HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 1 of 1 computer workstation (6 North - Medical/Surgical unit) reviewed for Protected Health Information [PHI], the Hospital failed to ensure that the patient's right to the confidentiality of clinical records was protected.

Findings include:

1. On 10/27/2020, the Hospital's protocol titled, "HIPAA [Health Insurance Portability and Accountability Act] Hot Topics" (undated) was reviewed and required, "Always log off computers when you are not in front of them. Do not leave material with PHI in public view, including computer screens..."

2. On 10/26/2020 at 9:50 AM, on 6 North (Medical/Surgical unit) a workstation computer, in the hallway, was left open and unattended. The PHI, which included patient names, locations, and medical record numbers, were visible and easily accessible to unauthorized staff and/or visitors.

3. On 10/26/2020 at 9:53 AM, an interview was conducted with the 6 North Clinical Coordinator (E #7). E #7 stated that staff should log off their computer before walking away from it.

Based on document review and interview, it was determined that for 2 of 9 (Pt. #11 and Pt. #15) clinical records reviewed for pain assessment/reassessment, the Hospital failed to ensure the Registered Nurse supervised and evaluated the nursing care of each patient, to ensure that patients were re-assessed, as required, after receiving pain medication.

Findings include:

1. On 10/27/2020, the Hospital's policy titled, "Pain Assessment and Management" revised by the Hospital on 10/10/2019 was reviewed. The policy required, "Treatment of Pain: Pain relief from pharmacological interventions should be assessed by the health care professionals one hour after medication administration."

2. On 10/26/2020, Pt. #15's clinical record was reviewed. Pt. #15 was admitted on 10/19/2020 with a diagnosis of fracture of radius/ulna (forearm). The Physician's order, dated 10/20/2020, included an order for Morphine (pain medication) 4 milligrams (mg) intravenous push (IVP), every 4 hours, as needed, for breakthrough pain. The electronic medication administration record showed that Pt. #15 received Morphine 4 mg IVP on 10/20/2020 at 3:02 PM, 10/21/2020 at 9:17 PM, 10/23/2020 at 3:32 PM, and 10/26/2020 at 2:18 PM. The clinical record lacked documentation of a pain assessment one hour after the administration of pain medication.

3. The clinical record for Pt #11 was reviewed on 10/26/2020. Pt #11 was admitted on 10/23/2020 with a diagnosis of severe vascular stenosis. The Physician's order, dated 10/24/2020, included an order for Morphine 3 mg intravenous (IV) every 4 hours, as needed, for pain. Pt #11 received Morphine 3 mg on 10/25/2020 at 9:01 PM. The clinical record lacked a pain assessment score one hour after the pain medication was administered.

4. On 10/26/2020 at approximately 1:15 PM, an interview was conducted with the Clinical Educator (E# 5). E # 5 stated that a pain assessment should be done an hour after an intravenous medication has been administered.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that foods were labeled with a use-by date. This had the potential to affect all 38 patients receiving oral diets on 10/28/2020.

Findings include:

1. The Hospital's policy titled, "Labeling and Dating Products" (dated 11/2019), was reviewed on 10/29/2020 and required, "...[for] food removed from original container... labels required [include]... date of preparation and/or 'use-by' date..."

2. A tour of Dietary Services was conducted on 10/28/2020, at approximately 10:30 AM. The following was observed:
- The walk-in freezer contained 5 opened boxes/bags of fish fillets that were not labeled with the date opened or a use-by date.
- The walk-in meat refrigerator contained 2 boxes of chicken quarters, a roll of ground beef and 2 inside round steaks, that were not labeled with a use-by date.

3. An interview was conducted with the System Director of Food & Nutrition Services (E#8) on 10/28/2020 at 2:40 PM. E#8 stated that all opened food items should be labeled with a use-by date. E#8 referred to the Hospital's "Labeling and Dating Products" policy and stated that the statement about removing food from its original container is considered the same as "opening" the food item and therefore, the items should be labeled with a use-by date. E#8 stated that all foods in the refrigerator should have been labeled with a use-by-date."


B. Based on document review, observation and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that food and dietary staff performed hand hygiene when hands were contaminated. This had the potential to affect all 38 patients receiving oral diets on 10/28/2020.

