HospitalInspections.org

Based on clinical record review, staff interview, and review of policy and procedures it was determined that the facility failed to follow the policy for medication administration for 2 (#1, #2) of 30 patients sampled. This practice does not ensure safe and effective medication therapy.

Findings include:

Review of the facility's policy "Medications: Ordering, Processing, Dispensing and Administration" last reviewed 12/10, stated Medications shall be dispensed and/or administered only upon the orders of an individual who is legally entitled to order medication and/or who has been assigned clinical privileges. All orders must be complete and include Drug, Dose, Route, and Frequency. Clarification of medication orders is the responsibility of the pharmacist reviewing the order. Page 2 or 5 section Order Processing: revealed "the pharmacist will clarify medication orders written by the physician directly with the physician. If additional clarification is required, the pharmacist will contact the ordering physician. Once order has been clarified, the pharmacist will contact the nurse to update them on the new order. The pharmacist will transcribe the order onto a physician order form and place on chart or send to appropriate nursing unit."

1. Patient #1's clinical record revealed a physician order dated 9/14/11 at 12:00 p.m. for a Cardene drip. The order was an incomplete. The physician's order did not include dose, route and frequency. The order was scanned at 12:15 p.m. and noted by nursing.

Review of patient #1's Medication Administration Record (MAR) revealed an order for Nicardipine (Cardene) 25 milligrams (mg) in Normal Saline. It indicated to begin the 250 milliliter (ml) bag at 5 ml per hour. The medication was administered on 9/15/11 at 2:29 a.m. as a continuous infusion with the nurse titrating the medication. There was no evidence the nurse called the pharmacy or physician to clarify the medication order before beginning the medication infusion.

An interview with the Unit Manager of the Critical Care Unit (CCU) during the chart review on 9/15/11 at approximately 3:00 p.m. confirmed the findings.

On 9/15/11 at approximately 4:30 p.m. an interview with Director of Pharmacy revealed the pharmacist had filled the incomplete physician's order for Cardene gtt, without clarifying the order with the physician before. profiling the medication into the system.

2. Patient #2's physician orders revealed a verbal order from a Physician Assistant (PA), dated 9/14/11 at 12:26 p.m., for Cardene drip, titrate to keep systolic blood pressure less than 160 was an incomplete order. The order was received by a nurse who indicated the order has been read back to the PA. The physician's order did not include dose, route and frequency. The order was scanned 9/14/11 at 14:12 p.m. and noted by the nurse. The nurse did not call the pharmacy or physician to clarify the medication order before beginning the medication infusion.

Review of patient #2's MAR revealed Nicardipine 25 mg in Normal Saline intravenous at a rate to titrate the Systolic Blood Pressure (SBP). The medication was administered on 9/14/11 at 1:00 p.m. as a continuous infusion with nurse titrating medication. The nurse did not call the pharmacy or physician to clarify the medication order before beginning the medication infusion.

An interview with Unit Manager of CCU during chart review on 9/16/11 at approximately 1:00 p.m. confirmed the findings.

9/16/11 at approximately 2:30 p.m. an interview with Director of Pharmacy revealed the pharmacist had filled the incomplete physician's order without clarifying the order with the physician.

Based on record reviews and staff interview, the facility failed to ensure that 6 of 30 (#7, #8, #10, #14, #18, #19) sampled patients' nutritional needs were met in accordance with recognized dietary practices/ The patients were not screened for potential nutritional risks upon admission. These patients would have a referral for a nutritional consult by a hospital dietitian, which could result in unmet nutritional needs.

Findings Include:

1. Patient #10 was admitted on 09/12/11 with obstructive uropathy and had a percutaneous transhepatic cholangiogram with stent placement. The hybrid electronic medical record (EMR) and the admission database were completed 9/12/11. The nutritional risk factors section of the nutritional screen in the admission data base was not complete. The instructions on the nutritional risk factors section in the EMR stated that " If the patient answers "No" for all questions in the nutritional risk factors grid, please click on the "No" in the "No" column. The action will provide a "No" response for every question in the grid." The grid lacked any "yes" or "no" responses and was blank. This patient might have triggered a nutritional consult, because the patient met the nutritional risk criteria for a geriatric surgical patient, but no referral was made.

