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Based on observation, interview, and review of hospital policy and procedure, the Critical Access Hospital failed to ensure the requirements for provision of a functioning and safe environment for patients were met as evidenced by:

1. Failure to maintain a working boiler to provide heat for patient care areas resulted in the use of portable heaters in patient areas, which created the potential for accidental fire. (See C 222.)

2. A cabinet used to warm patient care items lacked means to measure the temperature. (See C 222.)


The cumulative effects of these systemic problems resulted in diminished capacity of the Critical Access Hospital to provide a safe environment for patient care.

Based on observation and interview, and review of hospital records, the hospital failed to ensure: 1. All essential mechanical equipment was in operating condition, and 2. Patient care equipment was safe for use for patient care when, a) The boiler for heating patient rooms was not functioning which resulted in the use of portable heater(s) to heat patient room(s) with potential risk of accidental fire, and b) A cabinet, used for warming patient care items, in the Emergency Department was not equipped with a thermometer to measure temperature, with potential the patient care items would get hot enough to cause burns to patients.


Findings:

1. Upon entrance to the hospital, on 2/5/13 at 8:05 a.m., a portable heater was observed about 2 feet from the foot of Bed B in Room 101. The heater faced toward the two beds in the room, and was plugged into the wall opposite the beds. Both beds were occupied by patients. The patient in Bed A was sitting upright in bed, nodded when addressed, and shook hands, but did not speak. The patient in Bed B lay on her side with her eyes closed, both bed side rails were raised.

On 2/6/13 at 7:35 a.m., the portable heater was observed in Room 101. Both patients appeared to be asleep.

On 2/6/13 at 2:15 p.m., at the beginning of an environmental tour, when asked about the portable heater which remained in Room 101, the Engineering Manager stated the main boiler for the hydronic heating system, heat supplied by running heated water through pipes in the floor, had been down for two days. The Engineering Manager stated the portable heater was to supply heat while the boiler was repaired. The Engineering Manager stated he had used the same heater in other health care facilities and that it was UL approved, (United Laboratories, an independent company that certifies, tests, and validates products for safety).

During a visit, at 2:25 p.m., to the area housing the hospital boiler, the Engineering Manager explained the boiler heated water which then was pumped through piping that heated the patient care areas, (hydronic heating). No apparent work was underway on the boiler. Documentation of the boiler repair was requested from the Engineering Manager.

Further into the tour, outside the back of the hospital, the Engineering Manager showed a second HVAC, (Heat, Ventilation, Air Conditioning) unit. The Engineering Manager explained that this newer unit heated the Emergency Department, the clinic, and the clinical laboratory.

During an interview, on 2/7/13 at 2:30 p.m., the Engineering Manager stated the part needed for repair of the boiler had been ordered. The Engineering Manager stated the repair crew were out in the field but he would obtain documentation of the repair work to be done.

On 2/14/13 at 9:10 a.m., a facsimile was received at CDPH District Office from the Engineering Manager. Review, of the facsimile at noon, on 2/14/13, revealed a work order, dated 1/31/13, for repair of the boiler. A new part was ordered on 1/31/13. Subsequent entries, on 2/4/13 to the work order, indicated a second part was required for the repair, and on 2/5/13, a third part was required to complete the repair.

2. During an observation, on 2/5/13 at 8:25 a.m., the door to a waist high warming cabinet in the Emergency Department, (ED), was opened. The cabinet contained blankets and sheets. On the left side of the top shelf was a pile of large plastic bags containing intravenous (IV) fluid. The bags were hot to the touch. At the bottom of the cabinet was a dial that was illegible, and a sliding mechanism designed to adjust the temperature.

During a concurrent interview, Licensed Staff G, stated the hot IV bags were not administered intravenously, but were used as warmers like a hot water bag, for patients that were hypothermic, (too low a body temperature). Licensed Staff G stated that the warmer did not have a thermometer, to measure temperature, and the ED did not keep a log of the cabinet temperatures.

During an interview, on 2/8/13 at noon, the Engineering Manager acknowledged there was not a thermometer in the warming cabinet in the ED to monitor the cabinet temperature.

The American Burn Association Community Fire and Burn Prevention Program noted that exposure of skin to water at 120 degrees Fahrenheit for 5 minutes can cause a third degree burn.

