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Based on interviews, record reviews, and policy reviews the facility failed to inform four (Patients #1, #5, #6, and #8) of thirteen current patients and/or their representatives of their patient rights in advance of providing or discontinuing care. The facility also failed to provide an Important Message from Medicare to two Medicare Patients (#5, and #6) of seven Medicare Patients reviewed. The facility also failed to provide patients with the correct information in order to file a complaint regarding patient care. The failure had the potential to affect all patients and/or their representatives in the facility. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights and Responsibilities" revised 01/12 showed the following:
- Patients have the right: To receive notification of their patient rights in writing . . . in advance of furnishing or discontinuing patient care whenever possible;
- To voice any concerns that they may have concerning the care they receive and to have those concerns reviewed and resolved;
- If patients have concerns regarding care received, they are encouraged to contact any staff present, the management or director of the department, or the Patient Safety Department;
- The telephone number and address of the available state agency that they may contact is listed in the hospital information packet provided to them;
- RESOLUTION OF PATIENT CONCERNS: It is the policy of Barnes-Jewish West County Hospital to inform patients of their rights and give them the opportunity to present their concerns. The Department Manager will serve as the primary hospital resource for complaints and can be reached by calling the main hospital number at 314-996-8000. Patient has the right to contact the Joint Commission or the Missouri Department of Health and Senior Services (DHSS) to lodge a grievance directly at:
Missouri Department of Health
1730 Southridge
Jefferson City, MO 65102
573-751-6303.

2. During an interview on 05/21/12 at 9:55 AM, Patient #6 stated that he did not remember getting his Patient's Rights notice upon admission. Patient's spouse was also in the room and stated they didn't give the patient anything that looked like that upon admission.

Record review of Patient #6's medical record showed no signed copy of the Patient Right's.

3. Record review of Medicare Patient #5's medical record showed no signed copy of the Patient's Rights or An Important Message from Medicare notice.

Record review of the facility's policies showed no specific reference for providing the Important Message from Medicare notice.

During an interview on 05/21/12 at 3:40 PM, Staff H, Registered Nurse (RN), Certified Case Manager, stated that there was no proof that Patient #5 received their Patient's Rights or an Important Message from Medicare. She stated that patients are given the information upon admission at the front desk or if the patients were admitted from the emergency department then she wasn't sure what the procedures would be but stated it was ultimately the responsibility of the patients nurse to be sure the information had been provided.

4. Record review of Patient #8's medical record showed it contained a copy of the facility's "Patient Rights", which was signed electronically by Patient #8 on 05/19/12 at 4:26 PM.

During an interview on 05/22/12 at 9:05 AM, Patient #8 stated that he did not know what his "Patient Rights" were. When a copy of the electronically signed "Patient Rights" was presented to him, he stated he had never seen the "Patient Rights" form, and questioned how his signature was on the form. Patient #8's family member stated that she was with Patient #8 through the entire admission process and when the patient signed for his admission, he signed an electronic device similar to what is used when you make a purchase with your credit card at a store. Patient #8 and his family member stated that they never saw the "Patient Rights" form, and that no one explained what "Patient Rights" were.

5. Record review of Patient #1's medical record showed no documentation that the patient received her "Patient Rights" and the record contained no copy of her Patient Rights.

During an interview on 05/21/12 at 2:57 PM, Patient #1 stated that she knew about "Patient Rights" because she had received them before at the facility, but hadn't received "Patient Rights" information during this visit.

Observation on 05/21/12 at 2:57 PM showed no copies of Patient #1's "Patient Rights" located in the room.

6. Record review of the facility document titled, "Patient's Rights and Responsibilities" undated, given to patients in the information packet upon admission contained an incorrect name and street address as follows:
For an external grievance, you may contact:
Missouri Department of Health
1730 Elm Street
P.O. Box 570
Jefferson City, MO 65102
Phone: (573) 751-6400.

The correct contact information that should be provided to patients in order to file a complaint about patient care should be:
Missouri Department of Health and Senior Services
323 Veterans Drive
P.O. Box 570
Jefferson City, MO 65102
Telephone: (573)751-6303.









29047

Based on observation, interviews, record reviews and policy reviews, the facility failed to obtain a physician's order prior to the administration of medication to patients in the Post Anesthesia Care Unit (PACU).

