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Based on observation, interview, and record review, the facility failed to have a preventive maintenance program to ensure that all essential mechanical, electrical and patient-care equipment was maintained in a safe, sanitary, and operating condition in the dietary department when:

1. The ice machine was not maintained in sanitary condition.

2. The walk-in freezer had thick frost on shelving, food containers, plastic food packages, walls, pipes, and two motor fans.

3. Two food preparation sinks did not have an air gap (space to separate a water-supply outlet from any potentially contaminated source from backflow).

These failures had the potential to cause food borne illnesses within the medically vulnerable population of 18 patients, who received food prepared in the kitchen.


Findings:


1. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch.

During a review, of the facility's policy and procedure titled, "Equipment Maintenance Program," dated 11/28/18, it indicated that the proper maintenance of the dietary, and all equipment is the responsibility of the Director of the Dietary Department in cooperation with the facility's maintenance department, and subject to policies and procedures set forth by the facility's administration. The Director of the Dietary Department is informed of all routine, periodic and critical maintenance work done in the kitchen, or with its equipment. To ensure that all equipment is in safe operating condition, an equipment inspection program is followed.

During an interview, on 1/9/24 at 3 pm with Plant Maintenance (PM) 2, reported that the ice machine was cleaned every three-months, and they did not have the manufactures' manual. PM 2 stated, that he did not know where the paper was indicating how to clean the ice machine, or where the maintenance logs were located indicating when the ice machine was cleaned, or maintained by the maintenance staff.

During a concurrent observation, and interview, on 1/9/24 at 3:20 pm, in the kitchen with PM 1, whitish flakey mineral deposits were observed on the ice machine, above the ice chute and surrounding areas. PM 1 removed the ice chute, and white crusty discoloration and brownish substance on the rim of the chute was observed. PM 1 confirmed, that this was was not clean. PM 1 stated, that the ice machine was cleaned every three-months, and they did not have the manufactures' manual with instructions showing the procedure for maintaining and cleaning the ice machine. PM 1 stated, he did not know where the maintenance records were located indicating the dates the ice machine was cleaned, or maintained by the maintenance staff.

During an interview, on 1/10/24 at 2:15 pm with PM 3, they stated, that the ice machine should be cleaned monthly and deep cleaned every three months. PM 3 did not know if the facility had a policy and procedure specifically for cleaning the ice machine, or logs indicating the dates the ice machine was cleaned, or maintained by the maintenance staff.

2. During a concurrent observation, and interview, on 1/9/2024 at 3:10 pm, in the walk-in freezer located in the kitchen, with PM 1, an accumulation of thick frost on the walls, shelving, food storage bins, plastic bags containing food products, pipes and two motor fans was observed. PM 1 stated, that he was aware of the frost; it had been there for a while, and the frost build up on the motor fans appeared worse. PM 1 stated, that he had someone look at the walk-in freezer, but could not remember who, or when, and had no records of it. PM 1 stated, that he did not have a checklist, or logs indicating when the walk-in freezer was cleaned, or maintained by maintenance staff. PM 1 confirmed the walk-in freezer should not have a build up of frost on all the surfaces or the two motor fans.

3. According to the FDA Food Code Annex 2022: 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces.

According to the FDA Food Code 2022, Section 5-402.11 Backflow Prevention. Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

During a concurrent observation, and interview, on 1/10/24 at 1:55 pm, with PM 3, in the kitchen, two food preparation sinks with no air gaps were observed. PM 3 confirmed, that the two food preparation sinks currently did not have an air gap.

41600



Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored properly according to the facility's policies and procedures or manufactures' specifications and requirements for a census of 19, when:

1. Two injectable vials of epinephrine (an emergency medication to treat life-threatening medical conditions), located in the pharmacy were not protected from light in accordance with manufacturer's storage requirements, with the risk for potential medication degradation.

2. A bag of 10% dextrose injection (a sterile solution of dextrose [a type of sugar] in water for intravenous [in the vein] administration), located in the Emergency Department (ED) patient supply room, was found to be expired and therefore no longer guaranteed to be sterile.

3. Two bottles of 3% hydrogen peroxide (a cleansing antimicrobial solution), located in the wound supply cart in the Emergency Department, was found to be expired and therefore at risk of being less effective in the treatment of wounds.

These failures had the potential for medication degradation, and the administration of a potentially expired or contaminated products which could lead to negative clinical outcomes.


