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Based on interviews, clinical record review and review of hospital policies, it was determined staff failed to a) identify the use of a medication as a restraint and b) failed to monitor and document according to policy for one (1) of one (1) patient included in the sample who received medications to control behavior (Patient #15).

The findings include:

Surveyor review of the clinical record for Patient #15 was conducted on April 12, 2018 with the assistance of a navigator provided by the hospital staff (Staff Member #9).

Patient #15 was admitted for observation on 7/3/17 arriving to the 4th floor observation at 6:20PM. Ativan 1mg was given orally at 6:27PM. At 7:00PM, Patient #15 was noted to be confused and tearful. At 11:10PM, Patient #15 was documented as becoming more upset and harder to calm down with the patient trying to get out of bed and pulling the IV out. Orders were obtained and Valium 2mg was given IV at 11:13PM. At 11:30PM, nursing documentation reads "Medication given not much of response noted, patient unable to relax". Documentation at 7/4/17 at 00:50AM reads in part "bed alarm was alarming, patient ran out of room broke IV tubing in half. Unable to calm patient security called patient assisted by three personnel...restraints placed....orders received. Verbal order to give Geodon 2mg IM. Medication given...able to transport patient to the unit per order." Patient #15 arrived to unit at 1:50AM per orders, for delirium and combative behavior. Patient was cooperative at arrival. Bilateral wrist restraints reapplied to bed." At 1:53AM documentation notes the patient attempting to get out of bed unassisted breaking right wrist restraint. "Pt delusional, confused and combative." New orders given for Geodon 20mg IM given at 2:55AM. At 3:00AM order received for Precedex infusion starting at 0.2 mcg/kg/hr increase rate by 0.1mcg/kg/hr every 30 minutes until RASS goal is reached. Sedation goal RASS -1: Drowsy. Precedex infusion initiated at 3:06AM. At 3:59AM, nursing documentation reads "Pt remained confused combative attempting to get out of bed, call placed to Dr. (name). Order given to intubate. (name) NP at bedside". Patient was successfully intubated at 3:50AM on 7/4/17. Precedex was held and patient was placed on Propofol and Fentanyl for sedation. On 7/5/17 at 9:30AM sedation was placed on hold; patient remained on the ventilator until 2:25PM and was extubated without incident.

Giving a medication for the purpose of controlling the behavior of a patient as is documented for Patient #15 at 1:50AM, 2:55AM and 3:06AM constitutes a chemical restraint according to facility policy. Restraint documentation from the initiation of the restraint up to the intubation was for non-violent restraint and as such the patient was monitored every two hours from 1:15AM until 5:15AM. There is no evidence the medications were considered to be a chemical restraint by staff and there is no documentation of assessment for chemical restraint as defined in the hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)". The aforementioned policy requires an RN or Physician assessment within 5 minutes, and monitoring by an RN or Physician at least every 10 minutes for the next 30 minutes; for an IM medication, an RN or Physician assessment within 15 minutes, and monitoring by an RN or Physician at least every 15 minutes for the next 60 minutes: and for a PO medication an RN or Physician assessment within 30 minutes, and monitoring by an RN or Physician at least every 30 minutes for the next 60 minutes.

The use of medications restraints for violent behaviors was discussed on 4/17/18 at 11:00AM with Staff Member (SM) #21, the Chief Medical Officer for the hospital, (due to scheduling conflicts, and patient care duties the surveyor was unable to interview the physician or nurse who initiated the restraint). SM #15 stated that medications would be considered to be a restraint, if the purpose of the medication was not to allow the patient to interact with his environment but to restrict the patients movement or behavior. SM #15 stated his/her expectation would be for the medical staff to follow the policy.

The above findings were discussed with the management team at end of the day meetings on 4/12/18 at 5:00PM and 4/17/18 at 4:05PM. The discussion included an opportunity for the management to ask questions of the surveyor or for clarification of the issue. No questions were presented or further information provided to the surveyor.