The severity and cumulative effect of this practice resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services. This had the potential to affect any patient undergoing a surgical procedure in the facility. The facility performs 20 to 23 surgical procedures per day. The facility census was 27.

Refer to tag 0406 for details.

Based on observation, interview, record review, policy review and review of the Medical Staff Rules and Regulations, the facility failed to ensure nursing staff obtained physician orders prior to administering medications to three (#26, #31 and #32) of three Post Anesthesia Recovery Room (PACU) patients who's records were reviewed. This had the potential to affect any patient undergoing a surgical procedure in the facility. The facility performs 20 to 23 surgical procedures per day. The facility census was 27.

Findings included:

1. Record review of the facility's "Rules and Regulations of the Medical Staff" revised on 03/21/12, showed that:
-patient care and treatment will be rendered only upon orders of the responsible Physician;
-all orders shall be in writing, dated, timed and signed by the responsible Physician;
-only the responsible physician shall issue any orders for a patient under their care and responsibility.

Record review of the facility's policy titled "Medication Administration and Ordering" reviewed/revised 02/12, showed that a specific physician's order is required for administration of any medication.

Record review of the facility's policy titled "Medication Management - Medication Ordering Policy" reviewed/revised 04/12, showed that medication orders must include the following:
-Date and time;
-Patient name;
-Medication name;
-Dosage;
-Route of administration;
-Frequency of administration;
-Prescribers signature.

Record review of the PACU Order Form showed that:
-the order form contained preprinted medication and dose, fluid and rate, oxygen and rate, lab, and monitoring options;
-preceding the preprinted options were blank boxes which were to be checked to indicate an order;
-boxes which were left unchecked indicated the preprinted options were not ordered
-blank lines followed fluid options for the infusion rate to be filled in, which would indicate an order.

2. Observation on 05/23/12 at approximately 9:05 AM showed Staff VV, RN administer medication (unknown) to Patient #31 in the PACU. The nurse stated to the patient that she was giving the patient "some medication for pain".

Record review on 05/23/12 at 9:13 AM, of Patient #31's PACU order form showed that none of the boxes on the order form (preprinted medications) had been selected or checked (which indicated there were no orders), but the order form was signed and dated (without a time) by Staff EE, Anesthesiologist.

During an interview on 05/23/12 at 9:25 AM, Staff EE, stated that he signs the PACU order form but does not write (check the box for) the orders for the patients in the PACU. Staff EE stated that the Registered Nurse (RN) administers medications from the options on the preprinted order form based on clinical experience and "knowing the expectations of the doctor". Staff EE stated "it's impossible to know the needs of the patient while they're in the PACU, so the nurses make the decision" of what to administer to the patients.

During an interview on 05/23/12 at 9:30 AM, Staff CC, Director of Surgical Services and Staff FF, PACU Manager stated that the PACU RNs complete the orders (check the boxes and fill in the blanks) for the anesthesiologist. Staff CC stated that both she and Staff FF were aware since 04/26/12 that this process occurred. Staff CC stated that an accrediting organization brought the process to their attentions and that Staff EE had been spoken to about this process and directed to write his own patient orders. Staff CC stated that Staff EE was a "rogue" physician and was "not one of ours", indicating he was a contracted physician.

Record review on 05/23/12 at 4:09 PM of Patient #31's Medication Administration Record (MAR), showed that the patient received (without a physician's order) Meperidine hydrochloride (narcotic pain medication) 10 milligrams (mg - unit of measure) intravenous (IV - in the vein), on 05/23/12 at 8:53 AM, 8:57 AM, and 9:02 AM, while in the PACU.

Record review on 05/23/12 at 4:11 PM of Patient #31's PACU order form, showed boxes had been checked (to indicate an order) on the PACU order form which previously were not checked while the patient was in the PACU, but remained un-timed by the physician.

3. Observation on 05/23/12 at approximately 9:20 AM showed Staff DD, RN, administer medication (unknown) to Patient #32 in the PACU.

Record review on 05/23/12 at 9:20 AM, of Patient #32's PACU order form, showed that none of the boxes on the order form had been selected or checked and that the IV infusion rates were blank, but the form was signed and dated (without a time), by Staff EE.

