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Tag No.: C0222
Based on observation and a review of documentation, the facility failed to ensure that all essential mechanical, electrical, and patient care equipment was maintained in safe operating condition.
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Findings were:
During a tour of the dietary department on 10-12-16, the following observations were made:
· The dishwasher temperature log contained temperatures logged between the range of 130 to 150 degrees Fahrenheit. No target temperature or temperature range was listed for employee guidance.
The dishwasher manual for Champion model D-LFM5 indicated the minimum incoming water supply temperature requirement as 140 degrees Fahrenheit.
The following was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 10-12-16.
Tag No.: C0278
Based on observation and a review of documentation, the facility failed to ensure that policies governing investigating and controlling infections and communicable diseases were implemented and enforced.
Findings were:
During a tour of the dietary department on 10-12-16, the following observations were made:
· (Dietary) staff #18 wore polished fingernails extending over 1/4" from the tip of the finger. This staff member also wore rings on both hands, a necklace around the neck and a bracelet on the right wrist.
· A purse belonging to a member of the dietary staff was found on a kitchen countertop.
· A trash closet contained a trash barrel full of seldom-used, electrical cooking appliances (such as crockpots). The same trash closet also contained a cardboard box full of bags of potato chips and a cardboard box full of plastic sleeves of styrofoam cups.
Facility dietary policy #3.002 titled "Dress and Grooming" stated the following:
"Food service personnel will comply with the following standards to maintain the highest level of sanitation in the Food Service Department, and to present a professional attitude and appearance.
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3. Jewelry.
a. Excessive jewelry will not be allowed. This includes watchbands that contain turquoise or decorated in some other way. Wedding rings may be worn. Stud earring(sic) may be worn; earrings or necklaces which dangle will not be allowed. Bracelets will not be allowed.
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5. Nails
a. Fingernails will be clean and trimmed no longer than the end of the finger. Fingernail polish will not be allowed."
Facility dietary policy #3.037 titled "Employee Education/Infection Control" stated the following:
"1. Annual in-service education should include personal hygiene, sanitation, and hand-washing techniques."
Facility dietary policy #3.043 titled "Sanitation Standards for Equipment and Work Area" stated the following:
"2. Work area
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g. Garments and purses are to be kept in the closet. They are not allowed anywhere in the Department except in the closet."
A review of training documentation revealed that training titled "Dietary and Housekeeping Meeting - Annual Inservice [on] Personal Hygiene, Sanitation, Hand Hygiene Techniques" was conducted on 9-21-16 and (dietary) staff #18 received the training.
The following was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 10-12-16.
Tag No.: C0294
Based on a review of documentation and interview, the facility failed to ensure that nursing care was provided in accordance with the specialized qualifications and competence of the staff available. as evidence by competency based orientation not being provided and/or evaluated for all nursing employees per facility base policy.
Findings included:
Facility policy No. 12.045 entitled, "Orientation" stated in part, "The need for initial orientation to the job for on-going education needs of the staff is clearly recognized and supported ...Each new employee's knowledge and skills are assessed and an orientation period of 30 to 90 days (dependent on need) is allowed ...At the end of 90 days a performance evaluation is done by the Director of Nursing and filed in the employee's personnel record ...
Agency nurses are given a general Orientation for Agency Nurses and Trauma Room orientation checklist."
Review of the personnel files revealed that the "Competency Based Orientation Record" was not complete for 5 of 6 nursing staff members.
* Staff member #1's competency sheet completed on 08/12/15 only had the self-evaluation portion complete with no evaluation of the various competencies documented.
* Staff member #2's competency sheet completed on 09/14/15 only had the self-evaluation portion complete with no evaluation of the various competencies documented.
* Staff member #3's competency sheet completed on 08/13/15 only had the self-evaluation portion complete with no evaluation of the various competencies documented.
* Staff member #4's competency sheet completed on 08/13/15 had the self-evaluation portion completed with the only competencies documented as evaluated were for surgically placed drains, nasal gastric tubes, and restraints.
* Staff member #5's competency sheet completed on 08/14/15 was mostly complete, with a few competencies with no documented evaluation.
In an interview on 10/11/16, staff member #2 confirmed the competency records were not complete for 4 of 5 nursing staff members.
Review of the personnel files revealed that an "Orientation for Agency Nurses and Trauma Room orientation" checklists were not completed per policy, for 3 of 3 agency nurses employed at the facility.
* Staff members # 14, 15, and 16 did not have orientation or trauma room orientation checklist in their records.
In an interview on 10/12/16, staff member #2 confirmed that 3 of 3 agency nurses did not have an orientation checklist documented per policy.