Based on interviews, clinical record review and review of hospital policies, it was determined staff failed to release a patient from restraints at the earliest possible time for one (1) of six (6) patients included in the sample of patients who were restrained. (Patient #14)

The findings include:

The clinical record of Patient #14 was reviewed with the assistance of a navigator provided by the hospital Staff Member (SM) #9. Patient #14 was admitted on 4/10/18 with a diagnosis of bilateral pneumonia and arrived to the assigned room at approximately 7:00PM. Nursing documentation of the patient's behavior from time of arrival to 4/11/18 at 2:00PM was uneventful noting the patient was "resting quietly": and "no acute distress". At 10:00PM on 4/11/18, nursing documentation reads "Dr.(name) notified of pt agitation, cursing, hitting and spitting at staff. Husband requested "medication for [patient] please" Dr. (name) ordered Haldol 0.5mg IV, administered."(Haldol (haloperidol) is an antipsychotic medication). At 10:30PM, nursing documentation reads "Pt. cont to curse, swing and spit at staff. Dr. (name) notified, Ativan 0.5mg IV ordered and administered."(Ativan is a medication used to treat anxiety) Patient #15 was documented as "combative" by respiratory staff at 11:06PM.

An order for restraints was obtained and Patient #14 was placed in 4-point restraints (soft restraints placed on wrists and ankles) on 4/11/18 at 10:30PM. Physician documentation on 4/11/18 reads in part "Patient very agitated and hostile overnight, required restraints and one on one care".

The surveyor asked what the nurse or physician used to determine whether a restraint would be considered to be "Violent" or "Non-Violent". Staff Member (SM) #2 provided the surveyor with education materials that are used during each teammate's orientation. The surveyor was also provided a copy of hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)".

Educational materials contained the following information in part regarding non-violent restraints: "*Non-violent restraints are used when the patient is demonstrating behaviors such as pulling at tubes, confused, unable to follow instructions *The behavior is non-violent and not aggressive *The purpose of the restraint is to promote medical/surgical healing"

Educational materials contained the following information in part regarding violent restraints: "*The patient's behavior is aggressive or violent *Your assessment indicates a risk of serious danger to self or others". In addition the "Team Member Handbook orientation guide contains the following key restraint documentation phrases for violent restraints "combative, kicking, hitting, biting, aggressive."

Hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)", contains the following under definitions "Violent Restraint: Violent Restraint is utilized in emergency or crisis situation when a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to self or others".

Based on the information found in the policy, education documents and staff documentation of the behavior of the patient (combative, hitting spitting, swinging at staff), Patient #14's restraint should have been initially documented as violent. Per hospital policy, documentation relating to a patient in "violent" restraints is completed in 15 minute intervals with a nursing assessment every hour to determine the need to continue or release the restraint. Patient #14 was documented as being in non-violent restraints with documentation every 2 hours and a nursing assessment every 8 hours per policy.

The clinical record contains no documentation by the nurse related to the continued need for restraints from the time the restraints were applied until restraints were discontinued by physician order on 4/12/18 at approx 11:30AM. Patient #15's behavior after 2:30AM was documented as "confused, resting quietly, and/or sleeping". Restraint documentation during this time was completed by a staff member sitting with the patient for one to one observation, communication is expected to occur between the sitter and the registered nurse caring for the patient regarding the release the patient from restraints at the earliest possible time.

Hospital staff failed to recognize the restraint was placed for violent behaviors and failed to document according to hospital policy for violent restraints. Hospital staff failed to release the patient from restraints after documentation shows the patient was resting quietly from 2:30AM until 11:30AM. The use of restraints for violent vs non-violent behaviors was discussed on 4/17/18 at 11:00AM with (Staff Member (SM) #21) the Chief Medical Officer for the hospital, (due to scheduling conflicts, and patient care duties the surveyor was unable to interview the physician or nurses who initiated the restraint). SM #15 stated that restraints would be considered to be a violent restraint, if the patient was a threat to him/herself or others, and should be based on the patient's behavior not the diagnosis of the patient, violent behaviors requiring the use of restraints could be caused by medical and/or behavioral health problems. SM #15 stated his/her expectation would be for the medical staff to follow the policy.

