HospitalInspections.org

Based on observation, facility documents and staff (EMP) interview, is was determined the facility failed to ensure acceptable supplies were available for immediate use in the nursing supply room.

Findings include:

Review on October 1, 2020, of facility policy "Outdated Drugs, Devices and Supplies," last reviewed March 26, 2020, revealed "Policy: Nursing staff will have a method of meeting the responsibility and achieving the goal of identifying and disposing outdated, visibly deteriorated, recalled, discontinued, or obsolete drugs and supplies. Procedure: 1. The supplies and drugs will be checked to include type, expiration date, condition, label and quality monthly. ... 3. Any drug or supply which is outdated, visibly deteriorated, recalled, discontinued, or obsolete will be disposed of according to policy. ..."

Tour on October 1, 2020, of the nursing supply room, revealed two Central Line dressing kits with an expiration date of July 25, 2020, four Normal Saline Solution 500 ml. bags with an expiration date of June 2020, three Normal Saline Solution 500 ml. bags with an expiration date of September 2020, six Hydrocellular foam dressings with an expiration date of June 2020 and 21 Sterile Bordered gauze packs with expiration dates of April 2020.

Interview with EMP3, on October 1, 2020, at 10:10 AM, confirmed the nursing supply room had two Central Line dressing kits with an expiration date of July 25, 2020, four Normal Saline Solution 500 ml. bag with an expiration date of June 2020 and three with an expiration dates of September 2020, six Hydrocellular foam dressings with an expiration date of June 2020 and 21 Sterile Bordered gauze packages with an expiration date of April 2020. EMP3 confirmed the outdated expiration dates on the noted items. EMP3 confirmed the room supplies are to be checked monthly.

Based on review of facility policies, facility documents and staff (EMP) interview, it was determined the facility failed to ensure monitoring of the refrigerator, freezer and dishwasher temperatures in the dietary department were completed; failed to ensure the proper temperature controls were maintained for the refrigerator, freezer and dishwasher in the dietary department; failed to document action taken for out of range temperatures; failed to ensure the manufacture's recommended temperature range for the hydrocollator was noted on the temperature log sheet, failed to ensure the hydrocollator temperatures were within the manufacture's recommended range and failed to document action taken for out of range hydrocollator temperatures.

Findings include:

1. Review of facility policy "Dietary Guidelines for Infection Control," last reviewed August 19, 2020, revealed "Introduction. Prevention of infection in a food service department requires ... property" (sic) "maintained equipment ... and ongoing awareness of proper sanitation and hygiene. Maintenance of sanitation standards is of paramount importance in a health care facility. Responsibilities A. Food service Director 1. Evaluate ... food-handling practices. 2. Provide safe food service for patients and employees. 3. Ensure proper maintenance an" (sic) " operation of equipment. 5. Keep adequate records in regard to temperature and maintenance of refrigeration. ... Infection Control Practices ... C. Food Products and Storage ... 6. Fruits, vegetables, dairy products, meat, and poultry must be stored at temperatures between 33-45 degrees F " [Fahrenheit] " Fish and shellfish, ice cream, and frozen foods must be stored between 0- 10 degrees F. ... E. Equipment ... 5. Dishwashers c. The dishwasher final sanitizing rinse of at least 180 degree F and wash water of 150 degree or more. ... Controls on the system D. Records of proper temperature for refrigeration and freezing should be kept by dietary department ..."

Review of facility policy "Refrigerator and Freezer Temperatures," last reviewed by the facility August 19, 2020, revealed "Policy: It is the policy of the Bucktail Medical Center to ensure the proper storage of food by accurately monitoring the temperatures of all Refrigerators and Freezers utilized for patients ... Procedure: Dietary Staff 1. Acceptable temperatures for the safe and proper storage of food in a freezer unit is 0" (degrees) "F or below. 2. Acceptable temperatures for the safe and proper storage of food in a refrigerator unit is 41" (degrees) "F or below. ... 4. Temperatures of refrigerators and freezers utilized for the storage of residents/patient foods will be monitored and recorded on a Temperature Log Sheet twice daily. 5. Should temperatures be above normal, maintenance personal" (sic) "are to be notified and a work requisition issued. ..."

Review on September 30, 2020, at 11:45 AM of the refrigerator log form revealed documentation to monitor the temperature in AM and PM.

Review on September 30, 2020, at 11:45 AM of refrigerator temperature logs for July, August and September 2020 revealed missing documentation of monitoring on Refrigerator #1: July 1 (AM and PM), July 2 (AM and PM), July 3 (AM and PM), July 4 (AM and PM), July 5 (AM and PM), July 6 (AM and PM), July 7 (AM), August 17 (AM), September 16 (AM) and September 25 (AM).

Review on September 30, 2020, at 11:45 AM of refrigerator temperature logs for July, August and September 2020 revealed missing documentation of temperature monitoring on Refrigerator #2: July 1 (AM and PM), July 2 (AM and PM), July 3 (AM and PM), July 4 (AM and PM), July 5 (AM and PM), July 7 (AM), July 25 (PM), August 24 (AM), August 28 (AM and PM), August 31 (PM), September 1 (PM), September 2 (AM and PM), September 3 (PM), September 4 (PM), September 5 (PM), September 6 (PM) and September 29 (PM).

