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Based on observation and staff interview, the facility failed to ensure that oxygen was available for patient use, in case of emergency, in the cardiopulmonary outpatient clinic. This failure could result in oxygen not being available for patients with shortness of breath or patients with cardiac arrest situations.

Findings:

On 5/24/12 at 10:15 a.m., a cardiopulmonary outpatient clinic, under the facilities, license provider number, was toured. An oxygen tank, which was stabilized in its cradle, was on the floor of the clinic's break room. The oxygen tank was located behind the entry doorway however was visible. The Echocardiogram Technician (Echo Tech O) stated the tank was the only oxygen tank in the clinic. When questioned how he could tell how much oxygen was in the tank, he looked at the regulator, on the tank, and stated that the tank was empty and needed to be refilled. He stated he needed to get another oxygen tank immediately and left the facility to exchange the tank for a full oxygen tank. He returned 20 minutes later, from the acute care facility with a filled oxygen tank.

On 5/24/12 at 10:45 a.m., the Echo Tech O was questioned why the clinic had oxygen. He stated they used it for patients who were short of breath and for patients who "coded" (procedure for staff when patients undergo cardiopulmonary arrest.) He said that although the clinic staff would call 911 during a "code", they would place the oxygen on the patient with a nasal cannula tube, until the arrival of the ambulance. He stated the oxygen tank was last used about 6 months ago when he used the tank on a patient who was short of breath. He stated that after patient use, the oxygen tank was replaced by a full one. He did not know why the tank had lost the oxygen and stated that possibly someone, in the break room might have accidently turned the valve and caused a slow leak which caused the tank to empty. Echo Tech O was asked who was responsible for ensuring the only tank in the clinic was full and ready for emergency use. He said he was not sure and thought that possibly he was responsible. He stated the clinic had forms which were completed to indicate the oxygen tank was filled and ready for use at all times, however, he stated he had not completed any of these forms and had not checked the oxygen tank since its use 6 months ago.

On 5/24/12 at 11:15 a.m., Administrative Staff A was asked for the policy and procedure regarding the maintenance of the oxygen tank at the cardiopulmonary clinic, to ensure that it was full and available at all times. She stated there was no policy.

During the initial tour on 5/21/12 at 12:40 p.m., there was a mop in a bucket of water in the housekeeping closet in the ICU. ICU staff present at the time were uncertain if the mop was clean and did not know if it should be kept in water.

Facility policy, last revised 2/12 titled "Damp Mopping" indicated "If the mop bucket is found in the closet containing water, empty and rinse bucket and fill with clean water and a new mop head.

2. During a tour on 5/21/12 at 12:20 p.m., of the medical surgical unit medication room, it was noted that the medication cart contained removable cassettes of drawers. Each drawer had a label on the front which indicated the name of the patient. The area where the labels were placed was soiled with old label gum and a collection of debris. The shelf on the bottom of the cart was covered with a layer of dust and multiple dust bunnies.

There were two tackle style boxes tabled, "hypoglycemia kits." Both had a layer of dust on the surface. There were two additional large carts in the room that staff identified as central supply carts. They also were layered with dust.

During a concurrent interview, a pharmacy technician, stated that the pharmacy cleaned the drawer cassettes while they had them in the pharmacy. They wiped the drawers with housekeeping wipes but did not clean the medication cart which stayed in the medication room. When asked about the accumulation of debris and label gum on the drawers, the pharmacy tech agreed that the drawers did not look clean.

Facility Maintenance Staff M, also present during the observation, stated that the carts were not on the housekeepers cleaning schedule.


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Based on observation, staff interview, and facility policy review, the facility failed to ensure a clean and orderly facility when 1) mops were stored in buckets of dirty water in the housekeeping closets, and 2) the medication cart in the medical surgical area was soiled was not kept cleaned. This had the potential for an unclean environment for patients and staff.