The above findings were discussed with the management team at end of the day meetings on 4/12/18 at 5:00PM and 4/17/18 at 4:05PM. The discussion included an opportunity for the management to ask questions of the surveyor or for clarification of the issue. No questions were presented or further information provided to the surveyor.

Based on interviews, clinical record review and review of hospital policies, it was determined staff failed to a) identify the use of a restraint for violent behaviors and b) failed to monitor and document according to policy for two (2) of two (2) patients included in the sample who were placed in a 4 point restraint. (Patient #14 and #15).

The findings include:

1. The clinical record of Patient #14 was reviewed with the assistance of a navigator provided by the hospital (Staff Member (SM) #9). Patient #14 was admitted on 4/10/18 with a diagnosis of bilateral pneumonia and arrived to the assigned room at approximately 7:00PM. Nursing documentation of the patient's behavior from time of arrival to 4/11/18 at 2:00PM was uneventful noting the patient was "resting quietly": and "no acute distress". At 10:00PM on 4/11/18, nursing documentation reads "Dr.(name) notified of pt agitation, cursing, hitting and spitting at staff. Husband requested "medication for [patient] please" Dr. (name) ordered Haldol 0.5mg IV, administered."(Haldol (haloperidol) is an antipsychotic medication). At 10:30PM, nursing documentation reads "Pt. cont to curse, swing and spit at staff. Dr. (name) notified, Ativan 0.5mg IV ordered and administered."(Ativan is a medication used to treat anxiety) Patient #14 was documented as "combative" by respiratory staff at 11:06PM.

An order for restraints was obtained and Patient #14 was placed in 4-point restraints (soft restraints placed on wrists and ankles) on 4/11/18 at 10:30PM. Physician documentation on 4/11/18 reads in part "Patient very agitated and hostile overnight, required restraints and one on one care".

The surveyor asked what the nurse or physician used to determine whether a restraint would be considered to be "Violent" or "Non-Violent". Staff Member (SM) #2 provided the surveyor with education materials that are used during each teammate's orientation. The surveyor was also provided a copy of hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)".

Educational materials contained the following information in part regarding non-violent restraints: "*Non-violent restraints are used when the patient is demonstrating behaviors such as pulling at tubes, confused, unable to follow instructions *The behavior is non-violent and not aggressive *The purpose of the restraint is to promote medical/surgical healing"

Educational materials contained the following information in part regarding violent restraints: "*The patient's behavior is aggressive or violent *Your assessment indicates a risk of serious danger to self or others". In addition the "Team Member Handbook orientation guide contains the following key restraint documentation phrases for violent restraints "combative, kicking, hitting, biting, aggressive."

Hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)", contains the following under definitions "Violent Restraint: Violent Restraint is utilized in emergency or crisis situation when a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to self or others".

Based on the information found in the policy, education documents and staff documentation of the behavior of the patient (combative, hitting spitting, swinging at staff), Patient #14's restraint should have been initially documented as violent. Per hospital policy, documentation relating to a patient in "violent" restraints is completed in 15 minute intervals with a nursing assessment every hour to determine the need to continue or release the restraint. Patient #14 was documented as being in non-violent restraints with documentation every 2 hours and a nursing assessment every 8 hours per policy.

The clinical record contains no documentation by the nurse related to the continued need for restraints from the time the restraints were applied until restraints were discontinued by physician order on 4/12/18 at approx 11:30AM. Patient #15's behavior after 2:30AM was documented as "confused, resting quietly, and/or sleeping". Restraint documentation during this time was completed by a staff member sitting with the patient for one to one observation, communication is expected to occur between the sitter and the registered nurse caring for the patient regarding the release the patient from restraints at the earliest possible time.

