HospitalInspections.org

Based on staff interview and a review of facility documentation, the hospital failed to ensure that daily and weekly preventive maintenance tasks for the sterilizer was performed according to the sterilizer manufacturer's service manual.

Findings were:

During a tour of the hospital with the CNO and OR manager, on the morning of 11/1/16, the manual for the Steris Amsco Steam Sterilizer was requested. The manual included a section entitled Routine Maintenance (Section 8) which included the following:
"4. Preventive Maintenance is essential in keeping this equipment in optimal working condition...Operator inspections and procedures must be made on a daily, weekly or as needed basis as indicated in Section 8, Routine Maintenance..." Daily, weekly and "as needed" maintenance tasks were listed in this section.

The hospital could provide no facility policy addressing preventive maintenance of the sterilizer or an adopted schedule for such maintenance.

When asked if the daily and weekly preventive maintenance tasks were being performed, the OR manager stated she did not believe these tasks were being completed or documented. She did state that other preventive maintenance tasks on the sterilizer were completed according to the facility's equipment contract.

Based on observation, a review of facility documentation and staff interview, the failed to ensure that the entire hospital premises was clean and orderly.

Findings were:

During a tour of the facility on the morning of 11/1/16 with hospital administrative staff, the following items were noted:

o A large water stain covering two ceiling tiles in the small room used to perform medical screening examinations in the emergency department. Ceiling tiles exposed to water can crumble over patient care areas and harbor mold.
o Two boards used as shelving were found under the sink in the emergency department. There was a thick layer of dust in the cabinet and the DON stated, " It ' s been a while since someone ' s cleaned under here. "
o The flooring in the OR suite was cracked in numerous places and attempts had been made to fill the cracks with caulking. The floors of the two ORs themselves included numerous seams. Some of the seams were cracked and contained caulking. Cracked and caulked flooring makes thorough cleaning impossible.
o Patient rooms #404 and #456 included chairs with chipped paint on the wood which made them impossible to clean effectively.
These findings were confirmed in an interview with the hospital CEO and other administrative staff on the afternoon of 11/1/16 in the hospital meeting room.



36594

Based on review of facility policies, observation and interview, the facility failed to ensure the premises were clean and orderly.

Findings included:

Facility policy titled "Dishwashing procedure" stated in part "11. When all dishes have been washed, clean dish machine thoroughly."

Facility policy titled "Food and Supplies Purchasing" stated in part, "3. All deliveries must be inspected for accuracy, for quality and sanitation standards. All items must be clearly labeled with the container's contents. There must be no exceptions ...
19. Rotate stock so that older items are used first. Date products to ensure the use of AFirst [sic] In-First Out@ [sic] procedures."

Facility policy titled "Dietary Department Rules and Guidelines" stated in part, "21. All food in ALL refrigerators, freezers MUST BE LABELED with NAME OF FOOD ITEM, DATE IT IS PUT INTO STORAGE. Remember to label both the side and cover of bin-type storage containers."

In an interview with the dietary supervisor at 9:30 AM on 11/01/16, when asked when they clean the dishwasher, she stated, "We don't. They [the dishwasher servicers] clean at the end of every month."

Observation of the dish washer on the morning of 11/01/16 revealed dust and dirt build-up on the exterior of the machine.

Tour of the kitchen on the morning of 11/01/16 revealed the following in the freezer without labels of name of food and date placed in storage:
*Bag of chicken
*Bag of meat patties
*Bag of individual pizzas

The above was verified with the COO on the morning of 11/01/16 during the tour.

Based on review of facility documents, observation and interview, the facility failed to ensure proper temperature control in patient care and food preparation areas.

Findings included:

Facility policy titled "Food and Supplies Purchasing" stated in part, "3. All deliveries must be inspected for accuracy, for quality and sanitation standards. All items must be clearly labeled with the container's contents. There must be no exceptions.
4. All delivered items should be properly stored in accordance with State and County codes and standards:
...d. All refrigeration units must be maintained at 40 to 45 degrees F. Freezer units must be maintained at 0 to -10 degrees F."

Facility policy titled "Food Storage" stated in part, "B. Perishable Storage (Cooled and Frozen)
1. Cool storage facilities must be so constructed, insulated and installed as to insure the maintenance of a temperature range of 34 to 45 degrees F and 0 to -10 degrees F respectively.
...3. The temperature of all cool storage facilities should be checked and logged on the appropriate form daily with deviations from the norm reported and action recommended or taken recorded."

Facility policy titled "Equipment and Temperature Monitoring" stated in part, "4. Temperatures must be as follows:
Refrigerators 40-45 F
Freezers -10-0 F
Dishmachine Final Rinse 180-195 F
Dishmachine Wash 140-160 F ...
5. Any variance to these temperatures must be investigated and Maintenance must be contacted if the problem cannot easily be determined and fixed.
6. Temperature logs are also posted on each refrigerator in the hospital floors pantries used to store patient nourishments ..."

