HospitalInspections.org

Based on a review of facility policy, observation, and interview with staff (EMP), it was determined that the facility failed to follow their policy for proper labeling and storage of food.

Findings include:

A review on February 12, 2013, of facility policy "Proper Labeling of Food and Non-Food Items", last reviewed February 2011, revealed, "... 5. All foods prepared in the kitchen and leftovers must be labeled as to product and date of preparation and/or refrigeration. Items in the cook's refrigerators (leftovers, meat, entrees, soup) must be used within 72 hours of original refrigeration or frozen. ... "

Observation February 12, 2013, of the dietary department revealed the following: a container of prunes in the trayline refrigerator dated as opened February 5, 2013; a cheesecake and chocolate cake in the walk-in refrigerator with no date when opened; containers of beef patties, roast beef, and prepared onions in the cook's refrigerator that were opened and not dated or dated as prepared on February 2, 2013; bags of green beans, peas, carrots and spinach that were not dated when opened, and six trays of prepared pudding in the walk-in refrigerator that were not dated when prepared.

An interview conducted on February 12, 2013, at 10:45 AM with EMP2 confirmed the items were not dated when opened or dated and not used within 72 hours.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the facility failed to ensure the supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

A review on February 12, 2013, of facility policy "Defective Equipment and/or Equipment Accessories", last reviewed May 2012, revealed: " ... 1. When any piece of equipment or equipment accessory is found to be defective or an equipment breakdown is experienced, the affected item is to be immediately taken out of service...."

1) A tour on February 13, 2013, of the Operating Room suite revealed an arm rest in room B that contained many frayed and tattered edges which exposed the foam padding underneath.

An interview conducted on February 12, 2013, at 11:15 AM with EMP1 confirmed that the armrest in room B was tattered and torn and should have been taken out of service.

2) A tour on February 12, 2013, of the Rehabilitation unit revealed a shower room which contained a functioning shower, toilet and sink. Further observation of the room revealed that the room was also used for storage of clean bedside commodes, isolation carts, and clean patient care items such as shampoo, shaving cream, toothbrushes, skin care, adult briefs, and clean urinals.

An interview conducted on February 12, 2013, at 11:00 AM with EMP1 confirmed that the shower room was also used as a storage room for clean patient supplies.

3) A tour on February 13, 2013, of the Operating suite revealed a supply room and a corridor with several large windows each. Further observation revealed that most of the windows contained a large amount of condensation and puddle of water on the window sills. Observation in the clean supply room revealed a towel laying on the window sill to catch the condensation.

An interview conducted on February 12, 2013, at 11:15 AM with EMP1 confirmed that the windows contained significant amounts of condensation and that there was a towel placed on the sill in the clean supply room to catch the condensation.

4) A tour on February 13, 2013, revealed that there was an unclaimed body in the morgue. A review of the morgue log revealed that the body had been placed in the morgue on February 7, 2013.

A review was conducted of the morgue refrigerator temperature log from December 10, 2012, to February 13, 2013. The review revealed that the temperature of the morgue refrigerator was not taken consistently.

The refrigerator had not been checked as follows in December 2012: one shift December 15, 21, 23, 24, 27, 30 and 31; two shifts December 26; and no checks completed on December 25 and 29.

The refrigerator had not been checked as follows in January 2013: one shift January 7. 10, 16, 17, 23, 25, and 28; two shifts January 1, 2, 9, 11, 12, 14, 15, 20, and 26; and no checks completed on January 4, 5, 24, 27, 29, 30 and 31.

The refrigerator had not been checked as follows in February 2013: two shifts February 4 and 7; and no checks completed on February 1, 3, and 6.

An interview conducted on February 13, 2013, at 10:15 AM with EMP3 confirmed that the morgue refrigerator temperatures were non checked consistently. Further interview with EMP3 revealed that there was "an understanding" that the temperature be checked every shift but no formal policy existed. EMP3 also confirmed that there had been an unclaimed body in the morgue refrigerator since February 7, 2013, and that the morgue refrigerator temperature had not been checked since the body was placed in the morgue.