Hospital staff failed to recognize the restraint was placed for violent behaviors and failed to document according to hospital policy for violent restraints.

2. Surveyor review of the clinical record for Patient # 15 conducted on April 12, 2018 with the assistance of a navigator provided by the hospital (Staff Member #9).

Patient #15 was admitted with a diagnosis of seizure for observation on 7/3/17 arriving to the 4th floor at 6:20PM. Ativan 1mg was given orally at 6:27PM (Ativan is a medication used for anxiety). At 7:00PM, Patient #15 was noted to be confused and tearful. At 11:10PM, Patient #15 was documented as becoming more upset and harder to calm down with patient trying to get out of bed and pulling IV out. Orders were obtained and Valium 2mg was given IV at 11:13PM (Valium is a medication used for anxiety and sedation) . At 11:30PM, nursing documentation reads "Medication given not much of response noted, patient unable to relax". Documentation at 7/4/17 at 00:50AM reads in part "bed alarm was alarming, patient ran out of room broke IV tubing in half. Unable to calm patient security called patient assisted by three personnel...restraints placed....orders received. Verbal order to give Geodon 2mg IM. Medication given...able to transport patient to the unit per order." (Geodon (ziprasidone) is an antipsychotic medication) Patient was transferred to the critical care unit. Patient #15 arrived to unit at 1:50AM per orders, for delirium and combative behavior. Patient was cooperative at arrival. Bilateral wrist restraints reapplied to bed." At 1:53AM documentation notes patient attempting to get out of bed unassisted breaking right wrist restraint. "Pt delusional, confused and combative." New orders given for Geodon 20mg IM given at 2:55AM. At 3:00AM order received for Precedex infusion starting at 0.2 mcg/kg/hr increase rate by 0.1mcg/kg/hr every 30 minutes until RASS goal is reached.(Precedex is an anxiety reducing, sedative, and pain medication). Sedation goal RASS -1: Drowsy. Precedex infusion initiated at 3:06AM.(The Richmond Agitation and Sedation Scale (RASS) is a validated and reliable method to assess patients' level of sedation in the intensive care unit). At 3:59AM, nursing documentation reads "Pt remained confused combative attempting to get out of bed, call placed to Dr. (name). Order given to intubate. (name) NP at bedside". Patient was successfully intubated at 3:50AM on 7/4/17. Precedex was held and patient was placed on Propofol and Fentanyl for sedation. On 7/5/17 at 9:30AM sedation was placed on hold; patient remained on the ventilator until 2:25PM and was extubated without incident.

Giving a medication for the purpose of controlling the behavior of a patient as is documented for Patient #15 at 1:50AM, 2:55AM and 3:06AM constitutes a chemical restraint according to facility policy. The use of a restraint to control a patient who is a danger to himself or others is considered a violent restraint. There is no evidence the medications were considered to be a chemical restraint by staff and there is no documentation of assessment for chemical restraint as defined in hospital policy entitled "Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)". The aforementioned policy requires an RN or Physician assessment within 5 minutes, and monitoring by an RN or Physician at least every 10 minutes for the next 30 minutes; for an IM medication, an RN or Physician assessment within 15 minutes, and monitoring by an RN or Physician at least every 15 minutes for the next 60 minutes: and for a PO medication an RN or Physician assessment within 30 minutes, and monitoring by an RN or Physician at least every 30 minutes for the next 60 minutes. Hospital staff failed to monitor and document the use of a restraint for violent behavior and/or the use of a chemical restraint for Patient #15. Patient #15 was both medicated and physically restrained for behavior that was a threat to him/herself and staff. Restraint documentation from the initiation of the restraint up to the intubation was for non-violent restraint and as such the patient was monitored every two hours from 1:15AM until 5:15AM. Patients placed in violent restraints are monitored every 15 minutes according to hospital policy.

