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Based on review of records and interviews with the facility staff, the facility failed to assure that verbal orders are authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient as 2 of 30 medical records reviewed contained verbal orders that were not authenticated within 48 hours in violation of facility policy.

The findings were:
The facility policy entitled "Entries in the Medical Record" dated 2/20/12 reflected in part "Verbal orders must be authenticated within 48 hours." The Medical Staff Bylaws dated 8/26/10 reflected in part "All verbal orders must be dated, timed and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient ...."

Review of medical records on 8/6/12 through 8/8/12 revealed that 2 of 30 medical records reviewed contained verbal orders that were not authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient as follows.
1. The record of patient # 7 contained 3 verbal orders that were not authenticated within 48 hours.
2. The record of patient # 21 contained 1 verbal order that was not authenticated within 48 hours.

These records were shown to staff # 27 on 8/8/12 at 10:10 am and she verified that the verbal orders were not authenticated within 48 hours.

Based on observation, review of documents, and interviews with staff, the facility failed to meet the needs of the patients as there was not a variety of food provided to the patients.

Findings included:

Facility policy entitled, "Dietary Menu Plan," stated "The purpose of this policy is to proved nutritionally adequate meals within established guidelines with the TDA & Nutritional Board." Further review revealed, "1. The Dietary Director with assistance from staff will write a 15 day menu cycle for a regular diet which must be approved by the consulting dietitian. All therapeutic and modified diets will follow the regular menu with adjustments to comply with ordered diet. They will conform with TDA and Nutritional Board Recommendations." The policy was approved by the Dietary Director and the Dietitian on 2/16/12.

In an interview with staff member #4 on 8/6/12 beginning at 2:45pm, a copy of the menu was provided to the surveyor. Staff member #4 stated the patient's received the same menu daily and had the same choice every day. There was not a 15 day menu cycle as per facility policy.

For example the menu revealed the following:

Breakfast: Eggs (select one) Scrambled eggs, Egg beaters; Beverages (select one) Coffee, Decaf Coffee, 2% Milk, Skim Milk, and Non-Dairy Creamer

Lunch: Appetizer (select one) Garden Salad, Creamy Potato Soup; Entree (select one) Baked Tilapia, Chicken Fried Steak, Seasoned Grilled Chicken Breast; Vegetable (select one) Honey Dill Carrots, Seasoned Broccoli, Green Beans; Sides (select one) Mashed Potatoes, Baked Potato, and Seasoned Rice.

Dinner: Sandwiches (select one) Hamburger, Cheeseburger, Turkey, Ham, Chicken Salad Club: along with dinner comes garden salad, cottage cheese and pears; Sides (select one) French Fries, Potato Chips, and Crackers.

The menu did not provide a variety of choices for patients to choose especially the patients who had to stay in the hospital for any length of time.

The above was confirmed in an interview with staff member #4 the morning of 8/7/12. Staff member #4 also confirmed the facility did not prepare meatloaf or pork chops. Staff member #4 stated if a patient wanted a pimento cheese sandwich and it was in their diet they could have the food prepared. The concern was the patient's are not always aware they could order something else since it was not written on the menu.

Based on observation, review of documents, and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety and well-being as the condition of the physical plant and some of the equipment in the facility was a potential hazard to staff, patients, and the public.

Findings included:

The facility policy entitled "Environmental Surveillance" dated 7/20/11 reflected in part "The purpose of this policy is to provide guidelines that will promote patient safety and prevent transmission of infections." The policy stated, "It is the policy of Graham Regional Medical Center to adhere to infection prevention policies and provide a clean and disinfected environment. Inadvertant exposure to environmental pathogens can result in adverse patient outcomes, and cause illness among healthcare workers, patients, visitors and physician. Environmental infection prevention and control can effectively prevent infections. III. Procedure ...Walls shall not have holes or chipped paint.... Air Vents shall be cleaned on a schedule per Enviromental Services."

The facility policy entitled "Infection Preventionist Job Description," stated "Provides surveillance throughout the hospital for infection prevention and control purposes."

During a tour of the Kitchen on 8/6/12 beginning at 2:45pm, the following was revealed:

1. Paint from all areas of the wall was peeling over food prep areas and dishwashing areas which was a potential hazard to staff, patients, and the public.

2. Paint on the exhaust fans was peeling over the food prep areas and dishwashing areas which was a potential hazard to staff, patients, and the public.

3. In the dishwashing room there was a mop head hanging on a hook over the counter where the patient food trays are brought to the kitchen to be washed. On the same counter as the patient trays was a linen bag. This was a potential hazard to staff, patients, and the public.

4. In the cafeteria were a fire sprinkler and a smoke detector with visible layers of dust. This was a potential hazard to staff, patients, and the public.

The above kitchen issues were confirmed in an interview the afternoon of 8/6/12 with staff member #3, #4, #5, and #6.

Based on observation, review of documents, and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety as the crash cart in the post anesthesia recovery room was not checked daily and equipment in the kitchen area was not maintained to ensure safety and/or quality. This was a violation of facility policy.