2. Patient #14 was admitted on 9/09/11 with acute renal failure after presenting to the emergency room with nausea and diarrhea. The hybrid electronic medical record (EMR) and the admission database was completed 9/09/11. The nutritional risk factors section of the nutritional screen in the admission data base was not complete. The instructions on the nutritional risk factors section in the EMR stated that "If the patient answers "No" for all questions in the nutritional risk factors grid, please click on the "No" in the "No" column. The action will provide a "No" response for every question in the grid." The grid lacked any "yes" or "no" responses and was blank. The patient might have triggered a nutritional consult because the patient met the nutritional risk criteria for nausea, vomiting and diarrhea but no referral was made.

3. Patient #7 was admitted on 9/07/11 with persistent hypoglycemia and a history of an eating disorder. The hybrid EMR and the admission database were completed 9/07/11. The nutritional risk factors section of the nutritional screen in the admission data base was not completed. The instructions on the nutritional risk factors section in the EMR stated that "If the patient answers "No" for all questions in the nutritional risk factors grid, please click on the "No" in the "No" column. The action will provide a "No" response for every question in the grid. " The grid lacked any " yes " or "no" responses and was blank. This patient might have triggered a nutritional consult because the patient met the nutritional risk criteria for an eating disorder, but no referral was made. A nutrition consult was ordered on 09/09/11.

4. Patient #8 was admitted on 9/12/11 with hypertension and atrial fibrillation. The EMR and the admission database was completed on 9/12/11. The nutritional risk factors section of the nutritional screen in the admission data base was not completed. The instructions on the nutritional risk factors section in the EMR stated that "If the patient answers "No" for all questions in the nutritional risk factors grid, please click on the " No" in the " No" column. The action will provide a "No" response for every question in the grid." The grid lacked any " yes " or "no" responses and was blank.

5. Patient #18 was admitted on 9/3/11 with generalized weakness and Hypotension. The admission assessment was conducted at 2:59 a.m. by the Registered Nurse. The nutrition section of the assessment contained information at the time of admission of; Home diet (Regular); Feeding ability (Complete independence); and Appears significantly emaciated (No). The entire Nutritional Risk Factors were not documented as assessed.

6. Patient #19 was admitted on 9/5/11 with acute ischemic stroke and respiratory failure. The admission assessment was conducted at 10:21 a.m. on 9/5/11 by the Registered Nurse. The nutrition section of the assessment stated that the patient was independent for feeding (prior to admission). There were no complete assessments for other risks.

7. On 9/16/11 at 5:00 p.m. the hospital nursing director was interviewed about the admission database and the findings of the 6 record reviews that the nutritional risk factors section was not completed by the admitting nurse. The nursing director indicated that this section should have been completed with a yes or no response.

Review of the hospital policy and procedure titled, "Documentation: Admission Database" , sponsored by the Clinical Standards Committee, original issue date or 09/23/09 indicated that for the nutritional screen,"review criteria and complete screen as appropriate". Review of the hospital policy and procedure titled, " Nutritional Documentation in the Electronic Medical Record", sponsored by the Clinical Standards Committee, original issue date or 09/21/09 indicated under Procedures: "An initial nutritional assessment is done on admission. This is completed by nursing using the Admission Database Power Form in the Nutritional Screen Section". "This assessment includes a) home diet, food and beverage preferences; b) feeding ability; c) Nutritional Screen factors; and d) weight and body perception information.

Based on observation and interview, the physical plant of the dietary department was not maintained in a sanitary manner. This practice does not help to prevent infections.

Findings include:

1. On 09/16/11 at 9:55 a.m. the second and final day of the survey, the kitchen was toured with the Food Service Manager (FSM) and the Food Service Manager from the sister facility.

In the dishwashing area, the floor between the soiled tray return conveyor equipment and the dish machine had a large puddle of water. The floor was not properly graded and there was a capped floor drain near the water puddle. The source of the water could not be determined. The wall around the soiled tray return conveyor equipment had areas of black mold-like substance above, underneath the equipment, and on the equipment itself. There were spots of black mold-like substance on the ceiling above. There was high humidity in this area. The facility FSM said the soiled tray return was no longer in use.