Findings:

1) On 5/23/12 at 3:50 p.m., during the environmental tour, Housekeeping Staff E was asked to show how he filled the buckets with chemicals used for disinfecting the floors. The housekeeping closet was located in the Medical Surgical Area and close to the Obstetrics and Gynecology unit. The staff member opened the door to the closet and there was a wheeled bucket of dirty water and a mop that had been left in the dirty water. Housekeeping Staff E was questioned as to whether this was the facility's practice to leave a mop in the dirty water. He stated that housekeeper from the last shift should have emptied the bucket and cleaned the bucket before his shift ended and did not.

Based on staff interview, and document review, operating room (OR) staff failed to report abnormally low room temperatures to maintenance staff resulting in many days of low temperatures and the potential for adverse effects on the surgical patients.

Findings:

Review on 5/24/12 of OR temperature logs dated November 2011 through May of 2012 indicated that the "target temperature range" for the OR was 68 to 73 degrees Fahrenheit (F). During the month of November 2011 the temperature in the OR was recorded as low as 61 degrees and never higher than 64 degrees on the 16 days that the OR was open. There was handwritten documentation on the log that the pharmacy was notified of the low temperatures on 11/3/11 and 11/10/11 only.

During the month of December 2011 the temperatures in the OR were recorded as below 68 degrees F on all of the 14 days that the OR was open. The recorded temperature was 61 degrees F on six of the 14 days, 62 degrees F on five of the 14 days, 63 degrees F on two days, and 64 degrees F on one day. It was never above 64 degrees F. A hand written note on the bottom of the log indicated that environmental services (EVS) was notified of low humidity readings but there was no documentation that they were notified of the low room temperatures or that the temperature increased to within range.

The OR temperature log for the month of January 2012 indicated that the room temperature was below 68 degrees F on 14 of 17 days. The temperature was 63 degrees F on seven of the 14 days, 64 degrees F on two of the days, 65 F on two of the days, and 66 F on three days. There was no documentation that EVS was notified of the low room temperatures or that the temperature was adjusted to within range.

The OR temperature log for the month of February 2012 indicated that the OR temperature was lower that 68 degrees F on 12 of 16 days. There was no documentation that EVS was notified or that the temperatures came into range.

The March 2012 log indicated that the temperature in the OR was below 68 degrees F on eight of 17 days. There was no documentation that EVS was notified or that the temperature was adjusted.

The April 2012 temperature log indicated that on 16 of 17 days the temperature was below 68 degrees F. And the May 2012 log indicated that the temperature was below 68 degrees F on 12 of 14 days. The lowest recorded temperature was 61 degrees F on 5/7/12. There was no documentation on either log that EVS was notified or that the temperature was adjusted on any of the 12 days.

During an interview on 5/24/12 at 9 a.m., Administrative Staff X stated that she was aware that the OR was cold particularly when you were sitting in the area. Staff X stated that temperatures were taken in the morning when staff began work and that the room did warm up after a while. There was no documentation to support this statement. Additionally, Admin Staff X stated that staff in the OR knew that they should report the low temperatures but had not done so because they had been more concerned about reporting humidity readings that were out of range.

Concurrent review of a copy of the Perioperative Standards provided by Administrative Staff X indicated that temperatures in the OR should be maintained between 68 and 73 degrees F.

Based on observation, staff interview, and facility policy, the facility failed to ensure that medications in the cardiopulmonary clinic were securely locked and not accessible to unauthorized staff, visitors, and patients. This failure could potentially lead to pilfering of medications.

Findings:

On 5/24/12 at 9:50 a.m., observations of the cardiopulmonary clinic revealed a medication cabinet with multiple medication samples. The cabinet was located by the entrance into the patient exam rooms. The cabinet also was accessible to anyone in the waiting room.

The Cardiopulmonary Clinic Staff F was questioned regarding this unlocked cabinet. She stated they leave it open for the physicians. She stated that the cabinet is opened in the mornings, when they are opened, and is locked in the evenings when they close. She acknowledged that someone could possibly enter the cabinet who had no authority to do so.

