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Based on interview it was determined the facility failed to ensure the provider's signatures could be authenticated for all of the facility's providers. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. An interview was conducted with the Director of Quality and Risk Management on 11/17/21 at 8:10 a.m. The Director of Quality and Risk Management stated, "After speaking with the medical records department, we do not have a list of the provider's authenticated signatures for review. We are starting a list now and will get all the signatures as the providers present to the facility."

A. Based on a tour of the facility and staff interviews it was revealed the facility failed to provide a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure was identified in one (1) of two (2) clean supply areas for the Respiratory Department. This failure has the potential to adversely affect all patients who are admitted to the facility and require respiratory services.

Findings include:

1. A tour of the facility was conducted on 11/15/21 at 10:04 a.m. During the tour of the Respiratory Department, the Clinical Manager accompanied the surveyor on the tour of the department. One (1) of two (2) clean supply rooms for the Respiratory Department was located on the main floor of the hospital. Upon entering the clean supply room a ladder leading to the roof of the hospital was noted. When asked about the ladder, the Clinical Manager stated maintenance uses the ladder to go to the roof of the hospital when repair is needed. A soiled dolly was also located in the clean supply room. Dirty handprints were located on the door frame in the clean supply room. The walls of the clean supply room were dirty. The Clinical Manager stated the clean supply room has been in this location for at least seven (7) years.

2. An interview was conducted with the Vice President (VP) of Patient Care Services on 11/16/21 at approximately 11:30 a.m. The VP of Patient Care Services concurred clean supplies were located in an area for roof access for maintenance workers.


B. Based on a tour of the operating room (OR) and staff interview it was revealed the facility failed to ensure the OR staff provided a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure was identified in one (1) of one (1) OR surgical suite toured. This failure has the potential to adversely affect all patients who are admitted to the facility for surgery.

Findings include:

1. A tour of the OR department was conducted on 11/16/21 at 10:00 a.m. The OR Manager accompanied the surveyor on the tour. A tour of surgical suite/Room 2 was conducted. One (1) opened introducer adult bougie was taped to the top of the anesthesia cart. One (1) opened suction catheter was located in the top drawer of the anesthesia cart. One (1) doorstop was located on the frame of a dry erasable board. During the tour of Room 2, the OR Manager concurred open supplies were located on the anesthesia cart and a doorstop was located on the dry erasable board.


C. Based on a tour of the Outpatient Family Practice Clinic and staff interviews it was revealed the facility failed to ensure the clinic provided a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure was identified in one (1) of one (1) Outpatient Family Practice Clinics. This failure has the potential to adversely affect all patients who are seen at the Family Practice Clinic.

Findings include:

1. A tour of the Outpatient Family Practice Clinic was conducted on 11/15/21 at approximately 3:45 p.m. The Office Manager accompanied the surveyor on the tour of the laboratory supply area. Inside the supply area there was a refrigerator marked biohazard. A sign was located on the refrigerator which stated no food or drinks in the refrigerator. Located inside the refrigerator was food, drinks and Trulicity medication. When asked about the food, drinks and medication, the Office Manager concurred no food, drinks or medication should be located in the refrigerator.

2. An interview was conducted with the Vice President (VP) of Patient Care Services on 11/16/21 at approximately 11:30 a.m. The VP of Patient Care Services concurred no food, drinks or medication are to be located in a refrigerator listed as biohazard.


D. Based on a tour of the Outpatient Rehabilitation Facility and staff interviews it was revealed the facility failed to ensure the staff of the Outpatient Rehabilitation Facility provided a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure was identified in one (1) of one (1) Outpatient Rehabilitation Facility. This failure has the potential to adversely affect all patients receiving therapy at the Outpatient Rehabilitation Facility.

Findings include:

1. A tour of the Outpatient Rehabilitation Facility was conducted on 11/17/21 at 9:30 a.m. The Director of Therapies and the Director of Operations accompanied the surveyor on the tour. One (1) sensory swing was located in the therapy room. When the Director of Therapies was asked about cleaning of the sensory swing, the Director of Therapies stated the sensory swing was not cleaned between patients. Ten (10) small cloth bean bags were located in a basket in the therapy office. When asked if the cloth bean bags are cleaned between patients, the Director of Therapies stated no.

2. An interview was conducted with the Director of Operations during the tour of the Outpatient Rehabilitation Facility. He/she concurred the Rehabilitation facility was not following proper cleaning of the sensory swing or bean bags between patients.



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E. Based on observation, document review and interview it was determined the facility failed to promote a sanitary environment to prevent cross-contamination in three (3) out of three (3) dietary workers observed. This failure has the potential to negatively impact all patients provided meals at the facility.

Findings include:

1. An observation was conducted on 11/16/21 at approximately 12:40 p.m. in the facility's kitchen. Three (3) dietary staff were placing items on food trays for the patients according to their ordered diets, including placing drink cartons, pre-prepared side dish containers, handling plates and scooping food onto the plates with a utensil. All three (3) did not wear gloves throughout the process.

2. The "FDA (Food and Drug Administration) Food Code 2013" was reviewed. It states in part: "Chapter 2 Management and Personnel Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (L) Except when APPROVAL is obtained from the REGULATORY 30 AUTHORITY as specified in ¶ 3-301.11(E), EMPLOYEES are preventing cross-contamination of READY-TO-EAT FOOD with bare hands by properly using suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT."

3. An interview was conducted with the Director of Quality and Risk Management on 11/16/21 at approximately 1:00 p.m. The Director of Quality and Risk Management explained the kitchen staff follows the "Food Code 2013."