Recommended Practices for a Safe Environment of Care, from Perioperative Standards and Recommended Practices, published by the Association of periOperative Nurses, 2012, specified the temperature of blanket or linen warming cabinets should not exceed 130 degrees Fahrenheit, and the temperature should be checked and documented in a log at regular intervals.

Based on observation, interview, and review of the hospital records and policies and procedures, the Critical Access Hospital failed to ensure that written policies and procedures were followed and the the requirements for provision of services for Pharmaceutical Services, Infection Control and Nutritional Services were met as evidenced by:

1. Rules for storage of medications and biologicals were not followed when:

a. Local anesthetics in the emergency department and clinic were not dated when opened and;
b. Expired medications were available for use in the emergency department and the clinic and;
c. A refrigerator used for storage of vaccines was repeatedly out of temperature range. (See C 276)

2. Failure to ensure a system for control of infectious diseases when:

a. Environmental Services staff was unaware of the need for effective cleaning and disinfectant products for infectious diseases Clostridium Difficile and Tuberculosis.
b. Correct dilution practices were not followed for the dilution of a product used for disinfection.
c. Environmental Services staff did not have current evaluations or competencies for infection control.
d. Chemical reagents were stored with laboratory specimens.
e. The facility sterilizer was not cleaned following manufacturer's recommendations.
f. Clean patient care supplies and mechanisms for testing blood and urine samples were stored together on the counters of the clinic medication room.
(See C 278)

3. Food storage and sanitation standards were not followed when:

a. One dishwasher lacked an air gap.
b. Expired dry foods were not removed from storage and undated food was stored in the refrigerator.
c. Chemicals for cleaning were stored next to boxes of paper dish supplies.
(See C 279)

The cumulative effect of these systemic problems resulted in the diminished ability of the Critical Access Hospital to provide: 1. Safe and effective use of drugs and storage of medications to meet the needs of patients, 2. Infection Control measures to reduce the risk of hospital acquired infections, 3. Food services that were optimally safe and nutritious for hospitalized patients.

Based on observation, interview and review of hospital policy, the hospital failed to ensure that medications for patient use were not mislabeled or outdated and were stored according to professional guidelines when: 1. Multidose vials, (contain more than one dose of medication), of local anesthetics, (used to "numb" small areas of tissue), were not labeled with opened dates in the Emergency Department and clinic, 2. Expired medications were available for use in the Emergency Department, and 3. Medications were not stored in the clinic refrigerator at correct temperatures to maintain potency. These failures had the potential that patients were administered ineffective medications.

Findings:

1. During an observation, on 2/6/13 at 8:10 a.m., the Emergency Department, (ED), medication cart contained two opened multidose vials of Marcaine 0.5%. Neither vial was dated when opened. The ED cart also contained one opened bottle of Xylocaine 1.0% and one opened bottle of Lidocaine 1.0%. Marcaine, Lidocaine and Xylocaine can be used as local anesthetics for suturing, (sewing) of wounds, or starting intravenous lines, (insertion of needle into a vein to administer medication or fluids).

During concurrent interview, Licensed Staff A stated the ED physicians were used to grabbing a bottle to use, and didn't bother to date the vial when it was opened.

During an observation, on 2/7/13 at 10:50 a.m., an open, undated multidose vial of Marcaine 5%, was found in the clinic's medication storage area.

Multidose vials contain liquid medication intended for intravenous use or injection, and contain more than one dose of the medication. Multidose vials contain antimicrobials, (acts against disease causing organisms), to decrease the chance of infection from repeated use.

United States Pharmacopoeia (USP) General Chapter 797 recommended the following for multi-dose vials of sterile pharmaceuticals:" If the multidose vial had been opened or accessed (needle punctured) the vial should be dated and discarded after 28 days, unless the manufacturer specifies a different (shorter or longer) date".

2. During an observation, on 2/6/13 at 8:10 a.m., the Emergency Department, (ED), medication storage refrigerator contained a box of five vials of Anectine, a short acting skeletal muscle relaxer, with an expiration date of 12/12. Also in the refrigerator was one vial of Pitocin, a uterine stimulant used to induce or enhance contractions in labor, with an expiration date of 1/13.