2. During the exit at 5:50 p.m., it was discussed whether there were internal sanitation audits or quality control measures to identify food sanitation issues, particularly since they have a high risk food production that serves a highly susceptible population. There were none that the hospital administration and nursing administration were aware of. After the exit at about 6:00 p.m., the nursing director stated that she had contacted the food service director by telephone. The nursing director stated that the food service director indicted that the quarterly inspections by the local county health department were their quality control measures, which were not internal measures. Additionally, the quarterly inspections by the local county health department were not addressed in the hospital-wide infection control and Quality Assurance and Performance Improvement programs.

Based on observation, staff interview, and record review, the hospital failed to maintain the dish machine in a safe and quality manner to ensure that the hospital's multi-use eating-ware, food preparation equipment and utensils were properly sanitized for the hospital patients, employees, cafeteria patrons, and as well as the patients for a 30-bed long term acute care hospital located on the premises.

Findings:

1. The hospital dish washing machine was not working properly to ensure dishes were properly washed and sanitized in that a hot water pressure-measuring device was not available.

On 09/16/11 at 10:15 a.m. the second and final day of the survey, the hospital kitchen was toured with the facility Food Service Manager (FSM) and the Food Service Manager from the sister facility. The Champion conveyor multi-tank dish machine was in operation. This dish machine used hot water for sanitization. The dish washing temperatures were observed and found to be above the minimum temperatures indicated by the data plate on the dish machine for the wash and rinse temperatures. There was no hot water pressure gauge observed on the dish machine. There were several empty round holes observed on the machine near the temperature gauges. The dish machine data plate indicated the minimum hot water pressure was 20 PSI. Both FSMs asked why this machine did not have a pressure gauge and neither one of them could provide an answer.

2. At 12:55 p.m., the FSM from the sister facility stated that he called the dish machine manufacturer and they said that the hot water pressure gauge should have been located near the temperature gauges on the dish machine. The dish machine was examined and there was no hot water pressure gauge seen on the machine.

3. At 4:45 p.m. an interview was conducted with the two FSMs, the hospital administrative registered dietitian, the hospital nursing director and the hospital risk manager. The sister facility FSM stated that the dish machine hot water pressure gauge was missing and that they had a service technician install a new one. They were asked how long was this pressure gauge missing and no response was given. The same FSM stated he looked at a slot where the pressure gauge should have been located and it appeared to have fallen out of the slot.

A copy of the written documentation about the pressure gauge installation was requested. Additionally, the group was asked for documentation for any internal sanitation audits or quality control measures to identify food safety and sanitation issues. A copy of the work order for the dish machine was provided dated 09/16/11(the first day of survey). The work order stated under service work performed "Checked over machine and found that there was no pressure gauge to measure the cycle's pressure". "Replaced pressure gauge and found that the water pressure regulator was set too high." "Adjusted regulator to proper pressure and machine is running good at this time" (excessive hot water flow pressure will tend to atomize the water droplets needed to convey heat into a vapor mist that cools before reaching the surfaces to be sanitized).

4. During the exit at 5:50 p.m., it was discussed whether there were internal sanitation audits or quality control measures to identify food safety and sanitation issues, particularly since they have a high risk food production that serves a highly susceptible population. There were none that the hospital administration and nursing administration were aware of. After the exit at about 6:00 p.m., the nursing director stated that she had contacted the food service director by telephone. The nursing director stated that the food service director indicted that the quarterly inspections by the local county health department were their quality control measures, which were not internal measures. Additionally, the quarterly inspections by the local county health department were not addressed in the hospital-wide Infection Control and Quality Assurance and Performance Improvement programs.

Based on observation, staff interview, and record review, the hospital's infection control program did not provide a sanitary kitchen environment and proper food handling practices to prevent potential foodborne illness. The hospital used a "cook-chill" food production method to provide meals for the hospital's patients, as well as the patients for a 30-bed long term acute care hospital located on the premises. The cook-chill food production is considered higher risk food process. Additionally, the hospital did not have any internal quality control measures in place to identify unsanitary kitchen conditions and unsafe food handling practices as part of their hospital-wide infection control program. The hospital also failed to store patient care supplies in a sanitary manner to prevent contamination and spread of infection.

