HospitalInspections.org

Based on a review of facility documents and staff interviews, the facility failed to ensure the timely completion of medical records as the tracking of record completion had stopped in early 2020.

Findings were:

Facility policy entitled "Medical Record Suspension," last revised 5/27/03, included the following:
"POLICY:
A summary suspension shall be imposed upon a practitioner for failure to complete medical record, including H&P's (history & physical examinations), Operative Reports, Progress Notes, Discharge Summaries and signatures within thirty (30) days following a patients [sic] discharge ... Any practitioner who fails to complete medical records as required will receive specific notification from the Health Information Department prior to suspension. A suspension for delinquent medical records shall consist of loss of Medical Staff privileges, including voting and admitting privileges until medical records are completed. The suspension for delinquent medical records shall remain effective until all medical records are completed. The Medical Executive Committee is responsible for enforcing corrective actions ..."

In an interview with Staff #33, HIM Supervisor, on the morning of 9/15/21 in the conference room, she stated, "That all just stopped in March (2020) when they sent us home for covid. I just didn't get back to it. We've been so short-staffed. We're going to start it now on a monthly basis and it will be reported to quality."

Based on observation, staff interviews and review of documentation, the facility failed to ensure an adequate system for identifying, reporting, investigating and controlling infections of patients and personnel when:

1) Flies were noted in the kitchen
2) Expired food items were found in refrigerators and food was inappropriately stored in kitchen areas; and
3) Kitchen equipment was inappropriately maintained

Findings included:

1) During a tour of the kitchen with Staff #34, on the morning of 9/15/21, flies were seen near food items in the kitchen. When Staff #34 was asked about this, she stated, "We've had such a problem. They told me it was related to the outside doors being open." When asked to explain further, she escorted surveyors through 2 kitchen double doors into a hallway and down the hallway. Two exterior doors were propped open wide and supplies where supplies were brought into the facility and then taken to central supply. Upon returning to the kitchen, it was pointed out that the double doors from the hallway into the kitchen had open areas where the kitchen lighting could be seen between the doors and under them.

2) During a tour of the kitchen with Staff #34, on the morning of 9/15/21, the following observations
were made:

- in the small beverage refrigerator:
Qty. #4 Ensure with expiration date 8/1/21
Qty. #6 Glucerna with expiration date 7/1/21

- in the walk-in refrigerator:
Qty. #1 jug of apple juice with date 5/6
A rack with #21 small plates of cake left
uncovered

- in the freezer:
Numerous items were not dated and had
only a sticker that said, "Tuesday."
Among others, the items included
wrapped ham, cultured buttermilk, and
cheese. Staff #34 was unclear as to the
meaning of the sticker. She stated, "They
go through these things so fast ..."

- in the dry storage area:
Ranch dressing was stored in a previously
used container. Staff #34 stated, "I've told
them not to reuse this ..."

When asked what system they were using to ensure the oldest food was used first, for example, if the facility used a first-in, first-out method, Staff #34 replied "I need to get a method, I guess."

3) During a tour of the kitchen with Staff #34, on the morning of 9/15/21, the following observations
were made:

- in the small beverage refrigerator:
- The temperature log for the refrigerator had no expected range within which temperatures should fall, and Staff #34 was unsure of what the range was.

- A scoop was inappropriately stored in the large flour bin; the bin of sugar had no scoop. Food must be served with clean scoops to adhere to infection control management.

- A plate warmer had visible encrusted residue and food debris around the hinges.

In an interview with Staff #3, Infection Control Director, on the afternoon of 9/14/21, she said she did not tour the kitchen/dietary area when rounding the hospital to inspect for infection control issues.

These findings were confirmed in an interview with Staff #1, the hospital CNO/COO, on the afternoon of 9/15/21 in the hospital conference room. She stated, "There have been some problems with this company."