4/13 concerning the mittens. It is noted that the nurse had already documented her 8 AM nursing assessment. The nurse documented in front of the surveyor her assessment of the mittens for today. The surveyor then asked to look at the documentation from the previous day. There was no information concerning the mittens documented on 6/3/13 for the 7 AM-7 PM or 7 PM-7 AM shifts. There was no nursing plan of care documented for the use of the mittens for Patient #6. The stroke coordinator stated that an assessment of the mittens should be documented at each shift.

Record review for Patient #6 revealed that on 6/4/13 at 8 AM it is documented that the patient is "drowsy" has an "8.5 cm ET tube" and is on a "Diprivan drip at 20 mic/kg/minute." Her ventilator settings were as follows: "500 ml at 25 BPM with an FiO2 of 70%."

Interview with the unit manager of ICU on 6/6/13 at 11:42 AM stated that mittens should not be secured to the bed frame when used on a patient.

Review of the facility's restraint policy effective 10/29/12 revealed that the definition of a restraint is "any manual method or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely." The policy does not address mittens except that restraints "do not include mittens." There is no policy as to how often patients with mittens should be assessed or if the mittens have to be documented. There is no policy which states how to use mittens (secured to bed frame or not secured).

Based on observation interview and record review the hospital failed to ensure that 1 (#6) of 40 patients sampled had a nursing plan of care for the use of mittens.

Findings:

During observation of medication administration on 6/4/13 at 9:35 AM for Patient #6 it was observed that the patient was on a ventilator per endotrachea tube. She also had bilateral mittens which were secured to the bed frame. Her eyes were closed and she was calm as we entered the room. As the nurse explained the medication administration process she opened her eyes and was alert and cooperative. She received her medications through a nasogastric tube.

Interview with the nurse on 6/4/13 at 9:40 AM she stated that mittens are not considered a restraint therefore no physician's order is necessary. Review of the nursing notes with the nurse and the stroke coordinator revealed that no information was documented for 6/4/13 concerning the mittens. It is noted that the nurse had already documented her 8 AM nursing assessment. The nurse documented in front of the surveyor her assessment of the mittens for today. The surveyor then asked to look at the documentation from the previous day. There was no information concerning the mittens documented on 6/3/13 for the 7 AM-7 PM or 7 PM-7 AM shifts. There was no nursing plan of care documented for the use of the mittens for Patient #6. The stroke coordinator stated that an assessment of the mittens should be documented at each shift.

Record review for Patient #6 revealed that on 6/4/13 at 8 AM it is documented that the patient is "drowsy" has an "8.5 cm ET tube" and is on a "Diprivan drip at 20 mic/kg/minute." Her ventilator settings were as follows: "500 ml at 25 BPM with an FiO2 of 70%."

Interview with the unit manager of ICU on 6/6/13 at 11:42 AM stated that mittens should not be secured to the bed frame when used on a patient.

Review of the facility's restraint policy effective 10/29/12 revealed that the definition of a restraint is "any manual method or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely." The policy does not address mittens except that restraints "do not include mittens." There is no policy as to how often patients with mittens should be assessed or if the mittens have to be documented. There is no policy which states how to use mittens (secured to bed frame or not secured).

Based on observation, interviews, and review of the facility's policy and procedure manual the facility failed to ensure controlled drugs (with schedules of II, III, IV, and V) were kept locked to ensure adequate control and accountability in accordance with state and federal law.

The findings include:

1) During the tour of the hospital pharmacy on 6/5/13 at 3:30 p.m., noted that there was no locking door separating the hospital pharmacy from the outpatient retail pharmacy. Further observation within the outpatient retail pharmacy noted controlled drugs with schedules of II, III, IV, and V where kept on the shelves and not kept locked up failing to ensure adequate control and accountability.

Interview on 6/5/13 at 3:30 pm with the Director of the Pharmacy stated that the hospital pharmacy and the outpatient pharmacy operate under two separate licenses. Further discussion revealed that when the outpatient pharmacy is " closed " ; there is no lock or monitoring system to ensure adequate control of the controlled drugs in the outpatient pharmacy. The Director of Pharmacy acknowledged at night when the outpatient retail pharmacy was " closed " , pharmacy techs from the hospital pharmacy could access the outpatient retail pharmacy while no pharmacist was present.

Record Review on 6/5/13 at 3:30 pm of the hospital pharmacy policy titled " medication management - controlled substances " states " controlled substances are kept under double lock or in automated dispensing machines. " Interview on 6/5/13 at 3:30 pm, The Director of Pharmacy stated that the outpatient retail pharmacy has no policies related to securing controlled drugs. The facility failed to ensure controlled drugs were kept locked to ensure adequate control and accountability.

Based on observation of medication units, staff interview and record review the facility failed to ensure all medications used for patients were regularly checked for expiration dates to ensure the safety of the patients.

