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Based on observation, interview of facility staff and clinical record review the facility failed to ensure that 1 of 12 patients ( Patient #31) undergoing a procedure involving anesthesia had a medical history and physical examination completed within the last 30 days.

Findings include:

Patient #31 was admitted to facility as an outpatient on 04/04/2011 with an admitting diagnosis of atrial fibrillation. Patient #31 was scheduled to undergo an elective cardioversion on 04/04/2011 at 12:45 PM in the cardiac catherization lab of the facility. The elective cardioversion procedure is done under general anesthesia in the holding area of the catherization lab.

An observation was made of Patient #31 in the holding area of the cardiac catherization unit on 04//4/2011 at 3:20 PM. The patient was noted to be post procedure, resting on a stretcher and attached to a cardiac monitor for the purpose of monitoring the heart rate and rhythm. Patient #31 has a registered nurse at stretcher side giving post procedure instructions for discharge to home.

During review of the clinical record of Patient #31 it was noted that the resident had an elective cardioversion under general anesthesia. The "pause for the cause" (surgical timeout to identify correct patient and procedure) was performed at 1302 and the procedure began at 1305. The procedure ended at 1319. Further review of the clinical record of Patient #31 revealed a history and physical done by the cardiologist (physician performing the procedure). The history and physical had a date of 02/03/2011. No history and physical notes were available at the time of the chart review dated within the last 30 days.

During an interview with the registered nurse (RN) on 04/04/2011 at 3:50 PM, he stated the following," We usually have the paper work available to us the day before and we can go through and check the dates. This patient did not have his paperwork until today and I must have missed the fact that the history and physical was not current."

On 04/05/2011 at 9:00 AM, the nursing supervisor provided a dictated history and physical dated 04/04/2011 at 3:31 PM for Patient #31.

Based on interview and record review the facility failed to ensure the medical records of 3 of 35 sampled patients were signed by the person responsible for providing or evaluating services. (Patients #12, #26 and #30).

The findings include:

1) Review of patient #30's medical record indicated that she was admitted for physical therapy evaluation and treatment on 2-9-11 with a diagnosis of right shoulder impingement. This patient's medical record also indicated that on 2-9-11, the physical therapist established a plan of care which included therapeutic exercises with strengthening of the right shoulder with emphasis on posture as a treatment plan. In an interview with the rehabilitation director on 4-4-11 at 1:45pm, she stated that patient #30's plan of care was established by the physical therapist on 2-9-11 and it did not have a physician signature attached to it. At this time, the rehabilitation director also stated that it is customary and procedural to receive a physician's signature for every patients' plan of care within 30 days from the evaluation.

2) Review of patient #12's medical record indicated that she was admitted to the hospital on 4-2-11 with a diagnosis of labor check. This patient's medical record also indicated that on 4-3-11 at 9:50pm, she received a post-operative pain management (POPM) referral for consultation and follow-up by an anesthesiologist. The POPM consultation dated on 4-3-11 indicated that the patient's best post-op pain management was with morphine 4mg and it did not include the anesthesiologist's or another physician's signature. In an interview with he charge nurse on 4-5-11 at 2:00pm, she stated that patient #12's POPM referral did not have a physician signature attached to it and that it is customary and procedural to receive a physician's signature for every patient's POPM referral within 24 hours from the consultation request.

3) Interview with patient #26 on 4/4/11 at approximately 11:35 AM disclosed that her appetite is poor due to radiation treatment for her cancer. She was asked if anyone talked to her about her poor appetite and she stated they did not. Review of the clinical record (hard copy and computerized) disclosed she was admitted on 3/20/11 with abdominal pain and neo branch lung cancer. The physician's orders revealed a nutritional consult ordered for patient #26 on 3/27/11. An attempt was made to review the dietitians note regarding the 3/27/11 consult in the computer system. Two nurses familiar with the system tried to locate the note and after approximately 10 minutes a dietitian was called to locate the note. After a total of 30 minutes the dietitian located the note in the computer system. She was asked how the physician was to locate the note if it took this team so long. She responded that if it was important it would have been written in the progress note.
The dietitians note did not address the patient's poor appetite and there was no evidence that she spoke to the patient.

4) Review of the clinical record on 4/4/11 for patient #26 disclosed two physician consultations in the clinical record. One was dated 3/21/11 and the other 3/23/11, neither were signed by the physician.

Based on observation, the hospital failed to ensure that food service equipment was kept clean and in good repair, personal hygiene including handwashing, hair restraints and eating was maintained, food was dated, temperatures were maintained and proper washing in the 3-compartment sink.

Findings include:

1. The 6 th floor pantry refrigerator was observed to have storage of patient foods including several containers of ice cream, numerous containers of foods from restaurants and the hospital. None of the containers had a date on them so that the facility would know how long they were stored. This was observed on 4/4/11 at approximately 11:30 AM.