Review, on 2/6/13 at 11 a.m., of the facility policy and procedure "Medication Storage", dated 4/28/11, indicated, "5. All outdated medications will be stored in a separate box in the Drug Room...The consultant pharmacist is responsible for monitoring outdates".

3. During an observation and concurrent interview, on 2/7/13 at 10:25 a.m.,
in the clinic medication room, the refrigerator contained the following medications: pneumococcal and influenza vaccines, (used to prevent pneumonia and flu), Levinor, Novalog and Humalog insulin, (used to control elevated blood sugar), Bicillin, an antibiotic and vaccines for hepatitis B, diphtheria, tetanus and pertussis.

The freezer compartment was coated with approximately 1.5 centimeters of frost.

Review of the temperature log for the refrigerator revealed the following: 1/8/13 PM the temperature was 28 degrees.
1/9/13 AM the temperature was 34 degrees, engineering was notified.
1/10/13 AM the temperature was 34 degrees.
1/15/13 AM the temperature was 26 degrees, engineering was notified.
1/16/13 PM the temperature was 32 degrees.
1/21/13 AM the temperature was 32 degrees, engineering was notified.
1/24/13 AM the temperature was 32 degrees, engineering was notified.
1/24/13 PM the temperature was 34 degrees.
The log noted "Normal temperature range for refrigerator is 36-46 degrees F".

During an interview, on 2/7/13 at noon, the Engineering Manager stated he was aware of the low temperatures in the clinic medication refrigerator. The Engineering Manager stated he had recommended that the freezer of the clinic medication refrigerator be defrosted.

The Center for Disease Control guideline titled "Vaccine Storage and Handling Toolkit", November 2011, indicated that appropriate storage temperatures must be maintained at every link of the vaccine cold chain. Excessive heat or cold exposure can damage vaccines resulting in reduced potency. A single exposure to freezing temperatures can affect the potency of some vaccines. Hep B vaccine and dTaP, (combination of diptheria, tetanus and diptheria), are especially sensitive to freezing temperatures.

LexicompOnline, a medication resource for medical professionals, indicated the following guidelines for medication storage:
Pneumocccal vaccine: Store between 36-46 degrees F.
Influenza Vaccine: Store between 36-46 degrees F. Potency is destroyed by freezing, do not use if product has been frozen
Novolog: Store between 36-46 degrees F. Do not use if has been frozen.
Humalog: Do not freeze.
dTaP: Store between 36-46 degrees F. Discard if frozen.
Hepatitis B vaccine: Store between 36-46 degrees F. Do not freeze.

Review, of the hospital policy titled "Medication Storage", effective 4/28/11 indicated that "Medications shall be stored at appropriate temperatures. a. Refrigerator temperatures shall be between 2.2 degrees C, (36 degrees F) and 7.7 degrees C, (46 degrees F)".

Based on observation, staff interview and record review the facility failed to ensure there was a system for controlling infectious diseases when:

1. Two staff (The Environmental Services Worker and The Engineering/Environmental Services Manager ) were not aware of proper cleaning and disinfectant products to use for infectious diseases such as Clostridium Difficile (bacteria in the digestive tract) or TB (Tuberculosis- bacterial infection in the lungs), which could have resulted the in the use of incorrectly mixed chemicals, and the potential for patient exposure to infections and the spread of infections.

2. One Environmental Services Worker was not aware of correct dilution practices, and mixed an excessive amount of the bleach product for disinfection, which had the potential to result in patient and staff exposure to caustic chemicals and excessive fumes and had the potential for patients to develop health related problems for patients upon exposure.

3. Two staff, the Engineering/ Environmental Services Manager and The Environmental Services Worker did not have evaluations or appraisals to ensure competencies were done regarding infection control training or cleaning methods, for two years which could have resulted in the lack of oversight for the need for training, due to poor job performance or lack of skills.

4. Chemical reagents were stored with laboratory samples in a clinical laboratory refrigerator. This resulted in a potential for cross contamination of organisms from the lab specimens to the reagents.

5. The facility sterilizer was not cleaned following manufacturer's guidelines. This resulted in a potential for failure of sterilization of contaminated instruments, and use of contaminated instruments on patients.