Findings include:

The hospital dish washing machine was not properly maintained to ensure dishes were properly washed and sanitized in that a hot water pressure-measuring device was missing and the Food and Nutrition Services managers did not ensure that the proper wash temperature was being monitored.


1. On 09/16/11 at 9:55 a.m. the second and final day of the survey, the hospital kitchen was toured with the facility's Food Service Manager (FSM) and the Food Service Manager from a sister facility. In the dishwashing area, there were at least 7 beige plastic trays with cracked and chipped corners observed stored on a metal 3 tiered shelf that was soiled with liquid food spills.
The floor between the soiled tray return conveyor equipment and the dish machine had a large puddle of water. The floor was not properly graded and there was a capped floor drain near the water puddle. The source of the water could not be determined. The wall around the soiled tray return conveyor equipment had areas of black mold-like substance above, underneath the equipment, and on the equipment itself. There were spots of black mold-like substance on the ceiling above. There was high humidity in this area. The facility's FSM said the soiled tray return was no longer in use.

At 10:15 a.m., the Champion conveyor multi-tank dish machine was in operation. This dish machine used hot water for sanitization. The dishwashing temperatures were observed and found to be above the minimum temperatures indicated by the data plate on the dish machine for the wash and rinse temperatures. The temperature log for September 2011 stated that the minimum wash temperature was 140 ?F and there were multiple wash temperatures between 140 ?F and 150 ?F recorded three times daily on the log. The final rinse temperatures indicated on the temperature log were 180?F and above. The FSM was asked why there was a discrepancy between temperature log minimum temperature and the dish machine data plate. She could not answer.

There was no hot water pressure gauge observed on the dish machine. There were several empty round holes observed on the machine near the temperature gauges. The dish machine data plate indicated the minimum hot water pressure was 20 PSI. Both FSMs were asked why this machine did not have a pressure gauge and neither one of them could provide an answer.

There were several rimmed yellow plastic trays on the dish machine conveyor that were stained brown on the bottom interior surface of the tray and many had cracked rim corners exposing the interior metal frame.

The interior of the tray carts were observed. There was old brownish food crumbs and burnt grease buildup around the heating plates on the interior of at least 5 tray carts.

2. Linens were not properly stored in that bundled terry cloth rags were stored on the floor of the reach-in refrigerators that were not in operation. These were used as wiping cloths.

3. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and shall be cleaned at a frequency necessary to preclude accumulation of soil residues. There were old brownish-colored food spillage and food crumbs observed on the walls along the windows of the large walk-in refrigerator used to store meal carts.

4. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Silver-colored paint was chipped off the tabletop Hobart mixer. The metal on the mixer was rusted where paint was chipped off. The sprayer head at the 2 compartment prep sink had old dried brownish-colored food residue in the crevices.

5. Equipment food-contact surfaces were not clean to sight and touch. The white cutting board used for the sandwich station had black and brown colored stains on the surface that could not be removed from washing.

6. A hand-washing sink was used for purposes other than hand washing and a sink used for food preparation was provided with the hand washing aids and devices required for a hand-washing sink. The 2-compartment preparation sink located in the cold food preparation area had a sign designating a hand washing station on the right sink compartment. The sink was equipped with soap and paper towels. Employees were observed washing their hands in this sink.

7. Garbage cans in the kitchen that contained food residue and were not in continuous use were not kept covered.
Garbage can in the cold prep area was not in use and had no lids. Garbage cans throughout the kitchen were not covered and no lids were observed near the receptacles.

8. Food contact surfaces were not properly sanitized to prevent cross-contamination; potentially hazardous food was not held at 41 ?F or below; and food thermometer was not calibrated to ensure accuracy.
At 10:30 a.m., the facility's FSM was asked to take some temperatures of the sandwich items that were held cold in the sandwich station. She went to get a bimetallic thermometer. She was about to insert the probe in the food, when she was stopped and asked her if she had sanitized the thermometer probe. She said she had to go to the office to get alcohol wipes. She returned a few minutes later with the alcohol wipes and sanitized the probe. She took the temperature of the sliced ham. It was 50 ?F. The ambient temperature in the refrigeration unit was 34 ?F. She took the temperature of the sliced ham again and it was 48 ?F. The FSM was asked when these sandwich items were put in this sandwich station and she said yesterday afternoon. She checked the tuna salad on the sandwich station and it was 32 ?F. She was asked if there were any temperatures monitored or recorded and she said no.