The findings include:

1) Observation on 6/6/13 from 9:40 am until 11:40 am during the medication storage tour revealed Inside the Third Floor, CVI unit medication room, the blood bank refrigerator revealed the presence of 2 bottles (10 ml in each bottle) of Integrillin (eptifibatide) 2 milligrams per milliliter, expired 3/2012 and 3/2013.

Interview on 6/6/13 at 11:40 am with the Director of Pharmacy, she acknowledged the 2 bottles of Integrillin were expired and stated they were missed because they are not kept within the locked accu-dose medication cabinet. She adds that monthly inspections were completed for the locked medication refrigerator; however it missed this drawer.

Record Review on 6/6/13 at 12:00 pm, the policy related to " Medication Management - Medication Storage and Monthly Storage Area Inspections " dated 12/04/12 states the purpose of the policy is to ensure " medications are properly, securely, and safely stored throughout the organization. " The procedure states " 15. During Monthly Inspections, Pharmacy Services will remove any medication that is expiring within 60 days from the date of expiration. " The facility failed to ensure expired medications were removed from medication storage units.

Based on observation of medication units, staff interviews, and record review, the facility failed to ensure medication refrigerators were maintained in a clean and sanitary condition to ensure the safety of patients for 11 of 11 medication refrigerators observed (out of 56 potential medication refrigerators) located throughout the facility.

Based on observation, interviews, and review of the facility's policy and procedure manual the facility failed to ensure that sanitation of the kitchen to protect employees, patients, and customers by minimizing the possibility of contamination and the facility failed to ensure that adequate pest control was maintained in the kitchen to prevent contamination of the food supply.

The findings include:

A) Observation on 6/6/13 from 9:40 am until 11:40 am during the medication storage tour revealed:
1) Inside the Second Floor, South West medication room, the medication refrigerator inside the pharmacy accu-dose system had a white/gray powdery substance covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
2) Inside the Second Floor, South main medication room, the medication refrigerator inside the pharmacy accu-dose system had a white/gray powdery substance and hair covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
3) Inside the Second Floor, ICU unit medication room, the blood bank refrigerator had a thick brown substance covering the bottom of the refrigerator.
4) Inside the Third Floor, South East medication room, the medication refrigerator inside the pharmacy accu-dose system had a white/gray dirt substance covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
5) Inside the Third Floor, South Main medication room, the medication refrigerator inside the pharmacy accu-dose system had a white/gray dirt substance covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
6) Inside the Third Floor, West medication room, the medication refrigerator inside the pharmacy accu-dose system had a rust/brown substance covering the back of the refrigerator.
7) Inside the Third Floor, CVI unit medication room, the medication refrigerator inside the pharmacy accu-dose system had a white/gray power substance covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
8) Inside the Third Floor, Cath #2 unit medication room, the medication refrigerator had a white/gray power substance covering the bottom of the refrigerator. There was also a rust/brown substance covering the back of the refrigerator.
9) Inside the First Floor, ER #1 unit medication room, the medication refrigerator inside the pharmacy accu-dose system had a rust/brown substance covering the back of the refrigerator.
10) Inside the First Floor, ER #2 unit medication room, the medication refrigerator inside the pharmacy accu-dose system had a rust/brown substance covering the back of the refrigerator.
11) Inside the Fourth Floor, South unit medication room, the medication refrigerator had a white power substance covering the bottom of the refrigerator.
Interview on 6/6/13 at 11:40 am, the Pharmacy Director acknowledged the refrigerators should be clean and was unable to explain why they were not clean. She states that the responsibility to clean the refrigerators is either pharmacy when they stock the units or nursing when they access the medications.

Record Review on 6/6/13 at 12:00 pm, the policy related to " Medication Management - Medication Storage and Monthly Storage Area Inspections " dated 12/04/12 states the purpose of the policy is to ensure " medications are properly, securely, and safely stored throughout the organization. " The procedure states " 1. Medications are stored under proper conditions of sanitation. "

Record Review on 6/6/13 at 12:00 pm, the " Pharmacy Consultant Monthly Inspection " form does not address sanitation or cleanliness of the medication units. The facility failed to ensure medications were stored under proper conditions of sanitation.




B) Observations on 6/3/13 and 6/4/13 during the kitching tour revealed:

1) Observation on 6/3/13 at 11:00 and again on 6/4/13 at 9:00 am, the kitchen floor has scattered white pieces of paper on the floor along with dirt and crumbs underneath equipment and throughout the facility.

Interview on 6/4/13 at 9:00 am with the Food Service Director states that the production ovens and food coolers are too large to move and service underneath and behind the equipment. He also adds that the " building is very old " and the " floor is as clean as it will get. " When discussing the crumbs and the paper, he did acknowledge that staff could be cleaning the floors better and stated it was right after breakfast service.
2) Observation on 6/3/13 at 11:00 and again on 6/4/13 at 9:00 am in the kitchen revealed that the top of the production ovens has a thick black dust, crumbs and small dead insects on top of the ovens.