An undated Policy and Procedure was provided and titled "Sample Medication Controls" and indicated "Sample medications and prescription pads (if applicable) are kept in a secure locked cabinet. The designated clinical assistant is the only staff member allowed to open the cabinet and distribute samples to providers."

Based on observation, and maintenance staff interview, the facility failed to provide air gaps ( a fixture that provides back flow prevention) for two ice machines installed. The ice from the ice machines are used for patients. This had the potential for sewage back-up in the ice machines and contamination of the ice.

Findings:

On 5/23/12, at 3:05 p.m., observation of an ice machine, in the medical surgical department was observed to have no air gap (a fixture that provides back flow prevention.) Maintenance Staff M acknowledged that the ice from this ice machine was used for patients use and it did not have an air gap. He stated there was one other ice machine that was used specifically for patient use which was in the intensive care unit.

On 5/24/12 at 1:40 p.m., the Intensive Care Unit was toured and the ice machine in the unit, that was used for patient use, also did not have an air gap attached. Maintenance Staff M stated the ice machine was a new machine to the department and it did not have an air gap.

Food Code 2009, Chapter 5, regulation 202.13, indicated "The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow."

Based on observations, kitchen staff interviews and document reviews, the facility failed to ensure the safe practices of food handling when 1) kitchen staff did not notify the appropriate staff of refrigerator and freezer temperatures that were beyond the normal range of temperatures, 2) ready to eat food was served and not washed.


Findings:

1) On 5/23/12 at 10:46 a.m., during the kitchen observations, the outside of a freezer compartment door had a plastic paper holder taped to outside of the freezer door and indicated the daily temperatures for the month of May. The Freezer contained a left and right compartment freezers and temperatures were logged for each sides of the freezer. The log used to indicate the freezer temperatures indicated the normal range for the freezer temperatures was from 0° Farenheit (F) to 10° (F). The temperatures were taken once in the morning and once in the evening. The Dessert Freezer, for the period of 5/1/12 to 5/22/12, had 22 days of temperatures on the left side of the Freezer, which were not within the normal range of 0° F to 10° F (according to the log). The abnormal temperatures ranged from -1° to -7° Farenheit degrees. On 5/7/12, the left freezer log indicated an abnormal temperature of 13° F. The right side of the freezer had temperatures outside of the normal freezer temperature range for 22 days. There were 30 temperatures taken for those 22 days which were not within the normal freezer range of 0° to 10° F. Those abnormal temperatures were below 0° and ranged to -7° F. Notation on the logged sheet indicated that maintenance was notified only once on 5/5/12 regarding the abnormal temperatures.

On 5/23/12 at 10:46 a.m., Registered Dietitian B observed the temperatures which were out of range. She stated that the staff were to supposed to notify the maintenance staff and her of any out of range temperatures and they had not notified her. She stated that temperatures colder than the normal range could cause the food to become freezer burned and could affect the flavor.

On 5/24/12 at 10:50 a.m., The undated log used to indicate the freezer temperatures titled "Refrigerator Storage Log" indicated to report increase or decrease temperature to pharmacy and/or Engineering Services. The facility's reviewed on 1/11, policy and procedure titled "Dating Refrigerated/Frozen Foods" indicated that any out-of range temperatures are to be reported to the Maintenance Department for immediate correction and to the Nutritional Service Director.

2) On 5/22/12 at 10:05 a.m., Kitchen Staff C was observed to be filling tube shaped containers of vegetables which were to be used for the lunch that day. He stated that although the patient's received pre packaged meals from an outside source, patients did eat the cafeteria food, prepared by the kitchen staff, when they didn't like the packaged meals. Kitchen Staff C was observed to pour a box of small tomatoes in the cannister container used for self service by staff, visitors, or patients. Kitchen Staff C failed to wash the tomatoes which were stored in a cardboard box.