1. The Hospital's Food & Nutrition Services policy titled, "Hand Hygiene" (dated 11/2019), was reviewed on 10/28/2020 and required, "...Hands must be washed frequently and correctly... after touching hair, face, nose, other body parts of body... [and] after handling dirty equipment..."

2. A tour of Dietary Services was conducted on 10/28/2020, from approximately 10:30 AM to 12:10 PM. The following was observed:
- At approximately 10:35 AM, a Dishwasher (E#10) was moving soiled food pans and utensils into the dirty sink. E#10 then removed clean food pans and trays from the sanitizing sink, without performing hand hygiene.
-During the tour, 2 Cooks (E#11 and E#12) and 1 Patient Services Associate (E#13) were observed adjusting their facemasks and then handling prepared food trays without performing hand hygiene.

3. An interview was conducted with the Operations Manager of Food & Nutrition (E#9) on 10/28/2020, at approximately 12:00 PM. E#9 stated that E#10 should have washed hands after putting the dirty pans into the sink, before touching the clean pans. E#9 stated that it's important to wash hands when they are contaminated, such as after touching face masks, to prevent the spread of infection.

C. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that thermometers were rinsed prior to checking food temperatures. This could potentially affect the 38 patients receiving food trays on 10/28/2020.

Findings include:

1. The Hospital's Food & Nutrition Services policy titled, "Thermometer Usage" (dated 11/2019), was reviewed on 10/28/2020 and required, "...Thermometers must be accurate, clean and sanitized for every use... Cleaning Thermometers: Sanitize and rinse thermometer stem..."

2. During a tour of Dietary Services on 10/28/2020, at approximately 11:00 AM, a Cook (E#14) removed a thermometer from a container of sanitizing solution and dipped the thermometer probe into a pan of prepared food. E#14 repeated this process for 3 different pans/trays of prepared food and did not sanitize and rinse the thermometer probe prior to reinserting the probe into the food trays.

3. An interview was conducted with the System Director of Food & Nutrition Services (E#8) on 10/28/2020 at 2:40 PM. E#8 stated that the thermometer probe should be sanitized and rinsed per policy before inserting into food.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on October 27 & 28, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on October 27 & 28, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#1) observed exiting an isolation room on the Medical Surgical Unit (MSU), the Hospital failed to ensure that staff cleaned reusable equipment when leaving an isolation room, in order to prevent the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Transmission Based Precautions" (revised February 2020), was reviewed on 10/26/2020 and required, "...Contact Precautions... Re-usable instruments should be thoroughly cleaned with approved disinfectant wipes... when removed from room..."

2. During an observational tour of the Medical Stepdown Unit on 10/26/2020, at approximately 10:15 AM, a Registered Nurse (E#1) was providing care to a patient on contact and droplet precautions. After exiting the isolation room, at approximately 10:20 AM, the Registered Nurse (E#1) removed the reusable goggles and respirator mask, where and placed them on the clean workstation, with clean patient supplies were stored,without disinfecting the reusable supplies.

3. An interview was conducted with the Registered Nurse (E#1) on 10/26/2020, at approximately 10:30 AM. E#1 stated that she generally does wipe down the goggles and respirator mask after use.


B. Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#1) observed exiting an isolation room on the Medical Stepdown Unit (MSU), the Hospital failed to ensure that staff performed hand hygiene prior to touching clean supplies and equipment, in order to prevent the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (revised February 2020), was reviewed on 10/26/2020 and required, "...Moments for Hand Hygiene... Prior to using computers and other electronic devices..."

2. During an observational tour of the Medical Stepdown Unit on 10/26/2020, at approximately 10:20 AM, a Registered Nurse (E#1) exited the room of a patient who was on contact and droplet precautions. After removing the reusable goggles and respirator mask, E#1 touched a stack of clean medication cups on the workstation and then went to chart on the computer without performing hand hygiene.

3. An interview was conducted with the Infection Control Practitioner (E#2) on 10/27/2020, at approximately 2:00 PM. E#2 stated that hands are considered contaminated after removing personal protective equipment and should be washed prior to touching clean supplies/equipment.