The use of restraints for violent vs non-violent behaviors was discussed on 4/17/18 at 11:00AM with (Staff Member (SM) #21) the Chief Medical Officer for the hospital. SM #15 stated that restraints would be considered to be a violent restraint, if the patient was a threat to him/herself or others, and should be based on the patient's behavior not the diagnosis of the patient, violent behaviors requiring the use of restraints could be caused by medical and/or behavioral health problems. SM #15 stated his/her expectation would be for the medical staff to follow the policy

The above findings were discussed with the management team at end of the day meetings on 4/12/18 at 5:00PM and 4/17/18 at 4:05PM. The discussion included an opportunity for the management to ask questions of the surveyor or for clarification of the issue. No questions were presented or further information provided to the surveyor.

Based on interviews and the review of documents, it was determined a facility staff member failed to report a critically low pulse oximeter reading to a nurse for one (1) of thirty-one (31) patients sampled for chart review (Patient #18).

The findings include:

Review of Patient #18's clinical documentation on the afternoon of 4/16/18 revealed earlier the same day at 7:20 a.m. a critical pulse oximeter result of 83% was documented by a nursing assistant (Staff Member (SM) #36). No documentation was found to indicate a nurse had been notified of the critical low pulse oximeter result. (Pulse oximetry is a non-invasive method to monitor oxygen level/oxygen saturation of a patient's blood.) A screen shot of the facility's electronic documentation system, provided to the survey team, indicated the lowest normal value for a pulse oximeter result was 90% with the upper normal value being 100%.

Additional documentation by SM #36 on 4/16/18 at 7:38 a.m. indicated Patient #18 was attempting to get out of bed and the patient had to have his/her oxygen placed back into his/her nose.

The next clinical documentation entry found by or provided to the surveyor was documented on 4/16/18 at 8:05 a.m. indicating SM #22 (a registered nurse) had been notified of an elevated potassium level for Patient #18 and went to the patient's room where the patient was found "in distress".

On 4/17/18 at 1:14 p.m., SM #18 (the Quality Coordinator) was asked for a facility policy and procedure that addressed the normal range for vital signs. SM #18 reported back to the surveyor that no such policy existed; the survey team was provided the aforementioned screen shots that identified the normal ranges identified in the facility's electronic documentation system.

The failure of a facility non-licensed /non-certified staff member to notify a nurse of a critical low vital sign finding was discussed during a survey team meeting, on 4/17/18 at 4:05 p.m., with the facility's administrative staff. The administrative staff in attendance included but was not limited to the following: the Quality Coordinator (QC), the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer (CMO).

Based on interviews and the review of documents, it was determined the facility staff failed to ensure complete and accurate documentation for one (1) of thirty-one (31) patients sampled for chart review (Patient #18).

The findings include:

A member of the facility's laboratory (lab) staff failed to document an attempt to notify nursing staff of a critical laboratory result for Patient #18.

Review of Patient #18's clinical documentation found the following entry documented on 4/16/18 at 8:05 a.m. by a nurse: "was in the room of (number omitted) received the call of potassium 6.1 and then went to room (number omitted) patient in distress-m [sic] lab stated when they called to (name omitted) rn that they had tried to call earlier before dayshift and could not get an answer on the phone. [sic]" No documentation was found by or provided to the surveyor to show when the laboratory staff member had unsuccessfully attempted to call the critical result to the nursing staff.

Review of laboratory records on 4/16/18 at 3:34 p.m. with the facility's Director of Lab (Staff Member (SM) #45) and Lab Manager (SM #44) indicated Patient #18's blood sample was documented as collected on 4/16/18 at 5:41 a.m. SM #45 reported Patient #18's laboratory test results were reported off at 6:30 a.m. and the critical elevated potassium would have resulted in an audible alarm that had to be manually turned off by someone. Review of information provided to the survey team on 4/17/18 at 11:10 a.m. by SM #44 indicated the "BMP (basic metabolic panel) was Resulted 0630, the K (potassium) was manually posted ... at 06:50 [sic], and critical called and verified at 08:02 [sic]."