Findings:


1. During an inspection of the pharmacy on 1/9/24 at 11 am, two injectable vials of epinephrine 1 mg/1ml (milligram per milliliter, unit of measure) were observed outside of manufacture's box in a clear storage bin on the shelf in the main pharmacy room. The storage bin did not have any "protect from light," labels on the outside, and the two epinephrine vials were exposed to light.

During an interview, on 1/9/24 at 11:05 am, with the Director of Pharmacy (DOP), the DOP stated, that the two vials should not be there, and they should be protected from light.

During an inspection of the epinephrine box and manufacturer's label in the pharmacy on 1/11/24 at 2:15 pm, the manufacture label on the box indicated, "Protect from Light."

During a review of the facility's policy and procedure titled, "Storage of Medications," dated 8/17, indicated, light sensitive medications will be kept in the closed manufacturer's package... medication trays and bins in the pharmacy that hold light sensitive medications will be labeled with "protect from light," to assure proper handling after removal from the manufacture's package.

2. During a concurrent observation, and interview, made 1/10/24 at 12:35 pm, with Licensed Vocational Nurse (LVN) 2, a 1,000 mL (milliliter, a unit of measure) bag of 10% dextrose with an expiration date of 12/23, was found in the Emergency Department's patient supply closet. LVN 2 stated, that the product was most likely set aside to be used for training purposes once it had expired, but confirmed that it was still in the patient supply closet, and could have been inadvertently used on a patient by staff.

3. During a concurrent observation, and interview, on 1/10/24 at 12:40 pm, with LVN 2, two bottles of 3% hydrogen peroxide, with an expiration date of 10/23, were found in the wound supply cart in the Emergency Department. LVN 2 removed the expired products, and stated that they should not be used on patients because they were expired, and would be disposed of.

During an interview, on 1/11/24 at 1:40 pm, these findings were discussed and photographs shared with the temporary Director of Nurses, and ED Manager, who confirmed that these issues posed contamination risks to patients, and staff.

Based on observation, interview, and record review, the facility did not follow their policy when staff did not label the opened date on two reagent strips (patient monitoring device testing strip) bottles.

This failure to enter the date of the opening of the container can lead to using out of date testing strips, resulting in incorrect test results, and improper treatment based on incorrect results, and potential negative clinical outcomes.


Findings:


During a concurrent interview, and observation, of the Cardiac Clinic on 1/10/24 at 10:30 am, with the Clinic Manager (CM) one bottle of "Stat Strip," blood glucose (sugar) monitoring test strips was found opened. The bottle had no opened date filled in on the "Date Opened," manufacturers label. The CM observed the label, and no date entered by staff and stated, that they should have written that on it when it was opened.

The CM then provided a facility policy titled, "Nova Strip Glucometer," The CM confirmed that per this policy the staff should have documented on the bottle the date the bottle was opened. The CM confirmed that failure to write the date could lead to using expired strips.

During a concurrent interview, and observation, of the Cardiac Clinic on 1/10/24 at 11 am, with the CM one bottle of "Multi Stix Urine Reagent Strips," were found opened without the required opened date. The CM confirmed the same process is required, and staff did not comply. The CM states, that it was the same process, if opened, it must have the opened date written on the bottle.

47884


Based on observation, interview, and record review, the facility did not ensure that staff were adequately oriented to the Medical, and Emergency Room units when:

1. One Registered Nurse (RN) 10 was floated from the Medical Unit into the Emergency Room, without unit specific orientation or training.

2. 14 of 16 employee files reviewed did not contain documented unit specific orientation, or other mandatory trainings.

These failures resulted in an increased risk to patient safety, and had the potential to lead to negative clinical outcomes.


Findings:


During a review, of the facility's policy titled, "Education and Training," reviewed 12/14/18, and in effect, indicated that all employees would complete unit specific education to maintain a competent safe environment of care. And that all orientation and training records, would be maintained and stored in each employee's personnel file.

A review, of the facility's policy titled, "Orientation of Emergency Department Personnel," reviewed 9/26/19, and in effect, indicated that Emergency Room staff would be provided an orientation, and that the orientation would be completed under the supervision of an assigned preceptor. And that completion of orientation would assure each employee was familiar, and competent with unit policies, procedures, protocols, equipment, and able to provide safe competent care to the Emergency Room patient population. Additionally, the policy indicated that orientation checklists would be placed into each personnel file, after successful completion of orientation.