Record review on 05/23/12 at approximately 4:00 PM of Patient #32's Medication Administration Record (MAR), showed that the patient received the following medications (without a physician's order) while in the PACU by Staff DD, PACU RN:
-Normal Saline (NS - fluid) IV infusion at 2 ml/hr on 05/23/12 at 9:05;
-Ketorolac (non-narcotic pain medication) 15 mg IV on 05/23/12 at 9:10 AM;
-Hydromorphone (narcotic pain medication) 0.5 mg IV on 05/23/12 at 9:24 AM.

During an interview on 05/23/12 at 9:40 AM, Staff DD stated that the physician (Anesthesiologist) signs the preprinted PACU order form but does not select (order) medications or fluids from the options listed, when the patient is brought to the PACU. Staff DD stated that while the patient is in the PACU, she writes (checkmarks) the medications or fluids (indicating an order) for the physician, after he has signed the order form, based on what she has decided to give the patient.

Record review on 05/23/12 at approximately 4:00 PM of Patient #32's PACU order form, showed boxes had been checked on the PACU order form which previously were not checked and blanks were filled in which were previously blank while the patient was in the PACU, but the orders remained un-timed by the physician.

4. Observation on 05/23/12 at 10:35 AM, showed Staff UU, RN, administered Morphine (narcotic pain medication) 2 mg IV to Patient #26 in the PACU.

Record review of Patient #26's PACU order form showed no analgesics (pain medication) were ordered for Patient #26 and that the order form was not signed by the physician.

Based on observation, interview and policy review, the facility failed to ensure that outdated emergency medications were discarded and unavailable for patient use in two out of three crash carts (medical emergency cart) observed. This could potentially affect any patients in the facility with a life threatening situation. The census was 27.

Findings included:

1. Record review of the facility's policy titled "Pharmacy Department: Outdated Drug Control" revised on 01/09, showed that the Pharmacy personnel will constantly check all medication physically for dated items, remove all outdated packages, and isolate these medications from dispensing stocks.

2. Observation on 05/22/12 at 2:10 PM showed that the Emergency Department (ED) Pediatric Crash Cart contained two Epinephrine 1:10,000 injections (used to restore a patient's heart beat during cardiac arrest), Lot #L-92-476-DK, expired on 05/01/12.

During an interview on 05/22/12 at 2:20 PM, Staff P, Pharmacist, stated that the ED Pediatric Crash Cart was last checked 04/25/12, that the Epinephrine should have been removed at that time, but was missed.

3. Observation on 05/22/12 at 2:30 PM showed that the ED Adult Crash Cart contained a 2 gram (unit of measurement) Lidocaine infusion (used to return a patient's heart rhythm to normal during an emergency), Lot #95-931-KL, expired on 05/01/12.

During an interview on 05/22/12 at 2:40 PM, Staff P stated that she questioned the person responsible for checking the Adult Crash Cart on 04/25/12, and that the expired medication was accidentally returned to the Crash Cart instead of being replaced.

Based on interview, record review and policy review, the facility failed to ensure the losses of a controlled substance were properly reported in the facility's Safety Event System (SES) or to the Pharmacy Manager for one out of two controlled substance losses that were reviewed. The facility census was 27.

Findings included:

1. Record review of the facility policy titled "Medication Management - Controlled Substances Policy" reviewed/revised on 06/10, showed that:
-all losses of controlled substances are reported;
-an SES Report must be completed for any unresolved discrepancy or for a resolution which does not explain what occurred;
-the Pharmacy Manager is promptly notified of unresolved discrepancies.

2. Record review of an email dated 05/08/12 from Staff OO, Registered Pharmacist, to Staff QQ, Medical Director of Anesthesia, showed that during chart audits, Staff PP, Certified Registered Nurse Anesthetist (CRNA) was found to have withdrawn 300 micrograms (mcg) of Fentanyl (Narcotic Pain Medication) for two separate patients (specific patients and dates of the discrepancy were not documented in the email), but only documented administering 250 mcg to each patient, without documenting that the additional 50 mcg of Fentanyl was wasted (documentation that the controlled substance was discarded with a witness) for each patient.