The failure of facility staff to maintain a complete and accurate clinical record for Patient #18 as evidenced by the absence of documentation of an unsuccessful attempt to notify clinical staff of a critical potassium laboratory result was discussed during a survey team meeting, on 4/17/18 at 4:05 p.m., with the facility's administrative staff. The administrative staff in attendance included but was not limited to the following: the Quality Coordinator (QC), the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer (CMO).

Based on interviews and the review of documents, it was determined the facility staff failed to ensure critical laboratory results were appropriately reported to clinical staff for one (1) of thirty-one (31) patients sampled for chart review (Patient #18).

The findings include:

Laboratory staff failed to timely notify clinical staff of Patient #18's critical potassium results.

Review of Patient #18's clinical documentation found the following entry documented on 4/16/18 at 8:05 a.m.: "was in the room of (number omitted) received the call of potassium 6.1 and then went to room (number omitted) patient in distress-m [sic] lab stated when they called to (name omitted) rn that they had tried to call earlier before dayshift and could not get an answer on the phone." Review of Patient #18's clinical documentation failed to include the previous attempt to notify clinical staff of the critical potassium result.

Review of laboratory records on 4/16/18 at 3:34 p.m. with the facility's Director of Lab (Staff Member (SM) #45) and Lab Manager (SM #44) indicated Patient #18's blood sample was collected on 4/16/18 at 5:41 a.m. SM #45 reported Patient #18's laboratory test results were reported off on 6:30 a.m. and the critical elevated potassium would have resulted in an audible alarm that had to be manual turned off by someone. Review of information provided to the survey team on 4/17/18 at 11:10 a.m. by SM #44 indicated the "BMP (basic metabolic panel) was Resulted 0630, the K (potassium) was manually posted ... at 06:50 [sic], and critical called and verified at 08:02 [sic]. Partial BMP results verified at 6:40, which did not include the potassium."

The laboratory policy titled "LABORATORY CRITICAL VALUES" (Version #4/November 2007) provided the following information: "Critical results obtained on inpatients shall be called to the licensed provider no more than 30 minutes of obtaining the results. [sic]". This policy does not address what to do if unable to notify the 'licensed provider' within 30 minutes.

The "Patient Care" policy titled "COMMUNICATION CRITICAL RESULTS - LABORATORY" (effective November 10, 2016/reviewed November 9, 2016) provided the following information: "Critical laboratory results obtained on inpatients shall be called by the laboratory staff to the licensed clinical team member within fifteen (15) minutes of availability/discovery."

The delay of laboratory staff to notify clinical staff of Patient #18's critical laboratory result was discussed during a survey team meeting, on 4/17/18 at 4:05 p.m., with the facility's administrative staff. The administrative staff in attendance included but was not limited to the following: the Quality Coordinator (QC), the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer (CMO).

Based on observations, interviews, and the review of documents, it was determined the facility dietary staff failed to address when 'dishwasher test strips' did not react as required when used to monitor dishwasher temperature.

The findings include:

While making observations in the facility's dietary department on 4/11/18 at 2:55 p.m., it was noted the 'dishwasher test strips' log for March of 2018 included four (4) days (3/22/18, 3/24/18, 3/25/18, and 3/27/18) where the section of the strip that was supposed to change to orange to indicate the temperature had achieved 180F had not changed to orange; no facility staff intervention/response to the failure of the 'dishwasher test strip' to change color was found by or provided to the surveyor. Observations also revealed the 'dishwasher test strips' were being stored in a very warm area on top of the dishwasher; it was noted that at least three (3) of the unused 'dishwasher test strips' had already change to the orange color indicating a temperature of 180F had been achieved.

