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Based on observation and staff interview the facility failed to ensure the confidentiality of a patient clinical record.

Finding includes:
On 3/15/2017 at 9:50 AM observed Staff #2 in the room of Patient #21 (P #21) also in the room was a Computer on Wheels (COW) opened to the patient's medication screen. The patient's mother and 3 visitors were also in the room. Staff #2 prepared to disconnect and flush the IV line of Patient #21 but realized that an additional flush was needed for the procedure. Leaving the computer screen opened to the patient's clinical record, Staff #2 left the COW unattended and went to get an additional flush. Immediately after the procedure the observation was described to Staff #2. Staff #2 acknowledged that the patient's confidential clinical record was not protected when the COW was left unattended with the screen opened to the patient's medication record and visitors were present at the time. The staff failed to protect a patient's confidential information.

Based on record review and interview with staff members, the facility failed to ensure 1 of 30 patients (Patient #2) medical record was accurately written.

Finding includes:

On 3/15/17 at 3:30 P.M. a record review was done for Patient #2. The patient was admitted to the facility on 2/14/17 with diagnosis of left spastic hemiplegia after head injury with left spastic equinovarus foot deformity. A review of the History and Physical by the Advanced Practice Registered Nurse, dated 2/6/17 notes under "History of Present Illness" that this is the second admission for this patient with "left spastic cerebral palsy hemiplegia secondary to a traumatic head injury at approximately 2 months of age". The "Inpatient Progress Note" by the physician dated 2/13/17 notes in the history the patient "has a history of an acquired left spastic hemiplegia status post a head injury sustained when he was 3 years of age".

On the morning of 3/16/17, Staff Member #6 confirmed the discrepancy in the medical records between the ARNP and physician reports which states the patient had a head injury at two months of age and at three months of age, respectively. A request was made for a copy of the reports, the facility provided the copies on 3/16/17 at 9:17 A.M. A concurrent review of the reports was done with Staff Member #6, the staff member confirmed the discrepancy.

Further review of the record was done with the assistance of Staff Member #6. An "Outpatient Progress Note" dated 4/22/10 notes at approximately two months of age the patient sustained a head injury which lead to weakness to both upper and lower extremities on the left side.

Based on observations, interview with staff member and a review of the facility's policy and procedures, the facility failed to ensure the director of food and dietetic services managed the operation of dietary services to include safety practices for food handling.

Findings include:

1) The facility failed to ensure food was stored under sanitary conditions.

On 3/15/17 at 8:30 A.M. a tour of the facility's kitchen was done with Staff Member #1 and Staff Member #5. Observation of the refrigerator found two large trays of cupcakes that were not covered. The trays were stored on separate shelves atop soft drink bottles. The soft drink bottles were stored in its delivery packaging (card board box and plastic covering). Staff Member #1 reported the cupcakes were made yesterday and left uncovered so the icing would not be ruined.

Observation on the top shelf of a refrigerator found a plastic bag with no label. Inquired what was in the bag, Staff Member #1 brought the bag down which contained avocados; however, there was no label documenting the receive date. The staff member reported the avocados are purchased from a commercial company and is usually dated.

On 3/15/17, Staff Member #1 provided a copy of the policy and procedure for "Outdated Food". The policy addresses the prevention of use of outdated foods to ensure safe food production. The procedure includes that "all food received will have a received date (Nutrition Svcs, vendor)".

On 3/15/17 at 3:10 P.M. Staff Member #1 also provided a copy of the policy and procedure for "Hazard Analysis Critical Control Point - Food Storage". The policy addresses that "all food will be stored in a manner that ensures food safety and quality and prevents cross contamination". The procedures include the following: "1) Food, whether raw or prepared, if removed from the container or package in which it was obtained, shall be stored in a clean covered container except during necessary periods of preparation or service...2) Container covers shall be impervious and nonabsorbent, except that linens or napkins may be used for lining or covering bread or roll containers..."

2) The facility failed to ensure dry food items shall be stored above the floor and not subject to seepage or waste water back flow or contamination by condensation.

On 3/15/17 at 8:30 A.M. concurrent observation was made with Staff Member #1 and Staff Member #2 of the facility's kitchen. Observation of the walk-in refrigerator found a round cardboard container that was labeled chicken fry mix stored directly on the floor. The received date was 3/8/17. An observation of the walk in freezer found a box stored directly on the floor which was opened at the top. The box contained an opened package of french fries, a cellophane wrapped mini pizza and two opened packages of food. Also observed two tubs of ice cream stacked atop each other in a plastic bag stored directly on the floor of the freezer under the shelf. At this time, Staff Member #1 picked up the tubs of ice cream and placed it on the shelf.

On 3/15/17 at 3:10 P.M. Staff Member #1 provided a copy of the facility's policy and procedures for "HACCP (Hazard Analysis Critical Control Point) Guidelines - Food Storage" to address that "all food will be stored in a manner that ensures food safety and quality and prevents cross contamination". The procedure includes: "4. Containers of food shall be stored a minimum of 6 inches above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area, except that: A. Metal pressurized beverage containers and cased food packaged in cans, glass, or other waterproof containers need not be elevated when the food container is not exposed to floor moisture...B. Containers may be stored on dollies, racks or pallets, provided such equipment is easily movable..."

Based on observations, interviews, and policy review the facility failed to practice the control of infections and communicable diseases of patients and personnel.

Findings include:
1) On 3/15/2017 at 9:50 AM observed Staff #2 flush a leur lock cap for Patient #21. Staff #2 wiped the hub of the leur lock cap with an alcohol swab, then inserted and flushed the line with a premeasured syringe of fluid. Failing to do another alcohol wipe Staff #2 inserted another prefilled syringe of fluid into the patients leur lock cap and administered a second flush into the patients leur lock. Immediately after Staff #2 was interviewed regarding the observation. When asked if an alcohol wipe should have been done prior to the second flush Staff #2 agreed that for infection control practice an alcohol wipe of the leur lock should have been done prior to flushing the lock. The hospital policy titled "Intravenous Peripheral Line Flush PG-I-10" states, "6. Cleanse leur lock cap with alcohol wipe. 7. Flush the catheter with solution." On 3/16/2017 the observation was discussed with Staff #5. Staff #5 confirmed that for infection control practice the policy is an alcohol wipe prior to flusing the lock.

2) On 3/15/2017 at 10:17 AM interviewed Staff #4 on housekeeping practices. Staff #4 stated that Virex is the disinfectant used for beds, handrail, chairs, etc. When asked the wet time recommended for Virex, Staff #4 stated 1 - 2 minutes. A concurrent review of the Virex label was done with Staff #4. The Virex label stated, "Leave wet 10 minutes and allow to air dry." Staff #4 then shared that the beds, chairs are left wet for 10 minutes. But for the handrails in the hallways, a clean wet rag soaked in Virex and squeezed dry is used. Staff #4 stated "I don't keep the rails wet for 10 minutes." The hospital policy, subject; Patient Units, Cleaning. ENV-P-01 states under Procedure. 1. Damp Dust entire patient room and surrounding area with Virex II making sure surface remains wet for 10 minutes before wiping with dry microfiber wipe. On 3/16/2017 Staff # 5 was interviewed. The dwelling time for Virex and practice of not leaving the hand rail wet for 10 minutes was discussed with Staff #5. Staff #5 stated the dwell time should be for 10 minutes for disinfection. Manufactures recommendations for disinfection should be followed for infection control practice.