Further review of refrigerator temperature logs for July, August and September 2020 revealed out of range temperatures on the following dates without documentation of corrective action taken on Refrigerator #2: July 6 (PM) 42 F, July 7 (PM) 42 F, July 16 (PM) 45 F, July 17 (PM) 42 F, July 21 (PM) 42 F, July 23 (PM) 42 F, July 24 (PM) 42 F, July 26 (PM) 43 F, July 27 (PM) 44 F, July 28 (PM) 44 F, July 29 (PM) 44 F, July 30 (PM) 42 F, July 31 (PM) 42 F, August 1 (PM) 42 F, August 2 (PM) 44 F, August 3 (PM) 44 F, August 4 (AM) 46 F, August 4 (PM) 44 F, August 5 (PM) 46 F, August 6 (PM) 42 F, August 10 (PM) 44 F, August 11 (PM) 48 F, August 12 (PM) 48 F, August 13 (PM) 46 F, August 14 (PM) 45 F, August 17 (PM) 44 F, August 18 (PM) 42 F, August 19 (PM) 44 F, August 20 (PM) 44 F, August 21 (PM) 42 F, August 22 (PM) 42 F, August 23 (PM) 42 F, August 24 (PM) 42 F, August 25 (PM) 42 F, August 26 (PM) 44 F, August 27 (PM) 44 F, August 29 (PM) 42 F, August 30 (PM) 44 F, September 3 (AM) 46 F, September 4 (AM) 46 F, September 7 (PM) 42 F, September 10 (PM) 44 F, September 11 (PM) 45 F, September 12 (PM) 42 F, September 14 (PM) 44 F, September 15 (PM) 42 F, September 17 (AM) 42 F, September 17 (PM) 48 F, September 18 (PM) 48 F, September 21 (PM) 48 F, September 25 (PM) 45 F, September 26 (PM) 45 F, September 27 (PM) 44 F, September 28 (PM) 48 F.

Review on September 30, 2020, at 11:45 AM of freezer temperature logs for July, August and September 2020 revealed missing documentation of temperature monitoring on Freezer #1: July 1 (AM and PM), July 2 (AM and PM), July 3 (AM and PM), July 4 (AM and PM), July 5 (AM and PM), July 6 (AM and PM), July 7 (AM), August 17 (AM), August 24 (AM), August 28 (AM), September 16 (AM), September 25 (AM), September 30 (PM).

Review on September 30, 2020, at 11:45 AM of freezer temperature logs for July, August and September 2020 revealed missing documentation of temperature monitoring on Freezer #2: July 1 (AM and PM), July 2 (AM and PM), July 3 (AM and PM), July 4 (AM and PM), July 5 (AM and PM), July 6 (AM and PM), July 7 (AM and PM), August 9 (PM), August 10 (AM), August 14 (PM), September 1 (PM), September 2 (PM), September 3 (PM), September 4 (PM), September 5 (PM), September 6 (PM), September 16 (AM), September 24 (AM), and September 25 (AM).

Further review of freezer temperature logs for July, August and September 2020 revealed out of range temperatures on the following dates without documentation of corrective action taken on Freezer #1: July 18 (PM) 18 F, July 9 (AM) 2 F, July 9 (PM) 30 F, July 10 (AM) 7 F and July 10 (PM) 22 F.

Review of the "dish machine temp" log form revealed documentation to monitor the wash and rinse temperatures for breakfast, lunch and supper. The form lacked the temperature range the wash and rinse cycles should meet.

Review of the dishwasher temperature logs revealed missing documentation of monitoring for July 2020: July 1 (breakfast, lunch and supper), July 2 (breakfast, lunch and supper), July 3 (breakfast, lunch and supper), July 5 (breakfast and lunch), July 6 (breakfast and lunch), July 8 (breakfast and supper), July 10 (breakfast and lunch), July 11 (lunch and supper), July 12 (lunch and supper), July 15 (lunch), July 16 (breakfast), July 18 (supper), July 19 (supper), July 23 (breakfast), July 26 (supper), July 27 (breakfast), July 28 (lunch), July 29 (lunch), July 30 (supper) and July 31 (lunch); missing documentation of monitoring for August 2020: August 1 (breakfast), August 2 (lunch and supper) and August 7 (lunch); missing documentation of monitoring for 14 of 30 days in September 2020: September 3 (lunch), September 6 (breakfast and lunch), September 7 (breakfast), September 8 (breakfast, lunch and supper), September 10 (breakfast), September 11 (lunch), September 12 (supper), September 13 (supper), September 15 (lunch), September 20 (lunch), September 21 (lunch), September 26 (lunch and supper), September 27 (supper), and September 29 (lunch).