During an interview on 05/23/12 at 1:17 PM, Staff OO stated that Staff PP:
-pulled additional controlled medications from 04/01/12 through 04/15/12, which exceeded the normal amount pulled for a CRNA, which place him on the "Outliers Report" (report which identified potential risk of misappropriation of controlled substances);
-had removed a controlled substance from the medication dispensary to administer to a patient (unknown name) in the Operating Room (OR), but the amount administered to the patient didn't equal the amount of the medication that was removed, creating a discrepancy;
-had controlled substance discrepancies for two out of three patient records reviewed by Staff OO from 04/01/12 through 04/15/12;
-electronically "transfers" (in the medication dispensary) controlled medications (unused) from one patient to another, which made his records difficult to audit for controlled substance discrepancies.

During an interview on 05/23/12 at 3:05 PM, Staff QQ stated that he asked Staff NN Pharmacy Manager to continue to monitor Staff PP's controlled medication administration and wastes, after he received the email regarding Staff PP's controlled medication discrepancies.

During an interview on 05/23/12 at approximately 1:45 PM, Staff NN stated that she was unaware of Staff PP's discrepancies that were found between 04/01/12 and 04/15/12 and at 3:40 PM stated that she was not asked to monitor Staff PP's controlled medication administration and wastes by Staff QQ.

During an interview on 05/23/12 at approximately 2:10 PM, Staff OO, Registered Pharmacist stated that she didn't report Staff PP's missing controlled substance to Staff NN, Pharmacy Manager because it didn't seem as "suspicious" as other controlled substance discrepancies that had been investigated on the "Outliers Report".

During an interview on 05/23/12 at approximately 2:15 PM, Staff NN stated that she should have been notified of the discrepancies found with Staff PP and that an SES Report should have been completed. Staff NN added that Staff PP had previous unresolved discrepancies with controlled substances, which occurred approximately one year ago, but could not remember:
-if an SES report was completed at that time;
-any of the details related to the controlled substance discrepancy;
-if Staff OO was aware of the Staff PP's discrepancy history.

During an interview on 05/24/12 at approximately 9:00 AM, Staff PP stated that:
-all unused controlled substances should be wasted and documented in the medication dispensary with a witness;
-he was not aware of any facility concerns about his performance;
-he had never been spoken to or counseled about missing controlled substances.

3. Record review on 05/24/12 of Staff PP's employee file did not contain evidence that Staff PP's had been coached or counseled regarding the controlled substance discrepancy.

Based on observation, interview, record review and policy review, the facility failed to ensure outdated supplies were removed and unavailable for patient use in one out of three crash carts observed and for one out of one tackle box observed (contained specific medications and equipment used by a plastic surgeon). This had the potential to affect all patients. The census was 27.

Findings included:

1. Record review of an undated facility's process titled "Expired Products Process", showed that;
-Supply Distribution Technicians would conduct "Expired Goods Audits" one week per month;
-Expired items would be collected and recorded;
-Once the items have been recorded, they will be disposed of in the appropriate manner.

2. Observation in the Emergency Department (ED) on 05/21/12 at 1:52 PM showed a tackle style box (contained specific medications and equipment used by a plastic surgeon) contained the following outdated supplies, which were confirmed by Staff B, Manager of the ED, Intensive Care Unit (ICU), Step Down Unit (SDU) and Respiratory Services:
-nine sutures (stitches), Lot #ZAZ177, expired on 01/12;
-seven sutures, Lot #ZGE681, expired on 01/12;
-one suture, Lot #XDB035, expired on 01/11;
-three sutures, Lot #XJH331, expired on 07/11.

During an interview on 05/21/12 at 2:05 PM, Staff B stated that the ED Registered Nurse (RN) or Emergency Department Technician (EDT) should check expiration dates when the tackle style box was used, but added that the box wasn't checked on a regular basis, and "is not on our list of checks", indicating that it was not scheduled to be checked for expired supplies, as other areas in the ED were.

3. Observation on 05/22/12 at 3:15 PM showed the Step Down Unit (SDU)/Intensive Care Unit (ICU) Crash Cart (medical emergency cart) contained the following expired supplies, which were verified by Staff B:
-one electrode pad (used to defibrillate or shock a patient during cardiac arrest, to restart a patient's heart), Lot #090910-01, expired on 04/12;
-one extension port (used to lengthen intravenous tubing - used to administer fluid to a patient), Lot #08096038, expired on 09/11;
-one Provodine Iodine Scrub (used to cleanse an area of the skin before a procedure), Lot #08096038, expired 09/11;
-one Esophageal Nasogastric Tube (used to administer or remove fluids from a patient's stomach), Lot #L0092030, expired on 09/10.

