HospitalInspections.org

Based on review of facility policy, observation, and interview, the facility failed to maintain a daily refrigerator temperature log for 1 of 2 patient refrigerators and failed to properly obtain food temperatures in 1 of 1 kitchen observations made.

The findings included:

Review of the facility policy "Refrigerators" dated 10/2015, revealed "...Temperature is to be recorded DAILY in all departments/facilities...temperature checks will be documented on the refrigerator monitoring log..."

Review of the facility policy "Infection Control Procedures - Dietary, Kitchen" dated 9/21/15 revealed "...the Dietary Department will continuously monitor...employee training, in-service education, follow-up supervision, monitoring, and evaluating...keep hot foods at least 140 degrees F [Fahrenheit] and cold foods 41 degrees F or below...all meats...are to be heated throughout to a minimum temperature of 165 Fahrenheit...unannounced periodic inspections to be performed by Inpatient Director or Infection Control Nurse..."

Observation and interview with the Director of Inpatient Services on 1/29/18 at 10:40 AM, in the tech station, revealed the patient refrigerator temperatures were not documented for 1/16/18- 1/28/18 (13 days). Interview with the Director of Inpatient Services confirmed the temperature log was not maintained for the patient refrigerator.

Observation and interview with the Dietary Manager on 1/29/18 from 12:30 PM to 1:10 PM, in the kitchen, revealed the Dietary Manager failed to perform calibration (method to ensure accurate temperature is obtained) of the food thermometer prior to use. Interview with the Dietary Manager confirmed the facility failed to calibrate the food thermometer and "...[she] have not been trained on how to calibrate a thermometer prior to testing food temperatures..."

Interview with the Director of Inpatient Services on 1/31/18 at 11:30 AM, in the conference room, confirmed she had not performed any unannounced inspection of the food handling process and the facility failed to ensure dietary staff was properly trained.

Based on review of the facility policy, observation, and interview, the facility failed to ensure patient equipment was inspected to ensure safety and quality for 2 of 2 oxygen concentrators.

The findings included:

Review of the facility policy "Oxygen Concentrator" dated 10/1/15 revealed "...concentrator is checked monthly and with each use..."

Observation and interview with the Director of Inpatient Services on 1/29/18 at 11:20 AM, in the examination room, revealed one oxygen concentrator with an inspection date of 3/2015 and another oxygen concentrator was not labeled with an inspection day. Interview with the Director of Inpatient Services confirmed the facility failed to ensure the patient oxygen concentrators were serviced and maintained for patient use.

Based on facility policy review, observation, and interview, the facility failed to ensure expired juice was not available for patient use in 1 of 1 tech stations; failed to maintain a sanitary environment in 1 of 1 examination rooms; failed to ensure expired food was not available for patient use in 1 of 1 central supply storage areas observed.

The findings included:

Review of a facility policy "Infection Control/Inpatient Unit" dated 7/2015 revealed "...Items with expired dates...are disposed of and replaced...Stock Rotation...Unit Secretary...Weekly...Discard Outdated Stock...Rotate stock..."

Review of a facility policy "Infection Control Procedures - Dietary, Kitchen" dated 9/21/15 revealed "...Food Storage, Preparation, Holding, and Service...Food stored properly at all times...Old stock is rotated and used first...When replacing new stock, all current stock must be moved to the front of the shelf and new items placed in the back to assure the older stock is used first...Outdated items must not be used, but discarded in a timely manner..."

Review of a facility policy "Housekeeping Services" dated 7/2015 revealed "...Treatment Room...Nursing staff responsibilities for cleaning this room-following patient physical exams...removed used exam table paper...Spray exam table with disinfectant and wipe clean...Apply fresh exam table paper...Place used linen, such as gowns, in soiled linen container...any used disposable items soiled with blood or body fluid should be handled with disposable gloves and placed into the biohazard container...Physical exam instruments should be cleaned with disinfectant soap after each patient use..."

Observation and interview with the Director of Inpatient Services on 1/29/18 at 10:50 AM, in the tech station, revealed twenty 5.5 fluid ounce (fl. oz.) containers of orange juice with an expiration date of 11/9/17 and one 5.5 fl. oz. container of orange juice with an expiration date of 8/31/17. Interview with the Director of Inpatient Services confirmed the orange juice was expired and was available for patient use.

Observation on 1/29/18 at 11:22 AM, in the examination room, revealed the examination table was covered with white wrinkled examination paper. Further observation revealed medical instruments were on the bedside table uncovered and two unpackaged scissors were on a paper towel next to the sink.

Interview with Tech #1 on 1/29/18 at 11:25 AM, in the examination room, revealed the room was last used the day before (time unknown) and was ready for the next patient. Continued interview confirmed the examination table appeared to be unclean and the instruments were unpackaged and dirty.

Interview with the Director of Inpatient Services on 1/29/18 at 11:30 AM, in the examination room, confirmed the room should be cleaned after every patient examination and the facility failed to do so. Continued interview revealed the facility failed to follow facility policy.

Observation and interview with the Director of Inpatient Services on 1/29/18 at 11:35 AM, in the examination room, revealed 100 sterile latex examination gloves with an expiration date of 5/2017, 100 sterile latex examination gloves with an expiration date of 7/2017, and 100 sterile latex examination gloves with an expiration date of 8/2017. Interview with the Director of Inpatient Services confirmed the examination gloves were expired and were ready for patient use.

Observation and interview with the Director of Inpatient Services and Resource Coordinator on 1/31/18 at 9:30 AM, in the central supply storage area, revealed the following expired food items:
1) Sixteen 4 ounce (oz) containers of mixed fruit expired 4/30/17
2) Sixteen 4 oz containers of mixed fruit expired 9/26/17
3) Thirty-two 4 oz containers of mixed fruit expired 9/28/17
4) Eight 4 oz containers of diced peaches expired 11/17/17
5) Eight 4 oz containers of mixed fruit expired 11/17/17
6) Six 4 oz containers of diced peaches expired 1/4/18
7) Twelve 2.05 oz containers of macaroni and cheese expired 8/15/17
8) Twelve 2.05 oz containers of macaroni and cheese expired 8/29/17
9) Forty-eight 2.05 oz containers of macaroni and cheese expired 8/1/17
10) Twenty-two individual containers of noodles expired 10/14/17
11) Thirty-two 4 oz containers of mandarin oranges expired 6/23/17
12) Thirty-two 4 oz containers of mandarin oranges expired 8/16/17
13) Eight 4 oz containers of diced peaches expired 1/7/18
14) Eight 4 oz containers of mixed fruit expired 1/7/18
Interview with the Director of Inpatient Services and Resource Coordinator confirmed the food items were expired and were available for patient use.