Interview with EMP4 on September 30, 2020, at 11:55 AM confirmed the missing documentation and out of range temperatures. Further interview with EMP4 confirmed there was no staff re-education completed for the missed documentation and out of range temperatures. Further interview with EMP4 confirmed there were no ranges listed on the form for adequate temperatures of the dishwasher wash and rinse cycles and EMP4 was unaware of the appropriate temperatures required.

2. Review on September 30, 2020, of the Occupational Therapy contract service policy, "Hydrocollator Packs - Moist Heat," dated January 2015, revealed "Policy: Hydrocollator Pack - Moist Heat may be used as indicated per physician order for treatment of musculoskeletal symptoms. The hydrocollator unit is maintained to ensure proper performance. Procedure: ... 2. Ensure hydrocollator packs are heated to the appropriate temperature as per manual and ready for use. This checking of the temperature shall be separate and in addition to the daily checking of the temperature. ... 18 Maintenance: a. Refer to the Hydrocollator Heating Units User Manual from the {name} for safety and maintenance procedures. ... 160 degrees-165 degrees per manual."

Review on September 30, 2020, of the "Hydrocollator Heating Units" manufacturer's pamphlet, revealed "... Technical Specifications SS-2 ... Temperature Range ... (160 degrees F [Fahrenheit] - 165 degrees F) ..."

Tour on September 30, 2020, of the facility Occupational Therapy (OT) unit, revealed the hydrocollator temperature log without documentation of the manufacturer's recommended temperature range.

Interview with EMP2 on October 1, 2020, at 1:30 PM, confirmed the OT hydrocollator unit temperature log has no documentation of the manufacturer ' s recommended temperature range.

Review of the OT hydrocollator temperature log revealed the hydrocollator temperature was out of the recommended range all but one day from April 17, 2020 through September 30, 2020.

Review of the OT hydrocollator temperature log revealed no documentation of action taken when the temperature was out of range.

Interview with EMP1, on September 30, 2020, at 1:15 PM, revealed the OT hydrocollator unit was new on April 16, 2020. EMP1 confirmed the hydrocollator unit's temperature was out of range per the manufacture's recommendation on all but one day from April 17, 2020 through September 29, 2020. EMP1 confirmed there was no documentation of what was done when the temperature was out of range.

Review on October 1, 2020, of facility Physical Therapy (PT) contract service policy, "Hydrocollator Packs - Moist Heat," dated January 2015, revealed "Policy: Hydrocollator Pack - Moist Heat may be used as indicated perm physician order for treatment of musculoskeletal symptoms. The hydrocollator unit is maintained to ensure proper treatment. Procedure: ... 2. Ensure hydrocollator packs are heated in the appropriate temperature as per manual and ready for use. This checking of the temperature shall be separate and in addition to the daily checking of the temperature. ... 18 Maintenance: a. Refer to the Hydrocollator Heating Units User Manual from the {name} for safety and maintenance procedures. "

Review on October 1, 2020, of Physical Therapy (PT) " Thermal Agents: Cold and Heat " manufacturer's pamphlet, revealed " HOT PACKS ... They are stored in hot water kept at about 70 degrees to 75 degrees C (158 degrees to 167 degrees F) inside a purpose-designed, thermo-statically controlled water cabinet ... that stays on at all times. ... "

Review on October 1, 2020, of PT hydrocollator unit temperature log for April 1, 2020-September 30, 2020, revealed no documentation of what the manufacturer temperature range on the log for April 1, 2020- September 30, 2020.

Interview with EMP2 on October 1, 2020, at 1:30 PM, confirmed the PT hydrocollator unit temperature log for April 1, 2020-September 30, 2020 has no documentation of the manufacturer temperature range noted on the log sheet.

Based on observational tour, review of facility policy and staff (EMP) interview, it was determined the facility failed to follow manufacturer's instructions for proper storage and use of a multidose vial of Novalog insulin.

Findings include:

Review of facility policy "Ampules and Multi-dose Vials," last reviewed by the facility on March 26, 2020, revealed "Procedure: Nursing staff will follow the manufacturer's recommnedations or the provider pharmacy's directions for storage, use, and disposal. ... 2. The date opened and the initials of the first person to use a multi-dose vial are recorded on the vial. The solution in multi-dose vials is inspected prior to each use for unusual cloudiness, precipitation, or foreign bodies. The rubber stopper is inspected for deterioration. Medication may be used until the manufacturer's expiration date or discarded according to the recommendations of the contract pharmacy. 4. If a multi-dose vial shows visible evidence of precipitation or contamination prior to the manufacturer's expiration date or the thirty day expiration date, its use is discontinued immediately."

Review on September 30, 2020, of the manufacturer's instructions for use for Novolog revealed "once punctured (in use), vials may be stored under refrigeration or at room temperature [less than] 30 C" [Celsius] "(86 F)" [Fahrenheit] "use within 28 days..."

Observational tour in the emergency department medication room with EMP3 on September 29, 2020, at 3:05 PM revealed a multi-dose vial of Novolog insulin that was opened, the stopper previously punctured and dated January 28, 2020.

Interview with EMP3 on September 29, 2020, at 3:05 PM confirmed the date opened on the Novolog insulin and stated the multidose vials should be discarded after 28 days once opened.