HospitalInspections.org

Based on document review and interview, the facility does not ensure that the operating certificate is accurate as to services provided and correct bed count.

Findings include:

Review on 4/4/11 of the operating certificate, with an effective date of 1/5/09, revealed that the services provided and the number of intensive care beds was not accurate. During interview on 4/4/11, Staff #1 and 2 indicated that the facility does not provide part time clinic services, maternity services have not been provided since 2002, and the number of intensive care beds changed from three to two in October 2010.

Based on medical record review, document review and interview, the facility does not ensure that discharge summaries are completed within 30 days for 3 of 6 patients who had been discharged from the facility more than 30 days prior to review. (Patients #13, 14 and 16)

Findings include:

Medical record review on 4/6/11 revealed the discharge summaries had not been signed by the provider for the following patients:
--Patient #13, who was discharged from the facility on 11/19/10.
--Patient #14, who was discharged from the facility on 12/1/10.
--Patient #16, who was discharged from the facility on 12/16/10.

Review on 4/6/11 of the Medical Staff By-Laws (revised March 2010) with Staff #2 revealed that, under Discharge Summary, no time frame for completing the summary was provided.

These findings were reviewed with Staff #2 on 4/7/11.

Based on medical record review, policy and procedure review and interview, the facility does not ensure that verbal orders are authenticated (signed, dated and timed) by the practitioner within 24 hours for 4 of 18 patients. (Patients #1 and 9-11)

Findings include:

Review on 4/6/11 of policy #MedRec.497 "Diagnostic and Therapeutic Orders" (revised January 2009) revealed that "verbal orders must be signed within 24 hours". The policy did not indicate that the verbal order must also be authenticated with a date and time.

Medical record review revealed the following verbal orders:
--Patient #1: Review of the medical record on 4/4/11 at 1:45 PM revealed 3 verbal orders given to nursing personnel on 4/2/11.
--Patient #9: Review of the medical record on 4/6/11 at 11:30 AM revealed 5 verbal orders given to nursing personnel between 4/2/11 and 4/4/11.
--Patient #10: Review of the medical record on 4/6/11 at 1:00 PM revealed 19 verbal orders given to nursing personnel between 3/29/11 and 4/4/11.
--Patient #11: Review of the medical record on 4/6/11 at 11:00 AM revealed 1 verbal order given to nursing personnel on 4/4/11.
However, although all of the above orders were authenticated with the provider's signature, none of the signatures were dated or timed, so it could not be determined when the orders had been authenticated.

These findings were reviewed with Staff #2 on 4/7/11.

Based on observation and interview, the facility does not ensure the proper safe storage of refrigerated foods.

Findings include:

During facility tour of the kitchen area on 4/7/11, it was observed that a half-case of shelled raw eggs was stored on the third shelf in the walk-in cooler. These eggs were stored above a tub of hard boiled eggs. Raw, uncooked hazardous foods must not be stored above cooked foods or foods that do not required heat treatment.

This finding was verified with with Staff #22 on 4/7/11.

Based on interview and document review, the facility does not ensure that the therapeutic diet manual is current and approved by the dietitian and medical staff.

Findings include:

Interview on 4/7/11 with Staff #22 revealed that the facility utilizes the American Dietetic Manual - 2000 edition for therapeutic diets. Review of this manual with Staff #22 at that time did not reveal documentation that it has been approved by Staff #29 or the medical staff. The facility must utilize a therapeutic manual that is less than five years old and has been approved to be utilized throughout the facility by physicians, nursing and food service personnel.

Based on observation and interview, the facility does not ensure that the hot water temperature is maintained within acceptable parameters.

Findings include:

During tour of the operating rooms on 4/5/11, it was observed that the hot water in the scrub sinks of the operating room suite was greater than 120 degrees Fahrenheit. During interview at that time, Staff #17 stated that the operating room physicians will commence hand scrubbing in one sink and then utilize another scrub sink to rinse because the water is extremely hot.

During interview on 4/7/11, Staff #16 verified that the hot water temperature was greater than 120 degrees Fahrenheit, and that the hot water for the building was provided by a single source.

Based on observation and interview, the facility does not ensure that mechanical exhaust is present in 1 of 3 janitor's closets. (janitor's closet in the kitchen)

Findings include:

During tour of the kitchen area on 4/7/11, it was observed that mechanical exhaust was not present in the janitor's closet.

This finding was verified with Staff #22 on 4/7/11.

Based on policy and procedure review, document review and interview, the facility does not ensure that daily food temperatures are obtained at 3 of 3 designated times. (breakfast, lunch and supper)

Findings include:

Review on 4/7/11 of policy "Tray Line Checklist" (effective 1979, revised 2009, no review date) revealed that "the supervisor who is checking tray line must take a temperature of all foods on line".

Review on 4/7/11 of the daily food temperature logs revealed that daily temperatures of the foods for the tray line and for the dining room were not obtained on the following days:
--In January 2011, temperatures were not obtained 12 of 31 days;
--In February 2011, temperatures were not obtained 3 of 28 days;
--In March 2011, temperatures were not obtained 22 of 31 days;
--In April 2011, temperatures were not obtained 1 of 6 days.

This finding was verified with Staff #22 on 4/7/11.


Based on policy and procedure review, document review and interview, the facility does not ensure that the dish machine temperatures are obtained three times per day (6:00 AM, 12:00 PM and 7:30 PM).

Findings include:

Review on 4/7/11 of policy "Dietary 27" (effective 1997, reviewed 1995) revealed that the dish machine wash and rinse temperatures are to be obtained three times per day.

Review on 4/7/11 of the dish machine wash and rinse temperatures log revealed that daily dish machine wash and rinse temperatures were not obtained as required per the log sheet, as follows:

In January 2011:
--At 6:00 AM, they were not obtained for 23 of 31 days;
--At 12:00 PM, they were not obtained for 21 of 31 days;
--At 7:30 PM, they were not obtained for 7 of 31 days.

In February 2011:
--At 6:00 AM, they were not obtained for 12 of 28 days;
--At 12:00 PM, they were not obtained for 15 of 28 days;
--At 7:30 PM, they were not obtained for 2 of 28 days.

In March 2011:
--At 6:00 AM, they were not obtained for 23 of 29 days;
--At 12:00 PM, they were not obtained for 18 of 29 days;
--At 7:30 PM, they were not obtained for 5 of 29 days.

These findings were verified with Staff #22 on 4/7/11.

Based on document review and interview, the facility does not ensure that the cold sterilant, Metricide, is changed at least every 14 days.

Findings include:

Review on 4/5/11 of policy "MetriCide.doc" (revised 11/00, no review date) revealed that Metricide solution expires 14 days after preparation or when the potency testing shows "low" results.

Review on 4/5/11 and 4/7/11 of the endoscope disinfection log did not reveal evidence that the Metricide was changed at least every 14 days or when the potency testing showed "low" results. For the time frame from 9/13/10 through 3/28/11, Metricide was changed on the following days: 9/13/10, 9/29/10, 10/20/10, 11/30/10, 12/9/10, 12/22/10, 1/5/11, 2/9/11, 2/17/11, 3/17/11 and 3/28/11.

These findings were verified with Staff #17 and 18 on 4/5/11.