On 5/23/12 at 3:35 p.m., Kitchen Staff C was interviewed regarding the preparation of the tomatoes and that they were not washed before use. He stated " I guess I forgot to wash them that day. They should be washed in a colander in the sink."

On 5/24/12 at 10:00 a.m., facility policy, approved 1/2/11, titled "Safe Handling of Potentially Hazardous Food" indicated "All produce must be washed before using, even if it is to be cooked."

3) On 5/22/12 at 8:30 a.m., the kitchen was toured. In one of the kitchen refrigerators was a large bag of sliced ham dated 5/18/12. Kitchen Staff C stated the expired dates on the outside of the packaged meals meant it was not to be used after that date. Observations were made of a freezer in the food storage room. There were two large gallon plastic bags with breaded objects. The bags were half full and there was no label to show what the bags contained. One of the bags looked like hamburger patties however, the patties were discolored and looked dried, similar to freezer burn. There was also no date on the bags to determine when the bags were to be disposed. On 5/23/12 at 9:10 a.m., Registered Dietitian B stated she thought one of the bags had breaded chicken strips and acknowledged the bags should have been dated and labeled.

Further kitchen observations on 5/22/12 at 9:15 a.m. revealed a bread cart which contained 2 packages of hamburger buns dated 5/15/12, 4 hot dog buns dated 5/18/12, 2 packages of bagels dated 5/11, 1 package of bagels dated 5/4/12. There were two large packages of ham, in the freezer, in the food storage room. The ham had dates of 5/2/12 on the outside package. There was a box of white and dark chicken meat dated 4/6/12, 2 turkey salami loafs with handwritten date of 9/23/11. In the food storage room, there were three packages of what looked like chocolate chip cookies, oatmeal, and plain cookies that were sealed in plastic wrapping. They were not labeled nor was there a date on the package.
On 5/22/12 at 8:55 a.m., one of the kitchen refrigerators contained prepackaged food for patients. The foods were to be microwaved as per the preparer's instructions prior to delivery for patient's consumption. The plates of food were covered with a clear plastic sheet. A date was placed on a pink label which was affixed to the plastic packaging. Kitchen Staff C was asked what the date meant. He stated the dates meant that the kitchen staff could not serve the food beyond that date.

On 5/22/12 at 9:45 a.m., Kitchen Staff D was asked about the dates affixed to the prepared meals packages which were delivered from the outside contracted food supplier. She said those were the dates the food was received and they would throw away the foods in a couple of days, if not eaten. She stated the dates were confusing and there wasn't a guideline provided.

On 5/22/12, Concurrent observations of the refrigerator with the prepared plates included a prepared plate with a date of 5/19/12 and a prepared salad plate dated 5/21/12. Registered Dietician B stated they should be tossed and shouldn't be in the refrigerator.

On 5/23/12 at 11:30 a.m., a loaf of bread, on the bread cart in the kitchen area, was observed to have large mold spots. Although Registered Dietician B stated the facility had just received the loaf of bread, there was no date on the package. The Dietician stated she needed to talk to the company that delivered the bread to ask them to date their products. The Registered Dietitian B acknowledged the significance of the dates on the food packages were unclear to the staff as they were not certain of whether the dates on the food packages meant the food was received on the date that was on the label or whether the dates signified the foods needed to be disposed of. She stated that the kitchen supervisor had been out of the facility due to an injury and she was filling in for him. She stated the kitchen supervisor was overseen by the human resource department and not by a registered dietician.

on 5/24/12 at 9:20 a.m., facility policy, last revised 1/11, regarding dating of refrigerated and frozen foods indicated "Food procured from an outside source for patient room service has a "use by" date placed by the vendor." The policy further indicated "For bulk freezer and refrigerated food products are labeled with the receiving date and 'use by'date. If product is opened, the following procedure applies: label with the name of the food, open date, 'use by' date."