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Based on policy and procedure review, observations, and staff interviews, the hospital staff failed to ensure supplies and equpiment were manintained safety by failing to ensure refrigerated patient nourishments were not expired, laboratory blood collection tubes were not expired, and failing to ensure a main egress was not blocked.

The findings include:

Review of the "Management of Refrigerators and Freezers" policy with a last revision date of "May 2013" revealed, "I. Refrigerators and freezers are appropriately maintained to ensure safe food... V. PROCEDURE...C. Patient Nourishment/Food and Medication Storage 1. Food Storage a) Each unit/department, or designated personnel within the department, monitors the storage and stock rotation of Patient Nourishment/Food (as listed below), corrects deficiencies, and notifies the nurse manager/designees of action taken...c) Stock is rotated with each restocking. d) Dated items are discarded when expired."

1. Observation conducted September 25, 2013 at 1400 during tour of nursing unit #4 patient nourishment refrigerator had 12 of 20 expired refrigerated juices. Observation revealed two (2)-4 ounce orange juices were dated September 23, 2013 (expired 2 days). Observation revealed one (1)-4 ounce orange juice was dated September 20, 2013 (expired 5 days). Observation revealed eight (8)-4 ounce apple juices were dated September 14, 2013 (expired 11 days). Further observation revealed one (1)-4 ounce apple juice was dated September 14, 2013 (expired 11 days).

2. Observation conducted September 25, 2013 at 1430 during tour of nursing unit #4 clean supply room revealed 43 of 43 light blue laboratory blood collection tubes (coagulation tubes-blood clotting) were dated August 20, 2013 (expired 36 days).

3. Observation conducted September 25, 2013 at 1500 during tour of nursing unit #2 revealed 1 dietary cart blocked a main egress. Further observation revealed the dietary cart was not currently in use and blocked the main egress from 1500 until 1535.

Interview with Administrative Staff conducted September 25, 2013 at 1400 during tour of nuring unit #4 confirmed 12 of 20 juices were expired and 43 of 43 light blue laboratory blood collection tubes were expired.

Interview with Administrative Staff conducted September 25, 2013 at 1535 confirmed the dietary cart blocked the main egress.

Interview conducted September 26, 2013 at 0951 with the Dietary Manager revealed "FIFO (First In First Out) refrigeration stock method. Interview revealed nursing unit #4 patient nourishment refrigerator was last stocked on September 25, 2013. Further interview revealed the first dietary tray retrieval round was conducted one hour after service and the second dietary tray retrieval round was 20 minutes after the first tray retrieval.

Based on policy and procedure reviews, observations, and staff interview, the hospital staff failed to ensure the hospital equipment maintained a safe level of refrigeration by ensuring patient nourishment refrigerator temperatures were recorded daily for 1 of 3 nursing unit refrigerators (#2).

The findings include:

Review of the "Management of Refrigerators and Freezers" policy with a last revision dated of "May 2013" revealed, "...V. PROCEDURE...D. Manual Temperature Monitors 1. Each refrigerator/freezer is equipped with an internal thermometer...2. a) Department designees use the reading from the internal thermometer to record the daily refrigerator/freezer temperature on the appropriate temperature monitoring log."

Review of the "Quality Control - Monitor - Refrigeration" monitoring form revealed, "...Refrigeration and freezer temperatures are checked daily to assure safe storage of food.

Observation conducted September 25, 2013 at 1500 during tour of nursing unit #2 revealed no refirgerator temperature was documented on September 24, 2014 (1 day). A copy of unit #2 patient nourishment refrigerator log obtained September 26, 2013 revealed no refrigerator temperatures were documented September 24, 2013 nor September 25, 2013 (2 days).

Interview conducted September 25, 2013 at 1500 with Unit Manager of nursing unit #2 confirmed no refrigerator temperatures were recorded on September 24, 2013.

Interview conducted September 26, 2013 at 1010 with the Administrative Staff confirmed nursing unit #2 patient nourishment refrigerator temperatures were not recorded Septmeber 24, 2013 nor September 25, 2013.

Based on policy and procedure reviews, observations, and staff interviews, the hospital staff failed to reduce the risk of infection by failure to ensure clean and dirty equipment were stored separately and failed to ensure used patient trays were stored in the designated area.

The findings include:

Review of "(Hospital A) Infection Prevention Plan" with a date of January, 2013 revealed, "...IV. PROCESSES / PROGRAM COMPONENTS...RISK ASSESSMENT...2. National Patient Safety Goals and (Hospital A) goals to be addressed are...g. Limit transmission of infections associated with the use of medical equipment, devices, and supplies...VI. PERFORMANCE MONITORING PROGRAM GOALS, STRATEGIES AND ANALYSIS/EVALUATION...2013 Goals per Risk Assessment...Limit transmission of infections associated with the use of medical equipment, devices, and supplies. Strategies...Clearly designate clean equipment/supplies from dirty equipment/supplies. Measurement/Evaluation...Analyze service rounding data for improvements in separation of clean and dirty."

Review of the hospital, "TRAY IDENTIFICATION/DELIVERY/PICK-UP" with a revision date of "11/09" revealed, "POLICIES: ...PROCEDURES: ...Hospitality Assistant - Tray Retrieval...Places used trays on the cart. Checks the unit pantry for additional used trays."

1. Observation conducted September 25, 2013 at 1445 during tour of the "4th floor elevator hallway" revealed 3-uncovered PCA (Patient Controlled Analgesic) pumps on poles (1 pump per pole); 1-IV (intravenous) pump covered in plastic on a pole; 3-IV poles without IV pumps, and 1-covered dietary cart with 1-used patient tray.

2. Observation conducted September 25, 2013 at 1500 during tour of nursing unit #2 revealed 1-uncovered dietary cart with 3-used patient dietary trays in patient and visitor passageway.

Interview conducted September 25, 2013 at 1445 with the Nurse Manager of nursing unit #4 revealed the uncovered poles with pumps were dirty. Interview revealed the 1-plastic covered pump on a pole means the nursing staff had started the cleaning process. Interview revealed the "elevator hallway" was an employee area. Interview revealed no specific nursing personnel was assigned to ensure clean and dirty equipment was not stored together. Interview confirmed clean and dirty equipment were stored together in the elevator hallway.

Interview conducted September 25, 2013 at 1445 revealed the "elevator hallway" was not the appropriate area for clean and dirty equipment storage.

Interview conducted September 25, 2013 at 1530 with the Nurse Manager of nursing unit #2 confirmed 1-uncovered dietary cart with 3-used patient trays was in patient and visitor egress. Further interview confirmed the egress was not the designated area for the dietary cart with the 3-used patient trays.

NC00090670
NC00091513