During an interview on 05/22/12 at 3:20 PM, Staff B stated that the RNs were expected to check for expired items in the crash cart once per month and every time the cart was opened.

Record review of the "Emergency Adult Crash Cart Supply Checklist" showed instructions that the "entire contents of the cart are to be checked ...on checklist after every use and following the monthly pharmacy checks". The checklist indicated that the crash cart had been inventoried on 05/01/12 and 05/09/12.

Based on observation, interview and policy review the facility failed to ensure the following were compliant with standard procedures for infection control pertaining to hand hygiene for five (Patients #1, #2, #6, #10 and #41) of 10 patients observed, clean technique for one (Patient #1) of six patients observed, glove use for four (Patients #2, #6, #10 and #41) of four patients observed and Personal Protective Equipment (PPE) for one (Patient #41) of one patient observed and clean uniforms. This had the potential to affect all patients in the facility. The census was 27.

Findings included:

1. Record review of the facility's policy titled, "Infection Control Precautions" dated 02/12 showed the following direction to staff:
- Perform hand hygiene before and after patient contact and after removing gloves;
- Gloves must be worn when performing any vascular access procedures such as starting IV's or drawing blood; and
- Change gloves: Before moving from dirty to clean tasks on the same patient.

Record review of the facility's policy titled, "Sequence for Donning Personal Protective Equipment (PPE)" dated 10/10 showed the following:
- Gown, fully cover torso from neck to knees, arms to ends of writs, and wrap around the back;
- Mask;
- Gloves.

Record review of the facility's policy titled "Infection Control Precautions: Contact Precautions" approved on 02/12, showed that staff were to perform hand hygiene after removing gloves.
- Indications for hand hygiene: Before donning sterile gloves.

Record review of the facility's policy titled "Hand and Fingernail Hygiene" approved on 01/04/12, showed that staff were to perform hand hygiene after removing gloves and when moving from a contaminated body site to a clean body site during care.

2. Observation on 05/21/12 at 9:55 AM showed Staff J, Registered Nurse (RN) in Patient #6's room. Staff J did not donn gloves and proceeded to change the patient's IV (intravenous or in the vein) fluid and start the IV. Staff J did not perform hand hygiene after this procedure. Staff J then answered her telephone which was under her shirt, talked on the telephone and then replaced it under her shirt. No hand hygiene was performed. Staff J pulled a package of gauze out of her pocket and wrapped patient's IV tubing in place securing it with tape. Staff J then touched patient's leg which was blistered and seeping fluid with her bare hands. No hand hygiene was performed immediately after this exam.

3. Observation on 05/22/12 at 8:30 AM showed Staff I, RN, prepare medications for Patient #10. Staff I entered patient's room and did not perform hand hygiene but administered oral medications to patient. Staff I prepared to draw blood from the patient and performed hand hygiene but then typed on the computer and touched patient's bare skin before donning gloves. After drawing patient's blood Staff I removed the gloves but did not perform hand hygiene.

4. Observation on 05/22/12 at 8:45 AM showed Staff I, RN, enter Patient #2's room to administer medication through the IV line. Staff I did not perform hand hygiene when she entered the room and did not donn gloves to mix the IV medications. After IV medications were mixed, Staff I donned gloves without performing hand hygiene, touched patient's IV site and connected the IV medication.

5. Observation on 05/22/12 at 9:10 AM showed Staff I, RN, enter Patient #10's room to administer medications. Staff I talked on the telephone and touched patient several times on the bare skin. Staff I then donned gloves without performing hand hygiene and started the IV medication. Staff I then picked up soiled tissues off the bed and put them in the trash and removed the gloves. She then moved the computer into the hall and then used hand hygiene.

6. Observation on 05/22/12 at 2:50 PM showed Staff L, RN, and Staff M, RN, preparing to insert a peripherally inserted central catheter (PICC) line (a form of intravenous access) into Patient #41. Both Staff L and Staff M were wearing street clothes and masks while preparing the 'sterile field' (an operative field that is properly sterile according to surgical ASEPSIS. It includes having all furniture and equipment covered with sterile drapes and all personnel being properly attired) and gave direction for everyone else to remain at least five to seven feet from the area. Neither RN was wearing gloves while preparing the surgical area. Staff M assisted Staff L and prepared the surgical instruments, opened sterile packets and dropped them crossing the sterile field on the sterile pad.