On 4/12/18 at 11:50 a.m., the facility's Director of Food/Nutrition (Staff Member (SM) #11) provided the survey team with an empty 'dishwater test trips' package. Information on the package included the following: "Immediate, Irreversible color change From Blue/Black to Bright Orange when temperature has been achieved" [sic]. The package indicated the color change would take place at 180F. Directions on the package read as follows: "1. Attach the test strip to a utensile [sic] or rack by wrapping around and slipping the color bar through the slit in the strip. Wash the item. 2. If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. 3. When finished with the test, date and initial then place the strip in the dishwasher temperature log." SM #11 reported he/she is attempting to obtain strips that respond when the dishwasher temperature reaches 160F as required by the dietary policy; SM #11 stated the current strips require a temperature of 180F to react. SM #11 acknowledge no corrective actions were taken when the 'dishwasher test strips' failed to react during testing on the aforementioned four (4) dates.

The following information was found in a dietary policy with the subject of 'DISHMACHINE TEMPERATURES" (issued date - 5/95; revised date - 1/17): "High Temperature Dishmachine - record on Dishmachine Temperature Record form: - Wash and final rinse temperatures during each period of use. - Once a day, run a test strip though the dishmachine to verify the surface temperature of a dish. Attach the used test strip to the temperature log. The test strip must verify that the surface temperature of the plate reached 160°F ... - Immediately brings [sic] any substandard temperatures to the attention of management."

The following findings were discussed during a survey team meeting, on 4/17/18 at 4:05 p.m., with the facility's administrative staff: (a) the failure of facility dietary staff to take action when 'dishwasher test strips' did not appropriately change color during use and (b) 'dishwasher test strips' being stored in a manner which allowed for a strip color change without the strip being used. The administrative staff in attendance included but was not limited to the following: the Quality Coordinator (QC), the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer (CMO). No additional information related to these issues was provided to the survey team prior to the conclusion of the survey.

Based on interviews and the review of documents, it was determined the facility staff failed to document food safety training for a dietary contract employee (who prepares/handles food) for one (1) of seven (7) sampled dietary staff member personnel files.

The findings include:

On 4/12/18 at 2:25 p.m., dietary staff member personnel files/training documentation was reviewed with the facility's Director of Food/Nutrition (Staff Member (SM) #11). SM #46's documentation failed to provide evidence of his/her safe food handling training/competency. SM #11 reported SM #46, at times, had food preparation responsibilities. With SM #11 present the surveyor noted SM #46 had been assigned to cook on the grill at least one (1) day on the current dietary schedule/assignments.

SM #46's personnel/training documentation included:
- A "NEW ASSOCIATE ORIENTATION - KEY ELEMENTS" form. This form did include topics related to food handling/safety. This form was signed and dated by the employee on 2/1/18 but had not yet been signed and dated by his/her supervisor at the time of the personnel file review.
- A "(contractor company name omitted) ASSOCIATE SAFETY PLEDGE" form. This form addressed work place injuries. It was signed by the employee on 8/4/17 but had not yet been signed by his/her supervisor at the time of the personnel file review.

A dietary policy titled "ON-THE-JOB TRAINING" (issued 5/95; revised 1/17) included the following information: "Evidence of training to ensure competency in the new role is available in the associate's personnel file. Competencies are posted on (contractor company computer information omitted)." SM #11 provided the surveyor with a blank copy of the competency form. SM #11 reported the aforementioned competency form referenced in the policy was not found completed in the SM #46's personnel file.

The failure of SM #46's personnel file to contain evidence of competency related to safe food handling/preparation was discussed during a survey team meeting, on 4/17/18 at 4:05 p.m., with the facility's administrative staff. The administrative staff in attendance included but was not limited to the following: the Quality Coordinator (QC), the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer (CMO). No additional information related to this issue was provided to the survey team prior to the conclusion of the survey.

Based on observation and interviews, the facility did not meet the Condition of Participation related to Physical Environment.

The findings include:

During the Life Safety Code survey, it was noted the facility did not maintain smoke barriers in a smoke compartment on the second floor, at the birthing center nursery.