6. Clean patient care supplies and mechanisms for testing blood and urine were stored on the counters of the clinic medication room. This resulted in the potential for contamination of patient care items with body fluids.


Findings:

During an observation on 2/6/13 at 9:45 a.m., the Environmental Services Worker was standing next to her cleaning cart in the hallway outside a patient room. The Environmental Services Worker stated that the facility staff used a disinfectant "Neutral" cleaner to clean surfaces in the patient rooms. The Environmental Services Worker stated that if she cleaned a room where the patient had Clostridium Difficile, that she would wear a gown, mask and gloves and use the "Neutral" cleaner. The Environmental Services worker stated that she was not exactly sure what Clostridium Difficile was, but knew that you had to use precautions for cleaning the patient's room.

On 2/6/12, review of the manufacturer's reference sheet on the "Neutral" disinfectant cleaner, supplied by The Environmental Services Worker, did not indicate that it was a effective cleaner for Clostridium Difficile or Tuberculosis.

During an interview on 2/6/13 at 10:40 a.m., the Infection Preventionist Consultant verified that the "Neutral" cleaning Disinfectant was not effective against Clostridium Difficile or TB (Tuberculosis).

On 2/6/13, review of the guidelines titled "Clostridium difficile or "C-diff" (The down and dirty facts) from 2008 "APIC" (Association of Professionals in Infection Control) "Guide to the Elimination of Clostridium difficile in Healthcare Settings" that had been given to staff, by the Infection Preventionist Consultant, to review, indicated that Clostridium Difficile was a bacteria that lived in the GI (Gastrointestinal) or the digestive tract. Patients at risk were the elderly and those on antibiotics. Clostridium Difficile was transmitted via the fecal and oral route, mostly on the hands of health care workers or on inanimate objects in the environment. Hypochlorite (bleach mixture of 1 part bleach and 9 parts of water) solution was recommended as it was the most effective against Clostridium Difficile.

During an interview on 2/6/13 at 12:10 p.m., the Infection Preventionist Consultant stated that the supply company discontinued the former cleaning product and told the Engineering/Environmental Services Manager that the "Neutral" cleaning product was the same. The Infection Control Consultant stated that the Engineering/ Environmental Manager failed to tell her about the change in cleaning product. The Infection Preventionist Consultant stated that it was important that staff use the correct product to eliminate the bacteria on surfaces.

During an interview on 2/6/13 at 3 p.m., the Engineering/Environmental Manager stated that he did not know that the "Neutral" cleaner was not effective in eliminating Clostridium Difficile or TB.

2. During an observation and concurrent interview on 2/6/13 at 9:50 a.m., The Environmental Services Worker displayed the containers she used to mix a diluted bleach disinfectant solution, and stated it was used in the emergency room and the long term care area. The surfaces it was was used on included surfaces that both patients and staff had contact with. The Environmental Services Worker stated that she was not sure of the exact dilution. The Environmental Services worker held up the container that she filled with bleach and stated that she filled it to the black mark on the side. The mark was at the 1/2 cup marking on the plastic graduate. The Environmental Services Worker stated that she then poured it into a spray bottle and filled it with water. The spray bottle indicated that it held 28 ounces. The Environmental Services Worker stated that she did not personally use it because it smelled too strong.

During an interview on 2/6/13, the Infection Preventionist Consultant stated that staff were mixing bleach too strong and that it should be a 1:9 (1 part bleach to 9 parts water) dilution and that 4 ounces or 1/2 cup of bleach should be in around 40 ounces of solution not in 28 ounces.

3. During a review of personal files on 2/6/13, it was revealed that the Engineering/Environmental Manager's file had a annual competency evaluation dated 6/7/10. There had been no annual competency evaluations since then. The Environmental Services Worker's file had an annual competency evaluation dated 6/26/10. There had been no annual competency evaluation since then.

During an interview on 2/7/13 at 12:50 p.m., The Human Resources Director stated that staff are supposed to have annual evaluations or appraisals and stated that she told the managers monthly that staff were overdue for evaluations. The Human Resources Director stated that The Engineering/Environmental Manager and the Environmental Services worker were overdue for their competency evaluations.