She was asked to check the calibration of her thermometer. She was asked what temperature she looked for on her thermometer when she calibrated and she said 32 ?F or below. She calibrated her thermometer by ice point method and it was 28 ?F. The recipes were reviewed for the lunch food items. The recipe contained information about holding the food at 40?F, but there was a lack of instructions for other critical control points for food safety such as cooling and reheating.

9. Food employees did not wear hair restraints that were designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

A female employee was observed walking through the kitchen wearing a baseball cap with a long braided ponytail hanging out.

10. At 10:40 a.m., a sanitizer with bleach water was observed sitting on the table counter corner next to a prep sink in which frozen chicken pieces were being thawed under cold running water. The frozen chicken pieces were not completely submerged under the water for proper thawing.

11. Cold food holding temperatures were not monitored for the cook-chill food process, considered a high-risk food process. Thermometer probes, which are a food contact surface, were cross-contaminated and the food employees were not knowledgeable that cold foods must be held at 41 ?F or below. Thermometers were not inserted correctly to ensure an accurate temperature.

At 10:50 a.m., the cook-chill production lunch tray assembly had begun. The cook plating the entrees was asked if any holding temperatures were taken and she said no. She got out her thermometer and began taking temperatures. During this process, the cook used a terry cloth rag and wiped the thermometer probe after she took it out of the macaroni and cheese. The cook was stopped before inserting the probe into another food and FSM was notified. The cook taking the holding temperatures was asked what the minimum temperature she looks for cold holding was and she replied " between 40-45 ?F. The food items on the tray line were at 40 ?F. The tray line supervisor was observed taking the temperature of the salmon slices. She inserted the bimetallic thermometer probe so that it did not completely penetrate the salmon to achieve an accurate temperature. She then used a terry cloth rag to wipe a thermometer probe and put it back in a sheath.

12. A food employees failed to clean her hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles.
The employee working the beginning of the line was wiping the interior of the tray carts with a terry cloth rag. She was wearing gloves. She put the rag down and began touching clean meal trays. She was told she should change her gloves. She removed her soiled gloves and took clean gloves out of the glove carton and was about to put them on. She was told she must wash her hands before donning clean gloves. She proceeded to wipe the rest of the carts first and went to wash her hands at the hand sink located across the sink.

13. Equipment food-contact surfaces were not clean to sight and touch.
At 11:30 a.m., there was a slight mineral deposit build up on the interior lid to the ice storage bin. The ice scoop was stored in a blue ice scoop holder that had an accumulation of soil particles in the bottom. The ice scoop holder was permanently affixed to the side of the ice machine so that it could not be regularly removed for cleaning. The manual can opener in the cook's preparation area had blackish food material around the blade and gear. Six sheet pans had food residue and burnt grease and carbon build up on the interior and exterior surfaces. These sheet pans were stored on a suspension cart and had packages of frozen soup and vegetables thawing on them (potentially hazardous food not properly thawed).

14. Sanitizer chemical test kits were not readily available to periodically check the concentration of the sanitizer solution in sanitizer buckets.
The FSM asked if she had sanitizer strips available to measure the concentration of the sanitizers used in the kitchen. She said they were kept in the office. She went out of the kitchen to retrieve these and returned with chlorine and quaternary ammonium sanitizer strips. She was asked to check the chlorine sanitizer in the sanitizer bucket placed on the shelf underneath the cooks table where the frozen chicken pieces were thawed. The sanitizing strip appeared to turn black rather than dark purple. It indicated that it was above the upper safety limit of 200 parts per million which is toxic.

15. At 12:55 p.m., sister facility's FSM stated that he called the dish machine manufacturer and they said that the hot water pressure gauge should have been located near the temperature gauges on the dish machine. The dish machine was examined and there was no hot water pressure gauge seen on the machine. The sister facility FSM used a heat sensitive strip to check the hot water sanitizing temperature of 180 ?F. The heat sensitive strips were designed to measure 180 ?F minimum temperature. He ran these strips through the machine 3 times and they did not change color from blue to orange. These heat sensitive strips were designed to measure 180 ?F minimum temperature rather than 160 ?F minimum temperature of the hot water on the dish surface.