Staff L did not perform hand hygiene but opened sterile packets and donned a sterile gown. During the donning of the sterile gown the tie broke which would go around the waist and tie securing the gown in place. Staff L threw the broken tie in the trash and continued to donn sterile gloves without performing hand hygiene. Staff M proceeded to clean patient's right arm with antiseptic but did not perform hand hygiene and did not donn gloves. Staff M did not donn PPE, gloves or perform hand hygiene during the entire procedure but touched patient on two occasions adjusted his head, reached over the sterile fields, put items in the trash and moved the trash to a different location - all with bare hands, no hand hygiene and no PPE.

During an interview on 05/22/12 at 3:25 PM, Staff N, RN, who also observed the PICC line insertion, stated that she was a nurse practitioner and that she was very sensitive to sterile procedures. Staff N stated that she saw Staff M break the sterile field at least four times and did not donn PPE or use hand hygiene during the procedure. Staff N also stated that she was surprised when Staff L didn't put on a different sterile gown after she broke the tie and that she had worn the mask the entire time without changing it for the sterile procedure.

7. Observation on 05/21/12 at approximately 2:30 PM, showed Staff A, Emergency Room RN, started an intravenous catheter (used to deliver medication or fluids to the patient) on Patient #1. During the procedure, Staff A:
-failed to wash her hands between a glove change when was unable to start the first IV successfully and attempted a second IV;
-removed a cap from the end of sterile IV tubing with her mouth before attaching it to the end of the patient's sterile IV catheter;
-failed to disinfect the patient's bedside table after she rested a antiseptic pad on the table which was saturated with blood.

During an interview on 05/21/12 at 2:40 PM, Staff A stated that she:
-should have washed her hands between glove changes;
-should have removed the IV tubing cap with her hands and not her mouth;
-didn't realize the bloody antiseptic pad was in contact with the patient's bedside table and should have sanitized the bedside table.

8. Record review of the United States Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction:
-Chapter 2-301.14 Food service employees shall clean their hands before donning gloves for working with foods; after handling soiled equipment or utensils and after engaging in other activities that contaminate the hands.
-Chapter 3-304.15 Gloves shall be used for only one task and discarded when damaged or soiled.

Record review of the facility's dietary department policy titled "Hand washing (HACCP)", {Hazard Analysis and Critical Control Point system, a preventative approach to food borne hazards} reviewed 05/10 showed direction for facility dietary staff to wash hands before putting on gloves and after any activity that may contaminate the hands.

Record review of the facility's policy titled "Infection Control Precautions: Standard Precautions" approved 02/12 showed the following direction:
-Hand hygiene: Perform hand hygiene often and well, paying particular attention around and between fingers;
-An alcohol-based hand rub was preferred over soap and water unless hands were visibly soiled;
-Rub hands together, covering all surfaces of hands and fingers with antiseptic rub; and
-Perform hand hygiene after removing gloves.

9. Observation on 05/22/12 from 11:05 AM through 11:25 in the facility kitchen showed the following:
-Staff T, Cook, measured the temperatures of pans of food on the patient tray assembly line, removed soiled gloves then without hand washing put on another pair of gloves.
-Staff T removed soiled gloves after retrieving a pen from the floor then, without hand washing put on another pair of gloves.
-Staff U, Cook, removed gloves, then without hand washing, placed a pan of meat in the oven.

10. Observation on 05/22/12 from 12:05 PM through 12:10 PM on the second floor patient unit showed the following:
-Staff Q, Diet Aide delivered individual patient meal trays, moved items on the patient over-bed tables then, used alcohol foam by rubbing the foam only on the palms of his hands (not between his fingers or on the backs of the hands).

11. Record review of the facility's dietary department policy titled "Uniform Dress Code" dated 08/08 showed direction for staff to wear a clean uniform daily.

12. Observation on 05/22/12 from 11:05 AM through 11:16 AM in the kitchen showed Staff T, Cook served foods on the patient tray assembly line and wore a soiled long sleeved uniform with lines of dark unknown debris along the cuffs of each sleeve.

During an interview on 05/22/12 at 12:05 PM Staff Q, Director of Food and Nutrition confirmed Staff T was serving patient meal trays while wearing a soiled uniform with debris along the cuffs. Staff Q stated, "Yes, I saw the soiled uniform".


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