A review, of the facility's policy titled, "Nursing Services," reviewed 10/27/21, and in effect, indicated that care of each patient would be provided by competent and qualified nursing staff. And that to provide safe competent patient care each patient's specific needs, along with the qualification and competency of staff would be considered when making shift assignments.

During an interview, and concurrent record reviews, on 1/11/23, at 11:30 am, with Human Resources Manager (HRM), it was noted that there were no unit specific orientation checklists in 3 of 5 personnel files reviewed. HRM indicated that unit specific orientation checklists, and other mandatory training records should be in each employee's personnel file, and confirmed that 3 of 5 employee records reviewed were missing unit specific orientation checklists.


During a concurrent observation, and interview, in the Emergency Department (ED) on 1/11/24 at 8:30 am, the sole Registered Nurse (RN) on duty was RN 10. RN 10 confirmed, that they were the sole RN on duty.

During an interview, on 1/11/24 at 1:25 pm, RN 10 confirmed, that she was hired in 2023, and soon after her hire she was floated to the Emergency Department to cover lunch breaks, and then began being floated to cover entire shifts. RN 10 confirmed, that she has not had any specific ED unit training by the facility.

During a concurrent two-part interview, and record reviews, on 1/10/24, and 1/11/24, employee competencies were reviewed with the HRM, of eleven sampled employees (seven RNs, three Licensed Vocational Nurses [LVNs], and one ER Technologist [ERT]) who either worked in the Emergency Department or floated there from the Medical/Surgical units, eight employees were found to have incomplete unit-specific training, or cross-training (RN 6, RN 8, RN 9, RN 10, LVN 1, LVN 2, LVN 3, ERT 1) to the Emergency Department.

On 1/11/24 at 8:45 am, HRM confirmed, that the competencies were either not completed, or missing.

On 1/11/24 at 9:15 am, HRM confirmed, that RN 10 had been hired in 2023 to work in the Medical/Surgical unit, and was working in the ED, and had no ED-specific cross training. A schedule of the day's nursing assignments was printed, which indicated that the sole designated RN on duty 1/11/24 in the ED was RN 10.

During an interview, on 1/11/24 at 1:40 pm, the temporary Director of Nurses/ER Manager stated, that she would expect staff to have cross training for the different units that they work in.

Based on interview, and record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the nursing care of patients on the medical unit when:

1. There was no documented RN assessment for every patient on the unit for each shift.

2. When assessments performed by Licensed Vocational Nurses (LVNs) were not reviewed, and co-signed by the supervising RN for each shift.

This failure risked patient safety, and had the potential to lead to possible negative clinical outcomes.


Findings:


A review, of the facility's policy titled, "Patient Care Planning," reviewed 11/16/23, and in effect, indicated that all patients will have an individualized plan of care developed by an RN. The RN assessments would determine the specific needs and goals of each patient. Additionally, the policy indicated that LVN's would be under the supervision of an RN, when performing patient assessments, evaluations, or care plan activities.

A review, of the facility's policy titled, "Nursing Services," dated 10/27/21, indicated that an RN must supervise, and evaluate the nursing care for each patient 24-hours a day, on all shifts.

During a review, of Patient 22's medical record, a document titled, "Patient Progress Notes," indicated that, from 2:07 am on 1/10, through 7:05 am, on 1/11/24, (over a span greater than 24-hours, and two shifts) that there was no RN assessment.

During an interview, on 1/11/24 at 10:59 am, LVN 5 reported, that patient assessment and reassessment was a task delegated to LVNs on the medical unit, and that an RN did not regularly review, or co-sign those assessments.

During an interview, on 1/11/24 at 11:02 am, LVN 4 reported, that patient assessment and reassessment was a task delegated to LVNs on the medical unit, and that an RN did not review or co-sign those assessments. LVN 4 stated, that they never have an RN co-sign their patient assessments.

During an interview, on 1/11/24 at 11:10 am, with an RN 2, and temporary Director of Nursing (TDON), they reported that LVN's had performed patient assessments without RN supervision, and that there was no process for RN review, and co-signing of patient assessments completed and documented by the LVNs. RN 2, and TDON confirmed that all patient assessments performed by LVNs should have been reviewed, and co-signed by an RN, and were not.

Based on observation, interview, and record review, the hospital failed to ensure a medication was administered in accordance to physician orders, facility policy, and accepted standards of practice for one of 29 sampled patients (Patients 5) when:

A licensed nurse crushed a delayed release pantoprazole (medication to treat acid reflux, and heal stomach ulcers), 40 mg (milligrams) for Patient 5.