2. The following was observed on the initial food service tour, including the tray line, on 4/6/11 beginning at 10:35 AM in the presence of the Director of Food and Nutrition Services (FSD):

a. A staff member was observed with a visor on and very long hair. She did not have any hair restraint.
Three male employees had either a beard and/or a moustache, none were wearing a beard or moustache restraint.
Throughout the kitchen at least five other staff members wearing a hair restraint were wearing them incorrectly. Either their bangs were left out or the back of the long hair was left out of the restraint.

b. Staff was observed taking temperatures of the lunch meal food items. The staff member inserted the thermometer into the food and then went to the handwashing sink where she turned on the water and rinsed the thermometer. The thermometer must be sanitized and each time she put her gloved hands on the faucet she potentially cross-contaminated the gloves and the thermometer.

c. A staff member was observed filling coffee mugs and Styrofoam cups with ice. Each time he picked up one of the mugs/cups he put his hands inside of the lip of the cup, potentially causing cross-contamination. This was observed for over 20 minutes.

d. Numerous plates used for the patients were either darkened/stained/or had loss of glaze. Once the integrity is lost they can no longer be cleaned or sanitized properly.

e. During the lunch meal at least five staff members had colored cloth gloves on covered by a disposable glove. The FSD was asked about the gloves and she was not sure how they were supplied, but the purpose was to protect the staff members hands from getting burned by hot dishes. One of the staff members explained that the gloves are purchased by petty cash and she buys them. They are given out to those staff members who want them and they keep them and launder them at home.
Continued observation of the staff showed that from time to time they would wash their hands after their gloves had become contaminated. They would remove the disposable gloves, then the colored cloth gloves, wash their hands properly and then with their clean hands pick up and don the potentially soiled gloves. After donning the potentially soiled gloves the new disposable gloves were potentially cross-contaminated.
In a discussion with the FSD regarding the reason the staff use the double gloves (heat of the plates), it was explained that there are products made so that staff do not injure themselves.

f. The lowerator (food service equipment that heats and houses plates) was observed to be broken. The lowerator is designed to raise the plates to the top via a spring as they are taken out, however, as the plates are removed they did not rise. The employee working the lowerator was asked if she ever burned herself lowering her arm down the machine and she replied "all the time".

g. Several staff members were observed washing their hands at the hand washing sink. After they washed their hands they held the paper towel up. Some went to the large garbage container, opened the lid and threw the paper towel away. Some staff put it on top of a cart and the paper towels were thrown out later. There were no garbage receptacles at any of the handwashing sinks.

h. Several staff members were wearing excessive jewelry. This included several rings and several bracelets. Jewelry can harbor bacteria and therefore minimal amounts should be worn.

i. Observation of the 3-compartment sink disclosed a staff member vigorously washing food service equipment. Most of the equipment was not put into the wash compartment and after scrubbed was put into the second compartment which is the rinse, however, there was no water in it. It was then put into the sanitizing compartment.

j. Over 15 handles leading to refrigerator (reach-ins) had a large accumulation of caked on food debris in the inner part of the handle that was not visible. When opening the doors a thickness could be felt on the handles, they were scraped and a large amount of black debris came off. This could potentially cross contaminate gloves or hands that come into contact with the handles.

k. Observation of the stoves and ovens disclosed old food debris, caked on food debris and liquids and overall soiled areas.

l. Rusted shelves were observed in the reach-in refrigerators.

m. At 12:15 PM three hotel pans (deep, half pans) were observed on a shelf without refrigeration or heat. The cook was in the area and was asked what the items were and when were they going to be used. Two of the pans contained chicken soup and the third gravy, he stated that they were intended for the dinner meal. He was asked several times why they were not under refrigeration, but did not answer. The temperatures were taken using a calibrated thermometer and they were 116 and 124 degrees Fahrenheit. Food must be maintained under 41 degrees Fahrenheit or over 135 degrees Fahrenheit.

n. A staff member was observed at the food preparation sink washing vegetables and cutting them up. She was observed eating candy while doing the preparation.

Based on observation and interview, the facility failed to ensure the physician director who is responsible for the the overall direction of respiratory services conducts a review of the care/services, safety and appropriateness.

Findings include:

Interview with the respiratory manager on 4/5/11 at 2:30 PM regarding the role of the director of respiratory who is a medical doctor disclosed that he oversees the department. The manager stated he is a "resource" for the department and does daily rounds. He was asked about the rounds and stated that he does rounds only on his patients and that he had an office in the medical plaza. The manager was asked for any reports the director has completed in the last 12 months, however, none was provided.

During an interview with quality performance and improvement on 4/6/11 at 9:35 AM they were asked for any documentation from the respiratory physician. There was no documentation available.

The hospital was asked to contact the physician for an interview, however, the physician was not available during the survey week by telephone or in person. it was stated that he was working on the east side of town and his office had been contacted.