During an interview on 2/7/13 at 2:30 p.m., The Engineering/Environmental Manager stated that he did quarterly training with staff but agreed that they needed to do evaluations of competencies and that they were behind in making sure that it was done. The Engineering/Environmental Manager stated that Operations Director usually did his evaluation.

On 2/7/13 at 3:30 p.m., The Operations Director stated that he was aware that the annual competencies/evaluations have not been done for a while and needed to be done.

On 2/7/13 review of the facility policy for "Performance Appraisals" effective 7/29/04 and reviewed 2012, indicated that employees are evaluated at least annually, that appraisals measure the employee's performance against the performance standards of the employee's position and are meant to ensure that the employee and their managers mutually understand the employment standards. The failure to ensure staff met performance standards to ensure good infection control measures were in place or determine if staff needed training to ensure standards were met, put patients at risk for infections.


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4. During an observation on 2/6/13 at 3:30 p.m., the Laboratory Manager (Lab Manager), opened a refrigerator in the lab that was used to store reagents (chemicals used in testing biological samples). The right side of the large double door refrigerator was stacked with boxes of chemical reagents. The left side of the refrigerator contained more reagents. On the far left of the second shelf was a plastic basket that contained lab specimens in plastic bags. The Lab Manager stated he stored specimens waiting for pick up in the basket.

The third shelf on the left contained two large wooden racks holding numerous test tubes. Lab Manager stated the tubes were old blood samples that he held in case a physician needed additional blood tests from the samples. Additional reagents, in boxes, were stacked behind the test tube racks. The fourth shelf, below the test tube racks contained additional reagents. When asked about the potential of cross contamination between the lab samples and the reagents, the Lab Manager replied, "Oh, I guess I could change that".

During an interview, on 2/6/13 at 4 p.m., the Infection Preventionist stated she had, just the other day, seen that lab personnel were storing specimens in the refrigerator with chemical reagents. The Infection Preventionist stated she didn't think it was a good idea to store the items together, though, "It might be OK if they were separated by space, however not (stored) side by side the way it is now".

Guidelines for Good Clinical Laboratory Practice Standards, published by Division of AIDS, National Institute of Allergy and Infectious Disease, July 25, 2011, specified "Laboratory storage areas must...adequately preserve the identity, purity and stability of laboratory reagents, control materials...".

5. During an observation and concurrent interview, on 2/7/13 at 8:35 a.m., the Operations Assistant described the process the hospital used for sterilization of reusable instruments. After the housekeeping staff washed and dried the instruments in the housekeeping room, the instruments were transported, in a covered metal basin, down the hall to the central supply room for processing.

The Operations Assistant demonstrated how she wrapped the instruments, and the bio-indicators that were used for each load. The Operations Assistant stated she ran about two loads a week in the M11 Sterilizer. The Operations Assistant stated she cleaned the sterilizer, "about once a year", by washing the inside and outside, and running a cleaner through the system. The Operations Assistant stated she did not keep a log of when the sterilizer was cleaned.

Subsequent review, of the manufacturer's guidelines, "Caring For Your M9 and M11 Sterilizer", dated 1998, indicated that the sterilizer should be cleaned internally and externally, and the water drained and replaced, every week. The manufacturer's guidelines additionally specified the sterilizer system should be flushed monthly, using a specific sterilizer cleaner. The guidelines contained an alert, "Failure to flush unit with...sterilizer cleaner...may cause some components in the unit to fail", with the potential result of ineffective sterilization of contaminated instruments.

6. The clinic medication room was observed on 2/7/13 at 10:25 a.m. In the middle of the counter space was a sink. Immediately to the right of the sink was a covered metal container. The Director of Nursing stated the metal container was for dirty instruments.

Next to the dirty instrument container, a glucometer, used for blood sugar testing, stood in it's charging bay. Next to the glucometer was a Hemoglobin testing device, used to measure the amount of hemoglobin, (the oxygen carrying capacity of red blood cells), in a blood sample. In the corner of the right hand counter was the medication refrigerator that stored vaccines.