This failure had the potential for Patient 5 to have an inconsistent drug concentration in the body, or experience unwanted side effects which could lead to negative clinical outcomes.


Findings:


During a medication administration observation on 1/10/24 at 8:45 am, Registered Nurse (RN) 1 was observed to crush, and administer one pantoprazole 40 mg delayed release tablet by mouth to Patient 5, along with other morning medications.

During a review, and reconciliation of the medication administration observation with Patient 5's electronic orders on 1/10/24 at 9:15 am, a physician order (dated 1/3/24) indicated, pantoprazole 40 mg tablet, 40 mg orally daily.

During an interview, on 1/10/24 at 9:20 am, with RN 1, they stated there was no specific orders for crushing Patient 5's medications, and that they didn't know pantoprazole delayed release could not be crushed, since it is usually administered intravenously (into the vein).

During an interview, on 1/10/24 at 12:40 pm, with the facility's Registered Pharmacist (RPh), the RPh stated, that pantoprazole 40 mg tablet could not be crushed. In case of difficulties swallowing, the nurse could have asked the pharmacy for a recommendation.

During an inspection of the pantoprazole box in the pharmacy on 1/11/24 at 2:10 pm, the manufacture label on the box indicated, tablets must not be split, chewed, or crushed before administration.

During a review, of the facility's policy and procedure titled, "Administration of Medications," revised 12/22, it indicated, that the Registered Nurse, or Licensed Vocational Nurse will be knowledgeable regarding the dosage, therapeutic actions, indications, contraindications and sensitivity reactions of medications prior to administration.

During a review, of the facility's policy titled, "Drugs That May Not Be Crushed, or Divided," dated 9/16, it indicated, that nurses should consult with a pharmacist, or the, "Do Not Crush," list before altering drug forms for administration... Oral Dosage Form That Should Not Be Crushed... pantoprazole tablet.

Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary environment for its patient population.

This failure had the potential for poor health outcomes through the transmission of infectious pathogens which could lead to negative clinical outcomes.


Findings:


A review, of the facility's policy titled, "Infection Prevention Plan," dated 1/30/23, indicated that the facility's infection control program maintained a culture of zero tolerance for noncompliance with established infection prevention and control practices.

During an observation, on 1/9/24 at 9:33 am, in the Medical/Surgical Unit Dirty Utility Room. The following items were observed. In a cupboard was a DonJoy Iceman ice therapy unit with tubing and wrap-on pad, and a dirty metal object with cobwebs in it, and a box of sani-bags (a urinary and fecal collection device). This and adjoining cupboards were filled with peeling paint, and the shelves were dirty, and littered with paint chips.

During an observation, on 1/9/24 at 9:52 am, in the Medical/Surgical Medication Room, the following was observed. The under-sink pipe connection was thick with dark debris which overflowed onto the bottom of the cabinet. There was black, rusty red and yellow-brown material and stains on the bottom of the cabinet. A glass partition separated the sink from other items on the counter, the glass being supported by two gray brackets. Both brackets were rusting with small flecks of paint and rust, and the area around the edges of the sink and the glass, and the sink faucets were dirty with white built-up scale and soiling.

During an observation, on 1/9/24 at 9:55 am, of the Medical/Surgical Unit patient supply closet the following was observed. Patient supplies were found to be scattered on the floor in the right corner including a package of tubing, a specimen collection container, an ace wrap roll, and plastic bags.

During concurrent observation, and interview, on 1/9/24 10 am, with the Medical/Surgical RN on duty, Registered Nurse (RN) 2 who, when observing the patient supplies on the floor stated, that they posed an infection risk, and that she would dispose of them to prevent them from being used on patients.

During concurrent observation, and interview, on 1/10/24 at 12:25 pm, with Licensed Vocational Nurse (LVN) 2, in the Emergency Department patient supply room the following was observed. On the floor were supplies which included specimen collection cups, a bedpan, a urine strainer, a urinary catheter kit, and disposable briefs. LVN 2 retrieved the supplies off the floor to dispose of them, stating that the items posed an infection risk to patients.

During an interview, on 1/11/24 at 1:40 pm, these findings were discussed and photographs shared with the temporary Director of Nurses/ER Manager, who stated that these issues posed a contamination risks to patients, and staff.