Facility policy titled "Temperatures/Food Equipment" stated in part,
"Soup 160 degrees F
Entrée 140 degrees F ...
Cold beverage 45 degrees F ...
Refrigerators: Meat/Dairy and Reach-In - 34-38 degrees F
Produce - 38-45 degrees F
Freezers: Below 0 degrees F
Dish Machine: Wash 160 degrees F
Rinse 180 degrees F
If chemical sanitizer is used, a temperature of 120 degrees shall be maintained ...
Foot Item Serving Temperature
Soups/Broth 170-180 degrees F
Vegetable 150-160 degrees F
Creamed 150-160 degrees F ...
Cold Liquids 38-40 degrees F ..."

Facility policy titled "Dishwashing" stated in part, "All dishes must be scraped and run through the dishmachine. The wash water must be 160 degrees F. Final rinse water must be at least 180 F at the rinse manifold. A sanitizing agent dispensed by the machine may also be used instead of hot water to properly sanitize dish and silverware."

Review of food temperature logs in the kitchen for the past four months revealed no temperature ranges of acceptable food temperatures. When asked staff #11 what the temperatures should be at, staff #11 stated, "I don't know." When asked if the ranges were easily accessible, staff #11 stated, "No." Without food ranges accessible to staff, they have no way of knowing if food temperatures were maintained for the prevention of bacterial growth.

A small refrigerator in the emergency department was identified by Staff #1 as containing patient nutrition items. When asked, the facility could provide no documented evidence of temperature checks being performed on this refrigerator. Thus, there was no way to ascertain if the refrigerator remained within an acceptable temperature range to maintain the patient nutrition items.

Review of three different refrigerator and freezer logs for the last four months revealed none were labeled with which refrigerator or freezer was being tracked and none were labeled with the acceptable range for each; therefore, none showed documentation of deviations from the norm that were reported and action recommended or taken.

Review of the dish washer temperature and chemical sanitizing test strip logs for the last four months revealed no labels of acceptable ranges. For the month of September, the following dates were missing checks: 9/15/16 AM and PM, 9/16/16 AM and PM and 9/17/16 AM. Without ranges easily accessible to staff and the missing checks, they have no way of knowing if temperatures and sanitizing chemicals were maintained for sanitation of all dishes and utensils.

When asked what the temperatures the refrigerators, freezers and dishwasher should maintain, staff #11 and staff #12 were unsure. Review of facility policies revealed several different temperature ranges for food, refrigerators, freezers and dishwasher. In an interview with staff #12 on the afternoon of 11/01/16, staff #12 stated, "Yes, I've been trying to change the policies."

The above was confirmed with the CEO and other department heads on the afternoon of 11/01/16.

Based on a review of available documents, staff interviews, and tour of the facility, the governing body failed to assume full legal responsibility for determining, implementing and monitoring the CAH's total operation and ensuring that policies are administered and implemented. A policy for the facility laundry equipment and routine handling of facility's laundry process was not available.


Findings were:


During a tour of the facility and interview with staff it was revealed that the facility did not have a policy that identified the facility's laundry equipment, routine handling of contaminated laundry, laundry process or special laundry situations.

The above findings were confirmed by the Chief Executive Officer on the afternoon of 11/01/16. He stated, "We started doing the hospital's laundry here at our facility about six months ago and we do not have a policy, we just overlooked that."



36594

Based on review of facility documents and staff interview, the governing body failed to determine, implement and monitor policies governing the CAH's total operation.

Findings included:

Review of refrigerator, freezer, dishwasher and food temperature logs for the last four months revealed no ranges labeled on the logs.

Review of facility policies revealed several different temperature ranges for food, refrigerators, freezers and dishwasher. In an interview with the dietary director on the afternoon of 11/01/16, he verified the conflicting policies and stated, "Yes, I've been trying to change the policies."

The above was confirmed with the CEO and other department heads on the afternoon of 11/01/16.

Based on a review of facility documentation and staff interviews, the facility failed to ensure accuracy in the medical record documentation for 1 of 2 deceased patient records reviewed (Patient #22)

Findings were:

Facility policy #HIM-00.011 entitled Record Analysis Quantitative & Qualitative Inpatient Record, last revised 8/2013 included the following:
"Discharge Summary:
The following items are checked for completelness:...
g. Condition of patient on discharge..."

A review of the medical record of Patient #22, admitted on 6/6/16, revealed she was pronounced dead on 6/8/16 at 5:12 a.m. A Discharge Summary dictated on 6/15/16 for Patient #22, included the following:
"Her status maintained to be stable throughout her hospital stay and on hospital day #2, it was the family's decision to withdraw further care and pursue hospice services for care and comfort only. Hospice evaluated her and agreed that it would be appropriate for her to continue with supportive care only. She was therefore discharged back to the nursing home with hospice services in place to assist with her care and comfort only..."

These findings were reviewed in an interview with the facility CEO and other administrative staff on the afternoon of 11/1/16 in the hospital meeting room.