Above the counter were locked cabinets that stored medications. The only space to place removed medications was the counter space adjacent to the specimen testing equipment. Center for Disease Control, (CDC), Guide For Infection Prevention For Outpatient Settings:Minimum Expectations for Safe Care, updated 2011, indicated," Unsafe practices that have led to patient harm include...3) preparation of of medications in close proximity to contaminated supplies or equipment". Injection safety recommendations of the CDC included: "Injections are required to be prepared...in a clean area free from contamination or contact with blood, body fluids or contaminated equipment".

On the counter, to the left of the sink lay a pulse oximeter, used to measure oxygen levels with a finger probe. To the left of the oximeter, was a Clinitek Analyzer, used to test urine samples.

At 10:50 a.m., a fresh urine sample, in a covered cup, sat on a plastic backed blue paper sheet on the left hand counter, next to the Clinitek Analyzer, along with the pulse oximeter. A few minutes later, a peak flow device, used to measure the amount of exhaled air to check lung function, was left on the counter, along side the urine sample and pulse oximeter.

During the observation, the Director of Nursing stated with some rearrangement of the testing devices, the risk of contamination of patient care items with body fluids could be reduced.

The hospital's policy, "Transmission Based Isolation Precautions", dated 10/23/12, indicated that Standard Precautions were designed to reduce the risk of transmission of blood born pathogens(germs) from both recognized and unrecognized sources of infections within the hospital, regardless of the diagnosis or presumed infection status of the patient. The policy further stated,"Standard precautions apply to blood and all body fluids and secretions, except sweat, whether or not they contain visible blood" and "Are used on all patients, with no exceptions". The policy additionally stated one mode of transmission of pathogens was "Common Vehicle Transmission" by contaminated items such as devices or equipment.

CDC Guide to Infection Prevention for Outpatient Settings recommended that Standard Precautions are the "foundation for preventing the transmission of infectious agents during patient care in all healthcare settings".

Based on observation, staff interview and policy review, the facility failed to ensure dietary food storage policies and sanitation standards were followed to ensure nutritional/sanitary needs of the patient when:

1. One dishwasher lacked an air gap or back flow prevention device to prevent back flow of dirty water from a drainage outflow pipe causing the potential for food borne illness if clean dishes became contaminated with dirty water.

2. Expired dry food items were not removed from storage and undated food was kept in the freezer. The failure to ensure expired dietary food items were removed and food items were dated put the facility at risk of giving food to clients that lacked nutritional value due to deterioration of food.

3. Cleaning chemicals were stored next to boxes of dishes and paper dish supplies. The failure to ensure cleaning supplies were stored away from food serving utensils put the items at risk for spillage and contamination if the chemical containers broke.

Findings:

1. During an observation and interview, on 2/5/13 at 8:45 a.m., a room next to the kitchen contained a dishwasher and there was no visible air gap (an unobstructed vertical separation between the water outlet and the flood rim of the receptacle to prevent back flow) located at the out flow drainage pipe area of the dishwasher. The Dietary Manager stated at this time that she did not know if there was an air gap and that engineering or maintenance department manager would know.

During an interview on 2/5/13 at 3 p.m., the Manager of Engineering and Environmental services stated that he didn't think that there was an air gap to prevent dirty drainage water from backing up in the dishwasher.

During an interview on 2/6/13 at 2:05 p.m., the Manager of Engineering and Environmental Services stated that when he reviewed the dishwasher manual, and he did not see that there was a built in back flow prevention device for the dishwasher.

Review of the Food and Drug Administration on line "Food Establishment Guide For Design, Installation, And Construction Recommendations" updated 12/9/11 indicated that a potable (water that is safe to drink) water system or equipment that contacts food or utensils, shall be installed to preclude the possibility of back flow of non potable or questionable water supply. A air gap or back flow prevention device should be installed.

2. During an observation and interview, on 2/5/13 at 8:10 a.m., there was a box of 12 pastries in a box in the freezer that did not have an expiration date or best by date. The Dietary Manager stated that the pastries had been removed from the original box and that the original box had the date on it. The Dietary Manager stated that usually the food items are dated to ensure the oldest product was used first.