Interview on 6/4/13 at 9:00 am with the Food Service Director acknowledged the dirt on top of the ovens and stated that his staff " should be doing a better job with high level cleaning. "
3) Observation on 6/3/13 at 11:00 and again on 6/4/13 at 9:00 am in the kitchen revealed that the top shelf of the food service tray line was covered in a layer of gray dust. The shelf is located directly above the area where the plating of patient ' s food on the tray line occurs.

The tray lid covers were also stored on this dusty top shelf and observed being placed on food trays during food service. The tray lids were stored facing up and not upside down. Storing them face up could allow dirt to collect in the tray lids.

Interview on 6/4/13 at 9 am with the Food Service Director acknowledged that the shelf had a layer of dust on it. The Food Service Director stated that his staff should be doing a better job with high level cleaning. The Food Service Director stated that the " Tray lids should be stored on the storage rack; however they do not have enough space " and staff stores them on the top shelf " for convenience. " He stated that the tray lid covers should be stored upside down; but that staff " stores them face side up because they store easier. " The Food Service Director acknowledged that this practice should not be done to prevent dust or dirt from collecting in the plate lid covers.
4) Observation on 6/3/13 at 11:00 and again on 6/4/13 at 9:00 am in the kitchen revealed that on the walls and ceilings above the food coolers had a thick layer of dust and spider webs present. Also noted on top of the food cooler, was a very thick layer of dust in the vents on top of the machine.

Interview on 6/4/13 at 9 am with the Food Service Director acknowledged the dust and spider webs on the walls and on top of the food coolers. The Food Service Director stated that they " could not clean the walls of the kitchen because they do not have equipment to reach up that high. " The Food Service Director stated that his " staff is not responsible for cleaning the top of the food coolers " and that is " left up to Bio Med to clean the vents. "
5) Observation on 6/3/13 at 11:00 and again on 6/4/13 at 9:00 am in the kitchen revealed that on the walls behind the production ovens was a layer of brown grease on the wall and underneath the ovens.

Interview on 6/4/13 at 9 am with the Food Service Director acknowledged the grease on the walls and underneath the ovens and stated that he felt his " staff was doing an ok job with cleaning, " however they could probably improve the process. "
6) Interview on 6/5/13 at 3 pm with the Food Service Manager states that the kitchen does have an employee scheduled to perform deep cleaning around the kitchen. The Food Service Director provided a list titled " Master Sanitation Schedule " for all items within the kitchen with instructions how to clean each piece of equipment.

However the Food Service Director was unable to provide further detail of what specific date that each piece of equipment was last cleaned by kitchen staff. Review of the " Master Sanitation Schedule " states that some equipment is cleaned daily,weekly, and monthly. The Food Service Director stated there was no checklist to determine when the last time each piece of equipment was cleaned nor what days the weekly or monthly service was completed. He stated that the facility does not have a list of when the equipment was last cleaned and they " clean everything, every day and as needed. "

The Food Service Director was unable to provide an explanation for the sanitation issues noted during the survey. The Food Service Director stated that his supervisors should be watching for sanitation issues using the " Daily Supervisor Checklist for Opening and Closing. " He states that his Supervisors need to be " doing a better job and making sure the work is being done " and " not just checking off the check list saying everything is done. "
7) Review on 6/5/13 at 3 pm of the policy titled " cleaning schedules " states " to maintain the sanitation of the kitchen and meet regulatory requirements, " " routines for cleaning are established for each piece of equipment as well as the facility. " It adds " Daily cleaning routines are part of all employees task outline " and " daily cleaning assigned to the employees using the equipment. "
8) Review on 6/5/13 at 3 pm of the policy titled " food & nutrition - general overview infection control " states " to protect employees, patients, and customers by minimizing the possibility of contamination and transfer of infection " the facility will perform general housekeeping including " c. all work surfaces, utensils, and equipment shall be cleaned and sanitized after each use " and " e. all floor surfaces must be wet-mopped daily and as needed. " The facility failed to ensure the sanitation within the kitchen.

9) Observation on 6/3/13 at 11:00 am in the kitchen noted several (at least 10) small flying insects around the trashcans directly next to cold food prep area. The insects were observed flying around the trashcans and landing on the cold food prep table where salads were being currently be prepared.
Interview on 6/3/13 at 11:00 am with Food Service Director acknowledged the insects and states that the " entire building has issues with insects and nats. " He states that " patient rooms and the kitchen has issues " with insects " because it is an old building. " He states that " Steritech " pest control was here over the weekend and they service the kitchen all of the time for pest and insects.
Observation on 6/4/13 at 9:00 am in the cold food prep area and again on 6/5/13 at 2:00 pm revealed flying insects in the kitchen. On 6/5/13 at 2 pm during tour of the kitchen with the Food Service Manager tried to swat the insects flying around him while performing a tour of the kitchen area near the production ovens.
Review on 6/5/13 at 2:00 pm of the policy titled " Dietary Pest Control " states the purpose of the policy is to " protect the food supply from contamination by pest " by " the Nutrition Services Department must be kept free of soil and clutter. "