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Based on observation, staff interview and record review, the facility failed to ensure that proper kitchen sanitation measures were maintained in accordance with facility policies. Findings include:

1. Per review of the facility Dish Machine Temperature log on 7/18/11 at 2:15 P.M., staff failed to assure dishwasher temperatures were at proper levels in accordance with manufacturer instructions and facility policy. Between 3/1/11 - 7/18/11, 135 of a possible 452 opportunities to record dishwasher temperatures were not documented. Additionally, 15 documented rinse temperatures were below the 180 degrees Fahrenheit required for hot water sanitization. The Food Services Manager (FSM) confirmed at the time of the review that the temperatures were not documented as above and that staff failed to re-check those rinse temperatures that were less than 180 degrees, per facility policy.

2. On 7/18/11 at 2:20 P.M. during a tour of the kitchen, accompanied by the FSM, the following unsanitary conditions were observed:

- Drawers and cabinets containing utensils and assorted cooking tools in 2 food preparation tables were soiled with food particles and grease.
- A ventilation grill in operation and blowing air over food preparation equipment was soiled with dust and grease.
- A manual can opener was soiled with a brown substance.
- A sprinkler pipe extending above food preparation areas was soiled with a build up of dust and grease.
- The bottom interior shelf of a milk refrigerator was soiled.
The above observations were confirmed by the FSM at the time of the observations.

Based on observation, staff interview and record review, the Registered Nurse (RN) failed to adhere to clean technique during 1 of 2 observations of patient care. (Patient #18) Findings include:

Per observation of a clean surgical dressing change for Patient #18 on 7/19/11 at 9:30 AM, the RN failed to change gloves and sanitize hands after removing the soiled dressing and cleansing the wound and prior to applying the new dressing. The RN also failed to sanitize hands after removing gloves at the completion of the dressing change and then handled patient items and equipment in the room. In addition, prior to the dressing change,the RN failed to cleanse the blood pressure cuff(s) used for the patient prior to replacing equipment back into the hallway for general use for other patients. The failure to sanitize hands and/or reglove at appropriate times and cleanse the Blood Pressure cuffs was confirmed during interview with the RN at 9:45 AM. The RN's failure to adhere to clean technique was also confirmed with the Chief Nursing Officer (CNO) at 9:50 AM. The CNO verified the failure to change gloves when required and stated that it is facility policy to utilize the Lippincott Manual of Nursing Practice, 9th edition as a reference for basic/routine nursing procedures not found in the official Nursing Department Policies & Procedures Book. The hospital's policy on "Cleaning and Storing of Patient Equipment" stated "Non-invasive equipment in need if disinfection includes any device in contact with a patient that is meant for reuse by another patient." The CNO verified that the blood pressure cuffs should be sanitized between patient use.

Based on staff interview and record review, nurses failed to develop and/or revise care plans per hospital policy for 2 of 8 current inpatient records reviewed. (Patients #1 & #3) Findings include:

1. Per review on 7/18/11, Patient #3 was admitted to the hospital on 7/16/11 at 12:25 PM and the care plan was not developed timely as stated in the Admission Interview, Reassessments and Care Plan Policy" which stated that care plans must be developed within 24 hours of admission. Per review of the medical record on 7/19/11, the care plan was created on 7/19/11. The failure to develop the care plan in a timely manner was confirmed during interview with the Registered Nurse (RN) Manager on 7/20/11 at 8:45 AM.

2. Per record review on 7/19/11, Patient #1, who was admitted to the hospital on 7/16/11, did not have a care plan developed until 7/18/11. The Unit Manager confirmed on 7/19/11 at 10:20 A.M. that Patient #1's care plan had been developed on 7/18/11 and had not been developed within the 24-hour period after the patient's admission, per hospital policy.

3. Per record review on 7/19/11, there was a failure by nursing to revise the care plan for Patient # 1 regarding three Stage 2 pressure sores that were identified during the initial RN assessment, completed on admission on 7/16/11 at 7:42 PM. On 7/20/11 at 8:40 A.M. the Chief Nursing Officer (CNO) confirmed that although the initial nursing assessment, completed on 7/16/11 documented three Stage 2 pressure sores on the patient's buttocks, the care plan was not revised to include this problem.

Based on observation and staff interviews, the hospital failed to assure confidentiality of record information by failing to provide safeguards against loss, destruction or unauthorized use. Findings include:

Per observation during a tour of the radiology department on 7/18 /11 at 3:30 P.M., there were multiple shelves in a small room connected to the x-ray room where there were file folders which contained patient identifiable information including patient names, descriptions and dates of x-rays taken and copies of actual x-rays in the file folders. There were 2 doors to gain access to this x-ray room; one exited to the ED (emergency dept.) which had a door that was lockable, and the other door, which was not lockable,exited to a hallway in the hospital near a patient room, the hospital laboratory, registration area and physical therapy rooms, The main hospital cafeteria was located at the end of the hall.

Per interview on 7/18/11 at 3:30 P.M., he Chief Nursing Officer (CNO) and two radiology technicians each confirmed that there was no lock on the door leading to the hospital hallway and that when the technicians left in the evening (approximately 6:30 P.M.) until they arrived the next day (approximately 7:00 A.M.) they would just 'shut the door' to the hallway because they were unable to lock the door.