The findings were:

The facility policy entitled "Crash Cart" dated 7/28/11 was reviewed on the morning of 8/7/12 and reflected in part "Nursing personnel checking the cart shall initial the appropriate column to indicate that the cart is stocked and in working order ...Nursing will be responsible for daily cart check and restocking of supplies."

The facility policy entitled "Environmental Surveillance" dated 7/20/11 reflected in part "The purpose of this policy is to provide guidelines that will promote patient safety and prevent transmission of infections...Air vents shall be cleaned on a schedule per Environmental Services...Clean linen shall be stored in an enclosed shelf or in a closed closet or storage cart...Refrigerators shall be cleaned weekly with an approved detergent/disinfectant...Shelves, carts cabinets and bins are to be cleaned as needed when soiled and no less than monthly...Equipment and supplies may not be stored with linen...Storage areas shall be clean and free of bugs, debris and warehouse boxes..."

During a tour of the post anesthesia recovery room on 8/6/12 beginning at 4:00 pm in the company of staff #17 and staff #19, the crash cart check log was observed to not have checks documented on the following dates: 6/21/12, 5/11/12, 4/16/12, 3/19/12 through 3/23/12, and 3/16/12. Staff #19 was asked to check the recovery log to determine if there were patients in the recovery room on the before mentioned dates. Staff #19 stated that there were patients in the recovery room on 6/21/12, 5/11/12, 4/16/12, 3/19/12 through 3/23/12, and 3/16/12 and confirmed that crash cart checks were not documented on those dates.

During a tour of the Kitchen on 8/6/12 beginning at 2:45pm, in the company of staff #4 the following was revealed:

1. The vent cover in the walk-in freezer had fallen on the floor and a buildup of ice was on the vent. The exposed vent area had ice build up and was over a sealed cardboard box which contained food to prepare for patients.

2. There was an ice patch on the floor upon entering the walk-in freezer the size of a softball which was a fall hazard to staff members.

3. The shelving in the pantry which contained food containers to prepare for patients was rusty and the paint was peeling making proper cleaning impossible.

4. The right side handle of a refrigerator which held dairy products was broken and had clear tape holding it together making it difficult to close properly.

5. The door to the wash room was broken on the bottom right side which was a hazard to staff members opening and closing the door.

The above Kitchen issues were confirmed in an interview the afternoon of 8/6/12 with staff member #3, #4, #5, and #6.

Based on observation, review of documents and interviews with facility staff, the facility failed to implement policies governing the control of infections as hinged surgical instruments were not sterilized in the open position which created a potential source of infection. There was an instance of inadequate cleaning observed in 1 of 2 operating rooms which was a potential source of infection. There were chips in the painted walls exposing the plaster of 2 of 2 operating rooms which made proper disinfection impossible and created a potential source of infection. These findings were in violation of facility policies.

The findings were:
The facility policy entitled "Care and Cleaning of Surgical Instruments" dated 7/26/12 was reviewed on the afternoon of 8/6/12 and reflected in part "Ring-handled instruments should be secured in a manner that retains them in an open position for sterilization."

The facility policy entitled "Environmental Surveillance" dated 7/20/11 was reviewed on the morning of 8/8/12 and reflected in part "I. Policy: It is the policy of Graham Regional Medical Center to adhere to infection prevention policies and provide a clean disinfected environment ... III. Procedure ...Walls shall not have holes or chipped paint."

The facility policy entitled "Housekeeping in the OR" dated 7/26/12 was reviewed on the afternoon of 8/6/12 and reflected in part "D. Terminal cleaning at the end of the day: 6. Mop the entire floor with a detergent germicide. Move furniture and mop the floor under the furniture."

During a tour of the surgery department on 8/6/12 beginning at 2:45 pm in the company of staff #17, approximately 50 packages of hinged surgical instruments were observed in sterile packages in the sterile processing room. Approximately 25 of the 50 packages contained hinged instruments that were in the closed position which did not allow the sterilizing agent to contact all surfaces of the instruments. Staff #17 was shown the packages which contained instruments in the closed position. Staff #17 confirmed that the instruments were in the closed position.

A tour of 2 of 2 operating rooms on 8/6/12 beginning at 3:15 pm was conducted in the company of staff #17 after the surgical cases for the day had concluded. The following observations were made.
1. In operating room #1, approximately 15 chips ? inch to ? inch in diameter in the painted wall with the door to room were observed that exposed the plaster underneath. Approximately 4 chips ? inch in diameter in the painted back wall were observed that exposed the plaster underneath.
2. In operating room #2, approximately 15 chips ? inch to ? inch in diameter in the painted wall with the door to room were observed that exposed the plaster underneath.
3. In operating room #2, staff #17 was asked to move the surgical table and two reddish-brown stains were observed on the floor where the surgical table was moved from. One reddish-brown stain was 4 inches in diameter and the other was 3 inches in diameter.

During the tour, staff #17 was shown the chips in the painted walls in operating rooms #1 and 2 and the reddish-brown stains on the floor of operating room #2 and she confirmed that they were present. When asked if the operating rooms had been terminally cleaned for the day prior to the tour, she stated that they were.