During an observation of the dry storage area on 2/5/13 at 8:20 a.m., there was a cardboard box of crackers, 500 count, that did not have a lid. There was no date on the box or crackers which indicated an expiration date or when the item was placed on the shelf. The Dietary Manager stated that the date was probably on the lid which was taken off the crackers. There was one opened box of 15 packets of diet Italian dressing with an expiration date of 7/6/12, three full box of 200 packets of diet dressings with expiration dates of 6/24/12 , 9/8/12 and 10/26/12. There was a box of 50 packets of diet Concord grape jelly with a expiration date of 6/25/12 and another box of 20 packets of grape jelly without dates. There was a box of mayonnaise packets without expiration dates. There was a packet of barley without a date and 4 bottles of Pancake syrup without expiration dates, 4 boxes of buttermilk pancake mix without expiration dates and 7 boxes of assorted flavors of Jello without expiration dates. During a concurrent interview, the Dietary Manager stated the reason the food items had to have dates was to ensure the food was used in a certain amount of time to ensure quality of the food because otherwise you could not guarantee how good the food was.

On 2/7/13, review of the facility "Food Preparation And Storage" policy effective 1/8/2009, indicated that it was a policy to store food in a safe manner according to recognized standards for food handling. The policy indicated that all groceries were placed so newer items were placed behind older items and cans were dated to facilitate the process. The policy indicated under "Foods With Best By/Expiration Dates" that the best by dates was the manufacturer's quality assurance date, and foods that had an expiration date should be discarded after the specified date.

3. During an observation on 2/6/13 at 8:15 a.m., of the disaster supplies in a room outside of the kitchen there was a lower shelf with 4- 1 gallon bottles of lime away cleaner (hard water stain remover) and 11 bottles of liquid bleach cleaner and 5 one gallon bottles of germicidal bleach solution (bleach solution that kills germs). They were next to, and on the same shelf as a box of food bowls and box of paper plates. The storage room also contained emergency food cans and packages as well as water. During an interview at this time, The Dietary Manager stated that there was not a lot of storage area for the chemicals to be and that is why they were placed there.

On 2/7/13, review of the facility policy titled "Storage of Chemicals And Non-Food Items And Use Of Material Safety Data Sheets" effective 6/28/07 indicated chemicals and other toxic substances should be stored separately from food to ensure that contaminants are not accidentally mixed with food resulting in a food borne illness. The Policy indicated that dishwashing and cleaning chemicals will be stored in the cabinet in the dish room and that all cleaning chemicals will be stored separate from food, including unopened containers.

Based on staff interview and personal file and policy review, the facility failed to develop and implement a policy to ensure screening of all employees upon hire, when the hiring policy and abuse reporting policy did not specify what steps staff should take to check and document criminal background checks of all new employees. These failures could place patients at risk for abuse if new employees backgrounds had not documented as being cleared correctly.

Findings:

On 2/7/13, a review of 4 Non Licensed Staff personal files ( Environmental Services Worker, Engineering/Environmental Services Manager, Dietary Manager and, Cook) did not indicate documentation of results of criminal background checks done upon hire.

During an interview on 2/7/13 at 11:55 a.m., the Human Resources Director stated that the reason that there was nothing documented about criminal background checks when Non Licensed Staff were hired was because if she didn't find any problems with a criminal background, that she didn't document anything except reference checks. The Human Resources Director stated that she did a public records search and checked several sexual offenders registries, as well as, did reference checks of past employment.

On 2/7/13, review of the "Employment Process" policy with an revised date of 7/29/04 and last reviewed 2012, indicated under hiring that there should be verification that all pre-employment requirements have been met, but did not indicate what the pre-employment requirements were or what steps were included to do a criminal background check.

On 2/7/13, review of the abuse policy provided by the facility titled "Abuse Reporting Requirements" revised 7/29/04, last reviewed in 2012, indicated reporting requirements, but did not indicate pre-employment screening or criminal backgrounds checks and the importance in the prevention of abuse.

On 2/7/13, Review of the Joint Commission's (nationally recognized hospital accreditation agency) on line publication of "Preventing violence in the health care setting" dated 6/3/10, indicated that the human resources department had a critical role in performing a thorough criminal background checks on all new hires as healthcare workers could provide a threat to the facility or harm residents, who were not able to identify the responsible person. The publication indicated that facilities can take actions to prevent assault, rape and homicide in the healthcare setting by working with the human resources department to assure it thoroughly prescreened job applicants and established and followed procedures for conducting background checks.