16. At 1:05 p.m., a food employee was observed taking the reheating temperatures of a tray after it was re-thermalized. The soup was initially 140 ?F, but this was when she inserted the probe through the plastic lid. After she removed the lid and took the temperature again, the temperature was 166 ?F. This employee was asked what the minimum re-thermalization temperature she was looking for and she stated 160-180 ?F, rather than minimum of 165 ?F, which is a critical control point in food safety.
The FSM was asked what the minimum re-thermalization temperature should be and she stated 140 ?F. The temperature log reviewed included instructions to take the temperature of 2 trays per unit and the actual temperatures recorded on the September 2011 log indicated only one tray per unit were recorded. They served trays to 4 units and the long term acute care hospital on the premises
The FSM was observed touching her hair near her forehead that was not covered by her hair cap.

17. At 4:45 p.m., an interview was conducted with the FSMs, hospital administrative registered dietitian, the hospital nursing director and the hospital risk manager. The sister facility's FSM stated that the dish machine hot water pressure gauge was missing and that they had a service tech install a new one. They were asked how long was this pressure gauge missing and no response was given. The same FSM stated he looked at a slot where the pressure gauge should have been located and it appeared to have fallen out of the slot.
A copy of the written documentation about the pressure gauge installation was requested. Additionally, the group was asked documentation for any internal sanitation audits or quality control measures to identify food safety and sanitation issues. A copy of the work order for the dish machine was provided, dated 09/16/11, the last day of survey. The work order stated under service work performed "Checked over machine and found that there was no pressure gauge to measure the cycle's pressure". "Replaced pressure gauge and found that the water pressure regulator was set too high." "Adjusted regulator to proper pressure and machine is running good at this time". (excessive hot water flow pressure will tend to atomize the water droplets needed to convey heat into a vapor mist that cools before reaching the surfaces to be sanitized).

18. Review of the hospital policy and procedure titled, "Infection Prevention and Control, Food & Nutrition Services", effective date or 12/20/10, supersedes: 12/20/09 by Food & Nutrition Services included the following excerpts:
? "Food Protection: Potentially hazardous foods that have been cooked and quick chilled are reheated rapidly to 165 ?F to higher throughout. Temperatures are recorded daily on a login the cafeteria and during patient meal service. If temperatures are unacceptable, appropriate action is taken to bring temperatures up to standard and actions are documented."
? "Environmental Practices, Dishwashing - Machine: Temperatures: Wash 140?F, pumped rinse: 160 ?F, final rinse 180 ?F. Water pressure: final rinse 15-25 lbs. per square inch (PSI)."
? "Environmental Practices, Equipment and Utensil Storage: Any chipped or cracked [equipment and utensils] are discarded."
? "Environmental Practices, Food Service Equipment and Cleaning: Tray delivery carts - Meal service carts are cleaned thoroughly after each meal and/or at the end of the day. Dirty tray return carts are cleaned and sanitized when returned to the kitchen".
? "Environmental Practices, Food Service Equipment and Cleaning: Thermometers shall be calibrated daily. The stem of each thermometer shall be sanitized prior to use and between food items."

19. During the exit at 5:50 p.m., it was discussed whether there were internal sanitation audits or quality control measures to identify food safety and sanitation issues, particularly since they have a high risk food production that serves a highly susceptible population There were none that the hospital administration and nursing administration were aware of. After the exit at about 6:00 p.m., the nursing director stated that she had contacted the food service director by telephone. The nursing director stated that the food service director indicted that the quarterly inspections by the local county health department were their quality control measures, which were not internal measures. Additionally, the quarterly inspections by the local county health department were not addressed in the hospital-wide Infection Control and Quality Assurance and Performance Improvement programs.

20. On 09/16/11 at 1:20 p.m., there were 2 disposable blood pressure cuffs stuffed into the handrail next to room 332. Room 332 had a sign on the opened door indicating contract precautions. At 2:11 p.m., the same day, room 332 was checked again and the 2 disposable blood pressure cuffs were still stuffed into the handrail next to the room. The accompanying nurse manager was asked if these should be stored in the handrail and she replied no and asked another nurse to remove them.