HospitalInspections.org

Based on observation, the facility failed to maintain a drug storage area that is administered in accordance with accepted professional principles.

Findings were:

During a tour of the patient care unit on 11-20-19, the following observation was made:

* Inside the medication refrigerator was an unlocked, plastic, snap-top bin containing a quantity of 8, 1-milliliter vials of Ativan® at a concentration of 2 milligrams/milliliter. Ativan is a benzodiazepine and a Schedule IV controlled substance. The refrigerator also contained insulin and vaccines. Although the refrigerator itself had to be accessed through the Omnicell electronic drug system, no additional steps were needed to access the bin containing the Ativan® once the refrigerator had been opened.

Facility policy #20-1700 titled "Controlled Drug System" states, in part:
"Schedule III, IV and V Controlled Substances
C. Nursing Unit Stocks
1. Any schedule III-V drug that is ordered for an inpatient will be stocked in the locked Omnicell narcotic bins.
2. Perpetual inventory counts are kept in the Omnicell. Cycle counts on all C III-C V medication will be performed weekly by pharmacy personnel."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 11-20-19.

Based on observation and interview, the facility failed to ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings were:

During a tour of the dietary area on 11-20-19, the following observations were made:

* Crumbs and other debris were noted in the shelving under the food serving area. This debris can attract insects and rodents.
* Crumbs were noted inside the drink refrigerator.
* 3 of 34 ½ pints of 2% milk had expired 11-19-19 but were still available for use.
* 1 of 1 8-ounce carton of Glucerna® had expired 11-1-19 but was still available for patient use.
* Bins of potatoes were stored on a shelf under a food prep area.
* 3 employee purses and 1 employee jacket (personal items) were found hanging on a hook inside the dry goods storage area. These personal items were hanging over clean aprons that were ready for use.
* A tube of hand cream was found in the dry goods pantry.
* A can opener was found bolted to a metal, work area on which also sat paper napkins and straws destined for patient use. On a shelf above the work area were personal items to include eye glasses and 3 cell phones.
* A Hamilton Beach® portable mixer was found in a drawer under the food prep area. The mixer was flecked in what appeared to be particles of dried food.
* A Southbend oven contained crumbs, caked-on grease and other food debris. In an interview with staff #14 on 11-20-19, staff #14 stated that the oven had been cleaned on 11-17-19.
* 2 rolling, metal bins were labeled "sugar" and "tortilla flour". Both appeared to contain the substance labeled. Neither bin was covered in an airtight lid and one of the containers was slightly bent, preventing the lid from completely covering the contents. Dry, powdered items such as sugar and flour should be stored in airtight containers to prevent infestation by insects and rodents.
* Parchment paper was noted to be lining the bottom of a large oven beneath a cooktop. Liquid grease was dripping onto the parchment paper. In an interview with staff #14 on 11-20-19, staff #14 stated that the grease had been dripping into the oven for some time and that the paper was there to catch the grease and prevent it from getting onto the floor of the oven.
* The November temperature log for the "bread & juice" refrigerator revealed that the temperature was outside the acceptable range of 34-41 degrees Fahrenheit for 1 of 20 days. The log contained no documentation that maintenance had been notified or that any action had been taken regarding the temperature.

Facility policy #3001 titled "Infection Control" states, in part:
Purpose:
"To prevent and control contamination and the spread of infection within the department and the hospital.
Responsibilities:
Nutritional Services Director:
*To develop and maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards.
*To develop written standards and work procedures for daily operations. Procedures for preparation and serving of food must be such as to minimize contamination by microorganisms or by chemicals that may result in food poisoning.
*To develop programs for the training of personnel in food preparation procedures and personal cleanliness and care, in compliance with regulations established by the Infection Control Committee and the Employee Health Service. Programs shall include all mandated in-services.
*Provides for the proper receiving and storage of all food supplies.
*Maintains proper storage of perishable foods at 41 degrees F[ahrenheit] or below.
*Provides continuing preventive maintenance of equipment to meet safety and infection control standards.
Infection Control Practices:
*Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Nutritional Services Director. Adequate ventilation shall be provided in all storage areas.
*All refrigeration units shall be cleaned thoroughly weekly and wiped down on each shift.
*Procedures for the handling, preparation and serving of food shall meet the standards of all regulatory bodies. Separate areas shall be specified for food preparation and for cleanup. These food preparation areas shell be further defined as to meat, salad etc. Food not in its original container shall be stored in the smallest container possible, covered, labeled and dated. Foods stored in opened containers must be covered and dated.
Environment:
*Fruits, vegetables, dairy products, meat and poultry shall be stored at temperatures between 33-42 degrees F. Fish and shellfish, ice cream and frozen foods shall be stored between 0-10 degrees F.
*Cafeteria shall be maintained per department standards.
Refrigeration:
*Shall be kept in clean and sanitary condition through regular cleaning.
*Temperatures shall be checked and recorded daily by the Nutritional Services staff. Any out-of-range temperatures will be reported to the Engineering Department. Notification will be documented on the temperature log."

Facility policy #3005, titled "Cafeteria Infection Control" states, in part:
"Policy:
*All policies and procedures regarding sanitation and infection control for the Nutritional Services department shall be enforced in the cafeteria area by the Nutritional Services Director and line supervisors."

Facility policy #3010, titled "Maintenance of Logs for Refrigerator Temperatures", states, in part:
"*Policy:
To ensure that foods are maintained in a proper environment, the temperatures must be checked daily.
Procedure:
*Nutritional Services will check the patient food refrigerator temperature daily.
*All temperatures must be recorded on the Refrigerator Temperature Log attached to each refrigerator. Any out-of-range temperatures must be reported to engineering immediately and documented notification on the Temperature Log."

Facility policy #3011, titled "Temperatures of Refrigerators and Freezers" states, in part:
"Policy:
*Temperatures shall be recorded and kept on file of all refrigerators and freezers.
*Refrigerator temperatures shall be within the acceptable range [of] 30 to 41 degrees F.
*At any time any refrigerator or freezer is not within the acceptable range, it must be reported to Engineering immediately."

Facility policy #6011 titled "Preventive Maintenance" states, in part:
"Policy:
Preventive Maintenance for Appliances:
*Ovens are cleaned weekly by rotating cleaning schedule."

Facility policy #2139 titled "Food Storage" states, in part:
"Policy:
*Food and supplies will be received and stored in proper areas.
*The Nutritional Services Director or designee is responsible for receiving and storing all food and supplies in a proper area.
*All dry foods are stored in storeroom that is clean, dry and well ventilated, and kept 6 inches off the floor and at least 18 inches from the ceiling.
*Produce is stored in the refrigerator and the temperature is maintained at 35 to 41 degrees F.
*All food is rotated so that the first in will be the first out.
*If there is any question about a product's storage or expiration, discard that product."

Facility policy #6012 titled "Breakdown of Major Equipment" states, in part:
"Policy:
*In the event of a breakdown of any major equipment, the Engineering Department is contacted immediately for repairs.
*If engineering is unable to make the necessary repairs, Engineering Department are responsible for calling outside assistance."

Facility policy #2142 titled "General Requirements-Food Supply" states, in part:
"Policy:
*Food and non-food supplies will be purchased and stored under sanitary, safe and secure conditions as required to meet federal, state and local laws."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 11-20-19.